Running head: NECESSITY OF LIDOCAINE GEL

Necessity of Lidocaine Gel in Outpatient Cystoscopys

Kristine Krumdiack

Western Washington University

Nurs 301

Samms

November 28, 2016

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NECESSITY OF LIDOCAINE GEL

Necessity of Lidocaine Gel in Outpatient Cystoscopys

I pull the chart from the slot, open the door and call out the patients name listed at the

bottom of the folder. A man in his late sixties stands up. A smile is exchanged as I ask him how

are you today? With an unmistakable look of worry on is face, he states Well Im not really

sure! We proceed down the hall way to the pre-op room where I will proceed to take his vitals

and go over the consent forms. Noting that his blood pressure and pulse are elevated I reach to

remove the pulse ox feeling that his palms are now sweaty. I explain the procedure and will give

him a minute to change into his gown before taking him back to the procedure room. Before I

exiting the room, I ask him do you have any last questions for me? After a long pause and a

deep breath, he asks me, Will it hurt?

These are the words that are uttered to me just about every time I am admitting a patient

for a cystoscopy. Followed closely with Is there anything you can give me? As a surgical

urology nurse, there is always questions regarding the unknown that we are put into the position

of answering moments before surgery or a procedure. For some, the patient is put under a general

anesthetic and never knows the difference. For others, the clinical procedures where no

anesthetic is used seems to be the one that they are the most worried about. For the Individuals

who are having this procedure for the first time. They are unsure of what to expect and awaiting

the procedure is almost worse than the procedure itself.

A cystoscopy is one of the most common diagnostic procedures performed in a urology

office. It is an outpatient procedure that usually lasts less than 20 min and gives the urologist

visualization of the urethra and bladder lining. There are many indications for this procedure

such as hematuria, follow up for bladder cancer, incontinence, LUTS (lower urinary tract
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symptoms), recurrent urinary tract infections and many others. The procedure is performed by

inserting a rigid or flexible fiber scope into the urethra and advance into the bladder. The

insertion of the cystoscope has at times been associated with mild discomfort and pain;

especially in the instance were a ridged scope is used. The flexible scope is considered much

more superior then the rigid scope when it comes to maneuverability and comfort.

Historically, a gel of 2% lidocaine has been used as an intraurethral anesthetic agent for

patients undergoing a cystoscopy procedure where a ridged scope was used. (Akkoc et al.,2016)

The lidocaine is instilled via a prefilled 6-12 cc syringe and retained with a specialized clamp

until the procedure begins. But is this necessary? Is this best practice? It is these questions that I

have set out to answer. Variations in instillation time, questionable effectiveness, and the

introduction of other effective pain management techniques has now raised the question

regarding the need for lidocaine gel over its cheaper and equally as effective counterpart plain

lubrication gel.

Research Process

The search for the answers regarding whether or not lidocaine was necessary for patients

undergoing a cystoscopy was an interesting one. It began with a simple search on EBSCO using

the key terms: lidocaine gel and cystoscopies, lidocaine gel dwelling time, pain management for

cystoscopies. I was pleased that there was a lot of information available. Then I looked for the

most recent and credible sources using the process discussed in class regarding credible

sources. The part that I found most interesting was that for every article that stated that

lidocaine was not necessary I would find another that recommended its use. This was in

frustrating. The consistency in the evidence did not come until I found the most current research.
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It seems that there was a turning point when the research shifted suggesting that the lidocaine gel

may have at one time been necessary but with the introduction and wide spread use of the

flexible scope. The use of lidocaine gel wit cystoscopies may be outdated and un necessary.

Synthesis

Cystoscopys in women have been associated with little pain or discomfort. Do to this

low pain score women have been avoided as the main focus of this paper. Conversely, Men

statistically associate cystoscopys with a much higher pain score. This is due to the length of the

male urethra and angled passage into the bladder thus leading to increased discomfort during this

procedure. There for, the introduction of the flexible scope was considered ground breaking for

the male cystoscopy patient.

Questionable effectiveness

There have been various studies that have questioned the necessity of lidocaine gel for

men undergoing outpatient cystoscopy procedure. The concentration, volume instilled, exposure

time and temperature of the gel is highly controversial. One meta-analysis reported that there

was no statistical difference between the use of two percent lidocaine gel and plain lubrication

gel. In a different meta-analysis, it was found to be highly probable for the lidocaine gel to

significantly reduce mild to severe pain during and after the procedure (Aaronson et al., 2009). In

the study by (Borch et al., 2013) They reported that there was no difference in pain score when

using lidogel or plain lubricating gel. Another blind study conducted by Kobyashi and colleagues

concluded that there are no additional benefits to using and anesthetic gel over plain lubricant. In

the Cano-Garcia et al study not only did their findings show that their patients were not having

any significant pain reduction with the use of 2% lidocaine gel over plain lubricant, but the
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individuals that had received lidocaine gel had complains of stinging in the urethra upon

insertion of the lidocaine gel.

The rate of administration was tested by Khan and colleges it was found that

administering the lidocaine gel over 10 seconds was superior to 2 seconds in reducing the

discomfort of the anesthetic. Thomson et al suggested that cooling the lidocaine gel to 4 degrees

Celsius compared to the same agent decreased the irritation of the gel and increases its

effectiveness. Conversely, other studies have suggested that cooling the gel has no effect in

decreasing pain perception.

Procedural Time
Manufacture guidelines for the administration for lidocaine gel recommend delaying the

procedure by 3-5 minutes. This would allow the medication the time that is needed to be

absorbed through the mucosal surface. However, most studies regarding dwelling time for

lidocaine gel have determined that the time that is needed for the lidocaine gel to play an

effective role in reducing moderate to severe pain is a retention time of 15-25 minutes. In a

clinical setting time is precious. This addition of time would add to the increased inconvenience

for the patient creating a longer outpatient experience. As suggested by Losco and colleges, it

would also increase the anxiety levels of the patient as they wait between lidocaine instillation

and the cystoscopy. This intern leads to an increase in pain perception during the procedure. This

study reported that, there is no benefit to a short clinically manageable delay of indwelling time

of three minutes, which (Losco et al., 2011) supported was well with in the manufacture

recommendations.

Effective Alternatives
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With lidocaine gels questionable effectiveness its use it still controversial. The strive for

patient satisfaction and comfort is a driving force in healthcare. Clinicians want their patients to

be comfortable and this is the reason that a product proven time and time again to be not cost

effective is continued to be used in todays practice. Other alternatives have been used to

decrease the discomforts of this procedure such as increasing hydrostatic pressure (bag squeeze),

inhaled nitrous oxide, listening to music during the procedure (Zhang et al., 2014), and self-

viewing of the procedure have also been found reduce pain by 40 percent (Soomro, Nasir &

Ather, 2011). In some studies, plain lubrication gel has also been proven to be as effective in pain

management and it is half the price.

With all of these effective alternatives it is unknown why urologists continue to use such

an expensive lubricant. The topic of it being the way that they have done it for many years and

the unwillingness to change has come up a time or two in the research. Also, the fact that it is not

hurting anything to give it to them is another. Why should we give people extra things that they

dont need, that are costing not only them but the practice money and time? There are other

alternatives such as listening to music, self-viewing, and increasing hydrostatic pressure so why

not utilize them.

Conclusion

Does it hurt and is there something that you can give me? These questions will continue

to be answered each day that I admit my patients for their cystoscopys. It isnt until now, after

reviewing the research that I can answer with a confidence that I before did not possess. I am

now certain that the routine instillation of lidocaine gel prior to a cystoscopy is not best practice.

This quest for answers has not only improved my basic knowledge and practice regarding
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lidocaine gel, but it has improved my clinical reasoning and analyzing strategies during the

research process. This project has helped me to feel more confident in the research articles that I

choose. With the right environment and simple interventions there is no reason that the patient

needs to wait through another lidocaine installation and be set to wait for fifteen minutes to

ponder over what is to come. It is important to always tell your patients the truth. It is normal to

experience some slight discomfort associated with the insertion of the scope. Then when it is

asked if there is anything that I can do for the discomfort I then refer to the present evidence and

let them decide. In nursing school, I was taught that pain is what the patient says that it is. I

believe that it is up to them to decide what pain management route they would like to choose. I

am here to offer my guidance and now my evidence based advice on the matter.
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References
Aaronson, D. S., Walsh, T. J., Smith, J. F., Davies, B. J., Hsieh, M. H., & Konety, B. R. (2009).
Metaanalysis: does lidocaine gel before flexible cystoscopy provide pain relief? BJU
international, 104(4), 506-510.
Akko, A., Kartalm, M., Aydn, C., Topakta, R., Altn, S., & Ayka, A. (2016). 2% Lidocaine
gel or plain lubricating gel: Which one should be used in male flexible
cystoscopy?. Turkish journal of urology, 42(2), 92.
Borch, M., Scosyrev, E., Baron, B., Encarnacion, J., Smith, E. M., & Messing, E. (2013). A
randomized trial of 2% lidocaine gel versus plain lubricating gel for minimizing pain in
men undergoing flexible cystoscopy. Urologic nursing, 33(4), 187.
Cano-Garcia, M. D. C., Casares-Perez, R., Arrabal-Martin, M., Merino-Salas, S., & Arrabal-
Polo, M. A. (2015). Use of Lidocaine 2% Gel Does Not Reduce Pain during Flexible
Cystoscopy and Is Not Cost-Effective. Urology journal, 12(5), 2362-2365.
Chan, M. F., Tan, H. Y., Lian, X., Ng, L. Y. G., Ang, L. L. E., Lim, L. H. L., ... & Taylor, B. J.
(2014). A randomized controlled study to compare the 2% lignocaine and aqueous
lubricating gels for female urethral catheterization. Pain Practice, 14(2), 140-145.
Greenstein, A., Greenstein, I., Senderovich, S., & Mabjeesh, N. J. (2014). Is diagnostic
cystoscopy painful? Analysis of 1,320 consecutive procedures. International braz j
urol, 40(4), 533-538.
Gunendran, T., Briggs, R. H., Wemyss-Holden, G. D., & Neilson, D. (2008). Does increasing
hydrostatic pressure (bag squeeze) during flexible cystoscopy improve patient comfort:
a randomized, controlled study. Urology, 72(2), 255-258.
Kobayashi, T., Nishizawa, K., & Ogura, K. (2003). Is instillation of anesthetic gel necessary in
flexible cystoscopic examination? A prospective randomized study. Urology, 61(1), 65-
68.
Losco, G., Antoniou, S., & Mark, S. (2011). Male flexible cystoscopy: does waiting after
insertion of topical anesthetic lubricant improve patient comfort? BJU
international, 108(s2), 42-44.
Soomro, K. Q., Nasir, A. R., & Ather, M. H. (2011). Impact of patient's self-viewing of flexible
cystoscopy on pain using a visual analog scale in a randomized controlled
trial. Urology, 77(1), 21-23.
Zhang, Z. S., Wang, X. L., Xu, C. L., Zhang, C., Cao, Z., Xu, W. D., ... & Sun, Y. H. (2014).
Music reduces panic: An initial study of listening to preferred music improves male
patient discomfort and anxiety during flexible cystoscopy. Journal of Endourology, 28(6),
739-744.