MISCELLANEOUS
Use of Lidocaine 2% Gel Does Not Reduce Pain during Flexible Cystosco-
py and Is Not Cost-Effective
María del Carmen Cano-García,1 Rosario Casares-Perez,1 Miguel Arrabal-Martin,2* Sergio Merino-Salas,3
Miguel Angel Arrabal-Polo1
Purpose: To compare the use of lubricant gel with lidocaine versus lubricant gel without anesthetic in flexible
cystoscopy in terms of pain and tolerability.
Materials and Methods: In this observational non-randomized study, 72 patients were divided into two groups.
Group 1 included 38 patients in whom lidocaine gel 2% was used and group 2 included 34 patients in whom lu-
bricant gel without anesthetic was administered. The main variables analyzed were score in visual analogue scale
(VAS) and score in Spanish Pain Questionnaire (SPQ). Student's t-test and Chi-square test were used to compare
differences between 2 groups. The P values < .05% were considered statistically significant.
Results: Mean age of patients in group 1 was 64.50 ± 12.39 years and 67.79 ± 10.87 years in group 2 (P = .23). The
distribution according to sex was 29 men and 9 women in group 1 and 25 men and 9 women in group 2 (P = .78).
The total VAS score was 2.21 ± 2.05 in group 1 versus 1.59 ± 1.61 in group 2 (P = .16). In the SPQ, the current
intensity value was 1.82 ± 0.86 in group 1 versus 1.53 ± 0.74 in group 2 (P = .14), and the total intensity value was
1.92 ± 1.86 in group 1 versus 1.03 ± 1.75 in group 2 (P = .04). The cost of gel with lidocaine is 1.25 euro and gel
without anesthetic 0.22 euro.
Conclusion: The use of lidocaine gel does not produce benefit in terms of pain relief in flexible cystoscopy and
also is costly.
Keywords: cystoscopy; methods; adverse effects; diagnosis; anesthetics; local; lidocaine; therapeutic use; treat-
ment outcome; pain prevention & control; pain measurement.
INTRODUCTION
Flexible cystoscopy is a very useful outpatient tech-nique for studying the urethra and bladder, and es-
pecially for diagnosis and management of lower urinary
tract diseases. In most cases cystoscopy is performed
with local anesthesia. This technique revolutionized
the diagnostic area in urology, resulting in the replace-
ment of rigid cystoscopy with flexible cystoscopy in
most hospitals.(1) Although the diagnostic cystoscopy
procedure can be performed using either rigid or flex-
ible cystoscope, in men it is preferable to use flexible
instruments because it is better tolerated, causing less
pain and fewer complications.(2) In women, however,
indiscriminate use of flexible or rigid cystoscopy is
generally well tolerated.(3,4) Overall, cystoscopy is not
associated with a high perception of pain, although it is
an uncomfortable procedure that usually produces more
pain with the first procedure and less pain in subsequent
procedures.(5)
Flexible cystoscopy can be performed with or without
local anesthetic lubricant (mainly lidocaine). Choos-
ing each, depends primarily on the availability at the
hospital and preference of the urologist performing the
procedure, since there is no uniformity about whether
the use of lubricant gel with or without anesthetic is
better. Some studies indicate that the gel with lidocaine
reduces moderate to severe pain during the procedure,(5)
while others concluded that there is no significant dif-
ference in visual analogue scale.(6) The aim of this study
was to evaluate the differences in visual analogue scale
(VAS) and the Spanish pain questionnaire (SPQ) score
in patients undergoing flexible cystoscopy using lubri-
cant gel with 2% lidocaine versus lubricant gel without
anesthetic.
MATERIALS AND METHODS
Study Design
This is a non-randomized observational study com-
paring the use of lidocaine 2% gel versus lubricant gel
without anesthetic in patients undergoing simple flex-
ible cystoscopy. Patients were recruited between Sep-
tember and December 2014. The indications for cystos-
copy were hematuria, bladder cancer follow-up, lower
urinary tract symptoms (LUTS), recurrent urinary tract
infections, and others. The procedure was performed by
two different urologists with the same level of experi-
1 Department of Urology, La Inmaculada Hospital, Huercal Overa (Almeria), Spain.
2 Department of Urology, Granada Universitary Hospital, IBS Granada, Spain.
3 Department of Urology, Poniente Hospital, El Ejido (Almería), Spain.
*Correspondence: Department of Urology, Poniente Hospital, El Ejido (Almería), Spain.
Tel: +34 628 837188. Fax: +34 958 023084. E-mail: arrabalp@ono.com.
Received January 2015 & Accepted April 2015
Miscellaneous 2362
ence in flexible cystoscopy. One urologist used lubri-
cant gel with lidocaine and the other used lubricant gel
without anesthetic, following their usual clinical prac-
tice. The nurse was blinded for the type of lubricant.
Consecutive patients attending the urology outpatient
clinic in the urology department in La Inmaculada Hos-
pital in Huercal-Overa (Almería, Spain) were selected
for this study. Inclusion criteria were men or women
≥ 18 years of age with hematuria, bladder cancer fol-
low-up, LUTS, or recurrent urinary infections. Exclu-
sion criteria were patients younger than 18 years old
with suspicion for urethral stricture, permanent bladder
or suprapubic catheter, ureteral stent, active urinary
tract infection, or sensibility problems. All patients
were informed about the study and their informed con-
sent was obtained. The Ethics Committee of our Health
Area approved the study protocol.
All procedures were performed in the same manner:
supine (men) or lithotomy (women) position, skin and
genital preparation with povidone iodine, and introduc-
ing an 18 French (F) flexible cystoscope using gel with
lidocaine or gel without anesthetic. A total of 72 pa-
tients were recruited and divided into two groups: group
1 included 38 patients who underwent flexible cystos-
copy with lubricant gel with lidocaine 2%. Group 2 in-
cluded 34 patients who underwent flexible cystoscopy
with lubricant gel without anesthetic.
Main Variables
The main variables studied after the procedure were the
pain score evaluated using visual analogue scale (VAS)
and Spanish pain questionnaire (SPQ).(7) The SPQ is
consisting of two parts: current intensity value (0-14
points) and total intensity value (0-5) and VAS is meas-
ured as mild pain (0-3), moderate pain(4-7), or intense
pain(8-10). Others variables analyzed include sex, age,
reason for cystoscopy, results of cystoscopy and cost.
Statistical Analysis
For a study population of 150,000 inhabitants, taking a
precision of 5% and (1-α) of 95%, and 5% of dropout
rate, at least 72 patients are needed. Statistical analy-
sis was performed using Student's t-test for analysis of
qualitative and quantitative variables and Chi-squared
test for analysis of dichotomous variables. A multivar-
iate analysis was performed by binary logistic regres-
sion model. Normality of variables was checked using
Kolmogorov-Smirnov test and analysis of variance
with Levene's test was also performed. Statistical sig-
nificance was set as P < .05. Analyses were performed
with Statistical Package for the Social Science (SPSS
Inc, Chicago, Illinois, USA) version 17.0 for Windows.
RESULTS
Seventy-two patients were included in the study with a
mean age of 64.50 ± 12.39 years in group 1 and 67.79
± 10.87 years in group 2 (P = .23). The sex ratio (men:-
women) was 29:9 in group 1 and 25:9 in group 2 (P =
.78). The body mass index in group 1 was 28.7 ± 5.6
kg/m2 and in group 2 27.9 ± 4.9 kg/m2, with no statisti-
cally significant difference. About educational level, in
group 1, 35% presented university studies, 40% medi-
um studies and 25% basic studies and in group 2, 40%
had university studies, 40% had medium studies and
20% had basic studies with no differences. In occupa-
tional status, in group 1, 25% were employed and 75%
were retired, and in group 2, 20% were employed and
80% were retired, with no significant differences. The
reason and results of cystoscopy are shown in Table
1. The main pain score based on VAS was 2.21 ± 2.05
in group 1 versus 1.59 ± 1.61 in group 2 (P = .16). In
the SPQ, the current intensity value was 1.82 ± 0.86 in
group 1 versus 1.53 ± 0.74 in group 2 (P = .14), and the
total intensity value was 1.92 ± 1.86 in group 1 versus
1.03 ± 1.75 in group 2 (P = .04). These data are depicted
in Figure. In group 1, 24 patients presented a VAS ≤
2 (mild pain) versus 26 patients in group 2, which had
no statistically significant difference (P = .221). In a
multivariate analysis by binary logistic regression in-
cluding age, sex, occupational status, body mass index
and education level, no significant relation have been
observed (Table 2).
DISCUSSION
Some studies have analyzed the role of anesthetic lubri-
cant in rigid and flexible cystoscopy tolerability. The
studies have shown no differences in pain and tolera-
bility between immediate and delayed placement of
flexible cystoscopy after intraurethral anesthetic instal-
lation.(8,9) In the study by Herr and colleagues(8) with 288
patients undergoing flexible cystoscopy, they observed
Table 1. Main reasons for and results of cystoscopy. No significant
differences were observed in reasons for cystoscopy and results of cys-
toscopy analyzed with Chi-square test.
Variables Group 1 (n = 38) Group 2 (n = 34)
Reasons for cystoscopy, no.
Bladder cancer follow up 19 20
Hematuria 8 6
LUTS 8 1
Others 3 7
Results of cystoscopy
Normal 18 18
Bladder cancer 10 6
Edema / swelling 3 1
Trabecular bladder 0 1
Others 7 5
* Punctuation is a result coefficient of multivariate analysis that appears
with SPSS program.
Variables Punctuation* Gel P Value
Sex .253 1 .615
Age 1.812 1 .178
Body mass index 2.620 1 .106
Education level .013 1 .910
Occupational status .194 1 .660
Global statistics 4.967 5 .420
Table 2. Multivariate analysis by binary logistic regression using differ-
ent independent variables related to use lubricant with or without local
anesthesia. No significant differences were observed.
Lidocaine for Pain Reduction in Flexible Cystoscopy-Cano-García et al.
Vol 12 No 05 September-October 2015 2363
that neither immediate nor delayed cystoscopy after
the instillation of intraurethral lidocaine gel interfered
with the results of the VAS. Losco and colleagues(9)
agreed with Herr and co-workers’ conclusion,(8) in that
performing flexible cystoscopy immediately or delay-
ing after the instillation of local anesthetic gel does not
change the perception of pain by the patient.
Indeed, the controversy of whether or not intraurethral
instillation with lidocaine improves tolerability and
pain is ongoing. Studies have shown some benefit of
lidocaine gel versus plain lubricating gel,(5,10) while
others have shown no benefit in using an anesthetic
except adding to the cost of the procedure.(11-13) Borch
and colleagues(10) showed that intraurethral instillation
of lidocaine 2% gel reduced pain compared to plain lu-
bricating gel in patients undergoing cystoscopy. Simi-
larly, Aaronson and colleagues(5) showed reduction in
moderate to severe pain with the use of lidocaine gel
compared to not using any local anesthetic. On the
other hand, studies by Kobayashi and colleagues(10,11)
demonstrated no benefit from the use of an anesthetic
gel; moreover, the anesthetic gel may produce a more
painful sensation in the patient. The study of Palit and
colleagues(13) demonstrated that most patients undergo-
ing flexible cystoscopy with lignocaine gel or lubricant
gel without anesthetic, gave a score in VAS of < 3, with
no significant differences between them. In the study by
Chen and colleagues,(6) a score in VAS of 2.8 versus 2.6
was observed among patients undergoing flexible cys-
toscopy using lubricant gel with lidocaine 2% versus lu-
bricant gel without anesthetic, respectively, with no sta-
tistically significant difference. In our study, the results
demonstrate that the use of lubricant gel with lidocaine
2% give no benefit during the procedure and actually
produces more pain based on SPQ (total intensity val-
ue). In fact, most patients in our study commented that
the lubricant anesthetic gel produced a stinging sensa-
tion in the urethra. Also, the use of lubricant gel with
lidocaine increased the cost of the procedure: the indi-
vidual cost of lubricant gel with anesthetic is 1.25 euro
and lubricant gel without anesthetic is 0.22 euro. As we
know, there have been different studies assessing the
tolerability of the procedure using intraurethral gel with
local anesthetic versus no anesthetic. Some of the stud-
ies show the benefit of using local anesthetic gel, while
in others no significant differences are observed. In our
study, lubricant with lidocaine did not produce any ben-
efit and added to the cost of the procedure. Therefore,
we do not recommend its use. Other techniques, drugs
or maneuvers have been used to reduce pain and im-
prove tolerability during the cystoscopy procedure such
as increased hydrostatic pressure during cystoscopy,(14)
inhaled nitrous oxide,(15) and self-viewing during cys-
toscopy.(16-18) They appear to be effective, but they have
yet to become popular and are not routinely used.
We know that our study have some limitations such as
the number of patients and non-randomized manner, so
it is necessary to design a randomized clinical trial with
one surgeon and blinded to lubricant to avoid bias and
to obtain a definitive conclusion.
CONCLUSIONS
As a conclusion of this study, the use of lubricant gel
without anesthetic is recommended when performing
flexible cystoscopy, as it is not associated with more
pain sensation in comparison with lidocaine, in addition
it is more cost effective than lidocaine gel.
ACKNOWLEDGEMENTS
This article is part of the doctoral thesis by Maria del
Carmen Cano-Garcia whose Thesis Director is Miguel
Angel Arrabal-Polo.
CONFLICT OF INTEREST
None declared.
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