Article Data

  • Views 1271
  • Dowloads 157

Systematic review

Open Access

Several interventions to alleviate pain in male patients undergoing office-based flexible cystoscopy: a systematic review and meta-analysis

  • Zhihong Wang1
  • Wuran Wei1,*,

1Department of Urology, Institute of Urology, West China Hospital, Sichuan University, 610041 Chengdu, Sichuan Province, China

DOI: 10.31083/jomh.2021.077 Vol.18,Issue 1,January 2022 pp.1-7

Submitted: 16 March 2021 Accepted: 01 April 2021

Published: 31 January 2022

*Corresponding Author(s): Wuran Wei E-mail:


Background: The purpose of this study was to explore the ability of nonpharmacologic adjuvant interventions to alleviate pain in male patients during flexible cystoscopy (FC) under local anesthesia.

Methods: Electronic databases including PubMed, the Cochrane Library, and Embase were searched to identify eligible clinical trials from inception to 31 December 2020, with no language restrictions. Two independent reviewers used Cochrane Collaboration tools to assess the selection criteria, methodological rigor and risk of bias. Statistical analyses were performed using STATA 14.2.

Results: In total, 717 studies were initially identified, and fourteen randomized controlled trials were ultimately included. We observed that patients who underwent FC with higher irrigation pressures had significantly lower pain scores on the visual analog scale than their counterparts with lower irrigation pressure during FC (weight mean difference (WMD): −1.43; 95% confidence interval (CI): −1.72 to −1.14) with no between-study heterogeneity (p = 0.661). There were no significant differences in pain between immediate or delayed FC groups under the same local anesthetic (standard mean difference (SMD): −0.19; 95% CI: −0.39 to 0.01). A pooled analysis of three studies including 340 male patients showed that men who observed the cystoscopy on the monitor had significantly lower pain ratings compared to those who did not view the operation on the monitor (SMD: −0.64; 95% CI: −1.14 to −0.15). Two studies, including a total of 272 patients, assessed the influence of listening to music on pain and anxiety in male patients during FC. Our meta-analysis found that music significantly improved patient pain (WMD: −0.92; 95% CI: −1.29 to −0.54). Hand-holding and urination during FC also relieved pain and anxiety in male patients undergoing FC.

Conclusions: We observed that elevated irrigation pressure, real-time cystoscopy visualization, and music therapy alleviated pain in male patients undergoing FC. Well-designed trials are needed to confirm our findings.


Flexible cystoscopy; Music; Pressure; Bag squeeze; Real-time visualization

Cite and Share

Zhihong Wang,Wuran Wei. Several interventions to alleviate pain in male patients undergoing office-based flexible cystoscopy: a systematic review and meta-analysis. Journal of Men's Health. 2022. 18(1);1-7.


[1] Burke DM, Shackley DC, O’Reilly PH. The community‐based morbid-ity of flexible cystoscopy. BJU international. 2002; 89:347–349.

[2] Greenstein A, Greenstein I, Senderovich S, Mabjeesh NJ. Is diagnostic cystoscopy painful? Analysis of 1320 consecutive procedures. Interna-tional Brazilian Journal of Urology. 2014; 40: 533–538.

[3] Tsuchida S, Sugawara H. A new flexible fibercystoscope for visualiza-tion of the bladder neck. Journal of Urology. 1973; 109: 830–831.

[4] Seklehner S, Remzi M, Fajkovic H, Saratlija-Novakovic Z, Skopek M, Resch I, et al. Prospective multi-institutional study analyzing pain perception of flexible and rigid cystoscopy in men. Urology. 2015; 85: 737–741.

[5] Krajewski W, Kościelska-Kasprzak K, Rymaszewska J, Zdrojowy R. How different cystoscopy methods influence patient sexual satisfac-tion, anxiety, and depression levels: a randomized prospective trial. Quality of Life Research. 2017; 26: 625–634.

[6] Babjuk M, Böhle A, Burger M, Capoun O, Cohen D, Compérat EM, et al. EAU guidelines on non-muscle-invasive urothelial carcinoma of the bladder: update 2016. European Urology. 2017; 71: 447–461.

[7] Raskolnikov D, Brown B, Holt SK, Ball AL, Lotan Y, Strope S, et al. Reduction of pain during flexible cystoscopy: a systematic review and meta-analysis. Journal of Urology. 2019; 202: 1136–1142.

[8] Aaronson DS, Walsh TJ, Smith JF, Davies BJ, Hsieh MH, Konety BR. Meta-analysis: does lidocaine gel before flexible cystoscopy provide pain relief? BJU International. 2009; 104: 506–510.

[9] Patel AR, Jones JS, Babineau D. Lidocaine 2% gel versus plain lubricating gel for pain reduction during flexible cystoscopy: a meta-analysis of prospective, randomized, controlled trials. Journal of Urology. 2008; 179: 986–990.

[10] Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Medicine 2009; 6: e1000097.

[11] Collins SL, Moore RA, McQuay HJ. The visual analogue pain intensity scale: what is moderate pain in millimetres? Pain. 1997; 72: 95–97.

[12] Centre for Evidence-Based Medicine. Oxford Centre for evidence-based medicine: levels of evidence. 2009. Available at: (Accessed: 10 March 2021).

[13] Zhang Z, Wang X, Zeng S, Tang L, Cao Z, Zhang C, et al. Pressure makes pleasure: a preliminary study of increasing irrigation pressure of flexible cystoscopy improves male patient comfort by an easy way. Journal of Endourology. 2015; 29: 1361–1365.

[14] Berajoui MB, Aditya I, Herrera-Caceres J, Qaoud Y, Lajkosz K, Ajib K, et al. A prospective randomized controlled trial of irrigation “bag squeeze” to manage pain for patients undergoing flexible cystoscopy. Journal of Urology. 2020; 204: 1012–1018.

[15] Gunendran T, Briggs RH, Wemyss-Holden GD, Neilson D. Does in-creasing hydrostatic pressure (“bag squeeze”) during flexible cystoscopy improve patient comfort: a randomized, controlled study. Urology. 2008; 72: 255–258.

[16] Herr HW, Schneider M. Outpatient flexible cystoscopy in men: a randomized study of patient tolerance. Journal of Urology. 2001; 165: 1971–1972.

[17] Losco G, Antoniou S, Mark S. Male flexible cystoscopy: does waiting after insertion of topical anaesthetic lubricant improve patient comfort? BJU International. 2011; 108: 42–44.

[18] Panach-Navarrete J, Martínez-Jabaloyas JM. Is a retention time after the instillation of anesthetic lubricant necessary when performing male flexible cystoscopy? Journal of Endourology. 2015; 29: 223–225.

[19] Cornel EB, Oosterwijk E, Kiemeney LA. The effect on pain ex-perienced by male patients of watching their office-based flexible cystoscopy. BJU International. 2008; 102: 1445–1446.

[20] Patel AR, Jones JS, Angie S, Babineau D. Office based flexible cystoscopy may be less painful for men allowed to view the procedure. Journal of Urology. 2007; 177: 1843–1845.

[21] Zhang Z, Tang L, Wang X, Xu C, Sun Y. Seeing is believing: a randomized controlled study from China of real-time visualization of flexible cystoscopy to improve male patient comfort. Journal of Endourology. 2011; 25: 1343–1346.

[22] Zhang Z, Wang X, Xu C, Zhang C, Cao Z, Xu W, et al. Music reduces panic: an initial study of listening to preferred music improves male patient discomfort and anxiety during flexible cystoscopy. Journal of Endourology. 2014; 28: 739–744.

[23] Ölçücü MT, Yılmaz K, Karamık K, Okuducu Y, Özsoy Ç, Aktaş Y, et al. Effects of listening to binaural beats on anxiety levels and pain scores in male patients undergoing cystoscopy and ureteral stent removal: a randomized placebo-controlled trial. Journal of Endourology. 2021; 35: 54–61.

[24] Kwon W, Lee JW, Seo HK, Oh TH, Park SC, Jeong HJ, et al. Hand-holding during cystoscopy decreases patient anxiety, pain, and dissatisfaction: a pilot randomized controlled trial. Urologia Internationalis. 2018; 100: 222–227.

[25] Xie Y, Wang W, Yan W, Liu D, Liu Y. Efficacy of urination in alleviating man’s urethral pain associated with flexible cystoscopy: a single-center randomized trial. BMC Urology. 2020; 20: 2.

[26] Walker MR, Kallingal GJS, Musser JE, Folen R, Stetz MC, Clark JY. Treatment efficacy of virtual reality distraction in the reduction of pain and anxiety during cystoscopy. Military Medicine. 2014; 179: 891–896.

[27] Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Medical Research Methodology. 2006; 5: 13.

[28] Yang L, Wang G, Du Y, Ji B, Zheng Z. Remote ischemic precondi-tioning reduces cardiac troponin i release in cardiac surgery: a meta-analysis. Journal of Cardiothoracic and Vascular Anesthesia. 2015; 28: 682–689.

[29] Nadeem M, Ather MH. Effect of diclofenac suppository on pain control during flexible cystoscopy-a randomized controlled trial. F1000Research. 2016; 5: 2834.

[30] Calleary JG, Masood J, Van-Mallaerts R, Barua JM. Nitrous oxide inhalation to improve patient acceptance and reduce procedure related pain of flexible cystoscopy for men younger than 55 years. Journal of Urology. 2007; 178: 184–188.

[31] Carroll PR, Dixon CM. Surgical anatomy of the male and female urethra. Urologic Clinics of North America. 1992; 19: 339–346.

[32] Taghizadeh AK, El Madani A, Gard PR, Li C, Thomas PJ, Denyer SP. When does it hurt? Pain during flexible cystoscopy in men. Urologia Internationalis. 2006; 76: 301–303.

[33] Holmes M, Stewart J, Rice M. Flexible cystoscopy: is the volume and content of the urethral gel critical? Journal of Endourology. 2001; 15: 855–858.

[34] Gooran S, Pourfakhr P, Bahrami S, Fakhr Yasseri AM, Javid A, Behtash N, et al. A randomized control trial comparing combined glandular lidocaine injection and intraurethral lidocaine gel with intraurethral lidocaine gel alone in cystoscopy and urethral dilatation. Urology Journal. 2017; 14: 4044–4047.

Abstracted / indexed in

Science Citation Index Expanded (SciSearch) Created as SCI in 1964, Science Citation Index Expanded now indexes over 9,200 of the world’s most impactful journals across 178 scientific disciplines. More than 53 million records and 1.18 billion cited references date back from 1900 to present.

Journal Citation Reports/Science Edition Journal Citation Reports/Science Edition aims to evaluate a journal’s value from multiple perspectives including the journal impact factor, descriptive data about a journal’s open access content as well as contributing authors, and provide readers a transparent and publisher-neutral data & statistics information about the journal.

Directory of Open Access Journals (DOAJ) DOAJ is a unique and extensive index of diverse open access journals from around the world, driven by a growing community, committed to ensuring quality content is freely available online for everyone.

SCImago The SCImago Journal & Country Rank is a publicly available portal that includes the journals and country scientific indicators developed from the information contained in the Scopus® database (Elsevier B.V.)

Publication Forum - JUFO (Federation of Finnish Learned Societies) Publication Forum is a classification of publication channels created by the Finnish scientific community to support the quality assessment of academic research.

Scopus: CiteScore 0.7 (2022) Scopus is Elsevier's abstract and citation database launched in 2004. Scopus covers nearly 36,377 titles (22,794 active titles and 13,583 Inactive titles) from approximately 11,678 publishers, of which 34,346 are peer-reviewed journals in top-level subject fields: life sciences, social sciences, physical sciences and health sciences.

Norwegian Register for Scientific Journals, Series and Publishers Search for publication channels (journals, series and publishers) in the Norwegian Register for Scientific Journals, Series and Publishers to see if they are considered as scientific. (

Submission Turnaround Time