Looking at a patient's bladder with a cystoscope is: (1) Often the best way to find out what is going on inside it. (2) Usually more useful than an X-ray. (3) Particuarly useful in areas where S. haematobium is endemic, because it is the most practical way of diagnosing the cancer of the bladder that commonly complicates this disease, and which also causes haematuria (32.31). For this you only need the simplest instrument, without provision for catheterizing the ureters..

Cystoscopy is an acquired skill, even with modern equipment using a fibre-optic light source and a solid rod lens system. With the older Ringleb type of cystoscope described here, it is even more difficult[md]one problem is that bulbs have an infuriating tendency to ''blow', and need frequent replacement. Although we describe the use of such an instrument here, the methods in this manual have been chosen so that you can usually manage without one. If you look after a cystoscope carefully, it will serve you many years. Even so, cystoscopy is on the edge of this system of surgery, and at least one contributor doubts its relevance. The problems are: (1) to get the instrument in (modern practice is always to do this under direct vision, so as to avoid causing damage), (2) to have a good enough instrument to give you a diagnostic view, and (3) to know what the normal looks like.

CYSTOSCOPE, simple pattern, Ringleb type, for examination only, 19 Ch, with single irrigating sheath, and ''Autoface' pattern bulb, boilable, with battery box, rheostat, and 25 spare bulbs, one outfit only. A cystoscope like this can often be obtained free, or secondhand for less than $50. You can examine a patient with it, but you cannot use it to operate on him. It has a thin metal telescope with a side-looking prism at one end, and an eyepiece at the other. Around this is a sheath with an irrigating and lighting system. The ''Autoface bulb' can be twisted to face in any direction, after the thread has been fully engaged. The sheath has a detachable switch which clips on to two rings near its outer end, and is connected through a cord to a battery box.

At the proximal end of the sheath is a chamber, to which a valve is fixed, with a collar and screws. There is a groove on the upper surface of the valve, which fits into a projection on the roof of the valve chamber. At the outer end of the sheath is a washer and a compression ring. When this is tightened, no fluid can leak back along the side of the telescope.

Methods of irrigation differ. Some cystoscopes have a tap with two positions, some have two taps, and in others you have to remove the telescope and fix a tap (''the faucet') in the hole where the telescope was.

SYRINGE, bladder, Barrington's metal, one only. Use this to wash out the bladder during cystoscopy.

CAN, douche, metal, 3 litre, with rubber tubing, one only.

Fig. 23-4 A SIMPLE CYSTOSCOPE, of the Ringleb pattern. A, the assembled cystoscope. B, the parts of the chamber. C, the sheath. D, the telescope. The Albarran lever is for manipulating a ureteric catheter, which is not described here.

CYSTOSCOPY INDICATIONS. These include: (1) Urinary retention, or difficult micturition, particularly as a prelude to Freyer's prostatectomy. If the patient has an enlarged prostate, cystoscopy may precipitate acute retention, so do it as the first stage of a prostatectomy (23.19). (2) Haematuria over the age of 30 in areas where Schistosoma haematobium is highly endemic, see Section 32.31. (3) To diagnose schistosomiasis when it is strongly suspected clinically, but you cannot find ova in the urine. (4) Recurrent urinary infection.

CONTRAINDICATIONS. (1) Acute cystitis, until you have controlled the infection.

TESTING A CYSTOSCOPE. The theatre staff should do this before they sterilize it. Look down the telescope; the image should be clear. If it is misty, there is dirt on the lenses; clean them with spirit-soaked swabs. If it is still misty, water has probably entered the telescope, so return it to the makers or an agent for repair.

If a crescentic part of the visual field is cut off, the telescope has been bent. If this only happens after you have inserted the sheath, this is bent.

To test the bulb, connect up the battery box and set the rheostat to zero. Place the end of the cystoscope in water to cool the bulb and prevent it burning out. Gradually turn up the rheostat until the bulb begins to glow. Stop when the loops of the filament appear to coalesce.

If the bulb fails to light, scrape the electrode at the bottom of the bulb socket with a pin. Use a pin to raise the central contact on the bulb. If it still fails to light, replace it. Check that the battery is not exhausted, and that the slide on the battery box is not loose.

STERILIZATION. Even though your cystoscope may be boilable, an antiseptic solution will be safer for it. Keep it in its box until you want to use it. Remove the compression ring and valve, and immerse it in glutaraldehyde solution (''Cidex', Ethicon, 2.5) or 1% chlorhexidine, or 1/1000 mercury oxycyanide, or 1/80 phenol. Ten minutes immersion will kill all bacteria capable of infecting the bladder. Rinse it in sterile water, and place it on a sterile towel. Sterilize a spare bulb at the same time. After use, rinse it in water, and dry it with swabs soaked in spirit.

If it is boilable, and you do decide to boil it, immerse it in its perforated metal box in boiling water for 10 minutes. Then leave it in a sterile towel to cool.

ANAESTHESIA. You can examine a woman as an outpatient without any anaesthesia, unless she has a painful stricture of her external meatus, or a very irritable bladder.

General anaesthesia will be easier if the patient is male and you are inexperienced, or he has carcinoma of his bladder (32.31) or tuberculosis (uncommon).

If you are going to use local anaesthesia, lay him on his back, clean his glans penis with cetrimide, and use the nozzle of a tube of 2% lignocaine jelly to inject 5 g down his urethra. Apply a penile clamp proximal to his glans. Five minutes later inject a further 5 g, and reapply the clamp. Massage his penile urethra, so as to squeeze the jelly into his posterior urethra. After a further 10 minutes he is ready for cystoscopy.

PREPARATION. Put him into the semilithotomy position[md]flex his hips to only 75[de] and abduct them 30 to 45[de], so as to leave his buttocks further up the table than the poles. Don't use the full lithotomy position. To provide fluid for irrigation, use a douche can a metre above him filled with autoclaved water.

INTRODUCING THE CYSTOSCOPE. Loosen the compression ring, pass the cystoscope into its sheath, and lubricate it with KY or lignocaine jelly.

CAUTION! Because urethral strictures are so common, always start by passing a large (22 Ch) Jacques catheter, before you pass a cystoscope. If you find a stricture bougie him under general anaesthesia (23.8).

If the patient is female, you will have no difficulty, unless her meatus is stenosed. If so, dilate it with sounds.

Clean the glans penis of a man and hold his penis vertically with your left hand. Introduce the cystoscope gently into his urethra, and stretch his penis along it, as it descends under its own weight. When its tip lies against his triangular ligament, swing the eyepiece down between his thighs with a circular motion, and it will slip into his bladder.

If its beak sticks in his external urethra, depress the eyepiece further and it will probably slip in[md]never try to push it in. If it still will not pass, put your finger in his rectum, or on his perineum and guide it in that way[md]this is seldom necessary. If the beak is in his bladder, the cystoscope will rotate freely.

WASHING OUT HIS BLADDER. Remove the telescope and plug in the faucet. Collect the urine which comes out. If it is hazy, send it for culture. Crystal clear urine will be sterile.

Fill a bladder syringe with water, and expel any air by holding its nozzle upwards, and depressing the plunger. Then squirt some of the water on to your own hand, to make sure that it is not too hot. Wash out his bladder by injecting 50 ml at a time, until the washings are clear. Alternatively, wash it out with water from the douche can.

INSPECTION. Distend his bladder with 250 ml of water. Put in the telescope and look around. A normal bladder holds 250 to 400 ml. You will see very little, if it holds less than 50 ml. Bladders with advanced carcinoma, severe schistosomiasis, or tuberculosis are often very small, and need very careful handling; they may bleed if you fill them too full.

An object is the correct size when it is 5 cm from the prism: it looks larger if it is nearer, and smaller if it is further away. There is a small knob on the valve chamber in the same line as the prism. If you keep your finger on this as you rotate the cystoscope, you will always know where the prism is pointing.

If you see nothing to begin with: (1) The beak of the cystoscope may still be in his urethra. (2) The light may have gone out. (3) You may have inserted the telescope incorrectly. The small pin in the eyepiece should fit into the expanded end of the valve collar. Try twisting the compression ring a little. (4) There may be blood or clot on the objective. (5) If you see nothing but a ''red out', you may have failed to run fluid into his bladder.

Examine his bladder systematically, starting with the fenestra (window), looking downwards towards the base of his bladder. Note the size of the median lobe of his prostate as you enter his bladder (it looks like a ''termite hill'). Observe his interureteric bar. This is a ridge of tissue between his two ureteric orifices. It is a useful landmark, but it is sometimes not very conspicuous. Another landmark is the small air bubble which is always present in the top of his bladder. Return to his interureteric bar, and look all round the side walls and roof of his bladder. Turn the cystoscope through 360[de], so as to examine a circular strip of bladder wall. Then push it further into the fundus, withdraw it 2 cm and look around 360[de] again.

Find his ureteric orifices by finding his interureteric bar, and tracing it laterally. When you see an orifice, the cystoscope must be in either the 5 o'clock, or the 7 o'clock position.

Depress the eyepiece to look at the anterior wall of his bladder. This may be impossible to see in a man, unless he is fully relaxed under general anaesthesia.

The mucosa of a normal bladder is a yellow sandy colour, and has fine branching vessels under it. If the fluid in his bladder is bloody, the mucosa may look pink[md]don't confuse this with cystitis. A normal trigone is pink and vascular.

Finally, partly withdraw it and examine his trigone and his internal urinary meatus. You should be able to see everything except the base when it is obscured by a very large median lobe. When this is very large you may not see his ureteric orifices either.