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Reasons for a cystoscopy?

User
Posted 06 Jan 2020 at 19:57

Mr L has to have a cystoscopy.  After seeing the consultant and describing how he struggles to pee during the night, it was decided that he should have a cystoscopy to make sure the adhesions wasn't blocking the pipes.  Is this a safe procedure to have for someone that is doing really well with his ED and continence?  I'd hate for him to be set back after doing so well up to now.  Also just to reassure me but they wouldn't be looking for recurrence would they?  His latest PSA is <0.05 which was done in October, and he is very fit and well.  Am I overthinking things?


Thanks for any help.

User
Posted 07 Jan 2020 at 16:17

Originally Posted by: Online Community Member
I just don't understand why he only struggles to pee at night, when throughout the day he's totally normal?


This is not unusual. Almost all men pee slower at night and on first waking in the morning, whether they've noticed it or not.


This is because the internal urinary sphincter which is the primary continence control is smooth muscle under the control of the autonomous nervous system, not under conscious control. The autonomous nervous system takes longer to wake up than your conscious nervous system, so you are basically peeing when the nervous system controlling the internal sphincter is still half asleep.


However, as you've had a prostatectomy, you no longer have an internal urinary sphincter (it's removed with the prostate) - you just have the external one, and this leads me to some conjecture. The external sphincter in men (although not women) is normally thought of as skeletal muscle under conscious control. I've asked a few urologists how this learns to become the primary continence control after prostatectomy, and none seem to know, but certainly in women it's both a skeletal muscle under conscious control and a smooth muscle under control of the autonomous nervous system (women don't have the internal urinary sphincter in the first place, so their sphincter has to do some of both roles). My guess is that gaining continence after prostatectomy is the brain transferring autonomous nervous system control from the lost internal sphincter to smooth muscle parts of the external sphincter, so the same considerations would apply of the autonomous nervous system being half asleep when you are trying to pee at night, with or without a prostatectomy.


Any urinary tract outflow obstruction will make slower peeing at night worse, particularly if the obstruction is in the sphincter itself. In minor cases (at least when prostatectomy isn't involved), Tamsulosin may be given to take with the last meal of the day (so it works overnight) to help relax the internal urinary sphincter more, but it might be that there's a stricture (scar tissue causing narrowing) at that point which needs dilating, and that can sometimes be done with the cystoscopy camera if it's minor.

Originally Posted by: Online Community Member
I didn’t have any local anaesthetic on my 2nd procedure and didn’t really feel anything during or after


Bri
The local anesthetic for cystoscopy is in the lubrication gel (Instillagel), not any sort of injection, and you would certainly have had the lubrication gel. You might also have an additional local anesthetic if they plan to do something other than just a camera observation.

Edited by member 07 Jan 2020 at 16:19  | Reason: Not specified

User
Posted 07 Jan 2020 at 18:38

Originally Posted by: Online Community Member
Interesting theory about the sphincter control and it may be right but why are some men dry from day one.


I've thought about this quite a bit (which is why I've asked questions of urologists, only to find they don't know).


Let me start by explaining smooth muscle and skeletal muscle a bit more. Smooth muscle is under the control of the autonomous nervous system, and without direct conscious control. Another key aspect of smooth muscle is that it can remain contracted without ever tiring, which is kind of important for the primary continence control. Also, it doesn't contract and release very quickly. Conversely, skeletal muscle is under conscious control. (It can be, and often is, taught to behave automatically without consciously considering every muscle. For example raising your arm requires synchronised actions of very many muscles - at a very early age, you learnt to raise your arm by operating those muscles subconsciously, indeed "learning" meant committing them to your subconscious, because the action is too complicated to do with manual control of all the individual muscles. However, you can still consciously control them individually if you really want to.) Skeletal muscle operates quickly, but tires, and cannot remain contracted for extended periods. That's not much use for primary continence control.


Men have two urinary sphincters, an internal one between bladder and prostate (actually part of the bladder wall), and an external one below prostate and integral with pelvic floor muscles. The conventional wisdom is that the internal one which is smooth muscle provides primary continence, relaxing when you want to start peeing, and the external one is skeletal muscle and provides secondary conscious control of continence, e.g. contracting when you want to suddenly stop peeing mid-stream when your grandmother unexpectedly walks into the bathroom. We know the external one does more than just this - you learned at a very early age to contract the external one also when you cough, or stand up, or jump and land, and other actions than might cause the internal one to leak, but these are short lived contractions which need to happen quickly, and ideally suited to skeletal muscles.


My guess is that the male external urinary sphincter is probably both smooth muscle and skeletal muscle, just as it is in women (who have only one urinary sphincter). If this wasn't the case, the external urinary sphincter could never take over primary continence control when the internal one is lost during prostatectomy. This means when a man learned continence at a very young age, he had two options to pick, using just the internal urinary sphincter, or using both urinary sphincters - both methods will work. 60 years later when he loses the internal urinary sphincter in a prostatecomy, if he had originally learned to use just that for continence, he will now be leaking. However, if he's always been using smooth muscle of both sphincters for primary continence control, he will be dry as the external one is still there and working. Interestingly, if it's this simple, it should be possible to tell men in advance if they will leak or be dry after prostatectomy.


This is just my theory, because it fits what I know of the anatomy and the results seen after prostatectomy. However, it seems we simply don't know how this really works.

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User
Posted 06 Jan 2020 at 22:56

The procedure is straight forward. It won’t effect his continence or erectile function. If he’s struggle to pee they are just checking to see if there’s any restrictions. The cystoscopy in some cases can actually sort the problem


So yes you probably are overthinking it


All the best


Bri 


 


 


 

User
Posted 07 Jan 2020 at 06:51

Mr & Mrs L


I always say a cystoscopy camera in the right hands you don't feel a thing, in the wrong hands it might be slightly uncomfortable. 


The procedure is quite safe, I have had quite a few and never had any issues or infections. The procedure itself might just help the flow.


As Brian said they are looking for restrictions or a possible stricture or possibly a clip migration from the op.


PSA result is brilliant and you are fortunate to have a hospital that tests to 2 decimal points.


Hope all goes well and let us know what they find.


Thanks Chris

Edited by member 07 Jan 2020 at 06:53  | Reason: Not specified

User
Posted 07 Jan 2020 at 10:24

Thanks for your replies Bri and Chris.  I can say Mr L isn't looking forward to it!  I just don't understand why he only struggles to pee at night, when throughout the day he's totally normal?  Anyway as long as there's no ulterior motive on the consultants part for doing the cystoscopy then that has reassured me.  You just never stop worrying with this damn thing.


Thanks again.

User
Posted 07 Jan 2020 at 13:31

Not a pleasant procedure but ensure they give a few seconds after pumping the local anaesthetic in the urethra. It’s over in a few minutes and I had some discomfort for half a day afterwards as very sore and tender inside. Took me two hours to have a wee then slowly settled. 

User
Posted 07 Jan 2020 at 13:41
I didn’t have any local anaesthetic on my 2nd procedure and didn’t really feel anything during or after

Bri
User
Posted 07 Jan 2020 at 16:17

Originally Posted by: Online Community Member
I just don't understand why he only struggles to pee at night, when throughout the day he's totally normal?


This is not unusual. Almost all men pee slower at night and on first waking in the morning, whether they've noticed it or not.


This is because the internal urinary sphincter which is the primary continence control is smooth muscle under the control of the autonomous nervous system, not under conscious control. The autonomous nervous system takes longer to wake up than your conscious nervous system, so you are basically peeing when the nervous system controlling the internal sphincter is still half asleep.


However, as you've had a prostatectomy, you no longer have an internal urinary sphincter (it's removed with the prostate) - you just have the external one, and this leads me to some conjecture. The external sphincter in men (although not women) is normally thought of as skeletal muscle under conscious control. I've asked a few urologists how this learns to become the primary continence control after prostatectomy, and none seem to know, but certainly in women it's both a skeletal muscle under conscious control and a smooth muscle under control of the autonomous nervous system (women don't have the internal urinary sphincter in the first place, so their sphincter has to do some of both roles). My guess is that gaining continence after prostatectomy is the brain transferring autonomous nervous system control from the lost internal sphincter to smooth muscle parts of the external sphincter, so the same considerations would apply of the autonomous nervous system being half asleep when you are trying to pee at night, with or without a prostatectomy.


Any urinary tract outflow obstruction will make slower peeing at night worse, particularly if the obstruction is in the sphincter itself. In minor cases (at least when prostatectomy isn't involved), Tamsulosin may be given to take with the last meal of the day (so it works overnight) to help relax the internal urinary sphincter more, but it might be that there's a stricture (scar tissue causing narrowing) at that point which needs dilating, and that can sometimes be done with the cystoscopy camera if it's minor.

Originally Posted by: Online Community Member
I didn’t have any local anaesthetic on my 2nd procedure and didn’t really feel anything during or after


Bri
The local anesthetic for cystoscopy is in the lubrication gel (Instillagel), not any sort of injection, and you would certainly have had the lubrication gel. You might also have an additional local anesthetic if they plan to do something other than just a camera observation.

Edited by member 07 Jan 2020 at 16:19  | Reason: Not specified

User
Posted 07 Jan 2020 at 16:48
My cancer was slightly attached to bladder and before surgery they wanted to check it hadn’t got into the bladder. My Surgeon was in a rush and dragged me through a waiting room and jumped the queue. I lay on the bed and a nurse held my hand. He literally squirted the gel in my urethra and then shoved the camera in immediately afterwards. It got so far and then I nearly screamed the room down as he passed the sphincter. I think I broke the nurses hand. And I’m NOT a baby. I actually felt physically violated afterwards. When I read up on the procedure later it said the gel should have been left 15 mins to anaesthetise the urethra. Never again lol. Well I hope

If life gives you lemons , then make lemonade
User
Posted 07 Jan 2020 at 17:35

Chris,


There was no waiting 15 mins in my case, the whole procedure only took a few mins from start to finish, and this included a good look around all of the bladder. The only pain is mild stinging just for a few seconds when the gel is inserted, while you can feel the antiseptic and before it numbs. After that, I was much more interested in the image on the large screen of going up my urethra and looking all around my bladder, and I don't recall any discomfort. It stung a bit after the camera was removed and the anesthetic wore off, no worse than radiation cystitis that many people put up with for a month or more, but this only lasted perhaps an hour.

User
Posted 07 Jan 2020 at 17:36

Instilagel or hydrocaine is an anesthetic, antiseptic and lubricant, i think most urology staff ignore the anesthetic properties. It is used for SPC changes and the DNs do not hang about for the few minutes it takes to be effective. Mrs L, he will probably have the distraction of being able see the inside of his urethra and bladder as there may be a screen at the side of the treatment table.


Interesting theory about the sphincter control and it may be right but why are some men dry from day one. 


Thanks Chris

User
Posted 07 Jan 2020 at 18:38

Originally Posted by: Online Community Member
Interesting theory about the sphincter control and it may be right but why are some men dry from day one.


I've thought about this quite a bit (which is why I've asked questions of urologists, only to find they don't know).


Let me start by explaining smooth muscle and skeletal muscle a bit more. Smooth muscle is under the control of the autonomous nervous system, and without direct conscious control. Another key aspect of smooth muscle is that it can remain contracted without ever tiring, which is kind of important for the primary continence control. Also, it doesn't contract and release very quickly. Conversely, skeletal muscle is under conscious control. (It can be, and often is, taught to behave automatically without consciously considering every muscle. For example raising your arm requires synchronised actions of very many muscles - at a very early age, you learnt to raise your arm by operating those muscles subconsciously, indeed "learning" meant committing them to your subconscious, because the action is too complicated to do with manual control of all the individual muscles. However, you can still consciously control them individually if you really want to.) Skeletal muscle operates quickly, but tires, and cannot remain contracted for extended periods. That's not much use for primary continence control.


Men have two urinary sphincters, an internal one between bladder and prostate (actually part of the bladder wall), and an external one below prostate and integral with pelvic floor muscles. The conventional wisdom is that the internal one which is smooth muscle provides primary continence, relaxing when you want to start peeing, and the external one is skeletal muscle and provides secondary conscious control of continence, e.g. contracting when you want to suddenly stop peeing mid-stream when your grandmother unexpectedly walks into the bathroom. We know the external one does more than just this - you learned at a very early age to contract the external one also when you cough, or stand up, or jump and land, and other actions than might cause the internal one to leak, but these are short lived contractions which need to happen quickly, and ideally suited to skeletal muscles.


My guess is that the male external urinary sphincter is probably both smooth muscle and skeletal muscle, just as it is in women (who have only one urinary sphincter). If this wasn't the case, the external urinary sphincter could never take over primary continence control when the internal one is lost during prostatectomy. This means when a man learned continence at a very young age, he had two options to pick, using just the internal urinary sphincter, or using both urinary sphincters - both methods will work. 60 years later when he loses the internal urinary sphincter in a prostatecomy, if he had originally learned to use just that for continence, he will now be leaking. However, if he's always been using smooth muscle of both sphincters for primary continence control, he will be dry as the external one is still there and working. Interestingly, if it's this simple, it should be possible to tell men in advance if they will leak or be dry after prostatectomy.


This is just my theory, because it fits what I know of the anatomy and the results seen after prostatectomy. However, it seems we simply don't know how this really works.

User
Posted 07 Jan 2020 at 19:58

I'm sweating at the thought of some of your experiences guys, Ouch!  Lets hope Mr L has a very experienced consultant.


Andy thanks so much for your explanation, it really makes sense.  I'd like to show it to hubby but might wait until after the procedure (14/2) he might run a mile if not!


I'm just wanting to know that it isn't anything sinister going on down there, with his pathology results and latest undetectable PSA reading it can't be can it?

User
Posted 07 Jan 2020 at 20:52

Had similar chrisJ


I had mine done privately and consultant was in a rush and pumped the local anaesthetic gel in then tried to go straight in. I made him wait a minute. Pity I didn’t know about the 15mins. Was ok once he was into the bladder...although I almost laughed when he was trying to get past my inflamed prostate and said “relax”. I don’t think he had been through the procedure. I’d do it again but isn’t on my bucket list. Quite amazed a fine fibre optic camera with monitor wasn’t  used...the electro-optic mechanical endoscope didn’t look very 21st century 🤷🏼‍♂️

Edited by member 07 Jan 2020 at 20:54  | Reason: Not specified

 
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