Following cystoscopic procedures and urethral catheterization, patients usually have a degree of urethral discomfort ranging from a burning sensation with the desire to micturate to severe agony and distress about the indwelling catheter. Discomfort can be extremely disabling on arrival in the recovery room and can cause the nurse to spend an inordinate amount of time with these patients. This discomfort can be explained by bladder-induced irritation  with manifestations of overactive bladder. It has been reported to be relieved with pretreatment with oral antimuscarinic drugs  or intravenous analgesics with subsidiary antimuscarinic properties such as ketamine . We hypothesized that transurethral endoscopy or catheterization or both shear the urethral mucosa and induce a degree of inflammation, leading to varying degrees of discomfort. We believe that application of topical steroid may allay the urethral discomfort through its soothing and anti-inflammatory effects. This was tested in a controlled randomized observer-blinded study in patients undergoing urethral catheterization following transurethral endoscopic procedures under general anaesthesia. The outcome measures were recovery parameters and the degree of urethral discomfort.
After obtaining approval of the local ethics committee and consent of the patients, adult patients undergoing elective transurethral endoscopic procedures for suspected bladder disease were enrolled into the study. A pilot study was initially conducted to observe manifestations of discomfort in 85 patients, including 56 men and 29 women, undergoing transurethral endoscopy and catheterization. Moderate-to-severe discomfort was encountered in 26 men (46%) and four women (14%). These results demonstrate that urethral discomfort following transurethral endoscopy and catheterization is mainly a male complaint. Consequently, female patients were excluded from the study.
Patients were premedicated with oral diazepam (10 mg) 2 h before the procedure. Anaesthesia was induced with intravenous injection of fentanyl (1.5 μg kg−1) followed by propofol (2.0 mg kg−1) to facilitate insertion of the laryngeal mask airway. Anaesthesia was maintained during spontaneous breathing with isoflurane in a mixture of oxygen and nitrous oxide, with an FiO2 of 0.4.
A computer-generated randomization table was used to randomly allocate adult male patients to either the control group without application of topical cream or the study group with topical steroid cream applied to the whole urethra at the end of the procedure. The steroid cream, Dermatop (Aventis Pharma, Global Napi Pharmaceuticals, Cairo, Egypt) (5 g = 12.5 mg prednicarbate), was applied by the endoscopist with a special applicator. The endoscopist ensured distribution of the cream to the whole length of the urethra and clamped the glans for 2 min before insertion of the urethral catheter. In both groups, a Foley's catheter of size 18 Fr lubricated with KY jelly was used and fixed without traction. Its balloon was inflated with 20 ml of water. An observer, blinded to patient group assignment and unaware of the treatment, was present at the end of the anaesthesia and escorted the patient to the recovery room. Emergence was recorded in the form of behavioural responses such as flailing limbs, strong vocal response or attempts to pull the catheter out. The degree of discomfort was assessed according to Agarwal et al.  as: first, no discomfort when the patient is comfortable and not reporting any discomfort even after nonleading interrogation; second, mild discomfort with the patient comfortable but complaining about the catheter after nonleading interrogation; third, moderate discomfort when the patient reported discomfort from the catheter without questioning but this was not accompanied by behavioural responses; and, fourth, severe discomfort reported by the patient accompanied by behavioural responses. Rescue treatment was initiated in patients with moderate-to-severe discomfort with ketorolac (30 mg intravenous) then fentanyl (50 μg intravenous) bolus 10 min later when deemed necessary. Discharge criteria from the recovery room were stable vital signs and absence of urethral discomfort in a fully conscious patient, the study end point.
On the basis of the pilot study, we assumed that the application of topical steroid cream to the urethra would decrease the incidence of discomfort from 46 to 20%. A total of 42 patients in each group were needed to provide a power of 0.8 with α error 0.05 and β error 0.2. Statistical analysis was carried out using SPSS version 10.0 (SPSS Inc., Chicago, Illinois, USA). Parametric data were analysed by Student's t-test, whereas nonparametric variables were analysed using the Fisher's exact test. A P value of less than 0.05 was considered significant.
Two patients were excluded from the control group: one patient underwent meatotomy and dilatation and the other patient had bladder perforation that was discovered in the recovery room. Two patients were excluded from the study group: one patient underwent internal urethrotomy for stricture urethra and the second patient underwent bladder neck incision. Forty patients in each group were subjected to statistical analysis. Patients in the steroid group had a better quality of emergence, less discomfort, fewer analgesic requirements and shorter recovery room stay than the control group (Table 1). The incidence of discomfort in the control and steroid groups was 60 and 15%, respectively, with a relative risk reduction of 0.75, absolute risk reduction of 0.45 and a number needed to treat of 2.3, that is, two to three patients need to be treated with topical steroids in order to prevent one patient from having discomfort.
The female urethra (4 cm) is shorter than the male urethra (20 cm). The female urethra, 6 mm in diameter, is much more readily dilatable than the male urethra because it is rich in elastic and collagen fibres . These anatomical differences between the male and female urethra may explain the high incidence of discomfort in men undergoing transurethral manoeuvres.
Gabapentin was used in the treatment of catheter-related discomfort . Gabapentin was able to ameliorate this discomfort probably because of its peripheral anti-inflammatory effects . These effects may partially support our hypothesis about the urethral origin of catheter-related discomfort. From the embryological and anatomical standpoint, the urethral plate is a continuation of the trigone of the urinary bladder . Therefore, urethral irritation may induce bladder irritation through trigonal stimulation. Transurethral manoeuvres may lead to discomfort through many mechanisms, namely, sheared mucosa and foreign body irritation. In the present study, urethral application of prednicarbate relieved discomfort and improved patient recovery. Prednicarbate is a nonhalogenated prednisolone double ester with potent anti-inflammatory effects that inhibits interleukin (IL)-1 and IL-6 . The application of topical steroids was successfully used to reduce sore throat, cough and hoarseness after tracheal intubation . These effects on the tracheal mucosa may, in some ways, mimic the effects of catheter-induced urethral irritation.
In conclusion, discomfort following cystoscopy and catheterization is mainly a male complaint. Topical steroid cream (prednicarbate) applied to the urethra for 2 min can effectively reduce this discomfort and improve the quality of emergence from anaesthesia.
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