UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
CLINICAL POLICY AND PROCEDURE
TITLE: CYSTOSCOPY (Male)
Effective Date: January. 2005 Approval: See Authorization
Supersedes Protocol: None Contact: Clinical Staff Education
Reviewed November 2007 May 2009 March 2012
PURPOSE: To provide guidelines for the preparation and follow-up care for the male patient undergoing a
cystoscopy at UWMF Clinics.
DEFINITION: A cystoscopy is a direct visual examination of the lower urinary tract.
POLICY: The clinical staff will utilize the following guidelines to prepare a UWMF patient for a cystoscopy.
SUPPLIES: Provider’s order, Patient’s record, Mayo stand
Flexible cystoscope and stopcock, Cysto towel pack
1000 cc sterile water. irrigation set, IV pole
Penile clamp, 10cc Lidocaine urojet, betadine prep solution
Sterile pack with cotton balls, 3 x 3, Lubricating jelly
Non sterile gloves, 3 pairs sterile gloves, prescribed antibiotic (if ordered)
Consent form “Cystoscopy”
1. Verify provider order.
2. Wash hands and gather equipment.
3. Spike a 1000 cc sterile water bag and attach to irrigation set
4. Prime tubing with sterile water and hang set-up on IV pole.
5. Room patient using standard Urology Clinic procedure.
6. Identify patient, including date of birth. Explain procedure and purpose, answering any
7. Verify patient allergies, especially to Lidocaine, Betadine, antibiotics, and Latex.
8. Verify if patient has been off “blood thinners”, vitamins, or herbal medications for 7-10 days.
Exact list is per provider preference.
9. Following the provider’s discussion with patient, have patient sign Consent for Procedure and
sign consent form as a witness.
10. Give prophylactic antibiotic if ordered: (either PO or IM)
11. Assist or ask patient to lie on table in supine position.
NOTE: some providers may prefer dorsal lithotomy.
12. Wash hands and put on non-sterile gloves.
13. Open cotton ball packet and pour betadine onto cotton balls.
NOTE: If patient allergic to iodine, use 4% chlorhexidine gluconate solution for cleansing.
14. Clean entire penis, with betadine cotton balls, starting at the meatus of the penis and moving
15. Inject Lidocaine into urethra.
16. Gently apply and tighten the penile clamp on the penis behind the glans.
17. Remove non-sterile gloves and wash hands.
18. Put on sterile gloves.
19. Set up sterile field on Mayo stand.
Assemble scopes and place on stand
3 x 3 gauze
20. Drape patient with sterile drapes.
21. Attach stopcock tubing to sterile water tubing.
22. Drape tubing over patient.
23. Drape light cord over patient and turn on light source.
24. Place lubricating jelly on the 3 x 3 sterile gauze.
25. Remove sterile gloves and turn on small light.
1. Turn off overhead lights once physician has inserted scope
2. Don sterile gloves; provider preference.
3. Monitor patient for comfort and assist provider (as needed).
1. Assist patient to sitting position, offer bathroom and assist with dressing (if needed).
2. Clean scopes and clamp in Metrizyme solution.
3. Soak items in Metricide for 20 minutes.
4. Rinse items in sterile water tray and wrap in sterile towels.
5. Clean tray, counters and table with Dispatch
6. Empty and clean drain.
7. If ordered, administer prescribed antibiotic prophylaxis (if not before procedure).
8. Discharge instructions:
Patient may experience dysuria, frequency, or hematuria.
9. Documentation (in Progress Notes section of HealthLink) in the patient’s record:
the procedure performed, date & time completed
name and amount of any medications given (using SmartPhrase: .medinclinic)
how patient tolerated procedure
follow-up appointment (if any)
WRITTEN BY: Deb Brausen, R.N., Manager, Department of Urology
Tracy Ancheta R.N., Department of Urology
Leslie Calkins, R.N., Department of Urology
Donnette Deuser, R.N., Department of Urology
REVIEWED BY: Donnette Kelly, R.N., Department of Urology, 2012
Carol Decker, RN, MSN, Clinical Staff Educator, 2012
Department of Surgery, Urology Date
Medical Director Date