UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
CLINICAL POLICY AND PROCEDURE
Effective Date: January. 2005 Approval: See Authorization
Supersedes Protocol: None Contact: Clinical Staff Education
Reviewed November 2007 April 2010 March 2012
PURPOSE: To provide guidelines for the preparation and follow-up of patients undergoing a cystoscopy and
retrograde pyelogram at UWMF Clinics.
DEFINITION: A cystoscopy and retrograde pyelogram is a direct visual examination of the bladder and
medical imaging of the upper urinary tract.
POLICY: The clinical staff will utilize the following guidelines to prepare a patient for a cystoscopy
SUPPLIES: Provider’s order, Patient’s record
Cysto towel pack, 2 sets sterile gloves, non-sterile gloves
Rigid scopes 30 and 70 degree lenses / 110 degree lens MD preference
21Fr sheath and obturator, tubing with valve for water hook up
1000cc sterile water bag for irrigation with tubing attached
Lidocaine urojet 2% - 10ml for males - 5ml for females
Cotton ball pack, Penile clamp for males, Cotton swab for females, betadine
Sterile cup for urine collection for females, 10cc syringe
Wrapped sterile urine cup, 50ml contrast- omnipaque
Light source on stand, attached to table in retro room
Ureteral catheter - 8Fr cone tip- may vary with MD
Plastic ureteral catheter adaptor for syringe
Lead shield/apron/thyroid shield/glasses Use varies with MD.
Single use female urethral catheter for collection of sterile urine specimen- varies with MD.
2 x-ray cassette covers for lead shield (If using)
Consent form for Cystoscopy, Retrogrades
1. Verify provider order.
2. Room patient using standard Urology Clinic procedure.
3. Identify patient, including date of birth. Explain procedure and answer remaining questions.
4. Verify allergies, specifically to betadine, lidocaine, antibiotics and contrast.
NOTE: If allergic, should have been pre-medicated with benadryl and prednisone per UW Health Radiology
5. Ensure that patient has been off all blood thinners: aspirin, Coumadin, etc, along with vitamins and herbal
medications. (Per provider’s preference).
6. Following the provider’s discussion with patient, have patient sign Consent for Procedure and sign
consent form as a witness.
7. Assist or ask patient to change into gown, and pull privacy curtain across door.
8. Any IM prophylactic antibiotics are administered at this time, per MD orders.
9. Place patient into lithotomy position.
10. Cover lead shield with 2 x-ray cassette covers.
11. Wash hands and gather equipment in retrograde room.
12. Spike a 1000 cc sterile water bag and attach to irrigation set.
13. Prime tubing with sterile water and hang set-up on IV pole.
14. Create a sterile field on Mayo Stand.
15. Open scopes, cotton ball pack, (swab or penile clamp), syringe, urethral catheter
adaptor, sterile cup and place everything on sterile field.
16. Pour omnipaque into sterile cup on sterile field.
17. Using non-sterile gloves prep labia/penis with betadine solution on sterile cotton balls.
Clean entire penis, starting at the meatus moving down glans.
Clean labial folds and meatus from top to bottom
Use sterile gloves if obtaining catheterized urine prior to lidocaine injection on women
18. Using urojet (10ml male, 5ml female), squirt a small amount of Lidocaine onto
meatus, then insert urojet tip gently into the urethra and inject the remaining
Lidocaine into the urethra.
Note: Urine specimens collected after lidocaine instillation may not be suitable for all testing; ie. Urine
19. On male patients, gently tighten the penile clamp on the penis behind the glans,
20. On female patients, insert the cotton swab into the meatus.
21. Discard non-sterile gloves and wash hands.
22. Notify radiology that the patient is ready.
23. Put on sterile gloves and drape patient with sterile towels from cysto towel pack.
24. Assemble scopes if you have not already done so.
25. Fill sterile 10cc syringe with 10cc contrast using catheter adaptor.
26. Expel air bubbles.
27. Close valve for water hook up and attach to sterile water tubing.
28. Open adjustable clamp on long sterile water tubing.
29. Drape water tubing over leg.
30. Wipe cord from light source with alcohol and drape over leg.
31. Lubricant on table
32. Turn on light switch.
33. Radiology tech will adjust patient position and take a KUB.
34. After KUB, hang plastic covered shield from x-ray equipment over the patient’s abdomen.
35. Raise table.
36. Notify provider.
NOTE: If previous contrast study, have 15min film available.
Provider will use sterile gloves, and some/all of protective lead devices.
37. Catch sterile urine when provider inserts scope if not already collected in step 15
NOTE: possible only on female patients.
38. Turn down lights.
39. Open ureteral catheter of provider’s choice.
NOTE: Keep sterile.
Provider will take and attach syringe.
40. Move flaps of shield, if using, off abdomen, and onto patient’s thighs, clearing
the abdomen for x-rays.
NOTE: Provider will need lead glasses at this time, (if applicable).
41. Stand behind protective wall during x-rays.
NOTE: Radiology Tech will take films/develop films.
42. Do not remove patient from table until directed to do so by provider.
43. When directed, assist patient to sitting position, assist with dressing (if needed) and offer patient the chance to
44. Provide prophylactic antibiotic (usually oral if ordered by provider) post procedure.
45. Dispose of linens.
46. Clean scopes in Metrizyme.
47. Soak in Metricide for 20 minutes.
48. Rinse in sterile water and wrap in sterile towels.
49. Disinfect table and tray with Dispatch.
50. Assist patient with follow-up appointment (if needed)
51. Discharge instructions:
May experience some dysuria, frequency, or hematuria.
52. 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
Leslie Calkins, R.N., Department of Urology
Donnette Deuser, R.N., Department of Urology
Gail Jahnke, R.N., N.P., 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