Patient-Reported Pain and Satisfaction During Flexible Cystoscopy in Supine Versus Lithotomy Positions in Adult Men:...

Supine flexible cystoscopy is already established in routine urological practice. However, real-world patient-reported pain across specific procedural stages and other patient-centered outcomes according to clinician-selected procedural position remain incompletely characterized. This study evaluated the associations of supine and lithotomy positioning with patient-reported and procedural outcomes in adult men undergoing flexible cystoscopy.

This multicenter retrospective observational study included 80 adult male patients who underwent flexible cystoscopy under local anesthesia. Procedural position was selected by the treating urologist according to clinical feasibility and routine clinical judgment, including the patient's ability to assume the lithotomy position. Patients were classified according to the position used during the procedure as supine (n = 40) or lithotomy (n = 40). Pain was assessed using a 0-10 Visual Analog Scale (VAS), with higher scores indicating greater pain. Patient satisfaction was assessed using a separate 0-10 scale. Secondary outcomes included procedure duration, procedural success, complication rates, and patient tolerance. Procedural tolerance and overall patient satisfaction were assessed immediately after cystoscopy using separate single-item 0-10 rating scales. For the satisfaction scale, 0 indicated "completely dissatisfied" and 10 indicated "completely satisfied". Group comparisons and an exploratory multivariable linear regression analysis of the primary pain outcome were performed.

A total of 80 patients were included (40 supine and 40 lithotomy). Mean VAS scores were lower in the supine group during cystoscope insertion (2.1 ± 1.0 vs. 3.4 ± 1.2; mean difference [MD]: -1.30, 95% CI: -1.79 to -0.81; p < 0.001), bladder evaluation (1.8 ± 0.9 vs. 2.6 ± 1.1; MD: -0.80, 95% CI: -1.25 to -0.35; p = 0.001), and immediately after the procedure (1.2 ± 0.7 vs. 2.0 ± 0.9; MD: -0.80, 95% CI: -1.16 to -0.44; p < 0.001). Procedure duration was 6.8 ± 2.1 versus 7.4 ± 2.3 min (MD: -0.60 min, 95% CI: -1.58 to 0.38; p = 0.186). Procedural success occurred in 97.5% versus 95.0% of patients (risk difference [RD]: 2.5 percentage points, 95% CI: -8.5 to 14.2; p = 1.000). In an exploratory post hoc subgroup of patients with documented difficult catheterization (n = 40; 20 patients per group), cystoscopy-guided catheterization was successful in 19/20 patients (95.0%) in the supine group and 13/20 patients (65.0%) in the lithotomy group (RD: 30.0 percentage points, 95% CI: 4.9 to 52.1; p = 0.044). This small, non-prespecified subgroup analysis was considered hypothesis-generating. Complications occurred in 4/40 patients (10.0%) in the supine group and 7/40 patients (17.5%) in the lithotomy group (RD: -7.5 percentage points, 95% CI: -23.2 to 8.2; two-sided Fisher's exact p = 0.518). Procedural tolerance (8.6 ± 1.1 vs. 7.2 ± 1.4; MD: 1.40, 95% CI: 0.84 to 1.96; p < 0.001) and overall satisfaction scores (8.8 ± 1.0 vs. 7.4 ± 1.3; MD: 1.40, 95% CI: 0.88 to 1.92; p < 0.001) were higher in the supine group. After adjustment for the available covariates, supine positioning remained associated with a lower insertion-related VAS score (β = -1.21, 95% CI: -1.75 to -0.67; p < 0.001).

In this retrospective, non-randomized cohort, clinician-selected supine positioning was associated with lower reported pain and higher procedural tolerance and satisfaction compared with lithotomy positioning. No statistically significant between-group differences were observed in overall procedural success or complication rates. Because position selection was clinician-directed and potentially influenced by patient mobility and other unmeasured factors, these findings do not demonstrate a causal benefit of supine positioning. They should be considered hypothesis-generating and require confirmation in adequately powered prospective randomized studies before informing changes in routine clinical practice.