Virtual reality reduces pain during rigid cystoscopies

The use of virtual reality technology can reduce the pain that patients feel during uncomfortable medical procedures, according to research presented at the Annual European Association of Urology Congress.

Researchers at Wroclaw Medical University in Poland compared patients who were using or not using VR headsets during rigid cystoscopies, where a rigid telescope is inserted through the urethra into the bladder.

Bladder cancer diagnosis and treatment usually require a cystoscopy, which can be unpleasant and painful, the researchers said. Some patients avoid follow-up treatment and suffer uncontrolled and irreversible development of the disease as a result.

Flexible cystoscopies are less painful, but some treatments only can be performed via a rigid cystoscopy. Rigid cystoscopy may be performed under local anesthesia, the researchers said, as well as under general and spinal anesthetics.

“The risk of anesthesia during cystoscopy does not differ from its risk during other procedures,” researcher Wojciech Krajewski, MD, PhD, told Healio.

Krajewski also said that the risk of local anesthesia, which comprises intraurethral injection of lidocaine, is negligible, including some allergic reactions in susceptible patients.

Still, the researchers said, these complications are possible.

VR has been shown to be an effective tool for pain relief in some medical fields, the researchers said, such as when dressings are changed for burn patients. Patients tend to be upright and the VR experience interactive during these applications.

The researchers at Wrocaw Medical University recruited 103 patients (74 males, 29 females; mean age, 66 years) who were undergoing rigid cystoscopy with just local, intraurethral anesthesia. Some patients were receiving a first diagnosis, and others were receiving follow-up treatment after having experienced it before.

Patients were randomly assigned to undergo classic cystoscopy or the procedure with VR goggles and headphones. Those with VR headsets were presented a static image of the Skógafoss waterfall in Iceland, along with audio of the wind blowing, water flowing, and birds singing.

Wojciech Krajewski

“The idea was to isolate the patients from the sound of the OR, staff chat, machinery beeps, instruments tapping and knocking — the sounds that are frightening for the patients,” Krajewski said.

The researchers asked patients about their level of fear. During the cystoscopy, the researchers additionally measured BP, oxygen saturation and heart rate in patients. They measured pain using the FLACC score, which stands for Face, Legs, Activity, Cry and Consolability. The test is typically used in children but was adjusted for adults in this study.

After the procedure, patients were asked to rate their pain perception and nausea related to the cystoscopy.

The VR group reported lower pain scores than the control group (P = .049). Use of the VR headset was associated with a higher intensity of nausea (P = .001), the researchers said, but patients found it bearable, and no procedures had to stop as a result.

All patients saw increases in BP and heart rate, but the increases were statistically lower in the VR group. Oxygen saturation remained stable, although the researchers noted that these measurements are less reliable because masks were introduced during the trial when the COVID-19 pandemic began. 

The findings were the same for men and women, as well as for first and follow-up cystoscopies. The researchers said they believe the technology could be used for other uncomfortable or painful procedures.

The researchers said they were eager to develop techniques to help patients feel more comfortable. They had observed younger patients use interactive VR technology and thought they could come up with calming imagery that was more appropriate for older patients. 

“We have chosen this particular scenery from many available based only on our subjective perception that this one is the calmest and most relaxing one,” Krajewski said.

Noting that VR is an option for pain reduction in cystoscopies, the researchers said they are exploring whether it will have the same effect in other medical interventions, such as lithotripsy to break down kidney stones or prostate biopsy.

“Improving patients’ experience of the care they receive is as important as improving treatment outcomes,” James N’Dow, chair of the European Association of Urology Guidelines Office, said in a press release.

N’Dow noted that general anesthesia should be avoided whenever possible. Also, he said, telescopic bladder examinations under a local anesthetic still can be very uncomfortable and even frightening.

“This study increases our understanding of how virtual reality can distract patients and reduce their anxiety and pain,” N’Dow said. “What’s needed now is a larger trial, which would also do a cost-benefit analysis, to determine whether this approach should be considered as part of standard clinical practice.”

Reference:

Krajewski W, et al. Abstract AM21-1049. Presented at: European Association of Urology Annual Congress; July 8-12, 2021 (virtual meeting).