Policies for the Commissioning of Healthcare

Cystoscopy for Lower Urinary Tract Symptoms (LUTS) in Males Policy

  Introduction 
  This document is part of a suite of policies that the CCG uses to drive its commissioning of healthcare. Each policy in that suite is a separate public document in its own right, but will be applied with reference to other policies in that suite.
   
1.  Policy
1.1 The CCG will commission cystoscopy in adult males when a thorough history and examination, complemented by assessments and contextual information such as smoking and occupational history, as detailed in Section 2.4, is undertaken and one or more of the following features are present:
  a) Recurrent infection
  b) Sterile pyuria
  c) Haematuria
  d) Profound symptoms
  e) Plain
1.2 In addition, it may be reasonable to undertake flexible cystoscopy before undertaking some urological surgical interventions.
   
  OR
   

 

Exceptionality has been demonstrated in accordance with Section 8 below.
   
2. Scope and definitions
   
2.1 This policy is based on the CCGs Statement of Principles for Commissioning of Healthcare (version in force on the date on which this policy is adopted).
   
2.2

Cystoscopy is a diagnostic procedure used to examine the lining of the bladder and urethra. Either a rigid or flexible endoscope may be used, under general or local anaesthesia, respectively. Rigid cystoscopy is undertaken when flexible cystoscopy offers insufficiently clear views, or when biopsy is indicated. 

Cystoscopy can cause temporary discomfort, occasionally pain and haematuria (blood in the urine) and is associated with a small risk of infection. In the context of male lower urinary tract symptoms (LUTS), cystoscopy may offer indirect evidence regarding an underlying cause (commonly prostatic enlargement, for example).

   
2.3

The CCG recognises that a patient may have certain features, such as

a)    having lower urinary tract symptoms;

b)    wishing to have a service provided for lower urinary tract symptoms;

c)    being advised that they are clinically suitable for investigation of lower urinary tract symptoms, and

d)    being distressed by lower urinary tract symptoms, and by the fact that that they may not meet the criteria specified in this commissioning policy. 

Such features place the patient within the group to whom this policy applies and do not make them exceptions to it.
   
2.4

Assessment of men with LUTS should focus initially on a thorough history and examination, complemented by use of a frequency – volume chart, urine dipstick analysis and International Prostate Symptom Score where appropriate. This assessment may be initiated in primary care settings.

Specialist assessment should also incorporate a measurement of flow rate and post void residual volume.

Additional contextual information may also inform clinical decision-making around the use of cystoscopy in men with LUTS. Such factors might include, but not be limited to:

— Smoking history

— Travel or occupational history suggesting a high risk of malignancy

— Previous surgery.

Other adjunct investigations may become necessary in specific circumstances and are dealt with in NICE guideline CG97.

   
2.5

In the context of male lower urinary tract symptoms (LUTS), cystoscopy may offer indirect evidence regarding an underlying cause (commonly prostatic enlargement, for example). However, no evidence was discovered in preparing NICE guideline CG97 to suggest any benefit, in terms of outcome, related to performing cystoscopy in men with uncomplicated LUTS (i.e. LUTS with no clinical evidence of underlying bladder pathology). The consensus opinion of the NICE guideline development group therefore aligned with the position that unless likely to uncover other pathology, cystoscopy should not be performed in men presenting with LUTS.

The European Association of Urology guideline on the management of nonneurogenic male LUTS summarises evidence demonstrating a lack of clear correlation between findings on cystoscopy and findings on investigations into bladder function (urodynamic assessment).

   
3 Appropiate Healthcare
   
3.1 The purpose of cystoscopy for lower urinary tract symptoms is normally to investigate those symptoms.
   
3.2 The CCG regards the achievement of this purpose as according with the Principle of Appropriateness. Therefore, this policy does not rely on the principle of appropriateness. Nevertheless, if a patient is considered exceptional in relation to the principles on which the policy does rely, the CCG may consider the principle of appropriateness in the particular circumstances of the patient in question when considering an application to provide funding.
   
4 Effective Healthcare
   
4.1 The policy criteria are based on the Principle of Effectiveness as outlined in the national Evidence-Based Interventions List 2 Guidance1, NICE guidance CG 972 and the various studies as listed in the Section 10 (References).
   
5 Cost effectiveness
   
5.1 The CCG considers that an intervention cannot be cost-effective if it not effective, and therefore this policy is also based on the Principle of Cost Effectiveness.
   
6 Ethics
   
6.1 The CCG does not call into question the ethics of cystoscopy for lower urinary tract symptoms and therefore this policy does not rely on the Principle of Ethics.   Nevertheless if a patient is considered exceptional in relation to the principles on which the policy does rely, the CCG may consider whether the treatment is likely to raise ethical concerns in this patient when considering an application to provide funding.
   
7 Affordability
   
7.1 The CCG does not call into question the affordability of cystoscopy for lower urinary tract symptoms and therefore this policy does not rely on the Principle of Affordability.  Nevertheless if a patient is considered exceptional in relation to the principles on which the policy does rely, the CCG may consider whether the treatment is likely to be affordable in this patient when considering an application to provide funding.
   
8 Exceptions
   
8.1 The CCG will consider exceptions to this policy in accordance with the Policy for Considering Applications for Exceptionality to Commissioning Policies.
   
9 Force
   
9.1 This policy remains in force until it is superseded by a revised policy or by mandatory NICE guidance relating to this intervention, or to alternative treatments for the same condition.
   
9.2

In the event of NICE guidance referenced in this policy being superseded by new NICE guidance, then:

  • If the new NICE guidance has mandatory status, then that NICE guidance will supersede this policy with effect from the date on which it becomes mandatory.
  • If the new NICE guidance does not have mandatory status, then the CCG will aspire to review and update this policy accordingly. However, until the CCG adopts a revised policy, this policy will remain in force and any references in it to NICE guidance will remain valid as far as the decisions of this CCG are concerned.
   
10 References
 

1.Evidence-Based Interventions List 2 Guidance.  Academy of Medical Royal Colleges, published November 2020. https://www.aomrc.org.uk/wp-content/uploads/2020/12/EBI_list2_guidance_150321.pdf.

2.NICE clinical guideline 97. Lower urinary tract symptoms in men:

Management.  Last updated June 2015 https://www.nice.org.uk/guidance/cg97.

3. European Association of Urology guideline on the management of

non-neurogenic male LUTS: https://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/.

4. Shoukry, I., et al. Role of uroflowmetry in the assessment of lower urinary

tract obstruction in adult males. Br J Urol, 1975. 47: 559: https://pubmed.ncbi.nlm.nih.gov/1191927/

5. Anikwe, R.M. Correlations between clinical findings and urinary flow rate in

benign prostatic hypertrophy. Int Surg, 1976. 61: 39: https://pubmed.ncbi.nlm.nih.gov/61184/.

6. el Din, K.E., et al. The correlation between bladder outlet obstruction and

lower urinary tract symptoms as measured by the international prostate

symptom score. J Urol, 1996. 156: 1020: https://pubmed.ncbi.nlm.nih.gov/8583551/.
   

 

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