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Anticipating Pain: Investigating Patients' Predictive Abilities during Cystoscopy
Andrew Harper Williams, MD, Thaise Uzeda, MD, Jaleta Ahmed, BS, Boris Gershman, MD, Eric Macdonald, MD, Benjamin Green, MD, Heidi Rayala, MD, PhD.
BIDMC, Boston, MA, USA.
BACKGROUND: Cystoscopy is essential for urologic diagnosis and surveillance, yet pain experiences vary substantially. While most patients report minimal discomfort, a subset experience significant pain that may hinder adherence to surveillance protocols. This study aimed to identify practical methods to pre-procedurally screen patients at risk for severe cystoscopy pain.
METHODS: This single-institution, prospective observational study enrolled 106 adults undergoing office flexible cystoscopy. Patients completed pre-procedural surveys including anticipated pain (Numeric Rating Scale, NRS), State-Trait Anxiety Inventory (STAI-6), Fear of Pain Questionnaire (FPQ-9), and demographics. Post-procedurally, patients reported experienced pain and urologists independently rated perceived pain. Severe pain was defined as NRS ≥7 per validated pain assessment frameworks. Spearman correlations and Firth penalized logistic regression assessed predictors of severe pain.
RESULTS: Severe pain occurred in 13% of patients. Patient-anticipated pain was the strongest predictor of actual pain (Spearman ρ=0.60, p<0.001), outperforming anxiety (STAI-6) and fear-of-pain instruments (FPQ-9). Patients who anticipated severe pain had significantly higher odds of experiencing severe pain (OR 29.75, 95% CI 5.77-153.52) with 72.7% experiencing it, compared to 6.3% of those anticipating non-severe pain having severe pain (p<0.001). Physicians underestimated patients' pain, particularly in the severe pain group (mean difference -3.0 points on a 10 point scale, p<0.001). Racial disparities were observed, with Black and Hispanic patients reporting higher rates of severe pain (50% and 50% compared to 8.9% of white and 10.2% of non-Hispanic patients (p<0.001).
CONCLUSIONS: A single pre-procedural question about anticipated pain accurately identifies patients at risk for severe cystoscopy pain, outperforming complex screening instruments. This simple, scalable approach enables targeted pain mitigation for high-risk patients without overtreating patients at low-risk of severe pain.
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