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When her patient insisted on receiving Botox bladder injections in the operating room (OR), Anne Pelletier Cameron, MD, asked her why. The patient acknowledged her last time receiving the injections at a different practice had been negative.

She explained that six people had been in the room with her. A few were men and one was a representative from the Botox provider.

“No one talked to her,” said Cameron, the James Montie legacy professor of urology at the University of Michigan Medical School, Ann Arbor, Michigan. “She remembers [the experience] being very painful because she was scared to death. It was almost like a sexual trauma.”

Unfortunately, urology care can be inherently uncomfortable for female patients. Pain and fear of pain can hinder women from accessing the care they need for urinary incontinence or other urological problems.

But the medical field is starting to notice and address this issue. Recently, the American College of Obstetricians and Gynecologists (ACOG) introduced guidance on pain management for in-office gynecologic procedures. Central to their recommendations is providing comprehensive pain management counseling so patients are aware of their options and can choose for themselves.

“As urologists, we are working in the same vicinity [of the body], and it is really important to acknowledge and help manage patient pain,” said Cameron. Here’s how.

Reducing Physical Discomfort

“Doing the minimum number of invasive things to get your diagnosis is key,” said Felicia Lane, MD, a board-certified urogynecologist at UCI Health. In fact, a randomized controlled trial published this year found that urodynamics testing — which is invasive and often uncomfortable — is no more effective than a questionnaire, physical exam, bladder diary, and cough test in assessing female stress urinary incontinence.

This was an extension of a trial whose results were published in 2009, said Lane. That trial found “no value in urodynamics” for patients with stress urinary incontinence, she said. “We have moved to doing less invasive testing to diagnose our patients with these conditions.”

If possible, avoid routine catheterization, said Raveen Syan, MD, urologist and assistant professor of clinical urology, University of Miami Health System. Women have complained to her about urologists putting in a catheter during their first appointment. “This is unnecessary and uncomfortable, and patients are bothered. They remember, and don’t come back,” she said.

Pelvic exams can also be problematic. “No one likes a pelvic exam,” said Syan, who “tries to spare patients.” When possible, she conducts them while her patients are under anesthesia for another procedure, like a biopsy or cyst removal.

Syan teaches her trainees to use a small speculum and to lock it only when swabbing or conducting a cervical biopsy. “If it’s just an assessment of the pelvic floor, locking [the speculum] is unnecessary.”

For pain mitigation during cystoscopies, Syan uses a flexible rather than a rigid camera. When it comes to video urodynamics procedures, she places the catheter into the vagina, not the rectum. “Some urologists don’t realize they can do this, since with men, they need to place it in the rectum,” she said.

She starts with a low bladder fill rate of 30 mL/min because “a patient with an overactive bladder can have spasms and not tolerate the procedure,” she said.

With treatments, try to prioritize painless approaches. Lane often recommends vaginal estrogen cream for frequent urinary tract infections and pelvic floor physical therapy for urinary stress or urgency incontinence.

For Botox injections in the bladder, “there is growing evidence five to 10 injection points can be as effective as the traditional template of 12-15 injection points,” said Syan, referencing a recent literature search she co-authored. “I cut down my injection points to five with 100 units or 10 with 200 units.”

Be generous with lubricants and pain relievers, like lidocaine jelly. Allow several minutes for lidocaine to take effect before performing a procedure, like a pessary insertion, catheterization, or Botox injections.

What you should not do is minimize pain. “The least effective instruction you can give someone is to ‘just relax,’” said Cameron. “Don’t tell them it won’t hurt — and then hurt them. Say ‘this will feel like a strong pinch’ or ‘like a burn and a poke.’”

Easing Emotional Discomfort

Try to assuage any possible shame or embarrassment about the urologic condition. Syan tells patients that about 16% of all women and 30% of women in their 60s experience urinary continence. “It is common and not shameful,” she said.

“As the provider, my job is to put someone at ease” Cameron said. “If they need to hold the nurse’s hand, let’s make that happen. If they want their partner, let’s bring them in. Meet patients where they are. And if you can’t help them through a procedure, you can bring them to the OR.”

Then walk them through procedures, said Cameron. The procedure will go better if the patient is at ease and knows what to expect, like how long it will last, she said.

Distraction in the form of what Cameron calls “verbal anesthesia” can also help. “If you are calm enough to have a conversation while doing a procedure, patients will know you have got this,” she said. “I usually have a conversational talking point while I am doing a procedure, like if someone has beautiful earrings I will ask about them. By the time the patient has answered my questions, they are done.”

As the ACOG guidance emphasizes, offering patients agency is critical. For instance, with video urodynamics procedures, Syan informs her patients a third person (the x-ray technician) will be in the room. Since this can cause discomfort, Syan offers them the option of skipping the video component.

Above all, treat patients with respect and try to read their cues. Make sure they are draped, maintain eye contact, and tune in to their body language, said Lane. “When a patient rolls their toes, I can tell they are uncomfortable and I will ask if they need a break.”

Apply the Golden Rule 

When treating female urology patients, “it’s critical to listen to your patients,” said Lane. “Listening allows you to establish a relationship and really understand what provokes their embarrassment and anxiety.” Then try to put yourself in their shoes, offer them options, and prioritize less invasive, effective approaches.

Cameron had no conflicts of interest; Lane is a researcher/consultant for Axonics, Inc; Syan is a board member of the Interstitial Cystitis Association, site primary investigator for Axonics MOAB study, and board member for Sumitomo.

Dina Cheney is a health and lifestyle writer, who has contributed to publications including The New York Times, The Washington Post, The Los Angeles Times, Prevention, Health, Men’s Health, Good Housekeeping, and Medscape.