The visual image through a flexible fiberoptic laryngoscopy was reported first in 1954 [6]. Visual distraction plays a very important role in reducing the discomfort of the patient and has shown an overall better experience. Patients can watch their examination on the screen simultaneously while it is being performed. In our study, there was a statistically significant decrease in discomfort score in those that were visually distracted by a live video shown to them of the procedure in the outpatient setting and then the score was measured on the VAS scale which is quoted as a highly subjective method but still has a high sensitivity [15, 16].
Xiaolian et al. in their study have found that patients undergoing colonoscopy who were being distracted by visual and audiovisual stimuli had a better tolerance for the procedure [5]. Choudhury and Amer showed a significant reduction in pain perceived by audiovisual distraction during aural micro-suction [13].
Biggs showed that the discomfort scores significantly reduced in the visual distraction group with p = 0.04, while only the use of topical anesthesia did not show a significant reduction in discomfort scores with p > 0.05 when performing flexible laryngoscopy. However, the sample size of his study was very small (24 patients) which was further divided into four groups, so the very small sample size compromised the reliability of his study results [2]. In our study, the sample size was calculated keeping the power of study 90% and both groups were exposed to the same method of examination except for showing procedure video as a visual distractor.
Similarly, Marsdin showed that a group of patients who were distracted by viewing their own lithotripsy procedure had significantly lowered reported pain with the mean reduced from 6.1 to 2.4 (p < 0.0001) and distress score with the mean reduced from 4.4 to 1.0 (p = 0.0001) [3]. However, audiovisual distraction had no additional benefit in patient pain perception during nail surgery [14].
Koenig et al. in their observational prospective study investigated whether visualization aids in increasing patient comfort during urethrocystoscopy, and they have drawn the following conclusions that men who undergo flexible urethrocystoscopies should watch their procedure in real time on video along with the urologist [17]. Further efforts should be put into making urethrocystoscopy more comfortable for women, and lastly, real-time visualization alone is not sufficient enough to make the urethrocystoscopy less painful [17]. They have recommended to use music during urethrocystoscopy to help patients relax as found in the new observations made by Yeo et al. and Zhang et al. [17].
Another study of Patel in 2008, which was done on females, concluded that using the video monitor facilitates training and allows the patient to better understand disease conditions by visualizing endoscopic findings and appears beneficial in men from a pain standpoint but does not appear to offer decreased pain in women [18]. Further studies are needed to identify specific methods and factors that would make office cystoscopy more tolerable in women [18].
González-Padilla has shown that self-visualization in females could provide a benefit in the perception of pain during rigid cystoscopy as compared to males; however, these benefits were only shown in females with two or more previous cystoscopies [19].
Although our study design was a randomized control trial, there was an adequate sample size so a strong methodology. But a limitation of our study is that we sprayed local anesthetic nasal spray in both groups which may reduce the discomfort, that is why procedure discomfort scores were marked more leftward. However, this further opens the horizon for new studies of using visual distraction without local anesthesia.
