Effects of pre-procedural video education and intra-procedural virtual reality on anxiety and pain during flexible cystoscopy: a randomized controlled trial

BACKGROUND: This study aimed to investigate the effects of pre-procedural video education and intra-procedural distraction using virtual reality (VR) nature videos on patient anxiety and pain perception during office-based flexible cystoscopy. METHODS: In this single-center, four-arm, parallel-group randomized controlled trial, 240 adult patients scheduled for flexible cystoscopy were enrolled. Participants were randomized into four groups: Video + VR- (n = 60), Video + VR + (n = 60), Video- VR + (n = 60), and Video- VR- (control, n = 60). Anxiety was assessed using the Spielberger State-Trait Anxiety Inventory (STAI), and pain was measured with a visual analog scale (VAS). Intergroup comparisons were performed using nonparametric tests, and outcome assessors were blinded to group allocation. RESULTS: Pain scores differed significantly among groups (H = 44.604, p < 0.001). The lowest pain scores were observed in the Video + VR + group (4.3 ± 1.1), while the highest were in the control group (5.7 ± 1.1). Reductions in STAI-S (state anxiety) scores also showed significant group differences (H = 28.311, p < 0.001). Compared with the control group, the Video + VR + group demonstrated significant improvements in both VAS (p < 0.001, r = 0.610) and STAI-S reduction (p < 0.001, r = -0.493), with large effect sizes. Analyses based on baseline STAI-T (trait anxiety) scores indicated that the interventions were effective regardless of initial anxiety levels, with the combined Video + VR + approach consistently providing the greatest benefit. CONCLUSION: The combination of pre-procedural video education and intra-procedural VR distraction was associated with the greatest reduction in pain and anxiety during flexible cystoscopy. These findings support the potential value of multimodal approaches for improving patient comfort during urologic procedures. TRIAL REGISTRATION: Registered on 05 September 2025 in the ISRCTN registry (ISRCTN22513446).