4 Figure 3: Probe with electrodes deployed delivering treatment. Figure 4: Probe with markings. and rest within the submucosa. Energy is delivered for a 60-second cycle while sterile room temperature water simultaneously irrigates the mucosa to prevent thermal injury. The submucosa immediately surrounding the four tips is heated and maintained at 65 degrees Celsius for a minimum of 30 seconds. The electrodes are withdrawn, and the probe shaft is repositioned after the ﬁrst treatment cycle, ﬁrst 30 degrees to the right, and then 30 degrees to the left of midline for cycles 2 and 3, respectively. Markings to guide such rotation are in the form of longitudinal lines on the probe shaft (Figure 4). The bladder neck receives a total of 12 discrete foci of denaturation. To treat the proximal urethra, the same steps are carried out; however, traction is placed on the probe prior to Obstetrics and Gynecology International deployment of the electrodes. Three cycles of energy are delivered to the proximal urethra followed by another 3 cycles just distal to the initial site, achieved with a slightly greater degree of traction. Thus, the proximal urethra receives a total of 24 foci of denaturation. 7. Clinical Recommendations for Ofﬁce-Based Lower Urinary Tract Anesthesia The safe and eﬀective administration of topical and local anesthesia must be fully considered, as it is essential for the successful completion of Renessa in the oﬃce. Wells and Lenihan reported on the feasibility of in-oﬃce anesthesia in patients undergoing transurethral radiofrequency treat- ment, employing preprocedure diazepam with a bilateral periurethral block using a total of 10 cc of 2% lidocaine [24]. Thirty-three women completed a visual analog scale (0 = no pain, 10 = terrible pain) immediately prior to discharge. Overall, 42% of patients rated their pain as 0, with a mean pain score of 1.4 ± 1.8. The following is a summary of the anesthetic regimen we currently employ. 7.1. Preprocedure Oral Regimen. The patient is instructed to take an anxiolytic such as diazepam 5–10 mg and a nonsteroidal such as ibuprofen 800 mg about 30–60 minutes before the procedure. 7.2. Periurethral and Bladder Neck Topical Anesthesia. The introitus is prepared with povidone iodine. A 6-inch catheter is placed, and the bladder is drained. A negative urine dip is conﬁrmed. Five cc of 2% xylocaine jelly is then infused into the catheter as it is withdrawn. EMLA cream is placed on a cotton swab and inserted transurethrally to rest at the bladder neck. The resting urethral angle with swab in place is determined by a goniometer to direct the orientation of the Renessa probe during treatment. A small aliquot of EMLA cream is also applied adjacent to the urethral meatus at 3 and 9 o’clock in preparation for injection of local anesthesia at these sites. Experience with the safety and eﬃcacy of EMLA on the labia has been previously demonstrated [25]. 7.3. Periurethral and Bladder Neck Injection Anesthesia. After 10 minutes, a periurethral block is performed with a total of 10 cc of 1% xylocaine using a 22 gauge, 1 1/4” needle introduced at the previously anesthetized 3 and 9 o’clock sites. The needle is buried to the hub (to ensure anesthesia of the bladder neck) along the urethral axis as determined by the cotton swab present within the urethra. It should be noted that the proximal urethra and bladder neck are well vascularized, circumscribed by a pampiniform plexus of veins. It is therefore essential that prior to injecting xylocaine, one aspirates the syringe to reduce the possibility of intravascular injection. Anesthetic is infused at each site in two aliquots −3 cc at the bladder neck followed by 1/2 cm withdrawal, aspiration and reinjection of the remaining 2 cc’s. If additional anesthesia is required during treatment,