In many low- and middle-resource settings, unsedated colonoscopy remains widely practiced due to limited access to anesthetic support, cost constraints, and overloaded endoscopy units. Although safe and feasible, the procedure is often perceived as uncomfortable and anxiety-provoking, which may reduce patient adherence to surveillance programs. Virtual reality (VR) has emerged as a simple, low-cost, and scalable non-pharmacological tool that may enhance patient experience during endoscopic procedures. The aim of our study is to assess whether VR distraction can improve comfort, reduce pain and anxiety, and increase patient satisfaction during unsedated colonoscopy.

Adult patients undergoing elective unsedated colonoscopy at our department , were invited to participate. Participants were randomized either to receive VR immersion during the procedure or to standard care. A low-cost VR headset displaying 20-minute immersive tropical landscape sequences with low-volume audio was used. Exclusion criteria included cognitive impairment, visual/hearing deficits, balance disorders, epilepsy, or limited language abilities.Outcomes were evaluated at four time points using validated tools: Anxiety: State-Trait Anxiety Inventory (STAI), pre/post - Pain: Numeric Rating Scale (NRS) - Comfort: Gloucester 5-point scale- Satisfaction: Net Promoter Score (NPS) and willingness-to-return Procedural metrics included cecal intubation rate, cecal intubation time, and total procedure duration.

Of 40 invited patients, 32 consented; 24 were analyzed (VR: n=12; control: n=12). Baseline characteristics were similar between groups.

Technical success: 100% cecal intubation in both groups.

Cecal intubation time: shorter in the VR group (median 12 min vs 15 min), although not statistically significant.

Pain: lower expression in VR patients, without significant difference.

Comfort: higher in the VR group, with 64% reporting good comfort vs 42% in controls.

Anxiety: significantly reduced after the procedure in VR patients compared with controls.

Satisfaction: higher with VR (NPS 85.7% vs 50%).No VR-related adverse events occurred, and all VR participants completed the procedure wearing the headset and rated the experience as positive.

In a real-world setting where unsedated colonoscopy remains common due to resource limitations, VR proves to be a safe, inexpensive, and highly acceptable tool to improve patient comfort and reduce anxiety. While this pilot experience does not compromise procedural performance, it offers an innovative, scalable strategy to enhance patient experience and could support broader adoption of unsedated colonoscopy in similar healthcare systems. Larger studies are warranted to confirm these findings.