From the Guidelines
A cystoscopy is likely not necessary for this patient with resolved left flank pain and overactive bladder symptoms, unless there are specific concerning features present. The patient's symptoms of occasional dysuria, urgency, and frequency of urination, as well as stress and urge incontinence, are consistent with overactive bladder (OAB) [ 1 ]. The resolution of flank pain suggests that any potential upper urinary tract issue has resolved. According to the AUA/SUFU guideline on the diagnosis and treatment of idiopathic overactive bladder, initial management should focus on conservative treatments for OAB, including behavioral modifications and first-line pharmacotherapy [ 1 ].
The patient's past medical history of nephrolithiasis and current symptoms do not necessarily warrant a cystoscopy, especially since the renal sonogram revealed normal size kidneys, no hydronephrosis, and no calculi [ 1 ]. However, cystoscopy would be indicated if the patient has risk factors for bladder cancer (smoking history, occupational chemical exposure), persistent microscopic or gross hematuria, recurrent urinary tract infections, or if symptoms fail to improve with appropriate medical therapy after 4-6 weeks [ 1 ].
The European Association of Urology guidelines office systematic review on the diagnostic accuracy of cystoscopy for detecting bladder cancer in adults presenting with haematuria suggests that cystoscopy outperforms imaging modalities in detecting bladder cancer, but it also highlights the potential complications and limitations of cystoscopy [ 1 ]. The updates to microhematuria: AUA/SUFU guideline (2025) also emphasize the importance of considering the patient's risk category and the potential benefits and harms of cystoscopy [ 1 ].
In this case, since the patient does not have any specific concerning features, such as risk factors for bladder cancer or persistent hematuria, a cystoscopy is not recommended at this time. Instead, the patient should be managed conservatively with behavioral modifications and pharmacotherapy, and monitored for any changes in symptoms or development of concerning features [ 1 ].
From the Research
Patient Assessment
The patient is a 68-year-old female with resolved left flank pain and overactive bladder symptoms, including dysuria, frequency, urgency, and stress and urge incontinence. She has a history of nephrolithiasis and has undergone lithotripsy.
Cystoscopy Considerations
- The patient's symptoms have improved, and the renal sonogram revealed no evidence of obstruction or calculi.
- The study by 2 found that cystoscopy can cause de-novo overactive bladder symptoms, but it also noted a decline in OAB symptoms after cystoscopy in patients who were screened OAB-positive before the procedure.
- Another study by 3 highlighted the value of cystoscopy in detecting potential lower urinary tract injuries during major vaginal surgery.
- However, the patient's current symptoms and history do not necessarily indicate a need for cystoscopy, as she has already undergone a renal sonogram and pelvic sonogram, and the results are pending.
Indications for Cystoscopy
- Cystoscopy may be considered if the patient's symptoms persist or worsen, or if the results of the pelvic sonogram reveal any abnormalities.
- The study by 4 demonstrated the successful removal of an intrauterine contraceptive device embedded in the urinary bladder wall using cystoscopy, but this is not relevant to the patient's current condition.
- The study by 5 suggested that antibiotics may not be necessary before outpatient cystoscopy, but this does not directly address the question of whether cystoscopy is necessary for this patient.
- The study by 6 found that routine surveillance cystoscopy may not be necessary for patients with augmentation and substitution cystoplasty for benign urological conditions, but this is not applicable to the patient's situation.
Decision
- Based on the patient's current symptoms and history, cystoscopy may not be necessary at this time.
- The patient's symptoms have improved, and the results of the renal sonogram and pelvic sonogram are pending.
- However, if the patient's symptoms persist or worsen, or if the results of the pelvic sonogram reveal any abnormalities, cystoscopy may be considered.