What is Cystoscopy
Cystoscopy is a diagnostic endoscopic procedure that provides direct visualization of the bladder mucosa, urethra, and ureteral orifices using either a rigid or flexible scope, and serves as the cornerstone diagnostic tool for detecting bladder cancer and evaluating other urological conditions. 1
Procedure Overview
Cystoscopy involves inserting a specialized endoscope through the urethra into the bladder to directly inspect the urinary tract. 2 The procedure can be performed using two main types of instruments:
Rigid vs. Flexible Cystoscopy
Flexible cystoscopy is now considered the standard approach for most diagnostic evaluations due to several key advantages over rigid cystoscopy: 1, 3
- Causes significantly less pain and discomfort during and after the procedure 1, 4
- Reduces post-procedure symptoms including dysuria and urinary retention 1
- Simplifies patient positioning and preparation - patients can be examined in supine or frog-leg position rather than requiring lithotomy positioning 2, 5
- Decreases procedure time 1
- Provides at least equivalent diagnostic accuracy to rigid cystoscopy, with sensitivity ranging from 87-100% 1
- Offers superior visualization of certain areas, particularly lesions at the anterior bladder neck 1, 3
Anesthesia Requirements
Initial diagnostic cystoscopy can be performed under local anesthesia in an office setting, making it accessible as an outpatient procedure. 1, 3 This represents a significant evolution from earlier practices when rigid cystoscopy required general anesthesia. 4
Primary Clinical Indications
Bladder Cancer Detection and Surveillance
Cystoscopy remains the gold standard for detecting bladder cancer, with diagnostic accuracy exceeding any other imaging test. 1 The procedure is essential because:
- Complete visualization of the entire bladder mucosa is necessary to exclude bladder cancer 1, 3
- High diagnostic performance with sensitivity of 87-100% and specificity of 64-100% for detecting bladder malignancies 1
- Patients with non-muscle-invasive bladder cancer require repeated surveillance cystoscopy (typically every 3 months initially) due to high recurrence rates 1, 4
Hematuria Evaluation
Cystoscopy is the standard diagnostic tool for evaluating both visible (macroscopic) and non-visible (microscopic) hematuria. 1 The American Urological Association recommends specific criteria:
- All adults over 40 years with microscopic hematuria should undergo cystoscopy 1, 3
- Patients under 40 years with risk factors for bladder cancer (tobacco use, occupational exposures, irritative voiding symptoms) should undergo cystoscopy 1, 3
- Low-risk patients (younger than 40 with no risk factors) may have initial cystoscopy deferred, but urinary cytology should still be performed 1, 3
Other Indications
Cystoscopy is routinely used for evaluating urinary dysfunction, placing ureteral stents, and assessing for bladder injury during gynecological procedures. 1, 5, 6
What Can Be Visualized
During cystoscopy, the urologist can directly inspect: 1, 3
- The entire bladder mucosa for tumors, inflammation, or other abnormalities
- The urethra along its entire length
- Both ureteral orifices to confirm patency
- Bladder trabeculation, diverticula, stones, or foreign bodies 6
- Benign conditions including interstitial cystitis, endometriosis, ureteroceles 6
- Malignant lesions ranging from low-grade papillary tumors to carcinoma in situ 6
Limitations and Complications
Procedural Risks
Cystoscopy is an invasive procedure with associated complications that patients should understand: 1, 3
- Urinary tract infections
- Hematuria (blood in urine)
- Dysuria (painful urination)
- Bladder perforation (rare)
- Scar tissue formation
- Urinary retention (more common in men with pre-existing urination problems)
Diagnostic Limitations
- Cannot evaluate extravesical tumor extension - requires cross-sectional imaging (CT or MRI) for staging 3
- Limited utility during active bleeding or when blood clots are present in the bladder 5
- Virtual cystoscopy techniques (CT or MRI cystography) have been explored but do not eliminate the need for conventional cystoscopy 1
Follow-Up Considerations
Patients with negative initial cystoscopy for asymptomatic hematuria still require follow-up because some will eventually develop significant urologic disease. 1 This is particularly important for: