What are the indications and guidelines for performing cystourethroscopy (cystoscopy of the urethra and bladder)?

Cystourethroscopy: Indications and Guidelines

Primary Indications for Cystourethroscopy

Cystourethroscopy should be performed when specific clinical findings suggest urethral or bladder pathology, not as a routine screening tool. The most compelling indications are hematuria, recurrent urinary tract infections, suspected anatomic abnormalities, and intraoperative verification of urinary tract integrity 1.

Definitive Indications

Hematuria (Gross or Microscopic)

• Any patient with painless gross hematuria requires cystoscopy along with upper tract imaging 1
• In bladder cancer evaluation, cystoscopy is mandatory for diagnosis and should include thorough examination documenting tumor size, location, configuration, number, and mucosal abnormalities 1
• Patients with indwelling catheters or performing clean intermittent catheterization (CIC) who develop hematuria require cystoscopic investigation to differentiate between benign catheter trauma and serious pathology 1

Recurrent Urinary Tract Infections

• Cystoscopy should be performed in neurogenic lower urinary tract dysfunction (NLUTD) patients with recurrent UTIs to identify anatomic causes such as stones, strictures, or false passages 1
• In men with profound lower urinary tract symptoms or recurrent UTI, cystoscopy has a diagnostic yield of approximately 11-19% for clinically relevant abnormalities 2

Suspected Anatomic Abnormalities

• Urethral strictures or false passages (particularly in patients with history of urethritis, urethral injury, or difficult catheter passage) 1
• Bladder stones 1
• Suspected bladder neck contracture or urethral lesions 1
• History of prior lower urinary tract surgery, especially transurethral resection of prostate (TURP) 1

Intraoperative Verification

• Prior to surgical intervention for stress urinary incontinence, cystourethroscopy should be performed to assess for urethral and bladder pathology that may affect surgical outcomes 1
• During gynecologic procedures to rule out cystotomy, intravesical/intraurethral suture or mesh placement, and verify bilateral ureteral patency 3, 4
• During emergency laparotomy when bladder or urethral injury is suspected, direct inspection with possible use of methylene blue or indigo carmine is indicated 1

When NOT to Perform Cystoscopy

Routine Screening is Not Recommended

• Clinicians should NOT perform routine cystoscopy in the initial evaluation of NLUTD patients without specific indications 1
• Surveillance cystoscopy for bladder cancer screening in spinal cord injury patients is not supported by evidence, as cystoscopy and cytology are poor screening tests in this population 1
• Cystoscopy should not be used solely to determine "need for treatment" in benign prostatic hyperplasia (BPH) evaluation 1
• In patients investigated solely for pain without other findings, cystoscopy has zero diagnostic yield and is not recommended 2

Special Populations and Considerations

Neurogenic Lower Urinary Tract Dysfunction

• In NLUTD patients with positive cytology but normal cystoscopy, consider enhanced cystoscopic techniques (blue light cystoscopy when available), prostatic urethral biopsies, or random bladder biopsies 1
• Patients at risk for autonomic dysreflexia MUST be hemodynamically monitored during cystoscopy, with pharmacotherapy readily available 1
• If autonomic dysreflexia develops during cystoscopy, immediately terminate the procedure, drain the bladder, and continue monitoring 1
• Flexible cystoscopy can be performed safely in wheelchair-bound patients and causes minimal stimulation leading to autonomic dysreflexia 5

Trauma Evaluation

• In urethral trauma, retrograde urethrography and selective urethroscopy are the diagnostic modalities of choice 1
• For penile lesions, urethroscopy should be preferred over retrograde urethrography 1
• Patients with post-traumatic urethral hemorrhage should be investigated for urethral injuries 1

Benign Prostatic Hyperplasia

• Urethrocystoscopy is optional (not routine) in men choosing invasive therapies, particularly when prostate anatomy may impact treatment selection 1
• May be appropriate in men with history of urethral stricture, prior TURP, or microscopic/gross hematuria 1
• The endoscopic appearance does not predict response to BPH therapy but may guide choice of surgical intervention 1

Technical Considerations

Flexible vs. Rigid Cystoscopy

• Flexible cystoscopy can be performed under topical anesthesia with less patient discomfort than rigid cystoscopy 6
• Particularly useful for outpatient surveillance of bladder cancer and in patients with positioning difficulties 5, 6
• Can be performed in supine or wheelchair-seated positions 5

Common Pitfalls to Avoid

• Do not skip cystoscopy in hematuria workup: Even in catheterized patients, urinary tract irritation cannot be determined without cystoscopic investigation 1
• Do not perform cystoscopy before addressing hemodynamic instability: In trauma patients, stabilization takes priority 1
• Do not delay angioembolization for cystography: In pelvic bleeding amenable to angioembolization with suspected bladder injury, cystography should be postponed until after angiography to avoid impairing accuracy 1
• Do not assume catheter trauma: Hematuria with catheterization may indicate strictures or false passages requiring cystoscopic diagnosis and potential treatment modification 1