Cystoscopy for Evaluation of Frequent UTIs
Cystoscopy should NOT be routinely performed in women younger than 40 years with recurrent UTIs who have no risk factors, but should be considered in specific high-risk situations including neurogenic bladder dysfunction, hematuria, suspected anatomic abnormalities, or when non-invasive evaluation is unremarkable. 1
General Population: Routine Cystoscopy Not Recommended
The 2024 European Association of Urology guidelines explicitly recommend against performing extensive routine workup including cystoscopy in women younger than 40 years with recurrent UTI and no risk factors (weak recommendation). 1 This reflects the consistently low yield of significant findings in otherwise healthy women with simple recurrent UTIs.
Evidence Supporting Limited Use
Research demonstrates that only 8% of women undergoing cystoscopy for recurrent UTIs have significant abnormalities detected, with most findings occurring in women over 50 years of age. 2
Historical studies show cystoscopy occasionally yields helpful information but abnormalities rarely influence management in otherwise healthy women. 3, 4
A systematic review found that less than 1.5% of women investigated for recurrent simple UTIs with imaging or flexible cystoscopy had life-threatening pathology. 5
When Cystoscopy IS Indicated
Neurogenic Lower Urinary Tract Dysfunction (NLUTD)
In patients with neurogenic bladder and recurrent UTIs, cystoscopy should be performed as part of comprehensive evaluation of both upper and lower urinary tracts (moderate recommendation). 1 The AUA/SUFU guidelines emphasize that since the risks of lower urinary tract evaluation via cystoscopy are low, it is a necessary part of the evaluation of recurrent UTIs in this population. 1
Specific Clinical Scenarios Requiring Cystoscopy
Cystoscopy should be performed in the following situations:
Hematuria: Any patient with painless gross hematuria requires both upper tract imaging and cystoscopy, as this cannot be attributed to catheter trauma without cystoscopic investigation. 1
Suspected anatomic anomalies: Including urethral strictures, false passages from catheter trauma, bladder diverticula, or fistulas. 1
Difficult catheterization: Patients with difficult urethral catheter passage or hematuria with catheterization may have urethral strictures or false passages requiring cystoscopic diagnosis. 1
Known structural abnormalities: The American College of Radiology recommends cystoscopy in females with recurrent complicated UTIs and known structural abnormalities like ureteroceles, allowing direct visualization and identification of potential obstruction. 6
Imaging as First-Line Investigation
For complicated recurrent UTIs, CT urography (CTU) is the primary recommended imaging test, providing detailed anatomic depiction of the entire urinary tract. 6 This should be performed before considering cystoscopy in most cases.
Risk Factors Warranting Investigation
Investigation (imaging first, then cystoscopy if indicated) should be considered when patients have:
- Unexplained hematuria 4
- Obstructive symptoms 4
- Neurogenic bladder dysfunction 4
- Renal calculi 4
- Severe diabetes mellitus 4
- Bacteriologic evidence of rapid recurrence suggesting bacterial persistence 4
- Nonresponse to conventional therapy 6
- Frequent reinfections or relapses (particularly within 2 weeks of treatment) 6
Common Pitfalls to Avoid
Do not perform cystoscopy as a first-line investigation in young, otherwise healthy women with simple recurrent UTIs. 1 The yield is extremely low and does not justify the procedure.
Do not assume normal imaging excludes all pathology. While imaging has a 99% negative predictive value for significant abnormalities, cystoscopy may still occasionally reveal findings not detected on imaging. 2
Recognize that younger women (under 40-50 years) are significantly less likely to have pathology requiring cystoscopic diagnosis. 2 Age should factor into the decision to perform cystoscopy.
Practical Algorithm
Initial evaluation: Confirm recurrent UTIs with urine culture (≥3 UTIs/year or 2 UTIs in 6 months). 1
Risk stratification: Assess for risk factors including age >40-50 years, neurogenic bladder, hematuria, obstructive symptoms, or anatomic abnormalities. 4, 2
If no risk factors and age <40 years: Do NOT perform cystoscopy; focus on non-antimicrobial preventive measures. 1
If risk factors present: Consider CT urography first for comprehensive anatomic evaluation. 6
Perform cystoscopy if: Hematuria, suspected anatomic abnormality, neurogenic bladder with recurrent UTIs, or unremarkable upper tract evaluation in high-risk patients. 1, 6