What is a cystoscopy?

What is a Cystoscopy

Cystoscopy is a diagnostic procedure that uses a thin, flexible or rigid tube with a camera (cystoscope) inserted through the urethra to directly visualize the inside of the bladder, urethra, and ureteral orifices. 1, 2

Procedure Overview

Cystoscopy provides complete visualization of the bladder mucosa, urethra, and ureteral orifices, making it the cornerstone diagnostic tool for evaluating the urinary tract. 1, 2 The procedure has evolved significantly over time—from rigid cystoscopy requiring general anesthesia to flexible cystoscopy performed as an outpatient procedure using only local anesthesia. 1

Types of Cystoscopy

Flexible cystoscopy is now considered the standard approach for most diagnostic evaluations. 3 Compared to rigid cystoscopy, flexible cystoscopy offers several distinct advantages:

• Less pain and discomfort during and after the procedure 1, 2
• Fewer post-procedure symptoms 1, 2
• Simplified patient positioning and preparation 1, 2
• Reduced procedure time 1, 2
• At least equivalent diagnostic accuracy to rigid cystoscopy 1, 2
• Superior visualization of certain lesions, particularly those at the anterior bladder neck 1, 2

Rigid cystoscopy may still be used in specific clinical scenarios, though it causes greater patient discomfort. 3, 4

Primary Clinical Indications

The most common reasons for performing cystoscopy include:

• Evaluation of hematuria (blood in urine)—either visible or microscopic 1, 2
• Diagnosis and surveillance of bladder cancer—cystoscopy is the gold standard for detecting bladder malignancies 1, 2
• Follow-up of patients with previous bladder cancer, who require repeated cystoscopy (typically every three months) due to high recurrence rates 3

Specific Recommendations for Hematuria

For adults over 40 years of age with microscopic hematuria, cystoscopy is recommended as part of the initial evaluation. 1, 2 For patients under 40 years, cystoscopy is indicated if risk factors for bladder cancer are present (such as smoking, occupational exposures, or persistent hematuria). 1, 2 In low-risk patients younger than 40 with no risk factors, initial cystoscopy may be deferred, but urinary cytology should still be performed. 1, 2

Diagnostic Accuracy

Cystoscopy demonstrates very high diagnostic accuracy for bladder cancer detection:

• Sensitivity: 87% to 100% 1, 2
• Specificity: 64% to 100% 1, 2
• Positive predictive value: 79% to 98% 1
• Negative predictive value: 98% to 100% 1

Cystoscopy exceeds the diagnostic value of any other imaging test for bladder cancer detection. 1

Potential Complications

While generally well-tolerated, cystoscopy is an invasive procedure with potential complications:

• Urinary tract infections 1, 2
• Hematuria (blood in urine) 1, 2, 4
• Dysuria (painful urination) 1, 2, 4
• Bladder perforation (rare) 1, 2
• Scar tissue formation 1, 2
• Urinary retention—more common in men with pre-existing urination problems 1, 2
• Transient impairment of sexual performance and libido 4

The overall complication rate is approximately 15%, with most complications being mild. 4 Complications are more frequent in patients with benign prostatic hyperplasia (24% vs. 9.7%). 4

Practical Considerations

• Initial diagnostic cystoscopy can be performed under local anesthesia 1, 2
• The procedure can be done in an office setting with minimal preparation 5, 6
• Patient positioning is simplified with flexible instruments—supine for males, frog-leg supine for females 5
• Pre-procedure anxiety levels are generally low (average 2.01 on a 0-5 scale), and pain during examination averages 1.41 on the same scale 4

Follow-Up Considerations

For patients with a negative initial evaluation for asymptomatic microhematuria, some form of follow-up is indicated, as some patients may eventually develop significant urologic disease. 1, 2 This is especially important in high-risk groups, including patients older than 40 years and those with tobacco use or occupational exposures. 1