When should cystoscopy (visual examination of the bladder using a cystoscope) be performed?

When Cystoscopy Should Be Performed

Cystoscopy should be performed in all adults over age 40 with microscopic hematuria, in patients under 40 with bladder cancer risk factors (smoking, occupational exposures), and in any patient with gross hematuria regardless of age. 1, 2

Primary Indications for Cystoscopy

Age-Based Criteria

• All patients over 40 years old with asymptomatic microscopic hematuria require cystoscopy as part of initial evaluation 3, 1
• Patients under 40 years old should undergo cystoscopy if they have risk factors for bladder cancer, including:
  • Current or former tobacco use 1, 4
  • Occupational chemical exposures 3, 1
  • History of pelvic radiation 5
• Research confirms no bladder cancers were detected in patients under age 50 in one large series, though guideline thresholds remain at age 40 5, 6

Hematuria Type

• Gross (macroscopic) hematuria mandates cystoscopy in all patients regardless of age 1
• Microscopic hematuria requires cystoscopy when meeting age or risk factor criteria above 3, 1
• Patients with ≥5 RBCs/HPF on urinalysis have higher likelihood of significant pathology and should undergo cystoscopy 7

Special Circumstances

• Patients on anticoagulation therapy with microhematuria should still undergo cystoscopy 4
• Even when upper tract imaging reveals a potentially benign source for bleeding (such as kidney stones), cystoscopy is still indicated to exclude concurrent bladder pathology 3

When Cystoscopy May Be Deferred

Low-risk patients (men and women under 40 years without risk factors for bladder cancer) may have initial cystoscopy deferred, but urinary cytology should still be performed 3, 2

Patients with fewer than 5 RBCs/HPF on three separate urinalyses are unlikely to have significant pathology and could potentially be followed conservatively 7

Critical Timing Considerations

Cystoscopy should be performed directly without waiting for cytology results in patients meeting evaluation criteria 1. This is a critical pitfall to avoid—do not delay urologist referral to obtain cytology results, as urine cytology and tumor markers lack sufficient predictive value to replace cystoscopy in initial evaluation 1.

The American Urological Association explicitly states that cytology should not be used as a screening tool to determine who needs cystoscopy 1.

Procedure Selection

Flexible cystoscopy is preferred over rigid cystoscopy for initial diagnostic evaluation because it:

• Causes less pain and discomfort 3, 2
• Has fewer post-procedure symptoms 3, 2
• Provides at least equivalent diagnostic accuracy (sensitivity 87-100%, specificity 64-100%) 2
• Offers superior visualization of anterior bladder neck lesions 3, 2
• Can be performed under local anesthesia 3

Follow-Up Cystoscopy

Some patients with negative initial evaluation for asymptomatic microhematuria eventually develop significant urologic disease, making follow-up particularly important in high-risk groups (patients over 40 years, tobacco users, those with occupational exposures) 3, 2. For patients with persistent hematuria after negative initial workup, repeat cystoscopy may be warranted 2.

Contraindications

Cystoscopy should not be performed in:

• Healthy patients with completely normal urinalysis 4
• Patients with stress urinary incontinence unless there is specific concern for urinary tract abnormalities 4