Doctor Answers: What is a Cystoscopy and What to Expect?

The urinary tract plays a vital role in eliminating toxins and excess fluids from the body. Urine, collected from the kidneys, accumulates in the bladder and exits the body through the urethra. When any part of the urinary tract isn’t functioning properly, it can lead to lower urinary symptoms, infections, or even serious bladder conditions.

In certain cases, symptoms may become severe enough to warrant diagnostic procedures like a cystoscopy. We spoke with Doctor Ambardjieva, an experienced urologist, to discuss what cystoscopy involves, when it’s needed, how it’s performed, and what patients should expect. 

Throughout this article, Doctor Ambardjieva provides evidence-based insights and clinical observations. The information here has been reviewed to ensure medical accuracy and completeness.

Q: What is a Cystoscopy?

Doctor Ambardjieva answers: A cystoscopy is a medical procedure where we examine the inside of the bladder and urethra. The main goal is to get a direct visual assessment of these areas to check for problems.

Historically, cystoscopy evolved from early devices like the Lichtleiter in 1806, where mirrors and candles were used to inspect body cavities. Thankfully, technology has come a long way since then.

Today, we use a cystoscope, a thin, hollow tube with a lens at the tip. There are two main types: flexible cystoscopes and rigid cystoscopes. The choice depends on the patient’s condition and the reason for the procedure.

The cystoscope is inserted through the urethra. A numbing jelly, containing a local anesthetic, is usually applied to make the procedure more comfortable. Some cases require general anesthesia, particularly if a rigid cystoscopy is being performed in a hospital setting.

Q: What is a Cystoscopy Used For?

Doctor Ambardjieva answers: We recommend a cystoscopy to diagnose various urinary tract issues. If a patient presents with symptoms like blood in the urine, an overactive bladder, urinary incontinence, or pain during urination, a cystoscopy helps us get a clearer picture.

Beyond symptoms, it’s also used to investigate frequent urinary tract infections and diagnose conditions like:

• Bladder cancer
• Cystitis (bladder inflammation)
• Bladder stones
• Bladder tumors
• Interstitial cystitis
• Leucoplakia

In men, cystoscopy can reveal prostate problems, such as an enlarged prostate causing urethral narrowing.

Cystoscopy isn’t only diagnostic. It’s also therapeutic. We can use instruments passed through the hollow cystoscope to remove small bladder tumors during the same procedure. Sometimes, we also perform a ureterorenoscopy alongside cystoscopy to inspect the ureters, the tubes that carry urine from the kidneys.

Q: What are the Risks of a Cystoscopy?

Doctor Ambardjieva answers: While cystoscopy is generally safe, there are some risks to be aware of.

The most common risks include:

• Bleeding: It’s normal to see a small amount of blood in the urine after the procedure, but heavy bleeding is rare.
  
• Infection: Introducing instruments into the urinary tract can allow bacteria to enter, leading to urinary tract infections. 
• Pain: Some patients experience abdominal discomfort or a burning sensation while urinating afterward, but this usually fades within a few days.

The type of cystoscopy (rigid or flexible) and the patient’s overall health can influence the risk level.

Q: What Are the Signs of Serious Complications After a Cystoscopy?

Doctor Ambardjieva answers: It’s important for patients to recognize when they should contact their doctor urgently. Serious complications are rare, but signs to watch for include:

• Inability to urinate after the procedure (could signal a blockage)
  
• Severe abdominal pain, especially with nausea
  
• High fever and chills
  
• Persistent burning during urination for more than two days post-procedure
  
• Bright red blood or blood clots in the urine
  
• Recurrent urinary tract infections after the procedure

If any of these occur, patients should not delay contacting their urologist or healthcare provider.

Q: How Should You Prepare for a Cystoscopy?

Doctor Ambardjieva answers: Preparation for cystoscopy is usually simple, but there are important steps to follow.

First, I always encourage patients to ask questions in advance. Depending on individual risk factors, I may prescribe antibiotics before the procedure to minimize the chance of infection; this is called prophylaxis.

If antibiotics are prescribed, it’s critical to take them exactly as directed.

Other key points include:

• Patients might be asked to provide a urine sample before the procedure, so they should avoid emptying their bladder too soon. The urine sample should be sent to microbiology.
  
• If sedation or general anesthesia is planned, patients must arrange for someone to drive them home afterward.

Clear communication with the doctor beforehand is crucial to avoid any surprises.

Q: What Happens During a Cystoscopy?

Doctor Ambardjieva answers: The cystoscopy itself typically takes about 15 to 30 minutes. In most cases, it’s done right in the office.

Here’s how the process usually goes:

1. Patients first empty their bladder.
   
2. They lie down on a flat table, in lithotomy position (with knees bent).
   
3. If sedation or anesthesia is needed, it’s administered at this point.
   
4. The cystoscope is gently inserted through the urethra into the bladder.
   
5. A sterile solution is infused to expand the bladder, providing a clearer view.
   
6. I carefully inspect the bladder walls and urethra using a monitor.

If needed, I can also take small tissue samples (biopsies) during the procedure.

Q: What Happens After a Cystoscopy?

Doctor Ambardjieva answers: What happens afterward depends on the type of anesthesia used.

• If sedation was used: The patient will usually need someone to drive them home and may need to rest for the day.
• If only local anesthesia was used: Many patients can return to normal activities shortly after the procedure.

Some discomfort, like mild burning during urination or spotting, is common but temporary.

Applying a warm cloth to the urethra or taking a warm bath can help soothe any irritation. I always advise patients to drink plenty of fluids afterward to help flush the bladder.

Key FAQs on Cystoscopy Purpose

Q: Can a cystoscopy detect early-stage bladder cancer even without symptoms?

Doctor Ambardjieva answers: Yes, a cystoscopy can detect early-stage bladder cancer, even in patients without symptoms. This procedure allows direct visualization of the bladder lining, enabling identification of small or flat lesions (such as carcinoma in situ) that may not be picked up by imaging or urine cytology alone.

Key Points:

• Cystoscopy is the gold standard for bladder cancer detection.

• It can identify asymptomatic tumors, especially in high-risk individuals (e.g., those with hematuria, smoking history, occupational exposures).
• Flat lesions or early tumors may be missed on imaging but seen during cystoscopy.

Limitations:

• It is an invasive procedure.
• Small lesions can occasionally be overlooked, especially without enhanced imaging (e.g., blue light cystoscopy or narrow band imaging).
• So, while cystoscopy is highly effective, combining it with urine-based markers or cytology may improve sensitivity for early detection in asymptomatic patients.

Q: Is cystoscopy more accurate than ultrasound for diagnosing bladder problems?

Doctor Ambardjieva answers: Yes, as research shows, cystoscopy is considerably more accurate than ultrasound when it comes to diagnosing most bladder conditions, particularly bladder tumors, mucosal abnormalities, and early-stage bladder cancer.

While ultrasound is a useful, non-invasive imaging tool that can detect large bladder masses or significant wall thickening, it has limitations. Small tumors, especially flat lesions like carcinoma in situ, can easily be missed. In contrast, cystoscopy allows direct visualization of the bladder’s interior using a thin scope inserted through the urethra, making it the most precise method for identifying even subtle abnormalities.

Cystoscopy not only detects small and flat tumors but also enables immediate tissue sampling or tumor removal during the same procedure. Its high sensitivity makes it the preferred choice for evaluating unexplained blood in the urine, persistent urinary symptoms, or monitoring patients with a history of bladder cancer.

Ultrasound, on the other hand, plays a valuable role in initial screening, particularly in low-risk patients, children, or when evaluating residual urine volume or bladder wall changes. However, it does not offer the same level of detail or diagnostic certainty as cystoscopy.

In summary, cystoscopy is the gold standard for accurately diagnosing bladder problems. While ultrasound is helpful in many scenarios, it should not be relied upon alone when there is a clinical suspicion of serious bladder pathology.

Q: Can a cystoscopy detect urethral strictures that aren’t visible on imaging?

Doctor Ambardjieva answers: Yes — cystoscopy is a highly effective tool for detecting urethral strictures, even in cases where imaging studies fail to identify them. While imaging methods such as ultrasound, CT scans, or retrograde urethrography are often used to assess the urinary tract, they can occasionally miss short, subtle, or complex strictures, particularly in the anterior urethra.

Cystoscopy involves inserting a thin, flexible or rigid scope through the urethra to directly visualize the entire urethral lining. This enables the clinician to clearly identify any areas of narrowing, assess the severity and length of a stricture, and examine the condition of the surrounding mucosa. Even minor or partial strictures that do not cause significant obstruction on imaging can be readily seen during cystoscopy.

This makes cystoscopy especially valuable in cases where patients continue to experience symptoms, such as a weak urinary stream, straining, or incomplete bladder emptying, despite having normal imaging results. It is also frequently used when catheterization is difficult, or as a follow-up tool after urethral dilation or reconstructive surgery.

In summary, cystoscopy remains the most direct and reliable method for diagnosing urethral strictures, especially when imaging results are inconclusive. Its ability to provide real-time, detailed information about the urethral anatomy makes it indispensable in the evaluation of lower urinary tract symptoms.

Q: Can cystoscopy findings change the course of treatment for chronic urinary tract infections?

Doctor Ambardjieva answers: Yes,  according to the research, cystoscopy can significantly influence the course of treatment in patients with chronic or recurrent urinary tract infections (UTIs) by uncovering underlying anatomical or structural abnormalities that are not evident through standard urine tests or imaging.

While most UTIs are managed based on symptoms and urine cultures, patients with frequent recurrences or persistent symptoms often require further evaluation. Cystoscopy offers direct visualization of the bladder and urethra, allowing urologists to detect conditions such as:

• Bladder stones or foreign bodies
• Diverticula or anatomical deformities
• Chronic inflammation or suspicious lesions
• Interstitial cystitis or bladder pain syndrome
• Tumors or early-stage malignancies
• Urethral strictures or incomplete bladder emptying

Identifying these issues can lead to targeted treatment strategies, such as surgical correction, removal of irritants, or biopsy of abnormal areas. For instance, a patient with chronic UTIs due to a bladder stone or residual urine from a stricture may benefit from a surgical procedure rather than continued antibiotics alone.

In summary, cystoscopy is a valuable tool in the diagnostic workup of chronic UTIs. By revealing hidden causes of recurrent infection, it allows for a more individualized and effective treatment plan, often shifting the focus from symptom management to definitive resolution of the underlying problem

Q: Are there advancements in cystoscopy technology that make diagnosis faster or safer?

Doctor Ambardjieva answers​​: In recent years, significant advancements in cystoscopy technology have transformed this essential urological procedure into a faster, safer, and more accurate diagnostic tool. These innovations are particularly impactful in the detection and management of bladder cancer, chronic urinary conditions, and structural abnormalities of the lower urinary tract.

One of the most notable improvements is the development of flexible cystoscopes. Unlike traditional rigid instruments, flexible cystoscopes are thinner, more comfortable, and can often be used in outpatient settings without the need for anesthesia. This not only reduces patient discomfort but also shortens procedure time and recovery.

Another major leap forward is the integration of high-definition (HD) imaging. Modern cystoscopes are equipped with advanced digital optics that provide clearer, more detailed views of the bladder lining. This enhancement helps clinicians detect smaller lesions or subtle mucosal changes that may go unnoticed with standard imaging.

Blue light cystoscopy, also known as photodynamic diagnosis, is another breakthrough. By using a special dye that causes abnormal cells to fluoresce under blue light, this technique significantly improves the detection of flat or early-stage bladder tumors, including carcinoma in situ. As a result, blue light cystoscopy can lead to earlier diagnosis and more effective treatment planning.

Similarly, narrow band imaging (NBI) has been introduced to enhance visualization of blood vessels and bladder wall structures. Without the use of dyes or contrast agents, NBI improves the identification of abnormal tissue patterns and supports more accurate differentiation between healthy and diseased areas.

In terms of safety and convenience, single-use (disposable) cystoscopes are becoming increasingly popular. These sterile, ready-to-use devices eliminate the need for reprocessing and reduce the risk of cross-contamination between patients. They are especially useful in high-turnover clinics or emergency settings.

Taken together, these advancements have elevated cystoscopy from a purely diagnostic tool to a highly sophisticated and patient-friendly procedure. They not only improve the accuracy of diagnosis but also enhance the overall experience for patients and streamline workflows for healthcare providers.

In summary, modern cystoscopy is faster, more comfortable, and more effective than ever before, thanks to cutting-edge technologies that continue to improve outcomes in urologic care.

Q: How do biopsy results from cystoscopy help confirm a bladder cancer diagnosis?

Doctor Ambardjieva answers: When bladder cancer is suspected, cystoscopy is the first-line procedure used to visually inspect the inside of the bladder. However, while cystoscopy can reveal suspicious lesions, such as raised, red, or ulcerated areas, it cannot alone confirm whether those lesions are cancerous. This is where biopsy comes in.

During cystoscopy, if any abnormal tissue is observed, the urologist may take a biopsy, a small sample of tissue from the bladder wall, or perform a transurethral resection of bladder tumor (TURBT). This tissue is then sent to a pathology laboratory, where it is examined under a microscope by a pathologist.

The biopsy results provide a definitive diagnosis by revealing whether cancer cells are present and, if so, what type of cancer is involved, most commonly urothelial carcinoma. In addition to confirming the diagnosis, the biopsy determines the grade of the tumor, indicating how aggressive or abnormal the cells appear. It also assesses the depth of invasion, showing whether the cancer is confined to the inner bladder lining or has penetrated deeper into the muscle layers.

This information is essential for staging the cancer and planning treatment. For example, low-grade, non-invasive tumors may be managed with local therapies and regular monitoring, while high-grade or muscle-invasive tumors may require more aggressive approaches, such as surgery or chemotherapy.

In short, biopsy results from cystoscopy are crucial in confirming bladder cancer, identifying the cancer’s characteristics, and guiding the best course of treatment. Without a biopsy, decisions about care would be uncertain and potentially less effective.

Q: Is cystoscopy recommended for patients with unexplained hematuria even if imaging tests are normal?

Doctor Ambardjieva answers: Yes, cystoscopy is recommended for patients with unexplained hematuria, even when imaging results are normal, especially in adults over the age of 35 or those with risk factors for urinary tract malignancies.

Hematuria, or blood in the urine, can be a sign of a wide range of conditions, from benign causes like urinary tract infections or kidney stones to more serious issues such as bladder or upper urinary tract cancers. Imaging studies like ultrasound or CT scans are useful for detecting kidney and ureteral abnormalities, but they may miss subtle or flat bladder lesions, including carcinoma in situ.

Cystoscopy allows direct visualization of the bladder and urethral lining and is the only method capable of identifying certain mucosal abnormalities, small tumors, and areas of chronic inflammation that may not be visible on imaging. It also enables immediate biopsy or further evaluation if suspicious findings are noted.

In clinical practice, cystoscopy is considered an essential part of the hematuria workup when:

• Hematuria is persistent or recurrent
• No source of bleeding is identified through imaging
• The patient is in a high-risk group (e.g., smokers, men over 50, exposure to industrial chemicals)

In summary, even when imaging appears normal, cystoscopy remains a key diagnostic tool for uncovering underlying causes of hematuria and ensuring that potentially serious conditions are not overlooked.

Conclusion

Cystoscopy is a straightforward yet powerful tool for diagnosing and treating urinary tract conditions. While it can cause some short-term discomfort, it gives us critical insights into what’s happening inside the bladder and urethra.

Knowing what to expect before, during, and after the procedure helps patients feel more comfortable and confident when undergoing a cystoscopy.

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