What Is A Cystoscopy And Is It Helpful For Recurrent UTI?

We frequently receive the question, ‘What is a cystoscopy?’ in relation to recurrent UTI diagnostic methods. So we spent some time digging into the research in order to bring you some clarification around this question.

A cystoscopy is a diagnostic procedure in which a doctor or technician inserts a cystoscope into the urinary tract via the urethra. A cystoscope is a tube with a camera and light on the end. This is done in order to visualize the urethra, urethral sphincter, urethral orifices, bladder, and prostate.

But, is cystoscopy helpful in the diagnosis of recurrent UTIs, and is it necessary? 

The answer to this question can depend on the source. Below we’ll provide more insight into how cystoscopy is used and how this applies to recurrent urinary symptoms.

Jump To Section:

• What Is A Cystoscopy And How Is It Done? >>>>
• How Can A Cystoscopy Help Guide Diagnosis? >>>>
• Cystoscopy With A Bladder Biopsy >>>>
• Urethral Dilation: Can It Help ‘Cure’ Recurrent UTI? >>>>
• Can Urethral Dilation Cure Urethral Strictures? >>>>
• UTI After Cystoscopy: What Are The Risks? >>>>

A cystoscopy can be performed in your doctor’s office and requires minimal personnel, as local anesthetic is typically all that’s required. 

Between 8% and 21.5% of women with recurrent UTI that undergo a cystoscopy are found to have a significant abnormality. And one study discovered that only 3.8% of abnormal cystoscopy findings were uniquely found through cystoscopy. This means that other forms of imaging would not have been able to discover these findings. 

Success rates of cystoscopies also depend on the experience of the practitioner, and even then the usefulness is unclear. Further studies have shown that of patients with lower urinary tract symptoms (LUTS) and recurrent UTIs, 11.4%  and 21.5%, respectively, had significant cystoscopy findings. 

Like so many women’s health issues, more research needs to be completed to find an accurate and effective way to diagnose and treat LUTS and recurrent UTIs, but read on to learn what we’ve discovered about cystoscopies thus far.

What Is a Cystoscope?

A cystoscope is the tool your doctor will use to perform the cystoscopy. It is a long tube with a light and camera on the end that allows your doctor to view the inside of your bladder.

Cystoscopes come in a variety of sizes and are measured using the French (Fr) gauge unit, where 1 French is equal to a circumference of 0.33 millimeters. This can help to give you an idea of the true size of the scope.

Cystoscopes can be either flexible or rigid. Flexible cystoscopes are smaller in size (16-17 Fr) and are generally viewed as more comfortable. They have a moveable tip that allows for easier inspection of the bladder wall. 

Rigid cystoscopes are larger in size (15-25 Fr), allowing them to be used with a wider variety of instruments. Additional instruments may be used alongside cystoscopes for the purpose of obtaining a biopsy or performing a procedure or surgery. In some cases, depending on the technology, rigid cystoscopes may have better clarity. 

Your doctor may prescribe antibiotics prior to your cystoscopy if you exhibit certain risk factors. Examples of risk factors include older age, immunodeficiency, or a history of smoking. 

Cystoscopy Video

You might be wondering, ‘What does a cystoscopy look like?’ We’ve tracked down videos of a normal cystoscopy in both female and male anatomy. If you’re interested in having a closer look at the bladder and cystoscopy process, take a look at the following resources.

Fair warning, these videos provide a detailed (and somewhat graphic) view of the inside of a bladder.

Female Cystoscopy Video

Male Cystoscopy Video

Cystoscopy In Male vs. Female Anatomy

Though male and female bladder anatomy is similar, the anatomy of the urethra differs.

In male anatomy, the urethra is divided into sections. When the cystoscope first enters the male urethra it passes through the penile urethra. Then the cystoscope passes through the membranous urethra, up through the prostatic urethra where the ejaculatory ducts are, and then lastly into the bladder neck or the pre-prostatic urethra. 

We know this anatomical path can be a bit confusing, so we’ve included a diagram of the male urethral anatomy below. 

In female anatomy, the urethra is not divided into sections. The urethra, a tube approximately 4 cm in length, directly connects the bladder to the outside of the body. 

In both males and females, after the cystoscope has passed through the bladder neck, or the internal bladder sphincter, it enters into the bladder. At this point, the doctor can tilt the cystoscope downwards to see the bladder floor, known as the trigone, or tilt the cystoscope upward to see the ureters, which lead to the kidneys and sit 2-3 cm apart. 

Because of the overlap in symptoms between recurrent UTI and diagnoses such as overactive bladder (OAB), interstitial cystitis/bladder pain syndrome (IC/BPS), and urethral syndrome, a cystoscopy may be recommended to help inform a diagnosis.

However, it’s important to note that a diagnosis of OAB, IC/BPS or urethral syndrome is a diagnosis of exclusion. This means it is a diagnosis given in the absence of evidence of another cause, and it implies that the true cause has not yet been discovered. 

These diagnoses are not conditions themselves, but are instead a description of unexplained symptoms. We’ve explained this more in our article on chronic vs. recurrent UTI.

When A Cystoscopy May Be Suggested

Your doctor may suggest a cystoscopy if you have any of the following: 

1. Gross or microscopic hematuria: blood in the urine (gross hematuria can be seen with the naked eye whereas microscopic cannot)
2. Malignancy (tumors): identified cancer in the bladder, urethra, or upper urinary tract (cystoscopy can be used to diagnose/evaluate/survey)
3. Lower urinary tract Symptoms: recurrent UTIs, painful urination (dysuria), urinary incontinence 
4. Trauma or suspicion of a fistula: a fistula is an abnormal connection between two body parts; for example, vagina to bladder or urethra to vagina

Urinary Tract Abnormalities

In essence, a cystoscopy is used to diagnose urinary tract abnormalities. There are many possible abnormalities, but the following have been found to be the most prevalent: 

1. Urethral stricture: the narrowing of the urethra
2. Bladder diverticulum: a pouch protruding out of the bladder. Diverticulums can be congenital (present at birth), or acquired later.
3. Urethral mesh erosion: urethral meshes, or slings, are often surgically placed to correct for urinary incontinence (urine leakage) or prolapse.
4. Periurethral gland abscess: the Skene’s gland may become infected leading to a recurrent UTI.
5. Urinary system stones: stones are hardened clumps of biological minerals that can migrate through the urinary system and cause obstructions.
6. Intravesical Calculi: stones that occur in the bladder
7. Fistulas: the abnormal connection between two internal body parts, such as the bladder to the vagina or the urethra to the vagina
8. Urinary reflux: occurs when urine flows backward from the bladder, up the ureters, toward the kidneys 
9. Urethral diverticulum: a pouch protruding out of the urethra
10. Urinary tumors: may be cancerous, which can be diagnosed through a biopsy
11. Trigonitis and leukoplakia: changes in the bladder wall tissue due to chronic inflammation or infection

Though abnormal cystoscopy findings range from 8% to 21.5% for those with recurrent UTI, the ability to visualize the urethra and bladder and take a biopsy (more on biopsies next) may give your doctor more information when trying to find the root cause for your symptoms. 

During a cystoscopy a doctor may take a biopsy, removing tissue or cells to be analyzed in a lab to diagnose illness or determine if cells are cancerous. Biopsies during cystoscopy have found squamous metaplasia, cystitis cystica, and cystitis glandularis – all of which are a transformation or replacement of bladder lining cells. 

While cystoscopies have diagnostic limitations, a cystoscopy with bladder biopsy can be an accurate way to diagnose cancer. One study found that in 100% of cases, diagnostic impressions determined from cystoscopy images alone agreed with pathological diagnoses. The cystoscopic impressions were even able to distinguish between benign and malignant lesions. 

The identification of Hunner’s lesions is another area in which cystoscopies can be beneficial. Hunner’s lesions are inflammatory lesions that break through internal cell layers, with characteristic vessels radiating out from a central scar. 

The addition of a bladder distension (expansion of the bladder induced by the addition of liquid) during cystoscopy can result in the rupturing of these vessels. This can cause bleeding beneath the cell layers. These areas of bleeding, or ruptured vessels, are also called glomerulations.

According to the National Institute of Diabetes and Digestive and Kidney Diseases, the cystoscopic discovery of glomerulations or Hunner’s lesions calls for an undisputable diagnosis of interstitial cystitis/bladder pain syndrome (IC/BPS). 

However, glomerulations or Hunner’s lesions are not specific enough to diagnose IC/BPS, as both can be signs of other bladder conditions. Chronic infection, urinary tract stone disease or benign prostate hyperplasia can also result in Hunner’s lesions or glomerulations. Perfectly healthy women have also been discovered to have glomerulations. It’s clear that more research is needed to better understand their role in bladder health. 

Conventional Treatments For Hunner’s Lesions

Conventional treatment approaches for patients with Hunner’s lesions have varying rates of symptom improvement and are dependent upon a wide range of variables:

1. Transurethral resection (TUR): the removal of problematic tissue. This procedure has resulted in symptom improvement after the initial TUR  for an average of 23 months, with the duration of improvement shifting with additional resections.
2. (Nneodymium) Nd: YAG laser: a specific type of radiation that allows for blood clotting. Although Nd: YAG laser has a high rate of symptom improvement, it also has a 45.8% relapse rate.
3. Endoscopic ablation: a high frequency electrical current used to clot bleeding. Interestingly, in patients who had a relapse within 12 months, the location of a new lesion was in the same region as the previously removed lesion.
4. Triamcinolone injection: a corticosteroid used to treat inflammation. Similar to the other conventional treatments for Hunner’s lesions, symptom improvement is reported following the Triamcinolone injection, but repeated treatments can be necessary for many patients.

Alongside the question, ‘what is a cystoscopy?’, people often ask whether urethral dilation may help when it comes to persistent UTI. Let’s start with the basics.

What Is Urethral Dilation? 

Urethral dilation refers to the process of expanding the urethra. There are many methods used to achieve this, including balloon dilators, catheters of increasing size, and filiforms – a device similar to, but smaller than a catheter. 

The use of urethral dilation is controversial, perhaps even more so than cystoscopy. Urethral dilation is used more frequently by providers who have been practicing longer, and has been used in an attempt to treat recurrent UTI, urethral stricture, lower urinary tract symptoms (LUTS), and bladder pain syndrome/interstitial cystitis, among many other issues. 

Does Urethral Dilation Hurt?

Urethral dilation is often done under a local anesthesia. Lidocaine injections help to reduce discomfort of urethral dilations, and the procedure itself has been described by patients as causing varying levels of discomfort.

Will It Make My Symptoms Worse? Can It Cause Long Term Damage?

The risks of urethral dilation include urethral perforation, bleeding and pain, infection, and stress urinary incontinence (in up to 14% of patients). And although certain studies have found that urethral dilation can treat urethral stricture (a narrowing of the urethra), it is also possible that urethral dilation may cause urethral stricture. We’ll dig into that more soon. 

In What Percentage Of Patients Does Urethral Dilation Provide Relief From Symptoms?

Various studies have suggested that any possible benefits of urethral dilation (UD) may come with long-term side effects. UD may not be an appropriate option in patients with recurrent UTI, IC/BPS, and other LUTS. In fact, chronic UTI specialists we have spoken with suggest there is no evidence that UD is an effective tool and strongly advise their patients against it.

While urethral dilation is not often advisable for rUTI patients, one way it may be effective is by decreasing high detrusor muscle pressure, a bladder wall muscle that contracts when voiding. This could lead to relief from lower urinary tract symptoms. 

One study considered the benefits of cystoscopy alone versus urethral dilation for women with recurrent urgency and frequency. In both groups, 30% of participants had no residual symptoms, 50% had improved symptoms, and 20% had no change in symptoms. 

However, it is important to note that 7 out of 52 patients who underwent the urethral dilation had stress urinary incontinence following the procedure, a side effect not experienced by patients undergoing cystoscopy alone. 

Ultimately, the study suggests that urethral dilation provides no greater benefit than cystoscopy alone for frequency and painful urination. 

In contrast, a separate study found that 75% of patients diagnosed with urethral inflammation who received multiple urethral dilations for two to three weeks had no symptoms at an eight week follow-up. 

And in yet another study, 51% of women with LUTS had complete or major resolution of symptoms at a six-month follow-up following urethral dilation. However, definitions of complete or major resolution were not included and did not reference any individual symptom improvement. 

From the range of outcomes in these studies, one clear conclusion can be drawn: successful responses to urethral dilations vary. There is not enough evidence to support UD in rUTI patients. 

What Is The Recurrence Rate Of Symptoms After Urethral Dilation?

In a study of girls with UTIs, approximately one-third of girls had a recurrence of their symptoms in both the cystoscopy and urethral dilation groups. 

In a study of women with urethral strictures, 16 out of 17 women had recurrence of symptoms in a six year follow-up period despite repeat urethral dilation procedures, with only a 6% success rate. However, a similar but more invasive and comprehensive urethral procedure, a urethroplasty, appears to have a lower rate of recurrence, with only 2 of 17 patients experiencing recurrence.

Urethral dilation has been commonly suggested as a cure for urethral strictures (a narrowing of the urethra). While individual urethral dilations do not have a high rate of success, multiple urethral dilations have been found to be more successful, with up to 77.7% of patients having resolved symptoms during a two year follow-up. 

Other studies, however, have found that urethral dilation may in fact cause urethral stricture by traumatizing the area and worsening symptoms. Patients treated with urethral dilation have needed further dilations, and oftentimes, pain, UTIs, and detrusor activity had no significant change following dilation.

Urethroplasty, a surgical reconstruction of the urethra, has a documented success rate of 93% for correcting the structural abnormality. This may be a more definitive treatment for those with urethral stricture. Additionally, urethroplasty has been shown to resolve pain in 67% of cases and resolve recurrent UTI in 88% of patients. 

Overall, urethral dilation may provide a temporary improvement of symptoms in 62% to 75% of patients with recurrent UTI, IC/BPS, urethral syndrome or other lower urinary tract symptoms. 

Note, the keyword here is temporary, and some evidence argues that urethral dilations are no more effective than any other treatment method, such as antibiotics, antispasmodics, sedatives, estrogen, or silver nitrate application, and comes with risks of its own. 

Cystoscopy is widely accepted as a safe procedure, with complications being rare. The most common complications following a cystoscopy include:

• Urinary tract infection 
• Dysuria (painful or difficult urination)
• Hematuria (blood in the urine) 

1.9% to 4.3% of patients experience a UTI following a cystoscopy. Whie there is mixed evidence on whether or not taking antibiotics prior to the cystoscopy will reduce the chances of developing a post-cystoscopy UTI, a possible benefit of using povidone-iodine prior to performing a male cystoscopy has been shown. 

However, one study of cystoscopy in males found that 22% had a self-reported or culture positive UTI following the cystoscopy, while in a group that received povidone-iodine during the cystoscopy, only 7.2% experienced a UTI. 

When it comes to other post-cystoscopy effects, pain on voiding, urinary frequency, and visible blood in the urine have the potential to occur. Although many people find these symptoms ease within 1-2 days, some have found symptoms to persist for more than 48 hours. In this situation, a doctor should be notified.

Is Cystoscopy Safe?

Inflammation commonly occurs after a cystoscopy, as you might suspect. This increase in inflammation can result in painful or difficult urination, however, these symptoms are unlikely to last more than 48 hours.

As an additional note, the tools used during a cystoscopy can have an effect on post-procedure symptoms. When a rigid cystoscope is used, a majority of patients complain of pain with urination following the procedure.

Conversely, 89% of patients found flexible cystoscopy under local anesthesia to be painless. This suggests that flexible cystoscopy may be the more comfortable option. 

Can A Cystoscopy Cause Damage?

Blood in the urine following cystoscopy is considered to be normal, as the cystoscope may scrape the side of the urethra. But in some cases, it may be a sign of a larger problem. There is anecdotal evidence of bladder rupture, bladder necrosis, and acute pyelonephritis (kidney infection) following cystoscopy. Blood in the urine for more than a few days following a cystoscopy warrants follow up with your healthcare provider. 

What Is Cystoscopy? A Quick Summary

As we’ve discussed many times on Live UTI Free, numerous aspects of recurrent urinary tract infection and lower urinary tract symptoms are not supported by sufficient research. While cystoscopy is well documented as a useful method to diagnose certain conditions, it may only be appropriate in the presence of certain symptoms.

For this reason, it is important to discuss with your provider whether imaging may be helpful, and what type of imaging they recommend, as a cystoscopy is only one form of imaging available. A cystoscopy may help reveal an underlying abnormality, especially when performed by an experienced practitioner. It may also be helpful in ruling out more serious conditions. 

Learning about your options will allow you to advocate for yourself. It helps to research any procedures, diagnostic methods or treatments your provider suggests, so you can make an informed decision.

You can start with an overview of different causes of lower urinary tract symptoms, and an understanding of the limitations of standard UTI testing. 

To get answers to commonly asked questions about chronic and recurrent UTI, visit our FAQ page. You’re welcome to share any questions or comments below.