My clinical approach
Cystoscopy is the examination no patient likes to hear they need — and yet, in most cases, it ends far more easily than expected. With the flexible technology we use today, the procedure is performed in the office, with minimal discomfort, and is not very different from a routine urological examination.
Cystoscopy is the only examination that allows direct visual assessment of the inside of the bladder and urethra. No other method — not ultrasound, CT, or MRI — can fully replace it when direct observation of the mucosal surface is required.
I follow EAU guidelines on haematuria evaluation and cystoscopy indications: the procedure is performed only when there is a clear clinical indication — not as routine and not as a substitute for clinical assessment.
What is flexible cystoscopy?
Flexible cystoscopy is an endoscopic procedure in which a thin, flexible fibreoptic or digital endoscope (cystoscope) is inserted through the urethra and advanced into the bladder, allowing direct observation of the mucosal surface.
When is flexible cystoscopy indicated?
Haematuria
Blood in the urine (macroscopic or microscopic). Flexible cystoscopy is essential in the haematuria diagnostic algorithm to exclude bladder mucosal lesions.
Bladder cancer surveillance
Patients treated for bladder cancer require regular cystoscopies for early detection of recurrence, per EAU surveillance protocols.
Lower urinary tract symptoms (LUTS)
Frequency, urgency, dysuria, incontinence not explained by other causes. Cystoscopy rules out intravesical lesions as the underlying cause.
Recurrent urinary tract infections
Repeated UTIs in women or men in specific age groups, to exclude structural abnormalities.
Post-BCG or intravesical chemotherapy follow-up
To evaluate treatment response and exclude residual tumour.
Foreign bodies, suspected stone or diverticulum
Direct endoscopic evaluation when imaging is not definitive.
Flexible vs Rigid cystoscopy
Flexible cystoscopy
- Performed in the office
- Local anaesthesia (lidocaine gel)
- No hospitalisation
- Minimal discomfort
- Primarily diagnostic
- Immediate return to activities
Rigid cystoscopy
- Performed in operating theatre
- Spinal or general anaesthesia
- Brief hospitalisation (often same-day)
- Allows surgical interventions
- Biopsy, tumour resection, lithotripsy
- 1–2 days recovery
How to prepare
Urine culture
A urine dipstick or culture is usually requested before cystoscopy to exclude active infection. Active UTI is a contraindication — it must be treated first.
Medications
Patients on anticoagulants or antiplatelet agents should inform their urologist. For simple flexible cystoscopy without biopsy, discontinuation is usually not required.
Fluids
No fasting required. It is helpful to arrive with a mildly full bladder (avoid urinating for 1–2 hours beforehand).
Prophylactic antibiotics
Not routinely required for all patients. May be given to selected groups (immunosuppressed, recurrent UTIs, cardiac valves).
How the procedure is performed
Duration and recovery
What to expect after the procedure
- Mild burning or discomfort on urination for 24–48 hours — normal
- Faint pink urine initially — normal, resolves with hydration
- Increased fluid intake for 24–48 hours recommended
- Analgesia rarely required
- Contact your urologist if you develop fever, severe pain or significant haematuria
Possible complications
Urinary tract infection
Mainly in high-risk patients. Easily treated with antibiotics. Sterile technique and anaesthetic gel reduce this risk.
Transient dysuria
Mild burning or discomfort on urination for a few hours to 2 days. Normal mucosal irritation response. Resolves spontaneously.
Urethral or bladder injury
Very rare with modern flexible technology. Prevented by gentle technique and anaesthetic gel use.
Significant haematuria
Very rare without biopsy. If biopsy is taken, minor pink discolouration of urine is normal.
Contact your urologist immediately if you experience:
- Fever > 38°C
- Severe pain or colic
- Inability to urinate
- Heavy haematuria with clots
Bladder cancer surveillance
One of the most common reasons for regular cystoscopies is surveillance of patients treated for bladder cancer. The surveillance schedule depends on recurrence risk:
Per EAU 2024 guidelines, flexible office cystoscopy is an accepted and reliable option for surveillance of low and intermediate-risk NMIBC patients, reducing patient burden and cost.
Frequently Asked Questions (FAQ)
Is flexible cystoscopy painful?
Usually not significantly. Before the procedure, lidocaine anaesthetic gel is instilled into the urethra, which considerably reduces discomfort. You may feel mild pressure or irritation during scope insertion, particularly in men. The majority of patients tolerate the procedure comfortably in the office.
Do I need hospital admission or general anaesthesia?
No. Flexible cystoscopy is performed in the office under local anaesthesia (anaesthetic gel). No surgical theatre, no general or spinal anaesthesia, no hospitalisation is required. After the procedure you return immediately to your daily activities.
How long does it take?
The examination itself usually takes 5 to 15 minutes, depending on findings. Total time in the office, including preparation and result discussion, is typically 20–40 minutes.
Can I drive afterwards?
Yes. Because no general anaesthesia or sedatives are used, you can drive and work immediately after the procedure.
What is the difference between flexible and rigid cystoscopy?
Flexible cystoscopy is performed with a flexible fibreoptic or digital scope in the office under local anaesthesia and is used primarily for diagnostic purposes. Rigid cystoscopy is performed in the operating theatre under spinal or general anaesthesia and allows simultaneous therapeutic interventions such as biopsy, tumour resection (TURBT) or other surgical procedures.
When is cystoscopy indicated?
Cystoscopy is required for: haematuria (blood in the urine), recurrent urinary tract infections, lower urinary tract symptoms not explained by other causes, urgency incontinence not responding to treatment, surveillance after bladder cancer treatment, and other specific urological conditions.
Is there a risk of infection?
The risk of urinary tract infection after flexible cystoscopy is low. Prophylactic antibiotics may be given to high-risk patients. After the procedure, increased fluid intake for 24–48 hours is recommended.
Book your appointment in Rhodes
If you need a cystoscopy for haematuria, bladder cancer surveillance, or evaluation of urological symptoms, flexible office cystoscopy is fast, safe and minimally uncomfortable.
References
- EAU Guidelines on Non-muscle-invasive Bladder Cancer 2024 — uroweb.org
- EAU Guidelines on Urological Infections 2024 — uroweb.org
- NICE NG12: Suspected cancer — recognition and referral — nice.org.uk
- Herr HW — Tumour progression and survival of patients with high grade TaG3 bladder tumours. J Urol. 2000.
Medical review
Dr. Marinos Vasilas, Urologist – Andrologist
Dr. Vasilas performs flexible cystoscopies at his office in Rhodes, providing direct, reliable and comfortable evaluation for all diagnostic indications — from haematuria investigation to bladder cancer surveillance per EAU 2024 guidelines.
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