This document outlines the indications, preparation, and procedure for urethroscopy and cystoscopy. Urethroscopy is used to inspect the urethra for strictures, diverticula, fistulas, lesions, and tumors. Cystoscopy allows for a systematic evaluation of the bladder, including the trigone, bladder neck, walls, and roof to identify tumors, trabeculations, lesions, diverticula, stones, and foreign bodies. Normal findings include a healthy bladder mucosa and ureteral orifices located within the trigonal rim that appear as slit-like indentations. Additional investigations like bladder washing may be indicated.

2. Indication
 Gross hematuria
 Persistent hematuria
 Suspicion of bladder carcinoma,
tumour infiltration from outside or
metastases.
 Follow-up in superficial bladder
cancer
 For patients with upper tract
transitional cell carcinoma to rule
out coexistent bladder tumours.
 Inspection of orifices in
vesicoureteral/renal reflux or
ureterocele
 Recurrent urinary tract infection
(UTI).
 Diagnosis of interstitial cystitis.
 Suspicion of urogenital
tuberculosis
 Diagnosis of incontinence.
 Diagnosis of female urethral
diverticula
 Suspicion of vesicovaginal or
vesicoenteric fistula
 Neurogenic voiding
dysfunction.
 Suspicion of subvesical
obstruction (bladder outlet
stenosis).
 Detection of urethral or vesical
foreign bodies.
 Urethral inspection under
suspicion of stricture, tumour,
diverticulum or fistula.

3. Preparation

4. Urethroscopy
Inspect all parts of the urethra (penile,
bulbar, membranous and prostatic).
Assess luminal size (strictures,
diverticula, fistulas)
Evaluate mucosa (lesions, tumours)
External striated sphincter (pass with
gentle pressure)
Prostatic urethra.
Verumontanum.
Side lobes.
Estimate length of prostatic urethra.
Inspect the bladder neck opening.

5. Cystoscopy
 Start inspection with the 30° telescope,
supplement
 with different telescopes (i.e. 70°) if
 necessary to inspect all areas of the bladder
 (i.e. roof, bladder neck)
 Start with inspection of the trigone (position,
 form, numbers of ureteral orifices, colour of urine
jet)
 Systematic evaluation of the base, lateral
 walls, posterior wall and roof of the bladder and
bladder outlet
 Start at the base of bladder from left to right or
vice versa

6. Cystoscopy
 By turning the instrument, inspect the roof of the bladder; sometimes it is necessary to
push the bladder with your free hand from the abdominal wall towards your instrument
 In case of enlarged median lobe of the prostate, use a 70° telescope to inspect the
trigone and ureteral orifices.
 Use inflow and outflow of irrigation fluid as necessary.▬
 If vision is impaired (i.e. pus, blood), excessive
 irrigation of bladder may be necessary before inspection.
 Look for:
▬ Ureteral orifices (position and form).
▬ Tumours.
▬ Trabecula.
▬ Lesions of the mucosa.
▬ Diverticula and fistulas.
▬ Stones and foreign bodies.

7.  Additional investigations:
 Consider additional investigations as indicated:
 Bladder washing.
 Vaginal and/or rectal palpation.
 Vaginal inspection.
 Stress test and Marshall-Marchetti test
 Normal findings:
 Healthy bladder mucosa appears yellow to pink with small vascular branches.
 Ureteral orifices.
 Positioned within the trigonal rim.
 Slit-like or a flat indentation.
 Refluxive orifices are commonly lateralized and/or horseshoe-like in shape
Cystoscopy