Clinical UM Guideline

This document addresses cystourethroscopy in the outpatient setting.

Note: Please see the following for additional relevant information:

• CG-SURG-134 Treatments for Urinary Incontinence

Note: For a high-level overview of this document, please see “Summary for Members and Families” below.

Outpatient cystourethroscopy is considered medically necessary for any of the following indications:

1. Gross hematuria without evidence of glomerular disease or infection; or
2. Gross hematuria with blood clots; or
3. Microscopic hematuria without evidence of glomerular disease, infection, or known cause of hematuria and there is an increased risk for malignancy; or
4. Management of kidney stones unlikely to pass spontaneously; or
5. Suspected surgical urinary tract injury or foreign body (for example, injury to the ureter, incision into the bladder, intravesical placement or erosion of mesh or suture); or
6. Urinary urgency, urinary frequency, or urgency incontinence when there is no urinary tract infection (this also includes stress urinary incontinence); or
7. Suspected malignant involvement of the urinary tract (including diagnosis and staging of bladder cancer, as well as diagnosis and staging of cervical, endometrial, ovarian, vulvar, vaginal, and other gynecologic malignancies); or
8. Urine leakage from the vagina (for example, from a genitourinary fistula); or
9. Lower genital tract trauma with suspicion of urinary tract involvement, including urethral stricture; or
10. Urine dribbling post voiding (for example, from a urethral diverticulum); or
11. Injection of therapeutic agents for urinary incontinence; or
12. Verification of suprapubic catheter placement; or
13. Removal of indwelling ureteral stents not amenable to office-based procedure; or
14. Recurrent urinary tract infection (defined as 2 episodes of acute bacterial cystitis within 6 months sometime within the preceding year) when any of the following risk factors are present:
    1. Prior urinary tract surgery or trauma; or
    2. Gross hematuria after resolution of infection; or
    3. Previous bladder or renal calculi; or
    4. Obstructive symptoms (such as straining, weak stream, intermittency, hesitancy), low uroflowmetry or high post void residual; or
    5. Urea-splitting bacteria on culture (for example, Proteus, Yersinia); or
    6. Bacterial persistence after sensitivity-based therapy; or
    7. Prior abdominopelvic malignancy; or
    8. Diabetes or otherwise immunocompromised; or
    9. Pneumaturia, fecaluria, anaerobic bacteria or a history of diverticulitis; or
    10. Repeated pyelonephritis (fevers, chills, vomiting, costovertebral tenderness); or
    11. Asymptomatic microhematuria after resolution of infection.

Not Medically Necessary:

Outpatient cystourethroscopy is considered not medically necessary for any other indication not listed above as medically necessary.

This document describes clinical studies and expert recommendations, and explains whether an outpatient cystourethroscopy is clinically appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

Cystourethroscopy is a procedure that uses a thin tube with a small camera to look inside the bladder and urethra, the tube that transports urine from the bladder to the outside of the body. The tube is passed through the urethra into the bladder. Doctors can also pass small tools through the tube to treat certain problems during the same procedure. It can be done while a person is awake with numbing medicine, or during surgery with regional or general anesthesia. This test is often used to check blood in the urine, bladder problems, urethral problems, or kidney stones. It is considered the main test for looking directly inside the bladder. Like all surgeries, it has some risks.

What the Studies Show

Cystourethroscopy allows doctors to directly see the inside of the bladder and urethra. It can help find causes of blood in the urine, also called hematuria. In 1study of 1182 people with blood in the urine but no other symptoms, 245 were found to have bladder cancer. Another study of 1584 people with urinary symptoms found that some people with microscopic blood in the urine had bladder cancer confirmed by sampling tissue, also known as a biopsy. These studies suggest that blood in the urine should not be ignored and that cystourethroscopy can help find serious problems. In another study, ultrasound was compared to cystourethroscopy in people with blood in the urine. Ultrasound was helpful as a first test when cystourethroscopy was not available, but it did not replace cystourethroscopy as the main test for checking the bladder.

Cystourethroscopy can also help in the management of some kidney stones, especially stones in the middle or lower part of the tube that carries urine from the kidney to the bladder. Expert groups have stated that this procedure can be used in these cases. For women with repeated simple urinary tract infections, expert opinion states that cystoscopy and imaging of the upper urinary tract should not be done routinely if the woman is otherwise healthy. Although cystourethroscopy is usually low risk, it is still surgery. In 1 study of 7,795 people who had outpatient urology surgery, 3.7% were readmitted to the hospital within 30 days. Risks can include infection, bleeding, or injury. Doctors weigh these risks against the benefit of finding or treating a problem.

When is Cystourethroscopy Clinically Appropriate?

Cystourethroscopy may be appropriate in these situations:

• To evaluate blood in the urine, including microscopic blood in the urine
• To evaluate lower urinary tract symptoms when a serious cause such as bladder cancer needs to be ruled out
• To assist in management of certain kidney stones located in the middle or lower ureter

When is this not Clinically Appropriate?

For otherwise healthy adult women with recurrent uncomplicated urinary tract infections, routine cystoscopy and imaging of the upper urinary tract are not recommended. Expert groups state that routine use in this setting is not needed.

Cystourethroscopy is not clinically appropriate in scenarios other than those listed above.

(Return to Description)

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met for outpatient procedures:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met.

Summary

Cystourethroscopy is an outpatient procedure that allows visual examination of the bladder and urethra, and is medically necessary in cases such as unexplained blood in urine, recurrent urinary infections with risk factors, management of certain kidney stones, suspected urinary tract injury, or potential malignancy. It is generally considered safe, though not without risks, and is explicitly not recommended for routine evaluation in healthy women with recurrent uncomplicated urinary tract infections. Clinical evidence supports cystourethroscopy as the gold standard diagnostic tool for hematuria and related urinary tract concerns.

Discussion

A cystoscopy is a surgical procedure in which a tube with a small camera on the end (endoscope) is inserted into the bladder to examine the lumen of the bladder, urethra, and the prostate. A related procedure, the urethroscopy, is done to examine the urethral lumen to look for urethral diseases or abnormalities. For the cystoscopy, the endoscope is inserted into the urethra which allows visualization of both the bladder and the urethra, thus the term cystourethroscopy. In addition to the camera, small instruments can also be passed through the endoscope that can be used to address problems that may be identified during the procedure. A diagnostic cystourethroscopy can be done as part of an evaluation of abnormal symptoms or laboratory findings. Cystourethroscopy can be performed with local anesthesia while the member is awake, but it can also be performed during or after pelvic surgery with regional or general anesthesia.

Hematuria

Hematuria, the presence of blood in the urine, can occur with or without other urinary tract symptoms. Without symptoms, hematuria may still be indicative of urinary or bladder problems. A 2012 study by Cha reported on 1182 participants who presented with asymptomatic hematuria. A total of 245 participants were found to have bladder cancer; 138 had low-grade tumors while 97 participants had high-grade tumors. While there are limitations to this study, including a possible increased probability of bladder cancer in the cohort based on local referral patterns, the results indicate that hematuria should not be ignored.

Goldberg and colleagues (2008) reviewed the charts of 1584 participants who had lower urinary tract symptoms and subsequent cystourethroscopy in an attempt to ascertain whether microscopic hematuria was a reliable predictor of cancer risk. Microscopic hematuria was found in 14.8% of the participants, with 1.7% then found to have biopsy-confirmed bladder cancer. Among the participants without hematuria, 0.45% were found to have bladder cancer and 60% of the participants presented with a normal initial dipstick urinalysis. While this study has some limitations including its retrospective design, the findings suggest that cystourethroscopy can be used for the evaluation of lower urinary tract symptoms including hematuria.

In a 2015 study of 109 participants with hematuria, Ahmed and colleagues compared transabdominal ultrasound to cystourethroscopy. All participants had both ultrasound and cystourethroscopy. The authors concluded that while ultrasound can be used as a first-line imaging tool for evaluation of hematuria in settings where cystourethroscopy is not available, it cannot replace cystourethroscopy as the gold standard for evaluation of hematuria.

In a 2007 American College of Obstetricians and Gynecologists (ACOG) committee opinion for Asymptomatic Microscopic Hematuria in Women (which was reaffirmed in 2025) it is recommended to have a cystoscopy for those with asymptomatic hematuria after other causes have been ruled out.

Kidney Stones

Whether or not a stone passes spontaneously, stone passage can depend on the size and/or location of the stone. According to a 2025 American Urological Association (AUA) guideline for the Surgical Management of Kidney and Ureteral Stones , ureteroscopy can be used for distal ureteral stones ≤ 10 mm in size.

Urinary Tract Infection

 In 2019 the AUA/Canadian Urological Association (CUA)/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) published their guideline regarding Recurrent Uncomplicated Urinary Tract Infection in Women (Anger, 2019). The guideline was amended in 2025 (Ackerman, 2025) and states:

An infection of the urinary tract in a healthy patient with an anatomically and functionally normal urinary tract, no signs or symptoms of upper urinary involvement or bacteremia, and no known complicating factors that would make the patient susceptible to progression to a systemic infection.

The authors define a recurrent urinary tract infection as “two separate episodes of acute bacterial cystitis and associated symptoms over a six-month period within the preceding year.” Upon evaluation, according to expert opinion, for a healthy adult individual with an uncomplicated recurrent urinary tract infection, cystoscopy and upper tract imaging should not be routinely done.

While cystourethroscopy is considered to be the gold standard procedure for many indications and is a low-risk surgical procedure, like all surgical procedures it is not without risk. A 2014 study by Rambachan and colleagues reported on surgical outcomes and the rate of hospital readmissions following urological surgery. In looking at 7795 participants, outpatient urological surgery had a 3.7% readmission rate within 30 days. Cystourethroscopy and resection of bladder tumor was the most common procedure that had been performed. However, it is important to keep in mind that certain gynecologic surgical procedures themselves are considered to be high-risk for complications and the addition of cystourethroscopy may help to avoid additional surgery.

Cystourethroscopy: A surgical procedure which combines a cystoscopy and a urethroscopy. It can be done to examine the bladder and urethral lumen to look for urethral diseases or abnormalities.

Gross hematuria: Blood in the urine which is visible to the naked eye.

Hematuria: Blood in the urine.

Microscopic hematuria: Blood in the urine which is only visible by a microscope.

Recurrent urinary tract infection: Two episodes of acute bacterial cystitis within a 6 month period sometime within the preceding year.

Peer Reviewed Publications:

1. Ahmed FO, Hamdan HZ, Abdelgalil HB, Sharfi AA. A comparison between transabdominal ultrasonographic and cystourethroscopy findings in adult Sudanese patients presenting with haematuria. Int Urol Nephrol. 2015; 47(2):223-228.
2. Cha EK, Tirsar LA, Schwentner C, et al. Accurate risk assessment of patients with asymptomatic hematuria for the presence of bladder cancer. World J Urol. 2012; 30(6):847-852.
3. Gilmour DT, Das S, Flowerdew G. Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy. Obstet Gynecol. 2006; 107(6):1366-1372.
4. Gleason JL. Cystoscopy and other urogynecologic procedures. Obstet Gynecol Clin North Am. 2013; 40(4):773-785.
5. Goldberg RP, Sherman W, Sand PK. Cystoscopy for lower urinary tract symptoms in urogynecologic practice: the likelihood of finding bladder cancer. Int Urogynecol J Pelvic Floor Dysfunct. 2008; 19(7):991-1004.
6. Rambachan A, Matulewicz RS, Pilecki M, et al. Predictors of readmission following outpatient urological surgery. J Urol. 2014; 192(1):183-188.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Ackerman AL, Bradley M, D'Anci KE, et al. Updates to recurrent uncomplicated urinary tract infections in women: AUA/CUA/SUFU Guideline (2025). J Urol. 2026; 215(1):3-12.
2. American College of Obstetricians and Gynecologists. Committee opinion: asymptomatic microscopic hematuria in women. Obstet Gynecol. 2017; 129(6):e168-e172. Reaffirmed 2025.
3. Anger J, Lee U, Ackerman AL, et al. Recurrent uncomplicated urinary tract infections in women: AUA/CUA/SUFU guideline. J Urol. 2019; 202(2):282-289.
4. Barocas DA, Lotan Y, Matulewicz RS, et al. Updates to microhematuria: AUA/SUFU guideline (2025). J Urol. 2025; 213(5):547-557.
5. Grossfeld GD, Wolf JS Jr, Litwan MS, et al. Asymptomatic microscopic hematuria in adults: summary of the AUA best practice policy recommendations. Am Fam Physician. 2001; 63(6):1145-1154.
6. Pearle MS, Matlaga BR, Antonelli JA, et al. Surgical management of kidney and ureteral stones: AUA guideline (2026). Part I: evaluation and treatment of patients with kidney and/or ureteral stones. J Urol. 2026; 215(2):113-123.
7. Pearle MS, Matlaga BR, Antonelli JA, et al. Surgical management of kidney and ureteral stones: AUA guideline (2026). Part II: evaluation and treatment of patients with kidney and/or ureteral stones. J Urol. 2026; 215(2):124-131.
8. Rodgers M, Nixon J, Hempel S, et al. Diagnostic tests and algorithms used in the investigation of haematuria: systematic reviews and economic evaluation. Health Technol Assess. 2006; 10(18):iii-iv, xi-259.

1. National Institute of Diabetes and Digestive and Kidney Diseases. Cystoscopy and Ureteroscopy. Last reviewed July 2021. Available at: https://www.niddk.nih.gov/health-information/diagnostic-tests/cystoscopy-ureteroscopy. Accessed on March 11, 2026.

Cystoscopy
Cystourethroscopy
Urethroscopy

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