OBJECTIVE Urologists in the past, and many today, rely on the cystoscopic appearance of the female urethra as a guide to its functional integrity. To assess the accuracy of this approach better, we compared the cystoscopic appearance of the bladder neck and proximal urethra to the functional integrity of this mechanism during videourodynamic studies. METHODS One hundred consecutive videourodynamic studies were reviewed on female patients with more complex types of urinary incontinence. Reports of their cystoscopic examinations were reviewed and results compared. RESULTS Significant dysfunction of the intrinsic mechanism was noted in 36% of the patients (26% moderate dysfunction and 10% severe dysfunction) on video studies. Cystoscopy underestimated these deficits 74% and 44% of the time, respectively, in the moderate and severe dysfunction groups. CONCLUSIONS We conclude that the cystoscopic appearance of the bladder neck proximal urethra cannot predict the functional integrity of this mechanism.