Introduction: Cervical cancer is a major public health issue, especially in low- and middle-income countries. Visual inspection with acetic acid (VIA) is simple and affordable, but a positive result cannot confirm cervical precancerous lesions, requiring further diagnostics. This study compared colposcopy and cytology among VIA-positive women, using histopathology as the standard. Aim of this study: To compare the sensitivity, specificity, predictive values, and overall diagnostic accuracy of colposcopy and Pap smear for detecting cervical pre-invasive lesions in VIA-positive women. Methods & Materials: A cross-sectional study was conducted at Shaheed Suhrawardy Medical College Hospital (SSMCH), Dhaka, Bangladesh, from July 14, 2019, to January 15, 2020. It included 150 VIA-positive women selected by purposive sampling. Participants underwent Pap smear, colposcopy with 3% acetic acid, Lugol’s iodine, and Swede Score. Colposcopy-guided biopsy was performed when needed, with histopathology as the reference. Diagnostic performance was measured by sensitivity, specificity, PPV, NPV, and accuracy. Results: The mean age of the participants was 36.4 ± 11.5 years. Pap smear detected epithelial abnormalities in 69 (46.0%) women, whereas colposcopy identified suspected premalignant lesions in 58 (38.6%). Histopathology confirmed premalignant lesions in 51 (34.0%) women. The sensitivity, specificity, PPV, NPV, and accuracy of Pap smear were 78.4%, 70.7%, 58.0%, 86.4%, and 73.3%, respectively. For colposcopy, the corresponding values were 94.1%, 89.9%, 82.8%, 96.7%, and 91.3%. Conclusion: Colposcopy outperformed conventional cytology in VIA-positive women, showing higher sensitivity, specificity, predictive values, and accuracy. It can help evaluate women with positive VIA, but histopathology is still essential for a definitive diagnosis.