Voiding cystourethrography

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Voiding cystourethrogram
MedlinePlus 003784

In urology, voiding cystourethrography (VCUG) is a frequently performed technique for visualizing a person's urethra and urinary bladder while the person urinates (voids). It is used in the diagnosis of vesicoureteral reflux (kidney reflux), among other disorders. [1] The technique consists of catheterizing the person in order to fill the bladder with a radiocontrast agent, typically diatrizoic acid. Under fluoroscopy (real time x-rays) the radiologist watches the contrast enter the bladder and looks at the anatomy of the patient. If the contrast moves into the ureters and back into the kidneys, the radiologist makes the diagnosis of vesicoureteral reflux, and gives the degree of severity a score. The exam ends when the person voids while the radiologist is watching under fluoroscopy. Consumption of fluid promotes excretion of contrast media after the procedure. It is important to watch the contrast during voiding, because this is when the bladder has the most pressure, and it is most likely this is when reflux will occur. Despite this detailed description of the procedure, at least as of 2016 the technique had not been standardized across practices. [1]

Contents

Uses

Some uses of this procedure are: to study the presence of vesicoureteric reflux, study of urethra during micturition, presence of bladder leak post surgery or trauma, and is used in urodynamic testing to assess urinary incontinence. [2]

Indications for performing VCUG:

Contraindications for voiding cystourethrogram is when the subject is having:

Procedure

A high osmolar contrast agent such as diatrizoate or a low osmolar contrast agent such as Iotalamic acid with a concentration of 150 mg per ml is used for the procedure. [2] [1]

The urinary bladder is catheterised under aseptic technique. The contrast medium is slowly injected or dripped in. The level of bladder filling is observed by taking intermittent images using fluoroscopy. The early filling of the bladder should be monitored carefully to detect any accidental placement of the catheter in the distal ureter or vagina and to detect any reflux of contrast into the ureters. The bladder should be filled up with as much contrast as possible until the subject is unable to tolerate it or when there is no more contrast going into the bladder. If the subject is able to pee, then the catheter can be removed for the subject to do so. If there is no confidence that the subject is able to pee, then the urinary catheter should remain in place. It is more convenient for adults to pee in an erect position with a urine receiver. Meanwhile, children can pee while lying down on a table with a urine receiver. Infants and smaller children can lie down on a table and pee onto absorbent pads. For those children or infants with a neuropathic bladder, pressure on the suprabic region can help them to pee. [2]

Fluoroscopic spot images and videos are taken during the micturition phase to detect any reflux. The lower ureter is best seen on an anterior oblique position. In males, peeing should be done in oblique or lateral positions to visualise the whole of urethra. Finally, the whole abdomen is imaged to detect any undetected reflux in previous images. Any urine left in the bladder after peeing is also recorded in this image. Lateral views are useful to evaluate any fistulas from the bladder connecting into the rectum or vagina. Oblique views are used to evaluate any leaks from the bladder or urethra. Stress views are useful in urodynamic studies. [2] The verumontanum appears elongated and the proximal bulbal urethra has a less conical appearance. [4]

Complications

Children may have painful micturition after the procedure, which can lead to urinary retention (children afraid to pee due to pain). Some painkillers or peeing inside a warm bath may help. Those children who receive antibiotics before the procedure for urinary tract infection will double the dose for 3 days after the procedure. Those not already on antibiotics will be prescribed with 3 days of trimethoprim. Haematuria (blood in urine) may also occur after the procedure. [2] With respect to post-procedural urinary tract infection, the risk has been found to be sufficiently low, except in patients with a pre-existing urologic diagnosis, that pre-operative antibiotic use is not considered a necessary adjunct. [5]

The procedure is invasive and uncomfortable, and it carries a high potential for psychological trauma for both children and parents. [1] [6] The long-term psychological effects of VCUGs on children have been compared to that of childhood sexual abuse. [7]

Another complication is perforation of the bladder due to over-distension. Accidental catherisation of vagina or unusual urethral opening and retention of urinary catheter are also possible. [2]

An increased risk of cancer, in particular genitourinary cancer, has been observed in one study arising from the radiation exposure inherent in the procedure. [8]

See also

Related Research Articles

<span class="mw-page-title-main">Urethra</span> Tube that connects the urinary bladder to the external urethral orifice

The urethra is the tube that connects the mammalian urinary bladder to the urinary meatus. In placental mammals, the urethra transports urine through the penis or vulva during urination and semen through the penis during ejaculation.

<span class="mw-page-title-main">Cystoscopy</span> Medical procedure; endoscopy of the urinary bladder via the urethra

Cystoscopy is endoscopy of the urinary bladder via the urethra. It is carried out with a cystoscope.

<span class="mw-page-title-main">Ureter</span> Tubes used in the urinary system in most animals

The ureters are tubes composed of smooth muscle that transport urine from the kidneys to the urinary bladder. In an adult human, the ureters typically measure 20 to 30 centimeters in length and about 3 to 4 millimeters in diameter. They are lined with urothelial cells, a form of transitional epithelium, and feature an extra layer of smooth muscle in the lower third to aid in peristalsis. The ureters can be affected by a number of diseases, including urinary tract infections and kidney stone. Stenosis is when a ureter is narrowed, due to for example chronic inflammation. Congenital abnormalities that affect the ureters can include the development of two ureters on the same side or abnormally placed ureters. Additionally, reflux of urine from the bladder back up the ureters is a condition commonly seen in children.

<span class="mw-page-title-main">Urinary catheterization</span> Insertion of a catheter through the urethra to drain urine

In urinary catheterization, a latex, polyurethane, or silicone tube known as a urinary catheter is inserted into the bladder through the urethra to allow urine to drain from the bladder for collection. It may also be used to inject liquids used for treatment or diagnosis of bladder conditions. A clinician, often a nurse, usually performs the procedure, but self-catheterization is also possible. A catheter may be in place for long periods of time or removed after each use.

<span class="mw-page-title-main">Urinary retention</span> Inability to completely empty the bladder

Urinary retention is an inability to completely empty the bladder. Onset can be sudden or gradual. When of sudden onset, symptoms include an inability to urinate and lower abdominal pain. When of gradual onset, symptoms may include loss of bladder control, mild lower abdominal pain, and a weak urine stream. Those with long-term problems are at risk of urinary tract infections.

<span class="mw-page-title-main">Hydronephrosis</span> Dilation of the renal pelvis due to obstruction of urine flow

Hydronephrosis describes hydrostatic dilation of the renal pelvis and calyces as a result of obstruction to urine flow downstream. Alternatively, hydroureter describes the dilation of the ureter, and hydronephroureter describes the dilation of the entire upper urinary tract.

<span class="mw-page-title-main">Mitrofanoff procedure</span>

The Mitrofanoff procedure, also known as the Mitrofanoff appendicovesicostomy, is a surgical procedure in which the appendix is used to create a conduit, or channel, between the skin surface and the urinary bladder. The small opening on the skin surface, or the stoma, is typically located either in the navel or nearby the navel on the right lower side of the abdomen. Originally developed by Professor Paul Mitrofanoff in 1980, the procedure represents an alternative to urethral catheterization and is sometimes used by people with urethral damage or by those with severe autonomic dysreflexia. An intermittent catheter, or a catheter that is inserted and then removed after use, is typically passed through the channel every 3–4 hours and the urine is drained into a toilet or a bottle. As the bladder fills, rising pressure compresses the channel against the bladder wall, creating a one-way valve that prevents leakage of urine between catheterizations.

<span class="mw-page-title-main">Vesicoureteral reflux</span> Backwards flow of urine from the bladder into the ureters and kidneys

Vesicoureteral reflux (VUR), also known as vesicoureteric reflux, is a condition in which urine flows retrograde, or backward, from the bladder into one or both ureters and then to the renal calyx or kidneys. Urine normally travels in one direction from the kidneys to the bladder via the ureters, with a one-way valve at the vesicoureteral (ureteral-bladder) junction preventing backflow. The valve is formed by oblique tunneling of the distal ureter through the wall of the bladder, creating a short length of ureter (1–2 cm) that can be compressed as the bladder fills. Reflux occurs if the ureter enters the bladder without sufficient tunneling, i.e., too "end-on".

<span class="mw-page-title-main">Posterior urethral valve</span> Medical condition

Posterior urethral valve (PUV) disorder is an obstructive developmental anomaly in the urethra and genitourinary system of male newborns. A posterior urethral valve is an obstructing membrane in the posterior male urethra as a result of abnormal in utero development. It is the most common cause of bladder outlet obstruction in male newborns. The disorder varies in degree, with mild cases presenting late due to milder symptoms. More severe cases can have renal and respiratory failure from lung underdevelopment as result of low amniotic fluid volumes, requiring intensive care and close monitoring. It occurs in about one in 8,000 babies.

Pyelogram is a form of imaging of the renal pelvis and ureter.

Reflux nephropathy is kidney damage (nephropathy) due to urine flowing backward (reflux) from the bladder toward the kidneys; the latter is called vesicoureteral reflux (VUR). Longstanding VUR can result in small and scarred kidneys during the first five years of life in affected children. The end results of reflux nephropathy can include high blood pressure, excessive protein loss in the urine, and eventually kidney failure.

<span class="mw-page-title-main">Retrograde urethrogram</span> Medical imaging of the urethra

A retrograde urethrography is a routine radiologic procedure used to image the integrity of the urethra. Hence a retrograde urethrogram is essential for diagnosis of urethral injury, or urethral stricture.

Urologic diseases or conditions include urinary tract infections, kidney stones, bladder control problems, and prostate problems, among others. Some urologic conditions do not affect a person for that long and some are lifetime conditions. Kidney diseases are normally investigated and treated by nephrologists, while the specialty of urology deals with problems in the other organs. Gynecologists may deal with problems of incontinence in women.

<span class="mw-page-title-main">Cystometry</span> Medical evaluation of bladder function

Cystometry, also known as flow cystometry, is a clinical diagnostic procedure used to evaluate bladder function. Specifically, it measures contractile force of the bladder when voiding. The resulting chart generated from cystometric analysis is known as a cystometrogram (CMG), which plots intravesical pressure against the volume of fluid in the bladder.

<span class="mw-page-title-main">Cystography</span> X-ray imaging of the urinary bladder

In radiology and urology, a cystography is a procedure used to visualise the urinary bladder.

<span class="mw-page-title-main">Urodynamic testing</span> Assessment of bladder and urethra performance

Urodynamic testing or urodynamics is a study that assesses how the bladder and urethra are performing their job of storing and releasing urine. Urodynamic tests can help explain symptoms such as:

<span class="mw-page-title-main">Duplicated ureter</span>

Duplicated ureter or duplex collecting system is a congenital condition in which the ureteric bud, the embryological origin of the ureter, splits, resulting in two ureters draining a single kidney. It is the most common renal abnormality, occurring in approximately 1% of the population.

<span class="mw-page-title-main">Cystourethrography</span>

Cystourethrography is a radiographic, fluoroscopic medical procedure that is used to visualize and evaluate the bladder and the urethra. Voiding and positive pressure cystourethrograms help to assess lower urinary tract trauma, reflux, suspected fistulas, and to diagnose urinary retention. Magnetic imaging (MRI) has been replacing this diagnostic tool due to its increased sensitivity. This imaging technique is used to diagnose hydronephrosis, voiding anomalies, and urinary tract infections in children. abnormalities.

The genitourinary tract, or simply the urinary tract, consists of the kidneys, ureters, bladder, and the urethra. The kidney is the most frequently injured. Injuries to the kidney commonly occur after automobile or sports-related accidents. A blunt force is involved in 80-85% of injuries. Major decelerations can result in vascular injuries near the kidney's hilum. Gunshots and knife wounds and fractured ribs can result in penetrating injuries to the kidney.

References

  1. 1 2 3 4 Frimberger D, Mercado-Deane MG (November 2016). "Establishing a Standard Protocol for the Voiding Cystourethrography". Pediatrics (Clinical Report). 138 (5). American Academy of Pediatrics: e20162590. doi: 10.1542/peds.2016-2590 .
  2. 1 2 3 4 5 6 7 Watson N, Jones H (2018). Chapman and Nakielny's Guide to Radiological Procedures. Elsevier. pp. 138–140. ISBN   9780702071669.
  3. ↑ "Cystocele (Prolapsed Bladder) | NIDDK". National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved 2017-12-17.
  4. ↑ Kawashima, Akira; Sandler, Carl M.; Wasserman, Neil F.; LeRoy, Andrew J.; King, Bernard F.; Goldman, Stanford M. (October 2004). "Imaging of Urethral Disease: A Pictorial Review". RadioGraphics. 24 (suppl_1): S195–S216. doi:10.1148/rg.24si045504. ISSN   0271-5333.
  5. ↑ Johnson EK, Malhotra NR, Shannon R, Jacobson DL, Green J, Rigsby CK, Holl JL, Cheng EY (August 2017). "Urinary tract infection after voiding cystourethrogram". Journal of Pediatric Urology. 13 (4): 384.e1-e7. doi:10.1016/j.jpurol.2017.04.018.(subscription required)
  6. ↑ Herd DW (2008). "Anxiety in Children Undergoing VCUG: Sedation or No Sedation?". Advances in Urology (Review article). 2008. Hindawi Publishing Corporation. doi: 10.1155/2008/498614 . PMC   2443423 . Article ID 498614.
  7. ↑ Merritt, K. A.; Ornstein, P. A.; Spicker, B. (July 1994). "Children's memory for a salient medical procedure: implications for testimony". Pediatrics. 94 (1): 17–23. ISSN   0031-4005. PMID   8008531.
  8. ↑ Liao YH, Lin CL, Wei CC, Tsai PP, Shen WC, Sung FC, Li TC, Kao CH (30 December 2013). "Subsequent cancer risk of children receiving post voiding cystourethrography: A nationwide population-based retrospective cohort study". Pediatric Nephrology. 29 (5): 885–91. doi:10.1007/s00467-013-2703-5.(subscription required)
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