Voiding Cystourethrogram
Outline
• Indications
• Preparation for the examination
• Technique
• Examples
Indications
MOST COMMON Additional indications:
INDICATION: – Congenital anomalies of
– Vesicoureteral reflux urinary tract
(VUR) – Incontinence
• Hydronephrosis seen – Postoperative evaluation
on renal ultrasound
– Dysuria/difficulty voiding
• Urinary tract infection
– Dysfunctional voiding
Information to know before
doing the examination
• Age of the patient
• Pertinent past medical history
• Past surgical history (urinary bladder, ureters, urethra)
• Prior imaging studies
– Renal ultrasound
– Prior VCUG (if performed)
• Foley catheter or suprapubic catheter in place?
Preparation for the examination
Contrast
• Cysto-Conray II
(Iothalamate meglumin
injection USP 17.2%)
– Ionic, high osmolar
contrast agent
– Intended for instillation
into the urinary system
Basic Fluoro Rules in Kids
• Bring image intensifier as close as possible to the child
• Collimate
• Pulsed fluoro at lowest frame rate possible
• Magnification increases radiation dose
• Use fluoro store as primary imaging modality
– Radiographic exposures if there is a question about
something or need to delineate abnormality clearer
Anatomy
Anatomy
Normal flow of urinary bladder
Anatomy
Vesicoureteral Reflux
Technique
Sterile Catheterization
Attempt 8 French feeding catheter in all cases
• No balloon Foley catheter used
• Catheter secured in place by tape
• If difficult to catheterize with 8 French, can try 5 French catheter
• If congenital anomaly or postsurgical
– Try once
– Call urology to come down to help with catheterization
• Once catheter is in, empty the urinary bladder completely prior to
beginning the examination
– Urine in the bladder will dilute the contrast and make it difficult to see
Technique
Imaging
First Image:
Scout radiograph in the
supine position
– Include the abdomen
– Check correct
catheter position
Technique
Imaging
CONTRAST
Turn on the contrast
– Keep the pole with bottle in
FRONT of you and at the
highest position possible.
– Instill contrast under
gravity
– Pulse fluoro throughout the
examination and store
fluoro images
Technique
Imaging
Second Image:
Early filling shots of
the bladder
Technique
Imaging
Early filling shots of
the bladder
– Evaluate for
ureterocele
Technique
Imaging
• The next image you NEED to get is the
voiding image
– Male patient- oblique view AWAY from you with
the entire urethra in the image
– Female patient- supine view for voiding
Technique
Imaging
Males Females
– Oblique view – Supine
– Include entire urethra – Short urethra
Technique
Imaging
How to know when the patient is voiding
– Non potty trained children
• Look at when the bubbles slow down/stop in the bottle
– Potty trained children
• When the patient tells you they are ready to void
Technique
Imaging
Voiding views
– Have the upper
portion of the
urinary bladder in
the view
• Look for reflux
Technique
Imaging
Pitfall on voiding
view in females
– Reflux into the
vagina
Technique
Imaging
After voiding images,
take a look at the renal
fossa to make sure there
is no reflux into the
collecting system
Expected location of the reflux if it is there
Technique
Imaging
• Less than 1 year old
– Image for 3 voiding cycles
• More than 1 year old
– Image for 1 voiding cycle
Technique
Imaging
If there is vesicoureteral
reflux
– Do a 10 minute delay
radiograph of the
abdomen
• Done to evaluate emptying
of the reflux
• Determine if concomitant
obstruction with the reflux
REVIEW
Images needed for complete exam
– Scout radiograph with catheter in place
– Early filling views of the urinary bladder
• Ureterocele?
– Voiding views
• Full urinary bladder view at the beginning of the void
• Entire urethra included on the views
• Include top of the urinary bladder and renal fossa (if
possible) to evaluate for reflux
• If less than 1 year of age-> 3 voiding images
– If VUR-> 10 minute delayed radiograph
Technique
• DO NOT need to continuously watch as the
urinary bladder fills
• When the bubbles stop or the patient is
voiding-> look then
• Can look intermittently if there is a question if
the patient is voiding in order to not miss it
Technique
• Whenever you look with fluoro-> always store
fluoro the image
– It is OK to get extra images
– BUT need to get the standard images as part of
the study
• Scout image
• Early urinary bladder filling image
• Voiding Image
Normal VCUG
Scout Film
Normal VCUG
Early Bladder Filling Image
Normal VCUG
Early Bladder Filling Image
Normal VCUG
Voiding Image
Abnormal VCUG
Grading system of VUR
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
Grade 1- Contrast reaches distal ureter
Grade 2 through 4- contrast reached the renal pelvis, with progressive increase in
pelviectasis and caliectasis, and ureter dilatation
Grade 5- intrarenal reflux
References
ACR- SPR Practice Parameter fo rthe Performance of voiding
cystourethrography in children. ACR Practice Parameter. Revised 2014.
Fernbach SK et al. Pediatric voiding cystourethrography: A pictorial guide.
RadioGraphics 2000;20:155-68.
Lim R. Vesicoureteral reflux and urinary tract infection: evolving practices
and current controversies in pediatric imaging. AJR 2009; 192: 1197-1208.