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The term cystourethrography refers to a radiographic examination of the bladder and the urethra; the term cystography refers to a conventional radiographic examination of the bladder with contrast medium instilled through a urethral catheter. Cystography allows the evaluation of both anatomic defects and functional anomalies.
With the ongoing advances in imaging techniques (eg, voiding urosonography and eventually, perhaps, nonionizing photoacoustic cystography ), traditional cystography may no longer be the imaging examination of choice. For example, retrograde computed tomographic (CT) cystography may be preferred in the setting of trauma (see Bladder Trauma Imaging).[3, 4]
Nevertheless, cystography is still commonly performed in the form of voiding cystourethrography (VCUG), predominantly in children, and can serve as an adjunct to urodynamic evaluation in videourodynamics.
The anatomy of the bladder forms an extraperitoneal muscular urine reservoir that lies behind the pubic symphysis in the pelvis. A normal bladder functions through a complex coordination of musculoskeletal, neurologic, and psychological functions that allow filling and emptying of the bladder contents. The prime effector of continence is the synergic relaxation of detrusor muscles and contraction of the bladder neck and pelvic floor muscles. See the image below.
For more information about the relevant anatomy, see Bladder Anatomy.
Cystography is indicated for evaluation of bladder lesions (eg, diverticula, foreign bodies, or fistulas), rupture, or leakage. Indications for imaging in blunt trauma include gross hematuria or nonacetabular pelvic fracture with significant microscopic hematuria (>25-30 red blood cells [RBCs] per high-power field [HPF]).
In a study of CT cystography in which 157 blunt trauma patients were evaluated, one third of the bladder injuries identified would have been missed by the traditional criteria of pelvic fracture and gross hematuria: of the 12 patients found to have bladder injury, 8 had gross hematuria and 4 had significant microscopic hematuria (>25 RBCs/HPF).
Urinary tract infection (UTI) constitutes an indication for VCUG. However, the necessity of performing VCUG after UTIs in children has been controversial. In 1999, the American Academy of Pediatrics released a guideline containing the following recommendations :
Febrile infants and children aged 2 months to 2 years who do not exhibit the expected clinical response to antimicrobial therapy should undergo ultrasonography promptly and VCUG or radionuclide cystography at earliest convenience
Children aged 2 months to 2 years who do respond appropriately should undergo ultrasonography and VCUG or radionuclide cystography at earliest convenience
A subsequent review suggested routine VCUG in the following populations :
Children younger than 5 years with a febrile UTI
Males of any age with a first UTI
Females younger than 2 years with a febrile UTI
Children with recurrent UTIs
Although most clinicians recommend waiting 3 to 6 weeks and providing antibiotic prophylaxis in the interim, VCUG can be performed as soon as the patient resumes pre-UTI voiding patterns. A retrospective review found no difference in the detection rate for vesicoureteral reflux (VUR) between patients who underwent VCUG 1 week after the diagnosis of UTI and those who underwent VCUG more than 1 week after diagnosis; however, more than half of those scheduled for late VCUG did not have the study performed.
Other indications for VCUG include the following:
Follow-up evaluation of VUR
Dalirani et al conducted a study to assess the value of direct radionuclide cystography (DRNC) in the detection of vesicoureteral reflux (VUR) in children with urinary tract infection (UTI) and a normal voiding cystourethrography (VCUG). The authors concluded that DRNC may reveal VUR despite a normal VCUG in children with hydronephrosis, abnormal acute DMSA, and/or recurrent febrile UTI.
Urodynamics is the standard evaluation for all forms of voiding dysfunction. It is especially helpful in cases where the underlying pathophysiology may alter treatment, guide surgical intervention, or require monitoring. Urodynamics with concurrent radiologic visualization (ie, videourodynamics) is recommended in patients at high risk for complicated voiding dysfunction, such as the following:
Patients with known or suspected neurogenic bladder
Patients who have previously undergone radical pelvic surgery or irradiation
Patients with urinary diversion
Renal transplant patients
Contraindications for cystography include the following:
Active clinical UTI
Allergy or sensitivity to contrast medium
The presence of labial adhesions is a relative contraindication for VCUG ; VCUG is usually performed after the adhesions have been released.
For an effective videourodynamic evaluation, the patient must be able to communicate and cooperate. If the patient is unable to do so (eg, if he or she is severely demented or psychotic), the risk-benefit ratio of videourodynamics must be carefully considered.
Ascertain whether the patient has latex allergy or sensitivity to contrast media. Urine dipstick may be performed on the day of the examination.
According to the American Urological Association’s Best Practice Policy Statement on Antimicrobial Prophylaxis, prophylactic antibiotics for cystourethrography or urodynamic studies are recommended only for patients with risk factors. The revised American Heart Association guidelines no longer recommend prophylactic antibiotics solely for the prevention of infective endocarditis in patients undergoing procedures involving the genitourinary tract.
In spinal cord injury patients with lesions above the splanchnic sympathetic outflow tract (T5-T6), bladder filling during cystourethrography or urodynamics may trigger a life-threatening imbalance in reflexive sympathetic discharge. (See Autonomic Dysreflexia in Spinal Cord Injury .) Signs of autonomic dysreflexia include piloerection, skin pallor, sudden and severe hypertension with compensatory bradycardia, and profuse sweating and flushing above the level of the injury.
An open and sterile urinary catheterization catheter kit may be prepared in case there is an urgent need to drain the bladder. If a patient is known to have a diagnosis of autonomic dysreflexia, prophylactic nifedipine or an alpha-blocker may be given, and blood pressure should be monitored throughout the study.
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