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Cystography Technique

  • Author: Wellman W Cheung, MD, FACS; Chief Editor: Edward David Kim, MD, FACS  more...
 
Updated: Dec 30, 2014
 

Contrast Examination of Bladder

Obtain a scout film of the abdomen and pelvis (kidneys-ureters-bladder [KUB]). With the patient supine, catheterize and drain the bladder using aseptic technique. (See Urethral Catheterization, Men and Urethral Catheterization, Women.) Collect a urine sample in a sterile container for analysis if desired. Tape the catheter securely in position.

Instill the contrast agent through the catheter via gravity. (An intravenous (IV) pole may be helpful in this regard.) For children, the amount of contrast material administered depends on estimated bladder capacity, which is determined as follows:

Expected bladder capacity (mL) = (age + 2) × 30

For adults in the trauma setting, instill 300 to 400 mL of contrast material; false-negative examinations can occur with inadequate distention of the bladder.[20]

Obtain a sequence of views, keeping in mind that pulsed fluoroscopy can reduce the radiation exposure.

The first view is an early filling (anteroposterior [AP]) view of the bladder. In this view, an ureterocele or bladder tumor may be visualized, which may later become obscured by additional contrast material entering the bladder (see the image below).[21]

Ureterocele. Early anteroposterior voiding cystour Ureterocele. Early anteroposterior voiding cystourethrography (VCUG) demonstrates small ureterocele (left). Ureterocele had been seen at prior ultrasonography of bladder. On VCUG obtained after bladder filling (right), ureterocele is obscured by contrast material. Image courtesy of Fernbach SK, Feinstein KA, Schmidt MB. Pediatric voiding cystourethrography: a pictorial guide. Radiographics. 2000;20:155-16.

Next, obtain full bladder (oblique) views, centered on the ureterovesical junction (UVJ). Vesicoureteral reflux (VUR) and bladder diverticula at the posterolateral UVJ can be visualized, as well as the appearance of the bladder wall at capacity (see the image below).[21]

Oblique voiding cystourethrogram obtained at left Oblique voiding cystourethrogram obtained at left ureterovesical junction demonstrates primary vesicoureteral reflux (ie, reflux without underlying abnormality such as bladder diverticulum, neurogenic bladder, or bladder outlet obstruction). Image courtesy of Fernbach SK, Feinstein KA, Schmidt MB. Pediatric voiding cystourethrography: a pictorial guide. Radiographics. 2000;20:155-16.

For a voiding urethra view (see the images below), turn males to the left or right anterior oblique position; females remain in the supine position (see images below). Voiding around the catheter is encouraged and will not obscure detection of posterior urethral valves.[22, 21]

Posterior urethral valves. Oblique voiding cystour Posterior urethral valves. Oblique voiding cystourethrogram shows filling defect in the urethra with marked change in urethral caliber at level of defect, which indicates obstruction. Although catheter has remained in place during voiding, secondary changes crucial to diagnosis—trabeculated bladder, abnormally prominent bladder neck, and dilated and elongated posterior urethra—are clearly depicted. Image courtesy of Fernbach SK, Feinstein KA, Schmidt MB. Pediatric voiding cystourethrography: a pictorial guide. Radiographics. 2000;20:155-16.
Voiding cystourethrogram (VCUG) in patient with bu Voiding cystourethrogram (VCUG) in patient with bulbar urethral stricture. Graphics are superimposed on VCUG to show locations of prostate and external sphincter muscle (posterior urethra). Image courtesy of Joel Gelman, MD.
Voiding cystourethrogram in patient with detrusor Voiding cystourethrogram in patient with detrusor sphincter dyssynergia shows trabeculated bladder wall and lack of cone-shaped bladder neck during voiding.

Next, obtain a postvoiding (AP) bilateral renal view, centered on each renal fossa, to determine whether any contrast has reached the upper urinary tract. If a high degree of reflux is present, obtaining delayed images 15 minutes after voiding can help differentiate between simple reflux and reflux associated with an ureteropelvic or UVJ obstruction.

Finally, obtain a postvoiding (AP) bladder view to assess the degree of emptying (see the image below).[23]

Postvoiding film shows no residual contrast materi Postvoiding film shows no residual contrast material. Image courtesy of Radswiki.net.

The last 3 images may be repeated in a cyclical voiding study. This may be desirable in children younger than 5 years to search for VUR, which may be intermittent. Imaging a second voiding cycle has been shown to increase the VUR detection rate and upstage the grade of reflux detected.[18]

Once the study is complete, drain the bladder and remove the catheter and tape.

In videourodynamics, the bladder is catheterized and drained before catheterization with the urodynamics catheter. Infusion of contrast material into the bladder is usually controlled by a pump (which may be set to various rates, depending on the context of the study), with the infused volumes precisely recorded. After the patient is prepared, scout films are obtained to check for proper patient positioning with respect to the fluoroscope. The examiner obtains fluoroscopic images at relevant points during the study.

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Complications

The most common complications of cystography are postprocedural dysuria and perineal discomfort, usually attributable to the catheterization rather than to the contrast material.[24] The discomfort is usually transient; if patients are warned in advance that it might occur, they are less likely to become anxious if it does.

Urinary tract infections (UTIs) are also more common after cystography. Careful aseptic technique and judicious use of antibiotic prophylaxis can help decrease its incidence.

During urodynamic evaluation, patients may also experience a vasovagal response or syncope. In most cases, stopping bladder filling and permitting the patient to lie down for a while will allow the study to be resumed.

Autonomic dysreflexia is a potential life-threatening complication. Once it is identified, immediately drain the bladder and remove the catheter and stop the study. Having an open urethral catheterization setup for immediate access would be helpful. If blood pressure remains elevated, an antihypertensive agent with quick onset and short duration of action (eg, nifedipine or a nitrate) may be given, and blood pressure is monitored.

Hypersensitivity to the contrast material absorbed into the bloodstream through the bladder mucosa and subsequent anaphylactoid reactions have been reported.[25] Bladder perforation is extremely rare. If a feeding tube is used as a catheter, it should not be advanced any more than 1-2 cm further after urine is obtained; there is a risk that it may become knotted and difficult to remove.

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Contributor Information and Disclosures
Author

Wellman W Cheung, MD, FACS Clinical Professor, Department of Urology and Department of Obstetrics and Gynecology, State University of New York Downstate Medical School

Wellman W Cheung, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Chinese American Medical Society, Endourological Society, American Urogynecologic Society, International Urogynaecology Association, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction

Disclosure: Received grant/research funds from Astallas for pi.

Coauthor(s)

Sophia Kawa Chiu, MD, MA, MSc Resident Physician, Department of Urology, State University of New York Downstate Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

Acknowledgements

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References
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Ureterocele. Early anteroposterior voiding cystourethrography (VCUG) demonstrates small ureterocele (left). Ureterocele had been seen at prior ultrasonography of bladder. On VCUG obtained after bladder filling (right), ureterocele is obscured by contrast material. Image courtesy of Fernbach SK, Feinstein KA, Schmidt MB. Pediatric voiding cystourethrography: a pictorial guide. Radiographics. 2000;20:155-16.
Oblique voiding cystourethrogram obtained at left ureterovesical junction demonstrates primary vesicoureteral reflux (ie, reflux without underlying abnormality such as bladder diverticulum, neurogenic bladder, or bladder outlet obstruction). Image courtesy of Fernbach SK, Feinstein KA, Schmidt MB. Pediatric voiding cystourethrography: a pictorial guide. Radiographics. 2000;20:155-16.
Posterior urethral valves. Oblique voiding cystourethrogram shows filling defect in the urethra with marked change in urethral caliber at level of defect, which indicates obstruction. Although catheter has remained in place during voiding, secondary changes crucial to diagnosis—trabeculated bladder, abnormally prominent bladder neck, and dilated and elongated posterior urethra—are clearly depicted. Image courtesy of Fernbach SK, Feinstein KA, Schmidt MB. Pediatric voiding cystourethrography: a pictorial guide. Radiographics. 2000;20:155-16.
Voiding cystourethrogram (VCUG) in patient with bulbar urethral stricture. Graphics are superimposed on VCUG to show locations of prostate and external sphincter muscle (posterior urethra). Image courtesy of Joel Gelman, MD.
Voiding cystourethrogram in patient with detrusor sphincter dyssynergia shows trabeculated bladder wall and lack of cone-shaped bladder neck during voiding.
Postvoiding film shows no residual contrast material. Image courtesy of Radswiki.net.
Gross anatomy of the bladder.
 
 
 
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