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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.
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).
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).
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]
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).
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.
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.
The most common complications of cystography are postprocedural dysuria and perineal discomfort, usually attributable to the catheterization rather than to the contrast material. 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. 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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