Medication Summary
The goals of pharmacotherapy are to reduce anxiety, morbidity, and prevent complications.
Anxiolytics, Benzodiazepines
Class Summary
This drug class alleviates anxiety by prolonging the inhibitory effects of gamma-aminobutyrate (GABA), as well as other inhibitory neurotransmitters.
Midazolam
Midazolam is a short-acting benzodiazepine used for short-term sedation. It has been shown to be effective in reducing distress before voiding cystourethrography (VCUG) and does not interfere with the urodynamics being studied.
Antihypertensives, Other
Class Summary
Given that autonomic dysreflexia is a rare but life-threatening complication, a fast-acting antihypertensive is useful, especially if arterial pressure remains elevated after stopping the procedure.
Esmolol (Brevibloc)
Esmolol is an ultra–short-acting beta2-blocker. It is particularly useful in patients with labile arterial pressure, especially if surgery is planned, because it can be discontinued abruptly if necessary. This agent is normally used in conjunction with nitroprusside. It may be useful as a means to test beta-blocker safety and tolerance in patients with a history of obstructive pulmonary disease who are at possible risk of bronchospasm from beta-blockade. The elimination half-life of esmolol is 9 minutes.
Labetalol (Trandate)
Labetalol blocks alpha-, beta1-, and beta2-adrenergic receptor sites, decreasing blood pressure.
Propranolol (Inderal LA, InnoPran XL)
Propranolol is a class II antiarrhythmic nonselective beta-adrenergic receptor blocker. It has membrane-stabilizing activity and decreases the automaticity of contractions. Propranolol is not suitable for emergency treatment of hypertension. Do not administer propranolol intravenously in hypertensive emergencies.
Metoprolol (Lopressor, Toprol XL)
Metoprolol is a selective beta1-adrenergic receptor blocker that decreases the automaticity of contractions. During IV administration, carefully monitor the blood pressure, heart rate, and electrocardiogram (ECG). When considering conversion from intravenous to oral dosage forms, use the ratio of 1 mg IV to 2.5 mg PO metoprolol.
Nitroprusside (Nitropress)
Nitroprusside causes peripheral vasodilation by direct action on venous and arteriolar smooth muscle, thus reducing peripheral resistance. It is commonly given intravenously because of its rapid onset and short duration of action. It is easily titratable to reach the desired effect.
Nitroprusside is light sensitive; both bottle and tubing should be wrapped in aluminum foil. Before initiating nitroprusside, administer a beta-blocker to counteract the physiologic response of reflex tachycardia that occurs when nitroprusside is used alone. This physiologic response increases shear forces against the aortic wall, thus increasing arterial pressure. The objective is to keep the heart rate at 60-80 bpm.
Nifedipine (Procardia)
Nifedipine is a calcium channel blocker that can be considered in cases in which beta-blockers are contraindicated, such as in patients with chronic obstructive pulmonary disease who have known bronchospasm or those with second- or third-degree atrioventricular block.
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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.
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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.
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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.
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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.
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Voiding cystourethrogram in patient with detrusor sphincter dyssynergia shows trabeculated bladder wall and lack of cone-shaped bladder neck during voiding.
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Postvoiding film shows no residual contrast material. Image courtesy of Radswiki.net.
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Gross anatomy of the bladder.
