Pediatric Voiding Cystourethrography: A Pictorial Guide1
Sandra K. Fernbach, MD,
Kate A. Feinstein, MD and
Mary Beth Schmidt, MD
1 From the Department of Radiology, Evanston Hospital, 2650 Ridge Ave, Evanston, IL 60201 (S.K.F.); the Department of Radiology, Rush-Presbyterian-St Luke's Medical Center, Chicago, Ill (K.A.F.); and the Department of Radiology, Children's Memorial Hospital, Chicago, Ill (M.B.S.). Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received February 24, 1999; revision requested April 6 and final revision received August 18; accepted August 23. Address reprint requests to S.K.F.
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Figure 1. Epispadias in a girl with a bifid clitoris. Abdominal radiograph shows a widened symphysis pubis (arrows), which was the first sign of epispadias. Bifid clitoris, a clinical sign of epispadias, had not been noted previously. The associated absence of the external sphincter resulted in a negligible bladder capacity and immediate filling of the urethra, simulating a spastic bladder.
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Figure 2. Abnormal sacrum. Abdominal radiograph shows a deformed sacrum (scimitar sacrum), which was associated with a tethered spinal cord and a bladder capacity of 25 mL.
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Figure 3. Chronic lead ingestion. Abdominal radiograph shows dense bands in the iliac bones (arrowheads) and proximal femoral metaphyses (arrows).
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Figure 4. Foreign body in a girl with spinal dysraphism. Abdominal radiograph shows the tip of a lubricant tube that the patient had introduced into the bladder during clean intermittent catheterization.
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Figure 5a. Prostatic rhabdomyosarcoma. (a) Oblique voiding cystourethrogram demonstrates irregularity of the bladder base and an intravesical filling defect (arrowheads) caused by tumoral invasion of the bladder lumen. (b) On an oblique voiding cystourethrogram obtained shortly after a, the intravesical extension is obscured by contrast material in the distended bladder.
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Figure 5b. Prostatic rhabdomyosarcoma. (a) Oblique voiding cystourethrogram demonstrates irregularity of the bladder base and an intravesical filling defect (arrowheads) caused by tumoral invasion of the bladder lumen. (b) On an oblique voiding cystourethrogram obtained shortly after a, the intravesical extension is obscured by contrast material in the distended bladder.
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Figure 6a. Ureterocele. (a) Early anteroposterior voiding cystourethrogram demonstrates a small ureterocele. The ureterocele had been seen at prior ultrasonography of the bladder. (b) On a voiding cystourethrogram obtained after bladder filling, the ureterocele is obscured by contrast material. (c) On an oblique cystourethrogram obtained during voiding, the ureterocele is seen to evert and simulate a bladder diverticulum.
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Figure 6b. Ureterocele. (a) Early anteroposterior voiding cystourethrogram demonstrates a small ureterocele. The ureterocele had been seen at prior ultrasonography of the bladder. (b) On a voiding cystourethrogram obtained after bladder filling, the ureterocele is obscured by contrast material. (c) On an oblique cystourethrogram obtained during voiding, the ureterocele is seen to evert and simulate a bladder diverticulum.
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Figure 6c. Ureterocele. (a) Early anteroposterior voiding cystourethrogram demonstrates a small ureterocele. The ureterocele had been seen at prior ultrasonography of the bladder. (b) On a voiding cystourethrogram obtained after bladder filling, the ureterocele is obscured by contrast material. (c) On an oblique cystourethrogram obtained during voiding, the ureterocele is seen to evert and simulate a bladder diverticulum.
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Figure 7. Grading of vesicoureteral reflux with the International Reflux System. Drawings illustrate the five grades (I-V) of vesicoureteral reflux. Grade I represents reflux into the ureter. Grade II represents reflux into a nondilated ureter and nondilated pelvicaliceal system. Grade III represents reflux into a mildly dilated ureter and pelvicaliceal system. The forniceal angles and papillary impressions remain distinct. Grade IV represents reflux into a tortuous ureter and dilated pelvicaliceal system. The forniceal angles become blunted while the papillary impressions remain distinct. Grade V represents reflux into a markedly dilated and tortuous ureter and marked dilation of the pelvicaliceal system. Both the forniceal angles and the papillary impressions are obliterated.
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Figure 8. Intrarenal reflux. Anteroposterior voiding cystourethrogram demonstrates contrast material in the parenchyma adjacent to the upper and middle calices (arrows). The abnormal axis of the collecting system indicates that the ureters are duplicated. Intrarenal reflux is more common in very young patients and does not change the grade of reflux (grade IV in this case).
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Figure 9. Secondary reflux. Oblique voiding cystourethrogram shows the ureter inserting directly into the bladder diverticulum. This type of lesion prevents normal maturation of the ureterovesical junction and requires surgery to correct the reflux.
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Figure 10a. Good positioning. (a) Oblique voiding cystourethrogram demonstrates a normal right ureterovesical junction. (b) Oblique voiding cystourethrogram obtained at the left ureterovesical junction demonstrates primary vesicoureteral reflux (ie, reflux without an underlying abnormality such as bladder diverticulum, neurogenic bladder, or bladder outlet obstruction).
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Figure 10b. Good positioning. (a) Oblique voiding cystourethrogram demonstrates a normal right ureterovesical junction. (b) Oblique voiding cystourethrogram obtained at the left ureterovesical junction demonstrates primary vesicoureteral reflux (ie, reflux without an underlying abnormality such as bladder diverticulum, neurogenic bladder, or bladder outlet obstruction).
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Figure 11. Poor positioning. Oblique voiding cystourethrogram shows the bladder filled with contrast material but only limited depiction of contrast material within the ureter.
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Figure 12a. Hidden diverticulum. (a) Oblique voiding cystourethrogram demonstrates a posterolateral bladder diverticulum. (b) On an anteroposterior voiding cystourethrogram, the diverticulum is not visualized.
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Figure 12b. Hidden diverticulum. (a) Oblique voiding cystourethrogram demonstrates a posterolateral bladder diverticulum. (b) On an anteroposterior voiding cystourethrogram, the diverticulum is not visualized.
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Figure 13a. Bilateral ureteral duplication. (a) Anteroposterior voiding cystourethrogram demonstrates upper pole reflux bilaterally (arrows). Reflux into an upper pole is rare in children with complete ureteral duplication; therefore, this finding suggested incomplete ureteral duplication. (b) Oblique voiding cystourethrogram demonstrates incomplete ureteral duplication. In an incompletely duplicated system, the grade of reflux is not necessarily the same in the upper and lower segments.
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Figure 13b. Bilateral ureteral duplication. (a) Anteroposterior voiding cystourethrogram demonstrates upper pole reflux bilaterally (arrows). Reflux into an upper pole is rare in children with complete ureteral duplication; therefore, this finding suggested incomplete ureteral duplication. (b) Oblique voiding cystourethrogram demonstrates incomplete ureteral duplication. In an incompletely duplicated system, the grade of reflux is not necessarily the same in the upper and lower segments.
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Figure 14a. Vaginal reflux simulating spinning top urethra. (a) On an anteroposterior voiding cystourethrogram obtained with the patient supine, contrast material passing through the urethra is superimposed on the contrast material-filled vagina, causing the urethra to appear abnormally wide (arrowheads). The smooth-walled urethral channel can be distinguished from the more irregular walls of the vagina. (b) On an oblique voiding cystourethrogram obtained after voiding, the vagina is completely opacified, which is a common finding with supine urination.
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Figure 14b. Vaginal reflux simulating spinning top urethra. (a) On an anteroposterior voiding cystourethrogram obtained with the patient supine, contrast material passing through the urethra is superimposed on the contrast material-filled vagina, causing the urethra to appear abnormally wide (arrowheads). The smooth-walled urethral channel can be distinguished from the more irregular walls of the vagina. (b) On an oblique voiding cystourethrogram obtained after voiding, the vagina is completely opacified, which is a common finding with supine urination.
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Figure 15. Bladder sphincter dyssynergia. Oblique voiding cystourethrogram demonstrates an unusual urethral caliber and multiple bladder diverticula due to bladder contractions against the incompletely relaxed external sphincter. These findings indicate a neurogenic bladder.
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Figure 16a. Anterior urethral stricture. (a) Oblique voiding cystourethrogram of the posterior urethra poorly depicts a stricture, which is seen near the edge of the image (arrow). (b) On an oblique voiding cystourethrogram of the anterior urethra (including the urethral meatus) from the same study, the stricture is clearly visible.
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Figure 16b. Anterior urethral stricture. (a) Oblique voiding cystourethrogram of the posterior urethra poorly depicts a stricture, which is seen near the edge of the image (arrow). (b) On an oblique voiding cystourethrogram of the anterior urethra (including the urethral meatus) from the same study, the stricture is clearly visible.
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Figure 17. Meatal stenosis. Oblique voiding cystourethrogram demonstrates marked dilation of the prostatic urethra due to obstruction at the narrowed meatus. Note the abrupt change in the caliber of the contrast material stream at the level of the meatus. Although meatal stenosis can frequently be diagnosed clinically, imaging may be required to exclude a second lesion prior to surgical correction of the meatal lesion.
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Figure 18. Posterior urethral valves. Oblique voiding cystourethrogram shows a filling defect in the urethra with a marked change in urethral caliber at the level of the defect, a finding that indicates obstruction. Although the catheter has remained in place during voiding, the secondary changes crucial to the diagnosis—trabeculated bladder, abnormally prominent bladder neck, and dilated and elongated posterior urethra—are clearly depicted (16,17).
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Figure 19. Utricle. Lateral voiding cystourethrogram demonstrates a utricle, which is a variant of prostatic urethral anatomy. During voiding, contrast material enters and becomes diluted in the utricle. When the utricle is large and is associated with a short urethra as in this case, intersex should be considered (18). A large utricle can be mistaken for a bladder diverticulum if its origin in the prostatic urethra is not appreciated.
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Figure 20. Reflux into a horseshoe kidney. Anteroposterior voiding cystourethrogram shows opacification of the collecting system, in which the upper calices are lateral to the lower calices, due to grade II reflux. This finding suggests the midline connection of a horseshoe kidney.
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Figure 21a. Ureteropelvic junction obstruction. (a) Oblique voiding cystourethrogram demonstrates contrast material filling the slightly dilated ureter but becoming diluted as it enters the more dilated renal pelvis (arrowheads). (b) Anteroposterior voiding cystourethrogram obtained after voiding shows no contrast material in the ureter but does demonstrate marked dilation of the contrast material-filled, obstructed right pelvicaliceal system. The International Reflux System should not be used to grade this reflux. Contrast material has been retained in the nondilated, nonobstructed left pelvicaliceal system.
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Figure 21b. Ureteropelvic junction obstruction. (a) Oblique voiding cystourethrogram demonstrates contrast material filling the slightly dilated ureter but becoming diluted as it enters the more dilated renal pelvis (arrowheads). (b) Anteroposterior voiding cystourethrogram obtained after voiding shows no contrast material in the ureter but does demonstrate marked dilation of the contrast material-filled, obstructed right pelvicaliceal system. The International Reflux System should not be used to grade this reflux. Contrast material has been retained in the nondilated, nonobstructed left pelvicaliceal system.
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Figure 22. Pseudoureterocele. Anteroposterior voiding cystourethrogram shows a collection of air on the left side producing a filling defect (arrowheads). The air was introduced into the bladder via a catheter. Air can also simulate tumor or blood clots.
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Figure 23. Duplicated ureters. Anteroposterior voiding cystourethrogram of a patient with grade II reflux demonstrates a small, malrotated pelvicaliceal system, which is the lower pole in a duplicated system. The abnormal orientation of the calices should suggest ureteral duplication or fusion anomaly (eg, horseshoe kidney).
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Figure 24. Abnormal ureteral insertion. Oblique voiding cystourethrogram demonstrates insertion of the ureter into the urethra. This finding was associated with grade V reflux and a nonfunctioning kidney.
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Figure 25. Urachal remnant, posterior urethral valves, and reflux. Oblique voiding cystourethrogram demonstrates a large urachal remnant extending from the superior aspect of the small-capacity bladder. Reflux, which is reported in about one-third of children with posterior urethral valves, is also present in this case. Although the valve is clearly seen (arrow), the secondary changes are not well developed due to aberrant micturition into the urachal remnant and ureter.
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Copyright © 2000 by the Radiological Society of North America.
