(Radiographics. 2000;20:155-168.)
© RSNA, 2000
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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Abstract
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Voiding cystourethrography is commonly performed in children with prenatally diagnosed hydronephrosis, urinary tract infections, and voiding abnormalities. Voiding cystourethrography can be performed with many variations designed to optimize visualization of disease and minimize radiation exposure. The procedure should include assessment of the spine and pelvis; masses or opaque calculi; bladder capacity, contour, and emptying capability; presence and grade of reflux; and urethral appearance. Radiologists differ as to whether the patient should void prior to catheterization. Anteroposterior imaging of the bladder is performed during early filling; little or no imaging is necessary during intermediate filling. When bladder filling is complete, steep oblique images that are centered on the ureterovesical junction should be obtained. If reflux is observed, the ipsilateral renal fossa may be imaged prior to voiding. With a smaller than expected voiding volume, bladder refilling is recommended. Voiding around the catheter is also strongly recommended. In girls, one anteroposterior image of the urethra is usually sufficient; in boys, the entire urethra must be imaged. Steep oblique imaging is optimal. At the conclusion of voiding, each renal fossa should be imaged to detect reflux missed at fluoroscopy as well as other anomalies. Familiarity with these abnormalities and use of proper techniques will allow detection of most common pathologic conditions with very low radiation exposure.
Index Terms: Bladder, radiography, 83.123 • Catheters and catheterization, in infants and children, 80.4611 • Radiography, in infants and children, 80.123 • Ureter, reflux, 82.85 • Urethra, radiography, 84.1232, 85.1233 • Voiding cystourethrography, 80.123
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Introduction
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Voiding cystourethrography is a fluoroscopic examination that was introduced several decades ago and is commonly performed in children by general and pediatric radiologists. Familiarity with the anomalies and abnormalities that may occur in this patient population and use of techniques that improve visualization of disease allow detection of most common pathologic conditions with very low radiation exposure (1–3). Conversely, use of poor technique may result in excessive radiation exposure and poor disease depiction. In this article, we discuss the rationale for selected techniques of voiding cystourethrography. We also describe and illustrate the results of using good technique and the problems associated with poor technique.
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Preliminary Imaging
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Clinical data and results of prior imaging studies should be reviewed before starting the examination. Preliminary abdominal imaging usually precedes catheterization. If an abdominal radiograph or other stored image obtained within the past 3–6 months is available, a scout image may be unnecessary. This recently obtained image may provide information that directs the remainder of the examination. For example, an abdominal radiograph may reveal bone abnormalities, calcifications, foreign bodies, or other disease processes. At times, these findings may be crucial to the diagnosis (Figs 1–4).
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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 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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Catheterization
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The placement of the catheter is always of great concern to parents and to children old enough to understand an explanation of the procedure. Catheterization in children may also produce apprehension in staff who are unfamiliar with but are expected to perform the procedure. Catheterization can be performed atraumatically by experienced personnel.
Direct lighting and adequate manual separation of the labia are necessary to achieve adequate visualization of the urethra. Improved visualization of the urethra can be achieved with the following procedure: First, the intralabial region is generously cleansed with povidone iodine solution, after which the region is dried slightly with a cotton ball. A small drop of the solution remains pooled in the midline, depressed, slightly oval meatus, which thus becomes a clearly visible and easy target. This technique helps prevent accidental catheterization of the vagina and, more importantly, repeated poking of the sensitive perineum. A 5-F feeding tube is appropriate in children under 3 months of age and an 8-F feeding tube in all other children. Some authors use 8–12-F red rubber catheters (2), but we do not stock these lest one be used inadvertently in a child with latex sensitivity.
The external portion of the tube is taped to the inner thigh in girls. In boys, a long piece of tape is used to affix the catheter firmly along the lower abdomen and less firmly along the dorsum of the penis. This holds the catheter securely in place while allowing easy, nontender removal.
In boys, the external sphincter is the most common site of resistance to catheter advancement. Gentle, steady pressure rather than intermittent poking at this level permits advancement into the bladder. In older boys, retrograde injection of 2% lidocaine jelly into the urethra may be used to diminish sensation; this should be performed several minutes before catheterization to allow the medication to take effect.
Some radiologists prefer that the child not void prior to catheterization so that the presence of urine in the feeding tube can be used to confirm correct catheter placement. A secondary benefit of having the patient maintain a filled bladder is that a noncontaminated urine specimen can be obtained when clinically desired. Many pediatricians appreciate and take advantage of this option. Other radiologists prefer to have the child void prior to catheterization. This allows the postvoiding residual volume in the bladder, if any, to be measured at the time of catheterization. Occasionally, a small residual amount of urine will be available for culture.
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Bladder Filling
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Early Filling
Several seconds after the contrast material begins to flow, the minimally filled bladder is imaged in the anteroposterior projection. In most children, this will be the only direct anteroposterior image of the bladder. A ureterocele or bladder tumor that is well seen during early filling may become obscured as more contrast material enters the bladder (Figs 5, 6) (4).
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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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Intermediate Filling
Little or no imaging is necessary during bladder filling (1–3). If there is a desire to determine the bladder volume at which reflux occurs or the volume of ureteral reflux, both of which have prognostic significance, nuclear cystography is recommended (5,6). Nuclear cystography provides this information with little gonadal radiation exposure (5) and should be considered for screening (a) all girls, (b) boys in whom the urethra was evaluated previously and shown to be normal, and (c) siblings of children with known reflux.
Vesicoureteral reflux can be seen on oblique radiographs obtained just before voiding and can be graded after voiding with the International Reflux System (Figs 7, 8) (7). This grading system is based on the height to which contrast material ascends within the ureter and the degree of distention of the pelvicaliceal system. Each grade has prognostic significance, even in children with reflux into the lower pole of a system with duplicated ureters (Fig 8). All grades of reflux can be outgrown, but the process is seen more frequently and takes less time in patients with low-grade reflux (8–10). For example, 80%–82% of children with grade I or II vesicoureteral reflux will outgrow the reflux within 5 years (10). Only 46% of children with grade III vesicoureteral reflux will outgrow reflux in this same period, and 50% of those with grade IV reflux will continue to experience reflux 9 years after initial diagnosis (9,10). In addition, renal scarring is more likely to occur in patients with high-grade vesicoureteral reflux (9). Children with grade V reflux are usually treated surgically; infants are excepted because grade V reflux has been shown to diminish and disappear in this patient population.
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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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When a periureteral bladder diverticulum is associated with reflux, the grade is not prognostic. In such cases, surgical correction is usually required because maturational changes are unlikely to occur at the ureterovesical junction (Fig 9) (11).
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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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Prevoiding Imaging
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Older children may indicate when voiding is imminent, but even in younger children, observation of the rate of contrast material flow from the bottle can be instructive. As bladder capacity is reached, the flow of contrast material may slow, stop, or even reverse in the tubing. In younger children, the rate of contrast material flow indicates the status of bladder filling without fluoroscopy or radiation exposure.
When the flow of contrast material stops, indicating an abrupt rise in intravesical pressure and complete bladder filling, steep oblique images of the bladder that are centered on the ureterovesical junction should be obtained. This decreases contralateral gonadal exposure in female patients and increases detection of therapeutically significant abnormalities such as bladder diverticula at the posteriorly and laterally located ureterovesical junction (Fig 10) (3). When radiographs or fluoroscopic images centered on the contrast material–filled bladder are obtained, the bladder impedes radiation from reaching the phototimers, especially if the center cell is used. Exposure is complete only when these devices have received a preset amount of radiation. All radiation reaching the phototimers must pass through the perivesical structures; thus, anteroposterior imaging in this setting causes excessive gonadal exposure, and vesicoureteral reflux and perivesical anomalies become harder to visualize (Figs 11–13).
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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 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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If reflux is observed during late bladder filling, the ipsilateral renal fossa may be imaged in the anteroposterior projection prior to voiding. To decrease gonadal exposure in female patients, spot radiographs of the renal fossa should be centered on the fossa and should not include the region of the gonads or the urine-filled bladder.
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Imaging During Voiding
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Bladder capacity (in milliliters) is variable but can often be predicted with the following formula (12,13):
A voiding volume that is much smaller than expected may be due to bladder irritation from the catheter; in such cases, the bladder tends to hold a greater volume when refilled.
A smaller than expected voiding volume may also indicate a neurologic abnormality (spastic bladder) or active bladder infection. Refilling of the bladder with attention to bladder volume is recommended to document the reproducibility of this finding. An unexpectedly large bladder capacity may be due to noncompliance in recently toilet-trained children or in children who have difficulty voiding in new settings ("sensitive voiders") (13). It may also be a sign of infrequent, incomplete, or dysfunctional voiding, which may in turn be related to urinary tract infection (14).
Although the catheter may be removed as voiding is initiated, voiding around the catheter is strongly recommended because it allows the desired cyclic voiding in neonates, repeat filling if the examination is technically suboptimal, and bladder drainage in patients who are unable to empty the bladder completely (15). Leaving the catheter in place also prevents having to deal with a child who will not void after catheter removal despite gentle provocation (eg, running the nearby faucet, dribbling lukewarm water on the perineum). If the child cannot or will not void after the catheter has been removed, one must either reintroduce the catheter or settle for an incomplete study. Approximately 20% of reflux will be missed if voiding does not occur.
Urethral disease is exceedingly rare in girls, and one anteroposterior image of the urethra is usually sufficient. By centering this image on the urethra, the pelvic structures are spared direct radiation exposure and disease can be clearly depicted. Voiding while supine, especially with the legs immobilized and in close apposition, can produce vaginal reflux. This collection of contrast material can simulate an abnormally wide urethra or a urogenital sinus. Bladder sphincter dyssynergia may be confused with "spinning top" urethra if secondary changes are not appreciated (Figs 14, 15). In boys, the entire urethra must be imaged because disease can occur anywhere from the bladder base to the urethral meatus (Figs 16–19) (16–18). Steep oblique imaging is optimal because it prevents overlap of urethral segments. It may be necessary to image the posterior and anterior urethra separately to ensure that a significant lesion is not missed.
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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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Postvoiding Imaging
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At the conclusion of voiding, each renal fossa should be imaged. Still images may demonstrate reflux that is not appreciated at fluoroscopy as well as other anomalies or abnormalities (Fig 20). In children with high-grade reflux, delayed abdominal imaging performed about 15 minutes after voiding can help differentiate simple reflux from reflux associated with obstruction at the ureteropelvic or ureterovesical junction (Fig 21) (19). The latter is more apt to produce urinary tract infection and scarring and is treated differently than simple reflux. When grade IV or V reflux occurs at low bladder volumes, residual contrast material in the bladder or contrast material drained from the ureters may perpetuate reflux and simulate impeded drainage. For this reason, we routinely keep the bladder drained with use of a catheter during the interval between voiding and delayed imaging.
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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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Similarly, the presence of one lesion does not exclude a second lesion. Many congenital lesions of the urinary tract are known to coexist with reflux (eg, ureteral duplication, prune belly, bladder diverticula, posterior urethral valves) (Fig 22).
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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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The degree of bladder emptying must also be assessed. Incomplete emptying should not be given undue weight in this nonphysiologic setting; the amount of residual urine in the bladder at the time of catheterization (if voiding preceded catheterization) may be a more accurate indication of the child's ability to void.
As part of the examination, the radiologist should have assessed and reported (a) the status of the spine and pelvis, (b) the presence of masses or opaque calculi, (c) bladder capacity and contour and its emptying capability (Fig 22), (d) the presence and grade of reflux (Fig 23) and obstruction of a refluxing segment, (e) the insertion site of a refluxing ureter (Fig 24), and (f) the appearance of the entire urethra (Fig 25).
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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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Conclusions
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Pediatric voiding cystourethrography can be correctly performed with many variations. Some authors have described which spot radiographs should be obtained, whereas others have indicated the range of normal fluoroscopy times (1–3). Those who perform pediatric voiding cystourethrography should recognize that both unnecessary radiography (ie, that which reproduces previously documented abnormalities) and increased fluoroscopy time increase radiation exposure.
The radiologist's involvement does not end when imaging is completed. For example, when reflux is detected, it is important to determine whether the child is undergoing appropriate antibiotic therapy; if not, such therapy should be initiated as soon as possible—preferably on the day of the examination—because manipulation of the urinary tract is closely associated with urinary tract infection in children with reflux (20). This may require that the referring physician or other responsible health care provider be contacted and the parents apprised of the need for medication.
We also inform the parents and child about possible postprocedural symptoms (21). Dysuria, although uncommon and transient, can be worrisome when not anticipated.
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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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Footnotes
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See the commentary by McAlister
following this article.
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References
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Abstract
Introduction
