Cystography

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The term cystourethrography refers to a radiographic examination of the bladder and the urethra; the term cystography refers to a conventional radiographic examination of the bladder with contrast medium instilled through a urethral catheter. Cystography allows the evaluation of both anatomic defects and functional anomalies.

With the ongoing advances in imaging techniques (eg, voiding urosonography ^[1] and eventually, perhaps, nonionizing photoacoustic cystography ^[2] ), traditional cystography may no longer be the imaging examination of choice. For example, retrograde computed tomographic (CT) cystography may be preferred in the setting of trauma (see Bladder Trauma Imaging). ^{[3, 4]}

Nevertheless, cystography is still commonly performed in the form of voiding cystourethrography (VCUG), predominantly in children, ^[5] and can serve as an adjunct to urodynamic evaluation in videourodynamics.

The anatomy of the bladder forms an extraperitoneal muscular urine reservoir that lies behind the pubic symphysis in the pelvis. A normal bladder functions through a complex coordination of musculoskeletal, neurologic, and psychological functions that allow filling and emptying of the bladder contents. The prime effector of continence is the synergic relaxation of detrusor muscles and contraction of the bladder neck and pelvic floor muscles. See the image below.

For more information about the relevant anatomy, see Bladder Anatomy.

Cystography is indicated for evaluation of bladder lesions (eg, diverticula, foreign bodies, or fistulas), rupture, or leakage. Indications for imaging in blunt trauma include gross hematuria or nonacetabular pelvic fracture with significant microscopic hematuria (>25-30 red blood cells [RBCs] per high-power field [HPF]). ^[6]

In a study of CT cystography in which 157 blunt trauma patients were evaluated, one third of the bladder injuries identified would have been missed by the traditional criteria of pelvic fracture and gross hematuria: of the 12 patients found to have bladder injury, 8 had gross hematuria and 4 had significant microscopic hematuria (>25 RBCs/HPF). ^[7]

Urinary tract infection (UTI) constitutes an indication for VCUG. However, the necessity of performing VCUG after UTIs in children has been controversial. In 1999, the American Academy of Pediatrics released a guideline containing the following recommendations ^[8] :

Febrile infants and children aged 2 months to 2 years who do not exhibit the expected clinical response to antimicrobial therapy should undergo ultrasonography promptly and VCUG or radionuclide cystography at earliest convenience

Children aged 2 months to 2 years who do respond appropriately should undergo ultrasonography and VCUG or radionuclide cystography at earliest convenience

A subsequent review suggested routine VCUG in the following populations ^[9] :

Children younger than 5 years with a febrile UTI

Males of any age with a first UTI

Females younger than 2 years with a febrile UTI

Children with recurrent UTIs

Although most clinicians recommend waiting 3 to 6 weeks and providing antibiotic prophylaxis in the interim, VCUG can be performed as soon as the patient resumes pre-UTI voiding patterns. A retrospective review found no difference in the detection rate for vesicoureteral reflux (VUR) between patients who underwent VCUG 1 week after the diagnosis of UTI and those who underwent VCUG more than 1 week after diagnosis; however, more than half of those scheduled for late VCUG did not have the study performed. ^[10]

Other indications for VCUG include the following:

Follow-up evaluation of VUR

Hydronephrosis

Enuresis

Voiding dysfunction

Incontinence

Congenital conditions associated with genitourinary malformations (eg, spina bifida, anorectal malformations, and prune-belly syndrome)

Dalirani et al conducted a study to assess the value of direct radionuclide cystography (DRNC) in the detection of vesicoureteral reflux (VUR) in children with urinary tract infection (UTI) and a normal voiding cystourethrography (VCUG). The authors concluded that DRNC may reveal VUR despite a normal VCUG in children with hydronephrosis, abnormal acute DMSA, and/or recurrent febrile UTI. ^[11]

Urodynamics is the standard evaluation for all forms of voiding dysfunction. It is especially helpful in cases where the underlying pathophysiology may alter treatment, guide surgical intervention, or require monitoring. Urodynamics with concurrent radiologic visualization (ie, videourodynamics) is recommended in patients at high risk for complicated voiding dysfunction, ^[12] such as the following:

Patients with known or suspected neurogenic bladder

Patients who have previously undergone radical pelvic surgery or irradiation

Patients with urinary diversion

Renal transplant patients

Contraindications for cystography include the following:

Active clinical UTI

Pregnancy

Allergy or sensitivity to contrast medium

The presence of labial adhesions is a relative contraindication for VCUG ^[13] ; VCUG is usually performed after the adhesions have been released.

For an effective videourodynamic evaluation, the patient must be able to communicate and cooperate. If the patient is unable to do so (eg, if he or she is severely demented or psychotic), the risk-benefit ratio of videourodynamics must be carefully considered.

Ascertain whether the patient has latex allergy or sensitivity to contrast media. Urine dipstick may be performed on the day of the examination.

According to the American Urological Association’s Best Practice Policy Statement on Antimicrobial Prophylaxis, prophylactic antibiotics for cystourethrography or urodynamic studies are recommended only for patients with risk factors. ^[14] The revised American Heart Association guidelines no longer recommend prophylactic antibiotics solely for the prevention of infective endocarditis in patients undergoing procedures involving the genitourinary tract. ^[15]

Autonomic dysreflexia

In spinal cord injury patients with lesions above the splanchnic sympathetic outflow tract (T5-T6), bladder filling during cystourethrography or urodynamics may trigger a life-threatening imbalance in reflexive sympathetic discharge. (See Autonomic Dysreflexia in Spinal Cord Injury .) Signs of autonomic dysreflexia include piloerection, skin pallor, sudden and severe hypertension with compensatory bradycardia, and profuse sweating and flushing above the level of the injury.

An open and sterile urinary catheterization catheter kit may be prepared in case there is an urgent need to drain the bladder. If a patient is known to have a diagnosis of autonomic dysreflexia, prophylactic nifedipine or an alpha-blocker may be given, and blood pressure should be monitored throughout the study. ^[12]

Darge K. Voiding urosonography with US contrast agent for the diagnosis of vesicoureteric reflux in children: an update. Pediatr Radiol. 2010 Jun. 40(6):956-62. [Medline].

Kim C, Jeon M, Wang LV. Nonionizing photoacoustic cystography in vivo. Opt Lett. 2011 Sep 15. 36(18):3599-601. [Medline].

Shenfeld OZ, Gnessin E. Management of urogenital trauma: state of the art. Curr Opin Urol. 2011 Nov. 21(6):449-54. [Medline].

Ishak C, Kanth N. Bladder trauma: multidetector computed tomography cystography. Emerg Radiol. 2011 Aug. 18(4):321-7. [Medline].

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Broghammer J and Wessells H. Acute management of bladder and urethral trauma. AUA Update Series. 2008. 27(24):222-224.

Morgan DE, Nallamala LK, Kenney PJ, Mayo MS, Rue LW 3rd. CT cystography: radiographic and clinical predictors of bladder rupture. AJR Am J Roentgenol. 2000 Jan. 174(1):89-95. [Medline].

Committee on Quality Improvement, Subcommittee on Urinary Tract Infection. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. American Academy of Pediatrics. Committee on Quality Improvement. Subcommittee on Urinary Tract Infection. Pediatrics. 1999 Apr. 103(4 Pt 1):843-52. [Medline].

Bauer R, Kogan BA. New developments in the diagnosis and management of pediatric UTIs. Urol Clin North Am. 2008 Feb. 35(1):47-58; vi. [Medline].

McDonald A, Scranton M, Gillespie R, Mahajan V, Edwards GA. Voiding cystourethrograms and urinary tract infections: how long to wait?. Pediatrics. 2000 Apr. 105(4):E50. [Medline].

Dalirani R, Mahyar A, Sharifian M, Mohkam M, Esfandiar N, Ghehsareh Ardestani A. The value of direct radionuclide cystography in the detection of vesicoureteral reflux in children with normal voiding cystourethrography. Pediatr Nephrol. 2014 Dec. 29(12):2341-5. [Medline].

Scarpero HM, Koski M, Kaufman MR, Dmochowski RR. Urodynamics best practices. AUA Update Series. 2009. 28(9):74-83.

Blickman JG, Boetes C. Genitourinary Tract. Blikman JG, Parker BR, Barnes PD, eds. Pediatric radiology: the requisites. 3rd ed. Philadelphia: Mosby; 2009. 121-156.

Wolf JS Jr, Bennett CJ, Dmochowski RR, Hollenbeck BK, Pearle MS, Schaeffer AJ. Best practice policy statement on urologic surgery antimicrobial prophylaxis. J Urol. 2008 Apr. 179(4):1379-90. [Medline]. [Full Text].

Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007 Oct 9. 116(15):1736-54. [Medline].

Goodman TR, Kilborn T, Pearce R. Warm or cold contrast medium in the micturating cystourethrogram (MCUG): which is best?. Clin Radiol. 2003 Jul. 58(7):551-4. [Medline].

Herd DW. Anxiety in children undergoing VCUG: sedation or no sedation?. Adv Urol. 2008. 498614. [Medline]. [Full Text].

Agrawalla S, Pearce R, Goodman TR. How to perform the perfect voiding cystourethrogram. Pediatr Radiol. 2004 Feb. 34(2):114-9. [Medline].

Barbaric ZL. Principles of Genitourinary Radiology. 2nd ed. New York: Thieme Medical; 1994.

Kuan JK, Porter J, Wessells H. Imaging for genitourinary trauma. AUA Update Series. 2006. 25(4):26-27.

Fernbach SK, Feinstein KA, Schmidt MB. Pediatric voiding cystourethrography: a pictorial guide. Radiographics. 2000 Jan-Feb. 20(1):155-68; discussion 168-71. [Medline].

centerforreconstructiveurology.org. Available at http://www.centerforreconstructiveurology.org/urethralstricture/diagnosticeval.htm.

http://www.radswiki.net/main/index.php?title=File:Normal-VCUG-009.jpg. Available at http://www.radswiki.net/main/index.php?title=File:Normal-VCUG-009.jpg.

Joaquim AI, de Godoy MF, Burdmann EA. Cyclic Direct Radionuclide Cystography in the Diagnosis and Characterization of Vesicoureteral Reflux in Children and Adults. Clin Nucl Med. 2015 Aug. 40 (8):627-31. [Medline].

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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.

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

Disclosure: Nothing to disclose.

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, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Sexual Medicine Society of North America, Tennessee Medical Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Endo, Avadel.

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.

Cystography

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