VCUG and the recurring question of sedation: preparation and catheterization technique are the key

Abstract

The voiding cystourethrogram (VCUG) is the most frequently performed fluoroscopic examination in pediatric radiology departments for the investigation of the lower urogenital tract in children. Avariety of clinical indications exists and include urinary tract infections (UTI), vesico-ureteral reflux (VUR), prenatal hydronephrosis, congenital renal anomalies, posterior urethral valves (PUV), bladder diverticula, hypospadias, cloacal abnormalities, Mullerian duct remnants, imperforate anus, bladder and urethral trauma, hematuria, urolithiasis, renal transplantation and assessment of the unstable bladder [1–3]. The VCUG is not likely to be replaced any time soon. If one only considers vesicoureteral reflux, an estimated 50,000 children are diagnosed with VUR after urinary tract infection each year in the United States [4]. The number of children undergoing screening examinations, therefore, is likely in the many hundreds of thousands. The VCUG examination requires transurethral catheterization (excluding suprapubic puncture), instillation of contrast agent for bladder filling, and voiding under direct fluoroscopic imaging. Optimal evaluation includes an awake and cooperative child, limited and optimized image acquisition utilizing last-image-hold techniques and pulsed digital fluoroscopy units, minimal radiation burden and a short examination time [1, 5]. The vast majority of VCUG examinations are performed primarily on an outpatient basis, unfortunately often with little or no preparation of the child or parent [6]. The VCUG examination can therefore be perceived as a painful investigation associated with high levels of distress and anxiety for the child, parents and even the medical staff [1, 6–14]. The VCUG experience has been described by one author as follows: “The child may be separated from his or her parents; his or her legs and genitalia are spread apart, often forcibly; probing and intruding into a “private” area not usually touched by strangers; firm pressure may be used to clean the genitalia; a urinary catheter is inserted; and the child must tolerate the discomfort of an unusually full bladder and the indignity of voiding in public. As the child lies flat and still, cold and exposed, huge cameras approach within inches of his or her body and rotate around it” [6]. If this description of the VCUG is the perception of the lay public, then it is not surprising that an uninformed parent would desire, if not demand, that their child be sedated, preferably with general anesthesia. This misunderstanding is certainly doing our families and patients a great disservice. Unfortunately, many children have been irreparably traumatized by previous catheterizations as well as other invasive medical procedures and the mere thought of undergoing an unknown or repeat procedure is unbearable. I believe the use of sedation is entirely appropriate in these patients. As a pediatric radiologist, it is my job to provide the safest, most productive and least distressing examination possible. In my opinion, however, if thorough pre-test preparation of the parent and child were combined with appropriate catheterization techniques, the VCUG examination could be performed without the need for sedation in the vast majority of patients. The first component of this discussion revolves around patient education. The VCUG examination process actually begins in the ordering physician’s office. First and foremost, the physician needs to communicate to the family the reason for the examination, its medical importance to the health of Related articles can be found at doi:10.1007/s00247-011-2322-x and doi:10.1007/s00247-011-2323-9).