CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Establishing a Standard Protocol for the Voiding Cystourethrography Dominic Frimberger, MD, Maria-Gisela Mercado-Deane, MD, FAAP, SECTION ON UROLOGY, SECTION ON RADIOLOGY

The voiding cystourethrogram (VCUG) is a frequently performed test to abstract diagnose a variety of urologic conditions, such as vesicoureteral refl ux. The test results determine whether continued observation or an interventional procedure is indicated. VCUGs are ordered by many specialists and primary care providers, including pediatricians, family practitioners, nephrologists, hospitalists, emergency department physicians, and urologists. Current protocols for performing and interpreting a VCUG are based on the This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have International Refl ux Study in 1985. However, more recent information fi led confl ict of interest statements with the American Academy provided by many national and international institutions suggests a need of Pediatrics. Any confl icts have been resolved through a process approved by the Board of Directors. The American Academy of to refi ne those recommendations. The lead author of the 1985 study, R.L. Pediatrics has neither solicited nor accepted any commercial Lebowitz, agreed to and participated in the current protocol. In addition, involvement in the development of the content of this publication. a recent survey directed to the chairpersons of pediatric radiology of 65 Clinical reports from the American Academy of Pediatrics benefi t from expertise and resources of liaisons and internal (AAP) and external children’s hospitals throughout the United States and Canada showed that reviewers. However, clinical reports from the American Academy of Pediatrics may not refl ect the views of the liaisons or the organizations VCUG protocols vary substantially. Recent guidelines from the American or government agencies that they represent. Academy of Pediatrics (AAP) recommend a VCUG for children between 2 and The guidance in this report does not indicate an exclusive course of 24 months of age with urinary tract infections but did not specify how this treatment or serve as a standard of medical care. Variations, taking test should be performed. To improve patient safety and to standardize the into account individual circumstances, may be appropriate. data obtained when a VCUG is performed, the AAP Section on Radiology and All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffi rmed, the AAP Section on Urology initiated the current VCUG protocol to create a revised, or retired at or before that time. consensus on how to perform this test. DOI: 10.1542/peds.2016-2590

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2016 by the American Academy of Pediatrics INTRODUCTION FINANCIAL DISCLOSURE: The authors have indicated they do The voiding cystourethrogram (VCUG) and the nuclear cystogram are not have a fi nancial relationship relevant to this article to the accepted tests in national and international institutions to diagnose disclose. vesicoureteral reflux (VUR). The VCUG aims to image the urinary tract, FUNDING: No external funding. including the urethra, bladder, ureters, and kidneys, during bladder filling and emptying. The VCUG has many components that can be POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to individually reviewed on the basis of evidence, but no evidence-based disclose. protocol for the VCUG per se is available. The International Reflux Study in 1985 1 is the only published protocol. However, a recent survey To cite: Frimberger D, Mercado-Deane MG, AAP SECTION directed to the chairpersons of pediatric radiology of 65 children’s ON UROLOGY, AAP SECTION ON RADIOLOGY. Establishing a Standard Protocol for the Voiding Cystourethrography. hospitals in the United States and Canada showed that VCUG protocols Pediatrics. 2016;138(5):e20162590 vary substantially. 2 The use of different VCUG protocols raises concerns

Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 138 , number 5 , November 2016 :e 20162590 FROM THE AMERICAN ACADEMY OF PEDIATRICS about patient safety and does not technique and skill of the surgeon sedation or immobilization. These allow valid comparison of data and but also of the specific VCUG imaging controversies lead to different outcomes between individuals and technique. protocols among institutions, institutions. Unlike the VCUG, most Many components of the VCUG are making it problematic to compare imaging studies are performed by universally accepted and performed outcomes even when the details of using protocols that have national equally throughout different the technique are reported. and often international consensus institutions. Little discussion exists Standard evidence-based protocols in that allow the comparison of regarding the necessity to empty the medicine are important to minimize results across centers and achieve bladder before the test and to use a patient risk and to improve the a uniform level of patient safety. small nonballoon catheter for filling. validity of comparing data and Recent guidelines from the American The use of more than 1 bladder filling outcomes between individuals and Academy of Pediatrics (AAP) is a common standard, because several institutions. Great efforts were made recommend a VCUG for children groups showed that cyclic filling to ensure that the renal scan protocol between 2 and 24 months of age increases the reliability to detect VUR.8, 9 used in the Randomized Intervention with a urinary tract infection but did It is also well established that several for Children with VesicoUreteral not specify how this test should be voiding cycles may be necessary to Reflux (RIVUR) Study was uniform performed.3 Ward et al 4 compared detect the presence of an ectopic, across the participating centers.15 the radiation exposure and effective refluxing ureter. 10 The documented However, the very test that evaluated dose in children undergoing VCUG. relationship between bladder volume the presence and grade of VUR was They found an 8 times reduced at the onset of VUR and outcome not standardized. To improve our radiation exposure when using causes many pediatric urologists to understanding of VUR, a standardized grid-controlled, variable-rate pulsed ask their radiology departments to protocol of how to perform the fluoroscopy versus conventional note the bladder volume when VUR diagnostic VCUG study is necessary. continuous fluoroscopy. To strike first occurs. Bladder volume when Because the VCUG is ordered by many the balance between obtaining VUR first occurs is important, because different pediatric specialties and the high-quality images and minimizing previous studies have shown that VUR test results are used to determine radiation exposure, radiology occurring at lower bladder volumes treatment of the individual patient, departments should observe and pressure has a tendency to resolve this statement disseminates the the “as low as (is) reasonably spontaneously less often, independent current protocol to reach the broad achievable” (ALARA) and Image of grade.11 In addition, Alexander et al8 community of pediatric health care Gently guidelines. Image Gently is an verified that bladder volume at the providers. Medical circumstances can initiative of the Alliance for Radiation onset of VUR is an independent risk make it necessary to alter the protocol Safety in Pediatric Imaging. Both factor for breakthrough febrile urinary to accommodate a patient’s specific promote radiation protection for the tract infection. patient and radiologic personnel.5, 6 needs; in those cases, the reasons The VCUG can be a traumatizing test should be documented and the Differences in individual test for patients and parents alike. Sedation changes noted in the report. can be used as long as the effects do not parameters can have a significant effect VCUG TEMPLATE on the outcome of the test and have alter the voiding phase and therefore the potential to influence management the outcome of the test. However, Patient Name; Date of Birth; protocols for individual patients. In a patient and parent education, Medications; Medical Record Number study in 183 patients after minimally along with providing a comfortable invasive ureteral injection therapy, environment with well-trained staff Date of Study 60% of patients with a postoperative and the addition of child life specialists positive VCUG result did not show when available, is of great importance Reason for Examination: Information 12,13 VUR until the bladder was filled over to minimize stress. Provided by Ordering Physician 7 the age-adjusted bladder capacity. The multitude of data on the effect of Comparison: Previous Studies If an alternative protocol had been the VCUG technique on test outcome used that filled the bladder just to the has caused many departments to Technique age-adjusted capacity, those patients adapt similar parameters of the Informed consent is obtained and would have had a negative study result, VCUG in their protocols, such as the documented in the patient’s record. and their surgery would have been practice guidelines of the American considered successful. Therefore, the College of Radiology. 14 However, 1. Observe ALARA and Image postoperative success rates would other components of the VCUG are Gently principles (see ALARA/ be a function not only of the surgical controversial, such as the use of Image Gently Principles). 5, 6

Downloaded from www.aappublications.org/news by guest on September 30, 2021 e2 FROM THE AMERICAN ACADEMY OF PEDIATRICS 2. Observe recommendations for 3. Bowel gas pattern and amount of 2. Record reflux into ejaculatory possible sedation (see Sedation). stool in various portions of the ducts. colon to assess for constipation 3. Observe recommendations for Impression possible immobilization (see Bladder Immobilization). 1. Shape and contour Summarize findings. 4. Toilet trained: allow patient 2. Filling defects, trabeculations, or to void in private bathroom other abnormalities DEFINITION OF PARAMETERS immediately before the study. 3. Maximum bladder capacity (at ALARA and Image Gently Principles time of first void if cyclic study) 5. After voiding and for non–toilet- trained individuals: insert a 4. Estimate of PVR volume (mild, As defined in Title 10, Section small age-appropriate (3.5– moderate, or large) 20.1003, of the Code of Federal 8 French) nonballoon catheter Regulations (10 CFR 20.1003), 5. Note position and appearance of ALARA is an acronym for “as low as with the use of sterile technique the bladder neck (see Sterile Catheterization). (is) reasonably achievable,” which means making every reasonable VUR 6. Measure postvoid residual (PVR) effort to maintain exposures to urine in milliliters. 1. Record onset of VUR for each side: ionizing radiation as far below the 7. Obtain a single anterior- (a) approximate bladder volume dose limits as is practical, consistent posterior (AP) scout image at which reflux occurred and (b) with the purpose for which the covering the kidneys, ureters, onset of reflux during filling or licensed activity is undertaken, taking and bladder (KUB). voiding. into account the state of technology, 2. Grade VUR according to the the economics of improvements in 8. Retrograde fill the bladder International Reflux Study (see relation to the state of technology, (see Bladder Filling) with VUR Grading). the economics of improvements in radiographic contrast (see relation to benefits to the public Contrast) at body temperature. 3. Comment on the insertion site health and safety, and other societal and anatomy of the ureter(s): (a) 9. During filling, obtain multiple and socioeconomic considerations, normal versus ectopic, (b) single spot images in AP, right and left and in relation to the utilization versus duplicated or bifid system, oblique, and lateral positions of nuclear energy and licensed and (c) insertion near or in a (see Spot Images). materials in the public interest (US diverticulum. Nuclear Regulatory Commission; last 10. Fill bladder until voiding occurs 4. Assess drainage of VUR after updated December 10, 2012). and stop contrast flow (see void. In some patients with Bladder Filling). VUR, recatheterization may be The Image Gently Campaign is 11. Obtain voiding images of the necessary to assess drainage of an initiative of the Alliance for urethra (see Spot Images). the refluxed material, especially in Radiation Safety in Pediatric Imaging. The campaign goal is to change 12. Refill bladder until voiding non–toilet-trained children. practice by increasing awareness occurs (see Cyclic Voiding, Voiding of the opportunities to promote Bladder Filling). 1. Record bladder volume at onset of radiation protection in the imaging 13. Obtain voiding and postvoid voiding. of children (www. pedrad. org/ images of the kidneys and associations/ 5364/ ig and http:// bladder (see Spot Images). 2. Note appearance of bladder neck www. imagegently. org/ Portals/ 6/ as child voids. 14. Record maximum amount of Radiologists/ Background4radiol contrast instilled. 3. Estimate bladder volume residual ogists. pdf). (mild, moderate, or large). Sedation Findings Urethra Scout Image 1. Child and family education, 1. Record urethral abnormalities preparation, and support during 1. Osseous structures, especially including dilatation, valves, the examination are important symphysis and spine and strictures, and the appearance for the success of the study (use surrounding soft tissues in the region of the external a certified child life specialist if 2. Any other abnormalities sphincter. available). 13

Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 138 , number 5 , November 2016 e3 2. Encourage supportive family 2. Wash hands, reapply sterile Voiding Phase members to be present in the gloves, then insert catheter. 1. AP bladder when voiding occurs: fluoroscopic suite. 3. Appropriate use of lidocaine or d. Females: AP urethra (2–4 3. The use of sedation is acceptable other anesthetic gel has been images) shown to reduce discomfort but in certain situations when all less e. Males: lateral to oblique, entire requires adequate contact time intrusive methods fail to achieve a urethra during voiding from to be effective. In boys, lidocaine relaxed atmosphere for the child the bladder neck to the tip of gel is instilled into the urethra. and/or family. the penis (2–4 images) Lidocaine gel on a gauze pad can 4. Because voiding is an integral part be applied to the interlabial area of the VCUG, if sedation is used, it in girls, followed by instillation of Postvoid should not interfere with voiding. gel into the urethra. 17 Single KUB, including bladder, 5. The specific sedation used (oral, 4. Placement of the catheter is ureters, and kidneys. intravenous, or inhalation) is at facilitated by clear identification of the discretion of the physician and the urethral meatus, and exposure Bladder Filling the institution’s guidelines. When is often facilitated by an assistant 1. Fill bladder with gravity at 100 cm sedation is used, it should follow for girls. above the examination table. the guidelines for preparation, 5. Collect urine in a sterile container 2. If filling pump is used, infuse at monitoring, and recovery as set and record PVR. 10% of expected bladder capacity forth by the AAP. 16 6. Send urine for analysis and culture per minute. 6. Because sedation may alter as indicated. 3. Estimated bladder capacity as results, its use should be noted Radiology departments can make follows 18, 19: in reports, presentations, and specific arrangements to send a urine manuscripts. a. For patients <2 years of age: specimen for analysis and culture if weight (kg) × 7 requested by the ordering physician. Immobilization b. For patients >2 to 14 years of High-quality images with observation Spot Images age: of the ALARA and Image Gently Images must be of high quality i. In ounces: age in years + 1 principles are required. Restraining and should be taken in accordance ii. In milliliters: (age in years × devices usually are not necessary but with the ALARA and Image Gently 30) + 30 can be used in certain situations. principles. The usual number c. For patients >14 years of age: of images is KUB + 12 images. 500 mL Contrast Material Images should be saved from the 4. Record infused volume 20: Commonly used contrast materials fluoroscopic imaging rather than include the following: iothalamate obtained by separate reexposures a. Standard: record volume: to reduce radiation. If there is meglumine (Cysto-Conray 17%; i. At onset of VUR Mallinckrodt Pharmaceuticals, pathology, additional images can be ii. Maximum volume infused at manufactured by Liebel-Flarsheim obtained to show the abnormality. time of void Company LLC, Raleigh, NC) and Recommended images for the full-strength diatrizoate meglumine different VCUG phases are as follows: iii. PVR estimate (mild, (Cystografin; Bracco Diagnostics, moderate, or large) First fill: Monroe Township, NJ). The type of b. Additional recommendation for contrast should be identified in the 1. AP early first fill complex cases: report. 2. AP late first fill i. Volume when child is Sterile Catheterization 3. At late first fill: AP right uncomfortable Strict adherence to the principles of anterior oblique, AP left ii. Volume when voiding with medical and surgical asepsis should anterior oblique, lateral spine strong stream included be followed: 5. Fill bladder until voiding occurs. 1. Wash hands, clean perimeatal Second fill: If bladder filling reaches >2 times region with antiseptic solution AP right anterior oblique and AP left bladder capacity and no voiding and provide a sterile field. anterior oblique takes place, consider subsequent

Downloaded from www.aappublications.org/news by guest on September 30, 2021 e4 FROM THE AMERICAN ACADEMY OF PEDIATRICS evaluation of patient with development and writing of this REFERENCES videourodynamic study. report: Dr Christopher S. Cooper, MD, 1. Lebowitz RL, Olbing H, Parkkulainen FAAP, Dr Stuart B. Bauer, MD, FAAP, KV, Smellie JM, Tamminen-Möbius TE; Cyclic VCUG Dr Mark P. Cain, MD, FAAP, Dr Saul International Refl ux Study in Children. P. Greenfield, MD, FAAP, Dr Andrew At least 2 voiding cycles are International system of radiographic J. Kirsch, MD, and Dr Faridali Ramji, grading of vesicoureteric refl ux. recommended to identify a potential MD. The authors also express their Pediatr Radiol. 1985;15(2):105–109 ectopic ureter or intermittent VUR. 21 sincere gratitude to Ms Kathleen 2. Palmer BW, Ramji FG, Snyder CT, 1. Child can void around the catheter Ozmeral for her help in developing Hemphill M, Kropp BP, Frimberger D. for the first void. this report. Voiding cystourethrogram—are our protocols the same? J Urol. 2011;186(4 2. Refill bladder and remove catheter suppl):1668–1671 for second void. LEAD AUTHORS Dominic Frimberger, MD 3. Roberts KB; Subcommittee on Urinary 3. If an ectopic ureter and VUR is Maria-Gisela Mercado-Deane, MD, FAAP Tract Infection; Steering Committee on identified on first void and good Quality Improvement and Management. Urinary tract infection: clinical practice urethral images are obtained, SECTION ON UROLOGY EXECUTIVE guideline for the diagnosis and there may be no need for a second COMMITTEE, 2014–2015 cycle. management of the initial UTI in febrile Patrick H. McKenna, MD, FAAP, Chairperson infants and children 2 to 24 months. J. Christopher Austin, MD, FAAP Pediatrics. 2011;128(3):595–610 VUR Grading Paul F. Austin, MD, FAAP Christopher S. Cooper, MD, FAAP Grade I: ureter only 4. Ward VL, Strauss KJ, Barnewolt CE, Saul P. Greenfi eld, MD, FAAP et al. Pediatric radiation exposure Grade II: ureter, pelvis, and calyces; C.D. Anthony Herndon, MD, FAAP and effective dose reduction during Thomas F. Kolon, MD, FAAP voiding cystourethrography. Radiology. no dilatation; normal calyceal Andrew E. MacNeily, MD, FAAP fornices John M. Park, MD, FAAP 2008;249(3):1002–1009 Julian H. Wan, MD, FAAP, Immediate Past 5. ALARA: as defi ned in title 10, section Grade III: mild or moderate dilatation Chairperson and/or tortuosity of the ureter 20.1003, of the Code of Federal Regulations (10 CFR 20.1003). US and mild or moderate dilatation of SECTION ON RADIOLOGY EXECUTIVE Nuclear Regulatory Commission; last the renal pelvis; no or only slight COMMITTEE, 2014–2015 updated December 10, 2012. Available blunting of the fornices Maria-Gisela Mercado-Deane, MD, FAAP, at: http://www. nrc. gov/ reading- Grade IV: moderate dilatation and/ Chairperson rm/ basic- ref/ glossary/ alara. html. Aparna Annam, DO, FAAP Accessed September 8, 2016 or tortuosity of the ureter and Dorothy Bulas, MD, FAAP moderate dilatation of the renal John Cassese, MD, FAAP 6. Alliance for Pediatric Radiation in pelvis and calyces; blunting of Sarah Milla, MD, FAAP Imaging. Image Gently. Available the sharp angle of the fornices F. Glen Seidel, MD, FAAP at: www.imagegently. org. Accessed but maintenance of the papillary Christopher Cassady, MD, FAAP, January 25, 2016 Immediate Past Chairperson impressions in the majority of 7. Palmer BW, Frimberger D. Clinical calyces STAFF and radiographic success after Grade V: gross dilatation and Kathleen Kuk Ozmeral dextranomer/hyaluronic acid copolymer injection for the treatment tortuosity of the ureter; severe of vesicoureteral refl ux. Presented at: dilatation of the renal pelvis and South Central Section of the American calyces; the papillary impressions ABBREVIATIONS Urological Association; San Antonio, TX; are no longer visible in the AAP: American Academy of September 14–17, 2011. Abstract 48 majority of calyces Pediatrics 8. Alexander SE, Arlen AM, Storm ALARA: as low as (is) reasonably DW, Kieran K, Cooper CS. Bladder ACKNOWLEDGMENTS achievable volume at onset of vesicoureteral AP: anterior-posterior refl ux is an independent risk The current clinical report is the KUB: kidneys, ureters, and factor for breakthrough febrile work of the VCUG consensus team, urinary tract infection. J Urol. bladder working together closely in collecting 2015;193(4):1342–1346 PVR: postvoid residual and analyzing the available data. VCUG: voiding cystourethrogram 9. Papadopoulou F, Efremidis SC, The authors thank the members of VUR: vesicoureteral reflux Oiconomou A, et al. Cyclic voiding the team who contributed to the cystourethrography: is vesicoureteral

Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 138 , number 5 , November 2016 e5 refl ux missed with standard voiding procedural narration and distraction. 17. Gerard LL, Cooper CS, cystourethrography? [published J Pediatr Psychol. 2006;31(5):522–527 Duethman KS, Gordley BM, Kleiber CM. correction appears in Eur Radiol. 14. American College of Radiology; Effectiveness of lidocaine lubricant 2002;12(1):260]. Eur Radiol. Society for Pediatric Radiology. for discomfort during 2002;12(3):666–670 ACR–SPR Practice Parameter pediatric urethral catheterization. J Urol. 2003;170(2 pt 1): 10. Polito C, Moggio G, La Manna A, for the Performance of Voiding 564–567 Cioce F, Cappabianca S, Di Toro R. Cystourethrography in Children. Cyclic voiding cystourethrography Reston, VA: American College of 18. Fairhurst JJ, Rubin CM, Hyde I, in the diagnosis of occult Radiology and the Society for Pediatric Freeman NV, Williams JD. Bladder vesicoureteric refl ux. Pediatr Nephrol. Radiology; revised 2014 (Resolution capacity in infants. J Pediatr Surg. 2000;14(1):39–41 13). Available at: www. acr. org/ 1991;26(1):55–57 ~/ media/ ACR/ Documents/ PGTS/ 11. McMillan ZM, Austin JC, Knudson MJ, guidelines/ Voiding_ Cystourethrograph 19. Hjälmås K. Urodynamics in Hawtrey CE, Cooper CS. Bladder volume y. pdf. Accessed January 25, 2016 normal infants and children. at onset of refl ux on initial cystogram Scand J Urol Nephrol Suppl. predicts spontaneous resolution. J 15. Hoberman A, Greenfi eld SP, Mattoo 1988;114:20–27 Urol. 2006;176(4 pt 2):1838–1841 TK, et al; RIVUR Trial Investigators. Antimicrobial prophylaxis for children 20. Cooper CS, Madsen MT, Austin JC, 12. Stokland E, Andréasson S, with vesicoureteral refl ux. N Engl J Hawtrey CE, Gerard LL, Graham MM. Jacobsson B, Jodal U, Ljung B. Med. 2014;370(25):2367–2376 Bladder pressure at the onset of Sedation with midazolam for voiding vesicoureteral refl ux determined 16. Coté CJ, Wilson S; American Academy cystourethrography in children: by nuclear cystometrogram. J of Pediatrics; American Academy a randomised double-blind study. Urol. 2003;170(4 pt 2):1537–1540; of Pediatric Dentistry. Guidelines Pediatr Radiol. 2003;33(4):247–249 discussion: 1540 for monitoring and management of 13. Salmon K, McGuigan F, Pereira JK. Brief pediatric patients before, during, 21. Jequier S, Jequier JC. Reliability report: optimizing children’s memory and after sedation for diagnostic and of voiding cystourethrography to and management of an invasive therapeutic procedures: update 2016. detect refl ux. AJR Am J Roentgenol. medical procedure: the infl uence of Pediatrics. 2016;138(1):e20161212 1989;153(4):807–810

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2016 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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