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Pediatr Radiol (2012) 42:285289 DOI 10.1007/s00247-011-2321-y
POINT/COUNTERPOINT
VCUG and the recurring question of sedation: preparation and catheterization technique are the key
D. Gregory Bates
Received: 2 December 2011 /Accepted: 5 December 2011 /Published online: 30 December 2011 # Springer-Verlag 2011
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. A variety 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 [13]. 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, 614]. 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...