"

GU Studies

Cystography (Retrograde Cystography)

Anatomy

Students should be able to identify the following structures on radiographic images:

Ureters, Bladder (Apex, Base, Neck, Trigone), Ureterovesical junction (UVJ), Urethra,  Prostate (male)

Indications, Contraindications, and Patient Preparation

Indications

  • Trauma (bladder rupture, laceration, or fistulae)
  • Incontinence (inability to control urination)
  • Urinary retention (incomplete emptying of bladder)
  • Recurrent urinary tract infections
  • Post-surgical evaluation (bladder repairs, ureteral reimplantation).

Contraindications

  • Relative: Known sensitivity to iodinated contrast (rare).
  • No absolute contraindications beyond contrast precautions.

Patient Preparation

  • No special prep required
  • Patient should empty bladder before catheterization
  • Explain procedure, reassure patient.

Procedure Overview

  • The bladder is catheterized under sterile technique.
  • Dilute iodinated contrast (150–500 mL) is instilled retrograde into the bladder by gravity only, with the contrast bag positioned no more than 24 inches above the patient to prevent overdistension.
  • Images are obtained after sufficient filling in multiple projections—AP Axial, Obliques, and Lateral—to evaluate the bladder contour, ureterovesical junctions, and proximal urethra.
  • Voiding views may be obtained to assess urethral patency and vesicoureteral reflux.
  • After imaging, the patient is allowed to void, and post-void images may be taken to assess residual volume or reflux.

Routine Projections (ARRT Required)

AP Axial (or PA Axial) Cystogram

CR Location & Positioning

  • SID: 40 inches
  • Patient position: Supine for AP (preferred) or prone for PA. Arms at sides, legs extended.
  • Adjustments: Align midsagittal plane to IR; ensure shoulders and hips equidistant. For AP, slight lordotic curvature or 15–20° Trendelenburg may improve visualization of distal ureters and ureterovesical junctions.
  • CR: AP – 10–15° caudad, entering 2 inches (5 cm) above the pubic symphysis. PA – 10–15° cephalad, entering ~1 inch distal to the coccyx and exiting just above the pubic symphysis.
  • Patient instructions: Suspend respiration at end of expiration.
  • Exposure: 10 × 12 inch (24 × 30 cm) lengthwise collimation.

Evaluation Criteria

  • Coverage (what anatomy must be included and how you verify it’s complete): Bladder, distal ureters, and proximal urethra visualized.
  • Rotation checks (how symmetry or alignment tells you if positioning is correct): Symmetric pelvis and equidistant iliac wings.
  • Motion checks (how sharpness confirms patient cooperation/exposure timing): Sharp bladder margins; no peristaltic blur.
  • Technique checks (what contrast, density, soft tissue visibility, and artifacts to look for): Pubic bones projected below bladder neck and urethra; adequate contrast opacification.
  • Clinical aim (when applicable, e.g., reflux, obstruction, displacement, etc.): Assess bladder contour, integrity, and reflux at the ureterovesical junctions.

AP Oblique (RPO / LPO) Cystogram

CR Location & Positioning

  • SID: 40 inches
  • Patient position: Supine, rotated 40–60° into RPO or LPO.
  • Adjustments: Flex knee of elevated side; abduct uppermost thigh to clear pubic region. Arm of elevated side across chest. Pubic arch on dependent side aligned with midline of grid.
  • CR: Perpendicular, centered 2 inches above pubic symphysis and 2 inches medial to elevated ASIS. (For voiding studies: CR perpendicular at the pubic symphysis.)
  • Patient instructions: Suspend respiration at end of expiration.
  • Exposure: 10 × 12 inch (24 × 30 cm) lengthwise collimation.

Evaluation Criteria

  • Coverage: Bladder, distal ureters, and proximal urethra demonstrated.
  • Rotation checks: Open ureterovesical junction on elevated side; no thigh superimposition.
  • Motion checks: Sharp visualization of contrast column.
  • Technique checks: Pubic bones projected below bladder neck and urethra.
  • Clinical aim: Demonstrate ureterovesical junctions and reflux pathways; during voiding, entire urethra visualized.

Lateral Cystogram

CR Location & Positioning

  • SID: 40 inches
  • Patient position: Lateral recumbent (right or left).
  • Adjustments: Knees slightly flexed; MCP centered to midline of grid. Elbows flexed and arms raised to clear pelvis. Hips and femurs superimposed.
  • CR: Perpendicular to IR, centered 2 inches above the pubic symphysis at the midcoronal plane.
  • Patient instructions: Suspend respiration at end of expiration.
  • Exposure: 10 × 12 inch (24 × 30 cm) lengthwise collimation.

Evaluation Criteria

  • Coverage: Bladder in profile with anterior and posterior walls demonstrated.
  • Rotation checks: Hips and femurs superimposed, pelvis true lateral.
  • Motion checks: Clear margins; no patient movement.
  • Technique checks: Proper density showing bladder base and distal ureters.
  • Clinical aim: Evaluate fistulae between bladder and rectum, uterus, or vagina; assess wall defects or diverticula.

Hows & Whys of Cystography

Anatomy

  • How is the trigone different from other bladder regions?
    It remains fixed in position and does not expand during filling, making it an important landmark for ureteral and urethral openings.
  • How does prostate enlargement affect cystographic imaging?
    It elevates the bladder base and creates a smooth filling defect along the bladder floor.
  • How do bladder diverticula appear radiographically?
    As outpouchings or rounded projections of contrast beyond the normal bladder contour.

Positioning

  • Why must the contrast bag not exceed 24 inches above the bladder?
    To prevent excessive hydrostatic pressure that could overdistend or rupture the bladder.
  • Why is gravity filling used rather than manual injection?
    It ensures gentle, controlled filling and avoids trauma to the bladder wall.
  • Why is the AP axial projection angled caudad?
    The caudal angle projects the bladder neck and urethra below the pubic symphysis for unobstructed visualization.
  • Why are obliques performed?
    They separate the ureterovesical junctions from the bony pelvis and demonstrate reflux or obstruction without superimposition.
  • Why is the lateral projection important?
    It provides a profile view of the bladder walls, ideal for detecting fistulae, diverticula, or wall perforation.

Technique & Image Evaluation

  • How do you verify adequate bladder filling?
    Contrast should outline the entire bladder contour without evidence of rupture or overdistension.
  • How can you recognize patient rotation?
    Unequal distances between the symphysis and acetabula or asymmetry of iliac wings indicate rotation.
  • How can you assess image sharpness?
    Look for crisp bladder margins and visible trabecular pattern without motion blur.
  • How do you evaluate for leakage or perforation?
    Contrast extravasation outside the bladder outline or into the peritoneal cavity indicates rupture.
  • How can vesicoureteral reflux be confirmed?
    By observing contrast ascending from the bladder into the distal ureters during or after filling.

Clinical Applications

  • Why is iodinated contrast used instead of barium?
    Iodinated contrast is water-soluble and safely absorbed if bladder rupture occurs; barium would cause peritonitis if extravasated.
  • Why must the bladder be emptied before catheterization?
    To avoid dilution of contrast and provide a consistent baseline volume for evaluation.
  • Why is cystography indicated after trauma?
    It identifies ruptures, tears, or fistulae caused by pelvic injury.
  • Why is cystography helpful after bladder surgery?
    It assesses anastomosis integrity, detects leaks, and confirms postoperative bladder capacity.
  • Why should gonadal shielding generally be avoided?
    Shielding would obscure critical anatomy, particularly the bladder base and urethra.

 

License

Icon for the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License

Radiographic Procedures Review Guide Copyright © 2025 by Carla M. Allen and Taylor M. Otto is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, except where otherwise noted.