Indications, Contraindications, and Patient Preparation

Indications

• Vesicoureteral reflux (especially in pediatrics).
• Recurrent urinary tract infections.
• Evaluation of urethra during voiding (strictures, trauma, post-surgical assessment).
• Incontinence or abnormal voiding patterns.

Contraindications

• Relative: allergy to iodinated contrast.
• Active urinary tract infection (procedure may worsen infection).
• Severe urethral trauma (consult physician before catheterization).

Patient Preparation

• No dietary prep required.
• Patient should empty bladder before catheterization.
• Procedure explained carefully (especially to children and parents, since voiding during imaging can be stressful).
• Catheterization performed under aseptic technique.

Routine Projections (ARRT Required)

AP Projection (Female VCUG)

CR Location & Positioning

• SID: 40 inches
• Patient position: Supine or semi-upright AP; legs slightly apart, arms at sides.
• Adjustments: Center IR to superior border of the pubic symphysis.
• CR: Perpendicular to IR, entering 2 inches (5 cm) above pubic symphysis; 5° caudal angulation may project pubic bones below bladder neck.
• Patient instructions: Remain still during filling; void when instructed. Suspend respiration at end of expiration.
• Exposure: Routine urinary contrast technique.

Evaluation Criteria

• Coverage (what anatomy must be included and how you verify it’s complete): Bladder, urethra, and distal ureters visualized during filling and voiding.
• Rotation checks (how symmetry or alignment tells you if positioning is correct): Symmetric pelvis; pubic bones at midline.
• Motion checks (how sharpness confirms patient cooperation/exposure timing): Sharp bladder and urethral margins without motion blur.
• Technique checks (what contrast, density, soft tissue visibility, and artifacts to look for): Adequate contrast density in bladder and urethra; no cutoff at symphysis.
• Clinical aim (when applicable, e.g., reflux, obstruction, displacement, etc.): Evaluate bladder neck, urethra, and reflux during voiding.

AP Oblique Projection (Male VCUG – RPO)

CR Location & Positioning

• SID: 40 inches
• Patient position: Supine, rotated 30–40° into RPO.
• Adjustments: Position penis obliquely across thigh to prevent superimposition. Extend and abduct elevated thigh to avoid overlap.
• CR: Perpendicular to IR, centered 2 inches above pubic symphysis and 2 inches medial to elevated ASIS.
• Patient instructions: Remain still during filling; void on command. Suspend respiration at end of expiration.
• Exposure: Routine urinary contrast technique.

Evaluation Criteria

• Coverage: Entire urethra demonstrated from bladder neck to external meatus.
• Rotation checks: Pubic rami projected lateral to urethral course; urethra unobscured.
• Motion checks: Sharp margins of bladder and urethra without motion.
• Technique checks: Adequate density and contrast through bladder and urethra.
• Clinical aim: Demonstrate full urethral course and evaluate reflux or obstruction during micturition.

Supplemental Projections

Lateral Projection (Either Sex)

CR Location & Positioning

• SID: 40 inches
• Patient position: True lateral recumbent.
• Adjustments: Flex knees slightly for stability; raise or flex elbows at right angle to clear pelvis. Ensure hips and femurs are superimposed.
• CR: Perpendicular to IR, centered 2 inches above pubic symphysis at midcoronal plane.
• Patient instructions: Remain still during voiding if possible. Suspend respiration at end of expiration.
• Exposure: Routine urinary contrast technique.

Evaluation Criteria

• Coverage: Bladder and urethra in profile, distal urethra and external sphincter visualized.
• Rotation checks: Hips and femurs superimposed; pelvis true lateral.
• Motion checks: Sharp bladder outline and urethral course.
• Technique checks: Sufficient contrast opacification; no cutoff from soft tissue overlap.
• Clinical aim: Detect urethral fistulae, diverticula, or abnormal urethral course.