PYELOGRAPHY

 Retrograde pyelogram Any pyelogram in which contrast medium is introduced into the

lower urinary tract and flows toward the kidney (i.e. in a "retrograde" direction, against the
normal flow of urine).
 Anterograde pyelogram (Also antegrade pyelogram) Any pyelogram where a contrast
medium passes from the kidneys toward the bladder, mimicking the normal flow of urine.
Anterograde pyelogram

 An antegrade pyelogram is a type of X-ray used to diagnose an obstruction of the upper

urinary tract. During the procedure, a contrast dye is injected into a portion of the ureter
(narrow tube that carries urine from the kidney to the bladder) closest to the kidneys
called the renal pelvis. The flow of the contrast dye can then be observed with X-ray
images as it moves from the kidneys into the ureters and urinary bladder.
 Fluoroscopy (a type of X-ray "movie") or ultrasound (high frequency sound waves) may
be used during the procedure to locate the kidneys and ureters.

Reasons for the procedure

An antegrade pyelogram may be used to visualize the ureters when other procedures, such as
intravenous pyelogram and retrograde pyelogram, have not provided enough definitive
information.

The antegrade pyelogram may be used to detect an obstruction of the urinary tract due to a
stricture (narrowing), a kidney stone, a blood clot, or a tumor. In the presence of an obstruction,
the injected contrast dye is unable to move properly through the urinary tract and this is detected
on X-ray images.

An antegrade pyelogram may also be used to assess the kidneys or ureters prior to or after
surgical treatment. If a blockage is found, a nephrostomy tube may be inserted during the
procedure to divert the flow of urine past the obstruction.

There may be other reasons for your physician to recommend an antegrade pyelogram.

Risks of the procedure

You may want to ask your physician about the amount of radiation used during the procedure
and the risks related to your particular situation. It is a good idea to keep a record of your past
history of radiation exposure, such as previous scans and other types of X-rays, so that you can
inform your physician. Risks associated with radiation exposure may be related to the cumulative
number of X-ray examinations and/or treatments over a long period of time.

If you are pregnant or suspect that you may be pregnant, you should notify your physician.
Radiation exposure during pregnancy may lead to birth defects.
If contrast dye is used, there is a risk for allergic reaction to the dye. Patients who are allergic to
or sensitive to medications, contrast dye, or iodine should notify their physician.

Patients with kidney failure or other kidney problems should notify their physician.

Possible complications of antegrade pyelogram include, but are not limited to, the following:

 Bleeding

 Sepsis

 Urinoma (urine-filled cyst) formation

 Blood clots in the nephrostomy tube, if placed, or clots in the bladder

 Fast heart rate, low blood pressure, and electrolyte imbalance due to rapid urine loss after
nephrostomy tube placement (shock)

An antegrade pyelogram may be contraindicated for patients with blood clotting disorders.

There may be other risks depending on your specific medical condition. Be sure to discuss any
concerns with your physician prior to the procedure.

Before the procedure

 You will be asked to sign a consent form that gives permission to do the procedure.

 You will need to fast for a certain period of time prior to the procedure. Your physician will
notify you how long to fast, whether for a few hours or overnight.

 If you are pregnant or suspect that you may be pregnant, you should notify your physician.

 Notify your physician if you have ever had a reaction to any contrast dye, or if you are
allergic to iodine.

 Notify your physician if you are sensitive to or are allergic to any medications, latex, tape,
and anesthetic agents (local and general).

 Notify your physician of all medications (prescribed and over-the-counter) and herbal
supplements that you are taking.

 Notify your physician if you have a history of bleeding disorders or if you are taking any
anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood
clotting. It may be necessary for you to stop these medications prior to the procedure.

 You may receive a sedative prior to the procedure to help you relax. Because the sedative
may make you drowsy, you will need to arrange for someone to drive you home.

 You may be given antibiotics before and after the procedure.

 Based upon your medical condition, your physician may request other specific preparation.

During the procedure

An antegrade pyelogram may be performed on an outpatient basis or as part of your stay in a

hospital. Procedures may vary depending on your condition and your physician's practices.

Generally, an antegrade pyelogram follows this process:

 You will be asked to remove any clothing, jewelry, or other objects that may interfere
with the procedure.

 If you are asked to remove clothing, you will be given a gown to wear.

 An intravenous (IV) line may be inserted into your arm or hand.

 You will be asked to lie face down on the X-ray table. An area of skin on your lower
back will be wiped with an iodine solution to sterilize the area, and sterile drapes will be
placed around it.

 Local anesthetic will be injected. With the help of ultrasound or fluoroscopic guidance, a
needle will be advanced into the renal pelvis and the contrast dye will be injected. You may
feel mild discomfort during the injection of the local anesthetic, as well as a brief feeling of
warmth from the contrast dye.

 A series of X-rays will be taken at timed intervals as the dye travels through the ureters.

 Once the needle has been inserted, a thin wire may be threaded through the needle to
allow placement of catheters, a nephrostomy tube, or other devices.

 If a nephrostomy tube is not needed, the physician will remove the needle.

 A sterile bandage/dressing will be applied.

After the procedure

Your recovery process will vary depending upon the type of procedure performed and your
physician’s practices. After the procedure, you will be taken to the recovery room for
observation. Once your blood pressure, pulse, and breathing are stable and you are alert, you will
be taken to your hospital room or discharged to your home.

Your urine output will be monitored closely for volume and signs of blood. It may be red from
even a small amount of blood. This is considered normal and does not necessarily indicate a
problem. You may be instructed to continue monitoring your urine output for a day or so once
you are at home.

You may experience pain when you urinate. Take a pain reliever for soreness as recommended
by your physician. Aspirin or certain other pain medications may increase the chance of
bleeding. Be sure to take only recommended medications.
Notify your physician to report any of the following:

 Fever and/or chills

 Redness, swelling, or bleeding or other drainage from the insertion site

 Increased pain around the insertion site

 Increase in the amount of blood in your urine

 Difficulty urinating

Your physician may give you additional or alternate instructions after the procedure, depending
on your particular situation.

Retrograde pyelogram
A retrograde pyelogram is a type of X-ray that allows visualization of the bladder, ureters, and
renal pelvis. Generally, this test is performed during a procedure called cystoscopy —evaluation
of the bladder with an endoscope (a long, flexible lighted tube). During a cystoscopy, contrast
dye, which helps enhance the X-ray images, can be introduced into the ureters via a catheter.
Reasons for the procedure

A retrograde pyelogram may be used in people suspected of having an obstruction, such as a

tumor, stone, blood clot, or stricture (narrowing) in the kidneys or ureters. It evaluates the lower
portion of the ureter to which urine flow is obstructed. A retrograde pyelogram is also used to
evaluate placement of a catheter or a ureteral stent — a hollow tube that allows passage of urine
around an obstruction.

There may be other reasons for your doctor to recommend a retrograde pyelogram.

Risks of the procedure

You may want to ask your doctor about the amount of radiation used during the procedure and
the risks related to your particular situation. It's a good idea to keep a record of your past history
of radiation exposure, such as previous scans and other types of X-rays, so that you can inform
your doctor. Risks associated with radiation exposure may be related to the cumulative number
of X-ray examinations and/or treatments over a long period of time.

If you're pregnant or suspect that you may be pregnant, you should notify your doctor. Radiation
exposure during pregnancy may lead to birth defects.

There's a risk for allergic reaction to the dye. Patients who are allergic to or sensitive to
medications, contrast dye, or iodine should notify their doctor.

Patients with kidney failure or other kidney problems should notify their doctor.

Possible complications of retrograde pyelogram include, but are not limited to, sepsis, urinary
tract infection, bladder perforation, hemorrhage, nausea, and vomiting.
A retrograde pyelogram may be contraindicated for patients experiencing severe dehydration.

There may be other risks depending on your specific medical condition. Be sure to discuss any
concerns with your doctor prior to the procedure.

Certain factors or conditions may interfere with a retrograde pyelogram. These factors include,
but are not limited to:

 Feces or gas in the bowels

 Barium in the intestines from a previous barium procedure

Before the procedure

 Your doctor will explain the procedure to you and offer you the opportunity to ask any
questions that you might have about the procedure.

 You will be asked to sign a consent form that gives permission to do the procedure. Read
the form carefully and ask questions if something is not clear.

 You'll need to fast for a certain period of time prior to the procedure. Your doctor will
notify you how long to fast, whether for a few hours or overnight.

 If you're pregnant or suspect that you may be pregnant, you should notify your doctor.

 Notify your doctor if you've ever had a reaction to any contrast dye, or if you're allergic
to iodine.

 Notify your doctor if you're sensitive to or are allergic to any medications, latex, tape,
and anesthetic agents (local and general).

 Notify your doctor of all medications (prescribed and over-the-counter) and herbal
supplements that you're taking.

 Notify your doctor if you have a history of bleeding disorders or if you're taking any
anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood
clotting. It may be necessary for you to stop these medications prior to the procedure.

 A laxative may be prescribed the night before the test and a cleansing enema or
suppository may be given a few hours before the procedure.

 You may receive a sedative prior to the procedure to help you relax. Because the sedative
may make you drowsy, you'll need to arrange for someone to drive you home.

 Based on your medical condition, your doctor may request other specific preparation.

During the procedure

A retrograde pyelogram may be performed on an outpatient basis or as part of your stay in a
hospital. Procedures may vary depending on your condition and your doctor's practices.

Generally, the retrograde pyelogram follows this process:

 You'll be asked to remove any clothing, jewelry, or other objects that may interfere with
the procedure.

 You will be given a gown to wear.

 An intravenous (IV) line may be inserted in your arm or hand.

 You'll be asked to lie face up on the X-ray table and place your legs in stirrups.

 You may receive a sedative or general anesthesia in the IV prior to the insertion of the
endoscope.

 An endoscope will be inserted through the urethral opening and advanced into the
bladder. Once the endoscope is in place, the bladder can be examined and a catheter may be
inserted into one or both ureters.

 The contrast will be injected through the catheters.

 A series of X-rays will be taken at timed intervals.

 The catheter will be removed.

 The doctor will check for retention of the contrast.

After the procedure

Your recovery process will vary depending on the type of procedure performed and your
doctor’s practices. After the procedure, you'll be taken to the recovery room for observation.
Once your blood pressure, pulse, and breathing are stable and you're alert, you'll be taken to your
hospital room or discharged to your home.

Your urine output will be monitored closely for volume and signs of blood. It may be red from
even a small amount of blood. This is considered normal and doesn't necessarily indicate a
problem. You may be instructed to continue monitoring your urine output for a day or so once
you're at home.

You may experience pain when you urinate. Take a pain reliever for soreness as recommended
by your doctor. Aspirin or certain other pain medications may increase the chance of bleeding.
Be sure to take only recommended medications.

Notify your doctor to report any of the following:

 Fever and/or chills

  Redness, swelling, or bleeding or other drainage from the urinary opening

 Increased pain around the urinary opening

 Increase in the amount of blood in your urine

 Difficulty urinating

Your doctor may give you additional or alternate instructions after the procedure, depending on
your particular situation.

Cystoscopy

Cystoscopy is endoscopy of the urinary bladder via the urethra. It is carried out with

a cystoscope.
The cystoscope has lenses like a telescope ormicroscope. These lenses let the physician focus on
the inner surfaces of the urinary tract. Some cystoscopes use optical fibres(flexible glass fibres)
that carry an image from the tip of the instrument to a viewing piece at the other end.
There are two main types of cystoscopy — flexible and rigid — differing in the flexibility of the
cystoscope. Flexible cystoscopy is carried out with local anaesthesia on both sexes. Typically, a
topical anesthetic, most often xylocaine gel (common brand names are Anestacon and Instillagel)
is employed. The medication is instilled into the urethra via the urinary meatus five to ten
minutes prior to the beginning of the procedure. Rigid cystoscopy can be performed under the
same conditions, but is generally carried out under general anaesthesia, particularly in male
subjects, due to the pain caused by the probe.
Cystoscopy may be recommended for any of the following conditions:

 Find the cause of many urinary system problems. Examples include blood in the urine,
pain when you urinate, incontinence, frequenturinary tract infections, and blockages in the
urinary tract.
 Remove tissue samples for testing (biopsy).
 Remove a foreign object.
 Insert a stent. This helps urine flow from the kidneys to the bladder.
 Treat certain problems. The test can be used to remove stones or growths, help stop
bleeding in the bladder, or remove a blockage.
 Inject a dye that is used for a special type of X-ray of the ureter and kidney.

 Blood in the urine (hematuria)

 Unusual cells found in urine sample
 Painful urination, chronic pelvic pain, or interstitial cystitis
  Urinary blockage such as from prostate enlargement, stricture, or narrowing of the
urinary tract
 Stone in the urinary tract

Unusual growth, polyp, tumor, or cancer

How To Prepare

Tell your doctor if you:

 Are allergic to any medicines, including anesthetics.

 Have had bleeding problems or take blood-thinning medicine, such as aspirin or warfarin
(Coumadin).
 Are or might be pregnant.
The anesthesia used for this test may be local, spinal, or general

Follow the instructions exactly about when to stop eating and drinking, or your surgery may be
canceled. If your doctor told you to take your medicines on the day of surgery, use only a sip of
water.

Empty your bladder just before the test. You may get medicine to prevent a urinary tract
infection that could be caused by the test.

You will be asked to sign a consent form that says you understand the risks of the test and agree
to have it done.

Procedure
Physicians may have special instructions, but in most cases, patients are able to eat normally and
return to normal activities after the test.
Patients are sometimes asked to give a urine sample before the test to check for infection. These
patients should ensure that they do not urinate for a sufficient period time, such that they are able
to urinate prior to this part of the test.
Patients will have to remove their clothing covering the lower part of the body, although some
physicians may prefer if the patient wears a hospital gown for the examination and covers the
lower part of the body with a sterile drape.
In most cases, patients lie on their backs with their knees slightly parted. Occasionally, a patient
may also need to have their knees raised. This is particularly when undergoing a Rigid
Cystoscopy examination.
 For flexible cystoscopy procedures the patient is almost always alert and a local anesthetic is
applied to reduce discomfort. In cases requiring a rigid cystoscopy it is not unusual for the
patient to be given a general anesthetic, as these can be more uncomfortable, particularly for
men.
A physician, nurse or technician will clean the area around the urethral opening and apply a
local anesthetic. The local anesthetic is applied direct from a tube or needleless syringe into the
urinary tract. Often, skin preparation is performed
Patients receiving a ureteroscopy may receive a spinal or general anaesthetic.
The physician will gently insert the tip of the cystoscope into the urethra and slowly glide it up
into the bladder. The procedure is more painful for men than for women due to the length and
narrow diameter of the male urethra. Relaxing the pelvic muscles helps make this part of the test
easier. A sterile liquid (water, saline, or glycine solution) will flow through the cystoscope to
slowly fill the bladder and stretch it so that the physician has a better view of the bladder wall.
As the bladder reaches capacity, patients typically feel some mild discomfort and the urge to
urinate.
The time from insertion of the cystoscope to removal may be only a few minutes, or it may be
longer if the physician finds a stone and decides to remove it, or in cases where a biopsy is
required. Taking a biopsy (a small tissue sample for examination under a microscope) will also
make the procedure last longer. In most cases, the entire examination, including preparation, will
take about 15 to 20 minutes.

After the test

After the test, you may need to urinate often. You may have some burning during and after
urination for a day or two. It may help to drink lots of fluids. This also helps prevent a urinary
tract infection.

Slightly pink urine is common for several days after the test, especially if a biopsy was
performed. But call your doctor right away if:

 Your urine stays red or you see blood clots after you have urinated several times.
 You have not been able to urinate 8 hours after the test.
 You have a fever, chills, or severe pain in your flank or belly. These may be signs of
a kidney infection.
 You have symptoms of a urinary tract infection. These symptoms include:
o Pain or burning when you urinate.
o An urge to urinate often, but usually passing only small amounts of urine.
o Dribbling or leaking urine.
o Urine that is reddish or pinkish, smells bad, or is cloudy.
o Pain or a heavy feeling in the lower belly.

Urodynamic Testing

What is urodynamic testing?

Urodynamic testing is any procedure that looks at how well the bladder, sphincters, and urethra
are storing and releasing urine. Most urodynamic tests focus on the bladder’s ability to hold urine
and empty steadily and completely. Urodynamic tests can also show whether the bladder is
having involuntary contractions that cause urine leakage. A health care provider may recommend
urodynamic tests if symptoms suggest problems with the lower urinary tract. Lower urinary tract
symptoms (LUTS) include

 urine leakage
 frequent urination
 painful urination
 sudden, strong urges to urinate
 problems starting a urine stream
 problems emptying the bladder completely
 recurrent urinary tract infections

Urodynamic tests range from simple observation to precise measurements using sophisticated
instruments. For simple observation, a health care provider may record the length of time it takes
a person to produce a urinary stream, note the volume of urine produced, and record the ability
or inability to stop the urine flow in midstream. For precise measurements, imaging equipment
takes pictures of the bladder filling and emptying, pressure monitors record the pressures inside
the bladder, and sensors record muscle and nerve activity. The health care provider will decide
the type of urodynamic test based on the person’s health information, physical exam, and LUTS.
The urodynamic test results help diagnose the cause and nature of a lower urinary tract problem.

Most urodynamic tests do not involve special preparations, though some tests may require a
person to make a change in fluid intake or to stop taking certain medications. Depending on the
test, a person may be instructed to arrive for testing with a full bladder.

What are the urodynamic tests?

Urodynamic tests include

 uroflowmetry
 postvoid residual measurement
 cystometric test
 leak point pressure measurement
 pressure flow study
 electromyography
  video urodynamic tests

Uroflowmetry
Uroflowmetry is the measurement of urine speed and volume. Special equipment automatically
measures the amount of urine and the flow rate—how fast the urine comes out. Uroflowmetry
equipment includes a device for catching and measuring urine and a computer to record the data.
During a uroflowmetry test, the person urinates privately into a special toilet or funnel that has a
container for collecting the urine and a scale. The equipment creates a graph that shows changes
in flow rate from second to second so the health care provider can see when the flow rate is the
highest and how many seconds it takes to get there. Results of this test will be abnormal if the
bladder muscles are weak or urine flow is blocked. Another approach to measuring flow rate is
to record the time it takes to urinate into a special container that accurately measures the volume
of urine. Uroflowmetry measurements are performed in a health care provider’s office; no
anesthesia is needed.

Uroflowmetry equipment

Postvoid Residual Measurement

This urodynamic test measures the amount of urine left in the bladder after urination. The
remaining urine is called the postvoid residual. Postvoid residual can be measured with
ultrasound equipment that uses harmless sound waves to create a picture of the bladder. Bladder
ultrasounds are performed in a health care provider’s office, radiology center, or hospital by a
specially trained technician and interpreted by a doctor, usually a radiologist. Anesthesia is not
needed. Postvoid residual can also be measured using a catheter—a thin flexible tube. A health
care provider inserts the catheter through the urethra up into the bladder to remove and measure
the amount of remaining urine. A postvoid residual of 100 milliliters or more is a sign that the
bladder is not emptying completely. Catheter measurements are performed in a health care
provider’s office, clinic, or hospital with local anesthesia.

Cystometric Test
A cystometric test measures how much urine the bladder can hold, how much pressure builds up
inside the bladder as it stores urine, and how full it is when the urge to urinate begins. A catheter
is used to empty the bladder completely. Then a special, smaller catheter is placed in the bladder.
This catheter has a pressure-measuring device called a manometer. Another catheter may be
placed in the rectum to record pressure there.

Once the bladder is emptied completely, the bladder is filled slowly with warm water. During
this time, the person is asked to describe how the bladder feels and indicate when the need to
urinate arises. When the urge to urinate occurs, the volume of water and the bladder pressure are
recorded. The person may be asked to cough or strain during this procedure to see if the bladder
pressure changes. A cystometric test can also identify involuntary bladder contractions.
Cystometric tests are performed in a health care provider’s office, clinic, or hospital with local
anesthesia.

Cystometric test

Leak Point Pressure Measurement

This urodynamic test measures pressure at the point of leakage during a cystometric test. While
the bladder is being filled for the cystometric test, it may suddenly contract and squeeze some
water out without warning. The manometer measures the pressure inside the bladder when this
leakage occurs. This reading may provide information about the kind of bladder problem that
exists. The person may be asked to apply abdominal pressure to the bladder by coughing,
shifting position, or trying to exhale while holding the nose and mouth. These actions help the
health care provider evaluate the sphincters.

Pressure Flow Study

A pressure flow study measures the bladder pressure required to urinate and the flow rate a given
pressure generates. After the cystometric test, the person empties the bladder, during which time
a manometer is used to measure bladder pressure and flow rate. This pressure flow study helps
identify bladder outlet blockage that men may experience with prostate enlargement. Bladder
outlet blockage is less common in women but can occur with a cystocele or, rarely, after a
surgical procedure for urinary incontinence. Pressure flow studies are performed in a health care
provider’s office, clinic, or hospital with local anesthesia.
Electromyography
Electromyography uses special sensors to measure the electrical activity of the muscles and
nerves in and around the bladder and the sphincters. If the health care provider thinks the urinary
problem is related to nerve or muscle damage, the person may be given an electromyography.
The sensors are placed on the skin near the urethra and rectum or on a urethral or rectal catheter.
Muscle and nerve activity is recorded on a machine. The patterns of the nerve impulses show
whether the messages sent to the bladder and sphincters are coordinated correctly.
Electromyography is performed by a specially trained technician in a health care provider’s
office, outpatient clinic, or hospital. Anesthesia is not needed if sensors are placed on the skin.
Local anesthesia is needed if sensors are placed on a urethral or rectal catheter.

Video Urodynamic Tests

Video urodynamic tests take pictures and videos of the bladder during filling and emptying. The
imaging equipment may use x rays or ultrasound. If x-ray equipment is used, the bladder will be
filled with a special fluid, called contrast medium, that shows up on x rays. X rays are performed
by an x-ray technician in a health care provider’s office, outpatient facility, or hospital;
anesthesia is not needed. If ultrasound equipment is used, the bladder is filled with warm water
and harmless sound waves are used to create a picture of the bladder. The pictures and videos
show the size and shape of the bladder and help the health care provider understand the problem.
Bladder ultrasounds are performed in a health care provider’s office, radiology center, or hospital
by a specially trained technician and interpreted by a doctor, usually a radiologist. Although
anesthesia is not needed for the ultrasound, local anesthesia is needed to insert the catheter to fill
the bladder

What happens after urodynamic tests?

After having urodynamic tests, a person may feel mild discomfort for a few hours when
urinating. Drinking an 8-ounce glass of water every half-hour for 2 hours may help to reduce the
discomfort. The health care provider may recommend taking a warm bath or holding a warm,
damp washcloth over the urethral opening to relieve the discomfort.

An antibiotic may be prescribed for 1 or 2 days to prevent infection, but not always. People with
signs of infection—including pain, chills, or fever—should call their health care provider
immediately.

Cystogram

Cystography is a diagnostic procedure that uses X-rays to examine the urinary bladder. During
cystography, contrast dye is injected into the bladder. X-rays are taken of the bladder, and
fluoroscopy may be used to study the bladder emptying while a person urinates (voiding
cystography). Cystography may indicate how well the bladder empties during urination and
whether any urine backs up into the kidneys (vesicoureteral reflux).

Reasons for the Procedure

Cystography may be performed to assess the cause of hematuria (blood in the urine), recurring
urinary tract infections (UTIs), or to assess the urinary system when there has been trauma to the
 bladder. Cystography may also be used to assess problems with bladder emptying and urinary
incontinence.

Obstructions and strictures (narrowing) of the ureters or urethra may be evaluated by

cystography. Cystography may be used to assess enlargement of the prostate gland.

Cystography may be performed before and/or after certain surgeries of the spine to assess
possible problems with the nerves leading to the bladder from the spine. It may also be
performed following trauma to assess for a tear in the bladder wall.
Contraindications for cystography include the following:
 Active clinical UTI

 Pregnancy

 Allergy or sensitivity to contrast medium

Risks of the Procedure

Patients who are allergic to or sensitive to medications, contrast dyes, local anesthesia, iodine, or
latex should notify their doctor.

Patients with kidney failure or other kidney problems should notify their doctor.

Bladder infection may occur as a result of placing a catheter into the bladder for the procedure.
Insertion of a catheter into the bladder may also cause bleeding or hematuria.

Situations in which cystography may be contraindicated include, but are not limited to:

 Recent bladder surgery

 Blockage of the urethra, or damage or tearing of the urethra

 Acute phase of urinary tract infection

There may be other risks depending upon your specific medical condition. Be sure to discuss any
concerns with your physician prior to the procedure.

Certain factors or conditions may interfere with the results of the test. These may include, but are
not limited to:

 Gas or stool in the intestines

 Inability to maintain a steady stream when urinating

Barium in the intestines from a recent barium enema

 Equipment used for cystography includes the following:
 Sterile urethral catheterization kit with tubing
 Urethral catheter – In children, a 5- or 8-French pediatric feeding tube may be used
 Sterile gloves
 Surgical tape (for securing catheter in position)
 Intravenous (IV) pole
 Fluoroscope or image recording setup
 Contrast medium – For voiding cystourethrography (VCUG), this should ideally be
warmed to body temperature; temperature receptors in the bladder mucosa can mediate an
increase in detrusor tone in young children [16]
 Protective shielding equipment (eg, lead aprons and thyroid shields) for staff and
caregivers in the room
 Additional equipment for urodynamics – This includes specialized urethral catheters with
pressure transducers
Before the Procedure

 You may be asked to sign a consent form that gives your permission to do the procedure.
Read the form carefully and ask questions if something is not clear.

 Your doctor will give you specific instructions regarding withholding food and liquids
prior to the test if necessary.

 If you're pregnant or suspect that you may be pregnant, you should notify your doctor.

 Notify your doctor if you've ever had a reaction to any contrast dye, or if you are allergic
to iodine.

 Notify your doctor if you're sensitive to or are allergic to any medications, latex, tape,
and anesthetic agents (local and general).

 Notify your doctor of all medications (prescribed and over-the-counter) and herbal
supplements that you're taking.

 Notify your doctor if you have a history of bleeding disorders or if you're taking any
anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood
clotting. It may be necessary for you to stop these medications prior to the procedure.

 You may be instructed to take a laxative the night before the procedure. Alternatively,
you may be given an enema or a cathartic (medication to induce bowel movements)
medication the morning of the procedure.

Based on your medical condition, your doctor may request other specific preparation. Generally,
a cystography follows this process:

 You'll be asked to remove any clothing, jewelry, or other objects that might interfere with
the procedure.
 If you're asked to remove clothing, you'll be given a gown to wear.

 You'll be asked to empty your bladder prior to the procedure.

 You'll lie on your back on the X-ray table.

 A catheter will be inserted into your bladder for injection of the contrast dye into the
bladder.

 A kidney, ureter, and bladder (KUB) X-ray may be taken to verify that the urinary system
is visible. With male patients, a lead shield may be placed over the testes to protect the gonads
from the X-rays.

 The contrast dye will be injected into the bladder through the catheter. After the dye has
been injected, the catheter tubing will be clamped to prevent drainage of the dye from the
bladder.

 X-rays will be taken while the dye is being injected and afterward. You may be asked to
change position for different X-ray views of the urinary system.

 If a voiding cystography is requested, the catheter will be removed and you'll be asked to
urinate. X-ray or fluoroscopy films will be taken while you urinate. If you're unable to urinate
while lying down, you may be allowed to sit or stand up.

 If a voiding cystography isn't performed, the catheter will be removed after all required
X-ray views have been taken.

Contrast Examination of Bladder

Obtain a scout film of the abdomen and pelvis (kidneys-ureters-bladder [KUB]). With the patient
supine, catheterize and drain the bladder using aseptic technique. Collect a urine sample in a
sterile container for analysis if desired. Tape the catheter securely in position.
Instill the contrast agent through the catheter via gravity. (An intravenous (IV) pole may be
helpful in this regard.) For children, the amount of contrast material administered depends on
estimated bladder capacity, which is determined as follows:
Expected bladder capacity (mL) = (age + 2) × 30
For adults in the trauma setting, instill 300 to 400 mL of contrast material; false-negative
examinations can occur with inadequate distention of the bladder.[20]
Obtain a sequence of views, keeping in mind that pulsed fluoroscopy can reduce the radiation
exposure.
The first view is an early filling (anteroposterior [AP]) view of the bladder. In this view, an
ureterocele or bladder tumor may be visualized, which may later become obscured by additional
contrast material entering the bladder
After the Procedure
There is no special type of care required after a cystography. You may resume your usual diet
and activities, unless your physician advises you differently.

You should drink additional fluids for a day or so after the procedure to help eliminate the
contrast dye from your system and to help prevent infection of the bladder.

You may experience some mild pain with urination or notice a pink tinge to your urine for a day
or 2 after the procedure. This is to be expected after insertion of the catheter into your bladder.
However, if the pain increases or persists longer than 2 days, notify your doctor.

Also, notify your physician to report any of the following:

 Fever and/or chills

 Abdominal pain

 Blood in the urine

 Urine output is less than usual amount

Complications
The most common complications of cystography are postprocedural dysuria and perineal
discomfort, usually attributable to the catheterization rather than to the contrast material.[24] The
discomfort is usually transient; if patients are warned in advance that it might occur, they are less
likely to become anxious if it does.
Urinary tract infections (UTIs) are also more common after cystography. Careful aseptic
technique and judicious use of antibiotic prophylaxis can help decrease its incidence.
During urodynamic evaluation, patients may also experience a vasovagal response or syncope. In
most cases, stopping bladder filling and permitting the patient to lie down for a while will allow
the study to be resumed.
Autonomic dysreflexia is a potential life-threatening complication. Once it is identified,
immediately drain the bladder and remove the catheter and stop the study. Having an open
urethral catheterization setup for immediate access would be helpful. If blood pressure remains
elevated, an antihypertensive agent with quick onset and short duration of action (eg, nifedipine
or a nitrate) may be given, and blood pressure is monitored.
Hypersensitivity to the contrast material absorbed into the bloodstream through the bladder
mucosa and subsequent anaphylactoid reactions have been reported.[25]Bladder perforation is
extremely rare. If a feeding tube is used as a catheter, it should not be advanced any more than 1-
2 cm further after urine is obtained; there is a risk that it may become knotted and difficult to
remove.
URETHROGRAM

A urethrogram is an examination of the urethra by X-ray imaging, almost always carried out on
males. A urethrogram is usually carried out to show the cause of poor urinary flow thought to be
caused by narrowing (a stricture) of the urethra. The most common cause for narrowing of the
urethra in men is benign (non-cancerous) enlargement of the prostate gland. A urethrogram is
most often used to diagnose causes of narrowing of the urethra that are not caused by benign
enlargement of the prostate gland. The procedure will be explained to you by the radiologist
(specialist doctor) who will be carrying out the examination.

Indications
Trauma
The most common indication for a RUG in the setting of trauma is the presence of blood at the
urethral meatus after blunt or penetrating trauma. Penile fracture with gross hematuria is also an
indication for a RUG to elucidate the presence of a urethral injury. Another relative indication
for a RUG is the finding of a “floating prostate” on digital rectal examination, which may
indicate urethral disruption. (The prostate normally feels fixed on digital rectal examination, and
if the prostate is mobile or “floating,” a urethral disruption may have occurred.) A RUG would
diagnose the nature of the injury.
Lower urinary tract symptoms
Male patients with a previous history of urethral stricture who have symptoms of urinary
urgency, urinary frequency, and poor bladder emptying are at risk for a urethral stricture.
Postoperative evaluation
A RUG is often performed for the imaging and evaluation of the urethral after a surgical
procedure such a urethroplasty.[3]
Contraindications
Relative contraindications to RUG is a patient allergic to radiopaque contrast. However, because
a properly performed RUG does not inject contrast into the vascular system, some practitioners
may proceed carefully with RUG in these patients. Premedication with steroids, histamine-1
receptor blockers (such as cimetidine) and histamine-2 receptor blockers (such as Benadryl) may
be given preoperatively to decrease the chance of allergic reaction. The procedure should not be
performed with patients who have an active urinary tract infection.
Anesthesia
In most cases a retrograde urethrogram (RUG) can be performed without anesthesia. The
instillation of lidocaine gel into the urethra is one possible local anesthetic option but is usually
not used. In cases of urethral disruption, this would cause extravasation of the anesthetic jelly
into the surrounding tissue. In cases of urethral stricture, energetic installation of jelly can dissect
the urethral stricture in a way that makes subsequent instrumentation more difficult, so it is
generally avoided.
Positioning
The patient should be positioned obliquely at 45 º with the bottom leg flexed 90 º at the knee and
the top leg kept straight. . The patient is placed in the position stated above (see the Preparation
section). The fluoroscopic C-arm is positioned over the patients pelvis with the center focused
just below the pubic bone. A 16-F or 18-F Foley catheter is flushed with radiopaque contrast to
remove any air bubbles. The penile glans and urethral meatus should be cleaned with antiseptic.
The Foley catheter is then placed just inside the urethral meatus so that the Foley catheter
balloon rests in the fossa navicularis.
With the Foley in position, the catheter balloon is filled with 1-2 mL of radiopaque contrast or
saline solution. Overfilling must be avoided, or it will rupture the distal urethra. (A conscious
patient can be asked to alert the operator if pain accompanies balloon filling). The operator then
pulls the penis laterally to straighten the urethra, grasping the penis as distally as possible, and
distal to the inflated balloon. The catheter-tipped syringe is then filled with approximately 50 mL
of radiopaque contrast, and 20-30 mL of contrast is injected in a retrograde fashion. Taking a
preinjection “scout” film of the urethra to compare the RUG images is important. Static images
of the urethra are taken during retrograde injection of radiopaque contrast

You will usually be asked to empty your bladder, and then to remove your clothing, put on a
gown and lie down on an X-ray table called a fluoroscopy table..

Sterile drapes will be placed over your lower body, and your penis and groin will be cleaned with
antiseptic solution. The radiologist will wear sterile gloves to carry out the procedure.

Most radiologists will carry out the procedure by placing a narrow catheter (a thin plastic,
silicone or rubber tube) just into the end part of the penis where the urine comes out. A small
balloon will be inflated to keep the cathether in place and to stop contrast medium running out
the end of the penis. Most people will experience some discomfort during passage of the catheter
and inflation of the small balloon.

Contrast medium is gently injected through the catheter. Contrast medium, sometimes just called
‘contrast’ (or X-ray dye, even though it is a colourless fluid) is a fluid that makes a shadow on an
X-ray image. This fluid is used to fill the urethra, and pictures or images are taken using an X-
ray camera. These images will show if there is a narrowing in the urethra, where it is and how
severe the narrowing is.
This part of the test only shows narrowings involving the middle and lower part of the urethra.
Often this gives all the information required, but it can be necessary to obtain images of the
upper urethra when voiding (while the urine and contrast is flowing through the urethra from the
bladder). This usually involves removing the initial catheter and injecting local anaesthetic jelly
into the urethra, which lubricates and anaesthetises the urethra, and assists passing a catheter into
the bladder.

After the catheter has been passed into your bladder, your bladder will be filled with contrast.
When it feels so full that you feel the need to pass urine, the catheter will be removed. During
this filling stage, images of the bladder will be taken as necessary.
If you have a severe narrowing in the urethra, it may not be possible or safe to push the tube into
your bladder. If this is the case, there is usually enough information on the initial study for the
urologist.

The X-ray table will then be gradually tilted so that you are bought up to a standing position and
you will be given a bottle to pass urine into. While you are doing this, more pictures of your
bladder and urethra will be taken to see how well your bladder empties and to further show if
there are any narrowings in the urethra

What are the risks of a urethrogram

1. Damage to the urethra. This is rare, but more common if the urethrogram is carried out
as an emergency procedure. This is because the lining of the urethra is often torn before the
procedure and the catheter can pass through the torn area outside of the urethra.
In the emergency situation, a urethrogram, with the catheter just into the end of the penis,
should show urethral tears and then avoid further injury that could be caused by attempting
to pass a catheter into the bladder. Attempting to insert a catheter into the bladder if there is
already an injury to the urethra can cause the injury to be extended or the catheter to
perforate the urethra through the tear. Injury can occur when there is a tight narrowing in the
urethra and it is difficult to pass the catheter beyond the narrowing.
It is extremely rare for a urethrogram to injure the urethra if there is not already a tear in the
urethra or a severe narrowing before the urethrogram begins.
2. Urine infection. This also is very rare, because sterile technique is used. Some initial
discomfort or stinging is usual after the test. If you do have an infection, you will feel a
burning sensation when you pass urine. If this goes on for more than 36 hours, you will need
to see your doctor who may prescribe antibiotics. Other signs of an infection that you should
see your doctor about include feeling the need to constantly go to the toilet and pass urine
more than 36 hours after the procedure or a temperature or chills (shivering) at any time
after the procedure. It is important if you do develop a fever (a temperature greater than
38°C) to see your general practitioner promptly and have your urine tested for infection.
3. Allergic reaction to contrast medium. This is rare, as the contrast is not injected directly
into a blood vessel, but it can occur (see Iodinated Contrast). If you know you have had an
allergic reaction to iodine containing contrast in the past, you must tell the radiologist
before the procedure. You should also let the hospital or radiology practice know when
you make your appointment. They may decide that you require medication with
corticosteroids (steroids) for a day before the procedure or they may decide not to do the
procedure at all if your previous reaction was a severe one.