MICTURATING CYSTOURETHROGRAM

1. MICTURATING
CYSTOURETHRORAM
DR DEELIP SHAH
MD RADIODIAGNOSIS
PROFESSOR

2. Urethrography refers to the radiographic
study of the urethra using iodinated
media and is generally carried out in males.
When the urethra is studied with instillation
of contrast into the distal/anterior urethra it
has been referred to as
Retrograde urethrography (RUG)
Ascending urethrography (ASU)
When the posterior urethra is studied
micturation, this has been referred to as
Voiding cystourethrography (VCUG)
Descending urethrography
Micturating urethrography

3. ANATOMY OF URINARY BLADDER
• Hollow, distensible, muscular organ located within the
pelvic cavity, posterior to the symphysis pubis and inferior to
the parietal peritoneum.
Shape is that of a flattened tetrahedron when empty and
round/oval when distended with fluid.
The size of the bladder varies: when filled, the upper border of
the bladder, should not rise above the level of the lumbosacral
junction in the child and the second or third sacral segment in
the adult.
Normal bladder wall thickness is 2-3mm in fully distended
bladder.
Apex(superoanterior portion) of the bladder attached to
anterior abdominal wall by
median umbilical ligament(remnant of urachus).
Base(posterioinferior portion) is continuous with the bladder

4. • First urge to void is felt at a bladder volume of 150ml
• Bladder capacity is between 500-600 ml.
• The max capacity of bladder is up to 1200 ml. ( F> M
).
Bladder wall consists of mucosa,
submucosa,lamina propria and smooth
muscle. The mucosa consists of multilayered
transitional epithelium and
the muscle layer consists of longitudinal and
circular muscle bundles.

5. ANATOMY OF
URETHRAIn females:
Length of 4-5 cm.
In males:
20cm in length.
Ithas four namedregions:
Prostatic urethra:
Is approximately 3 cm in length.
Passes through the prostate gland.
Membranous urethra:
Is approximately 1 cm in length.
Passes through the urogenital
diaphragm.
Bulbar urethra
From inferior aspect of urogenital
diaphragm to penoscrotal junction.
Spongy (penile) urethra:
Passes through the length of the penis.

6. The interior of the prostatic urethra:
On the posterior wall of the prostatic
urethra there are:
• Urethral crest:
A longitudinal ridge.
• Seminal colliculus / Verumontanum:
An enlargement of the urethral crest.
( act as a normal filling defect on RGU )
• Prostatic sinus:
The groove on either side of the
seminal colliculus.
• Prostatic utricle:
A small opening on the midline
of the seminal colliculus.
• Opening of the ejaculatory duct:
One on either side of the prostatic utricle.

7. Female urethra
• Widest at bladder neck.
• 4-5cms in length
• Narrowest & least distensible
at meatus.
• This forms the Spinning top
configuration of urethra on
normal MCU.

8. SPHINCTERSOF URETHRA
• INTERNAL URETHRAL
SPHINCTER –
involuntary in nature
• Supplied by sympathetic nerves
• It controls the neck of the bladder
& prostatic urethra above the
opening of ejaculatory ducts
• EXTERNAL URETHRAL SPHINCTER-
• voluntary in nature
• Supplied by perineal branch of the
pudendal nerve (s2-s4)
• Controls the membranous urethra & is
responsible for voluntary holding of
urine

9. The division into anterior and posterior urethra is important
in terms of pathology and in imaging the urethra: the
anterior urethra being visualised
retrograde (ascending) urethrogram
by performing a
and the posterior
urethra with an antegrade (descending or micturating)
urethrogram.
Normal male urethral anatomy demonstrated by (A) voiding
cystourethrography and by (B) retrograde urethrography.

10. MCU
Voiding cystourethrography (VCUG), also known
as a micturating cystourethrography (MCU), is a
fluoroscopic study of the lower urinary tract in
which contrast is introduced into the bladder via a
catheter. The purpose of the examination is to
asses the bladder, urethra, postoperative anatomy
and micturition in order to determine the presence
or absence of bladder and urethral abnormalities,
including vesicoureteral reflux (VUR).

12. Indications:
Children:
Urinary tract infection– Usually done after some weeks of acute stage or may
be done under antibiotic converge. MCU is indicated after the 1st occurrence of
UTI in boys or girls.
voiding difficulties :
dysuria ,
thin stream dribbling,
frequency, urgency ,
vesico ureteric reflux,
trauma.
Baseline study prior to lower UT surgery.
Adults:
Trauma to urethra, urethral stricture, urethral diverticula ,UTI, Reflux
nephropathy prior to renal transplant of one/both kidneys.

13. CONTRAST MEDIA:
Water soluble contrast media like conray 280, trivideo
400mg,urograffin 60% are used which is diluted with normal
saline in 1:3 ratio

14. Contraindications
1)Acute urinary tract infection
2)Hypersensitivity to contrast medium
3)Pregnancy

15. Procedure
• Using a sterile technique , a catheter is introduced into the
bladder.
• A 5F feeding tube with side holes are used for children and in
older children or adults 8F or 10F catheters are used .
• In girls after initial inspection of perineum to identify any local
genitilia abnormalities (cystoceles or labial fusion ) the
catheter is introduced..
• When it enters the bladder a varying amount of urine will flow
through it. If no flow a catheter is introduced till urine is
obtained.

16.  Suprapubic pressure Is sometimes helpful.
 In males , foreskin is retracted and catheter is
introduced . The catheter should be lubricated
with anaesthetic jelly and inserted slowly and
gently into the urethra holding the penis is
vertical position .
 The normal bladder capacity in children is
estimated in ounces (1 ounce=29cc)as age(in
yrs)x2
 For newborns -30 to 35 cc can be instilled.
• For upto 3 yrs – 200 to 250 cc
 Adequate capacity is reached when the child
becomes uncomfortable and begins voiding
around the catheter.

17. Filming
 In children : upto 2 yrs of age bladder is filled by hand
injection. For older children contrast medium is instilled
from a bottle elevated one metre above the examination
table.
 During filming, fluroscopic screening is performed at
short intervals to see any vu reflux,diverticuli.
 The child is turned oblique on both sides to ensure that
minimal reflux is not overlooked.
 In infants : voiding starts the moment catheter is
removed. At the end of voiding ,frontal film is taken which
includes entire abdomen including the kidney region to
prevent overlooking the vu reflux which is apparent only
on termination of voiding and may reach upper collecting
system.

18.  In adult male : bladder is filled in the usual way as in
older child and voiding filming is done in both oblique
projection views.
 The voiding study in male adults can be modified by
getting the patient to void against resistance i.e. by
compression of distal part of penis thus enhancing the
visualization of urethra by artificial distention .

19. Formula for bladder capacity
For children>2 years
Bladder capacity in ml= ( Age[years] + 2 )X
30
For children< 2 years
Bladder capacity in ml= weight[kg] X 7
Adult: around 500 ml

20. Micturating film is taken
Female: AP/lateral
Male:RAO/LAO(left anterior oblique
position
with right hip and knee flexed –
entire urethra ,lower ureter)
 Finally, a post-void film is taken to
record post-void residual contrast in
bladder
 Post-void film should include whole
KUBregion to demonstrate any relfux
of contrast medium that might have
occurred unnoticed into the kidneys

22. Modifications
For stress incontinence , following additional
films are taken
1) Lateral full bladder,at rest
2) Lateral bladder, straining
3) Lateral bladder, during micturition
For fistulae ,a series of films in AP.lateral
and oblique positions may be required

23. Causes of incomplete bladder emptying
1)Effect of sedation
2)Dysuria following catheterisation
3)Neurogenic bladder
4)Refilling of bladder from above where there
is significant VUR

24. Complications
Due to technique
1) Urinary tract infection
2) Urethral or bladder
trauma
3) Rupture of bladder from
overdistension
Due to contrast medium
1) Adverse reactions due
to absorbed contrast
medium
2) Contrast-induced
cystitis

25. Autonomic dysreflexia:
In paraplegic patients due to spinal cord injury at or above
T6 level,forceful injection of contrast causes severe
headache,sweating and hypertension with bradycardia
due to forceful opening of bladder neck.this can be treated
by promptly relieving vesical distension or by diazoxide 3-
5mg/kg

26. SPECIFIC DISEASES
OF THE
URINARY BLADDER
Congenital Bladder agenesis
 Bladder hypoplasia
 Bladder duplication
 Congenital diverticulum
of bladder
 Urachal anomalies
• Urachal sinus
• Urachal cyst
• Urachal diverticulum
• Patent urachus
 Bladder exstrophy etc.
Acquired bladder
diverticulum
 Bladder calculi
 Cystitis
 Bladder fistula
 Bladder injury
 Detrusor hyperreflexia
 Detrusor areflexia etc
Acquire
d

27. A 2YROLD
CHILD H/O
RECURRENT
UTI

28. Vesico-ureteric reflux
Vesicoureteric reflux (VUR) is the term for abnormal flow of
urine from the bladder into the upper urinary tract and is
typically a problem encountered in young children.
VCUGis indicated after a first UTI only if ultrasound reveals
hydronephrosis, scarring, or other abnormalities suggestive of
high-grade VURor obstructive uropathy or in patients with
complex clinical conditions. VCUGis also recommended if
there is a recurrence of a febrile UTI
IDENTIFIED BY MCU

29. Complications of VUR:
 Recurrent UTI & consequent renal
scarring
 Reflux atrophy/nephropathy

30. Grades of VUR
Vesicoureteric reflux (VUR) grading divides vesicoureteric reflux
according to the height of reflux up the ureters and degree of dilatation
of the ureters:
grade 1:reflux limited to theureter
grade 2:reflux up to the renal pelvis
grade 3:mild dilatation of ureter and pelvicalyceal system
grade 4
tortuous ureter with moderate dilatation
blunting of fornices but preserved papillaryimpressions
grade 5
tortuous ureter with severe dilatation of ureter and pelvicalyceal
system
loss of fornices and papillary impressions.

31. Grade 1:reflux limited to theureter

32. Grade 2:reflux up to the renalpelvis

33. Grade 3:mild dilatation of ureter and
pelvicalyceal system

34. Grade 4 :tortuous ureter with moderate
dilatation blunting of fornices but preserved
papillary impressions

35. Grade 5:tortuous ureter with severe dilatation
of ureter and pelvicalyceal system
loss of fornices and papillary impressions.

36. A 2YROLD BOY
PRESENTED WITH
DIFFICULTYIN
MICTURATION
MCU SHOWS
Fusiform dilatation
& elongation of
proximal posterior urethra
Persist during voiding
Transverse/curvilinear
filling defect in
posterior urethra

37. Posterior urethral valves
Posterior urethral valves (PUVs), also referred as congenital obstructing posterior
urethral membranes (COPUM), are the most common congenital obstructive
lesion of the urethra and a common cause of obstructive uropathy in infancy.
Congenital thick folds of mucous membrane located in the posterior urethra
(prostatic +membranous) distal to the verumontanum.
Most common cause of severe obstructive uropathy in children.Almost exclusively
in males.
Leading cause of end stage renal disease in boys.
The valves (thickened mucosal folds) can be identified on VCUG or USG associated
with proximal dilatation of the posterior urethra.

38. According to Young's classification, there are
three types of posterior urethral valves
Type
Type 1
• most common
• occurs when
the two
mucosal folds
extend
anteroinferiorly
from bottom of
verumonatum
and fuse
Type
Type 2
• rare
• mucosal folds
extend along
posterolateral
urethral wall
from ureteric
orifice to
verumontanum
Type
Type 3
• circular diaphragm
with central opening
in membranous
urethra
• located below the
verumontanum and
occurs due to
abnormal canalization
of urogenital

39. Voiding cystourethrogram (VCUG) is
the best imaging technique for the
diagnosis of posterior urethral valves.
The diagnosis is best made during the
micturition phase in lateral or oblique
views, such that the posterior urethra can be imaged
adequately. Findings include :
dilatation and elongation of the posterior urethra (the equivalent of the
ultrasonographic keyhole sign)
linear radiolucent band corresponding to the valve (only occasionally seen)
vesicoureteral reflux (VUR): seen in 50% of patients
bladder trabeculation / diverticula

40. Anterior urethral valve
 Rare anamoly , but -Commonest cause of congenital anterior urethral obstruction .
 In most cases, the valve is in fact the dorsal wall of a congenital urethral
diverticulum.
 Occasionally, a membranous valve is present without an associated diverticulum.
 Etiology - Anomalous developmental membranes / congenital cystic dilation of
normal or accessory urethral glands
 Cusp / Iris / Semilunar shaped.
 The degree of obstruction is variable - may be subclinical or rarely may result in
severe obstruction.
PRESENTATION
 Infants / young children – obstruction.
 Older children – Diurnal enuresis , UTI.

41. Dilated proximal
urethra
AU
V
Normal distal
urethra

42. Meatal
stenosis
• Congenital narrowing of the urethral
orifice / may be caused by meatal webs.
• Can occur in both male and females.
• Associated with hypospadias.
• Acquired more common
• Presentation - Weakness of the urinary stream, and
straining during micturition.
• Diagnosis – clinical , imaging if obstructive features are
present.

43. • Congenital megalourethra
• This is a rare congenital anomaly
resulting from the faulty development of
the corpora cavernosa and corpus
spongiosum.

44. megalourethra in an infant. Lateral mcu
image reveals an extensively dilated
anterior and posterior urethra

45. Urachal
diverticulum :
• persistence of a segment of the
urachus, present as a protrusion at the
vertex of the bladder. It may
predispose to urolith formation.

46. Urachal diverticulum. Posteroanterior
mcu image shows a gross urachal
diverticulum bladder.

47. (a) Early anteroposterior
voiding cystourethrogram
demonstrates a ureterocele

48. HUTCH DIVERTICULA:
These are congenital bladder diverticula,seen at
vesico ureteric junction,in the absence of
posterior urethral valve or neurogenic bladder.
These are due to weakness in the detrusor
muscle anterolateral to the ureteral orifice.
On vcu contrast filled outpouchings from the
urinary bladder arise at the vesico ureteric
junction,giving MICKEY MOUSE appearance.
of

50. Bladder
diverticulum
Sac formed by herniation of bladder mucosa and submucosa through
muscular wall
Mostly acquired : males .
In the early stages, multiple small protrusions of the bladder lumen appear
between the trabeculae (sacculations).
As they enlarge above 2 cm they become defined as diverticula
Most found close to the uretericorifices
Stasis in diverticula may lead to stone formation.
2% cases leads to carcinoma, MC tumour is Squamous cell carcinoma

51. • A wide-necked diverticulum
empties readily when the
bladder empties while A
narrow-necked diverticulum
empties slowly
• Classical symptom of double
micturition; when the patient
empties the bladder a
significant amount of urine is
stored in the
diverticulum, which then
empties back into the
bladder, causing a desire to
micturate almost immediately
after the first micturition.

52. Bladder duplication
Complete :
 Both bladders lie side by
side, separated by a peritoneal fold.
Each bladder has normal musculature
and mucosa,
 Ipsilateral ureter drains into each
bladder.
 Each bladder has a separate urethral
orifice that may drain into a common
urethra with a single penis, or there
may be complete duplication of the
urethra and penis
Partial duplication :
 Coronal or sagittal septum completely
or incompletely divides the bladder
 A single urethra for drainage

53. Bladder
herniation
• At least 95% of bladder herniationis into
the inguinal or femoral canals
• usually small(2-3 cm)& asymptomatic
• Painful, partly obstructed micturition becausethe
tends to remain in normalposition,
• Usually narrow neck and fill poorly on routinecontrast
images
• So best seen on prone or erectfilms
• Most commonly is paraperitoneal in location, bladder
remaining extraperitoneal and medial to a trueinguinal
hernia sac

54.  MC cause in developing countries
=>prolonged obstructed labour
 MC cause in developed countries
=>abdominal hysterectomy
Rarely due to pelvic
malignancy, radiation ,
 Painless constant dribbling of urine
from the vagina.
Relatively easy to demonstrate during
urography or cystography
 Lateral and oblique films best
 Vesicouterine fistulae are a rare result
of cesarean delivery
May present with cyclic hematuria
pattern (Youseff s syndrome)
Vesicovaginal
fistula

55. Thank you