Retrograde Cystography

Retrograde cystography involves the instillation of contrast medium into the bladder, followed by radiographic examination. This procedure is used to diagnose bladder rupture without urethral involvement because it can determine the location and extent of the rupture. Other indications for retrograde cystography include neurogenic bladder, recurrent urinary tract infections (UTls, especially in children), suspected vesicoureteral reflux, and vesical fistulas, diverticula, and tumors. This test is also performed when cystoscopic examination is impractical, as in male infants, or when excretory urography has not adequately visualized the bladder. Voiding cystourethrography is often performed concomitantly.

Purpose

• To evaluate the structure and integrity of the bladder

Patient preparation

• Explain to the patient that this test permits radiographic examination of the bladder.
• Inform him that he needn't restrict food or fluids before the test.
• Tell him who will perform the test and where and that the procedure takes about 30 to 60 minutes.
• Inform the patient that he may experience some discomfort when the catheter is inserted and when the contrast medium is instilled through the catheter.
• Tell him that he may hear loud, clacking sounds as the X-ray films are made.
• Make sure the patient or a responsible family member has signed a consent form.
• Check the patient's history for hypersensitivity to contrast media, iodine, or shellfish; mark it on the chart.

Equipment

Drip infusion set or syringes, standard contrast medium, urethral indwelling urinary catheters

Procedure and posttest care

• The patient is placed in a supine position on the X-ray table, and a preliminary kidney-ureter-bladder radiograph is taken.
• The radiograph is developed immediately and scrutinized for renal shadows, calcifications, contours of the bone and psoas muscles, and gas patterns in the lumen of the GI tract.
• The bladder is catheterized, and 200 to 300 ml of sterile contrast medium (50 to 100 ml in an infant) is instilled by gravity or gentle syringe injection. The catheter is then clamped.
• With the patient supine, an anteroposterior film is taken. The patient is then tilted to one side, then the other, and two posterior oblique (and sometimes lateral) views are taken.
• If the patient's condition permits, he's placed in the jackknife position and a posteroanterior film is taken. A space-occupying vesical lesion may require additional exposures. Rarely, to enhance visualization, 100 to 300 ml of air may be insufflated into the bladder by syringe after removal of the contrast medium (double-contrast technique).
• The catheter is then unclamped, the bladder fluid is allowed to drain, and a radiograph is obtained to detect urethral diverticula, reflux into the ureters, fistulous tracts into the vagina, or intraperitoneal or extraperitoneal extravasation of the contrast medium.
• Monitor vital signs every 15 minutes for the first hour, every 30 minutes during the second hour, then every 2 hours for up to 24 hours.
• Record the time of the patient's voidings and the color and volume of the urine. Observe for hematuria that persists after the third voiding.
• Watch for signs of urinary sepsis from UTI (chills, fever, elevated pulse and respiration rates, and hypotension) or similar signs related to extravasation of contrast medium into the general circulation.

Precautions

• Retrograde cystography is contraindicated during exacerbation of an acute UTI or in patients with an obstruction that prevents passage of a urinary catheter.
• This test should not be performed in patients with urethral evulsion or transection, unless catheter passage and flow of contrast medium are monitored fluoroscopically.

Normal Findings

Retrograde cystography shows a bladder with normal contours, capacity, integrity, and urethrovesical angle and with no evidence of tumor, diverticula, or rupture. Vesicoureteral reflux should be absent. The bladder should not be displaced or externally compressed; the bladder wall should be smooth, not thick.

Abnormal findings

Retrograde cystography can identify vesical trabeculae or diverticula, spaceoccupying lesions (tumors), calculi or gravel, blood clots, high- or low-pressure vesicoureteral reflux, and a hypotonic or hypertonic bladder.

Interfering factors

• Gas, stool or residual barium from recent diagnostic tests in the bowel (possible poor imaging)