Radiological procedure of retrograde urethrography(rgu) and micturating

Radiological procedure of retrograde urethrography(rgu) and micturating cystourethrography

1. Radiological Procedure of Retrograde Urethrography(RGU) And Micturating Cystourethrography(MCU) Sanju Timilsina B.Sc.MIT 2 nd year

2. Overview Introduction Anatomy(Urinary System) Micturating Cystourethrography(MCU) Indication and Contraindication Patient Preparation Filming Sequence Technique Films Aftercare Complication RETROGRADE Urethrography(RGU) Radiation Protection Summary Bir Hospitals protocol for RGU & MCU REFERENCES

3. Introduction Urethrography Urethrography refers to radiological study of urethra using iodinated contrast media. Types of Urethrography : Micturating Cystourethrography : Radiographic examination of urethra, bladder by injecting contrast media through catheter. Retrograde urethrography: Male urethra is studied using water soluble contrast agent through retrograde filling . For both studies static images of bladder is obtained, assessed dynamically under fluoroscopy. Some patient are assessed with both techniques, usually RGU first followed by MCU

4. Anatomy Urinary System consist of : Kidneys which filters waste product and forms urine Ureters which convey urine from kidney to bladder Urinary bladder where urine is collected and stored temporarily. Urethra through which urine is discharged from bladder.

5. Urinary Bladder Roughly pear shaped hollow muscular organ, that acts as a reservoir of urine which lies in the pelvic cavity Its size and position vary, depending on the amount of urine it contains, When distended it becomes more oval and rise into the abdominal cavity. It has anterior, superior and posterior surfaces, posterior surface is the base, which is directed backwards and downwards and in female is related to the anterior wall of the vagina. In male, it is separated from the rectum by the retro vesical pouch of the peritoneum above the seminal vesicles and deferent ducts below. The bladder opens into the urethra at its lower point, the neck, which rest on the base of the prostate in male.

6. Organs associated with bladder Trigone : Triangular place formed by three orifice of bladder. Importance: Urine passes from kidney to bladder and bladder to urethra. Controls backflow of urine. Female Male Anteriorly Symphysis Pubis Symphysis Pubis Posteriorly Uterus Rectum and Seminal vesicle Superiorly Small intestine Small intestine Inferiorly Urethra and muscle forming pelvic floor Urethra and Prostate Gland

7. Urethra It extends from the neck of the bladder to the exterior. The male urethra is associated with urinary and reproductive system. The external urethral orifice -under voluntary control. F emale urethra is approximately 4cm (1.5inches) long and male urethra - 18-20 cm (8 inches) long and about 6 mm of diameter, has three parts : The prostatic portion The perineal or membranous portion . (c)The penile or spongy portion.

8. There are internal and external sphincters in urethra ; The internal sphincter is involuntary and the external sphincter is under voluntary control except in early infancy The opening of the urethra to the exterior is called the urinary meatus . Male Urethra It is 20 cm long from bladder to external urethral meatus It has twisting course It is further divided into 3 parts:

9. Prostatic part Widest portion It is 3cm long Most dilatable part Ducts of prostate gland and ejaculatory ducts open in it Membranous part Lies within urogenital diaphragm It is 1.5 cm long Least dilatable part

10. Penile part It is 15.5 cm Is surrounded by erectile tissue of bulb and corpus spongiosum It is dilated at the end as navicular fossa Bulbourethral and penile glands open in it

11. Female Urethra t is 4 cm in length and 6 mm in diameter It lies anterior to vagina It opens in the vestibule anterior to vaginal opening Para urethral glands They are mucus secreting glands located at the sides of external meatus It is easily dilatable It is straight

12. Micturating Cystourethrography Radiographic examination in which bladder is filled via suprapubic or retrograde catheterization and urethra is assessed during voiding. Micturating Cystourethrography includes : C atheterization . Injection of CM retrograde. Filling, voiding and post voiding situations evaluated under fluoroscopy. Spot radiographs of bladder and urethra.

13. Indication and Contraindication INDICATION Chronic urinary tract infection Dysuria Vesico-uretric reflux Trauma Urethral stricture Suspected diverticula Stress incontinence Contraindication Acute UTI Contrast agents allergies

14. Contrast Medium Water soluble contrast media diluted upto 500ml Pre warming of CM to body temperature helps to reduce incidence of spasm of external sphincter. Equipment Fluoroscopic unit with IITV or digital fluoroscopy Spot film devices Foley’s catheter( 5 -7 French in infants larger in adults .) Syringes Xylocaine jelly 1-2 % A septic procedure pack. Sterile towels Skin prep./ wash Tilting table .

15. Patient Preparation Patient micturates prior to examination NPO for 6hrs prior to the examination( Incase of children, if sedation is necessary ) Urea and creatinine should be within the normal range Informed consent should be taken

16. Technique To demonstrate vesico-ureteric reflux The patient lies supine on the X-ray table. Using aseptic technique a catheter, lubricated with Hibitane 0.05% in glycerine, is introduced into the bladder. Residual urine is drained. Initial filling is monitored by fluoroscopy to rule out slight VUR and small bladder tumor The catheter should not be removed until the radiologist is convinced that the patient will micturate or until no more contrast medium will drip into the bladder. The examination is expedited if the catheter remains in situ until micturition commences and then is quickly withdrawn. Small feeding tubes do not obstruct micturition.

17. Older children and adults are given a urine receiver but smaller children should be allowed to micturate onto absorbent pads on which they can lie. Children can lie on the table but adults will probably find it easier to micturate while standing erect. Spot films arc taken during micturition and any reflux recorded. The lower ureter is best seen in the anterior oblique position of that side. Boys should micturate in the LAO position or in the RAO position Finally, a full-length view of the abdomen is taken to demonstrate any reflux of contrast medium that might have occurred unnoticed into the kidneys and to record the post-micturition residue

18. To demonstrate a vesico-vaginal or recto-vesical fistula Technique is as for demonstrating vesico-ureteric reflux , but films are taken in the lateral position. To demonstrate stress incontinence Initially the technique is as for demonstrating vesico-ureteric reflux. The catheter is left in situ until the patient is in the erect position.

19. Filming Sequence These should include sacrum and symphysis pubis Preliminary film of bladder. Initial filling of bladder-AP Full bladder-AP Images during voiding is taken to see patency of urethra-RPO Variations : In stress incontinence Lateral of pelvis in case of recto-vesical fistula or vesico-vaginal fistula Full film of abdomen is taken to see reflux

20. Films AP of bladder

21. AP oblique of bladder showing distal ureter but centering on raised side to show any VUR.

22. Lateral view of bladder

23. Normal MCU MCU showing reflux

24. Some of images in MCU

25. Aftercare P atients and parents of children should be warned that dysuria, possibly leading to retention of urine, may rarely be experienced. Most children will already be receiving antibiotics for their recent urinary tract infection. Plenty drinking of fluids should be advised If hematuria persists past the third voiding, physician should be contacted. General patient post procedure care.

26. Complication Due to the contrast medium Adverse reactions may result from absorption of contrast medium Contrast medium-induced cystitis. Due to the technique Acute urinary tract infection. Catheter trauma Complications of bladder filling , e.g. perforation from over distension - prevented by using a non-retaining catheter Catheterization of vagina or an ectopic ureteral orifice. Retention of a Foley catheter.

27. Retrograde Urethrography(RGU) It is radiological examination of male urethra in which contrast is injected retrogradely with Foley catheter of which the balloon is inflated in navicularis fossa just proximal to urethral orifice. It is also called as ascending urethrogram. It is most commonly done to evaluate : membranous and anterior urethra, inflammatory lesions and diverticula. This procedure may be disadvantageous to demonstrate posterior (prostatic) urethra adequately

28. Indications and Contraindications Indications Strictures Urethral tears Congenital abnormalities Periurethral or prostatic abscess Fistulae or false passages Contraindications Acute urinary tract infection Contrast sensitivity Urethral trauma

29. Contrast Medium HOCM or LOCM 200-300, 20 ml. Pre-warming the contrast medium will help to reduce the incidence of spasm of the external sphincter . EQUIPMENT Fluoroscopic unit with IITV or digital fluoroscopy Spot film devices Foley’s catheter(5 -7 French in infants larger in adults.) Syringe Xylocaine jelly 1-2 % Aseptic procedure pack. Sterile towels Skin prep./ wash Tilting table .

30. Patient Preparation Patient micturates prior to examination NPO for 6hrs prior to the examination( Incase of children, if sedation is necessary ) Urea and creatinine should be within the normal range Informed consent should be taken

31. Technique Preliminary film- Coned PA of bladder base and urethra. Patient is made to lie supine and slightly tilted with legs. Under aseptic condition, tip of Foley’s catheter is inserted in urethra applying xylocaine jelly ensuring tip of balloon lies in navicularis fossa and balloon is inflated with 1-2 ml of water. Pressure is applied over glans penis to avoid expulsion of catheter and also penis is straighten over ipsilateral leg to prevent urethral overlapping. Contrast medium is injected slowly under fluoroscopic control

32. Filming Sequence Preliminary film 30º left anterior oblique 30º right anterior oblique

33. Films Normal RGU Anatomy in RGU

34. Aftercare Patients and parents of children should be warned that dysuria, possibly leading to retention of urine, may rarely be experienced. Most children will already be receiving antibiotics for their recent urinary tract infection. Plenty drinking of fluids should be advised If hematuria persists past the third voiding, physician should be contacted. General patient post procedure care Complications Due to the contrast medium Contrast reaction(due to absorption through bladder) Due to the technique Acute urinary tract infection Urethral trauma Intravasation of contrast medium- due to excessive pressure in stricture

35. Radiation Protection The following procedures will help to reduce the occupational exposure: During radiography, always remaining behind the operating console barrier. Never participating in the procedure without a protective apron. Always positioning occupational radiation monitor on your collar. During C-arm fluoroscopy, be sure the x-ray tube is below the patient. If the technologist is pregnant, inform the supervisor so that additional radiation protection procedures can be implemented. The following procedures will help to reduce patient radiation dose : Using high KVp technique for radiography. Practicing 10 day rule(In females).

36. Summary Urethrography refers to radiological study of urethra using iodinated contrast media . Types of Urethrography : MCU: Radiographic examination of urethra, bladder by injecting contrast media through catheter. RGU: Male urethra is studied using water soluble contrast agent through retrograde filling . Both of the procedure is carried out under the fluoroscopic control in addition to aseptic technique during catheterization Male urethra is best seen in oblique position Female urethra is best seen in lateral and AP position

37. Bir Hospitals protocol for RGU & MCUG In NAMS Bir Hospital RGU and MCUG is done under fluoroscopic control. Fluoroscopy unit here is of Shimadzu with rotating anode over couch tube with maximum Kvp of 150 and maximum mA of 800 but working range of mA is 500 and mA used during fluoroscopy is 2-5mA Most of the cases visiting Bir hospital for MCUG + RGU is : Frequent Urination Dysuria Nocturia Stress incontinence

38. Equipment's for RGU and MCUG Dressing set Foley’s catheter Surgical gloves 10ml syringe,50ml irrigation syringe Normal saline Xylocaine Jelly Urograffin-20ml(1 amp for RGU and 4-5 amp for MCUG) Procedure Patient lie in supine position, examination area is cleaned using aseptic technique and catheterization is done bladder is filled under fluoroscopy control after bladder is full the catheter is withdrawn and Patient is asked to micturate in different position and films are taken. We assist radiologist in whole procedure. Films : Full Bladder,Straining,Right oblique micturating,Left oblique micturating,Ap micturating and post void.

39. REFERENCES A Guide to Radiological Procedures, Chapman & Nakielny - 4th Edition. Clark’s Special Procedure . Internet

40. Thank You For Listening Have a great day

41. Questions What is mean by MCU? Why CM is diluted in MCU? Why pre warming of CM to body temperature is required? What is stress incontinence? What is mean by RGU? Why RGU is done in male but not in female? What are common indications of MCU & RGU examination visiting Bir Hospital?