Normal VCUG Report Template (Pediatric Voiding Cystourethrogram)

EXAMINATION: Voiding cystourethrogram (VCUG), fluoroscopic.

CLINICAL HISTORY: [indication, e.g. “Febrile urinary tract infection
at 8 months of age with hydronephrosis on renal ultrasound, evaluate
for vesicoureteral reflux” / “Antenatal hydronephrosis” / “Sibling
with vesicoureteral reflux”]

COMPARISON: [None available. / Renal and bladder ultrasound dated x.]

TECHNIQUE: Under sterile conditions, a [x] French feeding tube /
catheter was placed in the bladder via the urethra [after
application of topical anesthetic]. [Clear urine was obtained. /
Urine was sent for culture.] A scout image of the abdomen and pelvis
was obtained. The bladder was filled with dilute water-soluble
iodinated contrast by gravity drip until voiding, with intermittent
pulsed fluoroscopy and spot images of the bladder during early
filling, at capacity, and of each ureterovesical junction during
filling and voiding. Oblique views of the urethra were obtained
during voiding [with the catheter in place / after catheter removal].
Post-void images of the bladder and renal fossae were obtained.
[Cyclic VCUG with x filling-voiding cycles was performed.] Bladder
volume at voiding: [x] mL (expected capacity for age approximately
[x] mL). Fluoroscopy time: [x] seconds.

FINDINGS:
Scout: Normal bowel gas pattern. No urinary tract calcification.
Normal lumbosacral spine without a bony spinal dysraphism.
Bladder: Smooth-walled and normal in contour during filling and at
capacity. No trabeculation, diverticulum, ureterocele or filling
defect. Normal bladder base. Bladder capacity is appropriate for
age.
Vesicoureteral reflux: No vesicoureteral reflux into either ureter
during filling, at capacity, or during voiding. [No reflux on x
cycles.]
Urethra: The urethra is normal in caliber and contour throughout
during voiding. [Male: The posterior urethra is normal in caliber
without a posterior urethral valve, dilatation or an abrupt change
in caliber at the membranous urethra. The anterior urethra is
normal.] [Female: Normal spinning-top appearance within normal
limits for age / normal urethra.] No stricture or diverticulum.
Voiding: The patient voided spontaneously with a normal, continuous
stream.
Post-void: Minimal to no residual contrast in the bladder. No
contrast in the ureters or renal collecting systems on the post-void
image.
Complications: None. The catheter was removed at the end of the
examination.

IMPRESSION:
1. Normal voiding cystourethrogram. No vesicoureteral reflux.
2. Normal bladder and urethra. [No posterior urethral valve.]

Vesicoureteral reflux grading (International Reflux Study
Committee): Grade I, reflux into a non-dilated ureter only; Grade II,
reflux into the renal pelvis and calyces without dilatation; Grade
III, mild to moderate dilatation of the ureter and pelvis with
mild blunting of the fornices; Grade IV, moderate dilatation and
tortuosity of the ureter with blunting of the fornices but preserved
papillary impressions; Grade V, gross dilatation and tortuosity of
the ureter, pelvis and calyces with loss of the papillary
impressions and intrarenal reflux.

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