A REPORT ON MCU (MICTURATING CYSTOURETHROGRPHY) AND RGU (RETROGRATE UROGRAPHY)

1. A
REPORTON
MCU
(MICTURATINGCYSTOURETHROGRPHY)AND
RGU
IWAMURA COLLEGEOFHEALTH SCIENCE Sallaghari,bhaktapur

2. (RETROGRATEUROGRAPHY)
ACKNOWLEDGEMENT
I wouldlike to expressmy deepestappreciationtoall those who providedme the possibility
to complete this report. The writing of this project has been one of the significant academic
challenges I have faced and the completion of any inter-disciplinary project depends upon
cooperation, co-ordination and combined efforts of several source of knowledge Aspecial
gratitude I give to our final year project manager, as well as co-ordinbatorof radiography Mr.
sailendraraj pandey,whose contribution instimulatingsuggestionsand encouragement, helpedme
to coordinate my project especiallyinwritingthis report.
I also take this opportunity to express a great sence of graduate towards
administration department iwamura college of health science for providing me such a
great opportunity to manage our CCP in such a good hospital ie,
 Madhyapur hospital,
 Bhaktapur diatrict hospital ,
 Iwamura Hospital.
Finally I would like to thank all others who directly and indirectly helped me to
accomplish my report.
SUBMITTEDBY:IWAMURACOLLEGE OF HEALTH SALLAGHARI,BHAKTA[PUR
SUBMITTEDBY: PARBAT BASNET -RADIOGRAPHY3RD
year
6/25/2017

3. COUNCIL FOR TECHNICAL EDUCATION AND VOCATIONAL
TRAINING (CTEVT)
CTEVT is constituted in 2045 B.s is national bodyof technical and
vocational education and training a (CTEVT)committed forproductionof
technical and skillful human resources required forthe nation. It is mainly
involved in policy formation, preparation of competencybased curriculum
developing skill standard of various occupations and testing the skill of
people.
COMPRIHENCIVE CLINICAL PRACTICE
INTRODUCTIONTO CCP
 CCP stands for comprehensive clinicalpractice.[where
comprehensive means including or dealing with all around or nearly all
aspectof something.]
 So CCP means clinically practice of all the techniques, equipment
which we have studied theoretically to grave all the skills, knowledge
of technique and ability to modifythe techniques according to
condition without doing any mistakes in cooperative way.
INCASE OF DIAGNOSTIC RADIOLOGY
Incase of diagnostic radiology CCP is the clinical practice of all
the techniques of TECHNIQUE II ,all the positioning of TECHNIQUE I
,viewing and get to know use of all the radiologicalequipment which we

4. have studied theoretically in class with the cooperative manner in discipline
way.
CCP is done at hospital for 6 months on which
theoretically prepared students are allowed to face the working condition of
their concernfield.
CCPF
CCPF stands for Comprehensive Community practice Field.
Practical fields are:
Objectives ofCCP
 To know exactly what radiology means practically.
 Introduction to hospital.
 To know all the rules and regulations of particular hospital.
 For observation of real radiological equipmentand their properuses.

5.  To get practice of all the techniques and position of Technique I and
II.
 For direct dealing with patient.
 Practice for the radiologicalcontrast and their adverse reaction.
 To know about certain indication and contraindication for special
procedures.
 Information and practice for radiation protection.
Main TargetsOF CCP
1) Team Cooperation
2) Dealing with patient(Patient Care)
 Primary care
 1st
Check the OPD card properly
 Then enter the patient to x-ray room
 Keep the patient record in record book
 Check the emergencycases
 Give priority to old and child patient 1st
.
 Secondary care
 It includes
 positioning of patient and preparation for the examination(eg:-ring
necklace)
 Instructed to sit or stand according to need

6.  Instructed to inspire or expire
 Not to ask unnecessary questions
 Requestnot to move
 Making them comfortable and convincing
 Aftercare
 Not to move patient unnecessarily immediatelyafter examination
 Convince patient to wait outside for report for few min
 During giving report request patient to go to Dr room again for the
diagnosis.
Modifications oftechniques
 During practical we have to modify differenttechniques
 Incase of unstable patient we have to do CXR AP incase of PA
 Full inspiration and and expiration is not checked every time
 Rotation is done according to mobility
 In RTA cases all the views are taken in supine(CXR ,C-spine , skull
lat as trans lat)
RADIATION PROTECTION
 TO PATIENT AND VISITOR
 Not to do x-ray unnecessarily
 By modifying technique

7.  Incase of trauma patient requestvisitor to were lead apron
 Collimate as possible as
 Uses of radiation protection devices(lead devices)
 Decrease FFD to reduce radiation dose
 Follow ALARA principle,10dayrule,28day rule ,TDS rule
 TO OURSELVES
 Maintain TDS rule
 During exposure not to enter in room
 After exposure not to enter x-ray room for few sec
 During exposure lock the door properly

8. MICTURATING CYSTOURETHROGRAPHY
(MCU)
INTRODUCTION
 Study of the urethra during micturation
 It is the radiographic examination of urethra, bladderby injecting
contrast media through catheter.
 Voiding cystourethrogram demonstrates the lower urinary tract and
helps to detectthe existence of any vesico-urethral reflux, bladder
pathology and congenital or acquired of bladder outflow tract.
ANATOMY OF URINARY BLADDER

9.  Hollow, distensible,muscular organ located within the pelvic cavity,
posteriorto the symphysis pubis and inferior to the parietal
peritoneum.
 Normal bladder wall thickness is 2-3mm in fully distended bladder.
 Bladder wall consists of mucosa, submucosa,lamina propria and
smoothmuscle. The mucosa consists of multilayered transitional
epithelium and the muscle layer consists of longitudinal and circular
muscle bundles.
 Bladder capacity is between 500-600ml.
 First urge to void is felt at a bladder volume of 150ml.
 The max capacity of bladder is up to 1200 ml. ( F > M ).
ANATOMY OF URETHRA
FEMALE URETHRA
• Length of 3–4 cm.

10. • Widestat bladder neck.
• Narrowest & least distensible at meatus.
• This forms the Spinning top configuration of urethra on normal
MCU.
MALE URETHRA
 It IS 18-20 cms long .
 Extends from bladder neck till the meatal opening at penis.
 It has four named regions:
 Prostatic urethra:
- Is approximately 3 cm in length.
-Passes through the prostate gland.
 Membranous urethra:
-Is approximately 1 cm in length.

11. -Passes through the urogenital diaphragm.
 Bulbar urethra
-From inferior aspectof urogenital diaphragm to penoscrotal
junction.
 Spongy (penile) urethra:
-Passes through the length of the penis.
RADIOGRAPHIC ANATOMY

12. Indications
 Vesicoureteric reflux:
Abnormal flow of urine from your bladder
back up the tubes (ureters) that connect
your kidneys to your bladder. Normally,
urine flows only down from your kidneys to
your bladder.
 Abnormalities of bladder
 Stress incontinence
Unintentional loss of urine. Stress
incontinence happens when physical
movement or activity — such as coughing, sneezing,
running or heavy lifting — puts pressure (stress) on your
bladder.
 Dysuria
pain or discomfort when urinating. Often described as a
burning sensation, dysuria most commonly is caused by
bacterial infections of the urinary tract.
 Chronic urinarytractinfection
are infections of the urinary tract that
either don’t respond to treatment or
keep recurring. Trauma
 Suspected urethraldiverticulum

13. Urethral diverticulum is defined as a localized outpouching of the
urethra into the anterior vaginal wall.
 Urinary tractinfection
is an infection involving the kidneys, ureters, bladder, or urethra. These
are the structures that urine passes through before being eliminated from
the body.
 Dysfunctionalvoiding
Refer to daytime voiding disorders in children who do
not have neurologic, anatomic, obstructive, or infectious
abnormalities of the urinary tract.
 Hydronephrosisand/or hydroureter
refers to distension and dilation of the renal pelvis and calyces,
usually caused by urinary retention due to obstruction of the
free flow of urine from the kidney.
 Bladder outletobstruction
is a blockage at the base of the bladder. It reduces or stops the
flow of urine into the urethra.
 Haematuria
is the presence of red blood cells (erythrocytes) in the urine.
 Incontinence
also known as involuntary urination, is any leakage of urine.
 Neurogenic dysfunction of the bladder,e.g. spinal dysraphism
 Congenitalanomalies
also known as birth defect, is a condition existing at or before birth regardless of
cause.
 Postoperative evaluationof the urinary tract
Fever ≥39 C (102.2° F) and a pathogen other than E. coli after
a first febrile urinary tract infectionin a child is also considered a strong
indication due to n increased risk of renal scarring in this population

14. Contraindications
 Acute urinary tract infection
Urinary tract infections are
caused by microbes such as bacteria
overcoming the body's defenses in
the urinary tract. They can affect the
kidneys, bladder, and the tubes that
run between them.
 Pregnancy
 Risk of radiation
 Fever within the past 24 hours
Contrast media
 High osmolarcontrast material(HOCM) or
LOCM
 150ml
 Water soluble contrast media i.e, urografin,
ultravist, optiray
 Amount 200 to 500ml(dilute with normal
saline)

15. Choice of contrast media
• Always prefer nonionic LOCM over HOCM.
• The only factor inhibiting replacementof HOCM by LOCM is
financial.
Equipment
 Fluoroscopyunit with spotfilm device and tilting table
 Video recorder
 Jaques or foley catheter
 In small infants a fine (5-7F) feeding tube is adequate
 Syringes
 Xylocaine jelly 1-2%

16. Patient preparation
Many medicalprocedures or tests can be frightening for children. To help
your child feelmore comfortable or reassured you can try the following:
 bring comforters or any toys that will reassure your child; a dummy
(pacifier) for babies (if they normally suck on one) can be very soothing.
It is also helpful to bring something that will catch your child's interest

17. and help them to focus on something
else during the procedure (forexample,
a bookthat has an elementof surprise
or requires your child's concentration,
such as a 'pop up' book,a 'Where's
Wally?' or 'I spy')
 see other suggestions in Helping your
child manage their health care
treatment / procedure
 many hospitals have play specialists whose job it is to help explain these
tests to your child. Play specialists use play to show your child what is
going to happen and ways to help them cope
 if your child is old enough, ask if your hospital's x-ray or children's
department has a video explaining MCUs, for them to watch; your local
branch of Kidney Kids may also be able to help with this
 you will be able to stay with your child for the test and your presence can
help reassure them. Pregnant mothers cannot stay during the test, and
in this case fathers or someone else familiar to your child can be there
 Patients micturates prior to the examination
 Informed consentshould be taken.

18. Preliminary film
 Coned view of the bladder
Technique
 Vesico ureteric reflux
1. The patient lies supine on the x-ray table. Using aseptic technique a
catheter, lubricated with a sterile gel containing a local anesthesia and
antiseptic is introduced into the bladder
2. Any reflux is recorded om spotfilms
3. The catheter should not be removed until the radiologistis convinced
that the patient will micturate or until no more contrast medium will drip

19. into the bladder. The examination is expedited if the catheter is quickly
withdrawn. Small feeding tubes bdo not obstruct micturating.
4. Older children and adults are given a urine receiver but smaller children
should be allowed to micturate absorbent pad on which they can lie.
5. In infants and children with a neuro-pathic bladdermicturation may be
accomplishedby supra pubic pressure
6. Spot films are taken during micturation and any reflux reorded.
7. The lower ureter is bestseen in the anterior oblique positionof that side.
8. Boys should micturate in ab oblique or lateral projection.So that spot
films can be taken of the entire urethra.
9. Finally, a full length view of abdomenis taken to demonstrate any reflux
of contrast medium that might have occurred unnoticed into the kidneys
and to record the post micturation residue.
10. To demonstrate a vesico-vaginal or recto-vesicalfistula films are
taken in lateral.
Filming
The following projections should be acquired keeping within
the ALARA principle:
1. AP with full bladderfor demonstration of the presence or absence of
VUR.
2. Both obliques to demonstrate bilateral vesicoureteric junctions.
3. Post void film to check for a ureterocoele.

20. Aftercare
 No specialaftercare is necessary,but patients and parents of children
should be warned that dysuria, possiblyleading to retention of urine,
may rarely be experienced. In such cases a simple analgesic helpful
and children may be helped by allowing them to micturate in a warm
bath.
 Most children will already be receiving antibiotics for their recent
urinary tract infection. However, if reflux is demonstrated in a child
who is not receiving antibiotics, they should be prescribed.
Complications
 Due to the contrast medium

21. i. Adverse reactions may result from absorptionof contrast medium
by the bladder mucosa.The risk is small when compared with
excretion urography.
ii. Contrast medium induced cystitis
 Due to the technique
I. Acute urinary tract infection
II. Catheter trauma- may produce dysuria, frequencyhaematuria and
urinary retention
III. Complications of bladder filling e.g, perforationfrom overdistension-
prevented by using a non-retaining catheter, e.g. Jaques
IV. Catheterization of vagina or an etopic urethral orifice
V. Retention of a foley catheter
What are the benefits vs. risks?
Benefits
 Voiding cystourethrograms provide valuable, detailed information to
assist physicians in preventing kidney damage in patients with urinary
tract infections.

22.  The examination results allow physicians to determine whether
therapy is necessary. Some conditions require no therapy, while
others may require medications.Some may even need surgery.
 No radiation remains in a patient's body after an x-ray examination.
 X-rays usually have no side effects in the typical diagnostic range for
this exam.
Risks
 There is always a slight chance of cancer from excessive exposure to
radiation. However, the benefitof an accurate diagnosis far
outweighs the risk.
 The effective radiation dose for this procedure varies. See the Safety
page for more information aboutradiation dose.
 Some children experience discomfortduring urination immediately
after the procedure.This discomfortusually resolves in less than 12
hours

23. RETROGRADE URETHROGRAPHY
(RGU)
Definition
 It is retrograde demonstrationof the renal pelvis and ureter by the
retrograde injection of radio-opaque material through the ureters.
ANATOMY OF URETHRA
FEMALE URETHRA
• Length of 3–4 cm.
• Widestat bladder neck.
• Narrowest & least distensible at meatus.
• This forms the Spinning top configuration of urethra on normal MCU.

24. MALE URETHRA
 It IS 18-20 cms long .
 Extends from bladder neck till the meatal opening at penis.
 It has four named regions:
 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 aspectof urogenital diaphragm to penoscrotal
junction.
 Spongy (penile) urethra:
-Passes through the length of the penis.

25. Radiographic anatomy
This is an X-ray obtained in a patient with a normalurethra. This test is called a
retrogradeurethrogram(RUG). X-ray contrastis instilled through the tip of the
penis towards the bladder. As the contrastis injected, a film is obtained. The
contrastis clear and looks like water, but is white on an X-ray.
prostateand a sphincter that surrounds themembranous urethra
(external sphincter) are not seen on a this X-ray, and are illustrated to show
wherethey arelocated. The urethra in the area of the prostateand membranous
urethra are normally pinched closed, and this is a good thing as it prevents
incontinence. However, during urination, the prostatic and membranous urethra
open as the bladder is squeezing (contracting) to empty.

26. Indications
 Absentor unsatisfactoryvisualizationof the collecting system on
IVU
 Stricture
Urethral stricture is an abnormal
narrowing of the urethra
 Urethraltear
 urethral obstruction
causes acute abdominal pain wit
h grunting and straining to urinat
e, tail switching, distention of the
bladder,dripping of blood-
stained urine, protrusion of the penis. Eventually the
bladderruptures or the urethra perforates.Causedus
ually by calculus
 Unexplainedhematuria,
is the presence of red blood cells (erythrocytes) in the urine
 Evaluating persistentintraurethralor intrapelvic
filling defects on IVU
 Abnormalities
 Demonstrating the exactsite of urethralfistula
Urethral fistula is rare and usually a result of infectious
complications, trauma or surgery.
 Brushingand biopsy of suspectedlesions
a sample of your tissue or your cells to help diagnose an illness or
identify a cancer. The removal of tissue or cells for analysis is called
a biopsy.

27.  Evaluating the collectingsystem in patients who cannotreceive
intravenous contrastmedium
Contraindications
 Acute urinary tract infection
A urinary tract infection (UTI) is an infection involving the kidneys,
ureters, bladder, or urethra. These are the structures that urine passes
through before being eliminated from the body
 Pregnancy
 Risk of contrast reaction
Contrast medium
 HOCM or LOCM ; 20ml
 Pre-warning the contrast medium will help to reduce
the incidence of spasm of the external sphinter
Equipment
 Radiopaque contrast such as urographin, iothalamate meglumine
17.2% (Cysto-Conray II,Mallinckrodt Inc, St Louis, MO)
 Fluoroscopic x-ray machine
 Catheter tip syringe
Optional equipment:The Brodneyor Knudsen clamps are specially made
devices designed to perform RUG. They are
generally unnecessary.

28. Patient preparation
-Concent
Preliminary preparation
 Coned supine postero-anterior(PA)ofbladder
base and urethra
Positioning
The patient should be positioned obliquelyat 45 º with the bottom leg
flexed 90 º at the knee and the top leg kept straight. Alternatively, the
patient can be supine and, if using a fluoroscopic C-arm, the C-arm can be
rotated in the vertical plane 45 º degrees (see image below).

29. Technique
 retract the foreskin and clean the tip of penis with betadine or antiseptic
solution
 inject a small amount of topical local anesthetic (e.g. lignocaine gel) into
the urethra with a syringe
o local anaesthetic helps to relax the sphincter as the patient may
contract it during the procedure thus leading to a diagnosis of a
stricture
o some advocate against the use of lignocaine gel on the basis that an
inadequate seal is formed
 patient position should be oblique to visualise full length of urethra
 place the tip of the metallic adaptor into the urethral orifice and attach
the contrast loaded syringe to it
o an alternative is to place a Foley catheter tip in the navicular fossa
and gently inflate the balloon with sterile water until a seal is formed
making sure not to cause the patient pain or damage the distal
urethra
 inject the contrast and image as soon as a major part of the contrast has
been injected,taking spotimages when appropriate
Ideal images demonstrate the entire length of the urethra with contrast
beginning to fill the bladder
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 , fluroscopicscreening is performed atshort intervals
to see any vu reflux ,diverticuli .

30.  The child is turned oblique on both sides to ensure that minimal reflux
is not overlooked.
 In infants : voiding starts the momentcatheter 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.
 In adult male : bladder is filled in the usual way as in older child and
voiding filming is done in both oblique projectionviews.
 The voiding study in male adults can be modified by getting the
patient to void against resistance i.e. by compressionof distal part of
penis thus enhancing the visualization of urethra by artificial
distention .

31. Post-Procedure
Image interpretation
Normal retrograde urethrogram (RUG): If the radiopaque contrast is
injected properly,the entire anterior and posteriorurethra should be filled
with contrast and seen to jet into the bladder neck. The verumontanum is
seen as an ovoid filling defectin the posteriorurethra (see the image
below). The distal end of the verumontanum marks the proximal boundary
of the membranous urethra and constitutes the 1 cm of urethra that passes
through the urogenital diaphragm. [4]
Normal retrograde
urethrogram. Image used with permissionfrom Kawashima A, Sandler C
M, WassermanN F, et al. Imaging of urethral disease:a pictorial review.
Radiographics 2004;24:S195-S216.
View Media Gallery
Urethral trauma: If blunt or penetrating trauma has injured the urethra and a
RUG is performed,leakage of urine often occurs (see the image below).
Injuries are oftendescribedas involving the anterior urethra (consisting of
the penile and bulbar urethra) or the posteriorurethra (consisting of the
membranous and prostatic urethra).

32. Retrograde urethrogram with
extravasation of contrast at site of posteriorurethral injury.
View Media Gallery
Urethral stricture: When a RUG is used to evaluate for urethral stricture, the
image often illustrates a narrowed lumen in the anterior urethra (see the
image below).
Anterior urethral stricture.
Retrograde urethrogram reveals a segmentof narrowing in the distal
bulbous urethra with opacificationof the left Cowper duct (arrow). Image
used with permissionfrom Kawashima A, Sandler C M, WassermanN F, et
al. Imaging of urethral disease:a pictorial review. Radiographics
2004;24:S195-S216.

33. View Media Gallery
A study by Bach et al compared the accuracy of retrograde urethrogram
(RUG) interpretation between the primary physician performing the
procedure and the independentphysician interpreting the films to evaluate
the suitability of relying on independentphysician interpretations for the
purposes of preoperative urethral stricture surgery planning. The study
reported that independently reported RUGs are not as accurate as primary
physician-reported RUGs.[5]
COMPLICATIONS
 Contrast reaction.
 Contrast induced cystitis.
inflammation of the urinary bladder fromover administration of
contrastmedia.
 UTI.(urinary tract infection)
 Catheter trauma.
 Bladder perforation– overfilling.
 Retention of a foley catheter.
 Catheterisation of vagina / ectopic ureter.
 Radiation exposure
 Autonomic dysreflexia- in paraplegic patients due to spinal cord injury
at or above t6 level, forcefulinjection of contrast causes severe
headache ,sweating ,hypertension with bradycardia due to forceful
opening of bladder neck

34. AFTERCARE
 Warned – of rare dysuria , retention.
 Reflux - Antibiotcs.
RUG/ASU vs VCUG/MCU
Generally, a RUG/ASU is carried out to visualise anterior
urethral abnormalities and a VCUG/MCU for posteriorurethral
abnormalities.
Additionally, although the bladderis not generally the main target of the
exam, as with acystogram, a VCUG/MCU may be useful in detectionof
bladderabnormalities and vesico-ureteric reflux (VUR).
In a trauma situation, an RUG/ASU should be performedfirst. A
VCUG/MCU should not be performed firstbecause blindly trying to
introduce a Foleycatheter into the bladderin a trauma setting may lead to
creating additional urethral damage with the catheter

35. Adverse ReactionsTo contrastmedia
Minor reactions-
• Flushing, nausea, vomiting, , arm pain and mild urticaria, fever
• Of short duration & self-limiting.
• No specific treatmentother than reassurance.
• Rx- oral antihistaminic.
Intermediate reactions –
• More serious degrees of the above symptoms.
• Hypotension, vaso vagal shock
• Bronchospasm.
• Rx- Chlorpheniramine for urticaria.
Diazepam for anxiety.
Salbutamol inhalation for bronchospasm.
Hydrocortisone&Adrenaline for anaphylasis.
Severelife-threatening reactions ;-
• Severe manifestations of all symptoms discussedabove.
• Convulsions& Unconsciousness.
• Laryngeal oedema& pulmonary oedema.
• Bronchospasm.
• Pulmonary &cardiac arrest.
Rx;- Must be urgently & followthe ABC of resucitation.
 The airway must be secured.

36.  if require-oxygen, artificial respiration , defibrillation.
 Atropine& Adrenaline - cardiac failure.
 Hydrocortisone Adrenaline for anaphylasis .

37. CONCLUSION
Urethral imaging is a critical step in the preoperative patient evaluation prior to definitive
surgical management. RUG remains the current gold standard of imaging, providing reliable
and accurate diagnosis and staging of urethral stricture disease. Combination of RUG with
other imaging modalities can improve and facilitate diagnosis in complex situations. VCUG
can provide insight to the degree of functional impairment of the bladder neck and urethra,
and can provide critical staging information in combination with RUG in complex pelvic
fracture associated urethral injuries. Flexible cystoscopy is a useful adjunct as well, allowing
for direct visualization of the stricture and potential complicating features, as well as
improved measurement of distraction length. SU (Sonourethrography) remains an
adjunctive technique, and may play a role in intraoperative decision-making.
Cross sectional imaging via MRI and CT may provide additional information for complicating
features of structures, and can provide accurate assessment of stricture length, and is most
useful in situations where additional pathology is suspected. Overall, multiple imaging
modalities are available to the urologist for the diagnosis and staging of urethral stricture,
and in combination can provide a comprehensive assessment of disease that can lead to
optimal preoperative planning
REFRENCES
 GOOGLE
 A guide to RADIOLOGICAL procedures.
-CHAPMAN AND NAKIELNY
 Textbook of RADIOLOGY and imaging
-SATISH K. BHARGAVA.