What Is VCUG?
Voiding cystourethrogram or VCUG (also known as a micturating cystourethrogram or MCUG in Europe) is the gold standard for diagnosing kidney reflux (VUR) in pediatric patients. This test has been performed without a standardized protocol since the 1960s, leading to significant variations in VCUG referrals, performance, medical necessity, and follow-up among institutions and practitioners.
What Condition Does a VCUG Diagnose?
VCUG is intended to diagnose vesicoureteral reflux (VUR). This test is strictly diagnostic and does not treat any urological condition. While the test is commonly used to diagnose abnormalities of the urinary system, this gold-standard procedure is also known to miss life-threatening urological complications in children, such as ectopic ureters.
This puts pediatric patients at risk of undergoing repeated VCUGs without a medical purpose—and more importantly, without receiving the appropriate treatment they desperately need to restore their health.
How Is a VCUG Performed?
The VCUG test has been performed unchanged for several decades, subjecting millions of children each year to violating and painful testing, sometimes without medical necessity.
The procedure involves the following stages:
-
Preparation – The patient is positioned on an X-ray table.
-
Catheter insertion – A catheter is inserted into the bladder through the urethra.
-
Bladder filling – A contrast dye is injected into the bladder through the urethra.
-
Voiding – The provider will instruct the child to urinate on the table as their urinary tract is recorded using X-ray technology.
Each stage introduces potentially traumatic elements due to the frequent use of forced restraint during involuntary catheterization (e.g., adults and professionals holding down the child’s limbs and forcing legs apart). If the child is unable to void or proper imaging isn’t obtained, the test must be repeated.
VCUG is also routinely performed without sedation or pain management, despite the longstanding medical consensus that a urethral gel should be used for both male and female catheterizations to relieve pain and minimize trauma.
What Are the Risks of VCUG?
A routine Google search will only list 1-2 risks associated with voiding cystourethrography: ionizing radiation and “discomfort” with urination for up to 12 hours. However, this is far from the comprehensive list of VCUG risks, which are well-documented throughout decades of critically appraised literature.
These include:
-
Nocturia
-
Hematuria
-
Post-VCUG UTI
-
Phobia of urination
-
Cystitis and urinary dysfunction
-
Medical phobias and avoidance of care in adulthood
Is There Evidence That Children Experience VCUG as Sexual Abuse?
Yes, there is extensive evidence that children can experience VCUG as child sexual abuse (CSA). In fact, VCUG patients were used as proxies for child sexual abuse victims in multiple studies dating back as early as 1990 (Goodman, G.S.).
A 2004 study in particular aimed to learn more about how to protect children who had been sexually assaulted by studying how well they can remember and recall stressful experiences such as CSA. The study used VCUG patients as participants "because this invasive procedure is similar in many aspects to incidents of sexual abuse."
As part of their methodology to prove that VCUG is indeed similar to CSA, the researchers revealed strong correlations between features of voiding cystourethrogram testing and child sexual abuse. A blind panel of VCUG conductors was consulted to establish the degree of similarity between CSA and VCUGs.
The results are displayed below:
The researchers conclude, “The majority of the features that defined child sexual abuse for the counselors were also considered to be at least frequently associated with the VCUG procedure. [...] These results suggest a high rate of similarity between the features common to child sexual abuse.”
"The VCUG procedure is painful and involves intrusive, forced genital contact (catheterization through the urethra and infusion of a liquid into the bladder). Even the doctors administering the procedure admit that in many ways the VCUG procedure is similar to sexual assault on a child.”
Is Sedation Routinely Offered for a VCUG?
No. Although sedation was established as safe and effective for VCUG years ago, it’s rarely offered to families prior to the test being performed. Some providers mistakenly cite compromised test results as a reason not to administer sedation options, despite evidence to the contrary. In particular, midazolam and inhaled nitrous oxide can safely reduce distress in children undergoing VCUGs without compromising the procedure results.
“Currently, we do not routinely sedate children younger than 2 years,” says pediatric radiologist Dr. Karen Blumberg in her 2011 journal. “However, there is research suggesting that even newborns have a more prolonged effect from the pain and distress of medical procedures for which most practitioners currently don’t offer sedation.”
Is a VCUG Painful?
Yes. VCUG tests are painful for many patients. While every patient's experience is unique, thousands of survivors describe pain during VCUG as excruciating, and some go as far as to describe it as “the worst pain” of their lives.
A quick Google search might surprise you with words like “painless,” “harmless,” and “routine.” However, Googling “VCUG trauma” tells a different side of the story: the VCUG patient experience.
Below are some key reasons why VCUG can be painful for patients:
-
Lack of numbing gel during catheterization — In many cases, VCUGs are performed without any lidocaine or numbing gel, despite longstanding consensus in the medical community that a topical agent should be used for all male and female catheterizations (Nursing Times, 2009).
-
Use of improperly sized equipment — Improperly sized catheters and medical equipment are often forcibly used during the VCUG procedure, increasing the risk of pain and life-threatening complications like bladder rupture.
-
Active urinary tract infections — Most pediatric patients undergoing VCUGs have an active UTI or are recovering from one, resulting in a high potential for pain that is often exacerbated by the lack of topical agents.
-
Patient immobilization — Very often, the VCUG patient is physically restrained by the adults in the room or using a papoose board to proceed with involuntary catheterization. Many children resist the procedure due to the high pain involved, only to have their complaints of pain ignored and amplified by the violent and physical altercation of being restrained.
-
Frequent bladder overfilling — Decades of critically appraised research highlight the alarming prevalence of bladder overfilling during voiding cystourethrography. In 2018, researchers found that the child’s bladder was filled above the age-adjusted capacity at a rate of 32% in the whole group and 64% in infants. This increases the risk of post-VCUG health complications.
-
Poor quality of care — While large children’s hospitals are more likely to have child life specialists (CLS) and child-friendly resources available, most VCUGs are performed in hospitals and outpatient clinics that primarily serve adults. This not only results in a substantial lack of preparation for patients and parents, but increases the potential for rushed or inexperienced care.
Because this test involves painful genital penetration (often without a parent present) and is primarily performed on preschool-aged children, compassionate care isn't just preferable; it’s an absolute necessity.
Frequently Asked Questions About VCUG
How Often Are VCUGs Performed?
While hospitals and healthcare institutions won’t disclose how many VCUGs they perform, research suggests that up to 1 million children undergo VCUG testing every year. Because there is no standardized protocol for VCUG, many children undergo this procedure without medical necessity, potentially leading to lifelong sexual and medical trauma.
We believe that VCUG should only be ordered when medically necessary, only performed after true informed consent is obtained, and only administered by physicians who are capable of providing compassionate, trauma-informed care.
Is VCUG Performed on Girls or Boys?
VCUG tests are performed on both girls and boys. The potential for sexual and medical trauma applies to all genders. However, VCUGs are primarily performed on girls, who are more likely to develop urinary tract infections for anatomical reasons. Recurring UTIs are the longstanding sole clinical indication for VCUG referrals. Additionally, vesicoureteral reflux (VUR) tends to resolve spontaneously in boys before the age of 2, meaning boys are less likely to undergo VCUGs.
Can VCUG Increase Cancer Risk?
Yes. Pediatric VCUG is also associated with an increased cancer risk, especially in the genitourinary system. The overall cancer risk in VCUG patients is 1.92-fold higher than non-VCUG patients.
Who Is Profiting Off VCUG?
Voiding cystourethrography is one of the most profitable components of the VUR industry and is dominated by several “major industry players.” These companies include:
2011
“A voiding cystourethrogram is frequently a stressful procedure for pediatric patients, parents, and occasionally the radiology staff. I believe most radiologists would agree with that statement but if doubt exists, there is research that supports it.
“I am offering sedation to more and more patients for VCUG and their parents seem grateful. This is because of increasing knowledge that patient distress is real and can affect future medical procedures. Recent research […] has revealed that [VCUGs] cause true distress to patients that can last beyond the time of this procedure.”
2012
“The vast majority of VCUG examinations are performed primarily on an outpatient basis, unfortunately often with little or no preparation of the child or parent. The VCUG examination can therefore be perceived as a painful investigation associated with high levels of distress and anxiety for the child, parents, and even the medical staff.
“Unfortunately, many children have been irreparably traumatized by previous catheterizations as well as other invasive medical procedures and the mere thought of undergoing an unknown or repeat procedure is unbearable.”
2016
“The VCUG renders the child dependent on those in the room, as they may be separated from their parents and their legs may be forced apart and held down... The overall perception in healthcare is that the VCUG is a short and painless procedure, despite evidence that it is distressing to children.
“Additionally, children [...] are at risk for developing medical phobias and avoidance of medical care as adults. Children retain memories of their VCUG experience and that those who had a distressing experience can replay precisely the aspects of the procedure they found most traumatic, thereby affecting their emotional well-being in the long-term.”
Join the Unsilenced Movement
The Unsilenced Movement was launched in 2023 to unite survivors in VCUG trauma recovery and advocate for overdue reform in pediatric urology. For decades, the VCUG test has inflicted life-altering impacts on children’s well-being and quality of life. That’s why our grassroots organization community is committed to holding providers accountable for their legal and ethical obligations under the informed consent doctrine.
We believe every patient is entitled to respect and bodily autonomy, regardless of age. Whether you’re a former patient who recently put the pieces together or a healthcare provider looking for ways to contribute to our mission, our community is dedicated to supporting individuals from all walks of life. Join us in bridging the gap between physicians and families by raising awareness about the true and lasting effects of VCUG in early developmental stages.