VCUG Radiologist Speaks Out: “I Was Taught That the Procedure Is Not Painful. I Believed It.”

In this blog, we discuss Dr. Karen Blumberg's journal about pain and sedation during pediatric VCUG.

The voiding cystourethrogram (VCUG) test is an invasive and painful procedure primarily performed on toddlers and preschool-aged children to diagnose vesicoureteral reflux (VUR).

This alleged "gold standard" diagnostic test entailing physical restraint (by straps or multiple adult bodies), ionizing radiation, forced catheterization, and voiding in a room full of strange adults—all while naked and with an active urinary tract infection.

In her 2012 journal, Dr. Karen Blumberg, a pediatric radiologist at Children’s Hospitals and Clinics of Minnesota, introduces herself as a seasoned radiologist with over 25 years of experience.

“During the first half of my career, I never offered sedation to patients undergoing Voiding Cystourethrography,” she explains. “The occasional patient had the procedure cancelled due to inability to cooperate or inability of our staff to safely restrain the patient.”

She goes on to say that her time in residency taught her that the VCUG procedure isn’t painful, and that the patient must be conscious for the voiding part of the test.

“I took pride in my ability to calmly wait and offer reassurance to parents,” Dr. Blumberg explains, assuring them that although their child was crying and screaming, the child was "not really" in pain, and that it would all be over in a few minutes. “Sometimes, those minutes seemed like forever to everyone in the room."

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Providers Regularly Dismiss VCUG Patients' Pain

Unsilenced is exceedingly grateful to Dr. Blumberg and fellow providers for providing credible, research-backed testimony about pain during pediatric VCUG. The 2012 article explains that pain with medical procedures is intensified by fear and anxiety.

“Pre-operative anxiety in young children is associated with a more painful and difficult post-operative course,” Dr. Blumberg says. “I see fear and anxiety daily when performing VCUGs. In addition, the memory of previous painful experiences has effects on pain experience during subsequent procedures. The amount of pain and anxiety experienced during a child’s second visit to the dentist is best predicted by the amount of anxiety and pain experienced the first time.”

“I see fear and anxiety daily when performing VCUGs."

One survivor remembers her naked body being pinned down on the exam table during the test: “The catheter entered without anesthesia. There was no Tylenol, no localized numbing agent, no topical anesthetic…Nothing. The catheter was a foreign pierce of pain, [unlike] anything I’ve experienced.”

Given that one-third of VCUG patients will have kidney reflux, meaning that they will likely need follow-up imaging, it’s of the utmost importance to respect patients' voices and complaints of pain during potentially traumatic procedures.

One radiologist “changed his tune” after hearing from a former patient from the Unsilenced Movement,who is now 10 years old. This physician no longer conducts VCUG on children who “can have a conversation with him.” He also performs VCUGs with general anesthesia when possible.

Sedation vs. General Anesthesia for VCUG Patients

“The occasional referring physician ordered pre-procedural sedating medications or performed cystography under general anesthesia for patients they knew could not tolerate a routine VCUG while awake,” Dr. Blumberg mentions in her article, adding that while there are “certainly obstacles” to establishing a nurse-administered nitrous oxide program, the benefits of nitrous oxide make it worthwhile.

Nitrous Oxide for VCUG

“The onset of action is 30–60 s for nitrous oxide, and termination of its effects is in a similar time frame, so that the patient is discharged immediately after the procedure,” Dr. Blumberg explains.

She adds that the nitrous oxide can be titrated up and down during the procedure, meaning that it can be administered during the catheterization, then turned down or off if the child is calm during the bladder filling phase, and restarted if the child experiences discomfort from a full bladder and difficulty voiding.

Oral Midazolam for VCUG

Oral midazolam has a 20- to 30-minute onset of action, making it much more difficult to schedule in busy fluoroscopic rooms. It also has a prolonged duration, meaning the child must remain for observation following the procedure instead of being discharged right away.

“Midazolam results in significant behavioral side effects, including anger and inconsolability in up to 12% of patients, usually in the post-procedural time,” Dr. Blumberg says. “When this occurs it is problematic for the patient, family and staff. In my experience, however, in such a situation, parents are still satisfied that the child received sedation for the VCUG in spite of the adverse effect.”

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Are VCUG Patients Required to Be Conscious During Voiding?

“Conscious sedation utilizing either midazolam or inhaled nitrous oxide has been shown to be safe and to reduce distress in children undergoing VCUG without compromising the procedure results," Dr. Blumberg says. “The patients achieve sedation, but are awake and able to respond to questions and to void.”

The ideal sedative has a non-painful route of administration, predictable rapid onset with a duration of action suitable for the procedure, and a lack of adverse effects. How do these standards apply to sedation during VCUG?

“Both midazolam and nitrous oxide meet these criteria to varying degrees,” Dr. Blumberg says. She uses both extensively, but favors nitrous oxide as her first choice for VCUG sedation. Midazolam, she explains, is her second choice.

“Conscious sedation utilizing either midazolam or inhaled nitrous oxide has been shown to be safe and to reduce distress in children undergoing VCUG without compromising the procedure results.”

Since discovering how VCUGs are experienced by her pediatric patients, Dr. Blumberg mentions that her clinic uses sedation for approximately 25% of VCUG tests.

"I am offering sedation to more and more patients for VCUG and their parents seem grateful," Dr. Blumberg says.

The increasing knowledge that patient distress is real and can affect future medical procedures is a tremendous milestone for survivors of VCUG trauma.

“Parents want us to alleviate the child’s distress during this procedure, and safe resources are available to me for sedation,” Dr. Blumberg says.

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Join the Unsilenced Movement

While the VCUG test can be medically necessary, it is an invasive procedure that is over-performed and falsely promoted as "painless" and "harmless." Our movement is committed to amplifying patient voices and advocating for informed consent in pediatric urology.

Sources:

Source: Blumberg, K. “Sedation and the VCUG.” Pediatr Radiol 42, 290–292 (2012). https://doi.org/10.1007/s00247-011-2323-9