Cystography
Retrograde cystography evaluates bladder integrity; voiding cystourethrography (VCUG) adds urethral and reflux assessment. CT and conventional cystography are both suitable for suspected bladder rupture when the bladder is adequately filled. EAU summarizes their diagnostic performance as comparable: sensitivity approximately 90–95%, specificity 100%. These estimates do not guarantee exclusion of every leak, particularly in a reconstructed reservoir.[23]
See also: RUG & VCUG for urethral imaging and CT Urogram for upper-tract assessment.
Choosing the study
| Study | Main question | Practical distinction |
|---|---|---|
| CT cystography | Is the bladder leaking, and where does contrast travel? | Convenient during trauma CT; provides cross-sectional detail of the pelvis and associated injuries |
| Conventional cystography | Is the bladder leaking during retrograde filling or after drainage? | Useful for initial assessment or follow-up; allows real-time observation and targeted projections |
| Fluoroscopic VCUG | Is there reflux, a bladder/urethral abnormality, or an abnormal voiding outlet? | Requires filling and voiding images; remains a reference examination for reflux grading and urethral anatomy |
| Radionuclide cystography | Does known reflux persist? | Sensitive surveillance option with limited anatomic detail; radiation depends on the protocol and comparator |
| Contrast-enhanced voiding urosonography (ceVUS) | Is there vesicoureteral reflux? | Radiation-free ultrasound alternative where expertise is available; select the study according to whether detailed urethral evaluation is also needed |
CT is not automatically superior for every indication. A low-dose conventional examination may answer a follow-up leak question without repeating a pelvic CT. Neither a routine contrast-enhanced abdominal CT nor its excretory phase substitutes for a properly performed retrograde cystogram.[2][4]
VCUG images the bladder during filling and emptying, the urethra during voiding, and refluxing upper tracts when present. Reflux grade is only one factor in management; age, febrile infections, renal findings and bladder/bowel dysfunction also matter.[7][8]
ceVUS is an established option, not simply an emerging experimental test. Lumason has a US intravesical indication for evaluating suspected or known VUR in children. It still requires catheterization, appropriate contrast preparation and an experienced operator; follow the current product label and local pediatric imaging protocol.[25]
Contrast and filling technique
Contrast agents
Use a water-soluble agent and dilution appropriate to the examination. Examples of products labeled for retrograde cystography include:
- Cystografin: diatrizoate meglumine 30%; a separate Cystografin Dilute 18% product is available. These are retrograde preparations, not intravenous products.[9][10]
- Cysto-Conray II: iothalamate meglumine 17.2%, with administration volume adapted to age and bladder capacity.[11]
Product concentration, instilled volume and CT dilution are different quantities. Follow the radiology protocol rather than applying a manufacturer's maximum volume to every patient. Use sterile catheterization and avoid excessive instillation pressure.[9][11]
Adult trauma examination
- Establish safe bladder access; investigate suspected urethral injury before instrumentation when indicated.
- Instill dilute contrast retrograde by gravity. Adult trauma protocols commonly target 300–350 mL or adequate tolerated distension. Record the actual volume and any limitation; an underfilled examination may miss a tear.[23]
- CT cystography obtains pelvic images with the bladder distended. Additional intravenous contrast is unnecessary for the cystographic component, although other trauma questions may require it.
- Conventional cystography includes adequately filled views, additional projections as needed, and a post-drainage image. Drainage can reveal leakage obscured by the contrast-filled bladder. Routine post-drainage CT is generally unnecessary.[5]
Do not force an adult trauma volume into a child, a painful low-capacity bladder, a fresh repair, or an augmented reservoir. Agree on a tailored filling endpoint with the treating team. Clamping a catheter to collect renally excreted contrast does not provide a reliable trauma cystogram.[4][5]
Children
Use a pediatric protocol with low-dose pulsed fluoroscopy or an appropriate ultrasound technique. Age formulas such as (age + 2) × 30 mL are estimates, not targets that must be reached. Bael and colleagues' analysis of 386 children with grade III–IV VUR found a nonlinear age-capacity relationship and wide reference ranges; a single linear formula cannot define normal capacity for an individual child.[12] Cyclic filling can improve reflux detection in selected infants; avoid overdistension.[6]
Trauma indications and interpretation
Visible hematuria with pelvic fracture is a clear indication for retrograde cystography. Selected patients with microscopic hematuria and high-risk fracture anatomy, penetrating pelvic injury, or other clinical indicators also warrant evaluation. Microscopic hematuria or pelvic fracture alone is not a universal indication.[1][13]
Other concerning findings include inability to void, suprapubic pain, abdominal distension, unexplained low urine output, urinary ascites or otherwise unexplained pelvic fluid. A cystogram does not evaluate renal or ureteral injury adequately; choose upper-tract imaging separately.[4]
If urgent pelvic angioembolization is needed, coordinate sequencing: extravasated cystographic contrast may interfere with angiography. Hemorrhage control takes priority.[4]
| Pattern | Typical contrast appearance | Management implication in blunt trauma |
|---|---|---|
| Extraperitoneal | Perivesical leakage tracking through pelvic tissue planes | Uncomplicated injuries usually receive catheter drainage; bladder-neck involvement, bone fragments, rectal/vaginal injury or bladder-wall entrapment favor repair |
| Intraperitoneal | Contrast around bowel loops or freely within the peritoneal cavity | Surgical exploration and repair |
| Combined | Both patterns | Surgical repair |
| Contusion | No full-thickness leak demonstrated | Management depends on the complete clinical assessment; an inadequately filled negative study cannot establish a contusion |
ACS describes two-layer repair as standard practice; EAU notes that superiority over a watertight single-layer closure has not been demonstrated. Selected small uncomplicated endoscopic intraperitoneal perforations have a different management pathway from blunt traumatic rupture.[1][23]
Pediatric reflux: when to image
The AAP 2025 perinatal UTD report supports risk-based lower-tract imaging:[6]
| Postnatal category | Lower-tract imaging approach |
|---|---|
| UTD P1 | No routine VCUG/ceVUS or prophylactic antibiotics; repeat ultrasound in 3–6 months |
| UTD P2 | Individualize VCUG/ceVUS and prophylaxis; repeat ultrasound in 1–3 months |
| UTD P3 | Recommend VCUG/ceVUS, prophylaxis and functional assessment; repeat ultrasound at 1 month |
Ureteral dilation ≥7 mm supports VCUG/ceVUS and prophylaxis. Febrile UTI in a child with known UTD also prompts reflux evaluation. Suspected bladder outlet obstruction needs urgent specialist assessment rather than waiting for routine surveillance. For P3 without suspected outlet obstruction, lower-tract imaging can occur during the birth admission or at the repeat ultrasound.[6]
A first-versus-recurrent UTI rule alone is insufficient. NICE NG224 uses age, atypical infection and ultrasound/clinical findings: infants under 6 months with atypical or recurrent UTI receive MCUG; in children 6 months to under 3 years it is not routine but may be considered with dilation, poor flow, non-E. coli infection or a family history of VUR. Older children do not routinely receive MCUG solely because of recurrent UTI.[24]
For established VUR, follow-up combines ultrasound and selective repeat reflux imaging. The interval and modality depend on grade, age, bladder/bowel dysfunction, infections and whether the result would change management.[8]
Fistulas and reconstructed bladders
Suspected fistula
Select imaging for the suspected communication and its cause. CT abdomen/pelvis helps evaluate bowel disease, abscess and malignancy in suspected colovesical fistula; cystography may provide additional tract or leak information.[16]
Historical small cohorts illustrate why a negative cystogram is insufficient. Melchior's 49-patient surgical series detected CVF with cystography in 5/30, CT in 25/41, and the poppy-seed test in 35/37 tested patients. These are cohort-specific yields with different denominators, not universal accuracy estimates or evidence that the poppy-seed test replaces anatomic investigation. It does not define the tract or exclude cancer.[14] Najjar's 12-patient series likewise favored CT followed by evaluation for colonic malignancy.[15]
For vesicovaginal fistula, examination, dye testing and cystoscopy usually provide the primary localization; cystography is an adjunct. Routine VCUG is not indicated for uncomplicated recurrent UTI in women. In suspected structural disease, choose targeted imaging for the actual question rather than ordering VCUG for recurrent infection or prolapse alone.[3]
Suspected augmented-bladder perforation
New abdominal symptoms or unexplained systemic illness after augmentation require urgent urologic assessment. A negative cystogram does not exclude perforation. Sensory impairment may blunt abdominal findings. Braverman's historical series found leakage on 12/13 cystograms, whereas Glass and Rushton's four-patient series demonstrated an abnormal cystogram in only one case despite confirmed rupture; ultrasound detected free fluid in all four.[17][19]
CT/ultrasound may reveal fluid or other complications when contrast leakage is absent. Persistent clinical concern, peritonitis or instability requires immediate surgical decision-making; additional imaging must not delay needed treatment. Tailor filling to reservoir anatomy and the clinical situation. A historical recommendation for maximal reservoir filling is not a mandate to pressurize a suspected perforation.[1][18][20]
Follow-up after bladder injury or repair
Guidelines differ on routine imaging after a simple repair. EAST's 2019 systematic guideline makes the following recommendations, all based on very-low-certainty evidence:[2]
| Clinical group | EAST recommendation |
|---|---|
| Simple IP or EP injury surgically repaired, without concerning symptoms | Conditionally omit routine follow-up cystography |
| Complex IP injury surgically repaired | Obtain follow-up cystography; strong recommendation |
| Simple EP injury treated with catheter drainage | Obtain follow-up cystography; strong recommendation |
The underlying cohorts had 0/175, 2/22, and 34/200 leaks, respectively. The guideline's additional “per 1,000” estimates were diagnostic models, not observed trial results.[2]
Johnsen's retrospective 140-patient series found one leak among 49 imaged patients after cystorrhaphy; 10/56 patients managed with catheter drainage had persistent extravasation, and seven of those ten required operations for related complications. These findings support selective postoperative imaging and closer assessment after drainage-only treatment; they do not establish a universal leak probability.[21]
Timing and local protocol: ACS 2025 recommends cystography for most operative repairs, beginning at least 7 days after repair and potentially 3–4 weeks for complex injury. AUA describes 2–3 weeks of drainage with confirmation of healing for uncomplicated EP injury. Use the injury, repair, healing risks and clinical course to agree on catheter removal; document which pathway is being followed.[1][13]
After colovesical fistula repair, a postoperative cystogram may be reserved for a large defect or complex repair; the supporting 2025 Pau study was retrospective, with only 18 postoperative cystograms.[22] After augmentation or neobladder construction, the operating team's reconstruction-specific pathway determines whether and when cystography/pouchography is needed.
See also
References
1. Johnsen N, Wessells H, Archer-Arroyo K, et al. Best Practices Guidelines: Management of Genitourinary Injuries. American College of Surgeons; 2025.
2. Yeung LL, McDonald AA, Como JJ, et al. "Management of blunt force bladder injuries: a practice management guideline from the Eastern Association for the Surgery of Trauma." J Trauma Acute Care Surg. 2019;86(2):326–336. doi:10.1097/TA.0000000000002132
3. Venkatesan AM, Oto A, Allen BC, et al. "ACR Appropriateness Criteria® recurrent lower urinary tract infections in females." J Am Coll Radiol. 2020;17(11S):S487–S496. doi:10.1016/j.jacr.2020.09.003
4. Coccolini F, Moore EE, Kluger Y, et al. "Kidney and uro-trauma: WSES-AAST guidelines." World J Emerg Surg. 2019;14:54. doi:10.1186/s13017-019-0274-x
5. Tominaga GT, Bernstein M, Aquino MR, et al. Best Practices Guidelines in Imaging. American College of Surgeons; 2018.
6. Herndon CDA, Otero HJ, Hains D, Sweeney RM, Lockwood GM. "Perinatal urinary tract dilation: recommendations on pre- / postnatal imaging, prophylactic antibiotics, and follow-up — clinical report." Pediatrics. 2025;156(1):e2025071814. doi:10.1542/peds.2025-071814
7. Arlen AM, Cooper CS. "New trends in voiding cystourethrography and vesicoureteral reflux: who, when, and how?" Int J Urol. 2019;26(4):440–445. doi:10.1111/iju.13915
8. Peters CA, Skoog SJ, Arant BS Jr, et al. Management and Screening of Primary Vesicoureteral Reflux in Children (2017). American Urological Association.
9. DailyMed. Cystografin: prescribing information. Label record updated November 23, 2025.
10. DailyMed. Cystografin Dilute: prescribing information. Revised June 2024; 18% diatrizoate meglumine, retrograde use.
11. DailyMed. Cysto-Conray II: prescribing information. Iothalamate meglumine 17.2%.
12. Bael AM, Lax H, Hirche H, et al. "Reference ranges for cystographic bladder capacity in children — with special attention to vesicoureteral reflux." J Urol. 2006;176(4 Pt 1):1596–1600. doi:10.1016/j.juro.2006.06.037
13. Morey AF, Broghammer JA, Hollowell CMP, McKibben MJ, Souter L. "Urotrauma guideline 2020: AUA guideline." J Urol. 2021;205(1):30–35. doi:10.1097/JU.0000000000001408
14. Melchior S, Cudovic D, Jones J, et al. "Diagnosis and surgical management of colovesical fistulas due to sigmoid diverticulitis." J Urol. 2009;182(3):978–982. doi:10.1016/j.juro.2009.05.022
15. Najjar SF, Jamal MK, Savas JF, Miller TA. "The spectrum of colovesical fistula and diagnostic paradigm." Am J Surg. 2004;188(5):617–621. doi:10.1016/j.amjsurg.2004.08.016
16. Weinstein S, Kim DH, Fowler KJ, et al. "ACR Appropriateness Criteria® left lower quadrant pain: 2023 update." J Am Coll Radiol. 2023;20(11S):S471–S480. doi:10.1016/j.jacr.2023.08.013
17. Braverman RM, Lebowitz RL. "Perforation of the augmented urinary bladder in nine children and adolescents: importance of cystography." AJR Am J Roentgenol. 1991;157(5):1059–1063. doi:10.2214/ajr.157.5.1927793
18. Breen M, Phelps A, Estrada C, Chow JS. "The role of imaging in pediatric bladder augmentation." Pediatr Radiol. 2015;45(10):1440–1447. doi:10.1007/s00247-015-3349-1
19. Glass RB, Rushton HG. "Delayed spontaneous rupture of augmented bladder in children: diagnosis with sonography and CT." AJR Am J Roentgenol. 1992;158(4):833–835. doi:10.2214/ajr.158.4.1546602
20. Pagani JJ, Barbaric ZL, Cochran ST. "Augmentation enterocystoplasty." Radiology. 1979;131(2):321–326. doi:10.1148/131.2.321
21. Johnsen NV, Dmochowski RR, Guillamondegui OD. "Clinical utility of routine follow-up cystography in the management of traumatic bladder ruptures." Urology. 2018;113:230–234. doi:10.1016/j.urology.2017.11.011
22. Pau S, Patel A, Yap S, Eglinton T, Fischer J. "Colovesical fistula management and the role of cystoscopy: a single-institution experience." ANZ J Surg. 2025. doi:10.1111/ans.70273
23. European Association of Urology. Urological Trauma: urogenital trauma guidelines. 2026. Bladder injury section.
24. National Institute for Health and Care Excellence. Urinary tract infection in under 16s: diagnosis and management. NG224, recommendations 1.3 and tables 4–6.
25. DailyMed. Lumason: prescribing information. Revised July 2025; sections 1.3, 2.3 and 14.3.