What Is a VCUG?
The voiding cystourethrogram or VCUG (also known as a micturating cystourethrogram or MCUG in Europe) is the gold standard for diagnosing vesicoureteral reflux (VUR), also known as kidney reflux, 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/MCUG Diagnose?
VCUGs are intended to diagnose vesicoureteral reflux. 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.
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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/MCUG Performed?
While VCUG performance varies due to the absence of a standardized protocol, general steps include:
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Preparation: The patient is positioned on an X-ray table.
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Catheter insertion: A catheter is inserted into the bladder through the urethra.
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Bladder filling: A contrast dye is injected into the bladder through the urethra.
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Voiding: The provider will instruct the child to urinate on the table as their urinary tract is recorded using X-ray technology.
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If the child is unable to void or proper imaging isn’t obtained, the test must be repeated.
What Are the Risks of VCUG/MCUG?
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:
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Nocturia
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Hematuria
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Post-VCUG UTI
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Phobia of urination
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Cystitis and urinary dysfunction
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Medical phobias and avoidance of care in adulthood
Are VCUGs Linked to Cancer?
Yes. Pediatric VCUG is also associated with increased subsequent cancer risk, especially in the genitourinary system. The overall cancer risk in VCUG patients is 1.92-fold higher than non-VCUG patients.
Are VCUGs Performed on Girls or Boys?
VCUGs 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.
Is There Evidence That Children Experience VCUGs as Sexual Abuse?
Yes, there is extensive evidence that pediatric patients experience the VCUG test 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.).
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A 2004 study in particular revealed a shocking correlation between voiding cystourethrography and child sexual abuse. For this pilot study, researchers consulted with child sexual abuse specialists to identify key characteristics of CSA. Then, a blind panel of VCUG conductors was consulted to establish the degree of similarity between CSA and VCUGs. ​The results are outlined 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. Five of the eight features received mean responses of 2.00 or less, indicating that these features were between almost always and frequently a feature of the VCUG procedure. In addition, two of the eight features received mean responses of 2.54, indicating that these features were between frequently and occasionally features of the VCUG procedure…These results suggest a high rate of similarity between the features common to child sexual abuse.”
"[VCUG was] my first memory at age 2. No sedation. My parents were HORRIFIED when I told them I remembered it and gave exact details...They were told I wouldn’t remember and wouldn’t have trauma. They were lied to because I remember the whole fucking thing and have medical PTSD as a result."
"I had VCUG done every 6 months from age 2-7 and I will never stop talking about how traumatic it was for me. Didn’t have my first pelvic exam until I was 23 and had the most intense panic attack."
"I had this done at 6 (I’m 48 now). I’m still embarrassed and traumatized. I vividly remember everything about that day. It’s caused me to avoid going to the doctor unless I’m dying."
"The first time I had [a VCUG] they used the wrong sized catheter and ripped my urethra. I was bleeding all over and my mom flipped out […] After that they never let her in the room."
"I remember everything. I was 10. I didn’t understand and was terrified. Had my first pelvic exam at 12. I sobbed and screamed the whole time."
"I didn’t understand what was wrong with me until I found this page a few weeks ago. Been doing a lot of processing. Everything makes sense now. Thank you for spreading awareness."
"A couple months ago TikTok finally answered the question of where those terrifying memories came from. My mother didn’t bother to inform me or think it was what I was reliving in my nightmares, ever."
"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.”
Pezdek K, Morrow A, Blandon-Gitlin I, Goodman GS, Quas JA, Saywitz KJ, Bidrose S, Pipe ME, Rogers M, Brodie L. Detecting deception in children: event familiarity affects criterion-based content analysis ratings. J Appl Psychol. 2004.
Is Sedation Routinely Offered for VCUG/MCUG?
No. Although sedation was established as safe and effective for VCUGs 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.
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“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, it certainly can be. 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.​ Why is VCUG often so painful for kids? Here are some key reasons:
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Lack of numbing gel during catheterization — In the majority of 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).
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Use of improperly sized equipment — In some cases, improperly sized catheters and medical equipment are forcibly used during the VCUG procedure, increasing the risk of pain and life-threatening complications like bladder rupture.
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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.
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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.
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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.
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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.
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Because this test involves painful genital penetration (often without a parent present) and because VUCGs are primarily performed on preschool-aged children and toddlers, compassionate care isn't just preferable—it’s an absolute necessity.
How Often Are VCUGs Performed?
At Unsilenced, we believe that VCUGs 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.
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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.​ However, because there has been no standardized protocol for VCUG since its introduction several decades ago, many children undergo this procedure without medical necessity, potentially leading to lifelong sexual and medical trauma.
Research identifies a myriad of factors that may be contributing to VCUG over-performance, including:
1. VCUGs are marketed as the sole "gold standard" without available alternatives.
Since the 1960s, the voiding cystourethrogram procedure has been marketed as the sole diagnostic test for VUR in pediatrics. However, there are several safe alternatives available, including a more affordable, radiation-free test (ceVUS) with an equal or higher diagnostic value. While every patient is different, most providers still aren’t disclosing any of these alternatives today, robbing parents and families of their rights under the informed consent doctrine.
2. The VCUG is more profitable for hospitals and providers. ​
VCUGs are known to be very traumatic for children—and very profitable for hospitals. The global VUR and VCUG markets are both billion-dollar industries with anticipated growth. A 2024 VCUG market report “predict[s] substantial growth” in the global VCUG landscape with “impressive CAGR throughout the forecast period of 2024-2031.” While ceVUS and similar alternatives are less traumatic for kids and more cost-effective for families, they are rarely offered.
​3. VCUG conductors are compensated for quantity of care instead of quality.
Radiologists who routinely administer the VCUG and other imaging tests are compensated for the units of work performed. “Payment is dependent on the quantity of care, such as number of patients seen or examinations read,” one source explains. “The highly technical basis and complexity of medicine produces an asymmetry of understanding within the marketplace…[resulting in] more information in the hands of providers than patients.”
Who Is Profiting Off the VCUG Industry?
Voiding cystourethrography is one of the most profitable components of the VUR industry and is dominated by several “major industry players.” These companies include:
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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.
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“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.
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“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.
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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.