Unsilenced Co-Founder Explains Why Hospitals Aren't Offering "Superior" VCUG Alternatives
We've already established that VCUGs are traumatic, unnecessary in many cases, and have plenty of life-altering risks. One of the most frequent questions we get is, "If VCUGs are bad, then what are we supposed to do?"
This question typically comes from the widespread misconception that VCUGs are the only and best way to test for VUR. Most doctors tell patients and their families this, that VCUGs are the only way to save their child. Most people are not aware that alternatives exist, but they have actually existed for years, with some even being more efficient at testing for VUR!
So, if the evidence all points to VCUGs being traumatic and potentially life-altering in ways similar to CSA, then why aren't alternatives being offered?
Well, your guess is about as good as ours! Our best guess is convenience, stubbornness, and money. First, the VCUG procedure is typically shorter than other procedures and easier for doctors to perform (convenience). Second, many doctors are stuck in their ways and don't want to learn new procedures, even if they are better (stubbornness).
Finally, the VUR market is a billion-dollar industry (yeah, you read that right; a billion-dollar industry) led by huge medical companies such as Pfizer, Salix Pharmaceuticals, and Cook Medical. VCUGs are one of the most profitable parts of this industry, with market research even admitting that invasive surgeries (VUR corrective surgery specifically) are more expensive and a drag on the market, which may lead doctors to push annual VCUGs over one invasive surgery.
And which country has the largest share of this industry? The United States of America. Makes sense why they perform this procedure in favor of corrective surgery.
Despite many healthcare professionals' insistence, there are alternatives that are just as effective (if not more effective) and less traumatic than VCUGs. The problem with these alternatives are that they are not performed widely across the United States. In fact, most hospitals will not offer any alternatives.
Let's go through some of the alternatives and the research that surrounds them:
ceVUS ("Contrast-Enhanced Urosonography")
The ceVUS method is the most effective way to test for VUR and is less traumatic than VCUGs. ceVUS, short for "Contrast-Enhanced Voiding Urosonography," is very similar to the VCUG, but has a few key differences.
First, ceVUS uses no radiation, eliminating the cancer risk that VCUGs have. Because of this, parents/caregivers are able to hold their children throughout the entire procedure, which has been proven to lessen the effects of trauma during VCUGs. Also, the ceVUS allows children to sit up in a chair during the procedure, minimizing the confusion from voiding laying down (which has been shown to cause developmental regression in toilet trained children in some cases).
Unfortunately, the ceVUS method still requires the use of a catheter and voiding during the examination. However, the risk of trauma is lessened due to the lack of radiation, positioning of the patient, and parental support.
A 2018 study found that ceVUS has a 100% sensitivity rate and detected 4 more cases of VUR than the VCUG did. Additional studies have found similar results, that the ceVUS detects the same (if not more) cases of VUR and is just as effective, along with being less traumatic.
PIC Cystogram
PIC Cystogram, short for "Positioned Instillation of Contrast Cystogram," involves the child going under general anesthesia, which cannot be done for VCUGs as the child "must be" awake for voiding (although this claim is not exactly true).
PIC involves using a rigid cystoscope to insert contrast into the bladder and then empty the bladder to test for VUR. PIC Cystogram is used for children who have febrile UTIs but no sign of reflux. However, it isn't a good alternative to completely replace VCUGs, as it is not quite as accurate. There are also risks to putting kids under anesthesia and similar risks to VCUGs (bladder rupture, physical damage, etc.).
CT Urogram
The computed tomography urogram ("CT Urogram") is used to evaluate the urinary system. This procedure does not require a catheter and instead has the patient drink a certain amount of water beforehand and have X-ray dye inserted through an IV line. This procedure is painless and has no risk of sexual trauma (due to the lack of catheter) and it's also noninvasive.
The child may be afraid of the machine, especially if they are prone to claustrophobia, but many hospitals have movie goggles to distract the kids. This may not be beneficial for very young kids as they must stay completely still (less still than an MRI requires), otherwise the images will be too blurry to read. This procedure still uses radiation; however, it is less than that of VCUGs (which are occasionally repeated several times).
DMSA Renogram
This procedure evaluates the kidneys by injecting dimercapto succinic acid through an IV and then using a gamma camera to take pictures. The child is still required to void during the procedure and they must lie completely still. This test also takes several hours between the IV injection and the scans. However, most families are free to leave and then come back. The camera used does not produce any radiation either.
Renal Mag3 Scan
This scan is used to detect VUR and other ureter abnormalities. This test requires an IV with fluids and a trace amount of Mag 3 (which is radioactive). In some cases, a catheter is required. The scan takes roughly 20 minutes and the child is still required to void.
Intravenous Pyelogram
This test also requires an IV with contrast dye, and then X-rays will be taken. The child is still required to void during the test. No catheter is required.
It's High Time to Retire the "Gold Standard" VCUG
None of the alternatives to VCUG are perfect, but the reason for that is because the medical community has been ignoring the risks of VCUGs for decades, delaying research from being done. So many hospitals and radiology clinics refuse to offer these alternatives, despite the research for them and against VCUGs!
Parents deserve the option of these alternatives, and currently they aren't even being told about them. We have the research that VCUGs are traumatic and life-altering and we have the research that alternatives can be just as effective, it is time to start offering these alternatives. There is absolutely no excuse not to.
Thank you for this information. Knowledge is power.