Since its initiation in the 1960s, the gold-standard VCUG (“voiding cystourethrogram”) has been the only test used to detect vesicoureteral reflux (VUR) in children. Despite the availability of several safe alternatives, VCUGs are over-performed on up to 1 million patients every year.
One of these alternatives is contrast-enhanced voiding urosonography, or ceVUS. In this blog, we’ll review the similarities and differences between ceVUS and VCUG.
What Is Contrast-Enhanced Voiding Urosonography (ceVUS)?
Contrast-enhanced voiding urosonography or ceVUS is performed using ultrasound. Similarly to VCUG, ceVUS is a diagnostic imaging technique used to assess the urinary tract and diagnose vesicoureteral reflux (VUR).
However, unlike VCUG, which uses radiation and contrast medium visible on X-ray, ceVUS employs a contrast agent that enhances ultrasound images, offering a radiation-free alternative for evaluating urinary tract abnormalities.
Benefits of ceVUS vs. VCUG
Compared to its gold-standard counterpart, ceVUS offers several distinct advantages over VCUGs. Some notable benefits include:
Radiation-free: The primary risk of VCUGs is ionizing radiation, which “varies widely” between institutions. On the other hand, ceVUS has a radiation-free profile, eliminating the increased cancer risk associated with pediatric VCUGs.
Increased comfort: While children are generally required to void while restrained on their backs beneath huge fluoroscopy machinery, ceVUS allows the patient to void in the natural upright position.
Parental support: While parents are sometimes allowed in the VCUG exam room, most are required to wait outside the room due to the radiation involved. ceVUS eliminates this barrier by allowing parents to stay by their child’s side.
Cost savings: ceVUS is more affordable than VCUG and saves families an average of $800 per test.
Is ceVUS Offered at Most Hospitals?
No. Despite years of critically appraised research highlighting ceVUS as safe, less distressing, and equally or more effective at diagnosing urinary tract abnormalities, most U.S. hospitals and clinics don't offer ceVUS.
A 2021 study confirms that ceVUS “offers an excellent alternative to VCUG…[but] despite its advantages, is not yet widely used.” However, this doesn't mean parents don't overwhelmingly prefer ceVUS to its "gold-standard" counterpart.
Do Parents Prefer ceVUS to VCUG?
Yes. A 2022 study from Germany confirmed that the majority of parents (92.9%) prefer ceVUS to VCUG. “The vast majority of parents prefer ceVUS and CEUS to VCUG, CT or MRI because of the safety profile of the contrast agent and diagnostic accuracy,” researchers conclude.
Another article from the 2023 Journal of Pediatric Urology reads, “The majority of parents preferred ceVUS over [VCUG]. ceVUS was perceived to be more comfortable and provide better results. Many parents highlighted no radiation and no fluoroscopic machinery as factors in preference of ceVUS over [VCUG].”
Is ceVUS a Suitable Replacement for VCUG?
Yes and no. While ceVUS offers an excellent radiation-free alternative to VCUG, this procedure still involves traumatic elements that may result in adverse health effects for some children.
Our mission at the Unsilenced Movement is to improve the standard of care for future generations of children by advocating for overdue VCUG reform. While ceVUS might not offer a non-traumatic and long-term solution to VCUG trauma, it’s a significant step in the right direction—especially after decades of silence from the medical industry about the proven adverse health outcomes of VCUG.
Every family deserves to make INFORMED DECISIONS and give informed consent for their child’s care. For many parents, the ability to remain at their child’s side during a potentially stressful and sexually traumatic procedure is invaluable.
Clearly, ceVUS is the answer to eliminating the sole VCUG risk that is currently disclosed (ionizing radiation). Clearly, parents overwhelmingly prefer ceVUS over traditional fluoroscopy. Clearly, ceVUS offers excellent diagnostic accuracy that is the same or better than VCUG.
Thus, with its myriad of advantages over traditional fluoroscopy, we believe that ceVUS should be currently available and accessible to all families navigating VUR management and treatment.
Given that VCUGs are primarily performed on preschool-aged girls and are the proven equivalent of a “violent rape,” we believe that ceVUS should be offered as a safe and available alternative to VCUG until a better alternative is established.
This is a call-to-action for the medical community to address the known harm inflicted on generations of children since the 1960s.
Given that VCUGs are primarily performed on preschool-aged girls and are the proven equivalent of a “violent rape,” we believe that ceVUS should be offered as a safe and available alternative to VCUG until a better alternative is established.
Why Isn’t ceVUS Routinely Offered at Hospitals?
Your guess is as good as ours. However, data shows that the VCUG test is very profitable for healthcare institutions, as evidenced in the growing billion-dollar VCUG and VUR industries. This may play a role in the continued push for VCUG over ceVUS.
On the other hand, some healthcare providers complain that longer performance times and “personnel burnout” are legitimate reasons to forgo ceVUS (Rama S. Ayyala, MD and Andrew T. Trout, MD, 2022).
In response to this counterpoint, we argue that the delay in addressing the known issue of VCUG trauma and its associated health risks (suicidality, self-injurious behaviors, eating disorders, revictimization, chronic illnesses, vaginismus, avoidance of care, etc.) since the 1960s takes precedence over the longer performance time for ceVUS.
Is several decades long enough to address “personnel burnout” and prioritize the future well-being of millions of children by establishing a safer alternative to a falsely promoted, over-performed, and outdated diagnostic test? At the Unsilenced Movement, we certainly think so.
Are Providers Obligated to Inform Parents About ceVUS?
Yes. Under the informed consent doctrine, providers are legally obligated to disclose safe, available alternatives to a proposed treatment or procedure. Put simply, your child’s doctor must disclose all pertinent information that a reasonable person would need to make informed medical decisions.
Pediatric patients are no exception to this fundamental right. While VCUG patients cannot legally consent to medical care, they are entirely reliant on parents and guardians to make informed decisions on their behalf.
Children are a young and vulnerable patient demographic that is more than deserving of quality care that incorporates effective pain management and age-appropriate preparation. Asking about safe sedation options, pain relief, and whether you can remain in the exam room with your child during the procedure are all valid questions to ask your child's provider after a VCUG referral.
If your doctor refuses to discuss safe and available VCUG alternatives with you and your child, consider seeking additional opinions from providers who are willing to listen and address your concerns. While many hospitals don’t offer ceVUS, there may be a clinic near your local area that does.
Join the Unsilenced Movement
The decades-long awareness of the traumatic nature of the VCUG procedure (American Academy of Pediatrics, 2016) highlights the urgent need for VCUG reform. The Unsilenced Movement is dedicated to raising awareness and partnering with healthcare allies to establish improved standards and protocols for trauma-informed care in pediatric urology.
Join the Unsilenced Movement to raise awareness about VCUG trauma in the U.S. and beyond. Because kids deserve better. #MoreThanATest
Very well written. It's long past time for the medical community to be facing hard questions over this. Why has there not been an emphatic shift away from VCUG to ceVUS, with standardised provision of trauma-informed care and options for sedating pediatric patients, until a better alternative is established.