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.
Dr. Karen Blumberg, a pediatric radiologist at Children’s Hospitals and Clinics of Minnesota, blessed us with a groundbreaking article in 2012…one that could have moved mountains for the well-being of pediatric patients and parents alike.
Shockingly, her now eleven-year-old publication went ignored by many—despite confirming what other pediatric healthcare professionals continue to deny in 2023.
In her 2012 journal, Dr. Blumberg opens with the credible introduction she rightfully deserves as an expert in her field, introducing herself as a seasoned radiologist with over 25 years of experience.
As such, she goes on to state what most VUR families already know: that the VCUG is a “stressful procedure” for patients, parents, and staff members alike.
“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,” Dr. Blumberg admits.
Providers Regularly Dismiss VCUG Patients' Pain as “Not Real”
Unsilenced is exceedingly grateful to Dr. Blumberg for supporting what so many refuse to learn or believe about the ways in which trauma impacts our brains and bodies—and more importantly, the resulting link, a substantial one, between our mental and physical well-being.
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.”
Given that 1/3 of VCUG patients will have vesicoureteral reflux (VUR), meaning that they will inevitably require follow-up imaging and procedures, it’s of the utmost importance to do everything in our power to make the initial VCUG or alternative treatment—if medically necessary, as there is no standardized protocol for establishing this nor the reporting of VCUG results in the U.S—as pain-free and accommodating as possible.
This means acknowledging that the child’s pain is real. This means acknowledging that the “gold standard” procedure is NOT a walk in the park, as most websites callously suggest.
This means taking adequate time to prepare families before and after VCUG with needed resources and support, including mental health counseling for child sexual abuse (CSA) symptoms, to help their child heal and recover from this painful, invasive, sexual, and distressing procedure.
One survivor remembers her naked body being pinned down on the exam table during her VCUG. “The catheter entered without anesthesia. There was no Tylenol, no localized numbing agent, no topical anesthetic…Nothing,” she recalls. “The catheter was a foreign pierce of pain, [unlike] anything I’ve experienced.”
This begs the question: Why are we not already incorporating small improvements, such as sedation, topical anesthetics, and yes, even general anesthesia?
It’s common knowledge that the VCUG patient MUST BE AWAKE to void on the table—but is this a fact? According to some pediatric radiologists, no. It’s not.
One radiologist “changed his tune” after hearing from one of our Unsilenced survivors, who is now 10 years old. Now, this physician will not conduct a VCUG on any child “that 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.”
Do Patients Have to Be Awake for VCUG 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 confirms. “The patients achieve sedation, but are awake and able to respond to questions and to void.”
Take it from a seasoned expert in the pediatric radiology field: 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.” Dr. Blumberg confirms. “The patients achieve sedation, but are awake and able to respond to questions and to void.”
“I am offering sedation to more and more patients for VCUG, and their parents seem grateful."
At Unsilenced, our community of VCUG survivors are eternally grateful for Dr. Blumberg’s contributions to making this diagnostic test safer and less traumatizing for VUR families by administering sedation. Since discovering the truth about how VCUGs are experienced by her pediatric patients, Dr. Blumberg mentions that her clinic sedates approximately 25% of the VCUGs.
“I am offering sedation to more and more patients for VCUG and their parents seem grateful,” Dr. Blumberg concludes.
The good news is this: there is increasing knowledge that patient distress is real and can affect future medical procedures. “Parents want us to alleviate the child’s distress during this procedure, and safe resources are available to me for sedation,” Dr. Blumberg explains.
Although she acknowledges that not every child requires sedation, nor does every parent desire it—a decision that should always be left up to the child’s legal guardian—Dr. Blumberg drives her point home with this conclusion:
“Currently, we do not routinely sedate children younger than 2 years. 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.” ~Dr. Karen Blumberg, MD
The fact that even newborns can remember traumatic medical procedures like VCUGs has been further supported by our own research at Unsilenced.
Join the Unsilenced Movement
While the VCUG test can be medically necessary in select cases, it doesn’t change the fact that this sexual and invasive procedure is falsely promoted, over-performed, and utilized as the only effective means of VUR diagnosis…desperate the longstanding existence of multiple safe, reliable alternatives.
At Unsilenced, we’re here to ask the tough questions and do everything in our power to put parents back in the driver’s seat. Only you reserve the right to make decisions for your child’s health, happiness, and well-being. Help us hold doctors accountable for decades of withholding crucial information about VCUG and failing to obtain legally effective informed consent from parents.
Subscribe to Unsilenced to never miss an update on VCUG trauma, or explore our resources to learn more about the lasting health effects of this life-altering test.
Sources:
Source: Blumberg, K. “Sedation and the VCUG.” Pediatr Radiol 42, 290–292 (2012). https://doi.org/10.1007/s00247-011-2323-9
Thank you for this article. Please, any healthcare professionals on this site, your voices are important. To safeguard children from sexual trauma and its impacts is a duty we share as human beings. Children deserve our protection.