The voiding cystourethrogram: minimizing patient and parent distress in an invasive radiologic procedure

“The VCUG can be considered one of the more distressing invasive procedures that children may experience in the outpatient setting.”

“Due to the invasiveness of catheterization and the command to void in public, VCUGs can involve high levels of psychological and physical distress for the child”

“While the VCUG is considered the standard of investigation for diagnosing reflux in children, less attention has been paid to the stressful effect of this potentially painful procedure. Many aspects of the VCUG can be experienced as distressing to both the child and their parents. The anticipated anxiety of the procedure, the examination of the child’s genital area by a stranger, the insertion of a catheter into the child’s body, the embarrassment of lying uncovered on an exam table, and the command to urinate in front of those present in the exam room are all aspects of the VCUG that create the possibility for distress in the child.”

“…voiding on the exam table may be experienced as particularly traumatic for younger children who have recently been toilet-trained.”

“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. In one study, parents tended to rate their child’s distress and their own distress as higher than the staff ratings, indicating that parents see this procedure as having a significant impact on their child’s level of distress. In another study, 27% of the children were found to have high scores indicating severe distress on a scale measuring their reaction to the procedure.”

“In invasive procedures, children who experience high levels of pain and behavioral distress tend to form negatively exaggerated memories that later predict children's pain and distress in future procedures. Additionally, children with negatively exaggerated pain memories 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.”

“The long-term effects of the VCUG are perhaps most evident in the behaviors that children display in the weeks and months after the procedure. Gebarski (2013) found that behavioral changes, clinging to parents and disturbances in toilet-training and sleep routines were common after a child experienced a VCUG. In another study, 1/3 of parents reported behavior changes in their child after the procedure, including difficulty passing urine, a fear of medical personnel, and general irritability…. From this evidence, it is possible to conclude that the level of distress experienced during a VCUG can significantly influence children’s behavior in the long-term.”

“Restriction of a child’s mobility is a common feature of pediatric care, especially during invasive procedures. Restriction can be defined as a practice that occurs when risk-benefit favors immobilization for the purpose of delivering safe and timely care to the child. Among nursing and other clinical staff, restriction is so commonplace during procedures that often staff do not realize that they are doing it.”

“Research shows that restriction can impact children in negative ways in the long-term. Restriction has been linked to speech delays, high rates of recall of the distressing procedure, and raised cortisol levels after a procedure is finished….. Overall, causing distress to a child, even with potential clinical gain, is something that should be avoided by all healthcare professionals.”