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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 11  |  Issue : 2  |  Page : 168-170  

Practice patterns in ordering a voiding cystourethrogram for pediatric patients among different specialties in a Middle Eastern Tertiary care center


1 Division of Urology, American University of Beirut-Medical Center, Beirut, Lebanon
2 Division of Pediatric Nephrology, American University of Beiru-Medical Center, Beirut, Lebanon
3 Department of Radiology, American University of Beirut-Medical Center, Beirut, Lebanon

Date of Submission09-Sep-2018
Date of Acceptance26-Oct-2018
Date of Web Publication4-Apr-2019

Correspondence Address:
Dr. Yaser El-Hout
Division of Urology, American University of Beirut-Medical Center, Beirut
Lebanon
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DOI: 10.4103/UA.UA_124_18

PMID: 31040602

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   Abstract 


Introduction: Voiding cystourethrogram (VCUG) is a very popular test performed to evaluate genitourinary tract anomalies. Nevertheless, this test can be overused and can lead to unnecessary patient discomfort, radiation exposure, and cost. We sought to study the practice patterns in ordering a VCUG in a Middle Eastern tertiary care center.
Methods: Over a period of 3 years, a retrospective analysis of all VCUG images done for pediatric patients in a single center was made. Further clinical details were extracted from the electronic health records. The specialty of an ordering physician and the reported indication for the procedure were noted. Indications for VCUG were recorded based on the AAP 2011 guidelines, NICE guidelines 2007, and ACR 2011 guidelines. Based on these criteria, patients were analyzed.
Results: A total of 92 VCUGs were evaluated. Of all VCUGs done, pediatricians ordered the most VCUGs (50/92), followed by pediatric infectious disease (16/92), pediatric nephrology (9/92), pediatric urology (7/92), adult urology (5/92), pediatric surgery (3/92), obstetrician-gynecologist (1/92), and emergency medicine (1/92). Properly indicated VCUGs were 50% by general pediatrics, 55% by pediatric infectious disease, 45% by pediatric nephrology, 40% by adult urology, 33% by pediatric surgery, and 100% by pediatric urology.
Conclusion: VCUG is utilized differently by different specialties. In some centers, adult specialties may order a pediatric VCUG. General pediatricians order VCUG the most with a tendency for misuse in up to 50%. Pediatric urology is not the most ordering specialty of VCUG; however, it utilizes it most appropriately. The noted practice patterns may be improved with awareness of the indications and limitations of the study and with proper referral.

Keywords: Pediatrics, practice patterns, voiding cystourethrogram


How to cite this article:
Hout M, Aoun B, Atweh LA, Merhe A, El-Hout Y. Practice patterns in ordering a voiding cystourethrogram for pediatric patients among different specialties in a Middle Eastern Tertiary care center. Urol Ann 2019;11:168-70

How to cite this URL:
Hout M, Aoun B, Atweh LA, Merhe A, El-Hout Y. Practice patterns in ordering a voiding cystourethrogram for pediatric patients among different specialties in a Middle Eastern Tertiary care center. Urol Ann [serial online] 2019 [cited 2019 Aug 17];11:168-70. Available from: http://www.urologyannals.com/text.asp?2019/11/2/168/254264




   Introduction Top


Voiding cystourethrogram (VCUG) is a very popular test performed to evaluate genitourinary tract anomalies. Nevertheless, this test can be overused and can lead to unnecessary patient discomfort, radiation exposure, and cost. We sought to study our practice patterns and dissect the utilization of VCUGs among our different specialties to interpret its misuse and indications.


   Methods Top


Over a period of 3 years, a retrospective analysis of all VCUG images done for pediatric patients in a single center was made. Further clinical details were extracted from the electronic health records. The specialty of an ordering physician and the reported indication for the procedure were noted. Indications for VCUG were categorized as being: (i) indicated if second febrile urinary tract infection (UTI) or evidence of genitourinary anatomic abnormality on imaging, (ii) equivocal if evidence of genitourinary pathology not in the presence of a UTI, or (iii) not indicated if first febrile UTI or normal genitourinary imaging or older than 3 years with no evidence of genitourinary anomalies. This classification was based on the AAP 2011 guidelines, NICE guidelines 2007, and ACR 2011 guidelines. Based on these criteria, patients were classified by an evaluator blinded to the specialty and identity of the ordering physician. The data were entered into SPSS (Statistical package for the social sciences) software version 24 developed by IBM Corporation which was used for data management and analysis. Descriptive statistics were carried out by presenting number and percentage for categorical variables.


   Results Top


A total of 92 VCUGs were evaluated. Mean age at imaging was 3.75 years (range: 1 month to 16 years). 59/92 (64%) were female. The result was negative for vesicoureteral reflux (VUR) in 63/92 (68%). Seventeen (18%) had unilateral reflux (10 nondilating and 7 dilating renal units). Twelve (13%) had bilateral reflux (3 nondilating and 21 dilating renal units). The specialty and indication for imaging are recorded in [Figure 1]. Of all VCUGs done, pediatricians ordered the most VCUGs (50/92), followed by pediatric infectious disease (16/92), pediatric nephrology (9/92), pediatric urology (7/92), adult urology (5/92), pediatric surgery (3/92), obstetrician-gynecologist (OBGYN, 1/92), and emergency medicine (1/92). The percentage of properly indicated VCUGs among specialties is shown in [Figure 2]. Of the ordered VCUGs among specialties, the indicated VCUGs ordered by general pediatricians were 50%, pediatric infectious disease were 55%, pediatric nephrology were 55%, pediatric urology were 100%, adult urology were 40%, and pediatric surgery were 33%. OBGYN and emergency medicine each ordered one VCUG which was indicated.
Figure 1: Bar graph showing the distribution of ordered voiding cystourethrograms along with the fraction of indicated, equivocal, and not indicated

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Figure 2: Percentage of properly indicated voiding cystourethrograms among specialties

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   Discussion Top


VCUG is a very popular test performed to evaluate genitourinary tract anomalies. Nevertheless, this test can be overused and can lead to unnecessary patient discomfort, radiation exposure, and cost. It is interesting to note that multiple internet forums and sites are created to discuss the psychological abuse that may occur from VCUGs.[1]

Efforts to decrease anxiety and discomfort with regard to this testing modality have been explored. One study conducted by Herd, 2008 reports that using midazolam on children reduces anxiety, causes amnesia, and does not interfere with the voiding dynamics,[2] highlighting the psychological burden and technical difficulty required to perform it. A study conducted by Thacker et al., 2016 described the stress of children undergoing VCUG using the brief behavioral distress scale and concluded the need for pretest preparation including the need for sedation and parental comforting before performing the procedure.[3]

Mussurakis et al., 1995 studied the patterns of integration and clinical value of VCUG in decision-making for children with lower UTI. The study concluded that an increased effort is needed to minimize the overuse of VCUG. The testing modality was mostly either inappropriately integrated or unclear whether it should have been ordered. In addition, the test did not influence decision-making as anticipated.[4]

Main indications for performing this test are various, most commonly used in children with febrile UTIs to detect VUR. Detection of VUR in children is crucial to detect renal scarring and to prevent renal injury.[5] With regard to children aged between 2 and 24 months, VCUG is no longer recommended after the first febrile UTI unless evidence of severe hydronephrosis, scarring, or renal injury is found.[5] Other indications for VCUG include hydronephrosis, dysuria, hematuria, dysfunctional voiding, bladder outlet obstruction, postoperative urinary tract evaluation, and incontinence.[6]

Of all ordered VCUGs done, 68% were negative with 32% positive for either unilateral or bilateral reflux which shows that the low positive yield of this test should propel physicians to be more judicious in ordering it. Of the above ordering physicians, general pediatricians ordered the most amount of VCUGs most likely due to the fact that they are the first line in seeing patients before referral to specialists and may have a tendency to screen for pathologies of organ systems to identify a diagnosis before specialist referral. It is arguable that this testing modality is better utilized under specialist hands with regard to the above data showing that generalists had of the highest percentage of misuse. Despite the fact that adult urology ordered very few VCUGs (5.4%), the degree of misuse was quite high with only 40% indicated. This shows that despite being a specialist of the indicated organ system, a high risk of misuse could occur. Pediatric urology had a relatively very low number of ordered VCUGs (7.6% of total), with all of them being indicated which reveals that this testing modality can be avoided in a lot more scenarios if physicians were more prudent.

Ultrasound and DMSA Renal scan are resourceful modalities that can carry out the diagnostic challenges of VCUG.[7] According to the National Institute of Health and Care Excellence, DMSA and ultrasound are recommended instead of VCUG in children above 3 years of age.[8] It is imperative to minimize the overuse of VCUG. This practice pattern may be influenced by the experience and specialty of the ordering physician and by referral dynamics.


   Conclusion Top


VCUG is utilized differently by different specialties. In some centers, adult specialties may order a pediatric VCUG. General pediatricians order VCUG the most with a tendency for misuse in up to 50%. Pediatric urology is not the most ordering specialty of VCUG; however, it utilizes it most appropriately. The noted practice patterns may be improved with awareness of the indications and limitations of the study and with proper referral.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Available from: https://aasana.wordpress.com/tag/vcug/. [Last accessed on 2018 Dec 04].  Back to cited text no. 1
    
2.
Herd DW. Anxiety in children undergoing VCUG: sedation or no sedation?. Adv urol 2008;12. Article ID 498614. doi.org/10.1155/2008/498614.  Back to cited text no. 2
    
3.
Thacker PG, Collins HR, Hill J. Distress experienced during pediatric VCUGs-a granular, prospective assessment using the brief behavioral distress scale. Pediatr Radiol 2016;46:660-5.  Back to cited text no. 3
    
4.
Mussurakis S, Sprigg A, Steiner M. Patterns of integration and clinical value of voiding cystourethrography in the work-up of urinary tract infection in children. Eur Urol 1995;28:165-70.  Back to cited text no. 4
    
5.
Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management, Roberts KB. Urinary tract infection: Clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics 2011;128:595-610.  Back to cited text no. 5
    
6.
Routh JC, Bogaert GA, Kaefer M, Manzoni G, Park JM, Retik AB, et al. Vesicoureteral reflux: current trends in diagnosis, screening, and treatment. European urol 2012;61:773-82.  Back to cited text no. 6
    
7.
Yel S, Tülpar S, Düşünsel R, Poyrazoǧlu HM, Dursun İ, Abdülrezzak Ü, et al. Voiding cystourethrogram: How much should we be selective? Turk J Urol 2017;43:79-84.  Back to cited text no. 7
    
8.
National Collaborating Centre for Women's and Children's Health. Urinary Tract Infection in Children: Diagnosis, Treatment and Long-term Management. National Institute for Health and Clinical Excellence Clinical Guideline. London, United Kingdom: RCOG Press; 2007. Available from: https://www.nice.org.uk/guidance/cg54/chapter/Recommendations#diagnosis. [Last accessed on 2018 Dec 04].  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]



 

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