Sedation and the VCUG

A voiding cystourethrogram is frequently a stressful procedure for pediatric patients, parents and occasionally the radiology staff. I believe most radiologists would agree with that statement but if doubt exists, there is research that supports it [1, 2]. I have been a pediatric radiologist for more than 25 years. During the first half of my career I never offered sedation to patients undergoing voiding cystourethrography. The occasional patient had the procedure cancelled due to inability to cooperate or inability of our staff to safely restrain the patient. The occasional referring physician ordered preprocedural sedating medications or performed cystography under general anesthesia for patients they knew could not tolerate a routine VCUG while awake. I was taught during residency and fellowship that the patient needs to be conscious for voiding and that the procedure is not painful. I believed it. I took pride in my ability to calmly wait and offer reassurance to parents that though their child was crying and screaming the child was not really in pain and that it would be over in a few minutes. Sometimes, those minutes seemed like forever to everyone in the room. During those years no drugs were known to be safe and effective and readily available for administering in a radiology department. There was minimal nursing presence in most radiology departments, with the exception of those used for sedation for CTor interventional procedures. The times, however, have changed. Some things we were taught in medical school or postgraduate training turn out not to be true. A new procedure, further knowledge or a new drug changes the way we practice medicine. In recent years, far more emphasis has been placed on alleviating patient pain and discomfort. Nurses are required to routinely assess and document patients’ level of pain. Physicians are able to consult with other physicians specialty-trained in pain medicine and palliative care. Sedation and pain relief are being offered for other minor procedures in hospitals such as intravenous access, lumbar punctures and suture placement. Radiology departments need to make similar changes as medical care evolves. Current knowledge in pain management suggests that pain associated with medical procedures should be avoided when possible and that fear and anxiety will intensify the perception of pain. Pre-operative anxiety in young children is associated with a more painful and difficult post-operative course [3]. 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 [4]. About one-third of VCUG patients will have vesicoureteral reflux and will need to have follow-up imaging studies or surgical procedures. Inadequate analgesia for initial procedures may diminish the effect of adequate analgesia in subsequent procedures. The level of effectiveness of topical anesthetics for intravenous catheter insertion can be partially predicted by the number of previous painful medical procedures experienced by the child [5, 6]. In the past physicians including radiologists tended to avoid the use of sedation for procedures thought to cause relatively little physical pain though there might have been large amounts of anxiety associated with them for children. The VCUG is a good example of such procedures, along Pediatr Radiol (2012) 42:290–292 DOI 10.1007/s00247-011-2323-9