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Cystography

Cystography is one of the most versatile imaging studies in urology, serving as the gold standard for evaluating bladder integrity in trauma and as a critical diagnostic tool across a wide range of non-traumatic urologic conditions. Both CT cystography and conventional (fluoroscopic) cystography have equivalent sensitivity (95–100%) and specificity (100%) for detecting bladder injury, with CT cystography now preferred at most centers for its ability to be performed concurrently with trauma CT and for its superior detection of subtle injuries.[1][2][3]

See also: RUG & VCUG — retrograde urethrography and voiding cystourethrography for urethral imaging.

Part I: Types of cystography​

1. CT cystography (CTC)​

CT cystography has become the first-line imaging technique for evaluating suspected bladder injury and has largely replaced conventional cystography because it can be performed at the same time as whole-body trauma imaging without requiring patient transport to a fluoroscopy suite.[4]

  • Technique. Water-soluble iodinated contrast is instilled retrograde into the bladder via a Foley catheter, and pelvic CT images are obtained at maximal bladder distension. No additional oral or IV contrast is required for the cystographic component.[2][5]
  • Critical principle. Passive antegrade filling (clamping the Foley catheter and relying on IV contrast excreted by the kidneys) is not adequate to evaluate for bladder injury due to insufficient intravesical pressure and high false-negative rates. Active retrograde filling is mandatory.[1][6][7]
  • Advantages over conventional cystography. Better detection of subtle injuries obscured by overlying structures; simultaneous evaluation of pelvic fractures and associated injuries; no need for patient repositioning; and superior classification of injury type (intraperitoneal vs. extraperitoneal).[2][3]

2. Conventional (fluoroscopic) cystography​

Conventional cystography uses fluoroscopy or plain radiographs during retrograde bladder filling with iodinated contrast.[2][4]

  • Technique. After sterile catheterization, contrast is instilled by gravity. Images are obtained during filling, at maximum distension, and — critically — after drainage (post-void / post-drainage films), as up to 10–15% of injuries are only visible on drainage films when the contrast pool no longer obscures the leak.
  • Pitfall. Injuries on the posterior bladder wall may be missed on AP views because the lateral view is rarely feasible in patients with pelvic fractures.[6]
  • Current role. Useful when CT is unavailable, in the operating room for intraoperative assessment, and in resource-limited settings. Some authors advocate fluoroscopic cystography only when the patient is not already undergoing CT.[2]

3. Voiding cystourethrography (VCUG)​

VCUG is a specialized fluoroscopic study that images the bladder during both filling and voiding phases, providing dynamic assessment of the urethra and detection of vesicoureteral reflux (VUR).[8][5][9]

  • Technique. Iodinated contrast is instilled retrograde via catheter under pulsed fluoroscopy. Key images include the bladder at different filling levels, the urethra during voiding, and the renal fossae immediately after voiding to document reflux.[8]
  • Primary indications. Diagnosis and grading of VUR in children; evaluation of urethral abnormalities (posterior urethral valves, strictures); bladder diverticula near ureteral orifices; suspected bladder or urethral fistula; urethral diverticulum; and bladder prolapse.[8][5][9]
  • Gold standard for diagnosing and grading VUR — fluoroscopic VCUG remains the reference standard.[8][9]

4. Radionuclide cystography (RNC)​

RNC uses a radionuclide tracer instilled into the bladder and is used primarily for follow-up surveillance of known VUR in children. It delivers significantly less radiation than fluoroscopic VCUG but provides less anatomic detail and cannot grade reflux as precisely. The AUA recommends RNC or low-dose fluoroscopy for follow-up cystography in children with VUR.[10]

5. Contrast-enhanced voiding urosonography (ceVUS)​

An emerging radiation-free alternative to fluoroscopic VCUG, ceVUS uses intravesical ultrasound contrast agents to detect VUR. It is increasingly recognized as a viable alternative to fluoroscopic or radionuclide cystography, particularly in pediatric populations.[11]

Part II: Contrast agents and filling protocols​

Contrast agents​

Two FDA-approved agents are specifically indicated for retrograde cystography:

  • Cystografin (diatrizoate meglumine 30%) — dose 25–300 mL depending on patient age and bladder irritability; amounts >300 mL may be used if bladder capacity allows. Can be diluted with sterile water or saline to 18–30% w/v.[12][13]
  • Cysto-Conray II (iothalamate meglumine 17.2%) — adults typically require 200–400 mL; children 30–300 mL proportionate to body size. May be administered by gravity flow or syringe.[14]

Both agents emphasize that excessive pressure must be avoided during instillation, and sterile catheterization is essential. A scout film is recommended before contrast administration.[12][14]

Filling protocol — adults​

The ACS Best Practices Guidelines specify that a defined protocol must be used, unique for adults and children, to adequately fill the bladder in a retrograde fashion.[7] Standard adult protocol:

  • Instill 350–400 mL of dilute water-soluble contrast via Foley catheter by gravity (approximately 40 cm above the patient).
  • The bladder is considered full when the patient reports discomfort, spontaneous voiding occurs around the catheter, or the target volume is reached.
  • For CT cystography: scan at maximal distension; post-void images are not necessary for CT.[7]
  • For conventional cystography: obtain images at maximum fill and after bladder drainage; consider oblique views.[7]

Filling protocol — children​

Pediatric bladder capacity is estimated by the formula Capacity (mL) = (age in years + 2) × 30. However, Bael et al. demonstrated that the relationship between cystographic bladder capacity and age is logarithmic with a wide range between the 5th and 95th percentiles, and gender has no influence on capacity.[15] Multiple filling cycles may be needed in infants who void at low volumes.[8]

Part III: Indications for cystography​

A. Trauma — the primary indication​

Cystography is recommended by the ACS, AUA, EAU, WSES-AAST, EAST, and ACR for patients at risk of bladder injury:[1][6][3]

Absolute indications:

  • Gross hematuria with pelvic fracture (especially anterior ring or pubic rami).
  • Penetrating injury with trajectory toward the bladder and any degree of hematuria.
  • High-risk pelvic fracture features — obturator ring disruption with >1 cm displacement or pubic symphysis diastasis >1 cm — with any degree of hematuria.[1]

Clinical indicators raising suspicion:

  • Inability to void, low urine output, abdominal distension, suprapubic pain.
  • Elevated BUN / creatinine (peritoneal absorption of urine — "urinary ascites").
  • Low-density perivesical or peritoneal free fluid on imaging.[1][6]

When cystography is NOT indicated:

  • Microhematuria with pelvic fracture without high-risk features — low incidence of bladder rupture.[1]
  • Isolated flank pain with hematuria — CT urography is preferred to assess the entire urinary tract; CT cystogram alone cannot evaluate for renal or ureteral injury.[2]

Important sequencing consideration. If pelvic hemorrhage amenable to angioembolization is suspected concurrently with bladder injury, cystography should be postponed until after the angiographic procedure — extravasated contrast in the pelvis impairs angiographic accuracy.[6]

B. Bladder injury classification on cystogram​

Cystographic findings classify bladder injuries into distinct categories that directly determine management:

Injury typeCystographic appearanceIncidence (blunt)Management
Extraperitoneal (EP)Contrast extravasation confined to perivesical space; flame-shaped or streaky contrast around the bladder base, often tracking along fascial planes63%Catheter drainage alone (2–3 weeks); follow-up cystogram to confirm healing
Intraperitoneal (IP)Contrast outlines bowel loops, fills paracolic gutters, or pools in the cul-de-sac; contrast extends freely into the peritoneal cavity32%Surgical repair (two-layer closure); catheter drainage post-repair
Combined EP + IPFeatures of both patterns5%Surgical repair
Bladder contusionNormal cystogram; diagnosis of exclusion (mucosal injury without full-thickness perforation)VariableObservation
[6][16][1]

C. Non-trauma indications​

Vesicoureteral reflux (VUR) — VCUG is the gold standard for diagnosing and grading VUR in children.[8][9] The AAP clinical report notes that fluoroscopic VCUG provides information about bladder and urethral abnormalities contributing to urinary-tract dilation, in addition to reflux detection.[8]

  • VCUG is not routinely indicated for all children with prenatally detected urinary-tract dilation (UTD) — its optimal use is an area of ongoing research.[8]
  • 85–88% of pediatric urologists recommend VCUG for patients with UTD P3.[8]
  • The AAP and NICE recommend deferral of VCUG until UTI recurrence in children with febrile UTI, though many specialists contest this conservative approach.[11]
  • Follow-up cystography (RNC or low-dose fluoroscopy) is recommended every 12–24 months for children with grades III–V VUR on observation.[10]

Bladder fistulas — CT cystography is useful for diagnosing bladder fistulas and leaks, particularly colovesical fistulas from sigmoid diverticular disease.[5] However, the sensitivity of cystography for colovesical fistula is notably low (11–17%) — CT abdomen / pelvis with IV contrast (sensitivity ~61–90%) and the poppy-seed test (sensitivity ~95%) are far more sensitive for this diagnosis.[17][18] Cystography may be considered for presurgical planning when CT findings are ambiguous or to define fistula size and location.[19]

For vesicovaginal fistulas, cystography can demonstrate contrast leaking into the vaginal canal, though cystoscopy and examination under anesthesia are typically more informative for surgical planning.

Recurrent UTI in women — the ACR Appropriateness Criteria note that VCUG can be considered in complicated recurrent lower UTI in females to evaluate for VUR (especially when a bladder diverticulum is near a ureteral orifice), suspected bladder or urethral fistula, urethral diverticulum, or bladder prolapse.[5]

Augmented bladder evaluation — cystography plays a crucial role in evaluating suspected perforation of augmented bladders. Braverman and Lebowitz reported that among 250 augmentations, 9 patients had 16 episodes of postoperative extravasation — fluoroscopic cystography was diagnostic in 12 of 13 episodes studied. Three patients died of complications associated with perforation, underscoring that this is a potentially fatal complication requiring urgent cystographic evaluation.[20]

However, cystography has important limitations in augmented bladders — Glass and Rushton found that cystographic findings were frequently normal despite confirmed rupture, because the augmenting bowel segment may seal the perforation site. When cystography is negative but clinical suspicion remains, ultrasound or CT should be performed to detect free intraperitoneal fluid.[21][22]

Retrograde cystography is also the procedure of choice for optimal visualization of augmented bladder anatomy and most complications, with critical factors being maximal filling and radiographs in multiple projections.[23]

Part IV: Follow-up cystography after bladder injury​

The timing and necessity of follow-up cystography depend on injury type and management strategy. The EAST Practice Management Guideline provides the most granular risk-stratified recommendations:[3]

Low-risk patients (operative repair of simple IP or EP ruptures):

  • Conditionally recommend AGAINST routine follow-up cystography in the absence of clinical signs of urinary leakage — only 1 in 1,000 patients would have a leak detected.[3]
  • Johnsen et al. confirmed this: among 49 cystorrhaphy patients who underwent follow-up cystography, only 1 patient (2%) had a persistent leak. 42% of cystorrhaphy patients had no imaging before catheter removal without adverse consequences.[24]

Moderate-risk patients (operative repair of complex IP ruptures):

  • Strongly recommend follow-up cystography — 87 of 90 leaks per 1,000 patients would be correctly diagnosed.[3]

High-risk patients (nonoperative management of simple EP ruptures with catheter drainage):

  • Strongly recommend follow-up cystography — at least 18% of catheter-drainage EP patients will have persistent extravasation on initial follow-up imaging. Of those with persistent leaks, 70% required operations for related complications.[3][24]

Timing. The ACS Best Practices Guidelines recommend cystography at a minimum of 7 days post-repair, extended to 3–4 weeks for complex injuries.[1] The AUA Urotrauma Guideline recommends catheter drainage for 2–3 weeks for uncomplicated EP injuries, with follow-up cystography to confirm healing before catheter removal.[16]

Part V: Technical pitfalls and pearls​

PitfallConsequenceSolution
Passive antegrade filling (clamping Foley during IV-contrast CT)High false-negative rate; inadequate intravesical pressureAlways perform active retrograde filling via catheter
Inadequate filling volumeMissed injuries, especially small perforationsFill to capacity (350–400 mL adults); use gravity, not syringe pressure
Omitting post-drainage films (conventional cystography)10–15% of injuries only visible after drainageAlways obtain post-drainage images for fluoroscopic studies
Posterior-wall injuriesMissed on AP view; lateral view rarely feasible with pelvic fractureCT cystography superior; consider oblique views on fluoroscopy
Cystography before angioembolizationExtravasated contrast impairs angiographic accuracyPostpone cystography until after the angiographic procedure
Augmented-bladder perforationCystography frequently normal despite confirmed ruptureIf cystogram negative but clinical suspicion high, obtain US or CT for free fluid
Excessive instillation pressureIatrogenic bladder rupture or worsening of existing injuryUse gravity drip; avoid syringe injection; stop at discomfort / reflux
[1][2][3][6][12][14][20][21]

Part VI: Cystography in special contexts​

Intraoperative cystography​

Direct inspection of the bladder should always be performed during emergency laparotomy when bladder injury is suspected. Methylene blue or indigo carmine instilled retrograde through the catheter can aid in identifying the site of perforation intraoperatively.[6]

Post-surgical cystography (non-trauma)​

  • After colovesical fistula repair — post-operative cystogram may be reserved for cases with large bladder defects or complex bladder repair. Pau et al. found that among 18 patients who had post-operative cystograms after CVF repair, only 1 had a bladder leak, diagnosed on a planned early post-operative study.[25]
  • After augmentation cystoplasty — perforations occur in both early (<30 days) and late (>30 days) periods; cystography was diagnostic in 12 of 13 episodes in the Braverman series.[20]
  • After radical cystectomy with neobladder — cystography (or "pouchography") is used to evaluate for anastomotic leaks before catheter removal, typically at 2–3 weeks postoperatively.

Pediatric considerations​

  • Pediatric filling volumes are calculated by the formula (age + 2) × 30 mL, though actual capacity varies widely.[15]
  • Multiple filling cycles may be needed in infants.[8]
  • Radiation exposure is a significant concern — use pulsed fluoroscopy, limit imaging time, and consider RNC or ceVUS for follow-up studies.[8][11][10]

Summary — cystography at a glance​

ParameterCT cystographyConventional (fluoroscopic) cystographyVCUG
Sensitivity95–100%90–95%N/A (not used for injury)
Specificity100%100%N/A
Primary indicationBladder trauma (preferred)Bladder trauma (when CT unavailable)VUR diagnosis / grading; urethral evaluation
Filling methodRetrograde via Foley (mandatory)Retrograde via Foley (mandatory)Retrograde via catheter
Adult volume350–400 mL200–400 mL (to capacity)To capacity
Post-drainage imagesNot necessaryEssential (10–15% injuries only seen post-drainage)Obtained post-void
RadiationHigher (CT dose)ModerateModerate (pulsed fluoroscopy reduces dose)
Key advantageSimultaneous evaluation of associated injuries; superior anatomic detailReal-time dynamic imaging; available in ORDynamic voiding assessment; urethral evaluation

Cross-references​

  • RUG & VCUG — the urethral-imaging companion (retrograde urethrogram and voiding cystourethrogram for urethral assessment).
  • CT Urogram — comprehensive upper-tract evaluation when renal or ureteral injury is suspected.
  • Bladder Trauma — clinical management algorithm for bladder injuries.
  • Endoscopy (Cystoscopy & Ureteroscopy) — direct visual bladder evaluation complementary to cystography.
  • Acute Urinary Retention — catheterization principles shared with cystographic technique.

References​

1. Johnsen N, Wessells H, Archer-Arroyo K, et al. Best Practices Guidelines: Management of Genitourinary Injuries. American College of Surgeons; 2025.

2. Expert Panel on Polytrauma Imaging, Hoff CN, Hajibonabi F, et al. "ACR Appropriateness Criteria® Minor Blunt Trauma." J Am Coll Radiol. 2026. doi:10.1016/j.jacr.2026.01.034

3. Yeung LL, McDonald AA, Como JJ, et al. "Management of blunt force bladder injuries: a practice management guideline from the Eastern Association for the Surgery of Trauma." J Trauma Acute Care Surg. 2019;86(2):326–336. doi:10.1097/TA.0000000000002132

4. Expert Panel on Polytrauma Imaging, Lee JT, Camacho MA, et al. "ACR Appropriateness Criteria® Major Blunt Trauma: update 2025." J Am Coll Radiol. 2026. doi:10.1016/j.jacr.2026.01.030

5. Venkatesan AM, Oto A, Allen BC, et al. "ACR Appropriateness Criteria® recurrent lower urinary tract infections in females." J Am Coll Radiol. 2020;17(11S):S487–S496. doi:10.1016/j.jacr.2020.09.003

6. Coccolini F, Moore EE, Kluger Y, et al. "Kidney and uro-trauma: WSES-AAST guidelines." World J Emerg Surg. 2019;14:54. doi:10.1186/s13017-019-0274-x

7. Tominaga GT, Bernstein M, Aquino MR, et al. Best Practices Guidelines in Imaging. American College of Surgeons; 2018.

8. Herndon CDA, Otero HJ, Hains D, Sweeney RM, Lockwood GM. "Perinatal urinary tract dilation: recommendations on pre- / postnatal imaging, prophylactic antibiotics, and follow-up — clinical report." Pediatrics. 2025;156(1):e2025071814. doi:10.1542/peds.2025-071814

9. Arlen AM, Cooper CS. "New trends in voiding cystourethrography and vesicoureteral reflux: who, when, and how?" Int J Urol. 2019;26(4):440–445. doi:10.1111/iju.13915

10. Peters CA, Skoog SJ, Arant BS Jr, et al. Management and Screening of Primary Vesicoureteral Reflux in Children (2017). American Urological Association.

11. Diamond DA, Chan IHY, Holland AJA, et al. "Advances in paediatric urology." Lancet. 2017;390(10099):1061–1071. doi:10.1016/S0140-6736(17)32282-1

12. Food and Drug Administration. Cystografin. Updated 2025-11-23.

13. Food and Drug Administration. Cystografin Dilute. Updated 2025-11-23.

14. Food and Drug Administration. Cysto-Conray II. Updated 2020-12-31.

15. Bael AM, Lax H, Hirche H, et al. "Reference ranges for cystographic bladder capacity in children — with special attention to vesicoureteral reflux." J Urol. 2006;176(4 Pt 1):1596–1600. doi:10.1016/j.juro.2006.06.037

16. Morey AF, Broghammer JA, Hollowell CMP, McKibben MJ, Souter L. "Urotrauma guideline 2020: AUA guideline." J Urol. 2021;205(1):30–35. doi:10.1097/JU.0000000000001408

17. Melchior S, Cudovic D, Jones J, et al. "Diagnosis and surgical management of colovesical fistulas due to sigmoid diverticulitis." J Urol. 2009;182(3):978–982. doi:10.1016/j.juro.2009.05.022

18. Najjar SF, Jamal MK, Savas JF, Miller TA. "The spectrum of colovesical fistula and diagnostic paradigm." Am J Surg. 2004;188(5):617–621. doi:10.1016/j.amjsurg.2004.08.016

19. Weinstein S, Kim DH, Fowler KJ, et al. "ACR Appropriateness Criteria® left lower quadrant pain: 2023 update." J Am Coll Radiol. 2023;20(11S):S471–S480. doi:10.1016/j.jacr.2023.08.013

20. Braverman RM, Lebowitz RL. "Perforation of the augmented urinary bladder in nine children and adolescents: importance of cystography." AJR Am J Roentgenol. 1991;157(5):1059–1063. doi:10.2214/ajr.157.5.1927793

21. Breen M, Phelps A, Estrada C, Chow JS. "The role of imaging in pediatric bladder augmentation." Pediatr Radiol. 2015;45(10):1440–1447. doi:10.1007/s00247-015-3349-1

22. Glass RB, Rushton HG. "Delayed spontaneous rupture of augmented bladder in children: diagnosis with sonography and CT." AJR Am J Roentgenol. 1992;158(4):833–835. doi:10.2214/ajr.158.4.1546602

23. Pagani JJ, Barbaric ZL, Cochran ST. "Augmentation enterocystoplasty." Radiology. 1979;131(2):321–326. doi:10.1148/131.2.321

24. Johnsen NV, Dmochowski RR, Guillamondegui OD. "Clinical utility of routine follow-up cystography in the management of traumatic bladder ruptures." Urology. 2018;113:230–234. doi:10.1016/j.urology.2017.11.011

25. Pau S, Patel A, Yap S, Eglinton T, Fischer J. "Colovesical fistula management and the role of cystoscopy: a single-institution experience." ANZ J Surg. 2025. doi:10.1111/ans.70273