Voiding cystourethrography for the pediatric nephrologist: clinical value, challenges, and areas of debate

Voiding cystourethrography (VCUG) is indicated for evaluating the anatomy of the urethra and bladder. It is primarily used to diagnose vesicoureteral reflux (VUR) and posterior urethral valves (PUV), especially in cases of febrile urinary tract infections (UTIs), significant ureteral dilation on ultrasound, and—in continent children—urinary symptoms suggestive of infravesical obstruction. VCUG exposes children to a non-negligible dose of radiation and requires urethral catheterization, which can be painful—particularly in males—and carries a low but present risk of post-procedural UTI. Despite its widespread use, VCUG can miss VUR in up to 50% of cases. Moreover, recent studies report that preoperative suspicion of PUV on VCUG was present in only 46% of non-toilet-trained and 59% of toilet-trained males, likely due to challenges in interpreting the VCUG findings. In this review, we will highlight the clinical value, challenges, and areas of debate surrounding this diagnostic test, and offer practical tips to optimize its performance.