Urethrography, Retrograde

Urethrography, Retrograde

Synonym/acronym: N/A.

Common use

To assess urethral patency in order to evaluate the success of surgical interventions on patients who have urethral structures or other anomalies that interfere with urination.

Area of application

Urethra.

Contrast

Radiopaque contrast medium.

Description

Retrograde urethrography is performed almost exclusively in male patients. It uses contrast medium, either injected or instilled via a catheter into the urethra, to visualize the membranous, bulbar, and penile portions, particularly after surgical repair of the urethra to assess the success of the surgery. The posterior portion of the urethra is visualized better when the procedure is performed with voiding cystourethrography. In women, it may be performed after surgical repair of the urethra to assess the success of the surgery and to assess structural abnormalities in conjunction with an evaluation for voiding dysfunction.

This procedure is contraindicated for

  • high alert Patients who are pregnant or suspected of being pregnant, unless the potential benefits of a procedure using radiation far outweigh the risk of radiation exposure to the fetus and mother.
  • high alert Patients with conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Although patients are still asked specifically if they have a known allergy to iodine or shellfish, it has been well established that the reaction is not to iodine, in fact an actual iodine allergy would be very problematic because iodine is required for the production of thyroid hormones. In the case of shellfish, the reaction is to a muscle protein called tropomyosin; in the case of iodinated contrast medium, the reaction is to the noniodinated part of the contrast molecule. Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative noncontrast imaging study, if available, may be considered for patients who have severe asthma or who have experienced moderate to severe reactions to ionic contrast medium.
  • high alert Patients with conditions associated with preexisting renal insufficiency (e.g., renal failure, single kidney transplant, nephrectomy, diabetes, multiple myeloma, treatment with aminoglycosides and NSAIDs) because iodinated contrast is nephrotoxic.
  • high alert Elderly and compromised patients who are chronically dehydrated before the test because of their risk of contrast-induced renal failure.
  • high alert Patients with bleeding disorders because the puncture site may not stop bleeding.

Indications

  • Aid in the diagnosis of urethral strictures, lacerations, diverticula, and congenital anomalies

Potential diagnosis

Normal findings

  • Normal size, shape, and course of the membranous, bulbar, and penile portions of the urethra in male patients
  • If the prostatic portion can be visualized, it also should appear normal

Abnormal findings related to

  • Congenital anomalies, such as urethral valves and perineal hypospadias
  • False passages in the urethra
  • Prostatic enlargement
  • Tumors of the urethra
  • Urethral calculi
  • Urethral diverticula
  • Urethral fistulas
  • Urethral strictures indicated by a narrowing and lacerations

Critical findings

    N/A

Interfering factors

  • Factors that may impair clear imaging

    • Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status.
    • Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images.

  • Other considerations

    • Consultation with a health-care provider (HCP) should occur before the procedure for radiation safety concerns regarding younger patients or patients who are lactating. Pediatric & Geriatric Imaging Children and geriatric patients are at risk for receiving a higher radiation dose than necessary if settings are not adjusted for their small size. Pediatric Imaging Information on the Image Gently Campaign can be found at the Alliance for Radiation Safety in Pediatric Imaging (www.pedrad.org/associations/5364/ig/).
    • Risks associated with radiation overexposure can result from frequent x-ray procedures. Personnel in the room with the patient should wear a protective lead apron, stand behind a shield, or leave the area while the examination is being done. Personnel working in the examination area should wear badges to record their level of radiation exposure.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this procedure can assist in assessing the urethral patency.
  • Obtain a history of the patient’s complaints or clinical symptoms, including a list of known allergens, especially allergies or sensitivities to latex, anesthetics, contrast medium, or sedatives.
  • Obtain a history of the patient’s genitourinary system, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Ensure that this procedure is performed before an upper gastrointestinal study or barium swallow.
  • Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
  • Obtain a list of the patient’s current medications, including herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus).
  • If iodinated contrast medium is scheduled to be used in patients receiving metformin (Glucophage) for non-insulin-dependent (type 2) diabetes, the drug should be discontinued on the day of the test and continue to be withheld for 48 hr after the test. Iodinated contrast can temporarily impair kidney function, and failure to withhold metformin may indirectly result in drug-induced lactic acidosis, a dangerous and sometimes fatal side effect of metformin related to renal impairment that does not support sufficient excretion of metformin.
  • Review the procedure with the patient. Address concerns about pain and explain that there may be moments of discomfort and some pain experienced during the procedure. Inform the patient that the procedure is performed in a cystoscopy room by an HCP, with support staff, and takes approximately 30 min.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Inform the patient that some pressure may be experienced when the catheter is inserted and contrast medium is instilled.
  • Instruct the patient to remove jewelry and other metallic objects from the area to be examined prior to the procedure.
  • Note that there are no food or fluid restrictions unless by medical direction.
  • Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest

  • Potential complications:

  • Complications include allergic reaction to the contrast medium and bleeding.

  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient.
  • Ensure the patient has removed all external metallic objects from the area to be examined prior to the procedure.
  • Instruct the patient to void prior to the procedure and to change into the gown, robe, and foot coverings provided.
  • Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
  • Instruct the patient to cooperate fully and to follow directions. Ask the patient to lie still during the procedure because movement produces unclear images.
  • Obtain and record the patient’s baseline vital signs.
  • Place the patient on the table in a supine position.
  • A single plain film is taken of the bladder and urethra.
  • A catheter is filled with contrast medium to eliminate air pockets and is inserted until the balloon reaches the meatus. Inform the patient that the contrast medium may cause a temporary flushing of the face, a feeling of warmth, urticaria, headache, vomiting, or nausea.
  • After three-fourths of the contrast medium is injected, another image is taken while the remainder of the contrast medium is injected.
  • The procedure may be done on female patients using a double balloon to occlude the bladder neck from above and below the external meatus.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Instruct the patient to resume usual activities, as directed by the HCP.
  • Monitor vital and neurological signs every 15 min until they return to preprocedure levels.
  • Monitor fluid intake and urinary output for 24 hr after the procedure. Decreased urine output may indicate impending renal failure.
  • Monitor for signs and symptoms of sepsis, including fever, chills, and severe pain in the kidney area.
  • Instruct the patient to drink plenty of fluids to prevent stasis and to prevent the buildup of bacteria.
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.
  • Depending on the results of this procedure, additional testing may be needed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include CT abdomen, CT pelvis, cystometry, cystoscopy, IVP, MRI abdomen, PSA, renogram, retrograde ureteropyelography, urinalysis, and voiding cystourethrography.
  • Refer to the Genitourinary System table at the end of the book for related tests by body system.