Catheter malposition during a direct radionuclide cystography - case report

Area of Science:

• Pediatric Urology
• Diagnostic Imaging
• Medical Procedures

Background:

• Vesicoureteral reflux (VUR) is a condition where urine flows backward from the bladder to the ureters.
• Direct radionuclide cystography (DRC) is a diagnostic imaging technique used to detect VUR.
• Accurate bladder catheterization is crucial for the correct interpretation of DRC.

Observation:

• A 15-year-old female with a history of mild left VUR underwent DRC.
• Bladder catheterization was inadvertently placed in the vagina.
• The initial filling phase of the DRC demonstrated contrast in the vagina and uterine cavity.

Findings:

• The misplacement mimicked the appearance of VUR during the filling phase.
• Upon repeating the procedure with correct bladder catheterization, no VUR was observed.
• This indicates the initial findings were artifacts of incorrect catheter placement.

Implications:

• Highlights the critical importance of correct anatomical catheter placement in diagnostic procedures.
• Underscores the potential for misdiagnosis if procedural steps are not meticulously followed.
• Emphasizes the need for careful review of imaging and procedural technique in pediatric urology evaluations.