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

## TL;DR

Voiding cystourethrography (VCUG) is a diagnostic test for urinary tract issues in children, but it has limitations and risks that need careful consideration.

## Contribution

This review discusses the clinical value, challenges, and controversies of VCUG, offering practical tips to improve its use.

## Key findings

- VCUG can miss vesicoureteral reflux in up to 50% of cases.
- Preoperative suspicion of posterior urethral valves on VCUG is often inaccurate.
- VCUG exposes children to radiation and risks of infection and discomfort.

## Abstract

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.

A higher resolution version of the Graphical abstract is available as Supplementary information

A higher resolution version of the Graphical abstract is available as Supplementary information

The online version contains supplementary material available at 10.1007/s00467-025-06901-3.