INTRAVENOUS UROGRAM

UROGRAM
Intravenous Urogram (IVU) also known as Intravenous
pyelogram (IVP), is a radiological procedure used to visualise the
urinary system (kidneys, ureters, and bladder).
The procedure has several names.

Intravenous pyelography (IVP).

Urography.

Pyelography.

Indications:

Suspected urinary tract pathology.

Repeated Urinary Tract infections? Focus, damage, (when linked
with other symptoms.)

Haematuria.

Investigation of hypertension not controlled by medication in
young age.

Renal colic.

Trauma.
Significance:
The test may reveal kidney diseases, congenital anomalies, tumors,
kidney stones, and inflammation caused by infections.
IVU | By:Vijendra Kr.*Guided By: Dr.S.S.Mishra (Reader,Radiology)
1 Deptt. of Shalya Tantra, IMS-BHU
Additional conditions under which the test may be performed:
Acute arterial occlusion of the kidney Complicated UTI (pyelonephritis)
Acute bilateral obstructive uropathy Cystinuria
Acute unilateral obstructive uropathy Injury of the kidney and ureter
Analgesic nephropathy Polycystic kidney disease
Acute kidney infection Prostate cancer
Atheroembolic renal disease Renal cell carcinoma
Bilateral hydronephrosis Renovascular hypertension
Carcinoma of the renal pelvis or ureter Retroperitoneal fibrosis
Chronic bilateral obstructive uropathy Unilateral hydronephrosis
Chronic glomerulonephritis Ureterocele
Chronic unilateral obstructive uropathy Wilms' tumor

Contra Indications:

General contra indications to water soluble contrast agents.

Hepato renal syndrome,

Thyrotoxicosis,

Pregnancy

Blood urea raised above 12 mmol./L. urography unlikely to be
successful.
Patients Preparation:

Basic abdominal preparation, aperients taken for 24 hours
previous, to clear faecal residue.
IVU | By:Vijendra Kr.*Guided By: Dr.S.S.Mishra (Reader,Radiology)
2 Deptt. of Shalya Tantra, IMS-BHU

Nil orally for 6-8 hours before the examination.

Patient to remain ambulant as long as possible to reduce air
swallowing.

Adaptations to patient preparation will be required for certain
groups of patients e.g. children, diabetics and patients with other
predisposing medical conditions, in line with current department
practice.

Basic psychological preparation with reassurance and
explanation of technique.

Patient wears cotton examination gown.

Bladder emptied immediately before examination.
Normal patient examination interview plus:

Previous I.V.U.

Previous experience of iodinated contrast media.

Abdominal surgery.

Asthma / Allergies. (Hypersensitivity's.)

Current drug therapy (? thyroid function tests)

Breast feeding in appropriate females.

Blood urea levels (normal approx. 2.5-6.5 mmol./L.)
Equipment:

Medium powered X-Ray generator set-up, typical 60-80 kW.

Basic tomography equipment.

Abdominal compression equipment.
IVU | By:Vijendra Kr.*Guided By: Dr.S.S.Mishra (Reader,Radiology)
3 Deptt. of Shalya Tantra, IMS-BHU

Medium / Regular film screen combination in a variety of sizes.

Pads and immobilization aids.
Intravenous administration equipment:

50 ml syringe,

Filling needle,

Skin prep, sticky tape,

Selection of needles, straight/'butterfly' 18,20 gauge.

Tourniquet or blood pressure cuff.

Emergency drugs and equipment, checked and to hand.
Contrast agents and drugs:
Typical examples for a 70 kg adult with normal blood urea values
(2.5 - 7.5mmol/L.)
Contrast media must be warmed to body temperature before
injection.
Product Main Constituent Iodine mg/ml Dose Route
Niopam Iopamidol 300 50 ml i.v.
Ompaque Iohexhol 350 50 ml i.v.
Urograffin Diatrozates 370 50 ml i.v.

Technique:
The median cubital vein is punctured with a 20 gauge needle and the
warmed contrast agent is injected rapidly. Films are then taken at
intervals to demonstrate the whole of the renal tract.
IVU | By:Vijendra Kr.*Guided By: Dr.S.S.Mishra (Reader,Radiology)
4 Deptt. of Shalya Tantra, IMS-BHU
Procedure:
This examination is usually done on an outpatient basis.

The patient is positioned on the table and plain X-Ray abdomen
images are taken. The contrast material is then injected, usually
in a vein in the patient's arm, followed by additional images.

The patient must hold very still and may be asked to keep from
breathing for a few seconds while the x-ray picture is taken to
reduce the possibility of a blurred image. The technologist will
walk behind a wall or into the next room to activate the x-ray
machine.

As the contrast material is processed by the kidneys a series of
images is taken to determine the actual size of the kidneys and to
capture the urinary tract in action as it begins to empty.

The technologist may apply a compression bandon abdomen at
L-5 level to better visualize the urinary structures leading from
the kidney.

When the examination is complete, the patient will be asked to
wait until the technologist determines that the images are of high
enough quality for the radiologist to read.

An IVP study is usually completed within an hour. However,
because some kidneys empty at a slower rate the exam may last
up to four or more hours.

IVU | By:Vijendra Kr.*Guided By: Dr.S.S.Mishra (Reader,Radiology)

5 Deptt. of Shalya Tantra, IMS-BHU
Experience during and after the procedure:

The IVP is a painless procedure.

Patient will feel a minor sting as the iodine is injected into your
arm. Some patients experience a flush of warmth, a mild itching
sensation and a metallic taste in their mouth as the iodine begins
to circulate throughout their body. These common side effects
usually disappear within a minute or two and are harmless.
Itching that persists or is accompanied by hives, can be easily
treated with medication.

In rare cases, a patient may become short of breath or experience
swelling in the throat or other parts of the body.

These can be indications of a more serious reaction to the
contrast material that should be treated promptly. Tell the
radiologist immediately if you experience these symptoms.

During the imaging process, you may be asked to turn from side
to side and to hold several different positions to enable the
radiologist to capture views from several angles. Near the end of
the exam, you may be asked to empty your bladder so that an
additional x-ray can be taken of your urinary bladder after it
empties.

The contrast material used for IVP studies will not discolor your
urine or cause any discomfort when you urinate. If you

IVU | By:Vijendra Kr.*Guided By: Dr.S.S.Mishra (Reader,Radiology)

6 Deptt. of Shalya Tantra, IMS-BHU
 experience such symptoms after your IVP exam, you should let
your doctor know immediately.
Film Sequence:
1. Preliminary film, supine full A.P. abdomen to include lower
border of symphysis pubis and diaphragm, to check, abdominal
preparation, exposure values and for any calcifications overlying
the renal tract areas. Supplementary films to determine position
of any opacity.
2. Immediate film, (24 x 30cm) A.P. of the renal areas to show the
nephrogram, i.e. the renal parenchyma opacified by the contrast
medium in the renal tubules.
3. 5 Minute film, (24 x 30cm) A.P. of the renal areas to determine
if excretion is symmetrical or if uptake is poor and a further dose
of contrast agent is required. Compression may be applied in
some centers at this point to distend the pelvicalyceal systems to
demonstrate any filling defects and a film taken at 10 minutes of
the renal areas. Compression should not be used in cases of
suspected renal colic, renal trauma or after recent abdominal
surgery.
4. 15 Minute film (35 x 43cm) (On release if compression has been
applied) to demonstrate the pelvicalyceal systems and the
ureters.

IVU | By:Vijendra Kr.*Guided By: Dr.S.S.Mishra (Reader,Radiology)

7 Deptt. of Shalya Tantra, IMS-BHU
 5. 25 Minute film (24 x 30cm) 15° caudal angulation centred 5 cm
above the upper border of the symphysis pubis to demonstrate
the distended bladder.
6. Post Micturition film (24 x 30cm) 15° caudal angulation centred
5 cm above the upper border of the symphysis pubis to
demonstrate the bladder emptying success, and the return of the
previously distended lower ends of ureters to normal
Additional Projections:

Inspiratory, expiratory and oblique projections may be required
to demonstrate the relationship of opacities and filling defects to
the renal tract.

Tomography may be required to accurately demonstrate the
renal outlines and overcome shadowing from the gastro intestinal
tract.

Prone films may be required to investigate pelvi ureteric and
ureteric obstruction as the heavy contrast laden urine will more
readily gravitate to the site of the obstruction.

Rapid sequence films may be taken in cases of suspected renal
hypertension to evaluate differential rates of contrast excretion.

Delayed films may be taken for up to 24 hours in order to
demonstrate the actual site of ureteric obstruction.

IVU | By:Vijendra Kr.*Guided By: Dr.S.S.Mishra (Reader,Radiology)

8 Deptt. of Shalya Tantra, IMS-BHU
Radiographic appearances during Intravenous Urography:
Immediate post-injection radiograph:

A film taken immediately after injection of contrast should
demonstrate the kidneys increased in density because of the
contrast within the nephrons.

If either kidney is not seen in the normal place and has not be
visualized on the control film a full abdomen film will
demonstrate an ectopic kidney, common sites are low in the
pelvis or low down on the same side as one visualized in a cross
duplex situation.

Different density nephrograms may indicate renal artery stenosis,
if this is suspected a series of films at 1 min. 2min, 3min after
injection may aid more accurate visualization.

The kidney outlines should be smooth, any irregularity may
indicate a scar or a mass, a mass or bulge in the outline which
does not concentrate contrast is likely to be cystic whilst one
concentrating the medium will more likely be a tumor.
Five / Ten minute film:

At this stage the calyces, renal pelvis and part of the ureters will
be visible.

There is considerable anatomical variation in the number and
pattern of the renal calyces but they are normally reasonably
symmetrical.
IVU | By:Vijendra Kr.*Guided By: Dr.S.S.Mishra (Reader,Radiology)
9 Deptt. of Shalya Tantra, IMS-BHU

The nephrogram will be reduced but both kidneys should have
the same density.

If one or both kidneys appear to have two separate groups of
calyces then there may well be duplex collecting systems and
ureters.

When one kidney is denser than the other, this is due to
persistence of the contrast media within the kidney (persistent
nephrogram) and suggests ureteric obstruction.

The pelvi-caylceal system is not filled or apparent a delayed
film of that side should be taken 45 -60 minutes after injection
or later if required, determining the site of obstruction.
Horseshoe kidney:

The two kidneys may be joined together across the midline
nearly always by the lower poles.

The calyces are then pointing medially or backwards and the
ureters emerge laterally rather than medially.
Variations in calyceal patterns:

There are normally three major calyces with two minor calyces
at the end. However they may only two major calyces and the
pelvis may even be divided into two.

All the calyces should be smooth and cupped at the ends. If the
calyces appear blunted then it may be because the kidney is

IVU | By:Vijendra Kr.*Guided By: Dr.S.S.Mishra (Reader,Radiology)

10 Deptt. of Shalya Tantra, IMS-BHU
 rotated and an oblique projection will bring them into the
'normal' plane.

Hydronephrosis if bilateral, is usually due to bladder outflow
obstruction e.g., Urethral stricture or enlarged prostate, calculus
in urethra , posterior valve obstruction.

If the renal contour curves inwards this is likely to be from
scarring of the parenchyma from old infection, trauma, surgery
or infarct.

If there is a localized outward bulge with distorted calyces this
is most likely a cyst or tumour or from a haematoma following
trauma.
15 minute film, full length:
Causes of dilation of the ureters.

Obstruction at any level, if one ureter is obstructed this is
probably due to a stone or a clot or occasionally due to a
stricture or bladder tumour near the bladder ureteric orifice.

If both ureters are dilated, the cause is more probably in the
bladder or urethra.

Reflux due to malfunction of the ureterovesical junction, from
any cause with or without infection.

Pregnancy at any time after the first three months both ureters
undergo physiological dilatation, which may persist for up to
three months after delivery.
IVU | By:Vijendra Kr.*Guided By: Dr.S.S.Mishra (Reader,Radiology)
11 Deptt. of Shalya Tantra, IMS-BHU

Paralysed bladder after spinal injury.

Irregular dilatation, especially at the lower ends bilaterally is
usually due to schistosomiasis, if unilateral, it may be
attributable to tuberculosis or the passage of calculi.

The ureters may be pushed from their normal line by ovarian
tumours, fibroids Uterus, abdominal aortic aneurysm, tumours
or retroperitoneal fibrosis or haemorrhage.
Bladder Film:
The bladder may be large due to,

Prostatic enlargement,

Urethral obstruction,

Neurogenic bladder.

The bladder may be small due to,

Tuberculosis

Chronic cystitis

Pelvic irradiation, surgery
Irregular bladder outline:

Rough indistinct outline is commonly due to muscle wall
hypertrophy with trabecualtion or to diverticula.

Chronic cystitis

Neurogenic bladder

Schisotosomiasis
IVU | By:Vijendra Kr.*Guided By: Dr.S.S.Mishra (Reader,Radiology)
12 Deptt. of Shalya Tantra, IMS-BHU
Benefits
Imaging of the urinary tract with IVP is a minimally invasive
procedure with rare complications.

IVP images provide valuable, detailed information to assist
physicians in diagnosing and treating urinary tract conditions
from kidney stones to cancer.

An IVP can often provide enough information about kidney
stones and obstructions to direct treatment with medication and
avoid more invasive surgical procedures.

The imaging process is fast, painless and less expensive than
alternatives such as computed tomography (CT) and magnetic
resonance imaging (MRI).

No radiation remains in a patient's body after an x-ray
examination.

X-rays usually have no side effects.

Risks

The effective radiation dose from this procedure is the same as
the average person receives from background radiation in six
months.

Contrast materials used in IVP studies can cause adverse
reactions in some people.

IVU | By:Vijendra Kr.*Guided By: Dr.S.S.Mishra (Reader,Radiology)

13 Deptt. of Shalya Tantra, IMS-BHU

Women should always inform their physician or x-ray
technologist if there is any possibility that they are pregnant.

There is a slight risk that patients may be allergic to the iodine
in the dye.

People with an allergy, hay fever or asthma are at risk and an
alternative investigation may be suggested, or a small dose of
corticosteroids given to suppress the allergic response.

Diabetic patients on metformin (eg. Glucophage) need to stop
taking this medicine 48 hours before an IVU.

Pregnant women are not advised to undergo an IVU unless the
potential benefits outweigh the risks to the unborn foetus.

Anyone suffering from severe liver, heart or kidney diseases
may be given special instructions by a specialist before
undergoing the examination.

The risk of getting side effects from X-rays is very small.
Modern X-ray technology is designed to take pictures of very
high quality using very small doses of radiation.

*
IVU | By:Vijendra Kr.*Guided By: Dr.S.S.Mishra (Reader,Radiology)
14 Deptt. of Shalya Tantra, IMS-BHU