Ureth ra Prostate

The urethra, which conveys the urine out The prostate is a smal l glandular body
of the body, is a narrow, musculomembra­ surrounding the proximal part of the male
nous tube with a sphincter type of muscle urethra and is situated just posterior to the
at the neck of the bladder. The urethra inferior portion of the pubic symphysis.
arises at the i nternal urethral orifice in the The prostate is considered part of the male
urinary bladder and extends about I Y'2 reproductive system but, because of its
inches ( 3 . 8 cm) in the female and 7 to 8 close proximity to the bladder, is com­
inches ( 1 7 . 8 to 20 cm) in the male. monly described with the urinary system.
The female urethra passes along the The conical base of the prostate is at­
thick anterior wall of the vagina to the ex­ tached to the inferior surface of the uri­
ternal urethral orifice, which is located in nary bladder, and its apex is in contact
the vestibule about I i nch (2.5 cm) ante­ with the pelvic diaphragm. The prostate
rior to the vaginal opening (see Fig. 1 8-6). measures about l � inches (3.8 cm) trans­
The male urethra extends from the blad­ versely and % inch ( 1 .9 cm) anteroposte­
der to the end of the penis and is divided rioriy at its base; vertical ly the prostate is
into prostatic, membranous, and spongy approximately I inch (2.5 cm) long. The
portions (Fig. 1 8-7). The prostatic portion prostate gland secretes a mi lky fluid that
is about I inch (2.5 cm) in length, reaches combines with semen from the seminal
from the bladder to the floor of the pelvis, vesicles and vas deferens. These secre­
and is completely surrounded by the tions enter the urethra via ducts in the pro­
prostate. The membranous portion of the static urethra.
canal passes through the urogenital di­
aphragm; it is slightly constricted and
about Y'2 inch ( 1 .3 cm) long. The spongy
portion passes through the shaft of the pe­
nis, extending from the floor of the pelvis SUM MARY OF ANATOMY*
to the external urethral orifice. The distal
prostatic, membranous, and spongy parts Urinary system Kidneys Urinary bladder
of the male urethra also serve as the ex­ (excretory system) adipose capsule apex
cretory canal of the reproductive system. kidneys (2) renal fascia base
ureters (2) hilum neck
urinary bladder renal capsule trigone
urethra renal sinus rugae
renal cortex
Suprarenal glands renal columns Urethra
(adrenal glands) renal medulla male urethra
medullary portion renal pyramids prostatic
cortical portion nephrons membranous
renal corpuscle spongy
glomerular capsule
(Bowman's capsule) Prostate
glomerulus
afferent arteriole
efferent arteriole
renal tubule
proximal convoluted
tubule
nephron loop (Loop
of Henle)
distal convoluted
tubule
collecting ducts
renal papilla
calyces
minor calyces
major calyces
renal pelvis

'See Addendum at the end of the volume for a summary of the changes in the anatomic
terms that were introduced in the 9th edition.

199
 SUM MARY OF PATHOLOGY

Condition Definition

Benign Prostatic Hyperplasia CBPH) Enlargement of the prostate

Calculus Abnormal concretion of mineral salts. often called a stone

Carcinoma Malignant new growth composed of epithelial cells

Bladder Carcinoma located in the bladder

Renal Cell Carcinoma located in the kidney

Congenital Anomaly Abnormality present since birth

Duplicate Collecting System Two renal pelvi and/or ureters from the same kidney

Horseshoe Kidney Fusion of the kidneys. usually at the lower poles

Pelvic Kidney Kidney that fails to ascend and remains in the pelviS

Cystitis Inflammation of the bladder

Fistula Abnormal connection between two internal organs or between an organ

and the body surface

Glomerulonephritis Inflammation of the capillary loops in the glomeruli of the kidney

Hydronephrosis Distension of the renal pelvis and calyces with urine

Polycystic Kidney Massive enlargement of the kidney with the formation of many cysts

Pyelonephritis Inflammation of the kidney and renal pelviS

Renal Hypertension Increased blood pressure to the kidneys

Renal Obstruction Condition preventing the normal flow of urine through the urinary system

Stenosis Narrowing or contraction of a passage

Tumor New tissue growth where cell proliferation is uncontrolled

Wilms' Most common childhood abdominal neoplasm affecting the kidney

Ureterocele Ballooning of the lower end of the ureter into the bladder

Veslcoureteral Reflux Backward flow of urine from the bladder into the ureters

200
 EXPOSURE TEC H N IQUE CHART ESSE NTIAL PROJ ECTI ONS

U RI NARY SYSTEM

Part em kVp· tm mA mAs AEC SID IR Dose! (mrad)

Urinary System (Urography)t

AP 21 75 0.08 200s 16 48 in 35 x 43 em 1 85
AP Oblique 24 75 0.09 200s 18 48 in 35 x 43 em 222
Lateral 27 90 0.1 1 200s 22 48 in 35 x 43 em 916
Lateral (decubitus) 30 95 0.1 1 200s 22 48 in 35 x 43 em 1 040

Retrograde Urographyt
AP 21 75 0.08 200s 16 48 in 35 x 43 em 1 85

Urinary Bladdert
AP & PA Axial 18 75 0.06 200s 12 48 in 24 x 30 em 1 48
AP Oblique 21 75 0.08 200s 16 48 in 24 x 30 em 1 85
Lateral 31 95 0.24 200s 48 48 in 24 x 30 em 1 269

Male Cystourethrogramt
AP Oblique 21 75 0.08 200s 16 48 in 24 x 30 em 1 85

s.Small focal spot.

*kVp values are for a 3-phase 1 2-pulse generator.
IRelative doses for comparison use. All doses are skin entrance for average adult at cm indicated.
IBucky. 1 6: 1 Grid. Screen/Film Speed 300.

201
 U R I NARY SYSTEM RADI OGRAPHY
Overview
Radiography of the urinary system com­
prises numerous specialized procedures,
each of which requires the use of an arti­
ficial contrast medium and each of which
was evolved to serve a specific purpose.
The specialized procedures are pre­
ceded by a plain, or scout, radiograph of
the abdominopelvic areas for the detec­
tion of abnormal ities demonstrable by this
mean . The prelimjnary examjnation may
consist of no more than an AP projection
of the abdomen. When indicated, oblique
and/or lateral projections are taken to lo­
cal ize calcium and tumor masses, and an
upright position may be used to demon­
strate the mobility of the kidneys.
Fig. 1 8-8 Bolus injection nephrotomogram .
Kidney !---=-=� ___
Major calyx
Renal pelviS
Ureter
Fig. 1 8-9 Infusion nephrotomogram.
202
Prelimi nary radiography can usual ly
demonstrate the position and mobility of
the kidneys and usually their size and
shape. This is possible because of the con­
trast furnished by the radiolucent fatty cap­
sule surrounding the kidney . Visualization
of the thin-walled drainage, or collecting,
system (calyces and pelves, ureters, urinary
bladder, and urethra) requires that the
canals be filled with a contrast medium.
The urinary bladder is outlined when it is
filled with urine, but it is not adequately
demonstrated. The ureters and the urethra
cannot be distinguished on preliminary
radiographs.
.::�.
CONTRAST STUDIES
For the del i neation and differentiation of
cysts and tumor masses situated within
the kidney, the renal parenchyma is opaci­
fied by an intravenously introduced or­
gan ic, iodi nated contrast medium and
then radiographed by tomography or CT
The contrast solution may be introduced
into the vein by rapid i njection or by infu­
sion. These procedures are respectively
called bolus injection nephrotomography
(Fig. 1 8-8) and infusion nephrotomogra­
phy (Fig. 1 8-9).
Angiographic procedures are used to
investigate the blood vessels of the kid­
neys and the suprarenal gland (Chapter
26). An example of the direct injection of
contrast medium i nto the renal artery is
shown in Fig. 1 8- 1 0.
Radiologic i nvestigations of the renal
drainage, or collecting, system are per­
formed by various procedures classified un­
der the general term urography. This term
embraces two regularly used techniques for
filling the uri nary canals with a contrast
medium. I maging of cutaneous urinary di­
versions has been described by Long. I
' Long BW: Radiography of cutaneous urinary diver­
ions, Radiol TecilnoI 60( 2): 1 09, 1 988.
Antegrade filling
Antegrade filling techniques allow the
contrast medium to enter the kidney in the
normal direction of blood flow. In selec­
tive patients this is done by introducing
the contra t material directly into the kid­
ney through a percutaneous puncture of
the renal pelvis-a technjque caJled per­
cutaneou antegrade urography. M uch
more commonly used is the physiologic
technique, in which the contrast agent is
generally admin istered intravenously.
This technique is called excretory or in­
travenous urography (/VU) and is shown
in Fig. 1 8- 1 1 .
Fig. I S- 1 0 Selective right renal arteriogram.
The excretory techillque of urography is
used in examinations of the upper Uli nary
tracts in infants and children and is gener­
ally considered to be the preferred tech­
nique in adults unless use of the retrograde
technique is definitely indicated. Since the
contrast medium is administered i ntra­
venously and all parts of the urinary system
are normally demonstrated, the excretory
technique is correctly referred to as intra­
venous urography. The term pyelography
refers to the radiographic demonstration of
the renal pelves and calyces. For years the
examjnation has been erroneously called
an intravenous pyelogram (IVP).
Fig. I S- I I Excretory urogram.
Once the opaque contrast medium en­
ters the bloodstream, it is conveyed to the
renal glomeruli and is di scharged into the
capsules w i th the glomerular filtrate,
which is excreted as urine. With the reab­
sorption of water the contrast material be­
comes sufficiently concentrated to render
the urinary canals radiopaque. The urinary
bladder is well outl ined by this technique,
and satisfactory voiding urethrogram
may be obtained.
203
 Fig. 1 8- 1 2 Retrograde urogram. Fig. 1 8- 1 3 Voiding study after routine injection IVU. Dilation of
proximal urethra (arrows) is the result of urethral stricture.

Contrast­
filled
bladder �----

Catheter
in
urethra

Fig. 1 8- 1 4 Voiding studies of same patient as in Fig. 1 8- 1 3 after infusion Fig. 1 8- 1 5 Cystogram.
nephrourography. Note the increase in opacification of contrast-filled
cavities by this method and the bladder diverticulum (arrows).

204
Retrograde filling
In some procedures involving the urinary
system, the contrast material is introduced
against the normal flow. This is called ret­
rograde urography (Fig. 1 8- 1 2). The con­
trast medium is injected directly into the
canals by means of ureteral catheterization
for contrast fi lling of the upper urinary
tract and by means of urethral catheteriza­
tion for contrast filling of the lower part of
the urinary tract. Cystoscopy is required to
localize the vesicoureteral orifices for the
passage of ureteral catheters.
Retrograde urographic examjnation of
the proximal uri nary tract is primarily a
urologic procedure. Catheterization and
contrast fi ll ing of the urinary canals are
performed by the attending urologist in
conjunction with a physical or endoscopic
examination. This technique enables the
urologist to obtain catheterized specimens
of urine directly from each renal pelvis.
Fig. 1 8- 1 6 Cystoureterogram: AP bladder, showing distal ureters.
Because the canals can be fully distended
by direct injection of the contrast agent,
the retrograde urographic exami nation
sometimes provides more i nformation
about the anatomy of the different parts of
the collecting system than can be obtained
by the excretory technique. For the retro­
grade procedure an evaluation of kidney
function depends on an intravenously ad­
ministered dye substance to stain the color
of the urine subsequently trickling
through the respective ureteral catheters.
Both the antegrade and retrograde tech­
niques of examination are occasionally re­
quired for a complete urologic study.
Fig. 1 8· 1 7 Injection cystourethrogram showing urethra in male
patient.
I nvestigations of the lower urinary
tract-the bladder, lower ureters, and
urethra-are usually made by the retro­
grade technique, which requires no instru­
mentation beyond passage of a urethral
catheter. However, investigations may also
be made by the physiologic technique
(Figs. 1 8- 1 3 and 1 8- 1 4). Bladder examina­
tions are usually denoted by the general
term cystography (Fig. 1 8- 1 5). A proce­
dure understood to include inspection of
the lower ureters is cystoureterography
(Fig. 1 8- 1 6), and a procedure understood
to include inspection of the urethra is cys­
tourethrography (Fig. 1 8- 1 7).
205
 Contrast media
Retrograde urography (Figs. 1 8- 1 8 and
1 8- 1 9) was first performed in 1 904 with the
introduction of air into the urinary bladder.
[n 1 906 retrograde urography and cystog­
raphy were performed with the first opaque
medium, a colloidal silver preparation that
is no longer used. Silver iodide, which is a
nontoxic inorganic compound, was intro­
duced in 1 9 1 1 . Sodium iodide and sodium
bromide, also inorganic compounds, were
fir t used for retrograde urography in 1 9 1 8.
The bromides and iodides are no longer
widely used for examinations of the renal
pelves and ureters because they in'itate the
mucosa and commonly cause considerable
patient discomfort.
Becau e a large quantity of solution is
required to fill the uri nary bladder, iodi­
nated salts in concentrations of 30% or
Ie are used in cystography. A large se­
lection of commercially available contrast
media may be used for all types of radio­
graphic examinations of the urinary sys­
tem. It i important to review the product
insert packaged with every contrast agent.
206
Excretory urography (Figs. 1 8-20 and In the early I 970s, research was initi­
1 8-2 1 ) was first reported by Rowntree et ated to develop nonionic contrast media.
al in 1 923 . ' These i nvestigators used a Development progressed, and several
1 0% solution of chemically pure sodium nonionic contrast agents are currently
iodide as the contrast medi um. However, available for urographic, vascular, and in­
this agent was excreted too slowly to give trathecal injection. Al though non ionic
a satisfactory demonstration of the renal contrast media are generally less likely to
pelves and ureters, and it also proved too cause a reaction in the patient, they are
toxic for functional distribution. Early in twice as expen ive as ionic agents.
1 929, Roseno and Jepkins2 introduced a Many institutions have developed crite­
compound containing sodium iodide and ria to determine which patient receives
urea. The latter constituent, which is one which contrast medium. The choice of
of the nitrogenous substances removed whether to use an ionic or nonionic con­
from the blood and el iminated by the kid­ trast medium depends on patient ri k and
neys, served to accelerate excretion and economics.
thus quickly fill the renal pelves with
opacified urine. Although satisfactory re­
nal images were obtained with this com­
pound, patients experienced considerable
di tress as a result of its toxicity.
[n 1 929, Swick developed the organic
compound Uroselectan, which had an io­
dine content of 42%. The present-day
ionic contrast media for excretory urogra­
phy are the result of extensive research by
many investigators. These media are
available under various trade names in
concentrations ranging from approxi­
mately 50% to 70% . Sterile solutions of
the media are supplied in dose-size am­
pules or vials.
I Rowntree LG et al: Roentgenography of the urinary
tract during excretion of sodium iodide, lAMA
8 : 368, 1 923.
2Roseno A, Jepkins H: I ntravenous pyelography,
FOrlschr Roentgenstr 39:859, 1 929. Abstract: Am 1
Roentgeno/ 22:685, 1 929.
Fig. 1 8- 1 8 Retrograde urogram with contrast medium-filled right Fig. 1 8- 19 Retrograde urogram,
renal pelvis and catheter in left renal pelvis.

Fig. 1 8-20 Excretory urogram. 1 0 minutes after contrast medium Fig. 1 8-21 Excretory urogram on same patient as in Fig, 1 8-20. 25
injection. minutes ofter contrast medium injection,

207
 Adverse reactions to iodinated
media
The iodi nated organic preparations that
are compounded for urologic examina­
tions are of low toxicity. Consequently,
adverse reactions are usual ly mild and of
short duration. The characteri tic reac­
tions are a feeling of warmth, fl ushing,
and sometime a few hives. Occa ional ly,
nausea, vomiting, and edema of the respi­
ratory mucous membrane result. Severe
and serious reactions occur only rarely but
are always a possibility. Therefore the
clinical history of each patient must be
carefully checked, and the patient must be
kept under careful observation for any
sign of systemic reaction . Most reactions
to contrast media occur within the first 5
minutes after administration. Therefore
the patient should not be left unattended
during this time period. Emergency equip­
ment and medication to treat adverse reac­
tions must be readily avai lable.
Fig. 1 8-22 Preliminary AP abdomen for urogram.
208
Preparation of intestinal tract
Although unobstructed visualization of the
urinary tracts requires that the intestinal
tract be free of gas and solid fecal material
(Fig. 1 8-22), bowel preparation is not at­
tempted in infants and children. Further­
more, the use of cleansing measures in
adults depends on the condition of the pa­
tient. Gas (particularly swal lowed air,
which is quickly dispersed through the
small bowel ) rather than fecal material
usually interferes with the examination.
Renal calyces
Renal pelvis
Abdominal ureter
Pelvic ureter
Urinary bladder
Fig. 1 8-23 Supine urogram at 1 5-minute interval
with gas-filled stomach.
Hope and Campoy ' recommended that
infants and children be given a carbonated
soft drink to distend the stomach with gas.
By this maneuver, the gas-containing in­
testinal loops are usually pushed i nferi­
orly and the upper urinary tracts, particu­
larly those on the left side of the body, are
then clearly visualized through the outline
of the gas-fi l led stomach. Hope and
Campoy stated that the aerated drink
should be given in an amount adequate to
fully inflate the stomach: at least 2 ounces
are required for a newborn infant, and a
ful l 1 2 ounces are required for a child 7 or
8 years old. Tn conjunction with the car­
bonated drink, Hope and Campoy recom­
mended using a highly concentrated con­
trast medi um. A gas-distended stomach is
shown in Fig. 1 8-23.
' Hope JW, Campoy F: The use of carbonated bever­
ages in pediatric excretory urography, Radiology
64:66, 1 955.
 Berdon, Baker, and Leonidas2 stated
that the prone position resolves the prob­
lem of obscuring gas in a majority of pa­
tients ( Figs. 1 8-24 and 1 8-25). Therefore
it is not necessary to inflate the stomach
with air alone or with air as part of an aer­
ated drink. By exerting pressure on the ab­
domen, the prone position moves the gas
l aterally away from the pelvicalyceal
structures. Gas in the antral portion of the
stomach is displaced into its fundic por­
tion, gas in the transverse colon shifts into
the ascending and descending segments,
and gas in the sigmoid colon shifts into
the descending colon and rectum. These
investigators noted, however, that the
prone position occasionally fails to pro­
duce the de ired result in small infants
when the small intestine is dilated. Ga tric
inflation also fails in these patients be­
cause the dilated small intestine merely
elevates the gas-fi l led stomach and thus
does not improve visualization. They rec­
ommended examination of such infants
after the intestinal gas has passed.
2Berdon WE. Baker DH, Leonidas J: Prone radiog­
raphy in intravenous pyelography in infants and chil­
dren, Am J Roelllgello/ 1 03 :444, 1 968.
Fig. 1 8-24 Urogram: supine position. Intestinal gas obscuring the
left kidney.
Preparation of patient
Medical opinion concerning preparative
measures varies widely. However, with
modifications as required, the following
procedure seems to be in general use:
• When time permits, have the patient
follow a low-residue diet for I to 2 days
to prevent gas formation caused by ex­
cessive fermentation of the intestinal
contents.
• Have the patient eat a light evening
meal on the day before the examination.
• When indicated by costive bowel action,
administer a non-gas-forming laxative
the evening before the examination.
• Have the patient take nothing by mouth
after midnight on the day of the exam­
i nation. However, the patient should
not be dehydrated. Patients with multi­
ple myeloma, high uric acid levels, or
diabetes must be well hydrated before
I V U is performed; these patients are at
i ncreased risk for contrast medium­
induced renal failure if they are dehy­
drated.
Fig. 1 8-25 Urogram: prone position. in the same patient as in Fig.
1 8-24. Visualization of left kidney and ureter is markedly improved.
• rn preparation for retrograde urogra­
phy, have the patient drink a large
amount of water (4 or 5 cups) for sev­
eral hours before the exami nation to en­
sure excretion of urine in an amount
sufficient for bilateral catheterized
specimens and renal function tests.
• Note that no patient preparation is usu­
ally necessary for examinations of the
lower urinary tract.
Outpatients should be given explicit di­
rections regarding any order from the
physician pertai ning to diet, fluid intake,
and laxatives or other medication. The pa­
tient should also be given a suitable ex­
planation for each preparative measure to
ensure cooperation.
209
 EQUIPMENT
A combination cystoscopic-radiographic
unit facilitates retrograde urographic pro­
cedures requiring cystoscopy. Any stan­
dard radiographic table is suitable for the
performance of preliminary excretory
urography, a well as most retrograde stud­
ies of the bladder and urethra. The cysto­
scopic unit is also used for these proce­
dures; however, for the patient's comfort,
the table should have an extensible leg rest.
I nfusion nephrourography requires a
table equi pped with tomographic appara­
tu . Tomography should be performed
when intestinal gas obscures some of the
underlying structures or when hyper­
sthenic patients are being examined ( Figs.
1 8-26 to 1 8-28).
For the patient's comfort and to prevent
delays during the examination, all prepa­
rations for the examination should be
completed before the patient is placed on
the table. I n addition to an identification
and side marker, excretory urographic
tudies require a time-interval marker for
each postinjection study. Body-position
markers (supi ne, prone, upright or semi­
upright, Trendelenburg, decubitus) should
also be used.
Fig. 1 8-26 Urogram: AP projection.
210
Some institutions perform excretory
urograms (proximal urinary tract studies)
using 24 X 30 cm or 30 X 35 cm IRs
placed crosswise, but these studies can
also be made on 35 X 43 cm IRs placed
lengthwise. The upright study is made on
a 35 X 43 cm IR because it is taken to
demonstrate the mobility of the kidneys
and to outl ine the lower ureters and blad­
der. Studies of the bladder before and af­
ter voiding are usual ly taken on 24 X 30
cm ( I O X 1 2 inch) IRs.
Fig. 1 8-27 Urogram: AP projection using tomography.
The fol lowing guidelines are ob erved
in preparing additional equipment for the
examination:
• Have an emergency cart fully equipped
and conveniently placed.
• Arrange the instruments for injection of
the contrast agent on a smal l, movable
table or on a tray.
• Have frequently used sterile items read­
ily available. Disposable syringes and
needles are available in standard sizes
and are widely used in this procedure.
• Have required nonsterile items avail­
able: a tourniquet, a small waste basin,
an emesis basin, general disposable
wipes, one or two bottles of contrast
medium, and a small prepared dres ing
for application to the puncture site.
• Have iodine or alcohol wipes available.
• Provide a folded towel or a small pillow
that can be placed under the patient's
elbow to relieve pressure during the
injection.
PROCEDURE
Image quality and exposure
technique
Urograms should have the same contra t,
den ity, and degree of soft tissue density
as do abdominal radiographs. The radi­
ographs must show a sharply defined out­
line of the kidneys, lower border of the
liver, and lateral margin of the psoas mus­
cles. The amount of bone detail visible in
these studies varies according to the thick­
ness of the abdomen (Fig. 1 8-29).

Motion control
An immobilization band u ual ly is not ap­
plied over the upper abdomen in uro­
graphic examinations because the resul­
tant pre sure may i nterfere with the
pas age of fl uid through the ureters and
may at 0 cause distortion of the canals.
Thus the elimination of motion in uro­
graphic examinations depends on the ex­
posure time and on securing the ful l coop­
eration of the patient.
The examination procedure should be
explained so that the adult patient is pre­
pared for any transitory distress caused by
the injection of contrast solution or by the
cy to copic procedure. The patient should
be a sured that everything possible will be
done for the patient's comfort. The suc­
cess of the examinations depends in large
part on the abi lity of the radiographer to Fig. 1 8-28 Urogram: AP oblique projection, LPO position, using tomography. Note left kId­
gain the confidence of the patient. ney is perpendicular to IR.

Fig. 1 8-29 AP abdomen showing margins of the kidney (dots), liver (dashes), and psoas
muscles (dot-dash lines).

21 1
 Ureteral compression
In excretory urography, compression i s
sometimes applied over the distal ends of
the ureters. This is done to retard flow of
the opacified urine into the bladder and
thus ensure adequate filling of the renal
pelves and calyces. If compression is used,
it must be placed so that the pressure over
the distal ends of the ureters is centered at
the level of ASIS. As much pressure as the
patient can comfortabl y tolerate is then ap­
plied with the immobilization band (Figs.
1 8-30 and 1 8-3 1 ). The pressure should be
released slowly when the compression de­
vice is removed to avoid the possibility of
visceral rupture. Compression is generally
contraindicated if a patient has urinary
stones, an abdominal mass or aneurysm, a
colostomy, a suprapubic catheter, or trau­
matic i nj ury.
As a result of improvements in contrast
agents, ureteral compression is not rou­
Fig. 1 8-30 Ureteral compression device in place for urogram. tinely used in most health care facilities.
With the i ncreased doses of contrast
medium now employed, mo t of the
ureteral area is usuall y demonstrated over
a series of radiographs.

Respiration
For the purpose of comparison, all expo­
sures are made at the end of the same
phase of breathing-at the end of expira­
tion unless otherwise requested. Because
the normal respiratory excursion of the
kidneys varies from � to 1 \12 i nches ( 1 .3
to 3.8 cm), it is occasionall y possible to
differentiate renal shadows from other
shadows by making an exposure at a dif­
ferent phase of arrested respiration. When
an exposure is made at a respiratory phase
different from what is usually used, the
image should be so marked.

Ureteral compression device

Fig. 1 8-31 Urogram showing ureteral compression device in

proper position over distal ureters.

21 2
Renal Parenchyma

Fig. 1 8-51 Infusion nephrotomogram: AP projection at 9-cm level. Fig. 1 8-52 Infusion nephrotomogram: AP projection
at 5-cm level.

Fig. 1 8-53 Infusion nephrotomogram: AP projection, demonstrating para­ Fig. 1 8-54 Infusion nephrotomogram: lateral projec­
pelvic cyst on right kidney (arrows). tion, demonstrating para pelvic cyst (arrows).

223
 PERCUTANEOUS RENAL PUNCTURE
Percutaneous renal puncture, introduced
by Lindblom,J·2 is a radiologic procedure
for the investigation of renal masses.
Specifically, it is used to differentiate
cysts and tumors of the renal parenchyma.
This procedure is performed by direct in­
jection of a contrast medium into the cyst
under fl uoroscopic control (Figs. 1 8-55
and 1 8-56). Ultrasonography of the kid­
ney has practically eliminated the need for
percutaneous renal puncture. Most masses
that are clearly diagnosed as cystic by ul­
trasound examination are not surgically
managed.

' Lindblom K: Percutaneous puncture of renal cysts

and tumors, Acta Radio1 27:66, 1 946.
'Lindblom K: Diagnostic kidney puncture in cysts
and tumors, Am J RoentgenoI 68:209, 1 952.

Fig. 1 8-55 Upright AP left kidney: percutaneous injection of iodinated contrast material
and gas into renal cyst.

Fig. 1 8-56 AP projection left kidney, left lateral decubitus position, in the same patient as
in Fig. 1 8-55.

224
 In a similar procedure the renal pelvis
is entered percutaneously for direct con­
trast fi l l i ng of the pelvicalyceal system i n
elected patients with hydronephrosis.I.3
This procedure, called percutaneous ante­
grade pyelography to distinguish it from
the retrograde technique of direct pelvica­
Iyceal fi l ling, is usuall y restricted to the
i nve tigation of patients with marked hy­
dronephrosis and patients with suspected
hydronephrosis for which conclusive i n­
formation is not gained by excretory or
retrograde urography (Fig. 1 8-57).
Normally, AP abdominal radiographs are
obtained for this procedure, although
other projections may be requested.

' Wickbom I : Pyelography after direct puncture of

the renal pelvis, Acta RadioL 41 :505, 1 954.
2Weens HS, Florence TJ: The diagno is of hy­
dronephrosi by percutaneous renal puncture, J UroL
72:589, 1 954.
3Casey we, Goodwin WE: Percutaneous antegrade
pyelography and hydronephrosis, J Urol 74: 1 64, 1 955.

Fig. 1 8-57 Percutaneous antegrade pyelo­

gram demonstrating hydronephrosis.

225
 Pelvicalyceal System and U reters

Retrograde U rography If elevation of the thighs does not re­ The urologist then performs catheteri­
.. AP PROJECTION duce the lumbar curve, a pillow is ad­ zation of the ureters through a ureterocys­
Retrograde urography requires that the justed under the patient's head and shoul­ toscope, which is a cystoscope with an
ureter be catheterized so that a contrast ders so that the back is in contact with the arrangement that aids insertion of the
agent can be injected directly into the table. Most cystoscopic-radiographic ta­ catheters into the vesicoureteral orifices.
pelvicalyceal ystem. This technique pro­ bles are equipped with an adjustable leg After the endoscopic examination, the
vides improved opacification of the renal rest to permit extension of the patient's urologist passes a ureteral catheter well
collecting system but little physiologic in­ legs for certain radiographic studies. into one or both ureter (Fig. 1 8-59) and,
formation about the urinary sy tern. leaving the catheters in position, usual ly
withdraws the cystoscope.
Indications and contraindications
The retrograde urogram is indicated for
evaluation of the collecting system in pa­
tients who have renal insufficiency or who
are al lergic to iodinated contrast media.
Because the contrast medium is not intro­
duced into the circulatory system, the in­
cidence of reactions is reduced.

Examination procedure
Like all examinations requiring i nstru­
mentation, retrograde urography is classi­
fied as an operative procedure. This com­
bined urologic-radiologic examination is
carried out under careful aseptic condi­
tions by the attending urologist with the
a i tance of a nurse and radiographer.
The procedure is performed in a specially
equipped cy toscopic-radiographic exam­
ining room that, because of its collabora- Fig. 1 8-58 Patient positioned on table for retrograde urography. modified lithotomy position.
tive nature, may be located in the urology
department or the radiology department.
A nurse is responsible for the preparation
of the instruments and the care and drap­
ing of the patient. One of the radiogra­
pher's responsibilities is to ensure that the
overhead parts of the radiographic equip­
ment are free of du t for the protection of
the operative field and the sterile layout.
The radiographer positions the patient
on the cystoscopic table with knees flexed
over the stirrups of the adjustable leg sup­
port (Fig. 1 8-58). This is a modified
lithotomy position; the true lithotomy po-
ition requires acute flexion of the hips
and knees.
If a general anesthetic is not used, the
radiographer explains the breathing pro­
cedure to the patient and checks the pa­
tient' position on the table. The kidney
and the full extent of the ureter in pa­
tients of average height are included on a
35 X 43 cm IR when the third lumbar ver­
tebra is centered to the grid.

Fig. 1 8-59 Retrograde urogram with catheters in proximal ureters: AP projection.

226
 Pelvicalyceal System and U reters
After taking two catheterized speci­
mens of urine from each kidney for labo­
ratory tests--one specimen for culture
and one for microscopic examination­
the urologist tests kidney function. For
this test, a color dye is injected intra­
venously, and the function of each kidney
is determined by the specified time re­
quired for the dye substance to appear in
the urine as it trickles through the respec­
tive catheters.
I m mediately after the kidney function
test, the radiographer rechecks the posi­
tion of the patient and exposes the prelim­
inary IR (if this has not been done previ­
ously) so that the radiographs will be
ready for i nspection by the time the kid­
ney function test has been completed.
After reviewing the image, the urolo­
gist injects the contrast medium and pro­
ceeds with the urographic examination.
When a bilateral examination is to be per­
formed, both sides are fi lled simultane­
ously to avoid subjecting the patient to un­
necessary radiation exposure. Additional
studies in which only one side is refilled
may then be made as i ndicated.
Fig. 1 8-60 Retrograde urogram with renal pelves filled: AP
projection.
The most commonly used retrograde
urographic series usuall y consists of three
AP projections: the preli minary radi­
ograph showing the ureteral catheters in
position (see Fig. 1 8-59), the pyelogram,
and the ureterogram. Some urologists rec­
ommend that the head of the table be low­
ered 1 0 to 1 5 degrees for the pyelogram to
prevent the contrast solution from escap­
ing into the ureters. Other urologists rec­
ommend that pressure be maintained on
the syringe during the pyelographic expo­
sure to ensure complete filling of the
pelvicalyceal system. The head of the
table may be elevated 35 to 40 degrees for
the ureterogram to demonstrate any tortu­
osity of the ureters and the mobility of the
kidneys.
Filling of the average normal renal
pelvis requires 3 to 5 rnl of contrast solu­
tion; however, a larger quantity is required
when the structure is dilated. The best in­
dex of complete filling, and the one most
commonly used, is an indication from the
patient as soon as a sense of fullness is felt
in the back.
Fig. 1 8-61 Retrograde urogram showing renal pelves and
contrast-filled ureters: AP projection.
When both sides are to be filled, the
urologist i njects the contrast solution
through the catheters in an amount suffi­
cient to fil l the renal pelves and calyces.
When signaled by the physician, the pa­
tient suspends respiration at the end of ex­
piration, and the exposure for the pyelo­
gram is then made (Fig. 1 8-60).
After the pyelographic exposure, the IR
is quickly changed and the head of the table
may be elevated in preparation for the
ureterogram. For this exposure the patient is
instructed to inspire deeply and then sus­
pend respiration at the end of full expira­
tion. Simultaneously with the breathing
procedure, the catheters are slowly with­
drawn to the lower ends of the ureters as the
contrast solution is injected into the canals.
At a signal from the urologist, the uretero­
graphic exposure is made (Fig. 1 8-6 1 ).
Additional projections are sometimes
required. RPO or LPO (AP oblique) pro­
jections are often necessary. Occasional ly
a lateral projection, with the patient turned
onto the affected side, is performed to
demonstrate anterior displacement of a
kidney or ureter and to delineate a peri­
nephric abscess. Lateral projections with
the patient in the ventral or dorsal decubi­
tus position (as required) are also useful
demonstrating the ureteropelvic region in
patients with hydronephrosis.
227
 Urina ry Bladder, lower
Ureters, U rethra,
and Prostate
With few exceptions, radiologic examina­
tions of the lower urinary tract are per­
formed with the retrograde technique of
introducing contrast material. These ex­
aminations are identified, according to the
specific purpose of the i nvestigation, by
the terms cystography, cystoureterogra­
phy, cystourethrography, and prostatogra­
phy. Most often they are denoted by the
general term cystography. Cystoscopy is
not required before retrograde contrast
fill ing of the lower urinary canals, but,
when both examinations are indicated,
they are usually performed in a single­
stage procedure to spare the patient prepa­
ration and instrumentation for separate
examinations. When cystoscopy is not i n­
dicated, these examinations are best car­
ried out on an all-purpose radiographic
table unless the combi nation table is
equipped with an extensible leg rest.
Indications and contraindications
Retrograde studies of the lower urinary
tract are indicated for vesicoureteral re­
flux, recurrent lower urinary tract i nfec­
tion, neurogenic bladder, bladder trauma,
lower urinary tract fistulae, urethral stric­
ture, and posterior urethral valves. Contra­
indications to lower urinary tract studies
are related to catheterization of the urethra.
Contrast media
The contrast agents used for contrast stud­
ies of the lower urinary tracts are ionic so­
lutions of either sodium or meglumine dia­
trizoates or the newer non ionic contrast
media mentioned earl ier. These are the
same organic compounds used for IVU,
but their concentration is reduced for ret­
rograde urography.
Injection equipment
The examinations are performed under
careful aseptic conditions. I nfants, chil­
dren, and, usually, adults may be catheter­
ized before they are brought to the radiol­
ogy department. When the patient is to be
catheterized in the radiology department,
a sterile catheterization tray must be set
up to specifications. Because of the dan­
ger of contamination in transferri ng a ster­
ile liquid from one container to another,
the use of commercially available pre­
mixed contrast solutions is recommended.
228
Preliminary preparations RETROGRADE CYSTOGRAPHY
The following guidelines are observed in Contrast injection technique
preparing the patient for the examination: In preparing for this examination, the fol­
• Protect the examination table from lowing steps are observed:
urine soilage with radiolucent plastic • With the urethral catheter in place, ad­
sheeting and disposable underpadding. just the patient in the supine position
Correctly arranged disposable padding for a preliminary radiograph and the
does much to reduce soilage during first cystogram.
voiding studies and consequently elim­ • Usually, take cystograms of adult pa­
inates the need for extensive cleaning tients on 24 X 30 cm IRs placed length­
between patients. A suitable disposal wise.
receptacle should be available. • Center the IR at the level of the soft tissue
• A few minutes before the examination, depression just above the most prominent
accompany the patient to a lavatory. point of the greater trochanters. This cen­
Give the patient supplies for perineal tering coincides with the middle area of a
care, and instruct the patient to empty filled bladder of average size. Therefore
the bladder. the 30-cm IR will include the region of
• Once the patient is prepared, place the the distal end of the ureters for demon­
patient on the examination table for the stration of ureteral reflux, and it will also
catheterization procedure. include the prostate and proximal part of
Patients are usuall y tense, primaril y be­ the male urethra.
cause of embarrassment. It is important • Have large IRs nearby for use when
that they be given as much privacy as pos­ ureteral reflux is shown. Some radiolo­
sible. Only the required personnel should gists request studies during contrast fill­
be present during the examination, and i ng of the bladder, as well as during
patients should be properly draped and voiding.
covered according to room temperature. After the preliminary radiograph is
taken, the physician removes the catheter
Contrast injection clamp and the bladder is drained in prepa­
For retrograde cystography (Figs. 1 8-62 ration for the i ntroduction of the contrast
and 1 8-63), cystourethrography, and void­ material. After i ntroducing the contrast
ing cystourethrography, the contrast mate­ agent, the physician clamps the catheter
rial is introduced into the bladder by i n­ and tapes it to the thigh to keep it from be­
jection or infusion through a catheter ing displaced during position changes.
passed into position by way of the urethral The initial cystographic images generally
canal. A smal l, disposable Foley catheter consist of four projections: one AP, two AP
is used to occlude the vesicourethral ori­ obliques, and one lateral. Additional stud­
fice in the examination of i nfants and chil­ ies, including voiding cystourethrograms,
dren, and this catheter may be used in the are obtained as i ndicated. The Chassard­
examination of adults when interval stud­ Lapine method (see Chapter 7), often called
ies are to be made for the detection of de­ the "squat shot," is sometimes used to ob­
layed ureteral refl ux. tain an axial projection of the posterior sur­
Studies are made during voiding for the face of the bladder and the lower end of the
delineation of the urethral canal and for ureters when they are opacified. These pro­
the detection of ureteral reflux, which may jections of the bladder are also made when
occur only during urination (Fig. 1 8-64). it is opacified by the excretory technique of
When urethral studies are to be made dur­ urography.
ing injection of contrast material, a soft­
rubber urethral-orifice acorn is fitted di­
rectly onto a contrast-loaded syringe for
female patients and is usually fi lled onto a
cannula attached to a clamp device for
male patients.
 Fig. 1 8-62 Retrograde cystogram after introduction of contrast media: AP projection.

Fig. 1 8-63 Retrograde cystogram after introduction of air: AP Fig. 1 8-64 Serial (polygraphic) voiding cystourethrograms in an
projection. infant girl with bilateral ureteral reflux (arrowheads). Urethra is
normal. Vaginal reflux (arrows) is normal finding.

229
 Urinary Bladder
.. AP AXIAL OR PA AXIAL
PROJECTION
Image receptor: 24 X 30 cm
lengthwise
Position of patient
• Place the patient supine on the radio­
graphic table for the AP projection of
the urinary bladder.
NOTE: Preliminary (scout) and postinjection ra­
diographs are most commonly obtained with
the patient supine. The prone po ition is some­
times used to i mage areas of the bladder not
clearly seen on the AP axial projection. An AP
axial projection using the Trendelenburg posi­
tion at 1 5 to 20 degrees and with the central ray
directed vertical ly is sometimes used to demon­
strate the distal ends of the ureters. In this an­
gled position, the weight of the contained fluid
stretches the bladder fundus superiorly, giving
an unobstructed projection of the lower ureters
and the vesicoureteral orifice areas.
230
Position of part
• Center the midsagittal plane of the pa­
tient's body to the midline of the grid
device.
• Adj ust the patient's shoulders and hips
so that they are equidistant from the IR.
• Place the patient's arms where they will
not cast shadows on the IR.
• If the patient is positioned for a supine
radiograph, have the patient's legs ex­
tended so that the lumbosacral area of
the spine is arched enough to tilt the an­
terior pelvic bones inferiorly. In this po­
sition the pubic bones can more easily
be projected below the bladder neck
and proximal urethra (Fig. 1 8-6S ).
• Center the I R 2 inches (S cm) above the
upper border of the pubic symphysis
(or at the pubic symphysis for voiding
studies).
• Respiration: S uspend at the end of ex­
piration.
Fig. 1 8-65 Retrograde cystogram . AP axial bladder with 1 5-degree caudal angulation of
central ray.
Central ray
AP
• Angled 1 0 to I S degrees caudal to the
center of the IR. The central ray should
enter 2 inches (S cm) above the upper
border of the pubic symphysis. When
the bladder neck and proximal urethra
are the main areas of interest, a s-degree
'
caudal angulation of the central ray is
usually sufficient to project the pubic
bones below them. More or less angula­
tion may be necessary, depending on the
amount of lordosis of the lumbar spine.
With greater lordosis, less angulation
may be needed (see Fig. 1 8-6S).
PA
• When performing PA axial projections
of the bladder, direct the central ray
through the region of the bladder neck
at an angle of 1 0 to I S degrees cepha­
lad, entering about I inch (2.S cm) dis­
tal to the tip of the coccyx and exiting a
little above the superior border of the
pubic symphysis. If the prostate is the
area of interest, the central ray is di­
rected 20 to 2S degrees cephalad to pro­
ject it above the pubic bones. For PA
axial projections, the IR is centered to
the central ray.
• Perpendicular to the pubic symphysis
for voiding studies.
 Urinary Bladder
Structures shown
AP axial and PA axial projections demon­
strate the bladder filled with contrast
medium (Figs. 1 8-66 and 1 8-67). If reflux is
present, the distal ureters are also visualized.
Fig. 1 8-66 Excretory cystogram: AP axial projection.
EVALUATION CRITERIA
The fol lowi ng should be clearly demon­
strated:
• Regions of the distal end of the ureters,
bladder, and proximal portion of the
urethra
• Pubic bones projected below the blad­
der neck and proximal urethra
• Short scale of contrast clearly demon­
strating contrast medium in the bladder,
distal ureters, and proximal urethra
Fig. 1 8-67 Retrograde cystogram: AP axial projection. Note
catheter in bladder.
231
 U rinary Bladder

.. AP OBLIQUE PROJECTION Central roy

RPO or LPO position • Perpendicular to the center of the IR.
The CR will fal l 2 inches (5 cm) above
Image receptor: 24 x 30 cm the upper border of the pubic symphysis
lengthwise and 2 inches (5 cm) medjal to the upper
ASIS. When the bladder neck and prox­
Position of patient imal urethra are the main areas of inter­
• Place the patient in the supine position est, a 1 O-degree caudal angulation of the
on the radiographic table. central ray is usually sufficient to pro­
ject the pubic bones below them.
Position of port • Perpendicular at the level of the pubic
• Rotate the patient 40 to 60 degrees symphysis for voiding studies.
RPO or LPO, according to the prefer­
ence of the examjning physician (Fig. Structures shown
1 8-68). Oblique projections demonstrate the blad­
• Adjust the patient so that the pubic arch der fi l led with the contrast medium. If re­
closest to the table is aligned over the flux is present, the distal ureters are also
rlli dline of the grid. visualized (Figs. 1 8-69 and 1 8-70).
• Extend and abduct the uppermost thigh
enough to prevent its superimposition
on the bladder area.
• Center the IR 2 inches (5 cm) above the
upper border of the pubic symphysis
and approxi mately 2 inches (5 cm) me­
dial to the upper ASIS (or at the pubic
symphysis for voiding studies).
• Respiration: Suspend at the end of ex­
piration.

������""-"--*11""�
------- .

-� - -
- ----------- -

Fig. 1 8-68 Retrograde cystogram : AP oblique bladder. RPO position.

232
 Urinary Bladder

EVALUATION CRITERIA
The fol lowing should be clearly demon­
strated:
• Regions of the distal end of the ureters,
bladder, and proximal portion of the
urethra
• Pubic bones projected below the blad­
der neck and proximal urethra
• Short scale of contrast clearly demon­
strating the contrast medjum in the blad­
der, distal ureter , and proximal urethra
• No superimposition of the bladder by
the uppermost thjgh
Voiding studies
• Entire urethra visible and fi lled with the
contrast medium
• Urethra overlapping the thigh on oblique
projections for improved visibility
• Urethra lying posterior to the superim­
posed pubic and ischial rarm on the side
down in oblique projections

Fig. 1 8-69 Excretory cystogram: AP oblique bladder, RPO position.

Fig. 1 8-70 Retrograde cystogram with catheter in bladder.

233
 Urinary Bladder

'" LATERAL PROJECTION Central ray EVALUATION CRITERIA

R or L position • Perpendicular to the IR and 2 inches The fol lowing should be clearly demon­
(5 cm) above the upper border of the pu­ strated:
Image receptor: 24 x 30 cm bic symphysis at the midcoronal plane • Regions of the distal end of the ureters,
lengthwise bladder, and proximal portion of the
Structures shown urethra
Position of patient A lateral image demonstrates the bladder • Short scale of contrast clearly demon­
• Place the patient in the lateral recum­ fi l led with the contrast medium. If reflux strating the contrast medium in the
bent position on either the right or left is .present, the distal ureters are also visu­ bladder, distal ureters, and proximal
side, as indicated. alized. Lateral projections demonstrate urethra
the anterior and posterior bladder walls • B l adder and di stal ureters v i s ible
Position of part and the base of the bladder (Fig. 1 8-72). through the pelvis
• Sl ightly flex the patient's knees to a • Superimposed hips and femur
comfortable position, and adjust the
body so that the midcoronal plane is
centered to the midline of the grid.
• Flex the patient's elbows and place the
hand under the head (Fig. 1 8-7 1 ).
• Center the I R 2 inches (5 cm) above the
upper border of the pubic symphysis at
the midcoronal plane.
• Respiration: Suspend at the end of
expiration.

Fig. 1 8- 7 1 Cystogram: lateral projection. Fig. 1 8-72 Cystogram: lateral projection.

234
 Male Cystourethrography

'" AP OBLIQUE PROJECTION • The patient's lower knee is flexed only • At a signal from the phy ician, instruct
RPO or LPO position slightly to keep the soft tissues on the the patient to hold sti l l ; make the expo­
Male cystourethrography may be pre­ medial side of the thigh as near to the sure while the injection of the contrast
ceded by an endoscopic examination, af­ center of the IR as possible. material is continued to ensure filling of
ter which the bladder is catheterized so • The elevated thigh is extended and re­ the entire urethra (Fig. 1 8-74).
that it can be drained j ust before contra t tracted enough to prevent overlapping. • The bladder may then be fil led with a
material i injected. • With the patient in the correct position, contrast material so that a voiding study
The fol lowing steps are ob erved: the physician i nserts the contrast­ can be performed (Fig. 1 8-75). This i
• Use 24 X 30 cm IRs placed lengthwise loaded urethral syringe or the nozzle of usually done without changing the pa­
for cystourethrograms in adult male pa­ a device such as the Brodney clamp tient's position. When a tanding-upright
tients. i nto the urethral orifice. The physician voiding tudy is required, the patient is
• The patient is adjusted on the combina­ then extends the penis along the soft adjusted before a vertical grid device
tion table so that the IR can be centered tissues of the medial side of the lower and is supplied with a urinal. (Further in­
at the level of the superior border of the thigh to obtain a uniform density of formation on positioning is provided on
pubic symphysis. This centering coin­ both the deep and the cavernous por­ pp. 230 to 234 of this volume.)
cides with the root of the penis, and a tions of the urethral canal.
30-cm ( l 2-inch) I R will i nclude both
the bladder and the external urethral
orifice.
• After i nspecting the preliminary radi­
ograph, the physician drains the blad­
der and withdraws the catheter.
• The supine patient is adjusted in an
oblique position so that the bladder
neck and the entire urethra are delin­
eated as free of bony superimposition
a po sible. Rotate the patient' body
35 to 40 degrees, and adjust it so that
the elevated pubis is centered to the
midline of the grid. The superimpo ed
pubic and ischial rami of the down side
and the body of the elevated pubis usu­
ally are projected anterior to the blad­
der neck, proximal urethra, and prostate
(Fig. 1 8-73).
� -- .� I

Fig. 1 8-73 Cystourethrogram : AP oblique projection. RPO position.

Bladder

Prostatic urethra

Membranous urethra

Spongy
(cavernous) urethra "'-----::.=--'--::"--.:

Fig. 1 8-74 Injection cystourethrogram: AP oblique urethra. Fig. 1 8-75 Voiding cystourethrogram : AP
RPO position. oblique urethra. LPO position.

235
 Female Cystourethrography
AP PROJECTION
INJ ECTION METHOD
The female urethra averages 3 .5 cm in
length. Its opening into the bladder is situ­
ated at the level of the superior border of
the pubic symphysis. From this point the
vessel slants obliquely inferiorly and ante­
riorly to its termination in the vestibule of
the vulva, about I inch anterior to the vagi­
nal orifice. The female urethra is subject to
conditions such as tumors, abscesses, di­
verticula, dilation, and strictures. It is also
ubject to urinary incontinence during the
stress of increased intraabdominal pressure
such as occurs during sneezing or cough­
ing. In the investigation of abnormalities
other than stress incontinence, contrast
studies are made during the injection of
contrast medium or during voiding.
Cystourethrography is usually preceded
by an endoscopic examination. For this
reason, it may be performed by the at­
tending urologist or gynecologist with the
assistance of a nurse and a radiographer.
The following steps are ob erved:
• After the physical examination, the cys­
toscope is removed and a catheter is in­
serted into the bladder so that the blad­
der can be drained j ust before i njection
of the contrast solution.
• The patient is adjusted in the supine po­
sition on the table.
Fig. 1 8-76 Voiding cystourethrogram: AP projection.
236
• An 8 X 1 0 inch ( 1 8 X 24 cm) or 24 X
30 cm I R is placed lengthwise and cen­
tered at the level of the superior border
of the pubic symphysis.
• A 5-degree caudal angulation of the
central ray is usual ly sufficient to free
the bladder neck of superimposition.
• After inspecting the preliminary radi­
ograph, the physician drains the blad­
der and withdraws the catheter. The
physician uses a syringe fitted with a
blunt-nosed, soft-rubber acorn, which
is held firmly against the urethral ori­
fice to prevent reflux as the contrast so­
l ution is injected during the exposure.
• ]n addition to the AP projection,
oblique projection may also be re­
quired. For the oblique projections, the
patient is rotated 35 to 40 degrees so
that the urethra is posterior to the pubic
symphysis. The uppermost thigh is then
extended and abducted enough to pre­
vent overlapping.
• (Further information on positioning is
provided on pp. 230 to 234 of this vol­
ume.)
• The physician fi lls the bladder for each
voiding study to be made.
Controst-filled
bladder
Urethra
Fig. 1 8-77 Serial voiding images showing four stages of bladder
emptying.
• For an AP projection (Figs. 1 8-76 and
1 8-77), the patient is maintained in the
supine position, or the head of the table
is elevated enough to place the patient
in a semiseated position.
• A lateral voiding study of the female
vesicourethral canal is performed with
the patient recumbent or upright. In ei­
ther case, the IR is centered at the level
of the superior border of the pubic
symphysis.
Metallic bead chain
cystourethrography
The metallic bead chain technique of in­
vestigating anatomic abnormalities respon­
sible for stress incontinence in women was
descri bed by Stevens and S mi th l in 1 937
and by Bames2 in 1 940. This technique is
Stevens WE, Smith SP: Roentgenological examina­
tion of the female urethra, J Ural 37: 1 94, 1 937.
2Barnes AC: A method for evaluating the stress of
urinary incontinence, Am J Obslel GYlleco/ 40:38 1 ,
1 940.
 Female Cystourethrography

used to delineate anatomic changes that oc­ Comparison AP and lateral projections
cur in the shape and position of the bladder are made with the patient standing at rest
floor, in the posterior urethrovesical angle, (Figs. 1 8-78 and 1 8-79) and straining
in the position of the proximal urethral ori­ (Figs. 1 8-80 and 1 8-8 1 ).
fice, and in the angle of i nclination of the
urethral axi under the stress of increased
intraabdominal pressure as exerted by the
Val salva maneuver.

Bladder

Metallic
bead
chain

Fig. 1 8-78 Upright cystourethrogram : resting AP projection. Fig. 1 8-79 Upright cystourethrogram : resting lateral projection.

Fig. 1 8-80 Upright cystourethrogram: stress AP projection in the Fig. 1 8-81 Upright cystourethrogram: stress lateral projection.
same patient as in Fig. 1 8-78.
237
 For this examination the physician ex­
tends a flexible metal lic bead chain
through the urethral canal . The proximal
portion of the chain rests within the blad­
der, and the distal end i taped to the thigh.
For demon tration of the length of the ure­
thra, a small metal marker is attached with
a piece of tape to the vaginal muco a just
lateral to the urethral orifice. After instilla­
tion of the metal lic chain, a catheter is
passed into the bladder, the contents of the
bladder are drained, and an opaque con­
trast solution is injected. The catheter is re­
moved for the imaging procedure.
238
Hodgkinson, Doub, and Kel ly' recom­
mended the upright position, which uses
gravity and thus simulates normal body
activity. Two sets of images (AP and lat­
eral projections) are obtained, and the rest
of the studies must be exposed before the
stress studies are made because the blad­
der does not immediately return to its nor­
mal resting position after straining.
' H odgkinson CP, Doub HP, Kelly WT: Urethro­
cystograms: metallic bead chain technique, elin
Obstet GYllecol 1 :668, 1 958.
After the metallic chain and contrast
solution are instilled, the patient is usual ly
prepared for upright radiographs. The ex­
amining room should be readied in ad­
vance so that the patients, who will be un­
comfortable, can be given immediate
attention . The patient must be given kind
reassurance and must be examined in pri­
vacy. Klawon' found that the fear of in­
voluntary voiding can be relieved by plac­
i ng a folded towel or disposable pad
between the patient's thighs before the
stress radiographs are taken. Thus pro­
tected, the patient willingly applies ful l
pressure during the stress tudies.
The IR size and centering point are the
same as for other female cystourethro­
grams. (Fulther information on position­
ing of the lower urinary tract is provided
on pp. 230 to 234 of this volume. )
' Klawon Sister M M : Urethrocy tography and uri­
nary stress incontinence in women, Radiol Techn
39:353, 1 968.
 VE N I PU N CTU RE A N D IV CONTRAST M E D IA ADM I N ISTRATION
Michael R. Bloyd
Advances in medical science and modern
technology are creating tremendous
changes and improvement in IV therapy,
e pecially for tho e who perform diagnos­
tic imaging. As IV therapy has evolved
over the years, radiologic technologists
are being as igned roles in the patient­
focused, cost-effective collaborative team
concept of modern health care. An esti­
mated 80% of patients in acute-care set­
tings require some type of IV medication.
Administering medications accurately and
safely is an important responsibil ity that
must not be taken l ightly. I
The principals of I V therapy include
restoring and maintaining fl uid and elec­
trolyte balance, administering medication,
transfusing blood, and deliveri ng par­
enteral nutrition solutions. The radiologic
technologist may initiate venipuncture
and administer medications by physician
order for specific indications in certain
types of IV therapy related to radio­
graphic procedures. 2
Professional and Legal
Considerations
Because of patient risk and legal liabilities,
the radiologic technologist must follow
profe ional recommendations, state regu­
lations, and institutional policies for the ad­
ministration of medications. The informa­
tion presented in this section i meant to be
an introduction to IV therapy. Competency
in this area requires the completion of a
formal course of instruction with uper­
vi ed clinical practice and evaluation.
' Kowalczyk N, Donnett K: Integrated patient care
for tire imaging professional, SI Louis, 1 996, Mosby.
2"fortorici M: Administration of imaging pharmaceu­
ticals, Philadelphia, 1 996, WB Saunders.
The American Society of Radiologic
Technologists (ASRT) includes venipunc­
ture and IV medication administration i n
the curriculum guidelines for the educa­
tional opportunities offered to technolo­
gists. Additional support for the adminis­
tration of medications and venipuncture as
part of the technologist's scope of practice
is found in the 1 987 Resolution No. 27
from the American College of Radiology. I
Within specific established guidelines this
resolution supports the injection of con­
trast materials and diagnostic levels of ra­
diopharmaceuticals by certified and/or li­
censed radiologic technologists. The
ASRT Standards of Practice for Radiog­
raphy also support the administration of
medication by technologists.
Technologists who perform venipunc­
ture and contrast media administration
must be knowledgeable about the specific
state regulations and faci lity policies that
govern these activities. Technologists also
are responsible for professional decisions
and actions in their practice. Competency
in the skills of venipuncture and contrast
media administration are based on cogni­
tive knowledge, proficiency in psychomo­
tor skills, positive affective values, and
validation in a clinical setting.
Medications
Medications for a specific procedure are
prescribed by a physician, who is also re­
sponsible for obtaining informed consent
for the procedure. A technologist may ad­
minister medications for radiographic
procedures, which can require medica­
tions for sedation, pain management, con­
trast media administration, and emergen­
cies. 2 The technologist must have an
extensive knowledge of all medications
used in the radiology department. IV med­
ications are administered into the body via
the vascular system; once administered,
they cannot be retrieved. Therefore, be­
fore administering any medication, the
technologist must know the medication's
name, dosages, indications, contraindica­
tions, and possible adverse reactions.
(Table 1 8- 1 ).
'Tortorici M : Administration of imaging pharmaceu­
ticals, Philadelphia, 1 996, WB Saunders.
2 Kowalczyk N, Donnett K: Integrated patient care
for the imaging professional, SI Louis, 1 996, Mosby.
. ,:)_
Patient Education
The manner in which the technologist ap­
proaches the patient can have a direct in­
fl uence on the patient's response to the
procedure. Although the technologi t may
consider the procedure routine, the patient
may be total l y unfam i l i ar with it
specifics. Apprehen ion experienced by
the patient can cause vasoconstriction,
making the venipuncture more difficult
and more painful. I Careful explanation
and a confident, understanding attitude
can help the patient relax.
The technologist must provide informa­
tion about the procedure in terms of the
patient's understanding. The patient's
questions must be answered in "layman 's"
language. By explaining the detai ls of the
procedure, the technologist can help al le­
viate fears and solicit cooperation from
the patient. It is important to explain the
steps in the procedure, its expected dura­
tion, and any l i mitations or restrictions as­
sociated with its performance. The patient
may have heard an inaccurate "horror"
story about the procedure from a neighbor
or friend. Therefore the technologist may
need to correct misconceptions and pro­
vide accurate information.
For simple procedures the patient mu t
be reassured that the procedure is rela­
tively straightforward and causes only
slight discomfort. For more complex and
longer procedures, the technologist must
gain the patient's cooperation by provid­
ing appropriate, factual information and
offering upport. The patient should never
be told that insertion of the needle used in
venipuncture does not hurt. After all, a
foreign object is going to be inserted
through the patient's skin, which has a
myriad of nerves that will be aggravated
by insertion of a needle. The technologist
must tell the truth and explain that the
amount of pain experienced varies with
each patient. 2
'IV therapy: skillbuilders, Springhouse, Penn, 1 99 1 ,
Springhouse.
2Hoeltke L: The complete textbook of phlebotomy,
Albany, N Y, 1 994, Delmar.
239
 TABLE 18-1
Common medications utilized in an imaging department
Brand Generic Adverse
Name Name Indications Action Reactions
Demerol meperidine Mild to moderate pain Binds with opiate recep- Seizures, cardiac arrest.
How supplied hydrochloride Adjunct to anesthesia tors of the CNS shock, respiratory
Tablets, syrup, depression
injection

Morphine morphine sulfate Severe pain Binds with opiate recep- Bradycardia, shock, car-
How supplied: tors of the CNS diac arrest. apnea,
Tablets, syrup, respiratory depression,
oral suspension, respiratory arrest
injection

Versed midazolam Preoperative sedation Unknown, thought to de- Apnea, depressed respl-
How supplied: hydrochloride (to induce sleepiness press CNS at the limbic ratory rate, nausea,
Injection or drowsiness and re- and subcortical levels vomiting, hiccups,
lieve apprehension) pain at injection site

Valium diazepam Anxiety Unknown, probably de- Cardiovascular col-

How supplied: presses the CNS at the lapse, bradycardia,
Tablets, capsules, limbic and subcortical respiratory depression,
oral solutions, levels acute withdrawal
Injections syndrome

Noctec chloral hydrate Sedation Unknown, sedative effects Drowsiness, nightmares,

How supplied: may be caused by its hallucinations, nau-
Capsules, syrup, primary metabolite sea, vomiting, diarrhea
suppositories

Glucagon glucagon Hypoglycemia Raises blood glucose Bronchospasm, hy-

How supplied: level by promoting potension, nausea,
Injection catalytic depolymer- vomiting
ization of hepatiC
glycogen to glucose

Phenegran promethazine Nausea, sedation Competes with histamine Dry mouth

How supplied: hydrochloride for special receptors
Tablets, syrup, on effector cells.
injection, Prevents, but does not
suppositories reverse histamine me-
diated responses
V lstarll hydroxyzine Nausea and vomiting, Unknown, actions may Dry mouth, dyspnea,
How supplied: hydrochloride anxiety, preoperative be due to a suppres- wheezing, chest
Tablets, syrup, and postoperative sion of activity In key tightness
capsules, adjunctive therapy regions of the subcorti-
injection cal area of the CNS

Benadryl diphenhydramine Allergic reactions, Competes with histamine Seizures, sleepiness, in-
How supplied: hydrochloride sedation for special receptors somnia, incoordina-
Tablets, capsules, on effector cells. tion, restlessness, nau-
elixir, syrup, Prevents, but does not sea, vomiting, diarrhea
injection reverse histamine me-
diated responses
Narcan naloxone Known or suspected Thought to displace pre- Seizures, pulmonary
How supplied: hydrochloride narcotic induced res- viously administered edema, ventricular
Injection piratory depression narcotic analgesiCS fibrillation
from their receptors

Data from Nursing 200 1 drug handbook, Springhouse, Penn., 2001 , Springhouse Corporation.

240

Interactions
May be incompatible when
mixed in the same IV container
In combination with other de-
pressants and narcotics use
with extreme caution
CNS depressants may increase
risk of apnea
Other CNS depressants
Alkaline solutions incompatible
with aqueous solutions of
chloral hydrate
Inhibits glucagon induced insulin
release
Increased effects when used
with other CNS depressants
Can increase CNS depression
Increased effects when used
with other CNS depressants
None reported
Effects on Diagnostic
Imaging Procedures Contraindications
None known Patients with hypersensitivity
to drug and in those who
have received MAO in-
hibitors within past 1 4 days
None known Patients with hypersensitivity
to drug or conditions that
would preclude adminis-
tration of IV oploids.
None known Patients with hypersensitivity
to drug, acute angle-
closure glaucoma, shock,
coma or acute alcohol
intoxication
May cause minor changes Patients with hypersensitivity
in EKG patterns to drug or soy protein,
shock, coma or acute al-
cohol intoxication
None known Patients with hepatic or re-
nal impairment. severe
cardiac disease or hyper-
sensitivity to drug
None known Patients with hypersensitivity
to drug or with pheochro-
mocytoma
Discontinue drug 48 hours Patients with hypersensitivity
before a myelogram be- to drug; intestinal obstruc-
cause of high risk of tion, prostatic hyperplasias
seizures
None known Hypersensitivity to drug, dur­
ing pregnancy, and in
breast-feeding women
None known Hypersensitivity to drug, dur­
ing acute asthmatic at­
tacks, and in newborns or
premature neonates and
breast-feeding women
None known Hypersensitivity to drug
Patient Care
Considerations
Give slowly by direct IV
injection. Oral dose is
less than half as effec-
tive as parental dose.
Compatible with most IV
solutions
Use with extreme cau-
tion in patients with
head injuries, In-
creased intracranial
pressure or elderly
Use cautiosuly in patients
with uncompensated
acute illness and in el-
derly. Before adminis-
tering have emer-
gency resuscitation
equipment available
Monitor respirations and
before administering
have emergency re-
suscitation equipment
available
Note two strengths of
oral liquid form. Double
check dose especially
when administering to
children
Arouse patient from
coma as quickly as
possible and give ad-
ditional carbohydrates
orally to prevent sec-
ondary hypoglycemic
reactions
Do not administer
subcutaneously
If used in conjunction
with other CNS
Medication observe
for over sedation
Use with extreme cau­
tion in patients with
angle-closure glau­
coma, asthma, CO PO
Use cautiously in patients
with cardiac irritability
and opiate addiction
24 1
 Patient Assessment
The patient must be assessed before any
medication is administered. Information
about a history of allergy must be ob­
tained and documented. It is essential to
determine whether the patient has any
known al lergies to foods, medication , en­
vironmental agents, or other substances.
Before venipuncture is performed, the
technologist needs to be aware of the po­
tential for an al lergic reaction to the iodine
tincture used in puncture site preparation
or an adver e reaction to the medication
being injected.
Other assessment criteria include the
patient's current medications. Knowledge
of ome common medication actions can
help the radiologic technologist evaluate
changes in a patient's condition during a
procedure. Certain diabetic medications
interact adversely with contrast media.
Therefore assessment of the i nteraction of
medications must be evaluated prior to the
performance of the procedure.
During the physical evaluation, it is im­
portant to determine whether the patient
has prev iously undergone surgical proce­
dure that might affect site selection for
venipuncture, such as a mastectomy with
resultant compromi ed lymph nodes and
vascular abnormal ities. To determine the
appropriate type and amount of medica­
tion to be administered, the physician re­
quires information about the patient's past
and current di ease processes, such a hy­
perten ion and renal disease. Evaluation
of the BUN level (average range: 1 0 to 20
mg/dl) and the creatinine level (average
range: 0.05 to 1 .2 mg/dl) should be in­
cluded as assessment criteria.
Fig. 1 8-82 Plastic disposable syringes.
242
I nfection Control
Each time the body system is entered, the
potential for contamination exists. ' Strict
aseptic techniques and universal precau­
tions must always be used when medica­
tions are administered with a needle. 2 If a
medication is injected incorrectly, a mi­
croorganism may enter the body and
cause an infection or other complications.
The Centers for Disease Control and
Prevention have developed pecific guide­
li nes to prevent the transmission of infec­
tions during the preparation and adminis­
tration of medications. These guidelines
are part of the Standard Precautions used
by every health care facility and strict ad­
herence to the guidelines must be fol­
lowed by the technologist during the per­
formance of radiologic procedures.
Studies using IV filters have shown a
significant reduction in infusion phlebitis.
Filters are devices located within the tub­
ing used for IV administration. Filters pre­
vent the injection of particulate and mi­
crobial matter into the circulatory system.
The use of a fi lter for a bolus injection re­
duces the rate at which the medication can
be injected. In addition, the viscosity of a
medication may determine whether a fi lter
is used and the rate of injection. Although
a filter helps in reducing the possibility of
bacteria being introduced into the blood,
its use creates additional factors of risks
versus benefits. The physician or health
care facility should have policies to ad­
dress these issues.
'Smith S, Duell: Clillica/ nursing skills basic 10 ad­
vanced skills, ed 4, Stanford, Conn., 1 996, Appleton
& Lange.
2Adler AM, Carlton RR: Introduction to radiography
and patiellt care, Philadelphia, 1 994, WB Saunders.
Fig. 1 8-83 Types of needles: over-the-cannula needle, or angio­
catheter (bottom), a hypodermic needle (center). and metal
butterfly needle (top).
Venipuncture Supplies
and Equipment
NEEDLES AND SYRINGES
The technologist assembles the proper sy­
ringe and needle for the planned i njection.
The syringe may be glass or plastic. Plastic
syringes are disposed of after only one
use; glass syringes may be cleaned and
must be steril ized before they are used
again. The syringe has three parts: the tip,
where the needle attaches to the syringe;
the barrel, which includes the calibration
marki ngs; and the plunger, which fit
snugly i nside the barrel and allows the user
to instill the medication (Fig. 1 8-82). The
tip of the syringe for an rv injection has a
locking device to hold the needle secure.
The size of the syringe depends on the vol­
ume of material to be injected. The tech­
nologist should select the next-larger size
of syringe than the volume de ired. This
larger syringe assists in the accuracy of the
dose by allowing the total amount of med­
ication to be drawn into one syringe.
A ll needles used in venipuncture are
disposable and are used only once.
During the preparation and administration
of contrast media, the technologist uses
several types of needles, including a hy­
podermic needle, a butterfly set, and an
over-the-needle cannula (Fig. 1 8-83).
 Hypodermic needles vary in both gauge If the medication is supplied in a bottle on the syringe is inserted into the rubber
and length ( ee Fig. 1 8-83). Needle gauge or vial, the preparation procedure has sev­ stopper, all the way to the hub of the nee­
refers to the diameter of the needle bore, eral variations. First, the solution must be dle. Then the vial is inverted by placing
with the gauge increasing as the diameter evaluated for contamination. Then the the end of the needle above the fluid level
of the bore decrease . An 1 8-gauge needle protective cap is removed, with care taken in the bottle (Fig. 1 8-84). Next a small
is larger than a 22-gauge needle and de­ not to contaminate the underlying surface. amount of air is slowly injected into the
livers a given volume of fl uid more Containers have rubber stoppers through vial above the level of the fl uid. This tech­
rapidly. The length of a needle is mea­ which a hypodermic needle can be in­ nique helps decrease air bubbles in the so­
sured in inches and may vary from � inch serted. If a single-dose vial is being used, lution. After the air has been injected, the
( used for intradermal injections) to 412 and no contamination has occulTed, the vial and syringe are held inverted and per­
inches (used for intrathecal [spinal] injec­ rubber stopper requires no additional pendicular to a horizontal plane, and the
tions). As a general rule, needles I to 1 1/2 cleansing. M u l ti ple-dose vial stoppers tip of the needle is pulled below the fluid
inches long are most commonly used for must be cleaned with an alcohol wipe. level. The desired amount of medication is
IV injections. The needle has three parts: For a closed system to be maintained, aspirated into the syringe by pulling down
the hub, which is the part that attaches to and reduce the chance of possible infec­ on the plunger of the syringe. The above
the syringe; the cannula or shaft. which is tion, a volume of air equal to the amount procedure may have to be repeated several
the length of the needle; and the bevel, of desired fl uid must be injected into the times to get all of the medication out. I f
which is the slanted portion of the needle bottle. The plunger of the syringe is pul led air bubbles cling t o the syringe casing, the
tip. Needles should be visually examined back to the level of the desired amount of syringe may be lightly tapped to release
before and after use to determi ne whether medication. The shaft of the plunger must them. A one-handed method is used to re­
any structural defects. such as non beveled not be contaminated at any time during cap the syringe (Fig. 1 8-85).
points or bent shafts, are present. 1 preparation of the medication. The needle
Butterfly sets or angio catheters are
preferable to a conventional hypodermic
needle for most radiographic IV therapies.
The butterfly set con i ts of a stainless­
steel needle with plastic appendages on
either side and approximately 6 inches of
plastic tubi ng that ends with a connector.
The plastic appendages, often cal led
wi ngs, aid in inserting the needle and sta­
bilization of the needle once venous pa­
tency has been confirmed.
The over-the-needle cannula is a device
in which, once the venipuncture is made,
the catheter is sli pped off the needle into
the vein and the steel needle is removed.
This type of needle is recommended for
long-term therapy or for rapid infusions.
Fig. 1 8-84 Place the tip of the needle
The choice of needle should be based on
above the level of fluid before injection of
the assessment of the patient, institutional
air to decrease air bubbles in the solution.
policy and the technologist's preference.

MEDICATION PREPARATION
Although TV offers the most i mmediate
results in terms of effect, certain safety
precautions must be followed. The tech­
nologist must identify the correct patient
before medication is administered. During
preparation and again before administra­
tion, the medication in the container also
must be verified.

'Strasinger S. DiLorenzo M: Phlebotomy workbook for

the multiskilled healthcare professional, Philadelphia,
1 996, FA Davis.

Fig. 1 8-85 When recapping a syringe. use a one-handed method.

243
 Preparation of an infusion from a glass
bottle or plastic bag begins with the iden­
tification and verification of the solution
and its expiration date ( Fig. 1 8-86). The
solution should not contain any visible
particles. The tubing used for the infusion
is determined by the method of injection
and the type of container. Electronic infu­
sion devices require different tubing than
gravity infusion devices. A glass container
necessitates a vented tubing ( Fig. 1 8-87),
whereas a plastic container requires a
nonvented tubing ( Fig. 1 8-88).
Fig. 1 8-86 Identify the correct solution and
expiration date.
Fig. 1 8-87 A vented tubing is required for
glass bottle containers.
244
To prepare for drip infusion of a med­
ication, the technologist removes the tub­
ing from the sterile package and closes the
clamp (Fig. 1 8-89). Failure to close the
clamp may result in loss of the vacuum in
the solution container. The protective cov­
erings are removed from the port of the so­
lution and the tubing spike. Then the fill
chamber of the tubing is squeezed, and the
spike is inserted into the solution. The so­
l ution is then inverted and the chamber is
released. The solution shoul d fi l l the
chamber to the measurement line. The tub­
ing is primed by opening the clamp, which
allows the solution to travel the length of
the tubing, expelling any air. The tube is
fi lled with solution, the clamp is closed,
and the protective covering is secured. The
solution is then ready for administration.
Fig. 1 8-88 Solutions in plastic bags require
a nonvented tubing.
Fig. 1 8-89 Close the tubing clamp before
inserting the spike into a container of
solution.
Procedure
SITE SE LECTION
Selection of an appropriate vein for
venipuncture is critical. Finding the vein
is sometimes difficult, and the most visi­
ble veins are not always the best choice . '
Technologists administer IV medication
and contrast media v ia the venous system.
Therefore, if a pulse is palpated during as-
essment for a puncture site, that vessel
must not be used because it is an artery!
The prime factors to consider in selecting
a vein are ( I ) suitability of location, (2)
condition of the vein, (3) purpose of the
infusion, and (4) duration of therapy. The
veins most often used in establishing IV
access are found on the anterior forearm,
posterior hand, radial aspect of the wrist,
and antecubital space on the anterior sur­
face of the elbow ( Fig. 1 8-90).
A general rule is to select the most dis­
tal site that can accept the desired-size
needle and tolerate the injection rate and
solution. Although the veins located at the
antecubital space may be the most acces­
sible, largest, and easiest to puncture, they
may not be the best choice. Because of
their convenient location, these site may
be overused and can become scarred or
sclerotic. Antecubital accesses are located
over an area of joint flexion; therefore any
motion can di slodge the cannula and
cause infiltration or result in mechanical
phlebitis. A flexible IV catheter is the nee­
dle of choice for placement of a venous
access in the antecubital space. The pa­
tient's arm should be immobil ized to in­
hibit the ability to flex the elbow.
' S teele J: Practical IV therapy, Springhouse, Penn.,
1 988, Springhouse.
 The condition of the vein must also be
considered in the selection of an appropri­
ate puncture site. The selected vein must be
able to tolerate the needed or desired can­
nula size. The vein should have resilience
qualities and be anchored by surrounding Superficial
supportive tissues to prevent rolling. Dorsal dorsal veins
Another consideration in vein selection venous ������ Posterior
is the rate of flow required for the proce­ arch Right Hand
dure and the viscosity and amount of med­
Basilic
ication to be administered. Because the vein
purpose of the infusion determines the rate
of flow, the solution to be i nfused should
be evaluated during the site selection
process. Larger veins should be selected
for infusions of large quantities or for
rapid infusions. Large veins are also used
for the infusion of highly viscous solutions
or those that are irritating to vessels. I
The expected duration of the therapy
and the patient's comfort are other factors
that must be considered in selecting a
venipuncture site. If a prolonged course of
therapy is anticipated, areas over flexion
j oints should be avoided, and the dorsal
surfaces of the upper l imbs should be
carefu l ly exami ned. Venous access i n
these locations w i l l provide more freedom
Anterior
and comfort to the patient. Right Forearm

' Adler AM, Carlton RR: Introduction to radiography

Basilic
alld patient care, Philadelphia, 1 994, WB Saunders. vein
Median vein
of forearm

Median
1-....:u,
:!IIIIl I/-- cubital
vein
Cephalic
Basilic vein
vein

Fig. 1 8-90 Veins easily accessible for venipuncture.

245
 SITE PREPARATION
The skin's surface must be prepared and
cleaned. If the area selected for venipunc­
ture i hairy, the hair should be clipped to
permit better cleansing of the kin and vi-
ualization of the vein . This will also
make removal of the cannula less painful
when the infusion is terminated. Shaving
i not recommended. The skin is cleansed
with an antiseptic, which should remain in
contact with the skin for at least 30 sec­
onds. The preferred solution is iodine
ti ncture I % to 2%. I sopropyl alcohol 70%
i recommended if the patient is sensitive
to iodine. The skin should be cleaned in a
circular motion from the center of the in­
jection site to approximately a 2-inch clr­
cle. Once the swab has been placed on the
skin, it should not be lifted from the sur­
face until the cleansing process is com­
plete (Fig. 1 8-9 1 ).
Many facil ities have a policy that pro­
vides the patient an opportunity to request
a local anesthetic for IV infusion catheter
placement. This technique reduces the
pai n felt by the patient duri ng insertion of
an angiocatheter or needle. The local
anesthetic can be administered topically
or by injection.
Fig. 1 8·91 Prepare the site for venipuncture.
246
A facil ity's procedure for local anes­
thetic determines the pecific criteria for
that i nstitution. Commonly accepted
guidelines are as fol lows: First 0. 1 to 0.2
ml of I % lidocaine without epinephrine or
sterile sal ine is prepared in a tuberculin or
insulin syringe with a 23- to 25-gauge
needle. The site for injection is selected
and prepared. Then the anesthetic is in­
jected subcutaneously (beneath the skin,
into the soft tis ue) or intradermally (im­
mediately under the skin in the dermal
layer) at the venipuncture site. Topical
anesthesia is achieved by applying 5 g of
eutectic mi xture of local anesthetics
cream and covering the area with an oc­
clusive dressing. Maximum effects are
achieved in 45 to 60 minutes.
The medication to be injected should
already be prepared, and any tubing
should be primed with the solution to pre­
vent injection of any air i nto the vascular
system.
Fig. 1 8·92 Put on clean gloves.
VENI PUNCTURE
After the solution has been prepared, the
site selected, and the type of syringe and
needle to be used has been determined,
the technologist is ready to perform the
venipuncture.
Techniques for venipuncture follow one
of two cour es: ( I ) the direct, or one-step,
entry method or (2) the indirect method.
The direct, or one-step, method is per­
formed by thrusting the cannula through
the skin and i nto the vein in one quick mo­
tion. The needle and cannula enter the
skin directly over the vein. This technique
is excellent as long as large veins are
avai lable. ' The indirect method is a two­
step technique. First, the over-the-needle
cannula is i nserted through the skin adja­
cent to or below the point where the vein
is vi ible. The cannula is then advanced
and maneuvered to pierce the vein. For the
actual venipuncture procedure, the tech­
nologist washes the hands. The patient is
identified. Next the technologist instructs
the patient about the procedure. The tech­
nologist performs the fol lowing teps:
I . The technologist puts on gloves and
cleans the area in accordance with fa­
cil ity protocol (Fig. 1 8-92).
' Plumer AL: Principles and practice of illlravellOIlS
therapy, ed 4, Boston, 1 987, Little, Brown.
Fig. 1 8·93 Apply the tourniquet 6 to 8
inches above the intended venipuncture
site, with its free end directed superiorly.
 2. A local anesthetic is administered ac­
cording to facility policy (optional).
3 . A tourniquet is placed 6 to 8 i nches
above the intended site of puncture.
The tourniquet should be tight enough
to distend the vessels but not occlude
them. The loose ends of the tourniquet
should be placed away from the injec­
tion site to prevent contamination of
the aseptic area (Fig. 1 8-93).
Fig. 1 8-94 Stabilize the vein and enter the
skin with the needle at a 45-degree angle.
Fig. 1 8-95 Release the tourniquet after the
venous access has been obtained. Do not
permit tourniquet to touch needle.
4. The technologist holds the patient's
l i mb with the nondominant hand, us­
i ng that thumb to stabil ize and anchor
the selected vein. The best method of
accessing the vein-direct or indirect
technique-is then determined.
5. Using the dominant hand, the technol­
ogist places the needle bevel up at a 45-
degree angle to the skin's surface. The
bevel-up position produces less trauma
to the skin and vein (Fig. 1 8-94).
7. Once the vein is punctured and a
8. Release the tourniquet (Fig. 1 8-95 ).
9. I f a backftow of blood does not occur,
Fig. 1 8-96 Anchor the needle with tape to
secure placement.
1 0. Anchor the needle with tape and a
Fig. 1 8-97 Administer the medication.
6. The technologist uses a quick, sharp
darting motion to enter the skin with
the needle. Upon entering the kin,
the technologist decreases the angle
of the needle to I S degrees from the
long axis of the vessel. Using an indi­
rect method, the technologist slowly
proceeds with a downward motion on
the hub or wings of the needle; raising
the point of the needle, the technolo­
gist advances the needle parallel and
then punctures the vein. The needle
may have to be maneuvered sl ightly
to facilitate actual venous puncture. If
the direct method of access is used,
the needle is placed on the skin di­
rectly over the vein, and entry into the
vein is accomplished in one move­
ment of the needle through the skin
and vein. Once the vein is entered, a
backftow of blood may occur-this
indicates a successful venipuncture.
blood return is noted, the cannula is
advanced cautiously up the lumen of
the vessel for approximately % inch.
verify venous access before injecting
the medication. Aspiration of blood
directly into the syringe of medication
verifies placement before injecting.
Another method of placement verifi­
cation is to attach a syringe of normal
saline to the hub of the needle before
aspirating for blood. The advantage of
this method is that only saline, an iso­
tonic solution, is injected if the needle
is not in place and extravasation oc­
curs. A successful venipuncture does
not guarantee a successful injection. If
a bolus injection is desired, the tourni­
quet may not be released until the in­
jection has been completed. If this
technique i s used, the protocol must
be i ncluded in the facility 's policies
and procedures.
dressing, as required by policy (Fig.
1 8-96). Then administer the medica­
tion (Fig. 1 8-97) .
247
 With experience, a technologist's fingers
become sensitive to the sensation of the
needle entering the vein-the resistance en­
countered as the needle penetrates the wall
of the vein and the "pop" felt at the loss of
re istance as the cannula enter the lumen.
If both walls of the vein are punctured with
a needle, the vessel develops a hematoma.
The cannula should be removed immedi­
ately, and direct pressure should be applied
to the puncture site. If a venipuncture at­
tempt is unsuccessful with an over-the­
needle cannula and the needle has been re­
moved from the cannula, the needle should
not be reinserted into the catheter. Reinsert­
ing the needle into the cannula can sheer a
portion of the catheter.
Fig. 1 8-98 Remove the IV access.
248
ADMINISTRATION
The technologist should administer the
medication and/or contrast medium at the
established rate. During the injection
process, the injection site should be ob­
served and palpated proximal to the punc­
ture for signs of infiltration. An infiltration,
or extravasation, is a process whereby a fluid
passes into the tissue instead of the vein.
A patient may have a venous access that
was established before the radiologic pro­
cedure. A careful assessment of site and
medication compatibility must be per­
formed before the existing IV line can be
used. (Compatability is the abi lity of one
medication to mix with another.) Special
precautions should be taken with a patient
who is currently receiving cardiac, blood
pressure, heparin, or diabetes medications.
The physician, nur e, or pharmacist should
be consulted before medication is adminis­
tered to such a patient. Verification must
be obtained to ensure that the medication
being infused through the established IV
l i ne is compatible with the contrast
medium to be administered. Before the
contrast medium is injected, the infu ion
should be stopped and the line should be
fl ushed with normal saline through the
port nearest the insertion site. The contrast
medium is then administered, and the line
is fl ushed again with normal saline. The
amount of normal saline used depend on
the facility's policies and procedures. Once
Fig. 1 8-99 Discard needles in puncture­
resistant containers.
the contrast medium has been adminis­
tered, the r v infusion solution is restarted.
Heparin or saline locks allow intermit­
tent injections through a port. The port is
a smal l adapter with an access that is at­
tached to an IV catheter when more than
one injection is anticipated. I As deter­
mined by procedure criteria, the cannula
is flushed with heparin and saline to main­
tain patency during dormant periods.
The patency (open, unobstructed flow) of
the intermittent device is verified by aspirat­
ing blood and injecting normal saline with­
out infiltration. Then, the medication is ad­
ministered. Finally, the medication is flushed
through the device with saline. Depending
on protocols, the device may then be flushed
with heparin or normal saline.
After the medication has been adminis­
tered and the radiologic procedure has
been completed, the venous access may
be discontinued. The radiologic technolo­
gist should carefully remove any tape or
protective dressing covering the puncture
site. Using a 2 X 2-inch gauze pad at the
injection site, the technologist then re­
moves the needle by pulling it straight
from the vein. Direct pressure on the site
is applied with the gauze only after the
needle has been removed (Fig. 1 8-98).
The technologist then puts the contami­
nated gloves, needles, and gauze in appro­
priate di posal containers (Fig. 1 8-99).
' Ehrlich R, McCloskey E D : Patient care i/l radiog­
raphy, ed 4, St Louis, 1 994, Mosby.
Reactions
and Complications
Any medication has the potential to be
harmful if it is not administered properly. '
Technologists mu t be aware of possible
untoward medication reactions and be able
to recognize and report signs and symp­
toms of side effects as they occur. 2 The
technologist who prepares a medication
should also perform the administration.
Reactions can be mild, moderate, or se­
vere. M i ld reactions can include a sensa­
tion of warmth, a metallic taste, or sneez­
ing. Moderate reactions can manifest as
nausea, vomiting, or itching. Finally, a se­
vere, or anaphylactic, reaction can cause a
respiratory or cardiac crisis. The treatment
for each category of reaction should be es­
tablished in the procedures of each facility
or department. The role of the radiologic
technologist in the case of a reaction
should also be defined in the e documents.
Competent professional standards of prac­
tice for the technologist include monitoring
the patient's vital signs before, during, and
after the injection of a contrast medium or
certain types of medications. The specific
monitoring criteria should be established
by institutional policy. Therefore, if an un­
toward event should occur, responding per­
sonnel will have access to important infor­
mation about the patient's condition before
the event occurred.
Every health care provider should be fa­
miliar with emergency procedures in the
work environment. Emergency crash carts
contain many medications and pieces of
equipment that require regular review.
Proficiency in the operation of equipment
and the admini stration of medications
must be maintained. The technologist
must have the knowledge, proficiency, and
confidence to manage crisis situations.
' Kowalczyk N, Donnett K: Integrated patient care
for the imaging professiollal, St Louis, 1 996, Mosby.
2Adler A M , Carlton RR: IllIrodllctioll to radiography
and patielll care, Phi ladelphia, 1 994, WB Saunders.
Infiltration is another complication as­
sociated with the administration of con­
trast media or medications. This complica­
tion occurs when the medication or
contrast material enters the soft tissue in­
stead of the vei n . ' Signs of infiltration are
swelling, redness, burning, and pain. The
most common cause of extravasation is
needle displacement. If infiltration occurs,
the procedure should be stopped immedi­
ately and the venous access discontinued.
The physician must be notified, and spe­
cific treatment instructions must be re­
quested. Common therapies for infiltration
are ( I ) the application of ice if less than 30
minutes have passed since the infiltration
occurred or (2) the application of warm,
wet compresses if the i nfiltration occurred
more than 30 minutes previously. '
Docu mentation
In the administration of any medication,
the radiologic technologist should always
observe five "rights of medication admin­
istration":
• The right patient
• The right medication
• The right route
• The right amount
• The right lime
The right patient must receive the med­
ication. The identity of the patient must be
confirmed before the medication is ad­
ministered. Methods of patient identifica­
tion include checking the patient's wrist­
band and having the patient to restate his
or her name. If the patient is unable to
speak, seek assistance in identifying the
patient from a family member or signifi­
cant other. Ensuring that the right medica­
tion is administered requires that the name
of the medication be verified at least three
times: during the selection process, during
the preparation, and immediately before
the administration. The amount of med­
ication is determined by the physician or
by departmental protocols. The right
route, right amount, and right time are de­
termined by the physician, the type of
medication, and the procedure.
'Tortorici M: Administration of imaging pharmaceu­
ticals, Philadelphia, 1 996, WB Saunders.
Documentation of the five rights of med­
ication administration is to be included in
every patient's permanent medical record. I n
addition to these five rights, the documenta­
tion should include the size, type, and loca­
tion of the needle; the number of venipunc­
ture attempts; and the identity of the health
care personnel who performed the proce­
dure. Information about how the patient re­
sponded to the procedure should also be
documented. The following is an example
of correct documentation techniques for a
technologist performing venipuncture and
administering a medication:
4- 1 5-99 at 0900 a venous access on Mr. John
Q Public was performed using an 1 8-gauge an­
giocatheter. The access was established in the
dorsum of the left hand after one attempt. Then
1 00 ml of (the specific name of the medica­
tion) was administered by IV push via the ac­
cess. The patient tolerated the injection proce­
dure and medication without complaints of
pain or discomfort and with no unexpected
side effects. (Sandy R. Ray, R .T.)
The objective of medication therapy and
administration is to provide the maximum
benefit to the patient with the minimum
harm. Medications are intended to help
maintain health, treat or prevent disease, re­
lieve symptoms, alter body processes, and
diagnose disease. Unfortunately, all med­
ications are not ideal in their effects on the
human body. It is important that health care
providers understand their role and respon­
sibilities in the administration of medica­
tions. Because the medications used by the
radiologic technologist are less than perfect,
caution for the patient's well-being and skill
in the administration of the medications is a
priority. Patients have the right to expect
that the personnel who administer medica­
tions are informed about dosages, actions,
indications, adverse reactions, interactions,
contraindications, and special considera­
tions. Education, training, licensing, and
experience are critical in establishing com­
petency in this area of practice.
249
19

OUTLINE
 SUM MARY OF PROJ E CTIONS

P ROJECTIONS, POSITIONS, & M ETHODS

Page Essential Anatomy Projection Position Method
260 Hysterosalpingography AP. lateral, axial, oblique
267 Abdomen: pelvimetry AP COLCHER-SUSSMAN
268 Abdomen: pelvimetry Lateral R or L COLCHER-SUSSMAN
270 Seminal ducts AP or AP oblique

Icons In the Essential column indicate projections frequently performed in the United States and Canada. Students should be competent
In these projections
 ANATO MY
Female Reproductive
System
The female reproductive system consists
of an internal and an external group of or­
gans, with the two groups connected by
the vaginal canal. This chapter does not
address the anatomy of the external geni­
talia because those structures do not re­
quire radiographic demonstration. The in­
ternal genital organs consist of the female
gonads, or ovaries, which are two glandu­
lar bodies homologous to the male testes,
and a system of canals made up of the
uterine tubes, uterus, and vagina.
OVARIES
The two ovaries are small , glandular or­
gans with an internal secretion that con­
trols the menstrual cycle and an external
secretion containing the ova, or female re­
productive cells (Fig. 1 9- 1 ). Each ovary is
shaped approximately like an almond. The
Primary ovarian follicles
Fig. 1 9- 1 Section of an ovary.
�
Cavity of uterus ;;;���j����iiiA!i!���
Fig. 1 9-2 Section of left uterine tube.
ovaries l ie one on each side, inferior and
posterior to the uterine tube and near the
lateral wall of the pelvis. They are attached
to the posterior surface of the broad liga­
ment of the uterus by the mesovarium.
The ovary has a core of vascular tissue,
the medulla, and an outer portion of glan­
dular tissue termed the cortex. The cortex
contains ovarian follicles in all stages of
development, and each follicle contains
one ovum. A fully developed ovarian fol­
l icle is referred to as a graafianfollicle. As
the minute ovum matures, the size of the
fol licle and its fluid content increase so
that the wall of the fol licle's sac ap­
proaches the surface of the ovary and in
time ruptures, liberating the ovum and fol­
licular fl uid into the peritoneal cavity.
Extrusion of an ovum by the rupture of a
fol licle is called ovulation and usually oc­
curs one time during the menstrual cycle.
Once the ovum is in the pelvic cavity, it is
drawn toward the uterine tube.
Graafian follicle
Ampulla
Fimbriae
i "�.:.
UTERINE TUBES
The two uterine tubes, or fallopian tubes,
arise from the lateral angle of the uterus,
pass laterally above the ovaries, and open
into the peritoneal cavity. These tubes col­
lect ova released by the ovaries and convey
the cells to the uterine cavity. Each tube is
3 to 5 inches (7.6 to 1 3 cm) in length (Fig.
1 9-2) and has a small diameter at its uter­
ine end, which opens into the cavity of the
uterus by a minute orifice. The tube itself is
divided into three parts: the isthmus, the
ampulla, and the infundibulum. The isth­
mus is a short segment near the uterus. The
ampulla makes up most of the tube and is
wider than the isthmus. The terminal and
lateral portion of the tube is the infundibu­
lum and is flared in appearance. The in­
fundibulum ends in a series of irregular
prolonged processes called fimbriae. One
of the fimbriae is attached either to or near
the ovary.
The mucosal lining of the uterine tube
contains hairlike projections called cilia.
The lining is arranged in folds that in­
crease in number and complexity as they
approach the fimbriated extremity of the
tube. The cilia draw the ovum into the
tube, which then conveys it to the uterine
cavity by peristaltic movements. The pas­
sage of the ovum through the tube re­
quires several days. Fertilization of the
cel l occurs in the outer part of the tube,
and the fertilized ovum then migrates to
the uterus for implantation.
253
 UTERUS
The uterus is a pear-shaped, muscular or­
gan (Figs. 1 9-3 and 1 9-4). Its primary
functions are to receive and retain the fer­
til ized ovum until development of the fe­
tus is complete and, when the fetus is ma­
ture, to expel it during birth.
The uterus consists of four parts: the
fundus, body, isthmus, and cervix. The
fundus is the bluntly rounded superior
most portion of the uterus. The body nar­
rows from the fundus to the isthmus and is
the point of attachment for the ligaments
that secure the uteru within the pelvis.
The isthmus (superior part of the cervix), a
constricted area between the body and the
cervix, is approximately Y2 inch ( 1 .3 cm)
long. The cervix is the cylindric vaginal
end of the uterus and is approximately I
inch (2.5 cm) long. The vagina is attached
around the circumference of the cervix.
Round ligament
Uterine tube
Fig. 1 9-3 Superoposterior view of uterus, ovaries, and uterine
tubes.
Uterine tube (cut)
Fig. 1 9-4 Sagittal section showing relation of internal genitalia to surrounding
structures.
254
The nulliparous uterus ( i .e., the uterus
of a woman who has not given birth) is
approximately 3 inches (7.6 cm) in length,
almost half of which represents the length
of the cervix. The cervix is approximately
% inch ( 1 .9 cm) in diameter. During preg­
nancy the body of the uterus gradually ex­
pands into the abdominal cavity, reaching
the epigastric region in the eighth month.
Following parturition, the organ shrinks to
almost its original size but undergoes
characteristic changes in shape.
The uterus is situated in the central part
of the pelvic cavity, where it l ies posterior
and superior to the urinary bladder and
anterior to the rectal ampulla. The long
axis, which is slightly concave anteriorly,
is directed i nferiorly and posteriorly at a
near right angle to the axis of the vaginal
canal into which the lower end of the
cervix projects.
Fundus
Uterine tube
rinary bladder
The cavity of the body of the uterus, or
the uterine cavity proper, is triangular in
shape when viewed in the frontal plane.
The canal of the cervix is di lated in the
center and constricted at each extremity.
The proximal end of the canal is continu­
ous with the canal of the isthmus. The dis­
tal orifice is called the uterine ostium.
The mucosal l ining of the uterine cavity
is called the endometrium. Thi lining un­
dergoes cyclic changes, called the men­
strual cycle, at about 4-week intervals
from puberty to menopause. During each
premenstrual period the endometrium is
prepared for the implantation and nutri­
tion of the fertilized ovum. If fertilization
has not occurred, the menstrual flow of
blood and necrosed particles of uterine
muco a ensues.
VAGINA
The vagina is a muscular structure with
walls and a canal lying posterior to the
urinary bladder and urethra and anterior to
the rectum. Averaging about 3 inches (7.6
cm) in length, the vagina extends inferi­
orly and anteriorly from the uterus to the
exterior. The mucosa of the vagina is con­
tinuous with that of the uterus. The space
between the labia minora is known as the
vaginal vestibule and contains the vaginal
orifice and the urethral orifice.
FETAL DEVElOPMENT Placenta
During the implantation process, the fertil­
ized ovum, called a zygote, is passed from
the uterine tube into the uterine cavity,
where it adheres to and becomes embed­
ded in the uterine l ining. About 2 weeks
after fertilization of the ovum, the embryo
begins to appear. Nine weeks after fertil­
ization the embryo becomes a fetus and as­
sumes a human appearance (Fig. 1 9-5).
During the first 2 weeks of embryonic
development, the growing fertilized ovum
is pri marily concerned with the establ ish­
ment of its nutritive and protective cover­
ing, the chorion and the amnion. As the Urinary bladder
chorion develops, it forms ( I ) the outer
layer of the protective membranes enclos­
ing the embryo and (2) the embryonic
portion of the placenta, by which the um­
bil ical cord is attached to the mother's
uteru and through which food is supplied
to and waste is removed from the fetus.
The amnion, often refelTed to as the "bag
of water" by the laity, forms the inner Fig. 1 9-5 Sagittal section showing fetus of about 7 months of age.
layer of the fetal membrane and contains
amniotic fluid in which the fetus floats.
Following the birth, the uterine li ning is
expelled with the fetal membranes and the
placenta, constituting the afterbirth. A Lateral Central Posterior
new endometrium is then regenerated.
The fertilized ovum usually becomes
embedded near the fundus of the uterine
cavity, most frequently on the anterior or
posterior wal l . I mplantation occasionally
occurs so low, however, that the fully de­
veloped placenta encroaches on or ob­
structs the cervical canal. This condition
results in premature separation of the pla­
centa, termed placenta previa ( Fig. 1 9-6).

Fig. 1 9-6 Schematic drawings of several placental sites in low implantation.

255

Male Reproductive
System
The male genital system consists of the
fol lowi ng: a pair of male gonads, the
testes, which produce spermatozoa; two
excretory channels, the ductus deferens,
or vas deferens; the prostate; the ejacula­
tory ducts; the seminal vesicles; and a pair
of bulbourethral glands that produce e­
cretions which are added to the secretions
of the testes and ductal mucosa to consti­
tute the final product of seminal fl uid. The
penis, the scrotum, and the structures en­
closed by the scrotal sac (testes, epi­
didymides, spermatic cords, and part of
the ductus deferens) are the external geni­
tal organs.
SEMINAL VESICLES
The two seminal vesicles are sacculated
structures about 2 inches (5 cm) in length
(Fig. J 9-9). They are situated obliquely on
the lateroposterior surface of the bladder,
where, from the level of the ureterocystic
junction, each slants inferiorly and medi­
ally to the base of the prostate. Each am­
pulla of the ductus deferens l ies along the
medial border of the seminal vesicle to
form the ejaculatory duct.
EJACULATORY DUCTS
The ejaculatory ducts are formed by the
union of the ductus deferens and the duct
of the seminal vesicle. The ejaculatory
ducts average about Y2 inch ( 1 .3 cm) in
length and originate behind the neck of
the bladder. The two ducts enter the base
of the prostate and, passing obliquely in­
feriorly through the substance of the
gland, open into the prostatic urethra at
the lateral margins of the prostatic utricle.
These ducts eject sperm into the urethra
before ejaculation.

TESTES
The testes are ovoid bodies averagi ng
1 1/2 i nches ( 3 . 8 cm) i n length and about
Testicular artery
I inch ( 2 . 5 cm) in both width and depth
(Fig. 1 9-7). Each testis is divided i nto
Ductus
200 to 300 partial compartments that deferens
constitute the glandular substance of the
testis. Each compartment houses one or --"rt-- Head of epididymis
more convoluted, germ ce l l-producing Epididymis
Testis
tubules. These tubules in turn converge
and unite to form 1 5 to 20 ductules that
emerge from the testis to enter the head
of the epididymis. Fig. 1 9-7 Frontal section of testes and ductus deferens.
The epididymis is an oblong structure
that is attached to the superior and latero­
posterior aspects of the testis. The duc­
tules leading out of the testis enter the
head of the epididymis to become contin­
uous with the coiled and convoluted duc­ Sacrum --+f4.2f--r
tules that make up this structure. As the
ductules pass i nferiorly, they progres­
sively unite to form the main duct, which
is continuous with the ductus deferens.
[llpn�wn--7ff- Bladder
DUCTUS DEFE RENS
The ductus deferens is 1 6 to 1 8 inches (40 _�""'H- Pubis

to 45 cm) long, and extends from the tail Rectum --+---->,,>,----;r�<'<_

of the epididymis to the posteroinferior
surface of the urinary bladder. Only its
Prostate
first part is convoluted. From its beginning Urethra
the ductus deferens ascends along the me­
dial side of the epididymis on the poste­
rior surface of the testis to join the other
constituents of the spermatic cord, with
which it emerges from the scrotal sac and
passes into the pelvic cavity through the
i nguinal canal ( Fig. 1 9-8). Near its termi­ Fig. 1 9-8 Sagittal section showing male genital system.
nation the duct expands into an ampulla
for the storage of seminal fl uid and then
ends by uniting with the duct of the semi­
nal vesicle.

256
PROSTATE
The prostate, an accessory genital organ, is
a somewhat cone-shaped organ and aver­
aging I � inches (3.2 cm) in length. The
prostate encircles the proximal portion of
the male urethra and, extending from the
bladder neck to the pelvic floor, lies in front
of the rectal ampulla approximately I inch
(2.5 cm) posterior to the lower two thirds
of the pubic symphysis (see Fig. 1 9-9). The
prostate is composed of muscular and glan­
dular ti sue. The ducts of the prostate open
into the prostatic portion of the urethra.
A Prostate gland
Fig. 1 9-9 A, Sagittal section through male pelvis. B, Posterior view of male reproductive
organs.
Because of advances in diagnostic ul­
trasound imaging, radiographic examina­
tions of the male reproductive system are
performed less often than in the past. The
prostate can be ultrason ical ly i maged
through the urine-filled bladder or using a
special rectal transducer. The semi nal
ducts can be imaged when the rectum is
fi l led with an ultrasound gel and a special
rectal transducer is used. Testicular ultra­
sonic scans are performed to evaluate a
palpable mass or an enlarged testis and to
check for metastasis. The vast majority of
the testicular scans are performed because
of a palpable mass or an enlarged testis.
Urinary bladder
Ductus
deferens
_::;:.-...,..- Seminal vesicle duct
u.ilfS-7-+-+-- Ejaculatory duct
Penis
257
 SUMMARY OF ANATOMY*
Female reproductive Uterus Male reproductive
system fundus system
ovaries body testes
uterine tubes isthmus ductus deferens
uterus cervix (vas deferens)
vagina uterine ostium prostate
endometrium ejaculatory ducts
Ovaries seminal vesicles
ova Vagina bulbourethral glands
mesovarium mucosa penis
medulla vaginal vestibule scrotum
cortex vaginal orifice
ovarian follicles urethral orifice Testes
graafian follicle epididymis
ovulation Fetal development
zygote Ductus deferens
Uterine tubes embryo ampulla
(Fallopian tubes) fetus
isthmus placenta
ampulla
infundibulum
fimbriae
cilia

'See Addendum at the end of the volume for a summary of the changes in the anatomic
terms that were introduced in the 9th edition.

258
SUMMARY OF PATHOLOGY

Condition Definition

Adhesion Union of two surfaces that are normally separate

Endometrial Polyp Growth or mass protruding from the endometrium

Fallopian Tube Obstruction Condition preventing normal flow through the fallopian tube

Fistula Abnormal connection between two internal organs or between an organ and the body
surface

Tumor New tissue growth where cell proliferation is uncontrolled

Dermoid Cyst Tumor of the ovary filled with sebaceous material and hair

Uterine Fibroid Smooth-muscle tumor of the uterus

259
 Female Radiography
NON PREGNANT PATIENT
Radiologic investigation of the nonpreg­
nant uterus, accessory organs, and vagina
are denoted by the terms hysterosalpin­
gography, pelvic pneumography, and
vaginography. Each procedure requires
the use of a contrast medium and should
be carried out under aseptic conditions.
Hysterosalpingography i nvolves the intro­
duction of a radiopaque contrast medium
through a uterine cannula. The procedure
is performed to determine the size, shape,
and position of the uterus and uterine
tubes; to delineate lesions such as polyps,
submucous tumor masses, or fistulous
tracts; and to investigate the patency of the
uterine tubes in patients who have been
unable to conceive (Fig. 1 9- 1 0) .
Pelvic pneumography, which requires
the introduction of a gaseous contrast
medium directly into the peritoneal cavity,
is now rarely performed because of the de­
velopment of ultrasonic techniques for
evaluating the pelvic cavity. Vaginography
is performed to investigate congenital ab­
normalities, vaginal fistulae, and other
pathologic conditions involving the vagina.
Contrast media
Various opaque media are used in exami­
nations of the female genital passages.
The water-soluble contrast media em­
ployed for intravenous urography are
widely used for hysterosalpingography
and vaginography.
Preparation of intestinal tract
Preparation of the intestinal tract for any
of these examinations usually consists of
the fol lowing:
I . A non-gas-forming laxative is adminis­
tered on the preceding evening if the
patient is constipated.
2. Before reporting for the examination,
the patient receives cleansing enemas
until the return flow is clear.
3 . The meal preceding the examination is
withheld.
260
Appointment date
and care of patient
Gynecologic exami nations should be
scheduled approximately 1 0 days after the
onset of menstruation. This is the i nterval
during which the endometrium is least
congested. More importantly, because this
time interval is a few days before ovula­
tion normally occurs, there is little danger
of irradiating a recently fertilized ovum.
The relatively minor instrumentation
required for the introduction of contrast
medium in these examinations normally
necessitates neither hospital ization nor
premedication. Some patients experience
unpleasant but transitory aftereffects .
Therefore the radiology department
should have facilities for an outpatient to
rest in the recumbent position before re­
turning home.
The patient is requested to completely
empty her bladder immediately before the
exami nation. This procedure prevents
pressure displacement of and superimpo­
sition of the bladder on the pelvic geni­
talia. In addition, the patient's vagina is ir­
rigated just before the examination. At
this time the patient should be given the
necessary supplies and instructed to
cleanse the perineal region.
Fig. 1 9- 1 0 Hysterosalpingography reveals bilateral hydrosalpinx of uterine tubes (arrows).
The contrast-filled uterine cavity is normal (arrowheads).
Radiation protection
To deliver the least possible amount of ra­
diation to the gonads, the radiologist re-
tricts fl uoroscopy and i maging to the
minimum required for a satisfactory ex­
amination.
Hysterosalpingography
Hysterosalpingography is performed by a
physician with spot radiographs made
while the patient is in the supine position
on a fl uoroscopic table. The examination
may also be performed by the physician
with conventional radiographs obtained
using an overhead tube. When fluo­
roscopy is used, spot radiographs may be
the only i mages obtained. Preparing the
patient for the examination involves the
following steps:
• After irrigation of the vaginal canal,
complete emptying of the bladder, and
perineal cleansing, place the patient on
the examining table.
• Adjust the patient in the lithotomy po­
sition, with the knees flexed over leg
rests.
• When a combination table is used, ad­
just the patient's position to permit the
IRs to be centered to a point 2 i nches (5
cm) proxi mal to the pubic symphysis;
24 X 30 cm IRs are used for all studies
and are placed lengthwise.
 After inspection of the preliminary ra­
diograph and with a vaginal speculum i n
position, the physician inserts a uterine
cannula through the cervical canal, fits the
attached rubber plug, or acorn, firml y Uterine tube
against the external cervical 0 , applies
counterpressure with a tenaculum to pre­
vent reflux of the contrast medium, and Normol contrast 'spill"
into peritoneal cavity
withdraws the speculum unless it is radi­
olucent. An opaque or a gaseous contrast
medium may then be i njected via the can­
nula into the uterine cavity. The contrast
material flows through patent uterine Body of uterus
tubes and "spills" into the peritoneal cav­
ity (Figs. 1 9- 1 1 to 1 9- 1 3). Patency of the
uterine tubes can be determined by trans­ Speculum
uterine gas insufflation (Rubin test), but
the length, position, and course of the Fig. 1 9- 1 1 Hysterosalpingogram, AP projection, showing normal uterus and uterine tubes.
ducts can be demonstrated only by opaci­
fying the lumina.
The free-flowing, iodi nated organic
contrast agents are usuall y injected at
room temperature. These agents pass
through patent uterine tubes quickly, and
the resultant peritoneal spil l is absorbed
and eliminated by way of the urinary sys­
tem, usually within 2 hours or less.
The contrast medium may be i njected
with a pressometer or a syringe. I n tra­
uterine pressure is maintained for the ra­
diographjc studies by closing the cannu­
lar valve. In the absence of fl uoroscopy
the contrast medium is i ntroduced in two
to four fractional doses so that excessive
peritoneal spil lage does not occur. Each
fractional dose is fol lowed by a radio­
graphic study to determi ne whether the
fil li ng is adequate as shown by the peri­ Fig. 1 9- 1 2 Hysterosalpingogram, AP projection, showing submucous fibroid occupying entire
toneal spi l l . uterine cavity (arrowheads).
The radiographs may consist o f no
more than a single AP projection taken at
the end of each fractional injection. Other
projections (oblique, axial, and lateral) are
taken as indicated.

EVALUATION CRITERIA
The following should be clearly demon­
strated:
• The pelvic region 2 i nches (5 cm)
above the pubic symphysis centered on
the radiograph
• All contrast media visible, i ncluding
any "spill" areas
• A short scale of contrast on radiographs

Fig. 1 9- 1 3 Hysterosalpingogram, AP projection, revealing uterine cavity to be bicornate in

outline.

261

L-_---- Ovary
� Uterine tube
--- Round ligament
�--- Gaseous contrast medium
::;::====�� Urinary bladder
Fig. 1 9- 1 4 Normal pelvic pneumogram. (See Fig. 1 9-3 for correlation with radiograph.)
Fig. 1 9- 1 5 Vaginogram, spot rodiograph, PA oblique projection, LAO position. Sigmoid fis­
tula and two ileum fistulas are shown.
262
Pelvic pneumography
Pelvic pneumography, gynecography, and
pangynecography are the terms used to
denote radiologic examinations of the fe­
male pelvic organs by means of intraperi­
toneal gas i nsufflation (Fig. 1 9- 1 4). These
procedures have essentially been replaced
by ultrasonography and other diagnostic
techniques. ( Pelvic pneumography is de­
scribed in volume 3 of the fourth edition
of this atlas.)
Vaginography
Vaginography is used in the investigation
of congenital malformations and patho­
logic conditions such as vesicovagi nal and
enterovagi nal fistulas. The examination is
performed by introducing a contrast
medium into the vaginal canal . Lambie,
Rubin, and Dann' recommended the use
of a thin barium sulfate mixture for the in­
vestigation of fistulous communications
with the intestine. At the end of the exam­
ination the patient is instructed to expel as
much of the barium mixture as possible,
and the canal is then cleansed by vaginal
irrigation. For the i nvestigation of other
conditions, Coe2 advocated the use of an
iodinated organic compound.
A rectal retention tube is employed for
the introduction of the contrast medium so
that the moderately inflated balloon can be
used to prevent reflux. I n one technique,
the physician inserts only the tip of the tube
into the vaginal orifice. The patient is then
requested to extend the thighs and to hold
them in close approximation to keep the in­
flated balloon pressed firmly against the
vaginal entrance. In another technique, the
tube is inserted far enough to place the de­
flated balloon within the distal end of the
vagina, and the balloon is then inflated un­
der fluoroscopic observation. The barium
mixture is introduced with the usual enema
equipment. The water-soluble medium is
injected with a syringe.
Vaginography is performed on a combi­
nation fluoroscopic-radiographic table.
The contrast medium is i njected under flu­
oroscopic control, and spot radiographs
are exposed as indicated during the fi l ling
(Fig. 1 9- 1 5).
' Lambie RW, Rubin S , Dann D S : Demonstration of
fistulas by vaginography, AJR 90:7 1 7, 1 963 .
'Coe FO: Vaginography, AJR 90:72 1 , 1 963.
 The radiographs i n Figs. 1 9- \ 6, \ 9- 1 7,
and 1 9- 1 8 were taken with the central ray
directed perpendicular to the midpoint of
the IR. For localized studies, the central
ray is centered at the level of the superior
border of the pubic symphysis.
I n each examination the radiographic
projections required are determ ined by the
radiologist accordi ng to the fluoroscopic
findings. Low rectovaginal fistulas are
best shown i n the lateral projection, and
fistulous communications with the sig­
moid and/or i leum are best shown in
oblique projections.

EVALUATION CRITERIA
The following should be clearly demon­
strated:
• Superior border of the pubic symphysis
centered on the radiograph
• Any fistulas in their entirety
• Optimal density and contrast to visual­
ize the vagina and any fistula
• Pelvis on oblique projections not super­ Fig. 1 9- 1 6 Vaginogram, AP projection, showing small fistulous tract (arrow) projecting lat­
i mposed by the proximal thigh erally from apex of vagina and ending in abscess.
• Superimposed hips and femora in the
lateral i mage

Fig. 1 9- 1 7 Vaginogram, AP oblique projection, RPO position. Fistulas Fig. 1 9- 1 8 Vaginogram, lateral projection, showing low rectovagi­
to ileum and sigmoid are shown. nal fistula.

263
 PREGNANT PATIENT
Because ultrasonography provides visual­
ization of the fetus and placenta with no
apparent risk to the patient or fetus, it has
become the preferred diagnostic tool for
examination of the pregnant female. I n
some situations, however, certain radio­
logic examinations are sti l l indicated:
Fetography is the demonstration of the fe­
tus in utero. If possible, this examination
technique is avoided until after the eigh­
teenth week of gestation because of the
danger of radiation-induced fetal malfor­
mations. Fetography is employed to detect
su pected abnormalities of development,
to confirm su pected fetal death, to deter­
mine the presentation and position of the
fetus, and to determine whether the preg­
nancy is single or multiple.
Radiographic pelvimetry and fetal
cephalometry are performed to demon­
strate the architecture of the maternal
pelvis and to compare the size of the fetal
head with the size of the maternal bony
pelvic outlet. This purpose of the proce­
dure is to determine whether the pel vic di­
ameters are adequate for normal parturi­
tion or whether cesarean section i s
necessary for the delivery. Although many
techniques and combinations of tech­
niques are employed in radi ographic
pelvimetry, only a few of the body posi­
tions and pertinent technical factors are
included in this text.
Placentography is the radiographic ex­
ami nation in which the walls of the uterus
are investigated to locate the placenta in
cases of suspected placenta previa. At one
time radiographs were the only means
available to detect such conditions. With
advances in technology and the concern
over the dose of radiation received by the
fetus, diagnostic ultrasound (see Chapter
37) has become a valuable diagnostic tool
for placenta localization.
264
Radiation protection
Radiologic examinations of pregnant pa­
tients are performed only when required
information can be obtained in no other
way. In addition to the danger of genetic
changes that may result from reproductive
cell irradiation is the danger of radiation­
induced malformations of the developing
fetus. Whenever possible, radiation for any
purpose is avoided during pregnancy,
especially during the first trimester of ges­
tation. If examination of the abdomino­
pelvic region is necessary, it is restricted to
the absolute minimum number of radi­
ographs. The radiographer'S responsibility
is to carry out the work carefully and
thoughtfully so that repeat exposures are
not necessary.
Preparation of patient
Although it is desirable to clear the l arge
bowel of gas and fecal material with a
cleansing enema shortly before any radio­
logic examination, preliminary prepara­
tion depends on the condition of the pa­
tient. U nder no circu mstances is a
cleansing enema administered without the
express permission of the attending physi­
cian. The patient should completel y
empty the bladder i mmediately before the
examination. This is particularly i mpor­
tant when the upright position is used be­
cause the fil led bladder prevents the fetus
from descending to the most dependent
portion of the uterine cavity.
Care of patient
The patient who is in labor or is bleeding
because of a placental separation must
be treated as an emergency and must be
under constant observation by qualified
personnel.
Respiration
A change in the oxygen content of the ma­
ternal blood causes the fetus to react
quickly by movement. Just before suspen­
sion of respiration for the exposure, the
mother's blood should be hyperaerated by
having her i nhale deeply several times and
then suspend respiration during the i nspi­
ration phase.
Fetography
Fetography has generally been replaced
by sonography and therefore is not fully
described in this edition. A more complete
description of this technique is provided
in the seventh edition or even earlier edi­
tions of this atlas.
AP or PA and lateral projections are ob­
tained to demonstrate the maternal pelvis
and developing fetus (Figs. 1 9- 1 9 to 1 9-2 1 ).
The following steps are observed:
• Whenever possible, situate the patient
in a prone position to place the fetus
closer to the I R . To accomplish this,
place supports under the chest, upper
abdomen, and femora (Fig. 1 9-22) .
• I f the prone position cannot b e used,
place the patient supine on the radio­
graphic table with a support under the
knees to relieve back strain.
• For the lateral projection, have the patient
lie on her side and support the abdomen
to be parallel to the table if needed.
• Center the perpendicular central ray to
the abdomen.
Fig. 1 9- 1 9 Fetography. PA projection. Twin pregnancy showing two Fig. 1 9-20 Fetography. AP projection. showing one fetus,
fetal heads (arrows and arrowheads),

R,

Fig. 1 9-21 Fetography. lateral projection, showing triplet Fig. 1 9-22 Fetography, prone position, showing support under pa­
pregnancy, tient's legs and thorax,

265
 Radiographic pelvimetry
and cephalometry
Mo t pelvimetry techniques have been re­
placed by sonography. Thus the Ball and
Thoms methods have been deleted from
this edition. (See the eventh or earlier
edition of this atlas for descriptions of
these method s . ) However, obtai nable
pelvic measurements and the Colcher­
Sussman method of pelvimetry are de­
scri bed here.
The pelvi metry requires a knowledge
of pelvic anatomy. The entrance to the
true pelvis, called the superior strait or
pelvic inlet, is bounded by the sacral
promontory, the linea terminalis, and the
crests of the pubic bones and symphysis.
The internal anteroposterior diameter of
the inlet i measured from the center of
the sacral promontory to the superoposte­
rior margin of the pubic symphysis and is
called the internal conjugate diameter or
the conjugata vera. Other internal diame­
ters of the pelvic cavity are shown in the
accompanying ill ustrations (Figs. 1 9-23
and 1 9-24).
The external conjugate diameter ex­
tends from the space between the spinous
proce s of L4-L5 to the top of the pubic
ymphysis. The posterior landmark-the
inter pinous space-can be palpated at
the superior angle of the Michaelis rhom­
boid, which is the diamond-shaped de­
pression overlying the lumbosacral re­
gion. This depression i s bounded laterally
by the dimples overlying the posterior su­
perior iliac spines, superior to the L5
spinous process by the lines formed by the
gl uteus muscles, and inferior to the
groove at the end of the vertebral column.

Fig. 1 9-23 Pelvis seen from above. A, Anteroposterior diameter of Fig. 1 9-24 Lateral aspect of pelvis. A, Anteroposterior diameter
the inlet. B, Transverse diameter of inlet. C, Posterior sagittal di­ of inlet. B, Posterior sagittal diameter of inlet. C, Anteroposterior
ameter of inlet. D, Interspinous or transverse diameter of mid­ diameter of midplane. D, Posterior sagittal diameter of midplane.
plane. E Widest transverse diameter of outlet.

266
 Pelvimetry

AP PROJECTION
COLCHER-SUSSMAN METHOD
The two projections (AP and lateral) em­
ployed in this method of pelvimetry re­
quire the use of the Colcher-Sussman
pelvi meter. This device consists of a metal
ruler perforated at centimeter intervals
and mounted on a small stand in such a
way that it is always parallel to the plane
of the J R . The ruler can be rotated in .a
complete circle and adj usted for height
(Fig. 1 9-25 ) .

Image receptor: 35 x 43 c m for each

exposure

Position of patient
• Place the patient in the supine position,
and center the midsagittal plane of the
body to the midline of the grid.

Position of part
• Flex the patient's knees to elevate the
forepelv is, and separate the thighs
Fig. 1 9-25 Colcher-Sussman ruler.
enough to permit correct placement of
the pelvimeter.
• Center the horizontal ruler to the
gluteal fold at the level of the ischial Fig. 1 9-26 Pelvimetry. AP projection. with
ruler in place.
tuberosities. The tuberosities are easily
E Inlet
=

pal pated through the median part of the F = Mldpelvls

buttocks. If preferred, local ize the T Outlet
=

tuberosities by placing the ruler 1 0 cm

below the superior border of the pubic
symphysis (Fig. 1 9-26).
• Center the I R I � inches (3.8 cm) supe­
rior to the pubic symphysis (Fig. 1 9-27).
• Respiration: After determining that
the fetus is qu iet, instruct the patient to
suspend respiration at the end of
expiration.

Central ray
• Perpendicular to the midpoint of the I R
and 1 � inches (3.8 cm) superior to the
pubic symphysis

EVALUATION CRITERIA
The fol lowing should be clearly demon­
Pubic symphysis ----'-
_ _ .1
strated:
• Entire pelvis Ischial tuberosity --___

• Metal ruler with centimeter markings

visible
• Density permitting visualization of all
pelvic landmarks and intersecting di­
ameters Metal ruler ---...;-

• No rotation of the pelvis

• Entire fetal head

Fig. 1 9-27 Pelvimetry. AP projection.

267
 Pelvimetry

LATE RAL PROJECTION
COLCHER-SUSSMAN M ETHOD
R or L position
Imoge receptor: 35 x 43 cm
Position of patient
• A k the patient to turn to a lateral posi­
tion, and center the midcoronal plane of
the patient's body to the midline of the
table.
Position of part
Partially extend the patient's thighs so
that they do not obscure the pubic bones.
• Place sandbags under and between the
patient' knee and ankle to i mmobi­
lize the legs.
• Place a folded sheet or other suitable
support under the lower thorax, and ad­
just the support so that the long axis of
the lumbar vertebrae is parallel with the
tabletop.
• Adjust the patient's body in a true lat­
eral position.
• Turn the ruler lengthwise, and adjust its
height to coincide with the midsagittal
plane of the patient's body.
• Place the pelvimeter so that the metal
ruler l ies within the upper part of the
gluteal fold and against the midsacrum
(Fig. 1 9-28).
• Center the IR at the level of the most
prominent point of the greater trochanter
(Fig. 1 9-29).
• Respiration: Suspend at the end of ex­
piration.
Central ray
Perpendicular to the most prominent
point of the greater trochanter
EVALUATION CRITERIA
The fol lowing should be clearly demon­
strated:
• Superimposed hips and femora
• No superimposition of the pubic sym­
physis by the femurs
• Entire pelvis, sacrum, and coccyx
• Metal ruler with centi meter markings
visible
• Density permitting vi sual ization of
all pelvic landmarks and intersecting
diameters
• Entire fetal head

Fig. 1 9-28 Pelvimetry, lateral projection with ruler in place.

Sacrum

Fetal head

Pubic
symphysis

Ischial
tuberosities

Metal ruler

Fig. 1 9-29 Pelvimetry, lateral projection.

268
 --
LOCALIZATION OF I NTRAUTERINE INTRAUTERINE CONTRACEPTIVE DEVICES
DEVICES
Intrauterine devices ( f UDs) remain a con­
traceptive option. Occasionally an I U D
becomes dislocated from the uterine cav­
-,-
"I
r
ity. If this occurs, the exact location of the TATUM-T PROGI!STASERT CU - 7
device must be determi ned, in some cases SEARLE ALZA SEARLE

by radiography. Therefore it is necessary

to become acquainted with the radio­
graphic appearance of I U D .
The physician first performs a pelvic
examination to determine the location of SAF-T- COIL
JUUUS SCHMID
the I U D. If the ruD is not located, the 1 2 3 4
physician passes a sterile probe into the I I I I I I CIII

uterine cavity and radiographs are taken.

AP and lateral projections of the ab­ Fig. 1 9-30 Intrauterine contraceptive devices.
domen are suggested for f U D localiza­
tion. Occasionally, oblique projections are
indicated. Most f U Ds are radiopaque be­
cause of their inherent metallic density or
becau e of barium i mpregnated in the
plastic during their manufacture. It should
be emphasized that radiography alone is
not a reliable way to diagnose extrauterine
localization of an f UD.
I n the early 1 9805 five types of I U Ds
were available for u e. I n the late 1 980s
three fUDs were removed from the U.S.
market by their manufacturers. At this
time only two fUDs are available for use
in the United States: the Paragard and the
Progestasert (Fig. 1 9-30).

269
 Male Radiogra phy
SEMINAL DUCTS
Radiologic examinations of the seminal
ducts ' ·3 are performed in the investigation
of selected genitourinary abnormalities
such as cysts, abscesses, tumors, inflam­
mation, and steril ity. The regional terms
applied to these examinations are vesicu­
lography, epididymograp/7y, and, when
combined, epididymovesiculography.
The contrast medjum employed for these
procedures is one of the water-soluble, iod­
inated compounds used for intravenous
urography. A gaseous contrast medium can
be injected into each scrotal ac to improve
contrast in the examination of extrapelvic
structures.
The seminal vesicle are sometimes
opac ified directly by urethroscopic
catheterization of the ejaculatory ducts.
More frequently the entire duct system is
inspected by introducing contrast solution
into the canals by way of the ductus def­
erens. This requires small bi lateral inci­
sions in the upper part of the scrotum for
the exposure and identification of these
ducts. The needle that is used to inject the
contrast medium is inserted into the duct
in the direction of the portion of the tract
under investigation-distally for study of
the extrapelvic ducts and then proximally
for study of the intrapelvic ducts.
A nongrid exposure technique is used
for the delineation of extrapelvic struc­
tures (Figs. 1 9-3 1 to 1 9-33). The examin­
ing urologist places the IR and adj u ts the
position of the testes for the desired pro­
jections of the ducts. A grid technique is
used to demonstrate the intrapelvic ducts
(Figs. 1 9-34 to 1 9-36). AP and oblique
projections are made on 8 X 10 inch ( 1 8
X 24 cm) or 24 X 30 cm I Rs that are
placed lengthwise and centered at the
level of the superior border of the pubic
symphysis.

' Boreau J et al: Epididymography, Med Radiogr

PhotogI' 29:63. 1 95 3 .
'Boreau J : L 'bl/de radiologique des voies .VI?minales
I/oI'll/ales et pathologiques, Paris, 1 953, Masson &
Cie.
'Vasselle B : Etude radiologique des voies sell/iI/ales
Ductus deferens
de I 'holl/me, thesis. Paris, 1 953.

Proximal convoluted
ductus deferens

Epididymis

Needle

Fig. 1 9-31 Epididymogram showing normal epididymis and origin of ductus deferens. The
needle is at the epididymovasal kink, which can be palpated.

Fig. 1 9-32 Epididymogram demonstrating tuberculosis (cold ab­ Fig. 1 9-33 Epididymogram showing epididymal abscess (arrow)
scess) of epididymis (arrow). observed during acute orchitis (third relapse). Epididymovasal
kink is atrophiC.

270
 EVALUATION CRITERIA
The fol lowing should be clearly demon­
strated:
AP projection
• I R centered at the level of the superior
border of the pubic symphysis
• No rotation of the patient Distal ductus deferens
• A short scale of contrast on radiograph
Oblique projection
• IR centered at the level of the superior Seminal vesicle
border of the pubic symphysis
• No superi mposi tion of the seminal
ducts by the i l ia
• No overlap of the region of the prostate
or urethra by the uppermost thigh Proximal ductus deferens

PROSTATE
Prostatography is a term applied to the i n­
vestigation of the prostate by radiographic,
cystographic, or vesiculographic proce­
dures. It is seldom performed today be­
cause of advancements in the diagnostic
value of ultrasonography. Radiographic
examination of the prostate gland was de­
sClibed in the eighth and earlier editions of
this atlas.
Fig. 1 9-34 Normal vesiculogram.

Fig. 1 9-35 Vesiculogram of tuberculous seminal vesicle associ­ Fig. 1 9-36 Vesiculogram demonstrating beginning (budding) metasta­
ated with deferentitis, demonstrating small abscesses, ampul­ sis of crista urethralis (arrow) discovered 2 years after prostatectomy
litis, and considerable vesiculitis on left (arrow). for cancer of prostate.

27 1