Chapter 14
Urinary System and Venipuncture
Urinary System




Kidneys (2)
Ureters (2)
Urinary bladder
Urethra
Suprarenal (adrenal)
glands (endocrine
system)
Anterior view
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2
Urinary System

Retroperitoneal
structures


Kidneys and ureters
Infraperitoneal
structures



Distal ureters
Urinary bladder
Urethra
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Lateral view
3
Kidney Orientation
Frontal view
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4
Kidney Location



Halfway between
xiphoid process and
iliac crest
Between T11-T12
and L3
Nephroptosis
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5
Renal Blood Vessels
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Microscopic Structure
Collecting System
Cortex:
Medulla:
Nephrons
▼
Renal pyramids (8-18)
▼
Renal papilla (openings)
▼
Minor calyces (4-13)
▼
Major calyces (2-3)
▼
Renal pelvis
▼
Ureter
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Nephron



Structural and
functional unit
Over 1 million per
kidney
Blood filtered
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Components of Nephron and
Collecting Duct
99% of filtrate is reabsorbed
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Urine Production Summary
H2O intake (2.5 L/day)
Bloodstream
Filtrate
99% reabsorbed
Urine (1.5 L/day)
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Ureters




28-34 cm long, 1 mm
to 1 cm in diameter
Lie on psoas muscles
Enter posterolateral
bladder
Points of constriction
1. Ureteropelvic
junction (UPJ)
2. Pelvic brim
3. Ureterovesical
junction (UVJ)
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11
Male Urinary Bladder
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12
IVU Demonstrating Kidneys, Ureters,
and Bladder
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Bladder Functions and Terminology
Terminology:
1. Micturition
?
2. Incontinence
?
3. Retention
?
Capacities:
Urge to urinate
≈ 250 mL
Total capacity
?
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14
Male Pelvic Organs
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Female Pelvic Organs
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Full-Term Pregnancy and
Relationship to Bladder
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Anatomy Review
(A-G)
Retrograde Pyelogram
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Anatomy Review
(A-E)
Voiding Cystourethrogram
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Venipuncture
The percutaneous puncture of a vein for
withdrawal of blood or injection of a solution
such as contrast media for urographic
procedures
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Preparing Contrast Agents
Confirm contents and expiration date
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21
Preparing Contrast Agents
Bolus injection
Drip infusion
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22
Venipuncture Supplies
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Selection of Vein
Possible veins for venipuncture
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Types of Needles
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Venipuncture Procedure
Step 1: Handwashing and Gloves
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Venipuncture Procedure
Step 2: Apply Tourniquet
Apply tourniquet 3-4 inches (8-10 cm) above site
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Venipuncture Procedure
Step 2 (cont’d): Select Vein and
Cleanse Site
Palpate vein to confirm site
Cleanse site
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Venipuncture Procedure
Step 3: Initiate Puncture
Over-the-needle catheter
Insert needle with bevel up at
20° to 45° angle; advance
slightly
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Venipuncture Procedure
Step 3: Initiate Puncture
Butterfly needle in posterior
aspect of hand
Insert needle with bevel up;
advance slightly
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Venipuncture Procedure
Step 4: Confirm Entry
Observe “flashback” of blood, withdraw needle,
and release tourniquet
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Venipuncture Procedure
Step 4: Secure Needle
Tape catheter in place
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Venipuncture Procedure
Step 5: Prepare and Proceed with
Injection
Ready for injection
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Venipuncture Procedure
Step 6: Needle or Catheter Removal
Butterfly needle
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Venipuncture Procedure
Step 6: Needle or Catheter Removal


Secure gauze or cotton ball in place
Keep in place for approximately 20 minutes
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Safety Considerations
1. Always wear gloves during all aspects of procedure.
2. Follow Occupational Safety and Health
Administration (OSHA) Standard Precautions.
3. Place needles and syringes in a designated sharps
container.
4. If unsuccessful during initial puncture, use new
butterfly or over-the-needle catheter.
5. If extravasation of contrast media occurs, elevate
affected extremity and provide cold compress over
site of injection for approximately 20 minutes,
followed by warm compress.
6. Document procedure.
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36
Urography and Contrast Media
• Water-soluble,
iodinated contrast
media
• Ionic or nonionic
• Injected intravenously
or through a catheter
Radiographic
examination of urinary
system
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Tri-Iodinated (Ionic) Contrast Media
Anion (–) COO–
Cation (+)
• Sodium or HN
Meglumine CO
CH3
Anion (–)
• Diatrizoate or
Iothalamate
Summary (benzoic acid ring):
• Three atoms of iodine
=
Opacifying element
• Cation (+) side chains
=
Adds to solubility
• Anion (–)
=
Stabilizes
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Nonionic Contrast Media




Amide or glucose parent compound (replaces
benzoic acid ring)
Nonionic compound containing three iodine
atoms (opacifying agents)
No cation, will not form separate ions
Less chance of reaction to contrast media
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Effects of Ionic Versus Nonionic
Contrast Media
Ionic
Nonionic
Dissociates into separate
Does not dissociate
ions when injected
Creates hypertonic
condition
Remains near
isotonic
Increase in blood
osmolality
No significant
increase in
osmolality
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Side Effect Versus Reaction



Side effects: expected
outcome of injected
contrast media
Common side effects
 Temporary hot flash
 Metallic taste in
mouth
Reaction:
An unexpected
outcome of injected
contrast media
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Technologist Responsibilities
1. Patient history

Clinical complaints?
 Food or drug allergies?
 Previous contrast media reaction?
 Asthma, hay fever, or hives?
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Patient History


Management of non–insulin-dependent
diabetes: Glucophage (metformin
hydrochloride)
Check chart and/or ask patient the following:



“Are you currently taking glucophage or other
medication for diabetes mellitus?”
To be withheld 48 hours following iodinated
contrast media procedure
Must verify normal kidney function before
resuming medication
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Patient History

Check blood chemistry—normal ranges


Creatinine level (adult)—0.6 -1.5 mg/dL
BUN levels (adult)—8-25 mg/100 mL
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Technologist Responsibilities
1. Patient history
2. Selection and
preparation of
contrast media


Read label several
times
Have empty
container available
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Radiographer Responsibilities
1. Patient history
2. Selection and preparation of
contrast media
3. Preparation for possible
reaction

Fully stocked emergency
cart (epinephrine available)
 Cardiopulmonary
resuscitation equipment
 Oxygen and suction
available
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Premedication Protocol
Common protocol:
 Give combination of Benadryl and prednisone
over period of 12 or more hours before
procedure
 Patients who have history of hay fever,
asthma, food allergies, or previous contrast
media reaction may be candidates for
premedication procedure
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Categories of Contrast Media
Reactions

Local


Reactions that affect only a specific region of the
body
Systemic

Reactions that affect the entire body or a specific
organ system
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Local Reactions
1. Extravasation

Leakage of iodinated contrast media outside
the vessel and into surrounding soft tissues
(also referred to as infiltration)




May be toxic to skin
Notify department nurse and/or physician
Elevate affected extremity above heart
Cold compress followed by warm compresses
first to relieve pain and then to improve
resorption
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Local Reactions
2. Phlebitis

Inflammation of a vein



Signs include pain, redness, and possibly swelling
surrounding the venous access site
Discontinue the venous access at this site
Notify department nurse and/or physician
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Systemic Reactions
1. Mild


Nonallergic reaction does not typically require
drug intervention or medical assistance
Symptoms include the following:









Anxiety
Light-headedness
Nausea
Vomiting
Metallic taste (common side effect)
Mild erythema
Warm, flush sensation during injection (common side effect)
Itching
Mild, scattered hives
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Systemic Reactions
2. Moderate


A true allergic reaction (anaphylactic
reaction)
Symptoms include the following:







Urticaria (moderate to severe hives)
Possible laryngeal swelling
Bronchospasm
Tachycardia (100 beats/min)
Bradycardia (60 beats/min)
Angioedema
Hypotension
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Systemic Reactions
3. Severe (Vasovagal)


Life-threatening reaction
Symptoms include the following:









Hypotension (systolic blood pressure 80 mm Hg)
Bradycardia (50 beats/min)
Cardiac arrhythmias
Laryngeal swelling
Possible convulsions
Loss of consciousness
Cardiac arrest
Respiratory arrest
No detectable pulse
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Clinical Indications for Radiographic
Urinary Procedures
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Contraindications to IVU
1.
2.
3.
4.
5.
6.
7.
Hypersensitivity to iodinated contrast media
Anuria
Multiple myeloma
Diabetes, especially diabetes mellitus
Severe hepatic or renal disease
Congestive heart failure
Pheochromocytoma (fe-o-kro″-mo-si-to′mah)
8. Sickle cell anemia
9. Renal failure, acute or chronic
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Pathologic Indications
Note large calculus in the right ureter (arrow).
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Clinical Indications
What are some conditions that can lead to
hydronephrosis?
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Radiographic Urinary Procedures
Routines may vary depending on
departmental protocol
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Excretory Urography—IVU
•
•
Correct term
 Intravenous urogram
(IVU): Radiographic
examination of the
urinary system
Purpose of IVU
(twofold)
1. Visualize the collecting
portion of the urinary
system.
2. Assess the functional
ability of the kidneys (a
timed procedure).
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Common Clinical Indications—IVU
1. Abdominal or pelvic
mass
2. Renal or urethral
calculi
3. Kidney trauma
4. Flank pain
5. Hematuria
6. Hypertension
7. Renal failure
8. Urinary tract infection
(UTI) (pyelonephritis)
Renal calculi in right kidney
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CT Renal Studies
Benefits:
1. Minimal bowel prep: Water
only at least 1 hour prior to
procedure
2. Noncontrast images to
evaluate for presence and
location of renal calculi
3. Option to use contrast
media provides a structural
and functional study
4. Fast procedure with helical
CT scanner
5. Image reconstruction
capability
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Patient Preparation for IVU*





Light evening meal prior to procedure
Bowel-cleansing laxative
NPO after midnight (minimum of 8 hours)
Enema on the morning of examination
Voiding prior to procedure
* Suggested protocol; prep may vary among
departments and clinical needs
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Equipment Preparation for IVU
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Ureteric Compression
Method to enhance filling of pelvicalyceal system
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Ureteric Compression
Correct Placement of Inflated Paddles
Review the six contraindications for using ureteric
compression
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Trendelenburg Position
Alternative to Ureteric Compression
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IVU—Basic Routine


Scout radiograph
Injection


Note time at beginning
of injection
Sample imaging
routine





1 min nephrogram or
nephrotomography
5 min AP supine
10-15 min AP supine
20 min posterior
obliques
Postvoid (prone or
erect)
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Nephrogram or Nephrotomogram
Radiographs taken
early in study to
demonstrate renal
parenchyma or
functional portion of
kidney
•
•
•
•
•
Nephrotomogram—1 min
Timing critical
Nephrogram
Single radiograph (1
min)
Nephrotomogram
Series of tomograms
starting at 1 min
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Hypertensive IVU

Purpose: IVU for patients with high blood
pressure

Suggested protocol:



Radiographs taken every minute, up to 5 minutes
After 5-minute IR, standard IVU routine
Check with radiologist to determine additional
images to be taken
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Retrograde Urography


Performed in surgery
Contrast media delivered retrograde through
catheter
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Retrograde Urography Procedure



Scout radiograph
taken
Series of
radiographs taken
as requested
Ureterogram taken
once catheter has
been removed
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Retrograde Cystography





Contrast media
delivered through
catheter
Gravity flow of
contrast media
150-500 mL
Fluoro
AP and posterior
oblique projections
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Voiding Cystourethrography



Purpose: Functional study of the bladder and
urethra
Performed after routine cystogram
Catheter removed and imaged while voiding
Female—AP
Male—30° RPO
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Retrograde Urethrography





Purpose: Nonfunctional radiographic study of the male
urethra
Retrograde injection of contrast media
Use of Brodney clamp
Patient in 30° RPO position
Rarely performed
Male urethrogram—30° RPO
Brodney clamp
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IVU

Routine






AP scout
Nephrotomography (1 min following injection)
AP
RPO and LPO
AP postvoid (recumbent or erect)
Special

AP ureteric compression
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IVU—AP Projection
•
•
No rotation
CR to level of iliac crest (include symphysis pubis)
Routine
• AP
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Evaluation Criteria
AP IVU





Entire urinary system
demonstrated
No rotation
No motion
Appropriate technique
employed
Minute marker visible
10-minute IVU
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Nephrotomogram and Nephrogram
•
•
•
No rotation
CR midway between xiphoid and iliac crest
Three exposures taken (generally)
Routine
• AP
• Nephrotomogram
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Evaluation Criteria
Nephrotomography




Entire renal
parenchyma
visualized
No motion
Appropriate
technique employed
Specific level
markers visible
Linear tomography
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IVU—Posterior Obliques
CR at level of iliac crest
Routine
• AP
• Nephrotomogram
• Posterior oblique
30° RPO
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30° LPO
80
Evaluation Criteria
Posterior Oblique
•
•
•
•
•
•
Elevated side: Kidney is
parallel to plane of IR
Downside: Ureter is free
of superimposition from
spine
Entire urinary system
visualized
No motion
Appropriate technique
employed
Minute marker visible
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RPO
81
AP (PA) Postvoid
•
•
CR at level of iliac crest
Include symphysis pubis
Routine
• AP
• Nephrotomogram
• Posterior oblique
• AP (PA) postvoid
PA Prone
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AP Erect
82
Evaluation Criteria
AP Erect Postvoid
•
•
•
•
•
•
Entire urinary system
demonstrated
All of symphysis pubis
included
No rotation
No motion
Appropriate technique
employed
Erect/post void
markers visible
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AP with Ureteric Compression
•
•
CR at level of iliac crest, or alternate centering to
kidneys
Compression device medial to ASISs
Special
• AP ureteric
compression
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Evaluation Criteria
AP with Ureteric Compression




Upper urinary system
demonstrated with
enhanced
pelvicalyceal and
proximal ureteral filling
No rotation
No motion
Appropriate technique
employed
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Cystogram
CR 2 inches (5 cm) superior to symphysis pubis
Routine
• AP
• Posterior oblique
AP: 10° to 15°
caudad
Posterior oblique: 45°
to 60°
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Left Lateral Cystogram

Optional projection caused by high gonadal dose
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Evaluation Criteria
Cystogram



AP: urinary bladder
not superimposed
by pubic bones
Posterior obliques:
urinary bladder not
superimposed by
lower limbs
Distal ureter,
bladder, proximal
urethra on males
to be included
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Voiding Cystourethrography
(VCUG)

Technical—Positioning Factors




IR size: 24 × 30 cm (10 × 12 in), portrait
Analog: 70-75 kV, grid
Digital: 80-85 kV
CR perpendicular to symphysis pubis
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Voiding Cystourethrography
(VCUG)
Female
• AP, supine or erect
• Extend and slightly
separate legs
Male
• Recumbent or 30° RPO
• Superimpose urethra over
right thigh
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Radiographic Images
GU
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Calculus on KUB
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Bilateral Staghorn Kidney Stones
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Renal Simple Cyst
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Renal Cell Carcinoma
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5 Minutes Post Injection
No Compression
Compression
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Luminal Surfaces of Ureters Post
Void
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Hidden Calculus
Stone Obscured by
Sacrum
Stone Seen Near Sacrum
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Ectopic Kidney
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Ureteocele
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Urethral Calculus
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Bladder Diverticula
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Bladder
Collapsed Bladder
Collapsed Bladder PostVoid
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Abdominal Radiographic Anatomy
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Urinary System Anatomy with
Contrast
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Kidney Anatomy
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