For a condition as common as urinary tract infection (UTI), it is surprising how much controversy persists regarding its optimal imaging evaluation. Multiple studies have been performed over the years, with recommendations generally divided into “top down” and “bottom up” approaches, depending upon whether the emphasis is on upper tract disease (pyelonephritis) or lower tract abnormalities (vesicoureteral reflux [VUR]). While there is still dissent, recent European studies and an American Academy of Pediatrics position paper show a shift to emphasize evaluation of the upper urinary tract, with decreased emphasis on the diagnosis of VUR.

Regardless, the radiological investigation of VUR will continue to have some role in UTI evaluation. Whether one performs a fluoroscopic voiding cystourethrogram (VCUG), a nuclear medicine cystogram or a contrast-enhanced cystosonogram, catheterization of the bladder is required, and this creates anxiety in parents and patients. Part of pediatric radiology training is how to best minimize this anxiety by having confidence and skill in bladder catheterization, using numbing gels and having child life specialists assist during the procedure.

Increasingly, radiologists are being asked to provide some kind of pharmacological sedation or anxiolysis to make the experience even less stressful. Is this reasonable? Does the addition of sedative medication make for a “better” procedure? A safer procedure? A cost- and time-effective procedure? It is difficult to weigh these factors dispassionately, and there are strong opinions on each side. The following two commentaries explore both sides of the argument. Whatever your opinion, the radiological evaluation of VUR and the issue of procedural sedation are not going away.