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Imaging of the lower urinary tract( Part 111).
Dr/ ABD ALLAH NZEER. MD.
Imaging of the Urinary bladder.
Plain kidney, ureters and bladder (KUB)Intravenous urogram.Ultrasonography.Cystography(ascending and voiding).Computed tomography (CT) scanMagnetic resonance imaging (MRI) scanRadionuclide scan.More invasive tests.
Anatomy of the urinary bladder.The urinary bladder is the organ that collects urine excreted by the kidneys before disposal by urination. A hollow[1] muscular, and distensible (or elastic) organ, the bladder sits on the pelvic floor. Urine enters the bladder via the ureters and exits via the urethra.
The fundus of the bladder is the base of the bladder, formed by the posterior wall. It is lymphatically drained by the external iliac lymph nodes. The peritoneum lies superior to the fundus.
The fundus of the bladder is the base of the bladder, formed by the posterior wall. It is lymphatically drained by the external iliac lymph nodes. The peritoneum lies superior to the fundus.
Causes of urinary bladder diverticulaePrimary (congenital or idiopathic)Hutch diverticulum (in paraureteral region)SecondaryBladder outlet obstructionbladder neck stenosisneurogenic bladderposterior urethral valveprostatic enlargement (hypertrophy; carcinoma)ureterocele (large)urethral strictureCongenital syndromesDiamond-Blackfan syndromeEhlers-Danlos syndromeMenkes syndrome - kinky-hair syndromePrune-belly syndrome - Eagle-Barrett syndromeWilliams syndrome - idiopathic hypercalcemia
Axial post-contrast CT scans obtained in supine (A, B, C) and prone (D) positions show minimal thickening and enhancement of the medial wall of a left-sided narrow neck bladder diverticulum. The asterisk indicates the dilated lower left ureter.
A bladder exstrophy (also known as Ectopia vesicae) refers to a herniation of the urinary bladder through an anterior abdominal wall defect. It can occur to variable severity.
Vesicoureteral Reflux.
Backwash” or retrograde flow of urine from the bladder into the ureters, and usually up to the kidneys.VUR is a risk factor for upper tract infection=Pyelonephritis.VUR found in 50% of children with UTI.Affects 1% of all children.Boys typically dx with higher grades than girls.Female to Male ratio is 6:110 times more common in whites vs blacksHereditary components / Family history !parent: 50% / sibling 33-45%
Etiology / Pathophysiology.
Primary: (Congenital) defect of UVJ (ureterovesical junction) – Most common –deficient tunnel / laterally displaced orificesSecondary (Acquired) increased intravesical pressure secondary to neurogenic problems or DES, bladder instability, bladder outlet obstruction (PUVs)UTIs (problem #1) do not cause reflux!!Reflux (problem #2) does not cause UTIs!!
Grading of VUR from 1-5.
Does VUR increase the risk of renal injury?
Congenital megaureter with vesico-reflux nephropathy.
The urachus is a fibrous remnant of the allantois, a canal that drains the urinary bladder of the fetus that joins and runs within the umbilical cord.
Infected urachal cyst.
Bladder congenital anomalies duplication.
Duplication can be complete or partial, although the complete urinary bladder duplication more common.
Complete duplication of the urinary bladder and urethra.
MRI: A. Coronal, B. Sagittal T2-weighted view of the latero-lateral incomplete bladder duplication.
Vesico-vaginal fistula (VVF) is a subtype of female urogenital fistula (UGF). VVF is an abnormal fistulous tract extending between the bladder and the vagina that allows the continuous involuntary discharge of urine into the vaginal vault.
Fistula.
colovesical fistula (abnormal connection between colon and bladder) may develop in men or women with inflammatory bowel disease or diverticulitis and can result in passage of gas or stool in the urine, frequent UTI's and even sepsis (severe infection that enters the bloodstream).
Vesico-vaginal fistula. Vesico-vaginal fistula.
Bladder stones.
Bladder stones are hard buildups of minerals that form in the urinary bladder.CausesBladder stones are usually caused by another urinary system problem, such as:Bladder diverticulumEnlarged prostateNeurogenic bladderUrinary tract infectionAlmost all bladder stones occur in men. Bladder stones are much less common than kidney stones.Bladder stones may occur when urine in the bladder is concentrated and materials crystallize. Bladder stones may also result from foreign objects in the bladder.
Urinary bladder stone.
A urinary tract infection (UTI) (also known as acute cystitis or bladder infection) is an infection that affects part of the urinary tract. When it affects the lower urinary tract it is known as a simple cystitis (a bladder infection)
Urinary tract infection.
Urinary tract infections occur more commonly in women than men, with half of women having at least one infection at some point in their lives. Recurrences are common. Risk factors include female anatomy, sexual intercourse and family history.
The main causal agent of both types is Escherichia coli, though other bacteria, viruses or fungi may rarely be the cause.
Acute cystitis.
Emphysematous cystitis in a patient with diabetes mellitus.
Benign Tumors of the Bladder. There are numerous benign tumors of the bladder, but the more common ones include epithelial metaplasia, leukoplakia, inverted papilloma, nephrogenic adenoma, leiomyoma, cystitis cystica, cystitis glandularis and hemangioma .
Neoplasm of the urinary bladder.
Malignant tumour of the urinary bladder.Transitional cell carcinoma: Cancer that begins in cells in the innermost tissue layer of the bladder. Most bladder cancers begin in the transitional cells. Transitional cell carcinoma can be low-grade or high-grade:
Low-grade transitional cell carcinoma often recurs (comes back) after treatment, but rarely spreads into the muscle layer of the bladder or to other parts of the body. High-grade transitional cell carcinoma often recurs (comes back) after treatment and often spreads into the muscle layer of the bladder, to other parts of the body, and to lymph nodes. Almost all deaths from bladder cancer are due to high-grade disease.
Squamous cell carcinoma: Cancer that begins in squamous cells, which are thin, flat cells that may form in the bladder after long-term infection or irritation. Adenocarcinoma: Cancer that begins in glandular (secretory) cells that are found in the lining of the bladder. This is a very rare type of bladder cancer.
Bladder cancer is any of several types of malignancy arising from the epithelial lining (i.e., the urothelium) of the urinary bladder. Rarely the bladder is involved by non-epithelial cancers, such as lymphoma or sarcoma
Staging[edit]T (Primary tumour)TX Primary tumour cannot be assessedT0 No evidence of primary tumourTa Non-invasive papillary carcinomaTis Carcinoma in situ (‘flat tumour’)T1 Tumour invades subepithelial connective tissueT2a Tumour invades superficial muscle (inner half)T2b Tumour invades deep muscle (outer half)T3 Tumour invades perivesical tissue:T3a MicroscopicallyT3b Macroscopically (extravesical mass)T4a Tumour invades prostate, uterus or vaginaT4b Tumour invades pelvic wall or abdominal wall
N (Lymph nodes).NX Regional lymph nodes cannot be assessedN0 No regional lymph node metastasisN1 Metastasis in a single lymph node 2 cm or less in greatest dimensionN2 Metastasis in a single lymph node more than 2 cm but not more than 5 cm in greatest dimension, or multiple lymph nodes, none more than 5 cm in greatest dimensionN3 Metastasis in a lymph node more than 5 cm in greatest dimensionM (Distant metastasis).MX Distant metastasis cannot be assessedM0 No distant metastasisM1 Distant metastasis.
Diagram shows the stages of tumor invasion in bladder cancer.
Inverted papilloma of the urinary bladder and distal ureter.
Hemangioma. Axial CT image shows an intramural bladder mass (arrow) with marked enhancement.
Paraganglioma. Axial CT image of the bladder shows dense ring calcification (arrows) around the circumference of a paraganglioma.
Paraganglioma. (a) Axial gadolinium-enhanced fat-suppressed T1-weighted MR image shows a large bladder mass with significant extravesical extension. This appearance is nonspecific and may be seen with many tumors. (b) Frontal 131I-MIBG scan shows uptake in the mass (arrowhead), a finding that is highly specific for a paraganglioma.
Leiomyoma. Sagittal T1-weighted (a) and T2-weighted (b) MR images of the bladder show a smooth, low-signal-intensity, intramural mass (arrows), an appearance typical of a leiomyoma.
Plexiform neurofibroma in a patient with known neurofibromatosis type 1. Axial CT image shows low-attenuation, nodular thickening of the left lateral and posterior bladder walls. MRI Several nodules have a low-signal-intensity center surrounded by a high-signal-intensity rim (the target sign) (arrows).
Diverticular tumor. Axial CT image shows a urothelial tumor (arrow) within a bladder diverticulum. Urinary stasis occurs with bladder diverticula, thus predisposing them to tumor development.
Urothelial carcinoma. Axial CT image shows a large, lobular mass within the bladder.
Noninvasive papillary urothelial tumor at MRI with intact bladder wall.
Invasive urothelial carcinoma. Axial gadolinium-enhanced fat-suppressed T1-weighted MR image of the bladder shows tumor invasion into the perivesical fat (arrows).
Squamous cell carcinoma in a paraplegic patient. Axial unenhanced CT image of the bladder shows calcifications (arrow) encrusting a tumor. Axial contrast material–enhanced CT cystogram shows the tumor (arrow) more clearly. Note the loss of trabecular structure in the bones and the fatty infiltration of the muscles.
Squamous cell carcinoma.
Invasive squamous cell carcinoma
Adenocarcinoma
Small cell carcinoma.
Carcinoid.
Leiomyosarcoma. (a) Axial T2-weighted MR image shows a large, heterogeneous mass within the bladder wall. (b) Axial gadolinium-enhanced fat-suppressed T1-weighted MR image shows irregular enhancement of the mass. The adjacent bladder wall (arrow) is also abnormal and was found to be infiltrated by the tumor.
Botryoid rhabdomyosarcoma. (a, b) Transverse US (a) and axial CT (b) images show a grapelike mass filling the bladder lumen. (c) Photograph of the cut surface of the gross specimen shows the typical grayish, glistening, gelatinous appearance of the tumors
B-cell lymphoma. (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice. The latter mass is causing obstruction in the form of a hydroureter (black arrows). (b) Axial CT image shows the thickening at the ureteral orifice (arrows).
Imaging of Urethral Disease.
Retrograde Urethrography.Retrograde urethrography is considered to be the best initial study for urethral and periurethral imaging in men and is indicated in the evaluation of urethral injuries, strictures, and fistulas (1,2). Retrograde urethrography is a straightforward, readily available, cost-effective examination.
Voiding Cystourethrography.Voiding cystourethrography is currently the most commonly used imaging method in the evaluation of the female urethra and male posterior urethra. Voiding urethrography is usually performed after the bladder is filled with contrast material via a transurethral or suprapubic catheter.
Gonococcal urethral stricture. Retrograde urethrogram reveals a segment of irregular, beaded narrowing in the distal bulbous urethra with opacification of the left Cowper duct (arrow).
Gonococcal urethral stricture with periurethral abscess. Retrograde urethrogram shows a long segment of irregular, beaded narrowing in the bulbous urethra with opacification of the Littré glands (arrow). Note the irregular periurethral cavity originating from the ventral aspect of the bulbous urethra.
Retrograde urethrogram reveals a long segment of irregular stricture involving the anterior urethra and membranous urethra with extensive fistulous tracts. Note the opacification of multiple Littré glands and the prostatic glands.
Condyloma acuminata. Retrograde urethrogram demonstrates multiple small filling defects in the anterior urethra.
Female urethral diverticulum. Post-voiding image obtained during excretory urography demonstrates a contrast material-filled urethral diverticulum (arrow).
Retrograde urethrogram obtained with the patient supine shows the bulbous urethra as a diverticulum-like out-pouching
Urethral diverticulum (female prostate sign). Sagittal fast spin-echo T2-weighted MR image demonstrates a large diverticulum surrounding the urethra (arrow), with a septum that results in an impression at the bladder base. B = bladder, S = pubic symphysis.
Calculi associated with urethral stricture. (a) Conventional radiograph reveals faintly opaque stones projected over the penis (arrows). (b) Retrograde urethrogram demonstrates the stones (arrowhead) lying in a segment of anterior urethral stricture.
Squamous cell carcinoma of the male urethra. Retrograde urethrogram reveals a segment of irregular stricture of the bulbous urethra.
Squamous cell carcinoma of the male urethra. (a) Sagittal fast spin-echo T2-weighted MR image demonstrates a focal mass (M) with low signal intensity in the corpus spongiosum (cs) at the penoscrotal junction. (b) Coronal MR image shows that the mass (large arrow) occupies the corpus spongiosum but has not invaded the corpora cavernosa (small arrows), which are intact.
Squamous cell carcinoma of the female urethra. Voiding cystourethrogram reveals irregular narrowing in the urethra with irregular sinus tracts.
High-grade adenocarcinoma of the female urethra in a patient whose uterus had been surgically removed previously. Contrast-enhanced CT scan (a) and sagittal reformatted image from CT data (b) reveal an inhomogeneous soft-tissue mass of the urethra (m).
Urethral metastasis from prostate carcinoma. Retrograde urethrogram shows a segment of smooth extrinsic narrowing of the bulbous urethra. Note the skeletal metastases.
Intact but stretched posterior urethra following blunt trauma (type I urethral injury). (a) Retrograde urethrogram reveals stretching of the posterior urethra. Diastasis of the pubic symphysis was diagnosed. (b) Drawing illustrates type I urethral injury.
Posterior urethral rupture above the intact urogenital diaphragm following blunt trauma (type II urethral injury). (a) Partial type II urethral injury. Retrograde urethrogram demonstrates contrast material extravasation confined to the area above the normal cone-shaped proximal portion of the bulbous urethra. However, contrast material flows through the prostatic urethral lumen into the bladder. Fracture of the left pubic ramus was diagnosed. (b) Complete type II urethral injury. Retrograde urethrogram shows a large amount of contrast material extravasation without flow into the prostatic urethra or bladder. Fracture of the right pubic ramus was diagnosed. (c) Drawing illustrates type II urethral injury.
Posterior urethral rupture extending through the urogenital diaphragm to involve the bulbous urethra following blunt trauma (type III urethral injury). (a) Retrograde urethrogram reveals contrast material extravasation at the membranous urethra (arrow). The contrast material extends below the urogenital diaphragm and surrounds the proximal bulbous urethra.
Type IV urethral injury from blunt trauma. (a) Retrograde urethrogram reveals extra peritoneal periurethral contrast material extravasation at the bladder neck (arrow). The bladder is pear shaped, indicative of perivesical hematoma. Diastasis of the pubic symphysis was diagnosed. (b) Drawing illustrates type IV urethral injury.
Retrograde urethrogram obtained in a 32-year-old man with bladder base injury following blunt trauma (type IVa urethral injury) shows extra peritoneal contrast material extravasation that extends from the elevated bladder base and surrounds the proximal urethra. Fracture of the superior and inferior pubic rami bilaterally was diagnosed.
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