4.2 Urinary Bladder Flashcards
Ureteric development, Weigert Meyer rule
From ureteric bud (if >1 bud, can have ureteric duplication), arising from mesonephric duct; 10-25 calyces/kidney
Weigert-Meyer: Upper moiety ureter inserts inferomedial to lower moiety
Thus upper moiety can develop ureterocoele (cobra head on IVP; can project into bladder and obstruct other ureter), lower moiety develops reflux
Upper moiety may have extravesical insertion - typically bladder neck, urethra or vagina / seminal vesicles, vas deferens
Ectopic ureter F/M = 6/1; causes UTIs, obstruction, incontinence
Retrocaval ureter - path, IVP
Ureter passes behind IVC and exits between aorta and IVC
Medial looping at L2/L3 on IVP, can cause ureteral narrowing
Ovarian vein syndrome
Right gonadal vein crosses ureter and drains into IVC, left gonadal vein drains to left renal vein
Ureteral notching / dilatation / obstruction due to ovarian vein thrombosis / varices
Associated with pregnancy
Bladder development
From anterior urogenital sinus of cloaca; communicates with allantois via urachus (becomes median umbilical ligament)
Urogenital sinus has urethral (prostatic, membranous, female) and phallic (vestibule, penile) parts
Congenital urachal anomalies
Patent urachus
Umbilical-urachal sinus
Vesicourachal diverticulum
Urachal cyst
Retroperitoneal fibrosis - AKA, location, associations, CT/MR
Idiopathic form (two thirds) = Ormond’s Disease (M>F)
Originates just inferolateral to aortic bifurcation and extends superiorly, but limited anteriorly by peritoneum
Typically involves left ureter before right, usually at L3-L5 level
Associations - IBD, PSC, fibrosing mediastinitis, Riedel’s thyroiditis, sclerosing mesenteritis, orbital pseudotumour
Imaging - Soft tissue layered around aorta and IVC, loss of peristalsis in involved ureteric segment (but always spares ureteric mucosa), does not extend between aorta and vertebrae (unlike malignant lymphadenopathy)
Early or malignant RPF - high T2W; mature fibrotic plaque - low T2W
Renal impairment out of proportion with degree of hydronephrosis, but stenting usually easy
Causes and Sequelae of RPF
Causes: AAA RP metastases (lymphoma, breast, carcinoid) - Desmoplastic reaction: HD > NHL > anaplastic & metastases RP haematoma RP abscess (diverticular, appendix) Urinoma Drugs (hydralazine, methylsergide, methyldopa, ergot) Radiation Sequelae: Lower extremity / scrotal oedema DVT
Retroperitoneal tumours - types
90 % malignant, usually > 10 cm at diagnosis
Mesodermal: Liposarcoma (usually myxoid or pleomorphic; little fat on CT), Leiomyosarcoma (large heterogenously enhancing mass, central necrosis), Fibrosarcoma, Lymphoma, others
Neural: Neurofibroma, Neuroblastoma, Phaeochromocytoma
Embryonic: Teratoma, Primary germ cell tumour
Pelvic lipomatosis - definition, associations
True pelvis infiltrated by unencapsulated mature adipose tissue
Two thirds of cases are black males
Causes UTIs / obstruction, constipation
Associations: cystitis glandularis (75%, form of proliferative cystitis), increased risk bladder adenocarcinoma
‘Inverted pear’ shaped bladder, reduced bladder capacity, medial deviation of ureters
Enlarged retrorectal space on Ba enema
Ureteritis cystica - definiton, IVP
Sterile submucosal fluid collections due to intramural inflammation, causing encystment and submucosal extension of transitional epithelium; not premalignant
Usually unilateral, multicentric, smooth, round filling defects on IVU (most 2-4 mm diameter)
Associated with chronic UTIs
Ureteral Psuedodiverticulosis - definition, associations
Outpouchings 1-2 mm of epithelium into lamina propria, associated with inflammation
50% develop uroepithelial malignancy
Ureteric trauma - consequences
Usually penetrating injury causing urinoma / discontinuity / extravasation
Avulsion usually at PUJ due to deceleration (commonest in children)
Malakoplakia - definition, associations
Yellow subepithelial plaques of mononuclear histiocytes containing Michaelis-Gutmann bodies
Cobblestone appearance on IVP, most common in bladder
F>M, usually diabetic or immunocompromised, strong association with E Coli UTIs
Causes LUTs and haematuria; rarely invades bone
Ureteric tumours - types, signs
50% develop bladder cancer, 75% unilateral, 5% bladder cancer patients develop ureteric cancer
Malignant: Epithelial - TCC, SCC, adenocarcinoma; Mesodermal - Sarcoma, angiosarcoma, carcinosarcoma
Benign: Epithelial - inverted papilloma, polyp, adenoma; Mesodermal - fibroma, haemoangioma, myoma, lymphangioma
Goblet sign: retrograde pyelogram with dilated ureteral segment distal to obstruction, with filling defect and mensicus
Metastatic sites of ureteric primaries: RP LNs (75%) > liver, lung (60%) > bone (40%) > GIT (20%)
Bacterial cystitis - cause
E Coli > Staph > Strep > Psuedomonas Mucosal thickening (cobblestone), stranding perivesical fat Emphysematous cystitis usually E Coli in DM, neurogenic bladder (S2-S4 dermatome; UMN lesion = spastic, LMN lesion (= atonic) or outlet obstruction (intramural gas, air/fluid level in bladder)
