GENITOURINARY IMAGING 5 Flashcards
What are the Causes of Extraperitoneal Bladder rupture?
-
Extraperitoneal, 45%
-
Cause
- Pelvic fractures (bone spicule)
- avulsion tear
-
Cause
- Location
* Base of bladder,
* anterolateral- Imaging
- Pear-shaped bladder
- Fluid around bladder with displaced bowel loops
- Paralytic ileus
- Imaging
- Location
-
Intraperitoneal, 45%
- Cause
- Blunt trauma
- stab wounds
- invasive procedures
- Location
- Dome of bladder (weakest point)
- Imaging
- Contrast extravasation into paracolic gutters
- Urine ascites
- Cause
- Leukoplakia
- Ureteral involvement is less common than bladder and collecting system involvement.
- Leukoplakia is an uncommon lesion of the urothelium resulting from squamous metaplasia in the setting of chronic inflammation.
- Leukoplakia is characterized by plaque-like mural based filling defects which may be indistinguishable from urothelial carcinoma.
- Unlike pyeloureteritis cystica, leukoplakia is considered a premalignant lesion along the spectrum of development of squamous cell carcinoma.
- Indeed, when leukoplakia is found at one site in the urinary tract, a synchronous squamous cell carcinoma is often present.
- Malakoplakia is another cause of a plaque-like filling defect in the upper urinary tract.
- However, malakoplakia represents a granulomatous reaction to chronic inflammation and is not considered a premalignant lesion [9].
- Nevertheless, imaging differentiation of leukoplakia and malakoplakia from urothelial carcinoma is virtually impossible and tissue sampling is typically recommended.
- Treatment and prognosis
- Leukoplakia is considered a premalignant condition. There is an association with bladder neoplasia in 25% of cases.
- Differential diagnosis
- malakoplakia of the bladder
- non-neoplastic chronic granulomatous lesions due to chronic infection by Escherichia coli in an immunocompromised patient, commonly diabetes mellitus or transplant recipients
- transitional cell carcinoma
- tuberculous urethritis
- multifocal or long-segment strictures
- calcification is commonly seen
- ureteritis cystica
- reactive proliferative changes of the urothelium causing multiple small subepithelial cysts
- malakoplakia of the bladder
- https://radiopaedia.org/articles/leukoplakia-of-the-urinary-tract-1?lang=gb
- https://radiologykey.com/the-urinary-tract-renal-collecting-systems-ureters-and-urinary-bladder/
- https://pubs.rsna.org/doi/abs/10.1148/88.5.872?journalCode=radiology
What is the cause?
What isn’t this a/w
What are 3 complications?
Acquired diverticulum in bladder outlet obstruction
- Usually multiple
- Not associated with reflux
- Complications:
- Infection
- Calculi, 25%
- Tumor, 3%
Case courtesy of Dr Prat Matifoll, Radiopaedia.org, rID: 30578
What is the location of Extraperitoneal Bladder rupture?
Location
- Base of bladder
- anterolateral
What are the imaging features of Extraperitoneal Bladder rupture?
Imaging
- Pear-shaped bladder
- Fluid around bladder with displaced bowel loops
- Paralytic ileus
What are the causes of Intraperitoneal Bladder rupture?
Intraperitoneal, 45%
Cause
- Blunt trauma
- stab wounds
- invasive procedures
What is the typical location of an intraperitoneal bladder rupture?
Location
- Dome of bladder (weakest point)
What are the imaging features of an intraperitoneal bladder rupture?
Imaging
Contrast extravasation into paracolic gutters
Urine ascites
Presentation
Cerebral palsy patient with blunt abdominal trauma and haematuria.
Postvoid film shows a flame-shaped density adjacent to lateral walls of bladder representing extra-peritoneal contrast from a bladder rupture.
Case courtesy of Dr Ali Nourian, Radiopaedia.org, rID: 27806
Name the radiologic findings of extraperitoneal bladder rupture in VCUG?
A:
1- Pear-shaped bladder
2- Flame-shaped contrast extravasation into perivesical fat best seen on postvoid films
3- Paralytic ileus
https://radiopaedia.org/cases/bladder-rupture-5
Q: What is the most common type of bladder injury? hide answer
A: Extraperitoneal rupture is the most common type of bladder injury
What is the classification system of bladder injury?
Classification of Bladder Injury
- Type 1: Bladder contusion
- Type 2: Intraperitoneal rupture
- Type 3: Interstitial bladder injury
- Type 4: Extraperitoneal rupture
- Type 4a: Simple extraperitoneal rupture
- Type 4b: Complex extraperitoneal rupture
- Type 5: Combined bladder injury
https://pubs.rsna.org/doi/full/10.1148/rg.2018170125
Re Bladder injury, What should preceed cystogram if there is suspicion of urethral injury?
Retrograde urethrogram
Should precede cystogram if there is suspicion of urethral injury such as blood at meatus, “high-riding” prostate, or inability to void
https://www.amboss.com/us/knowledge/Genitourinary_trauma/
What is this procedure?
What percent of bladder ruptures are evident on post-void radiographs?
Cystogram
- Administer 350 mL of 30% water-soluble contrast
- Obtain scout view, AP, both obliques, and postvoid radiographs
- 10% of ruptures will become evident on postvoid radiographs.
https://www.verywellhealth.com/cystogram-uses-side-effects-procedure-results-4173214
What Type of examination is this?
CT cystogram
- Perform scan before the administration of intravesical contrast.
- Retrograde bladder distention is required before CT cystography.
- After Foley catheter insertion, adequate bladder distention is achieved by instilling at least 350 mL of a diluted mixture of contrast material under gravity control.
- Obtain contiguous 3–5 mm axial images from the dome of the diaphragm to the perineum, including the upper thighs.
- The normal CT cystogram will demonstrate a uniformly hyperattenuating, well-distended urinary bladder with thin walls. The adjacent fat planes will be distinct, with no evidence of extravasated contrast material.
Case courtesy of Dr Roberto Schubert, Radiopaedia.org, rID: 14924
What is this proceedure?
What is the indication?
What complication is seen here?
Cystostomy
Indication
• Bladder outlet obstruction
Abstract :
Patients with long-term suprapubic cystostomy can rarely develop squamous cell carcinoma (SCC) of the suprapubic cystostomy tract. In addition to the few reported cases in the literature, this paper reports a case of suprapubic cystostomy SCC in an 88-year-old man without bladder involvement. Vigilance about any abnormal lesion at the site of suprapubic cystostomy is important among health providers and patients for early detection of SCC.
https://www.google.com/url?sa=i&url=https%3A%2F%2Fgo.gale.com%2Fps%2Fi.do%3Fid%3DGALE%257CA551963159%26sid%3DgoogleScholar%26v%3D2.1%26it%3Dr%26linkaccess%3Dabs%26issn%3D2090696X%26p%3DAONE%26sw%3Dw&psig=AOvVaw3m3RiR7HgwGcuIHBBvu-7G&ust=1639441041914000&source=images&cd=vfe&ved=0CAwQjhxqFwoTCNi1oaXA3_QCFQAAAAAdAAAAABAD
What is the proceedure for a cystostomy?
Technique
- Preprocedure workup:
- Check bleeding status
- Antibiotic coverage: ampicillin, 1 g; gentamicin, 80 mg
- Review all radiographs and determine whether bowel loops lie anterior to bladder.
- Place Foley catheter to distend bladder with saline
- Local anesthesia with at least 10 mL lidocaine (Xylocaine)
- Make a skin incision which is approximately two times the diameter of the Foley catheter within the skin.
- Using a metallic trocar which fits around a 14-Fr or 16-Fr Foley catheter, insert the metallic trocar into the bladder under direct US guidance. Make sure that the device is well lubricated with lubricating jelly before insertion.
- Inflate the Foley balloon and peel the Foley catheter off the trocar. Inject the Foley catheter to confirm the position within the bladder.
What comprises the posterior urethra?
Posterior urethra = prostatic + membranous portions
What comprises the anterior Urethra?
• Anterior urethra = bulbous and penile portions
What is this?
- Verumontanum:
- dorsal elevation in prostatic urethra
- receives
- paired ejaculatory ducts and the
- utricle
- Verumontanum is a structure located on the floor of the posterior urethra, which marks the boundary between the membranous and the prostatic segment. During endoscopic resections, it represents a landmark of the striated sphincter and, implicitly, of the lower limit of the intervention. Usually it has a length of 15–17 mm and a height of 3 mm, although there are numerous variations of both shape and size. On both sides of the urethral ridge, the orifices of the prostatic ducts open, and the ejaculatory ducts orifices and prostatic utricle orifice can be found on the upper edge.
- https://www.sciencedirect.com/science/article/pii/B9780128024065000124
What does the membranous urethra demarcate?
Membranous urethra demarcates urogenital diaphragm;
Where do the bulbourethral glands drain into?
What are they AKA?
Cowper glands in urogenital diaphragm; ducts empty into proximal bulbous urethra
What are the labeled structures?
A. Utricle
B. Prostatic urethra
Utricle: müllerian duct remnant; blind-ending pouch in midline
https://caps.nationwidechildrens.org/radiology/atlas/Urethra_Atlas/Prostatic_utricle.html
The prostatic utricle is a small, epithelium-lined diverticulum of the prostatic urethra. It is located in the verumontanum between the two openings of the ejaculatory ducts and extends backward and slightly upward for a very short distance within the medial lobe of the prostate.
It is a normal anatomic variant representing the remnant of the fused caudal ends of the Müllerian ducts, and thus is the homolog of the female vagina and uterine cervix.
When there is deficient secretion or resistance to Müllerian inhibitory factor (MIF), there is failure of normal fusion of the urogenital folds resulting in hypospadius. Hypospadius has the most common association with the prostatic utricle, with an estimated incidence of 14-47%. In the absence of other Müllerian duct derivatives (fallopian tubes, uterus and upper vagina), hypospadius and utricular enlargement are not indicative of an intersex condition. The increasing severity of the hypospadius correlates with increasing size of the utricle. A utricle not uncommon in prune-belly syndrome, and may be seen in patients with imperforate anus and recto-urethral fistula, and in patients with Down syndrome.
The prostatic utricle distends with urine during voiding and then passively drains. Poor emptying leads to urine retention and stasis. Stone formation may result from obstruction. Patients present clinically with chronic urinary tract infection, hematuria, urethral discharge, epididymitis and voiding dysfunction.
The normal prostatic utricle is occasionally seen as an incidental finding on routine VCUG as a tiny diverticulum of a few millimeters in length or on rare occasions measuring up to 1 cm or more. A large prostatic utricle is more often associated with male hypospadius. VCUG and retrograde urethrography (RUG) define the utricular size and its origin from the prostatic urethra. Occasionally a prostatic utricle is bifid, reflecting the bifid nature of its precursors, namely the paired Müllerian ducts. In patients with a large prostatic utricle, direct catheterization of the bladder during VCUG may be difficult secondary to preferential passage into the utricle. Facilitation of catheter placement into the bladder can be accomplished with use of a Coude’ catheter with the tip directed anteriorly, direct perineal pressure and/or insertion of a finger in the rectum with upward pressure during catheter placement.
Differential Diagnosis
- Ectopic ureter. 2. Dilated ejaculatory duct. 3. Mullerian duct cyst.
- Extravasation
What are the 3 types of Urethral injury?
- Types
- Complex trauma with pelvic fractures
- Type 1:
- urethra intact but narrowed, stretched by periurethral hematoma
- Type 2:
- rupture above urogenital diaphragm;
- extraperitoneal contrast, none in perineum;
- partial rupture: contrast seen in bladder;
- complete rupture: no contrast seen in bladder.
- Type 3:
- rupture below urogenital diaphragm;
- contrast in extraperitoneal space and perineum
- Type 1:
- Complex trauma with pelvic fractures
- Soft tissue injury
- Straddle injury:
- injuries to penile or bulbous urethra
- Straddle injury:
SIGN
What is the diagnosis?
What is the sign?
Watering can perineum.
Primary tuberculosis of urethra presenting as stricture urethra and watering can perineum: A rarity
A young man presented with irritative lower urinary tract symptoms and multiple fistulae (watering can) in the perineum since 6 months. Micturating cystourethrogram and retrograde urethrogram was performed after 12 weeks following suprapubic cystostomy which showed bulbar urethral stricture with multiple urethrocutaneous fistulae. He underwent anastomotic urethroplasty and excision of the urethrocutaneous fistulae. Histopathology of the excised fistulous tract showed granulomatous pathology suggestive of tuberculosis. Antitubercular treatment was given for 9 months. The patient is voiding well at 12 months follow-up.
https://www.urologyannals.com/article.asp?issn=0974-7796;year=2016;volume=8;issue=4;spage=493;epage=495;aulast=Prakash
What sign is this?
What causes it?
A retrograde urethrogram opacifies multiple urethroperineal fistulas in a patient with a “watering can perineum”
A watering can (Fig. 1) metaphorically describes the fluoroscopic demonstration of contrast opacifying multiple fistulas from the urethra to the perineum, as seen on voiding or retrograde urethrography (Fig. 2) [1]. In patients with this condition, urine exits through multiple perineal openings, hence the descriptive “watering can” [2].
The urethroperineal fistulas are sequelae of traumatic or chronic inflammatory urethral strictures [2]. Classically, this sign is associated with advanced infection of the urethra and adjacent tissues, most commonly gonorrhea. Associated paraurethral abscesses are frequent [1]. Other etiologies include schistosomiasis, tuberculosis, and Crohn’s disease [1, 2].
https://link.springer.com/article/10.1007/s00261-016-0710-2/figures/2
What is this?
What is the test?
What is the finding?
What is the etiology?
Condyloma acuminata. Retrograde urethrogram demonstrates multiple small filling defects in the anterior urethra.
https://www.researchgate.net/figure/Condyloma-acuminata-Retrograde-urethrogram-demonstrates-multiple-small-filling-defects_fig12_8230962
What test is this?
What is the finding?
What is the cause?
Retrograde urethrogram (a, b) in a case of urethritis demonstrates long segment irregular urethral narrowing (long arrow) associated with Littre gland dilatation (short arrow)
Urethral inflammatory diseases
- Gonococcal urethritis is a sexually transmitted disease caused by Neisseria gonorrhoeae. It commonly presents with purulent discharge. It often leads to complications like strictures which can be severe.
Non-gonococcal urethritis is most commonly caused by Chlamydia Trachomatis, and unlike gonococcal urethritis, is associated with only scanty non-purulent discharge. Complications are less severe as compared to gonococcal infections.
Chronic inflammatory urethritis may result in strictures (15%). Other reported complications include periurethral abscess, pseudodiverticulum, fasciitis, and Fournier gangrene. Urethro-perineal fistulas are more common with tuberculosis and schistosomiasis, although severe non-tuberculous infections may also result in fistulae.
RUG in a case of urethritis typically demonstrates multifocal segmental or long segment irregular urethral narrowing.
There may be opacification of the glands of Littre;
visualization of the glands of Littre is quite specific for inflammatory urethritis.
There may be retrograde opacification of the Cowper’s duct, which is usually related to high voiding pressures due to the obstruction caused by the strictures, with resultant reflux into the Cowper’s ducts [2, 3] (Fig. 9).
https://link.springer.com/article/10.1007/s00261-019-02356-x
SIGN
What sign is this?
What are the findings?
What are the underlying causes?
Retrograde urethrogram in an adult male with genitourinary tuberculosis demonstrates a thimble bladder (asterisk), ureteric strictures (long arrow), and vesico-ureteric reflux (short arrow)
Tuberculosis rarely involves the urethra and is usually a descending infection from the kidneys. The acute inflammatory phase is characterized by urethral discharge, and associated with prostatitis and epididymitis. The chronic stricturing stage presents with periurethral abscesses, perineal and scrotal fistulas, and a ‘watering can’ perineum. RUG may demonstrate prostato-cutaneous and urethro-cutaneous fistulas, in addition to a small-volume contracted bladder (“thimble bladder”), vesico-ureteric reflux, and ureteric strictures [22] (Fig. 10).
https://link.springer.com/article/10.1007/s00261-019-02356-x
What is the test?
What is the finding?
Which specific anatomy does it affect?
Retrograde urethrogram in a case of poor urinary stream. There is a high-grade stricture in the bulbar urethra (long arrow) with retrograde opacification of the Cowper’s duct (short arrow)
https://link.springer.com/article/10.1007/s00261-019-02356-x
what is this?
Sphincter seen on US as a hypoechoic structure 1.0–1.3 cm in diameter
Urethral sphincter (US) manifested as an omega shape on reconstructed axial planes. Its volume was calculated automatically after drawing along the outline of the urethral sphincter on serial axial planes. A, Cranial portion of the urethral sphincter. B and C, Middle portions of the urethral sphincter. D, Caudal portion of the urethral sphincter. IC indicates inner core.
https://www.researchgate.net/figure/Urethral-sphincter-US-manifested-as-an-omega-shape-on-reconstructed-axial-planes-Its_fig1_321459511
Condyloma acuminata. Retrograde urethrogram demonstrates multiple small filling defects in the anterior urethra.
https://www.researchgate.net/figure/Condyloma-acuminata-Retrograde-urethrogram-demonstrates-multiple-small-filling-defects_fig12_8230962
Recurrent cystitis with impediment sensation of the urine passage and painful coitus.
Female uretral diverticulum.
In the proximal vagina exists oval hyperintense formation with regular margins that surrounding the urethra.
During urination is appreciable filling of a diverticulum located on the back urethra, about 15 mm to external urethral orifice. Normal bladder and the opening of the bladder neck.
Case courtesy of Dr Domenico Nicoletti, Radiopaedia.org, rID: 46630
SIGN
What sign is this?
what is the pathology?
Figure 23. 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.
https://pubs.rsna.org/doi/10.1148/rg.24si045504
What is the differential for this appearance?
What is the dx?
Which part of the urethra is affected?
Figure 25. Squamous cell carcinoma of the male urethra. Retrograde urethrogram reveals a segment of irregular stricture of the bulbous urethra.
Figure 26a. 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. The patient underwent perineal partial urethrectomy.
https://pubs.rsna.org/doi/10.1148/rg.24si045504
Figure 29. Urethral metastasis from prostate carcinoma. Retrograde urethrogram shows a segment of smooth extrinsic narrowing of the bulbous urethra. Note the skeletal metastases.
https://pubs.rsna.org/doi/10.1148/rg.24si045504
SIGN
What sign is this?
What is the etiology?
Figure 53. Pie-in-the-sky bladder. Scout image of the pelvis, obtained after administration of contrast material for CT, demonstrates bilateral pubic rami fractures. The associated pelvic hematoma elevates the bladder, giving it the pie-in-the-sky appearance. There was an associated posterior urethral injury
https://www.semanticscholar.org/paper/URORADIOLOGIC-SIGNS-S-247-Classic-Signs-in-1-CME-Dyer-Chen/62a3b8a1440bed14d6f2c581d2ed3b46e9fe1ff2/figure/34
When does this tend to occur?
Female urethral diverticula usually acquired after infection, followed by obstruction of Skene glands.
https://www.researchgate.net/figure/Urethral-diverticulum-arrow_fig1_43341879
How do you image female urethral Diverticulae?
- If nonobstructed,
- 75% will be seen on postvoid IVP radiograph (intravenous Pyelogram)
- 90% on voiding cystourethrogram,
- remainder require double-balloon catheter positive-pressure urethrography
A voiding cystourethrogram (VCUG) is an exam that takes images of the urinary system. The patient’s bladder is filled with a liquid called contrast material. Then, images of the bladder and kidneys are taken as the bladder fills and also while the patient urinates (pees).
Image = DBU
The preoperative work-up of female urethral diverticula should provide the surgeon with maximum data regarding the anatomy and structure of the diverticulum. Preoperatively, the number of diverticula, as well as the location, size, configuration, and communication to the urethra need to be clearly depicted. The objective of this study was to compare the information gained by voiding cystourethrography (VCUG) and positive-pressure double-balloon urethrography (DBU), and to verify which imaging modality can better delineate the features of the diverticula. Twelve women with a presumptive clinical diagnosis of a urethral diverticulum underwent VCUG followed by DBU, and the radiological data from each modality were compared. In 4 of 12 patients (33.3%) VCUG completely failed in demonstrating the diverticulum, whereas DBU showed a large complex diverticulum in 2 patients and a distinct mid-urethral diverticulum in 2 patients. In the remaining 8 women (66.7%) VCUG delineated only the lower part of the diverticulum, whereas DBU depicted a large diverticulum extending beneath the bladder neck in 3 patients and multiple diverticula in 5 patients. The sensitivity of DBU and VCUG, in our series, was therefore 100 and 66.7%, respectively. The DBU supplied excellent documentation regarding the location, size, configuration, and communication of the diverticula to the urethra in every case, which markedly facilitated surgical excision of the diverticula in 9 of 12 patients. Three patients refused surgery and elected conservative treatment. In our experience, VCUG had a low sensitivity as a screening test for the diagnosis of female urethral diverticula, and failed to demonstrate properly the major structural characteristics of the diverticula, whereas DBU was highly sensitive as a diagnostic tool and supplied excellent anatomical delineation of the diverticula.
https: //link.springer.com/article/10.1007%2Fs00330-002-1539-3
https: //www.ajronline.org/doi/pdf/10.2214/ajr.136.2.259
What is this?
How often does this occur?
Re female urethral diverticulae, how often do calculi occur?
Calculi, 5%–10%
Fig. 2. Four smooth stones inside the urethral diverticulum.
https://www.sciencedirect.com/science/article/pii/S1879522614000578
UD was first reported 2 centuries ago by Hey,1 but until the invention of positive-pressure urethrography in 1952 by Davis and Cian,2 only a few cases were discovered. Up to 20% of patients may be asymptomatic; therefore, the true incidence is unclear because of missed diagnoses, although the accepted prevalence is about 0.5–6%.3
UD patients present with diverse symptoms, but the classical symptoms of “3Ds” are dysuria, dyspareunia, and postvoiding dribbling. Other symptoms associated with UD are frequency, urgency, hematuria, SUI, and persistent pyuria. The most important findings on physical examination are palpable vaginal mass and discharge after stripping. However, in a series with 46 female patients with urethral diverticula, the mean time from occurrence of symptoms to diagnosis is 5.2 years, despite the fact that 52% of those patients had palpable vaginal masses3—as in the case of our patient, who did not notice the vaginal mass but sought medical advice because of symptoms of SUI.
Double balloon positive pressure urethrography is a good diagnostic tool but is not widely available. Compared to voiding cystourethrography and ultrasonography, high-resolution MRI has higher sensitivity and specificity, especially when differential diagnoses of urethral masses other than UD are present.4, 5
UD presenting with urolithiasis is uncommon, with an incidence of 1–10%. The etiology may be deposition, stasis of infected urine, or stone migration. To our knowledge, studies seldom compare the diagnosis and management between UD with or without stones. Almost all UD with stone present with palpable hard vaginal masses, and patients tend to receive surgical excision rather than conservative treatment.
