Module 4 - Genito-urinary Flashcards
difference in shape of adrenals
right is triangular
left is crescentic
shape of adrenal if kidney is absent
pancake
number of arteries to adrenals
3 to each
arteries arise from where to get to the adrenals
superior from the inferior phrenic
middle from aorta
inferior from renal artery
adrenal gland drainage
right to IVC
left to renal vein
anatomy of adrenal gland into two areas
cortex and medulla
cortex of adrneal gland can b broken into
Zona
- glomerulos
- fasciculata
- reticularis
What does each zone of the adrenal make
Glomerulos
- Aldosterone
Fascilculat
- Cortisol
Reticularis
-androgens
medulla
- catecholamins
Adrenal appearance onf US
(normally only seen in in babies)
bright cortex
dark medulla
causes of adrenal hypertrophy
conditions
21-hydroxylase deficiency
cushing syndrome
21 hydroxylase deficiency - how does it manifest
genital ambiguity in girls
salt losing nephropathy in boys
how does 21 hydroxylase deficiency look on US
loss of central hyperechoic stripe
adrneal limb width greater than 4mm
cushing syndrome - caused by what?
too much cortisol.
pituitary adenoma (disease).
Small cell lung cancer
How does adrenal haemorrhage manifest itself with stress in neonates?
fetal distress as trigger.
appearance based on timing since bleed.
calcification is end result
haemorrhage in adrenal gland as an adult - more common on which side?
right
Waterhouse-Friderichsen syndrome is what
haemorrhage of adrenal in the setting of fulminant meningitis
waterhouse -friederichsen caused by what organism?
Neisseria meningitiidis
PHaeo appearance on CT
heterogenous
Phaeo on MRI
bright T2
Which nuc med tests can be used for phaeo
MIBG and octreatide
Phaeo rule of 10s
10% are
extra adrenal
bilateral
in kids
hereditory
benign
Phaeo is ax with what syndromes?
VHL
Men 2a and 2b
NF1
sturge weber
Tuberous sclerosis
What is carney triad
extra adrenal phaeo
GIST
pulmonary chondroma
what is carney complex
cardiac myxoma and skin pigmentation
adenal myolelipoma - appears as what
fat
can be large
can bleed
ax with endocrine disorders
what mets to adrenal glands
breast
lung
melanoma
adrenal cortical carcinoma
size
features
large 4cm to 10cm
calcify in 20%
how to work out an adenoma on CT?
percentage enhancement.
over 60 adenoma
how to tell adneoma on MRi
drop out on in and out phase imaging
what happens if the adenoma is functioning?
can gets cushings or conns
calcified adrenals - think….
prior trauma
infection like tb
tumour - melanoma mets, corticol carcinoma, neuroblastoma
Wolman disease
bilateral enlarged calcified adrenals
fat metabolism error, kills in 6 months
MEN 1
Parathyroid hyperplasia
pituitary adenoma
pancreatic tumour
straight line, number 1.
MEN2A
Medullary thyroid
Parathyroid hyperplasia
phaeo
A shape over the body.
Men 2B
Medullary thyroid cancer
phaeochromocytoma
Mucosal neuroma
Marfanoid body habitus
if renal echogenicity is greater than the liver what are we thinking
impaired renal function
Fetal lobulation vs scarring
lobulation - renal surface indentations overle the space inbetween the pyramids
scarring - indentations overlie the medullary pyramids
What is the dromedary hump?
focal bulge on left kidney, forms as a result of adaption to adjacent spleen
Column of bertin - what is it
splaying of the sinus due to hypertrophy of the cortical tissue in the middle.
BILATERAL kidney agensis should think about what syndrome ?
Potter sequence
uni;ateral kidney agenesis - what else to look for in men and women
Women - genital anomalies, unicornuate uterus
Men - 20% have absence of ipsilateral epididymis/vas deferens or seminal vesicale cyst
Potter sequence - what happens to result in no lungs
No kidneys
no pee
no development of the lungs
Mayer-Rokitansky-Kuster-Hauser
what is it
mullerian duct anomalies, including atresia of the uterus.
unilateral renal agenesisi is associated
Pankcake adrenal
elongated adrenal if agenesis of the kidney
useful for surgical or congenital absence of the kidney
Horseshow kidney, what is the ax
Wilms tumour
TCC from lots of infecitons
Recurrent infeciton
Turners syndrome
Crossed fused renal ectopia - what is it
one kidney comes over the midline to fuse with the other.
get infection, stones and hydronephrosis
RCC risk factors
tobacco
VHL
Dialysis chronic
Fhx
RCC in bones as mets appear as what
lytic
RCC with contrast
avidly enhance
can RCC have fat in them
for sure, often with calcification
subtypes of RCC
clear cell
papillary
medullary
chromophobe
clear cell RCC - ax with what
behaves with contrast on corticomedullary phase
Ax with VHL
equal to cortex on corticomedullary phase
papillary RCC - how vascular are they?
how will they enhacne
less vascular
less enhancement
medullary RCC is ax with what condition ?
Sickle Cell
Chromophobe RCC is ax with what?
Birt Hog Dube
How will renal lymphoma look liek?
can be anything
bilateral enalrged with lymph nodes around enalrged also
low attneuation corticol nodules/masses.
often get a preserved shape
renal leukaemia will look like what?
corticol based lesions
oncotyoma
benign or malignant
benign
second most common after AML
Oncotyoma looks like an RCC except for
A central scar
spoke wheel vascular pattern
RCC vs oncocytoma on PET
RCC is colder than parenchyma
Oncotyoma is hotter
butreally not used as reanlly excreted
non communicating, fluid filled loculs surrounded bby thick fibrous capsule protrudes into the renal pelvis
Dx
and distribution
Mutlilocular cystic nephroma
MJ lesion -bibodal distribution
Describe the 1st Bozniak cyst classifications
Simple - less than 15HU. no enhacnement
Describe 2 Bozniak cyst
Hyperdense, less than 3cm, thin calcification, thin septations
Bozniak 2F classification - what is it ?
hyperdense (over 3cm)
Minimally thickened calcifications
Bozniak 3 classifcaiton s
thick sepatations.
irregularnode
Bozniak 4 - classificaiton
any enhancement (<15 HU)
mural nodule
hyperdense cysts
greater than 70HU and homogenous considered benign.
ADPKD.
what happens to the kidneys
Get larger and lose function
get cyst in liver
Berry aneurysms
ARPKD what do they get?
hypertension and renal failure
abnormal bile ducts and fibrosis of liver
liver and kidneys are inversely related in how well the organs do
uraemic cystic kidney disease - who gets it?
end stage renal failure patients
cysts regress after transplant
VHL - what do people get ?
Pancreas - cysts and serous adenomas
Adrenal - phaeo
CNS - haemangioblastoma
How does Tuberous sclerosis affect the kidneys?
multiple bilateral angiomyolipomas
Renal cysts in lithium nephropathy - how many
inumerable tiny cysts
also small kidneys
Multicystic dysplastic kidney - who does it affect
what happens
kids in utero
no fucntioning renal tissue
on T2 - renal cysts are normally
bright
if renal cyst is T2 Dark what do you do?
Need to work between
Lipid poor AML (think TS)
Haemorrhagic cyst (T1 bright)
Papillary subtype RCC
common infection cuasing pyelonephritis
e coli
what is seen on pyelonephritis on CT/
perinephric fat stranding
striaited nephrogram
straited nephrogram is related to areas of decreased perfusion
what are the differentials?
Acute ureteral obstruction
acute pyelonephritis
medullary sponge kidney
acute renal vein thrombosis
radiation nephritis
renal contusion
hypotension
infantile polycystic kidney (bilateral)
emphysematous pyelonephritis
life threatening
necortizing
gas within the kidney or around
diabetics
emphysematous pyelitis
less bad to previous one
gas in collecting system
Pyonephrosis
infected or obstructed collecting system.
Xanthogranulomatous pyelonephritis
chronic destructive granulomatous process.
often staghorn as nidus for repeated infections.
Bear paw appearance
Papillary necorosis
renal papillae die - commonly involves medullary pyramids
Ax diabetes
causes of papillary necrosis?
pyelo, sickle cell, TB, analgesic, cirrhosis,
and the big one DIABETES
How does HIV nephropathy appear ?
echogenic on US
Loss of corticomedullary differentiation
Obliteration of sinus fat
types of kidney stone
calcium oxolate
struvite stone
uric acid
indinavir
commonest type of kidney stone
calcium oxolate
type of stone associate with UTI
struvite
Cystine associated with what
metabolic disorders
stones not seen on CT
Indinavir
what is corticol nephrocalcinosis?
happens as a result of corticol necrosis
what is medullary nephrocalcinosis ?
US hyperechoic renal papilla/pyramids.
cause commonest is hyper PTH
what is medullary sponge kidney
congenital
causes nephrocalcinosis.
Ehler danlos ax.
Beckwith weidman ax.
What is page kidney ?
long standing compression of the kidney by a SUBcapsular colleciton.
eg post lithotripsy sub capsular haemotoma.
what does it mean if there are persistent nephrogram?
shock / hypotension
causing ATN.
unilateral delayed nephrogram ?
pressure on the kidney some how.
what are the various signs in renal infarction ?
corticol rim sign(due to blood supply)
flip flop enhancement
when do you see the corticol rim sign?
immediately then 8hour to days later
renal vein thrombosis can mimic what what?
A renal stone
flank pain, swollen kidney and delayed nephrogram
what does Renal vein thrombosis cause on doppler?
reversed arterial diastolic flow
absent venous flow
How is renal trauma graded? what levels of injury?
haematoma
laceration <1cm
involvement of the vein or lac >1cm
collecting system lac, artery laceration
shattered kidney
avulsion of renal hilum
What is meant by a fractured kidney?
laceration extending the full length of renal parenchyma
connects two corticol surfaces
What is meant by a shattered kidney ?
3 or more fragments
A segmental artery injury will appear as what kind of shape?
Wedge shaped perfusion defect
A persistent nephrogram will raise concern for a
renal vein thrombosis / injury
what kind of resitance should a transplant kidney have?
should always be low
RI in transplant kidney should stay below what value?
0.7
What will happen to the RI of a sick kidney
increase
Complication categories of a transplanted kidney are what?
3 of them
Urologic
Vascular
Cancer
Urologic complications of transplanted kidneys - what are they
Urinoma
haematoma
lymphocele
acute rejection / ATN
Chronic Rejection
Calculous disease
Urologic complications of transplanted kidneys - Urinoma
details
within 2 weeks post op
Urine leak / urinoma
Urologic complications of transplanted kidneys - haematoma
detial
Common immediately post op
Urologic complications of transplanted kidneys
lymphocele
details
1-2 months post op. Leakage of lymph after surgery.
often between graft kidney and bladder
Urologic complications of transplanted kidneys
acute rejection.
details
occurs in first week
RIs up, kidney enlarges
prominent pyramids
to distinguish acute rejection from ATN
MAG3.
ATN has normal perfusion
Rejeciton abnormal perfusion
both delayed excretion
Urologic complications of transplanted kidneys
chronic rejeciton
appearance
after 1 year
lose corticomedullary differentiation
Urologic complications of transplanted kidneys
calculous disease
post transplant more likely to get these
Vascular complications of transplanted kidneys:
what are they
renal artery thrombosis
renal artery stenosis
renal vein thrombosis
arteriovenous fistula
pseudoaneurysm
Vascular complications of transplanted kidneys
Renal artery thrombosis occurs when
1% of transplanted kidneys within 1 week
Vascular complications of transplanted kidneys
Renal artery thrombosis occurs because of
kinking
hypercoagulation
hyperacute rejection
Vascular complications of transplanted kidneys
Renal artery stenosis
occurs in…
5-10% of patients
occurs at the anastomosis
there are specific criteria for this
Vascular complications of transplanted kidneys
Renal artery stenosis
criteria on US
PSV >200-300cm/s
PSV ratio >3.0
Tardus parvus
anastomotic jetting
Vascular complications of transplanted kidneys
Renal vein thrombosis occurs when
2nd week post op
Vascular complications of transplanted kidneys
Renal vein thrombosis - doppler would show
in vein no flow
in artery reversed diastolic flow.
Reverse M sign
doppler in renal vein thrombosis causes reversed diastolic blood flow in artery
arteriovenous fistula
Vascular complications of transplanted kidneys
how do people get it
post biopsy - 20%
though most asymptomatic
arteriovenous fistula
Vascular complications of transplanted kidneys
what will it show on US
pulsatile vein
tissue vibration artefact
Vascular complications of transplanted kidneys
pseudoaneurysm
can get post biospy
yin yang color picture of doppler at the neck of the aneurysm
what are the types of cancer i nthe post transplant kidney patient
RCC
Post transplant lymphproliferative disorder
cyclophosphamide can give urothelial cancer
Cancer in the transplanted patient
RCC
normally occurs in native kidney
Post transplant lymphoproliferativ disorder
Assocaited b cell proliferation
often involves multiple organs
linkto EB virus
how many layers do the ureters have
3
inner ureter layer is what
transitional epithelium
Developmental Ureter anomalies
Congential primary MEGAureter
what is it
intrinsic dilation. not obstructed
almost always the left side only
Developmental Ureter anomalies
Congential primary MEGAureter
what causes it
distal adynamic segment
reflux at the UVJ
idiopathic
Developmental Ureter anomalies
Retrocaval ureter
what is it
developmental anomaly o the IVC
causes partial obstruction and recurrent UTI
Fishhook or reverse J appearance to the ureter
Developmental Ureter anomalies
Dupicated system
what is the weigert meyer rule
Upper - Infer medially inserts, obstructs + ureterocele.
Low - flow –> reflux
up obstructs
low flows
Developmental Ureter anomalies
ureterocele
what is it
cystic dilatation of the intravesicular ureter
secondary to obstruction at the ureteral orifice.
cobra head sign.
Developmental Ureter anomalies
pseduouroeterocele
what is it
acquired dilatation of submucosla portion of distal ureter.
stone or bladder mlignancy possibe
loss of the usual lucent line cobra head sign
Developmental Ureter anomalies
ectopic ureter
incontinence in women
inserts distal to the external sphincter in the vestibule
Developmental Ureter anomalies
vesicouroteral reflux
what is it
retrograde flow of urine
short ureter as it corsses the bladder so dodgy valve mechanism .
Developmental Ureter anomalies
congenital UPJ obstruction
20% are bilateral
defects in circular muscle bundle of the renal pelvis.
tx is pyeloplasty
ax with multicystic dysplastic kidney disease
crossing vessels.
Vesicoureteric reflux in opposite kidney
ureteral wall calcificaitons
two dx to think of ?
TB
schistosomiasis
ureteritis cystica
what is it
multiple small subepithelial fluid filled cysts in the wall
of the ureter.
diabetics with recurrent uti
ureteral pseduo diverticolosis
what is it ?
from chronic inflammation
multiple small outpouchings in the upper middle thirds
Leukoplakia
what is it?
premalignant squamous metaplasia
from chronic inflammation
Malacoplakia
what is it
who does it affect
what happens
treatment?
inflmmatory condition in setting of chronic UTI
Ax E coli and immunocompromised women
nodular intramural lesions of ureter
can obstructs.
Michaelis Gutmann bodies.
improves with antibiotics
causes of retroperitonealfibrosis
idiopathic 75% of the time
radiation
mediacionts (methyldopa, ergotamine, methysergie)
infalmmatory
malignancy (desmoplastic and lymphoma)
imaging options in retroperitoneal fibrosis
PET to find a primary
RF - PET will be avid if inflammatory active
which disorders are assocaited with Retroperitoneal fibrosis
Ig4
autoimmune pancreatitis
riedels thyroid
inflammatory pseudotumour
subepitheliai lrenal pelvishaemtoma
what is it
aslsocalled a Antopol-Goldman lesion
thickened upper tract wall
patients on long term anticoag
mimic for TCC but doesn’t enhance post contrast
Goblet and champgane glass sign think
TCC
TCC risk factors
Drugs - cyclophosphamide
Occupation - dye workers
Stones
Horseshow kidney
ureteral psedodiverticulosis
hereditory non polyposis colon cancer
Least likely place to get TCC
ureter
bladder most then renal pelvis
Balkan nephropathy
super high rate of upper ureter TCC
degenerative nephropathy
causedby eating aristolochic acidd in seeds of the Aristolochia clematitis plant
Schistomasis leads to
Squamous cell carcinoma
Haematogenous metastasis
normally through soft tissues into the walls.
What is a fibroepithelial polyp?
benign
proximal ureter
smooth oblong mobile defect on urography
what cna cause medial deviation of the ureters
4 things
Retroperitoneal fibrosis
retrocaval ureter (right side)
pelvic lipomatosis
psoas hypertrohy
What can cause lateral deviation of the ureters
retroperitoneal adneopathy
aortic aneurysm
psoas hypertrophy
bladder developmental anomalies
prune belly (Eagle barrett)
malformation triad
abdo wall deficiency
hydroureteronephrosis
cryptoorchidism
Bladder diverticula
seen in…
acquired due to…
boys
chronic outlet obstruction can cause
or ehlos dahnlos
what is Hutch diverticulum
assocaited with reflux because of VUJ valves not working.
where are bladder diverticula usually found
lateral walls or near ureteral orifices
ureters deviate medially adjacent to a diverticula
bladder ears are what
transitory extrapeirooneal herniation of the bladder
protrudes bladder into the unguinal canal.
Cloacal malformation
GU and GI drain together
Urachus is what
the umbiliacl attachement of the bladder
can get pee in it
can get adneocarcinoma
What are the types of bladder cancer
Rhabdomyosacoma
TCC
SCC
Adenocarcinoma of the bladder
Leimyoma
Rhabdomyosarcoma
Botryoid variant produces a polypoid mass which looks like
a bunch of grapes
greekBotrys means grape
Most common type of bladder TCC
superficial papillary 70-80%
in contrast to superfiicla high grade carcinoma in situ.
invasive.
superfiiclal - papillary or grade
invasive
how does SCC show on imaging
heavily calcified bladder and distal ureters
adenocarcinoma of the bladder ax with what
urachus
therefore midline
post bladder diversion surgery
describe some early complications
Altered bowel function
urinary leakage
fistula
Altered bowel function post bladder diversion surgery happens how
SBO or adynamic ileus
fistula in bladder diverisonvsurgery is most common in which group o patients q
those who have received radiation
describe some late complications of bladder diversion surgery
Urinary infection
Stones
Parastomal herniation
urinary stricture
tumor recurrence
WHAT is emphysematous cystitis
gas forming organism in wall of bladder
diabetic
E Coli.
How does TB in bladder presented
Calficiation
retracted bladder
will affect upper tracts before
what are the three different types of fistula and their assocaited conditions
Colovesicial fistula
- Diverticular disease
Ileovesical fistula
- Crohns
Rectovesical fistulas
- Neoplasm or trauma
neurogenic blader comes in what two forms/
small contracted bladder -above S2
atonic large bladder - motor or sensory
urine stases elads to complications
stones in bladder can cause whatB?
irritation - risk factor for TCC and SCC
Pear shaped bladder think
pelvic lipomatosis
haematoma
key quesiton ot answer with bladder rupture
extra or intra peritoneal rupture
CT cystography to review
Extraperitoneal bladder rupture
common with what fracture
pelvic
Molar Tooth sign for blader rupture is what
contrast in the prevesicle space of Rezius.
How does intraperiotneal bladder rupture happen
blow to a full bladder
blows the dome off
contrast around bowel loops
Urethral trauma injuries are based on what ?
location
what are the loctions of urethral injuries
Type 1 - stretched
T2 - rupture above UG diaphragm
T3 - belo UG diaphragm.
T4 - bladder extending to the urethra
T5 - injury to the anterior urethra.
differentiate traumatic bulbar stricture vs gonococcal urethral stricture
long irregular stricture for gonococcal, in the distal
urethrorectal fistula caused by
brachytherapy
urethral diveticulum caused by placement of
long term foley catheter
what kind of cancer will it be in. aurethral diverticulum
adenocarcinoma
female urethral diverticulum is caused by
repeat infections of the periurethral glands
how is a fractured penis defined
corpus cavernosum and its surround sheath the tunica albuginea
Prostate
Central gland comprises
transition zone and central zone
Prostate
Anterior fibromuscular gland on MRI
Dark on T1 and T2
Central gland on MRI
brighter than the anterior fibromuscular gland
Peripheral zone on T2 MRI
the brightest
Prostate adenocarcinoma is found. inwhich zone
peripheral the most
then transition 20%
then Central zone 10%
What does cancer do on T2 prostate
darkv
cancer on MRI
diffusion does waht
restricts
if prostate cancer restricts on MRI
what is the ADC
low
Enhacnement and washout of prostate cancer on MRI
Type 3 curve
enhances and washes out
prostate cancer stage b vs c
b - confined to the capsule
c - extension though. bulging of the capsule
BPH involves which zone?
Transitional zone
median lobe indents bladder
BPH nodules on MRI are
transitional zone
T2 heterogenous
restrict diffusion
enhance and washout
post biopsy T1 bright in the gland
subacute blood
prostatic utricle cyst / mullerian duct cyst
what are they
anatomical variant of caudal ends of mullerian ducts in men.
prostatic utricle is a focal dilationin the prostatic urethra.
What conditions. areassociate with prostatic utricle cyst
Hypospadias
Prune belly syndrome, downs, unilateral renal agenesis, imperforate anus
large can get infected
mullerian duct cyst can contains which cancers
endometrial
clear cell
squamous
seminal vesicle cysts
unilateral, lateral cysts
congential or acquired
associated with
renal agensis, vas deferens agenesis, ectopic ureter insertion, PKD
what are the midline male pelvic cysts
prostatic utricle -
urticlecyst - ax hypospadis
mullerian duct cyst - 30s 40s.
ejaculatory duct cysts
lateral pelvic cysts in men
seminal vesicle cyst
diverticulosis of the ampulla of vas deferens
testicle trauma
rupture vs fracture
why important
rupture need surgical intervention
testicular rupture, what happens to the tunica albuginia
disrupted
heterogenous testicle and poorly defined testicular outline think
Rupture testicle
fracture testicle - aluginea layer
intact
US appearance of testicle in a fracture
hypoechoic band across the testicle
cause of torted testicle
Bellclapper deformity
abnormal high attachement of tunical vaginalis
increases mobility and predisposes to torsion
bilat so bilat orchiopexy
epididymitis. caused by
chlamydia or gonorrhea
old men ecoli
epidydymitis US findings
increased size and vascularity
can then go to orchid
Isolated orchitis think….
mumps
epidermoid cysts in testicle - what are they
benign
onion skin look.
non vascular
calcified vas deferns in which patient group
diabetics
hypodense leison ins testicle
cancer until proven otherwise
absent doppler on hypoechoic testicular mass think
haematoma
testicular mets via
except for
lymphatics
but choriocarcinoma is via blood
testicle cancer risk factors
crypto orchidism
gonadal dysgenesis
klinefelters
trauma
orchitis
What is recommended for testicular microlythisasis ?
6 month follow up
uncertain link wuth Germ Cell TUmours
Seminoma appear as what
US - homogenous hypoechoic mass repalces entire testicle
MRI 0 homogenously T2 dark
Non seminomatous germ cell tumour
types
mixed germ cell tumours
teratomas
yolk sac tumours
choriocarcinoma
heterogenous and larger calcificaitons
Testicular lymphoma - why can it hide
blood testes barrier means difficult for chemo to get to. can hide
Testicular lymphoma
what type
non hodkin B cell
US appearance. oftesituclar lymphoma
focally or diffusely
hypoechoic vascular lymphomatous tissues
Multiople hypoechoic masses of the testicle
Burned out testicular tumour
what is it
large dense calficiations of. anold tumour. May be active still. most take them out.
which tumours get Gynecomastia
Sertoli Leydig Tumours
Sertoli cell tumours also seen with
Peutz Jeghers
Elevated hCG testicle tumours
Seminoma
Choriocarcinoma
Elevated AFP testicle tumours
Mixed germ cell
yolk sac
Casues of male infertility can be categorised as
Obstructive or Non obstructive
OBstructive causes of male infertility
absent vas deferens (CF)
ejaculatory duct obstruction
prostatic cysts
Zinner syndrome
Non obstructive cause of male infertility
variocele
cryptochidism
anabolic steroids
ED
cryptorchidism is what
undescended testes
cryptorchidism increased risk. of
cancer. inthat testicle
infertility
torsion
bowel incarcerated - ax indirect inguinal hernia
Syndrome of cant smell and infertile
Kallmans
Syndorme
tall gynecomastia
infertile
Klinefelters
renal agenesis
ipsilateral vesicle cyst
syndrome
Zimmer syndrome
Angiomyolipomas >40mm are more at risk of what?
What may be offered?
Haemorrhage
Embolisation
