Module 4 - Genito-urinary Flashcards by Nicholas Bridger

difference in shape of adrenals

right is triangular
left is crescentic

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shape of adrenal if kidney is absent

pancake

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number of arteries to adrenals

3 to each

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arteries arise from where to get to the adrenals

superior from the inferior phrenic
middle from aorta
inferior from renal artery

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adrenal gland drainage

right to IVC
left to renal vein

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anatomy of adrenal gland into two areas

cortex and medulla

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cortex of adrneal gland can b broken into

Zona
- glomerulos
- fasciculata
- reticularis

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What does each zone of the adrenal make

Glomerulos
- Aldosterone

Fascilculat
- Cortisol

Reticularis
-androgens

medulla
- catecholamins

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Adrenal appearance onf US
(normally only seen in in babies)

bright cortex
dark medulla

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causes of adrenal hypertrophy

conditions

21-hydroxylase deficiency

cushing syndrome

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21 hydroxylase deficiency - how does it manifest

genital ambiguity in girls
salt losing nephropathy in boys

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how does 21 hydroxylase deficiency look on US

loss of central hyperechoic stripe
adrneal limb width greater than 4mm

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cushing syndrome - caused by what?

too much cortisol.
pituitary adenoma (disease).
Small cell lung cancer

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How does adrenal haemorrhage manifest itself with stress in neonates?

fetal distress as trigger.
appearance based on timing since bleed.

calcification is end result

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haemorrhage in adrenal gland as an adult - more common on which side?

right

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Waterhouse-Friderichsen syndrome is what

haemorrhage of adrenal in the setting of fulminant meningitis

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waterhouse -friederichsen caused by what organism?

Neisseria meningitiidis

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PHaeo appearance on CT

heterogenous

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Phaeo on MRI

bright T2

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Which nuc med tests can be used for phaeo

MIBG and octreatide

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Phaeo rule of 10s

10% are
extra adrenal
bilateral
in kids
hereditory
benign

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Phaeo is ax with what syndromes?

VHL
Men 2a and 2b

NF1
sturge weber
Tuberous sclerosis

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What is carney triad

extra adrenal phaeo
GIST
pulmonary chondroma

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what is carney complex

cardiac myxoma and skin pigmentation

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adenal myolelipoma - appears as what

fat
can be large
can bleed

ax with endocrine disorders

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what mets to adrenal glands

breast
lung
melanoma

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adrenal cortical carcinoma

size
features

large 4cm to 10cm
calcify in 20%

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how to work out an adenoma on CT?

percentage enhancement.

over 60 adenoma

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how to tell adneoma on MRi

drop out on in and out phase imaging

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what happens if the adenoma is functioning?

can gets cushings or conns

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calcified adrenals - think….

prior trauma
infection like tb

tumour - melanoma mets, corticol carcinoma, neuroblastoma

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Wolman disease

bilateral enlarged calcified adrenals

fat metabolism error, kills in 6 months

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MEN 1

Parathyroid hyperplasia
pituitary adenoma
pancreatic tumour

straight line, number 1.

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MEN2A

Medullary thyroid
Parathyroid hyperplasia
phaeo

A shape over the body.

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Men 2B

Medullary thyroid cancer
phaeochromocytoma
Mucosal neuroma
Marfanoid body habitus

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if renal echogenicity is greater than the liver what are we thinking

impaired renal function

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Fetal lobulation vs scarring

lobulation - renal surface indentations overle the space inbetween the pyramids

scarring - indentations overlie the medullary pyramids

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What is the dromedary hump?

focal bulge on left kidney, forms as a result of adaption to adjacent spleen

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Column of bertin - what is it

splaying of the sinus due to hypertrophy of the cortical tissue in the middle.

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BILATERAL kidney agensis should think about what syndrome ?

Potter sequence

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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

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Potter sequence - what happens to result in no lungs

No kidneys
no pee
no development of the lungs

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Mayer-Rokitansky-Kuster-Hauser

what is it

mullerian duct anomalies, including atresia of the uterus.

unilateral renal agenesisi is associated

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Pankcake adrenal

elongated adrenal if agenesis of the kidney

useful for surgical or congenital absence of the kidney

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Horseshow kidney, what is the ax

Wilms tumour
TCC from lots of infecitons
Recurrent infeciton

Turners syndrome

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Crossed fused renal ectopia - what is it

one kidney comes over the midline to fuse with the other.

get infection, stones and hydronephrosis

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RCC risk factors

tobacco
VHL
Dialysis chronic
Fhx

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RCC in bones as mets appear as what

lytic

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RCC with contrast

avidly enhance

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can RCC have fat in them

for sure, often with calcification

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subtypes of RCC

clear cell
papillary
medullary
chromophobe

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clear cell RCC - ax with what
behaves with contrast on corticomedullary phase

Ax with VHL
equal to cortex on corticomedullary phase

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papillary RCC - how vascular are they?

how will they enhacne

less vascular

less enhancement

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medullary RCC is ax with what condition ?

Sickle Cell

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Chromophobe RCC is ax with what?

Birt Hog Dube

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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

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renal leukaemia will look like what?

corticol based lesions

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oncotyoma

benign or malignant

benign

second most common after AML

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Oncotyoma looks like an RCC except for

A central scar

spoke wheel vascular pattern

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RCC vs oncocytoma on PET

RCC is colder than parenchyma

Oncotyoma is hotter

butreally not used as reanlly excreted

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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

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Describe the 1st Bozniak cyst classifications

Simple - less than 15HU. no enhacnement

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Describe 2 Bozniak cyst

Hyperdense, less than 3cm, thin calcification, thin septations

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Bozniak 2F classification - what is it ?

hyperdense (over 3cm)
Minimally thickened calcifications

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Bozniak 3 classifcaiton s

thick sepatations.
irregularnode

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Bozniak 4 - classificaiton

any enhancement (<15 HU)
mural nodule

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hyperdense cysts

greater than 70HU and homogenous considered benign.

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ADPKD.
what happens to the kidneys

Get larger and lose function

get cyst in liver
Berry aneurysms

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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

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uraemic cystic kidney disease - who gets it?

end stage renal failure patients

cysts regress after transplant

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VHL - what do people get ?

Pancreas - cysts and serous adenomas

Adrenal - phaeo

CNS - haemangioblastoma

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How does Tuberous sclerosis affect the kidneys?

multiple bilateral angiomyolipomas

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Renal cysts in lithium nephropathy - how many

inumerable tiny cysts

also small kidneys

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Multicystic dysplastic kidney - who does it affect

what happens

kids in utero

no fucntioning renal tissue

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on T2 - renal cysts are normally

bright

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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

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common infection cuasing pyelonephritis

e coli

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what is seen on pyelonephritis on CT/

perinephric fat stranding
striaited nephrogram

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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)

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emphysematous pyelonephritis

life threatening
necortizing

gas within the kidney or around

diabetics

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emphysematous pyelitis

less bad to previous one

gas in collecting system

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Pyonephrosis

infected or obstructed collecting system.

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Xanthogranulomatous pyelonephritis

chronic destructive granulomatous process.

often staghorn as nidus for repeated infections.

Bear paw appearance

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Papillary necorosis

renal papillae die - commonly involves medullary pyramids

Ax diabetes

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causes of papillary necrosis?

pyelo, sickle cell, TB, analgesic, cirrhosis,

and the big one DIABETES

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How does HIV nephropathy appear ?

echogenic on US
Loss of corticomedullary differentiation

Obliteration of sinus fat

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types of kidney stone

calcium oxolate
struvite stone
uric acid
indinavir

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commonest type of kidney stone

calcium oxolate

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type of stone associate with UTI

struvite

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Cystine associated with what

metabolic disorders

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stones not seen on CT

Indinavir

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what is corticol nephrocalcinosis?

happens as a result of corticol necrosis

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what is medullary nephrocalcinosis ?

US hyperechoic renal papilla/pyramids.

cause commonest is hyper PTH

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what is medullary sponge kidney

congenital
causes nephrocalcinosis.
Ehler danlos ax.
Beckwith weidman ax.

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What is page kidney ?

long standing compression of the kidney by a SUBcapsular colleciton.

eg post lithotripsy sub capsular haemotoma.

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what does it mean if there are persistent nephrogram?

shock / hypotension
causing ATN.

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unilateral delayed nephrogram ?

pressure on the kidney some how.

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what are the various signs in renal infarction ?

corticol rim sign(due to blood supply)

flip flop enhancement

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when do you see the corticol rim sign?

immediately then 8hour to days later

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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

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 ?

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

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Module 4 - Genito-urinary Flashcards

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