Professional Documents
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Urinary Tract
DR.SULTAN ALHAJAHJEH
RADIOLOGY DEPARTMENT
JORDAN UNIVERSITY HOSPITAL
Anatomy of the urinary tract
The ureters
Each is 25-30 cm long and is described as having a pelvis and
abdominal, pelvic and intravesical parts
the ureter has a diameter of about 3 mm but is narrower at the
following three sites:
The junction of the pelvis and ureter.
The pelvic brim
The intravesical ureter where it runs through the muscular bladder
wall.
Anatomy of the urinary tract
1. Right upper-pole
(major) calyx
2. Right middle (major)
calyx
3. Right lower-pole
(major) calyx
4. Left upper-pole
(major) calyx
5. Left lower-pole
(major) calyx
6. Minor calyx
(infundibulum of)
7. Papilla
8. Infundibulum
9. Fornix
10. Bifid left renal pelvis
11. Right renal pelvis
12. Right ureter
13. Left ureter: vascular
impression
14. Upper pole right
kidney
15. Right psoas outline
16. Gas in body of
stomach
17. Gas in transverse
colon
18. Intravesical ureter
Anatomy of the urinary tract
Bladder
This is a pyramidal muscular organ when empty. It has a triangular-shaped base
posteriorly.
The ureters enter the posterolateral angles and the urethra leaves inferiorly at the
narrow neck, which is surrounded by the (involuntary) internal urethral sphincter.
It has one superior and two inferolateral walls, which meet at an apex behind the
pubic symphysiss.
In the female, the body of the uterus rests on its postero¬superior surface and the
cervix and vagina are posterior, with the rectum behind.
In the male the neck is fused with the prostate.
The bladder is supplied via the internal iliac artery via superior and inferior vesical
arteries.
Urinary bladder
prostate
rectum
Anatomy of the urinary tract
The urethra
The male urethra runs from the internal urethral sphincter at the neck
of the bladder to the external urethral orifice at the tip of the penis.
The posterior urethra comprises the prostatic and membranous
urethra and the anterior part comprises the bulbous and penile
urethra.
In females This is 4 cm long. It extends from the internal urethral
sphincter at the bladder neck through the urogenital diaphragm to
the external urethral meatus anterior to the vaginal opening.
1.Balloon of catheter in
navicular fossa
2. Penile urethra
3. Bulbous urethra
4. Membranous urethra
5. Impression of
verumontanum in
prostatic urethra
6. Filling of utricle (not
usually seen)
7. Air bubbles in
contrast
Imaging techniques of the urinary
tract
kub
Ivu
Mcug
Ultrasound
Ascending urethrogram
Mri
Pelvicalyceal system
Ultrasound
will often show a dilated renal pelvis with a collapsed proximal ureter
with Doppler sonography the obstructed kidneys can show higher RI's
(resistive indices).
CT
May show evidence of hydronephrosis +/- calyectasis with collapsed
ureters. Useful for assessing crossing vessels at the PUJ especially when
surgical intervention is planned
Congenital ureteropelvic junction
(UPJ) obstruction
Left sided
hydronephrosis is seen
with dilated and
ballooned out left renal
pelvis.
Left pelviureteric
junction is markedly
narrowed with probably
delayed contrast
excretion into left ureter.
Congenital ureteropelvic junction
(UPJ) obstruction
Right PUJ obstruction.
Dilated renal pelvis and renal
calices with normal ureter.
Congenital megacalyces
Imaging features :-
Cystic lesion connects through channel with collecting
system.
• If the neck is not obstructed, diverticula opacify retrograde from the
collecting system on delayed IVP films.
• May contain calculi or milk of calcium, 50%
Calyceal diverticulum
with multiple stones. a,
Abdominal plain film
shows multiple calculi
(arrow) over the upper
pole of the right kidney.
On ten-minute excretory
urogram (EXU), all stones
are shown to be locate in
an upper pole calyceal
diverticulum (arrow).
(PYELO)Calyceal diverticulum
On Sonography, a pyelocalyceal
diverticulum appears as a cystic lesion,
which is difficult to distinguish from
simple renal cyst. However, the
presence of mobile, echogenic and
dependent layering due to milk of
calcium is pathognomic of a
pyelocalyceal diverticulum.
Renal papillary necrosis (RPN)
Imaging features :
• Enlargement (early)
• Small collection of contrast medium extends outside the interpapillary
line in partial necrosis.
• Contrast may extend into central portion of papilla in “medullary type”
RPN.
• Eventually contrast curves around papilla from both fornices, resulting in
“lobster-claw” deformity.
Sequestered, sloughed papillae cause filling defects in collecting
system: “ring sign.”
• Tissue necrosis leads to blunted or clubbedcalyces.
Multiple papillae affected in 85%. Rimlike calcificationof necrotic
papilla occurs.
Renal papillary necrosis (RPN)
Ultrasound:
CT
The presence of clinical signs of infection with hydronephrosis on CT
is considered a more sensitive indicator of pyonephrosis than many
of the CT findings alone .
thickening of the renal pelvic wall (>2 mm)
parenchymal or perinephric inflammatory changes, dilatation and
obstruction of the collecting system, higher than usual attenuation
values of the fluid within the renal collecting system, and layering of
contrast material above and anterior to the purulent fluid on
excretory studies.
Pyonephrosis
Ectopic ureter.
Ureterocele.
Primary megaureter.
Obstruction of collecting system.
Ureteral injury .
Ureteral tumors.
Ectopic ureter
Ureter does not insert in the normal location in the trigone of the
bladder.
Incidence: M:F = 1:6.
Associations
• 80% have complete ureteral duplication.
• 30% have a ureterocele (“cobra head” appearanceon IVP)
Insertion Sites
• Males: ureter inserts ectopically into the bladder> prostatic urethra >
seminal vesicles, vas deferens, ejaculatory ducts.
• Females: ectopic ureter commonly empties into postsphincteric
urethra, vagina, tubes, perineum
Ectopic ureter
Radiographic Features
• Ureterocele causes filling defect in bladder on IVP.
• Typical appearance of a cystic structure by US
• Ureterocele may be distended, collapsed, or everted to represent a
diverticulum.
Complications:
Ureteroceles may contain calculi.
May be very large (bladder outlet obstruction)
Ureterocele
Megaureter
VCUG demonstrating
bilateral Grade III
vesicoureteral reflux
Vesicoureteral reflux (VUR)
Types
Benign tumors
• Epithelial: inverted papilloma, polyp, adenoma
• Mesodermal: fibroma, hemangioma, myoma, lymphangioma
• Fibroepithelial polyp: mobile long intraluminal mass, ureteral
intussusception
Malignant tumors
• Epithelial: transitional cell carcinoma, SCC,
adenocarcinoma
• Mesodermal: sarcoma, angiosarcoma,
carcinosarcoma
Ureteral tumors
Due to the small caliber of the ureter, tumours are more likely to
obstruct the kidney at small tumour size.
Obstruction may lead to hyrdonephrosis with or without hydroureter
and may also result in a non-functioning kidney or delayed
nephrogram.
• Bergman's coiled catheter sign: on retrograde pyelogram the
catheter is typically coiled in dilated portion of ureter just distal to the
lesion
Ureteral tumors
Prognosis
• 50% of patients will develop bladder cancer.
• 75% of tumors are unilateral.
• 5% of patients with bladder cancer will develop ureteral cancer.
Sites of metastatic spread of primary ureteral neoplasm:
• Retroperitoneal lymph nodes, 75%
• Liver, 60%
• Lung, 60%
• Bone, 40%
• Gastrointestinal tract, 20%
• Peritoneum, 20%
• Other (<15%): adrenal glands, ovary, uterus
Ureteral tumors
Classification
Ureteric injury can be classified into three types according to its site:
upper-third
upper-third and pelvico-ureteric junction (PUJ) most affected by blunt
trauma 5, 7
mid-third
distal-third
most common site
often following iatrogenic injury
Ureteric injury
Fluoroscopy
Excretory intravenous urography if CT is not available: demonstrates
contrast leakage and spillage outside the course of the urinary
system.
Retrograde pyelography may be performed if both
excretory intravenous urographyand CT with intravenous
contrast are inconclusive and there is still a high suspicion of injury 1.
Ureteric injury
CT
CT with intravenous contrast and delayed scan with full reformatted
sagittal and coronal images and 3D reconstruction. The delayed
scan should be performed between 5-8 minutes after IV contrast to
ensure a CT-IVU (a.k.a. excretory phase) set of images is acquired.
intra-abdominal fluid collections without other cause shown
contrast extravasation from renal hilum/PUJ (usually medially)
without associated renal injury
Ureteric injury
Bladder exstrophy.
Bladder diverticulum.
Bacterial cystitis.
Emphysematous cystitis.
Neurogenic bladder.
Bladder calculi.
Malignant bladder neoplasm.
Bladder injuries.
Bladder exstrophy
Bladder exstrophy (also known as ectopia vesicae) refers to a herniation of the urinary
bladder through an anterior abdominal wall defect. The severity of these defects is widely
variable.
The estimated incidence of bladder exstrophy is 1:10,000-50,000 live births .
It is thought to be caused by a developmental defect of the cloacal membrane which results in a
subsequent eversion of the bladder mucosa. This then protrudes out like the mass like lesion.
General associations
extension of the bladder defect into the urethra
cryptorchidism
bilateral inguinal herniation
OEIS complex
epispadia
vaginal duplication
clitoral cleft
Bladder exstrophy
Acute Cystitis
Pathogens: E. coli > Staphylococcus > Streptococcus
> Pseudomonas
Predisposing Factors
• Instrumentation, trauma
• Bladder outlet obstruction, neurogenic bladder
• Calculus
• Cystitis
• Tumor
Imaging Features
• Mucosal thickening (cobblestone appearance)
• Reduced bladder capacity
• Stranding of perivesical fat
Emphysematous cystitis
CT
CT is a highly sensitive examination that allows early detection of
intraluminal or intramural gas.
CT is also useful in evaluating other causes of intraluminal gas such
as enteric fistula formation from adjacent bowel carcinoma or
inflammatory disease.
Ultrasound
Can demonstrate echogenic air within the bladder wall with dirty
shadowing artefact.
Ultrasound will also commonly demonstrate diffuse bladder wall
thickening and increased echogenicity.
Emphysematous cystitis
Neurogenic bladder
uoroscopic/IVP
Sensory neurogenic bladder
Inability to sense bladder fullness results in a large rounded and smooth bladder. Voiding is often
preserved.
Motor paralytic bladder
Atonic large bladder with inability of detrusor contraction during voiding.
Unhibited neurogenic bladder
Rounded bladder with a trabeculated apperance to the mucosa above the trigone from detrusor
contractions. On voiding large interureteric ridge is noted
Reflex neurogenic bladder
Results from detrusor hyperreflexia with a dyssynergic sphincter. This leads to contrast extension to the
posterior urethra and an elongated pointed urthera with pseudodverticula.
Autonomous neurogenic bladder
Intermediate between detrusor hyperreflexia (contracted) and dysreflexia (atonic).
Neurogenic bladder
Ultrasound
Detailed images of the bladder often demonstrate a thick wall with
a small contracted or large atonic bladder.
A large post void residual is often noted.
Neurogenic bladder
VCUR examination
demonstrate elongated
distended urinary bladder with
multiple urinary bladder
diverticulae characteristic of
neurogenic bladder.
Grade III VUR on the left side is
also demonstrated.
Neurogenic bladder
Neurogenic bladder, typically occurs in
those with sacral abnormalities at birth.
The appearances has been described as
a Christmas tree of pine cone bladder.
The shape of the bladder is highly
abnormality with an elongated
appearance, with the dome like the top of
a Christmas tree.
The associated bladder wall hypertrophy
gives an outline, which mimics the
decorations that adorn a Christmas tree.
Neurogenic bladder
associated with :-
bladder outlet obstruction
cystocoele
neurogenic bladder
foreign body.
Radiographic features
Plain Film
Usually densely radio-opaque, calculi may be single or multiple and often large.
Frequently lamination is observed internally, like the skin of an onion.
Ultrasound
Sonographically they are mobile, echogenic, and shadow distally.
They may be associated with bladder wall thickening due to inflammation.
Bladder calculi
Malignant bladder neoplasm
Clinical Finding
• Painless hematuria.
Types and Underlying Causes
Transitional cell carcinoma, 90%
• Aniline dyes
• Phenacetin
• Pelvic radiation
• Tobacco
• Interstitial nephritis
SCC, 5%
• Calculi
• Chronic infection, leukoplakia
• Schistosomiasis
Adenocarcinoma, 2%
• Bladder exstrophy
• Urachal remnant
• Cystitis glandularis. 10% pass mucu s
Malignant bladder neoplasm
Ct :
bladder transitional cell carcinomas appear as either focal regions of thickening
of the bladder wall, or as masses protruding into the bladder lumen, or in
advanced cases, extending into adjacent tissues.
The masses are of soft tissue attenuation and may be encrusted with small
calcifications.
MRI
MRI is superior to other modalities in locally staging the tumour and is in some
instances able to distinguish T1 from T2 tumours on T2 weighted image.
CT
Bladder rupture is one form of genitourinary tract trauma, along with
renal trauma and urethral injuries.
Contrast enhanced CT is the imaging technique of choice for
bladder injuries in the form of CT cystography.
This may be combined with standard CT to evauluate the upper
tracts.
Standard cystography has a more limited role
Bladder injuries
Associations
Posterior urethral valves are also seen in association with other
congenital abnormalities including :
Ultrasound
Antenatal ultrasound:
On antenatal ultrasound the appearance is that of marked distention
and hypertrophy of the bladder, with or without hydronephrosis and
hydroureter, and depending on the severity, oligohydramnios and renal
dysplasia.
Postnatal ultrasound
The bladder is typically thick-walled and trabeculated with an
elongated and dilated posterior urethra (keyhole sign).
The kidneys in most cases are hydronephrotic, although it is important to
note that in up to 10% of cases they appear normal 5. They may also be
hyperechoic with loss of the normal corticomedullary differentiation, a
manifestation of renal dysplasia 5.
Posterior urethral valves (PUVs)
Voiding cystourethrogram
Voiding cystourethrogram (VCUG) is the best imaging technique for the
diagnosis of posterior urethral valves.
The diagnosis is best made during the micturition phase in a lateral or
oblique views, such that the posterior urethra can be imaged
adequately .
Findings include :
dilatation and elongation of the posterior urethra (equivalent of the
ultrasonographic keyhole sign)
linear radiolucent band corresponding to the valve (only occasionally
seen)
vesicoureteral reflux (VUR): seen in 50% of patients .
bladder trabeculation/diverticula
Posterior urethral valves (PUVs)
Micturating
cystourethrogram reveals
marked dilatation of the
prostatic portion of the
urethra consistent with
posterior urethral valves.
Posterior urethral valves (PUVs)
Classification:
blunt trauma: due to shearing or straddle injuries associated with
pelvic fractures (occurs in ~10%) often associated with bladder
injury.
penetrating trauma: e.g. stab wounds, gunshot wounds, dog bites
(more commonly affect the anterior urethra)
iatrogenic, for example urethral instrumentation, e.g.
catheterisation, Foley catheter removal without balloon deflation,
cystoscopy,post-surgical (e.g. surgery for benign prostatic
hyperplasia)
Urethral injuries
Fluoroscopy
CT
Retrograde urethrogram in
a patient with pelvic
fractures demonstrates
contained contrast leakage
at the posterior urethra
(membranous portion).
Contrast does ascend into
the bladder and therefore
the urethral injury is
incomplete.
Urethral injuries
Clinical presentation
poor urine stream
Aetiology
Infection(gonococcal urethritis (more common)),
trauma
straddle injury (most common)
pelvic fractures
iatrogenic
instrumentation
prolonged catheterisation
transurethral resection of the prostate
open radical prostatectomy
urethra reconstruction (hypospadia/epispadia)
congenital
uncommon
Urethral stricture
Past history of
chlamyida infection.
20mm stricture in the
bulbous urethra.
Urethral stricture