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Journal Reading

Imaging of Acute and Emergent


Genitourinary Conditions: What
the Radiologist Needs to Know

By : Monica Novyanti Nasution


Consultant : dr. Dieby Adrisyel, Sp.Rad
Emergent genitourinary conditions require timely diagnosis and
treatment to ensure a favorable clinical outcome and to prevent
morbidity and mortality. CT is typically the imaging modality of
choice for most emergent conditions of the genitourinary tract,
and ultrasound is used less frequently. MRI is primarily used as a
problem-solving modality because of its improved soft-tissue
characterization and higher resolution. The aim of this article is
to summarize the role of imaging in diagnosing acute and
emergent genitourinary conditions using a case-based approach
and to show how imaging can aid in the diagnosis of common
clinical entities presenting to the emergency department
Urinary System
Patient 1 : 45-year-old man with acute
onset of right flank pain
The diagnosis is urolithiasis. Urolithiasis is a
condition in which there are dense calculi within
the kidney or ureteral lumen and possible
hydroureteronephrosis, with dilatation of the ureter
proximal to the calculus and normal-caliber ureter
distal to the calculus (Fig. 1). Secondary signs of
ureterolithiasis include hydroureteronephrosis,
perinephric and periureteral inflammatory
stranding, and unilateral renal enlargement or a
subtle hypodensity related to parenchymal edema.
Patient 2 : 18-year-old woman in a
motor vehicle collision with a pelvic
fracture and gross hematuria
The diagnosis is bladder rupture. Bladder rupture is seen as
the presence of extravesicular contrast material on CT
cystography. In intraperitoneal bladder rupture, contrast
material accumulates around the bowel loops and in the
peritoneal recesses including the paracolic gutters,
rectovesical or rectouterine pouch, and subphrenic space (Fig.
2A). In extraperitoneal rupture, the extravasated contrast
material tracks into the perivesicular and prevesical space of
Retzius to form the classic molar tooth sign (Fig. 2B).
Combined intraperitoneal and extraperitoneal bladder
ruptures involve both spaces.
Patient 3 : 69-year-old woman with
acute right flank pain
The diagnosis is retroperitoneal hematoma.
Retroperitoneal hematoma is seen as a high-
density retroperitoneal collection with an
occasional blood-fluid level (Figs. 3A3C) and
occasional associated lesion (Fig. 3C).
Patient 4 : 21-year-old woman with a
history of urinary tract infections
presents with flank pain
The diagnosis is pyelonephritis. Pyelonephritis is seen on
imaging as renal parenchymal edema, often with one or
more wedge-shaped areas of decreased enhancement
and with decreased corticomedullary differentiation. A
striated nephrogramconsisting of linear areas of
decreased enhancement from the papilla to the cortex
can also be seen (Fig. 4A). Urothelial thickening and
enhancement of the renal pelvis and ureter are
suggestive of pyelitis (i.e., urinary tract infection
ascending to the collecting system) and may be seen with
or without parenchymal changes indicative of
pyelonephritis.
Patient 5 : 75-year-old diabetic man
presents with flank pain, hypotension,
and urinary retention
The diagnosis is emphysematous pyelonephritis
(EPN). EPN appears on imaging as small bubbles
or linear foci of parenchymal gas, gas-fluid
levels, fluid collections, parenchymal
enlargement and destruction, and tissue
necrosis (Fig. 5A).
Male Reproductive Organs
Patient 6 : 18-year-old man with acute
testicular pain and swelling
The diagnosis is epididymitis and orchitis.
Epididymitis and orchitis manifest as
heterogeneity, enlargement, and
hypoechogenicity of the epididymis or testicle
with associated hypervascularity on color
Doppler imaging (Fig. 6A). Reactive hydroceles
and scrotal edema and thickening are commonly
seen. Doppler flow can be helpful in
differentiating epididymitis and orchitis from
testicular torsion with absent flow.
Patient 7 : 32-year-old man with pelvic
pain after trauma
The diagnosis is penile fracture. Penile fracture
is seen as a focal disruption of the tunica
albuginea with an adjacent hematoma and can
be seen on both ultrasound and MRI (Fig. 7).
Female Reproductive Organs
Patient 8 : 23-year-old woman with
acute pelvic pain
The diagnosis is tuboovarian abscess (TOA). A TOA has a
variable appearance on ultrasound and may be a solid, cystic,
or complex mass in the adnexa or cul-de-sac with adjacent
fluid (Fig. 8A). CT findings suggestive of TOA include uniformly
thick walls with internal septations. Pyosalpinx is a common
associated finding manifesting as a fluid-filled tubular
structure with a thick enhancing peripheral wall. On MRI, a
TOA is typically hypointense on T1-weighted imaging and
heterogeneously hyperintense on T2-weighted imaging,
although the signal intensity is variable and depends on the
internal protein concentration and viscosity. Hypointense
meshlike strands secondary to adhesions or fibrosis are
common findings on T2-weighted images and may enhance
on contrast-enhanced T1-weighted images (Fig. 8B).
Patient 9 : 26-year-old woman with
positive HCG value and pelvic pain
The diagnosis is ectopic pregnancy. Ectopic
pregnancy is visualized on imaging as an
extrauterine pregnancy where a fetal heartbeat
may be present. More commonly, ectopic
pregnancies are seen as an extraovarian adnexal
mass that can manifest as a tubal ring containing
a yolk sac and embryo, a tubal ring with only a
yolk sac and no embryo, or a complex mass
separate from the ovary (Fig. 10A).

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