Bladder Imaging(and some urethra and ureteral imaging)

Academic Half DayOctober 2, 2012

Rebecca Hibbert, MD, FRCPC

32 yo male with focal midline tenderness.

CASE 1

Congenital Anomalies

• Urachal anomalies– Patent urachus– Urachal sinus– Urachal diverticulum– Urachal cyst

• Complications– Infection– Tumor (90% =

adenocarcinoma)

73 yo male diabetic, septic, in ICU with multiple medical issues.

CASE 2

Infection

• Predisposing causes• Instrumentation• Outlet obstruction• Stones• Tumor

• Types of bladder infections• Bacterial (acute, chronic)• Emphysematous (E. Coli)• Tuberculous (small, thick-walled bladder +/- mural calcification)• Schistosomiasis (Circumferential calcification and psudopolyps)

– At risk for SQUAMOUS Cell Ca

• Radiation

CASE 3

Fistula

• Predisposing causes• Instrumentation/surgery/catheters• Diverticular and Cronh’s disease• Radiation• Tumor• Trauma

• Types• Vesico – vaginal• Vesico – enteric• Vesico – cutaneous• Vesico – uterine• Vesico – ureteral

65 yo female with recent fall.

CASE 4

Trauma

• Consensus panel of the Societe Internationale D'Urologie– Type 1: contusion– Type 2: intraperitoneal rupture – Type 3: extraperitoneal rupture– Type 4: combined injury.

• AAST– Type 1: contusion, intramural hematoma, and partial thickness laceration– Type 2: extraperitoneal wall lacerations < 2 cm– Type 3: extraperitoneal lacerations > 2 cm and intraperitoneal lacerations < 2

cm– Type 4: intraperitoneal lacerations > 2 cm– Type 5: intraperitoneal or extraperitoneal lacerations that extend into the

bladder neck or trigone.

Extraperitoneal bladder rupture

Intraperitoneal bladder rupture

CASE 5Demented 78 yo male with low urine output.

Trauma

• Foley balloon inflated in urethra• Common cause of “trauma” on the wards• Clue: Foley present, but bladder still full• Check Foley position on all CTs

CASE 637 yo female with dribbling after voiding.

Urethral Diverticulum

• Features– Sequelae of periurethral gland infection that result in glandular dilatation

and then progress to fistulization with the urethra– Mid urethra at the level of the pubic symphysis– Typically involves posterolateral wall

• DDx:– Submucosal cyst, – Abscess of a Skene's gland

• Complications:– Infection– Stones– Carcinoma

Adenocarcinoma in urethral diverticulum

CASE 7 16 yo female with hematuria.

Carcinoma

• Types– TCC (90%)• Aniline dyes, phenacetin, tobacco, pelvic radiation,

interstitial nephritis

– SCC (5%)• Calculi, chronic infection, Schistosomiasis

– Adenocarcinoma (2%)• Bladder extrophy, urachal remnant

TNM Classification

CASE 8

Ureteric TCC

• DDx luminal ureteral filling defects:• Calculi• Blood clot• Sloughed papillae• Fungus ball• Air• Tumor

• Nearly 2–4% of patients with bladder cancer develop upper tract TCC, but 40% of patients with upper tract TCC develop bladder cancer.

TNM Upper tract TCC

CASE 9 56 yo male with hematuria.

Multifocal TCC within a ureteral diverticulum (blind ending, partially duplicated ureter)