4-disorders of the ureter and urinary bladdder.pdf

git

1. Urology
imaging

Presented by: — :
Dr,Ahmed Abdelkarim,‚MD =

2. Disorder of the ureters and urinary Dackel
|”

LEE

Duplicated & Urachal # Cystitis _ Urinary Neurogenic
ectopic ureter anomalies À diverticulum bladder
Inflammatory egenerative

3. Disorder of the ureters and urinary Dackel
|”

Congenital

Duplicated & Urachal

ectopic ureter anomalies

4. Duplicated and Ectopic Ureter

+ Definitions
+ Duplicated ureter:
+ 2ureters drain duplex kidney and remain separate down to bladder insertion or beyond
« Ectopic ureter:
+ Ureteral orifice below normal insertion in trigone; commonly associated with duplex collecting system
= Most common signs/symptoms
+ Intermittent or persistent UTI +/-acute pyelonephritis, frequently in females
« Often asymptomatic in males
« May have recurrent epididymitis, urinary tract infection, or flank pain
«Incontinence “only seen in females “
+ Due to insertion of upper pole ureteral orifice below bladder sphincter
= Gender

+ Female predominance (M:F = 1:10) = Young girl with incontinence or
« May be artifactual since males often remain asymptomatic recurrent urinary tract infections

5. Duplicated and Ectopic Ureter u

Best
diagnostic clue

= Double (duplex) collecting system with complete separation of ureters down to their insertion

6. Duplicated and Ectopic Ureter

= Upper pole ureter is ectopic inserts medial and caudal to lower pole ureter and obstructed (due to
ureterocele

= 85% of duplicated ureters obey Weigert-
Meyer rule

" Lower pole ureter refluxes

7. Duplicated and Ectopic Ureter

» Ectopic insertion within bladder
= Usually no clinical sequela
= Ectopic insertion outside bladder
= Bladder neck and upper urethra (33%), vestibule (33%), vagina (25%), cervix and uterus (5%)

8. Duplicated and Ectopic Ureter

= Ureterocele
« Dilated distal ureter "Cobra head" or "spring onion" deformity
« Smooth round intravesical filling defect
* Surrounding radiolucent halo

9. Duplicated and Ectopic Ureter

= Drooping lily sign
« Hydronephrosis and | function of obstructed upper pole — downward displacement of lower pole calyces

10. Duplicated and Ectopic Ureter

- Bifid Ureters
« 2 ureters drain duplex kidney but join before emptying into bladder; can be ectopic
« Ureters usually join above bladder as "V" or "Y" junction
« IVP
+ Ureteroureteral reflux or "yo-yo" phenomenon:
+ Peristalsis down 1 limb of ureter forces urine via reflux up other limb

= Asymmetric dilatation of 1 ureteral segment

11. Urachal Anomalies

- Definitions

« Spectrum of anomalies due to incomplete obliteration of allantoic duct

= Most common signs/symptoms
+ Patent urachus
+ Urine leakage from umbilicus
+ Urachal sinus
+ Discharge from umbilicus
= Complicated urachal cyst
+ Suprapubic pain, tenderness, fever
+ Urachal diverticulum
+ Stone formation and infection "UTI"
= Age
« Patent urachus: Diagnosed at birth
- M:F = 3:1

Patent urachus: Entire urachal channel fails to
close

Urachal cyst: Umbilical and bladder openings
close; channel in between remains open and fluid
filled

Urachal sinus: Dilatation of urachus at umbilical
end; no communication with bladder

Urachal diverticulum Dilatation of urachus at
vesical end; no communication with umbilicus

12. Urachal Anomalies

* Urachal diverticulum
+ Diverticular outpunching at the anterior superior wall of the urinary bladder

= Urachal sinus

+ Blind end pouch opening to the umbilicus MUL

+ Patent urachus
= Fluid filled channel connect the umbilicus to the bladder dome

13. Urachal Anomalies

Best diagnostic
clue

» Urachal cyst
« Midline cyst above bladder dome
+ May have rim calcification

= No soft tissue component unless complicated

14. Urachal Anomalies

= Infected urachal cyst
+ Wall enhancement
+ Fluid-fluid level/ air loculi within

= Smudging of the surrounding fascial planes.

15. Urachal Anomalies
Best diagnostic
clue
= Urachal carcinoma
« Midline supravesical soft tissue mass
* Calcification in 70%

16. Disorder of the ureters and urinary Dackel
|”

Inflammatory

an
pi

17. Cystitis

Definitions
= Inflammation of urinary bladder

Most common signs/symptoms

= Dysuria, frequency, urgency; hematuria, pyuria

Gender
« M:F = 1:10 (for bacterial cystitis)

= Etiology
* Infectious cystitis

Noninfectious cystitis

E.coli,

Schistosomiasis: Inflammatory response to ova deposited in
bladder submucosa

Tuberculosis: Descending infection from kidney

Emphysematous Infection with E.coli, or Candida infection; seen
in immunosuppressed and diabetic patients

Mechanical: Local irritation from indwelling catheter, stone,
foreign body, etc.
Drug related: Cyclophosphamide (hemorrhagic cystitis)

Radiation induced

18. Cystitis

= Diffuse bladder wall thickening
« + hypodensity of bladder wall (edema)
« + hyperemia and infiltration of peri-vesical fat

19. Cystitis

= Chronic
« Contracted, irregular, thick-walled bladder
« Decreased bladder capacity/volume

20. Cystitis

= Emphysematous cystitis
= Air loculai within lumen or wall

21. Cystitis

= Etiology

Catheter induced cystitis

Radiation induced cystitis

22. Cystitis

= Curvilinear bladder wall and distal ureter calcification in patient from endemic area
+ Calcified deposited ova in chronic stage
« Resemble fetal head + Bladder Schistosomiasi

23. Cystitis

« Distal ureteral dilatation “early” stricture “late”

24. Cystitis

« Cystitis /ureteritis cystica
« Air bubble filling defect

25. Disorder of the ureters and urinary Dackel
|”

Degenerative

Urinary Neurogenic
diverticulum bladder

26. Bladder Diverticulum

Definition

Sac formed by herniation of bladder mucosa and submucosa through muscular wall

Most common signs/symptoms

Usually asymptomatic in adults
+ If symptomatic, UTI and hematuria are most common symptoms
Prevalence of clinical symptoms is higher in children
+ UTI, hydronephrosis, hematuria, and nephrolithiasis are common symptoms
+ Hutch diverticulum is commonly associated with vesicoureteral reflux (VUR),
+ Due to altered UVJ anatomy (High-grade VUR results in hydronephrosis)

Age

Mostly in older age; 6th and 7th decades
Mean age of presentation in children is 8 years

M:F = 9:1

(Hutch diverticulum occurs almost exclusively in boys)

Etiology
= Acquired (most common type)
= Secondary to bladder outlet
obstruction
= in adults: Prostatic enlargement,
neurogenic bladder, large
ureterocele, urethral stricture
= in children: Posterior urethral
valves, prune belly syndrome
= Congenital, known as Hutch
diverticulum (rare)
= Congenital weakness in detrusor
muscle anterolateral to ureteral orifice

27. Bladder Diverticulum

Perivesical outpouching with connection to bladder lumen
« Can occur anywhere in bladder
= Common locations are

+ Near ureterovesical junction (UVJ)
+ Bladder dome

+ Consider urachal remnant if solitary, midline, and extending along median umbilical ligament

28. Bladder Diverticulum

= Can exceed size of bladder

= Large diverticulum may be confused with bladder,
especially if bladder is contracted

= Continuity with urethra distinguishes bladder from
diverticulum

29. Bladder Diverticulum

Complication

= Stone formation

= Neoplasm

30. Neurogenic Bladder

Definitions

Most common signs/symptoms
Frequency, nocturia, urgency, retention, incontinence

Bladder dysfunction caused by neurologic damage

Complications:

« Infection, reflux, hydronephrosis, urolithiasis

Etiology and levels

hyperreflexia

Suprapontine: Stroke, arteriosclerosis, brain tumor, Parkinson
disease, Shy-Drager syndrome, multiple sclerosis
Spinal : Trauma, tumor, multiple sclerosis

Peripheral(motor) (pelvic + pudendal nerve): Pelvic surgery, cauda
equina
Sensory: Diabetes mellitus, pernicious anemia, or tabes dorsalis

Areflexia

31. Neurogenic Bladder

= Wall thickness and trabeculations
= In presence of proper clinical history
= Absence of bladder outlet obstruction

= Detrusor hyperreflexia

32. Neurogenic Bladder

= Christmas tree or pine cone shape (severe) = =
= Detrusor hyperreflexia with
« Elongated and pointed with pseudodiverticula detrusor-sphincter dyssynergia

= Distended posterior urethra
« Beak of contrast (slightly open posterior urethra)
= Contrast extends to external sphincter/urogenital diaphragm

33. Neurogenic Bladder

> Large atonic bladder

+ Detrusor areflexia

34. ae
ge
25
22
as
A ©
ao