COMMON URINARY TRACT CONDITIONS-somed.pptx

Uti

1. IMAGING OF COMMON URINARY TRACT PATHOLOGIES DR WATITI NALIAKA CONSULTANT RADIOLOGIST/LECTURER JKUAT SOMED

2. OUTLINE Introduction. Imaging modalities for Urinary tract(UT) Normal radiological anatomy of UT Common UT pathologies Justifiable imaging modalities Conclusion.

3. Introduction The urinary tract consists of the kidneys, ureter, bladder and urethra. It spans the abdomen and pelvis. Divided into Upper and lower urinary tract. The prime purpose is filtration of blood and disposal of urine. It also serves a key role in regulation of body PH and BP.

4. IMAGING MODALITIES Plain abdominal radiograph (KUB)- Renal colic, abd pain. Monitoring renal stones. Abdominal ultrasound/KUB- Renal angle pain, hematuria, abdominal mass. Micturating Cysto Urethrogram(MCU)/Retrograde Urethrogram - Procedure where contrast is introduced into the bladder via a catheter. Evaluates the urinary bladder and the urethra. Indications- UTI, Dysuria, Trauma, urinary incontinence, BOO/urethral strictures, hematuria, post operative evaluation of the genitourinary tract. Active UTI is a  contraindication for MCU . Meatal stenosis in boys or vulval adhesions in girls are a  contraindication  as the catheter cannot be safely inserted into the urethra or the bladder when these conditions are present.

5. imaging IVU-Intra-Venous Urography- Also known as excretory urography- Radiographic study of the Renal parenchyma, pelvicalyceal system,ureters and urinary bladder. Contrast is introduced into the system intravenously via a peripheral vein. Serial plain abd . Radiographs are taken at different times. (2-15min) CT urogram /abdominal CT -Replaced IVU. It gives both anatomical and functional information. MRI/MR Urogram - Patients allergic to contrast/pregnant patients. Nuclear medicine/ Radionuclear studies -renal structure and anatomy. NB: Known case of previous acute reaction to contrast is a contraindication for contrast studies.

6. MCU

7. ASCENDING URETHROGRAM

8. IVU

9. PATHOLOGIES Hematuria- Renal calculi , Urinary tract tumours ( RCC ). Bladder O utlet Obstruction- Urethral strictures , prostatic enlargement, PUV. Vesico -ureteric reflux Infection- Pyelonephritis, Cystitis.

10. 1.HEMATURIA Occurs when blood enters the urinary collecting system and is excreted in urine. Origin can be Kidneys, ureters, bladder or urethra. Types -Frank hematuria -microscopic Causes/ Aetiology - Infections - Tumours - Renal calculi- urolithiasis IMAGING: Plain KUB radiograph and ultrasound remain initial imaging modalities of choice for evaluation of hematuria . KUB radiograph is however non diagnostic/Non specific.

11. 1a) UROLITHIASIS Refers to presence of calculi anywhere along the course of the urinary tract. C/presentation- Mostly asymptomatic. -Abdominal/renal angle pain -Renal colic- When a stone passes -Hematuria. Complications- Pyelonephritis

12. imaging KUB radiograph is the initial modality but non specific. Ultrasound- Initial diagnostic modality of choice. Very effective in detection of hydronephrosis in cases of obstructing calculi. Disadvantage-small stones difficult to detect on ultrasound. CT Scan/CT urogram -unenhanced CT scan of the abdomen and pelvis has become the 1 st line modality of choice-sensitivity of over 95%. Advantage of evaluating/diagnosis of other causes of abdominal pain or hematuria. Good anatomical evaluation of the entire urinary tract.

13. 1b). Renal cell carcinoma Commonest malignant renal tumour . C/presentation-Macroscopic hematuria occurs in 60% of cases, flank pain, palpable flank mass. -IMAGING: Ultrasound -Frequently requested for hematuria patients but very non specific for RCC. Has a limitation in locally staging the tumour . CT SCAN- Used to both diagnose and stage the tumour . -Seen as soft tissue mass that enhances on post contrast scans. MRI -Good in staging and also histological prediction of tumour from the T2 characteristics.

14. 1c) BLADDER CANCER All cancers affecting the urinary bladder. Transitional cell carcinoma(TCC) is the commonest. Others- Sq CC, Adenocarcinoma and Small cell carcinoma. C/presentation- Hematuria- Most common presentation. Bladder outlet obstruction if tumour invades the urethral orifice.

15. Imaging Diagnosis is made at cystoscopy with biopsies taken. Role of imaging- Staging. Early cancer could be an incidental finding. Ultrasound- Has a limited role in staging. Can however pick suspicious bladder wall thickening or polypoid bladder masses.

16. IMAGING CT urogram -Highly sensitive in diagnosis and staging of bladder tumours . Can replace cystoscopy in diagnosis of bladder tumours , advantage of cystoscopy is obtaining of samples for histology. Main limitation is not able to distinguish the different T stages. MRI- Superior in locally staging the tumour . Able to distinguish T1/T2 tumour stages.

17. 2. BLADDER OUTLET OBSTRUCTION Clinical presentation arising from a number of conditions affecting the urethra and/or bladder outlet. Common in elderly men due to prostate enlargement. Other causes- Urethral strictures, posterior urethral valves. C/presentation- Difficulty in urination, retention and urinary discomfort.

18. 2a) Urethral strictures Scarring of the anterior urethra resulting in luminal narrowing. Common in the setting of trauma and infection. Gonoccocal infection being the commonest In trauma-pelvic fractures Iatrogenic causes-instrumentation, prolonged catheterization, post prostatectomy. Congenital-uncommon

19. Imaging Retrograde/Ascending urethrogram is the primary method used to image the anterior urethra. For posterior urethra, a simultaneous MCU with retrograde urethrogram are done to determine length of the stricture. Ultrasound has no role. Sonourethrogram can be done to pediatric patients. MRI-Additional/secondary modality in evaluation of post traumatic pelvic anatomy.

20. 2.b)Posterior urethral valves Also known as congenital obstructing posterior urethral membranes. Commonest obstructing lesion of the urethra and common cause of obstructive uropathy in infancy. Commonly seen in male infants. C/presentation-Depends on severity of obstruction Diagnosis can be made antenatally -obstetric ultrasound. Findings-Small for age gestation, oligohydramnios, markedly distended bladder with foetal hydronephrosis . Post natal ultrasound-similar to prenatal findings.

21. MCU Is the diagnostic imaging modality/technique for diagnosis of PUV. Findings: Dilated and elongated posterior urethra, VUR, Bladder diverticular.

22. 3.INFECTIONS Urinary tract infections(UTI) is a common clinical condition involving the bladder-cystitis or the kidneys-pyelonephritis. Complicated or uncomplicated. C/presentation- Painful urination, bloody, dark or cloudy urine. urine frequency, incontinence and urgency. Systemic symptoms- fever,chills,rigors

23. Imaging Unnecessary in uncomplicated UTI. Patient is managed on a course of antibiotics. Complicated uti - Upper urinary tract- Renal/KUB ultrasound is initial modality . Not as sensitive as CT scan in evaluation of renal parenchymal changes. Ct scan- good in evaluation of renal parenchymal changes and associated peri renal complications-abscesses. MRI-Not primary modality but can be used in pregnant patients and in patients with allergy to contrast.

24. 4. VESICOURETERIC REFLUX Abnormal flow of urine from the bladder into the upper urinary tract. Commonly seen in children. Reflux from the bladder into the upper urinary tract predisposes to pyelonephritis. A diagnosis of VUR is suspected in a child with recurrent upper UTI. C/presentation- Isolated abnormality or associated with other congenital anomalies

25. Imaging The primary diagnostic procedure for evaluation of VUR is MCU . Presence of reflux is seen in real time. Occurrence of reflux during urination or during bladder filling Anatomical anomalies Ultrasound- Performed as a secondary modality to assess renal parenchyma-scarring and anatomic anomalies. Nuclear medicine and MRI urethrogram still not being commonly used.

26. THANK YOU

27. Read on BPH/Prostatic hypertrophy. Definition Clinical presentation. Pathology Radiographic features/imaging modalities.

28. Psoas muscles on ct