Imaging cystitis Dr Ahmed Esawy

IMAGING OF LOWER URINARY TRACT INFECTION LUTI
include different cases for oral radiodiagnosis examination all over the world
CT /MRI Plain X ray ultrasound images
Cystitis
Prostatitis
urethritis
Orchitis
Epidydmitis
Epidydmo-orchitis
funiculitis
Vastitis/differentitis
Seminal vesiculitis

1. Cystitis
imaging
Cystitis is defined as inflammation of the urinary
bladder from any cause
Cystitis is a clinical diagnosis; in most patients, imaging is not required
Dr. Ahmed Esawy
MBBS M.Sc MD
Dr Ahmed Esawy

2. Normal
UB
Ultrasound
Dr Ahmed Esawy

3. Suprapubic abdominal ultrasound examination of the bladder. The bladder of this
young male is partly filled with 257ml of clear urine. A healthy bladder content should
appear anechoic.
anechoic urine reverberation artefacts can often be seen
Dr Ahmed Esawy

4. Suprapubic transverse scan of the bladder in a young male. Dorsal to the bladder, the
symmetric seminal vesicles can be seen. Behind the bladder roof hyperechoic reverberation
echoes are often seen. This ultrasound artefact is produced by multiple reflections
of an object if the acoustic impedances are too different (body to water). In
this case the sound waves are reflected back into the bladder from the transducer-skin
interface
Dr Ahmed Esawy

5. The normal bladder wall is 3−5mm thick. The thickness of the bladder wall depends
on how full it is. In a full bladder the thickness decreases to approximately 2−3mm.

When filled, a normal bladder wall should have a plain appearance without any contour
irregularity
Dr Ahmed Esawy

6. Transrectal ultrasound of the bladder. Urine from the right ostium is seen just above
the right seminal vesicle in a 34-year-old male.
Dr Ahmed Esawy

7. Bladder volume can be calculated by scanning the
bladder transversely and longitudinally and using the
following ellipsoid formula:
Volume = height × width × depth × 0.5236
Dr Ahmed Esawy

8. Measurement of post-void residual urine (153ml) with the ellipsoid formula
(69.9×61.2×68.3mm×0.52 = 153ml) in a 72-year-old male with benign prostate
hyperplasia
Stage 2. Note the bladder wall thickened with trabeculation.
Dr Ahmed Esawy

9. cystitis
Infectious
Bacterial
Cystitis


Non-Infectious
Non-bacterial
Cystitis


Infectious nonbacterial
cystitis
Viral
Mycobacterial
Chlamydial
Fungal
Schistosomal
Eosinophilic cystitis
Dr Ahmed Esawy

10. Interstitial cystitis (IC)/painful bladder syndrome (PBS)
Radiation induced
Chemical
Autoimmune
Hypersensitivity
Drug-induced cystitis
(chemotherapy drugs cyclophosphamide and ifosfamide can cause cystitis.)
Radiation cystitis
Foreign body cystitis (catheter)
Chemical cystitis
spermicidal jellies
use of a diaphragm with spermicide
feminine hygiene sprays
chemicals from a bubble bath
Cystitis associated with other conditions
diabetes
kidney stones
HIV
enlarged prostate
spinal injuries
Non-Infectious Non-bacterial Cystitis
Dr Ahmed Esawy

11. Differential diagnosis for bladder wall thickening depends
on whether the bladder is adequately distended. The bladder
wall may be thickened if:

>3 mm when distended
>5 mm when nondistended

If the bladder is not distended, then it is difficult to exclude
artifactual thickening from a collapsed bladder
If the bladder wall is adequately distended, then a differential
may be developed based on whether the bladder is diffusely
thickened or focally thickened
Bladder wall thickening
Dr Ahmed Esawy

12. Diffuse bladder wall thickening
bladder outlet obstruction
neurogenic bladder
infectious cystitis
cystitis from radiation or chemotherapy
Dr Ahmed Esawy

13. Focal bladder wall thickening
urothelial cell carcinoma of the bladder (transitional cell carcinoma)
artifact: blood products / clot
will not enhance on postcontrast CT or MRI; no vascularity on colour Doppler
may be adherent to the bladder wall, like tumour, but clot is more likely to have a
concave margin, unlike tumor
other bladder neoplasm
squamous cell carcinoma of the bladder
adenocarcinoma of the bladder
bladder lymphoma
small cell bladder tumour
bladder paraganglioma
bladder wall leiomyoma
(cystitis): more commonly diffuse than focal, but may mimic neoplasm
adjacent inflammatory process (e.g. diverticulitis)
cystitis cystica and cystitis glandularis
may mimic bladder cancer
amyloidosis of the bladder: rare
malacoplakia of the bladder: rare
Dr Ahmed Esawy

14. Microbial / bacterial
cystitis
Dr Ahmed Esawy

15. imaging features
Acute infectious cystitis

Heterochioc urine on ultrasound
Diffuse mural UB wall thickening particularly if marked more than 1 cm
Hypoenchancing
Oedematous at T2 wighted image
Increased compared to previous study
Urothelial hyperenhancment
minimally thickened
uniform ,circumferential
perivesical fat inflammatory changes


Dr Ahmed Esawy

16. imaging features
Mural Bladder abscess

Intramural /exophytic collection
Internally hypoattenuating (10-15 HU non enhancing)
Irregular often thick peripheral enhancment
Usual : upper bladder site





Dr Ahmed Esawy

17. Heterochioc urine
Multiple echoes within UB : pus
epithelial cells
blood cells
leucocytes and proteins

Normal urine appears anechoic; in patients with chronic bladder
infection the bladder content appears cloudy because of the
reflection of leucocytes and proteins.
Dr Ahmed Esawy

18. thickened urinary bladder wall, debris in the bladder, a patent urachus, and
hypertrophied mucosa in the urachus.
Dr Ahmed Esawy

19. Sonograms in a 16-year-old male adolescent with recurrent urinary tract infections.
Sagittal and axial scans show a thickened bladder wall and a tubular cystic structure right
posterolateral to the urinary bladder (arrowhead). An intravenous urogram was normal
(not shown). Left panel: Retrograde pyelogram shows the tubular structure to be a blind-
ending ureter.
Dr Ahmed Esawy

20. Acute urinary retention in a 55-year-old male with chronic prostate obstruction and
over-distended detrusor muscle. A volume of 1800ml clear urine was collected by
catheterisation.
Dr Ahmed Esawy

21. Chronic bacterial bladder infection in a female patient with a post-void residual volume
of 139ml. The urine appears cloudy as a result of chronic infection.
Dr Ahmed Esawy

22. An 80-year-old male with a permanent transurethral catheter for bladder outlet obstruction
therapy. The bladder content is cloudy because of chronic urinary tract infection
Dr Ahmed Esawy

23. Sonograhic appearance of a papillary transitional cell carcinoma in a male with obstructive
benign prostate hyperplasia and macrohaematuria. Note the non-anechoic
urine as a result of haematuria as well as the thickened bladder wall.
Dr Ahmed Esawy

24. Blood clot
Bladder ultrasound presents a large coagulated haematoma in this patient post-operatively.
As a complication following transurethral-bladder (TUR-B) or transurethral-prostate (TUR-P)
surgery, post-operative bleeding
Dr Ahmed Esawy

25. The sonographic appearance of a pigtail catheter is characterised by a typical hyperechoic
double contour of the ureter catheter. If there is some calcification on the
catheter surface “stone shadowing” can be demonstrated.
Dr Ahmed Esawy

26. Post-void residual urine measurement after cystoscopy with hyperechoic air inside the
bladder lumen.
Dr Ahmed Esawy

27. (b–d) multidetector CT images showed contracted urinary bladder with catheter (thick arrows),
and marked circumferential mural thickening (*) with hypoenhancing oedematous wall and
urothelial hyperenhancement (thin arrows). Urine cultures revealed polymicrobial infection
including Staphylococcus aureus and multiresistant extended-spectrum beta-lactamase
(ESBL)-positive Escherichia coli
Active infectious cystitis in a 52-year-
old woman with poorly controlled
diabetes, dehydration, pelvic and
flank pain, pyuria and elevated
Creactive protein (CRP). Unenhanced
(a) and contrastenhanced
Dr Ahmed Esawy

28. Polymicrobial urinary tract infection (UTI) complicated by mural bladder abscess in a 67-
year-old man with a history of benign prostatic hyperplasia (BPH) and indwelling catheter
(thick arrows). Four months earlier, CT (a) revealed contracted urinary bladder with calcific
lithiasis, circumferential mural thickening (*) from detrusor hypertrophy, and urothelial
hyperenhancement (thin arrow in b) consistent with active UTI. The current urgent CT
Dr Ahmed Esawy

29. (c–e) requested to investigate
urosepsis showed increased mural
thickening of the urinary bladder (*),
with persistent urothelial
enhancement (thin arrows in d), the
appearance of inflammatory stranding
of the perivesical fat planes (+), and
the development of a sizeable
(7.5×6×5.5 cm) collection attached to
the bladder dome (arrowheads), with
nonenhancing hypoattenuating (10–15
Hounsfield units, HU) content and
enhancing peripheral rim.
Cystoscopy confirmed severely inflamed bladder mucosa. Postoperative CT after
surgical abscess drainage depicted normalised bladder wall (thin
arrows in e) and appearance of ascites
Dr Ahmed Esawy

30. Mural bladder abscess in a 61-year-old man
with recurrent UTIs and clinical and
sonographic suspicion of bladder carcinoma

Multiplanar CT images (a–d) depicted a poorly
distensible bladder with mural thickening (*),
urothelial hyperenhancement (thin arrows)
consistent with active UTI, and a fluid-like
collection (arrowheads) with irregular
peripheral enhancement along the
posterolateral aspect. Urine cytology and
cystoscopy excluded the presence of tumour.

Six weeks later, repeated CT (d) after
antibiotic treatment showed resolved abscess,
persistent mural thickening (*) and infectious
urothelial enhancement (thin arrow).

Further follow-up with MRI including T2- (e)
and postgadolinium
T1-weighted (f)
sequences confirmed abscess disappearance
(arrowheads)
Dr Ahmed Esawy

31. Acute infectious cystitis in 66-year-old bedridden man with several comorbidities and
urosepsis. After inconclusive abdominopelvic
CT (not shown), MRI showed contracted bladder with Foley catheter
(thick arrows) and diffuse mural thickening with multifocal high-signal
oedematous regions, best appreciated with fat saturation (c)
Dr Ahmed Esawy

32. Acute infectious cystitis
with mural bladder abscess in
an 89-year-old man with acute
urinary retention, fever,
leukocytosis and impaired
renal function. Unenhanced

MRI including MR
pyelographic (a)
and axial fat-suppressed (b)
images revealed bilateral
hydronephrosis, contracted
bladder and prominent
inflammatory changes (+) in
the surrounding
extraperitoneal fat
planes. Additionally,

sagittal T2-weighted image (c)
showed a focal thickening
(arrows) at the bladder dome,
with intramural fluid collection
(arrowhead).

Repeated CT (d) after medical
treatment revealed the
disappearance of abnormal
mural changes
Dr Ahmed Esawy

33. Interstitial cystitis (bladder pain syndrome, Hunner ulcer) is a painful bladder disease
characterized by chronic urinary urgency, frequency, and pain without evidence of
bacterial infection. Nearly 90% of patients with interstitial cystitis are women.

Triad of urgency ,frequency and bladder or pelvic pain in absence of bacterial infection or
definable pathology is definition of interstitial cystitis

Interstitial cystitis
Interstitial cystitis (IC)/painful bladder syndrome (PBS)
Interstitial cystitis is best diagnosed on the basis of its clinical features
The cause of IC/PBS is unknown, but abnormalities in the leakiness or structure of the
lining of the bladder are believed to play a role in the development of IC/PBS.
Dr Ahmed Esawy

34. Most Common Symptoms:
Urinary Frequency (includes multiple night time voids)
Urinary Urgency
Suprapubic Pelvic Pain Related to the Bladder filling

Associated Symptoms:
Dyspareunia (pain with intercourse)
Chronic Constipation
Slow Urinary Stream
Food Sensitivities that worsen symptoms
Radiating pain in the groin, vagina, rectum, or sacrum
[

Dr Ahmed Esawy

35. All of them presented with lower urinary tract
symptoms (LUTS), urinary tract infection (UTI) and
intermittent hematuria
Cystitis cystica
Cystitis glandularis

Common chronic reactive inflammatory disorders,
which occur in the setting of chronic irritation
Dr Ahmed Esawy

36. Ultrasound features

cystica-sub mucosal cyst of bladder

Polypoidal mass arising from inferior wall of bladder

Bladder wall thickened >1.5 cm at trigone

Papillary mass arising from trigonal region? Malignant

Ca bladder at base

Papillary mass with calcification? Calculus

B/L HN, HU polyploidal lesion at UVJ

DIFFERENTIAL DIAGNOSIS :

bladder tumour
Dr Ahmed Esawy

37. Cystitis cystica-sub mucosal cyst of bladder
Coronal TRUS Sagittal TRUS
This elderly male patient shows a distinct,
small cyst on the mucosal surface of the
bladder just above the neck of bladder, and in
close proximity to the upper surface of the
prostate in this TRUS image of the urinary
bladder and prostate. Transrectal ultrasound
was done to evaluate the prostate following
treatment for proven carcinoma of the
prostate. Presently this patient has a few
episodes of hematuria.
Dr Ahmed Esawy

38. Cystitis cystica-sub mucosal cyst of bladder
The above images are TRUS studies of the
prostate; Power Doppler image on right shows
the lack of significant vascularity to the cystic
lesion in the submucosal region of the urinary
bladder. The urinary bladder cyst in this case
measures just 4.5 mm. in size and is thin
walled, almost sac like. These ultrasound
images and appearances of this submucosal
cyst of the urinary bladder are highly
suggestive of cystitis cystica
Dr Ahmed Esawy

39. Cystitis cystica and cystitis glandularis. Oblique view of the bladder obtained during
intravenous urography shows a lobulated contour of the bladder, with a nodular
filling defect (arrow).
Dr Ahmed Esawy

40. Polypoidal lesion close to left UVJ causing hydroureter
Dr Ahmed Esawy

41. Trigonal mass like lesion mimicking malignant lesion on ultrasonography
Dr Ahmed Esawy

42. Cystitis cystica is a relatively rare and poorly understood lesion of the
urinary bladder mucosa resulting from cyst formation within
hypertrophied clusters of bladder mucosal cells.

There are 2 schools of thought regarding the significance of cystitis
cystica of the urinary bladder.

Some believe this lesion to be a pre-malignant condition whilst others
maintain, that this (cystitis cystica) is just an indientaly finding of little
significance.

Other differential diagnoses in this case include retention cysts of the
prostate or urinary bladder.
Dr Ahmed Esawy

43. Cystitis cystica
Cystitis glandularis
Fluoroscopy: IVP
Lobulated outline of urinary bladder with nodular filling defect within.
CT
Hypervascular polypoid masses within urinary bladder.
MRI
T1: may be seen as low signal polypoidal lesion
T2: low signal lesion with central branching hyperintensity. Central hyperintensity
enhances on contrast administration, and represents vascular stalk.
Dr Ahmed Esawy

44. Eosinophilic cystitis
Eosinophilic cystitis is another rare chronic inflammatory disease of the bladder
single masses are observed more frequently than multiple bladder masses
and may be sessile

The bladder wall may appear normal or thickened
A cystic variant with an enhancing wall may be seen.

MR imaging shows a mass that is hyperintense relative to muscle with T1-
weighted sequences, isointense with T2-weighted sequences, and enhanced
after intravenous administration of contrast material.

In the fibrotic stage, the bladder is small and contracted, and there may be
resultant hydronephrosis
Dr Ahmed Esawy

45. Eosinophilic cystitis. (a) Sagittal T1-weighted MR image shows a single, sessile mass
(arrow) arising from the posterior bladder wall; the mass is mildly hyperintense relative to
muscle. (b) Sagittal gadolinium-enhanced fat-suppressed MR image shows enhancement
of the mass (arrow) and the adjacent bladder wall.
Dr Ahmed Esawy

46. Cystic eosinophilic cystitis. (a, b) Axial (a) and sagittal reconstructed (b) contrast-enhanced
CT images show a thick-walled cystic mass (arrow) arising from the anterior dome of the
bladder
Dr Ahmed Esawy

47. The term malacoplakia signifies soft plaque.
Malacoplakia is a rare chronic granulomatous condition
that can affect any organ, with the urinary tract being
the most common system involved.
Malacoplakia
Dr Ahmed Esawy

48. Within the urinary tract, the bladder is the most frequently affected organ, with 40%
of patients with malacoplakia having bladder involvement and 16% renal
involvement .

The disease is found predominantly in women, with a female-to male ratio of 4:1 .

Patients of any age may develop malacoplakia, but the peak occurrence is in middle
age.

The disease is more common in patients with diabetes mellitus or in
immunocompromised individuals, such as those with autoimmune diseases, those
with acquired immunodeficiency syndrome, or recent transplant recipients.

Presenting symptoms include gross hematuria and signs of urinary tract infection
such as hesitancy, dysuria, and frequency. Patients may have variable proteinuria,
as well as leukocytes and erythrocytes in their urine
Dr Ahmed Esawy

49. Imaging characteristics of malacoplakia are likewise varied.

multiple, polypoid, vascular, solid masses or circumferential wall thickening
associated with vesicoureteric reflux and dilatation of the upper urinary tract.

Malacoplakia may be extremely aggressive, invading the perivesical space
it can even cause bone destruction .

Ring-shaped bladder calcification representing adherent calculi has been described after
treatment .

A less common radiologic manifestation is that of a predominantly retrovesical mass
involving the uterus or an extravesical anterior mass
Dr Ahmed Esawy

50. Malacoplakia. (a) Axial CT image shows marked circumferential bladder wall
thickening.
Dr Ahmed Esawy

51. Malacoplakia. Axial CT images through the upper (a) and lower (b) pelvis show a large,
irregularly enhancing mass (arrows in a), which is contiguous with the bladder. Note the
diffuse thickening of the bladder wall (arrow in b).
Dr Ahmed Esawy

52. Emphysematous cystitis (EC)
Dr Ahmed Esawy

53. Emphysematous cystitis (EC)
gas forming infection of the bladder wall.
Plain radiograph

Conventional radiography characteristically shows curvilinear or mottled areas of
increased radiolucency in the region of the urinary bladder, separate from more posterior
rectal gas.

Intraluminal gas will be seen as an air-fluid level that changes with patient position, and,
when adjacent to the nondependent mucosal surface, may have a cobblestone or
“beaded necklace” appearance.

This is thought to reflect the irregular thickening produced by submucosal blebs as seen
at direct cystoscopy.
Dr Ahmed Esawy

54. 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.
Dr Ahmed Esawy

55. The sonogram demonstrates bladder wall thickening and
hyperechoic foci, due to intramural vs. intraluminal gas
Dr Ahmed Esawy

56. This sonogram shows hyperechoic foci,due to gas, within
or adjacent to the thickened bladder wall.
Dr Ahmed Esawy

57. Emphysematous cystitis as incidental finding
in a case of hip fracture on the left
Dr Ahmed Esawy

58. Dr Ahmed Esawy

59. Dr Ahmed Esawy

60. Dr Ahmed Esawy

61. Dr Ahmed Esawy

62. Suprapubic ultrasound: cross-sectional (a) and cross-sectional (b). It showed an
hyperechoic area of the anterior bladder wall (vertical white arrows) as indicator of
intraparietal air, reverberation echoes and dirty shadow cones associated
with intravesical air (5-pointed star). Existence of a posterior parietal and bladder
thickening with column, characterized by aerial hyperechogenicities which seem to be
tightly held between the columns (horizontal white arrows) and causing shadow
cones (arrowheads). There is a hypertrophic median lobe pushing into the posterior
lower part of the bladder face located down the back of the ureteric fold (4-pointed
star).
Dr Ahmed Esawy

63. Ultrasound image of the anterior bladder wall with a superficial probe (c);
the hyperechoic aspect of the wall with reverberation echoes backwards is
identified (5-pointed star). The wall is irregular
and characterized by the presence of more superficial gaseous bubbles (arrows).
Longitudinal ultrasound scans of left kidneys
(d); there is a pyelocaliceal dilatation with presence of repeat echoes suggesting
presence of gas (5-pointed Star)
Dr Ahmed Esawy

64. Axial
tomographic scan of the bladder’s iodinated contrast agent (e) which showed an irregular
parietal bladder thickening with presence of intracystic (5-pointed Star) and intraparietal
(black arrow) air. We note peripheral air bubble (hollow arrow) implying fluid accumulation
in favor of subserosal bladder rupture (shaded arrow). Down the back of bladder, an air
bubble is noted in the left ureter (white arrow). CT axial scanof the left kidney (f).
Hydronephrosis and left pyelic air bubble (hollow arrow).
Dr Ahmed Esawy

65. Cross-sectional suprapubic ultrasound scan with a convex probe (a) and a superficial
linear probe (b). There is a hyperechoic bladder wall of irregular aspect in the posterior
part (white arrows). There is also presence of repeat echoes down the back of anterior
bladder wall suggesting existence of intraluminal air (5-pointed star). There is a
diffraction of echoes which impedes the visualization of retrovesical pelvic structures (4-
pointed star). Exploration with linear probe (b) provides a better analysis of the anterior
bladder wall with regular hyperechoic border and diffraction of echoes down the
back of the latter
Dr Ahmed Esawy

66. Unprepared negative of pelvis in frontal (c) and profile spine positions (d). Presence of a
concave arcuate linear hyperlucency at the top of the iliopelvic branches. This is suggestive
of cystic intraparietal air (white arrows) and hypogastric fluid-air level under the anterior
abdominal wall associated with presence of intracystic air (5-pointed Star).
Dr Ahmed Esawy

67. Cross-sectional suprapubic ultrasound with a convex probe (a) showing an irregular
hyperechoic bladder wall (white arrows). Retrovesical pelvic structures are not visualized (4-
pointed Star). Bladder content is heterogeneous with presence of liquid level suggestive of
pyuria (arrow).
Unprepared radiography in supine position with vertical radius (b) identifying distended
bladder with air content (5-pointed star) with spontaneous visualization of the bladder wall
(white arrow).
Dr Ahmed Esawy

68. Emphysematous cystitis in a 69-year-old
man with congestive heart failure, diabetes
and chronic obstructive lung disease,
suffering from urinary frequency and pain.

CT urography (a–d) revealed distended
urinary bladder with linear gas-attenuation
changes (thin arrows) along the right lateral
and upper posterior walls.

Associated findings included inflammatory
stranding (+) of the perivesical fat planes and
a small bilobated fluid-like intraprostatic
collection consistent with abscess
(arrowheads).

Follow-up CT (e,f) 3 months later revealed
resolution of changes after prolonged
antibiotic therapy
Dr Ahmed Esawy

69. Gas in the urinary bladder
iatrogenic
IDC by far the most common cause
cystoscopy etc...
emphysematous cystitis
intraluminal and intramural gas
most frequently in patients with diabetes mellitus
fistula
enterovesical fistula
colovesical fistula - most commonly due
to diverticulitis or colorectal carcinoma
rectovesical fistula
vesical fungus ball - most frequently Candida albicans in debilitated
patients.
foreign bodies
trauma
Dr Ahmed Esawy

70. sigmoid-carcinoma-with-colovesical-fistula
Dr Ahmed Esawy

71. emphysematous-cystitis
Dr Ahmed Esawy

72. rectovesical-fistula-due-to-rectal-carcinoma contrast
Dr Ahmed Esawy

73. Imaging findings mirror the pathologic course.

In the acute phase, nodular bladder wall thickening is observed at urography or cross-
sectional imaging. There may be ureteral dilatation.

The chronic phase is characterized by a contracted, fibrotic, thick-walled bladder with
calcifications.

These calcifications are typically curvilinear and represent the large numbers of
calcified eggs within the bladder wall.

Distal ureteral calcification may also be present.

A mass may be secondary to inflammation or complicating carcinoma, typically
squamous carcinoma.
Schistosomiasis
Dr Ahmed Esawy

74. presented with lower urinary tract symptoms (LUTS).
On bladder ultrasound with a high-frequency linear probe a calcified schistosomiasis
egg within the bladder mucosa of the anterior wall is easily detectable (yellow mark).
Dr Ahmed Esawy

75. Schistosomiasis. Longitudinal US image through the bladder shows nodular
bladder wall thickening (arrows), an appearance more typical in the acute
phase of infection
Dr Ahmed Esawy

76. Schistosomiasis. Anteroposterior radiograph (a) and axial CT image (b) of the bladder
shows curvilinear calcification in the bladder wall (arrowheads), which also extends to the
distal left ureter (arrow).
Calcification, representing an abundance of calcified ova, is typically seen in the chronic
phase of the infection.
Dr Ahmed Esawy

77. Schistosomiasis with superimposed squamocellular carcinoma in a 48 year-old
Gambian man with pelvic pain and tenderness, dysuria and difficult urination.

Unenhanced (a) and post-contrast (b) CT images showed marked asymmetric solid
mural thickening (*), with poor enhancement along the anterior right lateral and
superior bladder aspects. Additional findings included thin calcifications (thin arrows)
along the left posterolateral bladder wall, and intraluminal stones (arrowhead).

CT-cystography (c) with retrograde contrast filling and
cystoscopy confirmed extensive bladder occupation by tumour (*)
Dr Ahmed Esawy

78. Crohn Disease
Cystoscopy and CT are the most useful diagnostic tools ).

At cystoscopy, the fistula may be directly visualized, and there
may be pus, feces, and bullous edema in the bladder .

At CT, air within the bladder, focal irregularity
of the wall (most commonly on the right side of bladder), and
tethering of thickened adjacent bowel are the usual findings
Dr Ahmed Esawy

79. Crohn disease with a fistula to the bladder. (a) Contrast-enhanced, coronal CT reformation
shows wall thickening of the distal small bowel (straight arrow) and the adjacent bladder
(curved arrow). (b) Collimated radiograph obtained during a small bowel contrast study
shows an enterovesical fistula (curved arrow), extending from the abnormal segment of
the ileum to the bladder (arrow).
Dr Ahmed Esawy

80. Tuberculosis
In the acute phase of bladder tuberculosis, sonographic findings include irregular
mucosal masses due to coalescing tubercles with ulceration and edema, diffuse wall
thickening, and trabeculation
At urography, the bladder mucosa is irregular , and there may be ureteral strictures
and thickening with obstruction, or a fixed and patulous vesicoureteric junction orifice,
resulting in vesicoureteric reflux.

In the chronic phase, imaging findings are a thick-walled contracted bladder from fibrosis . The
diminution of bladder volume accounts for symptoms of frequency.
There may be associated calcification in the seminal vesicles, but bladder wall calcification is
rare and seen only after healing .
Bladder tuberculosis may be complicated by fistulas or sinus tract formation,
although these complications are rare and are demonstrated better on CT and MR images.
Dr Ahmed Esawy

81. Tuberculosis. Anteroposterior view obtained during intravenous urography shows
irregularity of the bladder contour (arrowheads). There is also distortion and irregularity
of the renal calices (arrows).
Dr Ahmed Esawy

82. Diverticulitis with a fistula to the bladder. (a) Axial CT image shows diffuse wall
thickening of the sigmoid colon with an adjacent focal, thick-walled, gas-containing
abscess (arrowhead). (b) Coronal CT reformation shows the abscess (arrowhead)
immediately adjacent to the bladder. A fistula has formed with gas
within the bladder lumen, as well as diffuse bladder wall thickening (arrow).
Diverticulitis
Dr Ahmed Esawy

83. Sigmiod diverticulitis

Focal wall thickening is seen in the left posterior part of the bladder
adjacent to the inflamed sigmoid(arrow)

A moderate amount of air is also present in the bladder, a finding
compatible with a colovesical fistula.
Dr Ahmed Esawy

84. CT scanning shows:.

Transverse contrast-enhanced CT scans in a case with pneumaturia and prior diverticulitis
show air (arrowhead) in the bladder and the site of fistulous communication (arrow)
between sigmoid colon and bladder.

Provisional diagnosis: Colovesical fistula
Dr Ahmed Esawy

85. Chemotherapy cystitis from cyclophosphamide. (a) Longitudinal US image shows
diffuse wall thickening (arrows). (b) Axial contrast-enhanced CT image shows
enhancement of the mucosal surface (arrow),
as well as diffuse wall thickening. The hyperemic mucosa may ulcerate and cause
significant hematuria
Radiation and
Chemotherapy Cystitis
Dr Ahmed Esawy

86. Radiation cystitis, chronic changes. Axial CT image shows focal thickening and calcification
of the right posterior bladder wall (straight arrow). There is subtle widening of the presacral
space (curved arrow) and fatty infiltration of the pelvic musculature (arrowheads).
Dr Ahmed Esawy

87. Radiation cystitis with fistula.
(a) Collimated anteroposterior view of the bladder obtained during cystography shows
a fistulous communication between the bladder and perivesical space (arrow).
(b) Axial CT image obtained after cystography helps confirm the presence of contrast
material posterolateral to the bladder (arrow). Note the radiation changes within the
bones. * Foley catheter balloon.
Dr Ahmed Esawy

88. Severe hemorrhagic cystitis may develop after chemotherapy or irradiation of the
bladder. Chemotherapy-related cystitis occurs from systemic or local chemotherapy.
Radiation injury may result from external, interstitial, or intracavitary
hemorrhagic cystitis
Dr Ahmed Esawy

89. Thickened bladder wall in a 6-year-old boy
with juvenile myelomonocytic leukemia after
hematopoietic cell transplant from the mother –
grade 3 of hemorrhagic cystitis on the Droller
scale
Irregular thickening of the wall with
hypervascularization and small blood clots in a
5-year-old girl with acute lymphoblastic
leukemia after progenitor cell transplant from a
compatible sibling
Dr Ahmed Esawy

90. Segmental bladder wall thickening with
mucosal and submucosal edema and
hypervascularization
Bladder wall thickened to 1.1 cm in the course
of grade 2 hemorrhagic cystitis in a 5-year-old
boy with acute lymphoblastic leukemia after
progenitor cell transplant from a compatible
sibling
Dr Ahmed Esawy

91. Grade of hemorrhagic cystitis severity

Dr Ahmed Esawy

92. hemorrhagic cystitis
Dr Ahmed Esawy

93. Severe bladder wall thickening of over 1.5 cm
with edema and loss of definition of the
structure of the surrounding tissues – grade 3
hemorrhagic cystitis in a 15-year-old boy with
non-Hodgkin’s lymphoma after allogeneic
transplant from an unrelated donor
Significant thickening of the wall with edema,
inflammatory reaction around the bladder wall
and the surrounding tissues,
hypervascularyzation and clots in the bladder
lumen
Dr Ahmed Esawy

94. An inflammatory pseudotumor is a nonneoplastic proliferation of myofibroblastic
spindle cells and inflammatory cells with myxoid components.

Patients present most commonly with an ulcerating bleeding mass, hematuria, and
voiding symptoms.
Other signs and symptoms include fever and iron deficiency anemia.

This condition is more common in adults, with the mean age at diagnosis reported to
be 38 years, with a range of 15–74 years (2). Inflammatory pseudotumors also
occur in children, and rare in a neonate has been reported
Inflammatory Pseudotumor
(Pseudosarcomatous
Fibromyxoid Tumor)
Dr Ahmed Esawy

95. Polypoid inflammatory pseudotumor. (a–c) Coronal T1-weighted (a), gadolinium-enhanced
fat-suppressed T1-weighted (b), and T2-weighted (c) magnetic resonance (MR) images show
an enhancing polypoid mass projecting into the bladder lumen (arrow).
Dr Ahmed Esawy

96. Cystic inflammatory pseudotumor. Axial contrast material–enhanced computed
tomographic (CT) image shows a predominantly cystic mass (arrow) arising from
the anterior bladder wall. * bladder lumen.
Dr Ahmed Esawy

97. Invasive inflammatory pseudotumor.
Transverse ultrasonographic (US) (a), axial
contrast-
enhanced CT (b), and axial gadoliniumenhanced
fat-suppressed T1-weighted MR (c) images show
a large, lobulated mass arising from the lateral
wall of the bladder with significant extravesicular
extension (arrows).
Dr Ahmed Esawy

98. Inflammatory pseudotumor. Axial T2- weighted MR image shows a lobulated
polypoid mass arising from the anterior wall of the bladder with central
hyperintensity (*) and low peripheral signal intensity (arrowhead).
Dr Ahmed Esawy

99. Urinary bladder wall trabeculation
Dr Ahmed Esawy

100. Urinary bladder wall trabeculation in a case
of Lower urinary tract obstruction
Sonography of the urinary system was done on this elderly male patient having lower
urinary tract symptoms. Ultrasound images show evidence of trabeculation of the
urinary bladder. This is seen as folds of hypertrophied bladder mucosa and bladder
smooth muscle. There is also evidence of bilateral moderate hydronephrosis
Dr Ahmed Esawy

101. The cause of Lower urinary tract obstruction appears to the enlarged prostate
(benign prostatic hypertrophy) with intravesical enlargement of the median lobe
(image on lower left). The fourth image shows significant post-voiding residual
urine in the urinary bladder (Ultrasound image on lower right).
Dr Ahmed Esawy

102. Bladder trabeculation has been graded from 0 to 3 as:

grade 0- no trabeculation.

grade1- mild: area affected is less than 1/2 of the bladder
and depth of trabeculation less than 5 mm.

grade2- moderate: area affected is greater than 1/2 of the
bladder and depth of trabeculation is 5 to 10 mm.

grade 3- severe: area affected is greater than 1/2 of the
bladder and depth of trabeculation is greater than 10 mm.
Bladder trabeculation
Dr Ahmed Esawy

103. Bilharziasis (Schistosomiasis) of the urinary bladder
This patient presented
with lower urinary
symptoms, dysuria and
hematuria.
The disease is caused by contact with water
infested with the parasite- schistosoma and is
endemic in parts of Africa (Egypt and Sudan)
Sonography of the pelvis showed
thickening of the wall of the urinary
bladder with extensive calcification.
These ultrasound images suggest a
diagnosis of schistosomiasis or
bilharziasis of the wall of the urinary
bladder. Bilharziasis is a parasitic
infestation which primarily involves the
urinary bladder, though the liver and
spleen may also be affected.
Dr Ahmed Esawy

104. Dr Ahmed Esawy

105. Bladder diverticulum are outpouchings from the bladder wall, whereby mucosa
herniates through the bladder wall. They may be solitary or multiple in nature and can
very considerably in size.
Dr Ahmed Esawy

106. Muscle-invasive bladder
carcinoma in a 54-year-old man
with urolithiasis (arrows) and
long-term bladder catheterisation
(thick arrows).

Unenhanced (a),portal (b, c) and excretory
(d, e) phase CT images showed focal solid
mural thickening (*) at the
left posterolateral bladder wall,
with an irregular configuration
and positive contrast enhancement (thin
arrows).



Postoperative status after radical
cystectomy (f) with orthotopic
neobladder (§) is shown on
follow-up CT (f)
Dr Ahmed Esawy