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Imaging cystitis Dr Ahmed Esawy

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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

Published in: Health & Medicine
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Imaging cystitis Dr Ahmed Esawy

  1. 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. 2. Normal UB Ultrasound Dr Ahmed Esawy
  3. 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. 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. 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. 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. 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. 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. 9. cystitis Infectious Bacterial Cystitis Non-Infectious Non-bacterial Cystitis Infectious nonbacterial cystitis Viral Mycobacterial Chlamydial Fungal Schistosomal Eosinophilic cystitis Dr Ahmed Esawy
  10. 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. 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. 12. Diffuse bladder wall thickening bladder outlet obstruction neurogenic bladder infectious cystitis cystitis from radiation or chemotherapy Dr Ahmed Esawy
  13. 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. 14. Microbial / bacterial cystitis Dr Ahmed Esawy
  15. 15. imaging features Acute infectious cystitis Heterochioc urine on ultrasound Diffuse mural UB wall thickening particularly if marked more than 1 cm Hypoenchancing Oedematous atT2 wighted image Increased compared to previous study Urothelial hyperenhancment minimally thickened uniform ,circumferential perivesical fat inflammatory changes Dr Ahmed Esawy
  16. 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. 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. 18. thickened urinary bladder wall, debris in the bladder, a patent urachus, and hypertrophied mucosa in the urachus. Dr Ahmed Esawy
  19. 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. 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. 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. 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. 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. 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. 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. 26. Post-void residual urine measurement after cystoscopy with hyperechoic air inside the bladder lumen. Dr Ahmed Esawy
  27. 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. 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. 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. 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 includingT2- (e) and postgadolinium T1-weighted (f) sequences confirmed abscess disappearance (arrowheads) Dr Ahmed Esawy
  31. 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. 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, sagittalT2-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. 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. 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. 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. 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. 37. Cystitis cystica-sub mucosal cyst of bladder CoronalTRUS SagittalTRUS 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 thisTRUS 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. 38. Cystitis cystica-sub mucosal cyst of bladder The above images areTRUS 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. 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. 40. Polypoidal lesion close to left UVJ causing hydroureter Dr Ahmed Esawy
  41. 41. Trigonal mass like lesion mimicking malignant lesion on ultrasonography Dr Ahmed Esawy
  42. 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. 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. 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 withT1- weighted sequences, isointense withT2-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. 45. Eosinophilic cystitis. (a) SagittalT1-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. 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. 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. 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. 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. 50. Malacoplakia. (a) Axial CT image shows marked circumferential bladder wall thickening. Dr Ahmed Esawy
  51. 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. 52. Emphysematous cystitis (EC) Dr Ahmed Esawy
  53. 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. 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. 55. The sonogram demonstrates bladder wall thickening and hyperechoic foci, due to intramural vs. intraluminal gas Dr Ahmed Esawy
  56. 56. This sonogram shows hyperechoic foci,due to gas, within or adjacent to the thickened bladder wall. Dr Ahmed Esawy
  57. 57. Emphysematous cystitis as incidental finding in a case of hip fracture on the left Dr Ahmed Esawy
  58. 58. Dr Ahmed Esawy
  59. 59. Dr Ahmed Esawy
  60. 60. Dr Ahmed Esawy
  61. 61. Dr Ahmed Esawy
  62. 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. 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. 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. 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. 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. 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. 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. 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. 70. sigmoid-carcinoma-with-colovesical-fistula Dr Ahmed Esawy
  71. 71. emphysematous-cystitis Dr Ahmed Esawy
  72. 72. rectovesical-fistula-due-to-rectal-carcinoma contrast Dr Ahmed Esawy
  73. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 91. Grade of hemorrhagic cystitis severity Dr Ahmed Esawy
  92. 92. hemorrhagic cystitis Dr Ahmed Esawy
  93. 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. 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 FibromyxoidTumor) Dr Ahmed Esawy
  95. 95. Polypoid inflammatory pseudotumor. (a–c) CoronalT1-weighted (a), gadolinium-enhanced fat-suppressedT1-weighted (b), andT2-weighted (c) magnetic resonance (MR) images show an enhancing polypoid mass projecting into the bladder lumen (arrow). Dr Ahmed Esawy
  96. 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. 97. Invasive inflammatory pseudotumor. Transverse ultrasonographic (US) (a), axial contrast- enhanced CT (b), and axial gadoliniumenhanced fat-suppressedT1-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. 98. Inflammatory pseudotumor. AxialT2- 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. 99. Urinary bladder wall trabeculation Dr Ahmed Esawy
  100. 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. 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. 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. 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. 104. Dr Ahmed Esawy
  105. 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. 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

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