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Imaging prostatitis ,urethritis Dr Ahmed Esawy

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Imaging prostatitis ,urethritis 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 TRANSRECTAL ULTRASOUND images
Cystitis
Prostatitis
urethritis
Orchitis
Epidydmitis
Epidydmo-orchitis
funiculitis
Vastitis/differentitis
Seminal vesiculitis

Published in: Health & Medicine
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Imaging prostatitis ,urethritis Dr Ahmed Esawy

  1. 1. Dr Ahmed Esawy Prostatitis Imaging Dr. Ahmed Esawy MBBS M.Sc MD
  2. 2. Dr Ahmed Esawy Anatomy of Urethra • Extends from bladder neck to the membranous urethra • Divides the prostate into anterior FMS and posterior glandular structures. • Veromontanum • Prostatic utricle. • Ejaculatory duct openings. • Internal urethral sph. at the bladder neck • External urethral sph. at the prostatic apex
  3. 3. Dr Ahmed Esawy Orientation of images
  4. 4. Dr Ahmed Esawy Seminal Vesicles, Vas deferences
  5. 5. Dr Ahmed Esawy Prostatic base-TS Dr Ahmed Esawy
  6. 6. Dr Ahmed Esawy Mid prostate-TS Dr Ahmed Esawy
  7. 7. Dr Ahmed Esawy Prostatic apex-TS Dr Ahmed Esawy
  8. 8. Dr Ahmed Esawy Mid prostate-LS Dr Ahmed Esawy
  9. 9. Dr Ahmed Esawy Periprostatic structures • Urinary bladder • Obturator internus& levator ani • Anterior periprostatic fat • Pubic bone • Neurovascular bundles • Rectal wall
  10. 10. Dr Ahmed Esawy Normal MRI of the Prostate
  11. 11. Dr Ahmed Esawy
  12. 12. Dr Ahmed Esawy category III prostatitis, also known as chronic pelvic pain syndrome (CPPS) is a common condition of unclear etiology and few validated effective therapies. It is even controversial whether all patients with CPPS have prostatic pathology Prostatitis infection or inflammation of the prostate gland Acute prostatitis Chronic focal prostatitis symptomatic oligo or asymptomatic Typical pelvic or perineal pain lasting more than 3 month can be bacteria or non infectious
  13. 13. Dr Ahmed Esawy The National Institutes of Health (NIH) classified prostatitis into four distinct syndromes I: acute bacterial prostatitis II: chronic bacterial prostatitis III: chronic prostatitis and chronic pelvic pain syndrome (CPPS); further classified as inflammatory or noninflammatory) IV: asymptomatic inflammatory prostatitis
  14. 14. Dr Ahmed Esawy Prostatitis • Diffuse or focal. • Involve inner or outer gland. • Acute, chronic or granulomatous. .
  15. 15. Dr Ahmed Esawy Ultrasonographic findings in prostatitis Enlarged prostate diffuse enlargement focal high-density and mid-range echoes represent corpora amylacea concretion , Calcifications Focal hypoechoic region in the peripheral zone of the gland the mid-range echoes represent inflammation, fibrosis, or both echo-lucent zones Discrete fluid collection suggests abscess formation. capsular irregularity and thickening, ejaculatory duct echoes, and periurethral-zone irregularity. Colour Doppler ultrasound demonstrates increase flow in the periphery of the abscess Granulomatous prostatitis: * Focal hypoechoic lesion
  16. 16. Dr Ahmed Esawy TRUS findings Edema of the verumontanum Edema of the prostatic lobes (peripheral zone) Dilated Ejaculatory Ducts Changes of the Seminal Vesicles Median prostatic cysts (utricular cysts, Mülleriancysts)
  17. 17. Dr Ahmed Esawy MRI The prostate will be diffusely enlarged, often with associated inflammatory changes of periprostatic fat and of the seminal vesicles Acute prostatitis T1: peripheral zone iso- or hypo-intense to transitional zone T2: hyperintense T1 C+ (Gd) diffusely enhancing CT abscess is present it is seen as a rim-enhancing, unilocular or multilocular, hypodensity in the peripheral zone Infection can extend through capsule into periprostatic tissues, seminal vesicles, and peritoneum Chronic prostatitis: * heterogenous gland DD cancer * Ca in PZ
  18. 18. Dr Ahmed Esawy Group I. Prostatic calculi associated with prostatitis Group II. Prostatic calculi associated with hypertrophy of the gland Group III. Prostatic calculi that simulate carcinoma Group IV. Calculi in both the prostatic urethra and the urinary tract Prostatic Calculi Calcification formed within prostate gland. It is mainly composed of calcium carbonate and/or calcium phosphate. They are usually asymptomatic. These calculi can be well demonstrated by Plain X-ray, CT scan,
  19. 19. Dr Ahmed Esawy small multiple concretions corresponding to the corpora amylacea. Prostatic parenchymal calculi are usually incidental findings Small, multiple calcifications are a normal, often incidental ultrasonographic finding in the prostate and represent a result of age rather than a pathologic entity. However, larger prostatic calculi may be related to underlying inflammation and require further evaluation and possibly, treatment
  20. 20. Dr Ahmed Esawy Prostatic concretions ( corpora amylacea [starch bodies) 1. Small spherical or ellipsoid bodies 2. Number increases with age 3. May become calcified as male ages 4. May simulate carcinoma
  21. 21. Dr Ahmed Esawy Prostatic calculi • Occur in conjunction of BPH • Concretion of corpora amylacia • Localized in PUG • As gland enlarge-calculi at surgical capsule • May dystrophic calcifications Dr Ahmed Esawy
  22. 22. Dr Ahmed Esawy Longitudinal transrectal ultrasound image of the left lobe of the prostate demonstrating extensive concretions. Dr Ahmed Esawy
  23. 23. Dr Ahmed Esawy This middle aged patient underwent TRUS imaging (transrectal ultrasound) of the prostate for prostatism (symptoms related to the prostate). TRUS images show multiple hyperechoic foci (arrows), each of 4 to 7 mm. in the inner gland of the prostate and also along the prostatic urethra. Power Doppler image (bottom) shows normal flow in the prostate. These ultrasound images suggest prostatic calcification or calculi. Calcific foci in prostate are associated with normal aging process in the male and may be the result of formation of corpora amylacea. These are formed by calcification of secretions of the gland. It is also seen in chronic inflammation of the prostate (chronic prostatitis).
  24. 24. Dr Ahmed Esawy Power Doppler TRUS image (on right above), shows no significant changes in vascularity of the prostate and suggesting absence of prostatitis at present. The calcification of the walls of this midline utricle cyst of the prostate may be the result of dystrophic changes
  25. 25. Dr Ahmed Esawy Micturating cystourethrogram (MCUG) showing huge prostatic cavity Plain pelvic X-ray showing prostatic urethral calculus
  26. 26. Dr Ahmed Esawy Multiple, small prostatic calculi (type A) in a young patient.
  27. 27. Dr Ahmed Esawy Coarse echoes representing larger, discrete prostatic calculi
  28. 28. Dr Ahmed Esawy The above TRUS ultrasound and color doppler images in a young male patient show a) hypoechoic prostate b) gross augmentation of vascularity in the prostatic tissue. These ultrasound findings suggest presence of acute prostatitis
  29. 29. Dr Ahmed Esawy Note the markedly hypoechoic patches in the inner zone of the prostate (arrowed), which appear overtly vascular on color doppler imaging
  30. 30. Dr Ahmed Esawy acute-bacterial-prostatitis-and-abscess
  31. 31. Dr Ahmed Esawy Acute bacterial prostatitis and abscess
  32. 32. Dr Ahmed Esawy
  33. 33. Dr Ahmed Esawy
  34. 34. Dr Ahmed Esawy
  35. 35. Dr Ahmed Esawy T2 T1 fat sat severe urinary tract infection with complicating prostatic abscess
  36. 36. Dr Ahmed Esawy • Chronic prostatitis. CT revealed multiple, coarse, ring like calcification inside the normal-sized prostate, which is sharply marginated. The prostate clearly absorbs contrast medium as an expression of current prostatitis.
  37. 37. Dr Ahmed Esawy Chronic Prostatitis heterogenous gland
  38. 38. Dr Ahmed Esawy Chronic Prostatitis-MRI
  39. 39. Dr Ahmed Esawy Prostate abscess-TRUS
  40. 40. Dr Ahmed Esawy Prostatic Abscess-MRI C C
  41. 41. Dr Ahmed Esawy Prostatic Abscess-MRI
  42. 42. Dr Ahmed Esawy Prostatic abscess in a 48- year-old man with perineal pain and abnormally ncreased CRP. Axial unenhanced (a) and postcontrast (b) CT images showed mild asymmetric prostatic enlargement, occupied by a 4-cm septated fluid-like Collection (arrowheads) with peripheral and septal enhancement. Note displacement of periurethral calcifications (thick arrows) from midline. Ultrasound-guided transperineal drainage confirmed Escherichia coli infection
  43. 43. Dr Ahmed Esawy Large prostatic abscess from ESBL-positive Escherichia coli infection in a 61-year-old man with previous chemo- and radiotherapy for non-Hodgkin lymphoma, fever (38 °C), dysuria, pelvic pain and enlarged tender prostate at digital rectal examination. Multiplanar CT images (a–d) showed marked prostatic enlargement by confluent nonenhancing hypoattenuating (17–19 HU) regions, with peripheral and septal enhancement (arrowheads). The prostatic infection also involved the left seminal vesicle (arrows in b, d), displaced upwards of the urinary bladder, with mild circumferential mural thickening and mucosal hyperenhancement (thin arrows) consistent with UTI. After transperineal evacuation (e), follow-up CT urography (f) confirmed persistent resolution of the abscess
  44. 44. Dr Ahmed Esawy
  45. 45. Dr Ahmed Esawy PROSTATIC CANCER ON TRUS
  46. 46. Dr Ahmed Esawy
  47. 47. Dr Ahmed Esawy PROSTATITIS ON MRI
  48. 48. Dr Ahmed Esawy PROSTATITIS ON TRUS
  49. 49. Dr Ahmed Esawy PROSTATIC ABSCESS ON TRUS
  50. 50. Dr Ahmed Esawy urethritis
  51. 51. Dr Ahmed Esawy Acute uncomplicated urethritis in a 30-year-old man with neurogenic bladder treated by intermittent selfcatheterisation. Physical examination revealed induration and tenderness of the corpus spongiosum and purulent urethral secretions. Unenhanced T2- weighted MRI images (a) revealed a diffuse, uniform hypersignal in the corpus spongiosum (*) with corresponding intense homogeneous enhancement on post-gadolinium T1- weighted sequences (b, c). The infection did not appear to interrupt the tunica dartos or Buck’s fascia, and did not involve the corpora cavernosa, scrotum or ischioanal spaces. Note Foley catheter in place (thick arrows). The patient successfully
  52. 52. Dr Ahmed Esawy Urethral infection complicated by penile and perineal abscess in a 53-year-old man with tender, inflamed perineal swelling despite antibiotics. Infection was initially detected at contrast-enhanced CT (a) as an elongated midline abscess with peripheral enhancement (arrowheads) and internal fluid. MRI showed corresponding inhomogeneous fluid-like content on T2-weighted sequences (b–d), with surrounding inflammatory stranding (+) and strong contrast enhancement in the abscess walls (arrowheads in e, f). The infected corpus spongiosum (*) showed similar signal features. Surgical evacuation was required to relieve the abscess
  53. 53. Dr Ahmed Esawy
  54. 54. Dr Ahmed Esawy This middle aged male patient presented with a history of hemospermia (passage of blood in semen) with mild pain during ejaculation. Sonography of the abdomen was normal. Transrectal ultrasound (TRUS) of the prostate and seminal vesicles showed multiple echogenic foci/ lesions in the terminal (proximal) part of the seminal vesicles, bilaterally. The ultrasound images show multiple seminal vesical calculi bilaterally, each measuring 2 to 4 mm. in size. Studies suggest that such stones are related to inflammation, obstruction or diabetes mellitus. The ultrasound image on bottom right shows Power Doppler study of the prostate; no abnormal flow was found. Calculi in this case can cause poor flow of semen during ejaculation, hemospermia and painful ejaculation.
  55. 55. Dr Ahmed Esawy This late middle aged male patient presented with lower urinary tract symptoms. TRUS ultrasound shows a 9 mm. midline cyst of the prostate; what is interesting is the markedly hyperechoic rim of the prostate cyst suggesting calcification of the cyst walls. This is an unusual appearance for what is obviously a cyst of the prostatic utricle with almost no literature available.

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