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MCU and AUG - CYSTOURETHEROGRAM Urology.pptx
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- 2. Radiological Anatomy OfThe Bladder โข In a newborn infant the bladder lies above the symphysis pubis , but as the child grows, the bladder descends, until at about 5 years of age the bladder floor lies at or somewhat below the level of the symphysis pubis. โข Shopfner and Hutch divide the bladder into two units: the vault and the bladder floor. โข When the patient is in either the supine or the upright position, the top of the bladder appears round. โข Sometimes an indentation is seen at both sides of the distended bladder and gives the appearance of a โwaistโ
- 3. Radiological Anatomy OfThe Bladder โข The base of the bladder is flat in the supine position and becomes cone shaped when the patient stands upright โข Its lowest point is anterior to the internal urethral orifice. Therefore, in the anteroposterior view the bladder is superimposed on both the bladder outlet and proximal end of the urethra. โข As a result, voiding studies must always be filmed in the steep oblique to lateral projection.
- 4. Radiological Anatomy OfThe Bladder โข Most of the bladder floor is occupied by the base plate, which is circular when the bladder is full and at rest. โข It consists of an anterior and posterior trigonal plate with the vesicourethral junction slightly anterior to its center. โข It is best identified on a lateral cystogram as the posteroinferior wall of the bladder and extends from its most dependent point to a small indentation representing the inter-ureteric ridge, which is part of the trigone
- 5. Radiological Anatomy OfThe Male Urethra โข Male Urethra is 18 โ 20cms long โข The male urethra has 4 sections: the prostatic and membranous (diaphragmatic) parts, together referred to as the posterior urethra, and the cavernous part (anterior urethra), which consists of the bulbar and pendulous penile urethra. โข Prostatic Urethra โ Starts at Bladder base and ends distal to the verumontanum, a narrow longitudinal ridge on the posterior wall.
- 7. Radiological Anatomy OfThe Male Urethra โข The ejaculatory ducts enter the verumontanum on either side, the prostatic utricle passes through its center, and multiple prostatic ducts open on its surface. โข On a lateral urethrogram, the verumontanum is indicated as an oval filling defect in the posterior urethra. โข The verumontanum is the only constant landmark in the male urethra.
- 8. Radiological Anatomy OfThe Male Urethra
- 9. Radiological Anatomy OfThe Female Urethra โข The urethra in an adult woman is about 4 cm long โข Extends from the internal to the external urethral orifice. Its course is obliquely downward and slightly curved โข Widest at bladder neck โข Narrowest & least distensible at meatus โข This forms the spinning top configuration of the urethra on normal MCU
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- 11. Voiding Cystourethrogram โข VCUis the most widely used examination for radiological evaluation of the bladder and urethra in both children and adults
- 12. Indications Children โข Recurrent UTI โขVoiding difficulties โข VUR โข Meningomyelocele, sacral agenesis, Rectal anomalies โข Baseline study prior to lower urinary tract surgery โข Post-op evaluation of ureteric abnormalities โข Pelvic trauma โข In renal failure to exclude reflux โข Posterior urethral valve or polyp โข Congenital anomalies of bladder & urethra.
- 13. Indications โข Trauma tourethra โข Urethral stricture โข Urethral diverticulum โข Recurrent UTI โข Reflux nephropathy prior to renal transplant โข Follow up patients of spinal cord injury โข Stress incontinence
- 14. Kidney/Ureter โข Obstruction โข VCUGhas been obtained routinely as part of the evaluation of children with hydronephrosis. Instead, most algorithms reserve VCUG when hydronephrosis is seen along with dilated ureter(s). Bladder/Urethra โข Obstruction โข VCUG is an excellent high-resolution anatomic study that is used to detect abnormalities such as those of the bladder wall (e.g., trabeculation, ureterocele, diverticula, bladder neck hypertrophy, tumors), those of the urethra (posterior urethral valve, urethral stricture, diverticulum), bladder stones, bladder rupture, and foreign bodies. VCUG can be used to assess bladder emptying. The initial scout film can also identify many spinal abnormalities. โข Cysts/Masses โข Among the dilations and masses identified on VCUG, one finds urachal diverticula, bladder diverticula, dilated utricles, and fibroepithelial polyps.
- 15. Technique โข No preparationis needed; no cleansing enema, fasting, or anesthesia is required โข To rule out UTI โข Bladder capacity โข Less than one year, โข Weight (kg) x 7 = capacity (ml) โข Less than two years, โข (2 x age in years + 2) x 30 = capacity (ml) โข More than two years, โข (Age in years/2 + 6) x 30 = capacity (ml)
- 16. Technique โข With steriletechnique, a catheter is introduced into the bladder (Infants 5-7 Fr feeding tube and Foleys for adults) โข A No. 5 feeding tube with side holes is used for babies, and in older children, No. 8 or 10 polyethylene or soft rubber catheters with end holes are quite suitable โข Once the catheter has safely reached the bladder and residual urine has been removed, filling with contrast material can begin.
- 17. Technique โข Methods ofInstillation โข Hand-injected โข Gravity method, which is usually less uncomfortable for the child. โข An infusion set is connected to the catheter, and the contrast- filled bottle is suspended above the table to a height of 35 to 40 cm โข Capacity is reached when the child becomes uncomfortable and restless or begins voiding around the catheter or when bladder and infusion pressure becomes equal and flow ceases or reverses. Forceful flexion of the toes sometimes signifies that bladder capacity has been reached โข In Adults, The patient can manually compress the meatus to improve visualization of the urethra. โข Bladder trabeculation, vesicoureteral reflux and narrowing of the bladder neck or urethra, if present, will be successfully demonstrated.
- 18. Alternative Techniques โข Suprapubicbladder puncture โข Sometimes in PUV & pelvic trauma - not possible to catheterize. โข Urethrocystography โข Contrast medium introduced into the bladder during RGU. โข Excretion MCU ( MCU followed by IVU ) โข Advantage - avoid catheterization and related risk of infection. โข Disadvantage - VUR can not be visualized properly takes longer time
- 19. Posterior urethral Valve โขCongenital thick folds of mucous membrane located in the posterior urethra (prostatic + membranous) distal to the verumontanum. โข Most common cause of severe obstructive uropathy in children. โข Almost exclusively in males. โข Leading cause of end stage renal disease in boys. โข Now rare for them to present with severe UTI and septicaemia - diagnosis is generally made in early infancy and antenatal period. โข Procedure of choice for defining the valves.
- 25. Prostatic utricle โข Theprostatic utricle is a small, blind-ending midline pouch arising from the prostatic urethra at the level of the verumontanum โข A large prostatic utricle may be associated with urinary retention, stasis, and infection
- 26. Complications โข Contrast reaction โขContrast induced cystitis โข UTI โข Catheter trauma โข Bladder perforation - overfilling โข Retention of a foley catheter โข Catheterisation of vagina / ectopic ureter โข Radiation exposure
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- 28. Retrograde Urethrography โข Aretrograde urethrogram is a study meant to evaluate the anterior and posterior urethra. โข Retrograde urethrography may be particularly beneficial in demonstrating the total length of a urethral stricture, which cannot be negotiated by cystoscopy. โข Retrograde urethrography also demonstrates the anatomy of the urethra distal to a stricture, which may not be assessable by voiding cystourethrography.
- 29. Indications โข Evaluation ofurethral stricture disease โข Location of stricture โข Length of stricture โข Assessment for foreign bodies โข Evaluation of penile or urethral penetrating trauma โข Evaluation of traumatic gross hematuria โข Urethral foreign body โข Periurethral abscess โข Fistula/ false passage โข Urethral mucosal tumor โข Postoperative evaluation
- 30. Retrograde Urethrography โข Penisglans and urethral meatus should be cleaned with antiseptic โข The Foley catheter, with care taken to place the balloon in the fossa navicularis, which is the most distal part of the urethra. โข The balloon, distended with 1 to 2 mL of saline, should effectively close off the urethral meatus. โข We do not use a local anesthetic because it may cause mucosal edema, increased permeability, and vascular stasis, as well as poor retention of the balloon, which may slip out of the urethra, or leakage of contrast material. โข Contrast material can now be injected and will visualize the anterior urethra facilitated by resistance of the external sphincter.
- 31. Retrograde Urethrography Position โข Exposuresare made with the patient in a 45-degree oblique position lying on either side and the dependent thigh acutely flexed with penis placed in slight tension.
- 32. Interpretation โข If theradiopaque contrast is injected properly, the entire anterior and posterior urethra should be filled with contrast and seen to jet into the bladder neck. โข The verumontanum is seen as an ovoid filling defect in the posterior urethra โข The distal end of the verumontanum marks the proximal boundary of the membranous urethra and constitutes the urethra that passes through the urogenital diaphragm.
- 38. Role of urethrographyin stricture โข Accurately delineates the anatomy of urethra. โข Location, number and extent of the strictures are very well displayed โข Delineation of the bladder neck and urethra is best achieved on the MCU in the oblique projection. โข Secondary changes in the bladder. โข To demonstrate the VUR โข Visualization of any associated fistulas.
- 44. Blunt Urethral Trauma ClassifiedAnatomically as โข Anterior โข Posterior Anterior urethral injury โข MC iatrogenic (due to instrumentation) โข May occur if patient falls on a blunt object or direct injury to perineum โข Straddle Injury - compression of urethra against anterior pelvic ring Posterior urethral injury results from โข A crushing force to the pelvis โข Is associated with pelvic fractures.
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