This document provides information on ultrasound examination of the urinary bladder and prostate. It begins with descriptions of normal ultrasound images of the bladder and prostate. It then discusses the role of ultrasound in assessing these structures. Common pathologies that can be identified include trabeculation, diverticula, calculi, ureterocele, infections, and cancers. Scanning techniques for bladder and prostate ultrasound are outlined. The document concludes with ultrasound images demonstrating various normal and abnormal findings of the bladder and prostate.

1. Ultrasound examination of the urinary bladder and prostate.
Dr/ ABD ALLAH NAZEER. MD.

2. ULTRASOUND OF THE BLADDER – Normal.
Longitudinal Bladder View Longitudinal Bladder Image.

3. Transverse Scan Plane Transverse Bladder Image.

4. Ultrasound of the Bladder - Protocol
Role of Ultrasound.
Ultrasound is an important tool for assessing the bladder wall for
wall thickening, trabeculation, masses and diverticulae. Pre and
post micturition volumes. Vesico-ureteric junctions also can be
visualized. Bladder calculi & foreign bodies. Use the full bladder as
an acoustic window to assess the prostate in males and
gynecological structures in females.
Common Pathology.
Trabeculation
Diverticulum
Calculus
Ureterocele
Urinary bladder infection
Adenocarcinoma
Transitional Cell carcinoma

5. Scanning Technique
Patient supine with suprapubic area exposed.
Examine the bladder sagittally in the midline. Now angle laterally & sweep
the probe both left and right to check the lateral margins.
Rotate 90degrees into the axial(transverse) plane. Sweep through from
the superior dome to the bladder base. Ensure the ultrasound beam is
projected as close to perpendicular to the bladder wall as possible.
Look for ureteric jets at the bladder base. This confirms bilateral renal
function and ureteric patency. To do this, in transverse angle inferiorly
using power Doppler (or colour Doppler with low PRF & wall filter
settings). You may need to be patient to wait for the ureteric jet depending
on renal function and degree of hydration.
Document the normal anatomy and any pathology found (including
measurements and vascularity if indicated). Measure the bladder volume
pre and post micturition. As a rule of thumb, the bladder should empty to
approximately 10% of the pre-micturition volume. If the initial post-void
volume is greater than 100mL, encourage the patient to try again because
a large residual volume may be artefactual following a very full bladder.

6. Trabeculated bladder, a noncompliant, hypotonic bladder
resulting from hypertrophy of the muscular coat, usually
caused by obstruction of the urethra. Increasing postvoid
residuals and risk of urinary tract infection may ensue.
Trabeculation of the bladder wall.

8. 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.

9. Pelvic (Bladder) ultrasound shows a large outpouching (D) of the
bladder wall and mucosa projecting from the lumen of the bladder (B).

10. U. Bladder Diverticulum.

12. Bladder calculi occur either from migrated renal
calculi or urinary stasis. Bladder calculi can be
divided into primary and secondary stones:
primary: stones form de novo in the bladder
secondary: stones are either from renal calculi
which have migrated down into the bladder, or
from concretions on foreign material (e.g. urinary
catheters)
Ultrasound
Sonographically they are mobile, echogenic, and
shadow distally. They may be associated with
bladder wall thickening due to inflammation.

14. Large urinary bladder calculus.

17. Ureteroceles represent congenital dilatation of the distal-
most portion of the ureter. The dilated portion of the ureter
may herniate into the bladder secondary to the abnormal
structure of vesicoureteric junction (VUJ).
There are two main types of ureterocele, both of which are the
result of cystic ectasia of the subepithelial portion of the ureter
as it inters the bladder.
simple: a ureterocele that occurs at a VUJ in a normal position
ectopic: that which occurs at a VUJ whose site is abnormal
Ultrasound
A ureterocele appears as a cystic structure projecting into the
bladder, often near the normal location of the vesicoureteric
junction (VUJ). This is ectopic in the majority of cases and
therefore not at the expected location of the ureteric orifice.
The associated ureter is usually noticeably dilated.

21. A bladder infection, also called cystitis, is caused by an
abnormal growth of bacteria inside the bladder, the balloon-like
organ that stores urine. Bladder infections are one of the most
common bacterial infections to affect humans, with up to one-third
of all females having at least one infection at some point in their
lives. Bladder infections are classified as either simple or
complicated. Simple bladder infections affect only healthy women
with normal urinary systems. Bladder infections are rare in men who
are otherwise healthy.
Ultrasonography
There are many causes of inflammation of the bladder wall,
including infection, radiation, drugs (e.g, cyclophosphamide), and
trauma (e.g, indwelling catheter, surgery). The bladder appears
sonographically normal in most cases but may show thickening of its
wall as a result of edema. The bladder mucosa is normally less than
2mm thick when measured at full distention and less than 5mm
thick when non-distended.

22. Acute cystitis.

23. Acute and chronic cystitis. Neurogenic bladder. Gray-scale ultrasound on axial
(a) and sagital (b) planes showed a focal tissular thickening in postero-superior
bladder wall (arrows). (c, d) CEUS showed preservation of the lineal
enhancement in the mucosa-submucosa layer (arrows) and a marked thickening
of muscular layer (double head arrow), therefore neoplasia could be excluded.
Biopsy confirmed acute and chronic cystitis.

24. Follicular cystitis. Ultrasound showed irregular
thickening tissue on the right trigone (arrows),

25. Cystitis glandularis. A 72 year-old man with paraplegia and obesity. (a) Gray-
scale ultrasound showed an irregular echogenic tissue thickening at bladder
base, simulating urothelial carcinoma. (b) CEUS showed enhancement similar
to urothelial neoplasia with effacement of the mucosa-submucosa line that
correlates with mucosal denudation in pathologic analysis.

26. Eosinophilic cystitis. A 50 year-old woman presenting with hematuria. (a)
Gray-scale ultrasound showed an intravesical mass (asterisk) non-enhancing
on CEUS (b) that corresponds to blood clot, and a hyperenhanced focus of 1,3
cm on the right lateral bladder wall (arrow), simulating neoplastic lesion. On
pathologic study this lesion corresponded to eosinophilic cystitis.

27. Acute cystitis. A paraplegic 20 year-old man presenting with hematuria. (a) Gray-scale
ultrasound showed irregular tissue thickening on the right bladder wall (arrows). (b) CEUS
showed marked enhancement on the preserved mucosa-submucosa line (arrows) with a
less-enhanced and thickened muscular layer (discontinues arrow), with delayed wash-out
(c). Pathologic study revealed intense acute inflammatory change.

29. Bladder wall abscess secondary to Crohn disease. Crohn disease presenting with pyuria
and hematuria. (a) Gray-scale ultrasound showed a mass protruding intraluminally
(arrows). (c) CEUS excluded neoplasia, revealing preservation of the mucosa-submucosa
line with a non-enhancing collection inside the bladder wall, corresponding to an
abscess secondary to a fistulizing Crohn disease as CT (b) confirms (R: Rectum).

30. Adenomatous hyperplasia. A 47 year-old man with hematuria. (a) Gray-scale ultrasound
showed a hardly distensible bladder with wall thickening and nodular intraluminal
projections (arrows). (b) CEUS showed enhancement with effacement of the mucosa-
submucosa line (arrow), being the finding indistinguishable from a neoplastic lesion. After
cystoscopy and biopsy the pathologic diagnosis was adenomatous hyperplasia.

31. Squamous metaplasia. A 66 year-old woman with previous history of bladder lithiasis and
hematuria. (a) Gray-scale ultrasound showed a scarcely distensible bladder with an
intraluminal mass. (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing
papillary nodules in the right bladder wall (arrow), indistinguishable from neoplastic focus.
Pathologic study revealed squamous metaplasia, with chronic and acute inflammation.

32. Endometriosis. Longitudinal US image shows a solid homogeneous,
hypoechoic mass protruding into the bladder lumen.

33. Invasive inflammatory pseudotumor. Transverse ultrasonographic
(US) large, lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows).

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

35. Benign urinary bladder tumour; benign neoplasms
including leiomyoma, hemangioma, neurofibroma,
and schwannoma; and tumors of uncertain malignant
potential including paraganglioma, granular cell
tumor, and perivascular epithelioid cell tumor.
Common clinical presentations, morphological
characteristics, and immunohistochemical features
are described to aid the practicing pathologist in the
identification of these entities. This review also
describes current theories as to the pathogenesis of
inflammatory myofibroblastic tumor and
postoperative spindle cell nodule and details the
current molecular markers identifying several of these
lesions.

36. Leiomyoma of the urinary bladder is a rare benign tumour
predominantly found in women, although men can also be affected.
The most common presenting complaints are urinary voiding
symptoms such as obstruction and irritation. US examination
typically shows a smooth-walled homogeneous hypoechoic solid
mass in the bladder with thin echogenic surface

37. Inverted papilloma of the urinary bladder is a rare
entity. According to literature data, this disease is
not malignant, and has low recurrence rate.

38. Echographic appearance of schwannoma bladder.
Schwannoma of the urinary bladder is an extremely rare tumor. It
arises from Schwann cells in nerve sheaths and may be malignant or
benign and is often associated with von Recklinghausen´s disease.

39. Bladder pheochromocytoma.

40. Extra-adrenal paragangliomas of the urinary bladder are rare.
Typically, patients present with symptoms related to catecholamine
hypersecretion or mass effect, but these tumors can also be encountered
incidentally on imaging studies obtained for a different purpose.

41. Non-functional paraganglioma of the urinary bladder.

42. Bladder cancer is any of several types of cancer arising from the
epithelial lining (i.e., the urothelium) of the urinary bladder. Rarely the
bladder is involved by non-epithelial cancers, such as lymphoma or
sarcoma, but these are not ordinarily included in the colloquial term
"bladder cancer." It is a disease in which abnormal cells multiply
without control in the bladder.
The most common type of bladder cancer recapitulates the normal
histology of the urothelium and is known as transitional cell carcinoma
or more properly urothelial cell carcinoma. Five-year survival rates in
the United States are around 77%.
Squamous cell carcinoma (4%)
Worst prognosis
Associated with chronic infection and irritation
In underdeveloped nations, associated with bladder infection by
Schistosoma haematobium
Adenocarcinoma (1%)
Most common in bladder exstrophy
Respond poorly to radiation therapy

43. Infiltrative bladder neoplasm CEUS shows irregular, hyperenhancing tissue
thickening that effaces mucosa-submucosa line CEUS, invading the hypoechogenic
muscular layer (arrows-preserved line),pointing to neoplastic origin.

45. Carcinoma
urinary
bladder- 3D
ultrasound
images.

46. TRUS ultrasound images of the prostate and bladder.

47. Urinary bladder carcinoma.

48. Images for bladder transitional cell carcinoma.

49. Multiple
bladder
masses.

50. Squamous cell carcinoma.

51. Botryoid rhabdomyosarcoma. Transverse US

52. B-cell lymphoma. (a) Longitudinal US image shows intraluminal bladder
masses (white arrows) involving the posterior wall and ureteral orifice. The
latter mass is causing obstruction in the form of a hydroureter (black arrows).
(b) Axial CT image shows the thickening at the ureteral orifice (arrows).

53. ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the
midline to get a sagittal view of the
prostate. Prostate is situated behind the bladder.

54. Turn the probe 90degrees and angle
caudally to get the transverse view. Transverse View Prostate.

55. NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS).
Prostate Volume. Axial Image.

56. Role of Ultrasound
Visualization of the Prostate using the TRUS (
Transrectal Ultrasound) technique has improved the
diagnostic ability of the sonologist. It plays an
important role in most prostatic diseases. It is
necessary for all prostate biopsies.
If the PSA is elevated or increasing rapidly or there is
an abnormal prostate examination then a transrectal
ultrasound and prostate biopsy may be indicated to
obtain tissue to make the diagnosis of prostate
cancer.
Transabdominal Ultrasound can assess the volume of
the prostate but is not reliable to diagnose carcinoma.

57. Scanning Technique
TRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladder.
Ask the patient to try and relax and "bear down" to open the sphincter as the
transducer is inserted slowly. Ensure the transducer has a latex free dedicated
probe cover with plenty of gel. The highest frequency sector probe 7-12MHz
should be used.
The scanning begins in the axial plane. The seminal vesicles are examined initially.
As the probe is angled caudally the base of the prostate is seen.
Once the prostate is examined in its entirety in this plane the probe is turned
90degrees in a sagittal plane. The probe is angled from one side across to the
other.
A volume is taken by measuring height x length in the sagittal plane and x width
in the axial plane and multiply by 0.52.
Look for changes in the contours and echogenicity in each zone.
TRANSABDOMINAL TECHNIQUE
The patient lies supine. The patient should have a half full bladder .500 mls of
water 1 hr before the scan if possible is recommended.
The probe is angled approximately 30 degrees caudal using the bladder as a
window. Slight compression to ensure the inferior portion of the prostate is not
obscured by the shadow artifact from the base of the bladder.

58. Common Pathology
Prostatitis
Cysts
Benign Prostatic Hyperplasia (BPH)
Prostate Carcinoma
Enlarged seminal vesicles
Stones in the seminal vesicles,
Prostate or ejaculatory ducts

60. Acute prostatitis with increased blood flow.

61. Acute prostatitis with increased blood flow.

62. Images
of acute
prostatitis.

63. Granulomatous prostatitis with multiple hypoechoic area inside.

64. Prostatic abscess.
Prostatic abscesses can be a rare complication of prostatitis.
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose
a prostatic abscess. It usually demonstrates ill-defined hypoechoic areas within an
enlarged and/or distorted prostate gland. They may be inhomogenous echoes within

65. Prostatic abscess.

66. Cysts of the prostate gland can be classified into 6
categories, including 1) isolated medial cysts, 2) cysts of
the ejaculatory duct, 3) simple or multiple cysts of the
parenchyma, 4) complicated infectious or hemorrhagic
cysts, 5) cystic tumors and 6) cysts secondary to parasitic
disease. Cysts of the prostate are related to atrophy of the
prostate gland as well as to other well-known factors,
such as inflammatory disease, benign prostatic
hyperplasia, ejaculatory duct obstruction and cancer. The
differential diagnosis and diagnostic criteria are shown for
each category. A possible limitation of this classification is
that the quantitative aspect of the cyst was not evaluated.
This is the initial step toward a more detailed classification
and the basis for further pathological studies.

67. Prostatic utricle cyst.

68. Images for prostatic cyst.

69. Large
cyst of
seminal
vesicle.

70. Prostatic calcification is a common finding, especially after the
age of 50. They may be solitary but usually occur in clusters.
Ultrasound
Calcifications appear as brightly echogenic foci that may or
may not show posterior shadowing

71. Calcified cyst of the prostatic utricle.

72. (C) Ejaculatory duct calcifications. (D) Seminal
vesicle calcifications. (E) Ejaculatory duct dilation.

73. Seminal vesicle calculi (seminal vesicle calcification).

74. Benign prostatic hypertrophy (BPH) is an extremely
common condition in elderly men and is a major cause of
outflow obstruction. Although the term prostatomegaly is
often used interchangeably, strictly speaking
prostatomegaly may refer to any cause of prostatic
enlargement.
Ultrasound
Ultrasound has become the standard first line investigation
after the urologist's finger. Typically there is an increase in
volume of the prostate with a calculated volume exceeding
30 cc ((A x B x C)/2). The central gland is enlarged, and is
hypoechoic or of mixed echogenicity. Calcification can be
seen both within the hypertrophied gland as well as in the
pseudocapsule (representing compressed peripheral zone).
Post-micturition residual volume is typically elevated.

75. Benign prostatic hypertrophy.

76. Benign prostatic hyperplasia.

77. Benign prostatic hyperplasia.

78. Benign prostatic hyperplasia.

79. Prostatic carcinoma ranks as the most common malignant
tumour in men and the second most common cause of cancer-
related deaths in men. Prostatic adenocarcinoma is by far the most
common histological type and is the primary focus of the article.
Ultrasound
Transrectal ultrasonography (TRUS) is often initially performed in
order to detect abnormalities and to guide biopsy, usually
following an abnormal PSA level or DRE.
Ultrasound is used to direct biopsy of suspicious, hypoechoic
regions, usually in the peripheral zone. Because of the high
incidence of multifocality, systematic sextant biopsies are
recommended.
On ultrasound prostate cancer is usually seen as a hypoechoic
lesion (60-70%) in the peripheral zone of the gland, but can be
hyperechoic or isoechoic (30-40% of lesions).
Transrectal ultrasound is also the modality of choice for directing
brachytherapy seeds into the prostate gland.

81. Carcinoma of the prostate.

82. Carcinoma prostate- Ultrasound and Color Doppler imaging.

83. Contrast-enhanced ultrasound showing an enhancing prostate cancer.

84. Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow).
There is interruption of the normal green band on elastography with a stiff area that
corresponds to the nodule. Biopsy confirmed Gleason grade 7 prostate cancer.

86. A. Conventional gray scale image shows a hypoechoic mass extending
exophytically from the prostate (arrows). The hypoechoic appearance is the
classic description for prostate cancer. B. Real-time elastography shows
reduced tissue elasticity (darker blue color) in the region of the mass (arrows).
C. Color Doppler shows increased flow within and around the mass (arrows).

87. A. Conventional gray scale image shows a hypoechoic area in the left base (arrows).
B. Power Doppler image shows no significant increase in flow in this hypoechoic
area. C. Harmonic gray scale during contrast infusion shows a clearly defined area of
focal enhancement, corresponding to the cancer (arrows). D. Harmonic gray scale
with intermittent imaging shows a less well-defined, larger area of parenchymal
enhancement around the cancer. E. Contrast-enhanced color Doppler image shows
increased flow associated with the cancer. F. Contrast-enhanced power Doppler
image also shows increased flow associated with the cancer.

88. Conventional gray scale transverse image does
not show any suspicious lesion. B. Only contrast-
enhanced colour Doppler transverse image
shows increased flow associated with the cancer.
A. Conventional gray scale transverse
image shows no focal lesion. B. Contrast-
enhanced colour Doppler transverse
image shows increased flow in the left
base, corresponding to the cancer. C.
Also contrast-enhanced power Doppler
transverse image shows increased flow
corresponding to the cancer.

89. A. Power Doppler image showed limited
blood flux in the central gland of the
prostate (arrow), suggesting that this
area had not been totally destroyed by
the HIFU ablation. B. Simultaneous
acquisition of a low mechanical index
ultrasound image (right side of the
screen) and of a contrast ultrasound
image (left side of the screen) 30sec
after bolus injection of 4.8ml of
Sonovue. The HIFU-induced coagulation
necrosis was clearly seen as a
devascularized area with no contrast
enhancement (straight arrows). The
anterior part of the left lobe showed
intense enhancement on contrast image
(arrowheads), suggesting it had not
been destroyed by HIFU. Obtaining
biopsy from that anterior territory might
increase the sensitivity of residual
cancer detection. Note that the
devascularized area extended into the
periprostatic tissues (curved arrow).

90. Sarcoma: Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation. The TRUS appearance of this
lesion is typified by an irregular hypoechoic prostatic mass with an
anechoic area consistent with the echogenicity of muscle and/or necrosis.
This appearance is distinctly dissimilar to prostatic adenocarcinoma. The
sonographic finding of an irregular, hypoechoic, prostatic mass with an
anechoic area should raise the suggestion of prostatic sarcoma in patients
with a history of pelvic irradiation who develop an abnormal prostate
found during a rectal examination and/or who have worsening voiding
symptoms despite a normal serum PSA level.
Unlike radiation-induced sarcoma involving the prostate, which is
predominantly hypoechoic, the echogenicity of rhabdomyosarcoma is
similar to that of the normal prostate. TRUS can provide a means of
monitoring prostate size and sampling tissue in older patients with
prostatic rhabdomyosarcoma but has little value as a diagnostic imaging
technique. TRUS is inappropriate in children, who are more commonly
affected with prostatic rhabdomyosarcoma.
Cystosarcoma phyllodes involving the prostate appear as a large irregular
mass containing multiple large anechoic cysts of variable size.

92. Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice. In the 2 largest consecutive series,
leukemia/lymphoma was identified in less than 1% of prostates.
Lymphoma of the prostate.

93. Melanoma of the prostate with lung metastasis.

94. Metastasis of the prostate from cancer rectum.

95. Thank You.