Urinary bladder pathologies
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This document describes the anatomy and common conditions of the urinary bladder seen on imaging. It discusses bladder wall thickening which can be seen with conditions like benign prostatic hypertrophy, neurogenic bladder, and cystitis. Calcifications of the bladder wall are also addressed and can result from schistosomiasis, tuberculosis, or chronic cystitis. Filling defects within the bladder may indicate tumors, blood clots, stones, or other masses. Other findings include bladder outpouchings such as diverticula and fistulas connecting the bladder to other organs. Bladder trauma can also be identified on imaging.
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Urinary bladder pathologies
- 1. URINARY BLADDER • Anatomy • Thickened Bladder Wall / Small Bladder Capacity • Calcified Bladder Wall • Bladder Wall Mass or Filling Defect • Bladder Outpouchings and Fistulas • Bladder Trauma
- 2. - Hollow muscular organ - Pyramidal / Triangular - Stores Urine - Max 400-600 ml (Post-void 5-12ml)
- 3. - Superior surface: peritoneum - Trigone: - Adult: Pelvic and Abdominal - superior angle - ureter - Inferior angle - urethra
- 4. Urinary Bladder Wall Normal Bladder Wall • Smooth • Thickness: – Distended: <3 mm. – Collapsed: <5 mm. Urine: Anechoic
- 5. Conditions associated with Bladder Wall Thickening: • Benign prostatic hypertrophy • Urethral stricture and posterior urethral valves • Neurogenic bladder • Cystitis
- 6. Benign Prostatic Hypertrophy - 50% to 75% of men older than age 50. - “J-hooking” of the distal ureters. - Thickening of the bladder wall.
- 7. Urethral stricture and posterior urethral valves - Cause chronic obstruction - The bladder wall thickens reflecting muscle hypertrophy. - Voiding or retrograde urethrography.
- 8. Neurogenic bladder • Spastic or hypotonic. • Stroke, Parkinson’s disease, multiple sclerosis, disk herniation • Prone to urinary stasis, chronic infection, and stone formation. • Trabeculated, thick-walled, and reduced in capacity.
- 9. Cystitis - Infection, drugs (cyclophosphamid e), radiation, and autoimmune reaction. - CT shows bladder wall thickening and perivesical edema.
- 10. Emphysematous cystitis - diabetes mellitus, bladder outlet obstruction, E. coli infection, instrumentation, and vesicocolic fistula.
- 11. URINARY BLADDER • Anatomy • Thickened Bladder Wall / Small Bladder Capacity • Calcified Bladder Wall • Bladder Wall Mass or Filling Defect • Bladder Outpouchings and Fistulas • Bladder Trauma
- 12. Calcified Bladder Wall • Schistosomiasis • Tuberculosis • Cystitis • Neoplasm
- 13. Schistosomiasis • Blood flukes • Endemic in 12 regions in the Phil. • Samar, Leyte Eggs laid in wall of bladder Granulomatous reaction Calcifications
- 14. Tuberculosis • Primarily affects the kidneys • Shrunken bladder with wall thickening. • Calcification affect proximal ureter but may extend up to the bladder. • Calcification of the bladder wall is uncommon and patchy.
- 15. Cystitis • Post irradiation • Chronic infection • Cyclophosphamide-induced • Curvilinear or flocculent bladder wall calcification.
- 16. Neoplasm • Transitional Cell and Squamous Cell CA – Rarely calcify (1% to 7% incidence). • Tumor calcification – Punctate or curvilinear
- 18. URINARY BLADDER • Anatomy • Thickened Bladder Wall / Small Bladder Capacity • Calcified Bladder Wall • Bladder Wall Mass or Filling Defect • Bladder Outpouchings and Fistulas • Bladder Trauma
- 19. Bladder Wall Mass or Filling Defect • Simple ureterocele • Ectopic ureterocele • Transitional cell carcinoma • Squamous cell carcinoma • Adenocarcinoma • Benign bladder tumors • Blood clots • Bladder stones • Malacoplakia
- 20. Simple ureterocele Congenital prolapse of distal ureter at the trigone Cystic dilatation of the intravesicular segment • Usually incidental finding • “Cobra head” or “Spring onion” appearance • Large -> obstruction, infection, stones
- 22. Ectopic ureterocele • Associated with ureteral duplication. • Females, ureter may insert distal to the external sphincter into the vestibule, uterus, or vagina -> urinary incontinence • Males, insertion is proximal to the external sphincter • Large -> obstruction
- 23. Urothelial / Transitional Cell Carcinoma • Most common – ~90% of bladder neoplasms • Risk factors: tobacco, arsenic, cyclophosphamide, schistosomiasis, recurrent UTI/stones • Classified as Superficial or Invasive • Hallmark: multiplicity and recurrence • CT and MR: equal staging capability
- 27. Squamous Cell Carcinoma • 4% of bladder neoplasms. • Highly associated with Schistosomiasis. • Sessile bladder mass • Focal or diffuse bladder wall thickening • Muscle invasion in 80% • Extravesical spread
- 28. Invasive Squamous Cell Carcinoma
- 29. Adenocarcinoma • Rare, less than 1% • Most cases are associated with bladder extrophy or urachal remnants. • Adenocarcinoma metastases to the bladder are more common than primary bladder adenocarcinoma.
- 30. Benign bladder tumors • Well-defined masses and smooth filling defects. • Leiomyoma • Hemangioma • Pheochromocytoma • Neurofibroma.
- 31. Blood clots • Migrate from kidney or formed primarily within bladder • Solitary stones are most common • Chronic stones increase risk of CA Bladder stones • Usually irregular in shape • Mobile • Change in size and appearance over time.
- 33. URINARY BLADDER • Anatomy • Thickened Bladder Wall / Small Bladder Capacity • Calcified Bladder Wall • Bladder Wall Mass or Filling Defect • Bladder Outpouchings and Fistulas • Bladder Trauma
- 34. Bladder Outpouchings and Fistulas • Bladder diverticula • Vesicocolonic fistula • Vesicovaginal fistula • Vesicoenteric fistula
- 35. Bladder Diverticula • Herniations between interlacing muscle bundles • Most are located postero - laterally near the UVJ
- 37. VESICOCOLONIC FISTULA • Complication of diverticulitis • Colon or bladder CA, Ulcerative colitis, and Crohn disease • Pneumaturia and fecaluria • Barium enema and cystography detect only 35% • Occasionally by CT VESICOVAGINAL FISTULA • Iatrogenic causes VESICOENTERIC FISTULA • Attributable to Crohn’s disease.
- 38. URINARY BLADDER • Anatomy • Thickened Bladder Wall / Small Bladder Capacity • Calcified Bladder Wall • Bladder Wall Mass or Filling Defect • Bladder Outpouchings and Fistulas • Bladder Trauma
- 39. Bladder Trauma • Susceptibility of the bladder to traumatic injury depends largely on the degree of bladder filling at the time of injury. • A distended bladder is more prone to injury than a collapsed bladder.
- 40. Extraperitoneal Bladder Rupture -80% of bladder ruptures -Extravasation - Retropubic space of Retzius Pelvic fracture Bone spicule Bladder rupture
- 41. -20% -Extravasation- Paracolic gutters - outlines loops of bowel Blunt trauma Distended bladder Ruptured dome Peritoneal space Intraperitoneal Bladder Rupture
Editor's Notes
- Hollow muscular organ Situated immediately behind the pubic bones It stores urine and in the adult has a maximum capacity of about 400-600 mL. It can hold significantly more in pathological conditions. Empty bladder is pyramid shaped located within the pelvic cavity. It becomes part of the abdominal cavity whenever it expands. In children, it cannot be accommodated in the pelvic cavity hence abdominal organ.
- -When the bladder fills, the posterior surface and neck remain more or less unchanged in position, but the superior surface rises into the abdomen -Superior surface covered by the peritoneum, which forms the anterior wall of the rectovesical pouch -The area of mucous membrane covering the internal surface of the base of the bladder is called the trigone. The superior angles of the trigone correspond to the openings of the ureters, and the inferior angle to the internal urethral orifice. The ureters pierce the bladder wall obliquely, and this provides a valvelike action, which prevents a reverse flow of urine toward the kidneys as the bladder fills. -The muscular coat of the bladder is composed of smooth muscle and is arranged as three layers of interlacing bundles known as the detrusor muscle. At the neck of the bladder, the circular component of the muscle coat is thickened to form the sphincter vesicae.
- -Bladder wall: urothelium, lamina propria, muscularis, adventitia -US is valuable for evaluation of bladder wall, distal ureters, intravesical, and extravesical masses -The volume of bladder contents may be calculated by the standard formula for volume of a prolate ellipse (length × width × height × 0.52). US measurements are used to calculate postvoid urine residual and overdistended bladder volumes when the bladder is neurogenic. -Ureteral jets are spurts of urine into the bladder due to ureteral peristalsis. They are best visualized by color Doppler but are occasionally seen on gray-scale US as swirling microbubbles. -Visualization of ureteral jets confirms patency of the ureter.
- - affects 50% to 75% of men older than age 50. Prostate enlargement projects into the base of the bladder, uplifting the bladder trigone, and causing “J-hooking” of the distal ureters. - Chronic bladder outlet obstruction results in thickening and trabeculation of the bladder wall. Benign Prostatic Hypertrophy. A radiograph from an excretory urogram shows marked uplifting of the bladder base because of massive enlargement of the prostate (P). The trigone (open arrow) and the ureteral orifices are markedly elevated, resulting in a J-shaped appearance to the distal ureters. The bladder wall is thickened (between black arrowhead ) and the bladder (B) mucosal pattern is prominent.
- Urethral stricture and posterior urethral valves - Cause chronic obstruction to the outflow of urine from the bladder. - The bladder wall thickens reflecting muscle hypertrophy in an attempt to overcome the obstruction. - Voiding or retrograde urethrography demonstrates the urethral abnormality.
- In this example, there is a bulbar stricture seen during injection. The posterior urethra is not wide open as would be expected at rest. However during voiding, the area of the membranous urethra remains very narrow. If the RUG were the only test performed, then the posterior stricture would have been missed. *Retrograde Urethrogram *Voiding Cystourethrogram
- Spastic (volume is typically normal or small, and involuntary contractions occur) or Hypotonic (volume is large, pressure is low, and contractions are absent). - Causes include stroke, parkinson’s disease, multiple sclerosis, disk herniation/spinal trauma, meningomyelocele, diabetes mellitus, poliomyelitis, CNS tumor, and multiple sclerosis. - Neurogenic bladders are prone to urinary stasis, chronic infection, and stone formation eventually leading to thickening of the bladder wall - Most neurogenic bladders eventually become trabeculated, thick-walled, and reduced in capacity.
- Inflammation of the bladder has many causes, including infection (bacteria, adenovirus, tuberculosis, and schistosomiasis), drugs (cyclophosphamide), radiation, and autoimmune reaction. CT scan of a patient presenting with pyuria and hematuria. Badder wall thickening and perivesical edema (arrows). Urine culture confirmed cystitis caused by Escherichia coli.
- - Emphysematous cystitis is a form of bladder inflammation with gas within the bladder wall. - It is associated with E. coli infection which ferment sugar in the urine to release carbon dioxide and hydrogen gasses. - Gas within the bladder lumen is also seen with instrumentation and vesicocolic fistula.
- - Caused by blood flukes which are endemic in 12 regions in the Philippines most commonly in Samar and Leyte. - Adult females migrate to the vesical venous plexus and lay their eggs in the wall of the urinary bladder and the ureter. The eggs incite a fibrosing granulomatous reaction that results in calcification of the walls of the distal ureters and the bladder. Granulomatous reaction also result in the beaded stenosis and irregular dilatation of the ureters The ureters become aperistaltic resulting in vesicoureteral reflux. Eventually, the bladder may become shrunken, fibrotic, and contracted
- Affects the kidneys primarily and the ureters and the bladder secondarily. Tuberculous infection of the bladder causes wall thickening and reduced capacity. - Calcification affects the ureters proximally and may eventually extend into the distal ureters and the bladder. Calcification of the bladder wall is uncommon and patchy.
- - The following are subtypes of cystitis that can cause calcifications in the bladder wall. - Calcifications appear as curvilinear or flocculent (resembling tufts of wool)
- - Transitional cell and squamous cell carcinomas of the bladder may rarely calcify (1% to 7% incidence). - Tumor calcification may be punctate or curvilinear and is best demonstrated by CT.
- Two small masses with surface calcification (arrows) are seen projecting into the lumen of the bladder. Multifocal, noninvasive papillary urothelial carcinoma was diagnosed at transurethral resection.
- A cystic dilatation of the intravesicular segment of the ureter caused by a congenital prolapse of the distal ureter into the bladder lumen at the normal insertion site of the ureter into the trigone. It is usually an incidental finding in adults, although large, simple ureteroceles may be associated with ureter obstruction, infection, and stone formation. Contrast studies demonstrate a rounded filling defect in the bladder at the ureteral insertion. This is appreciated as a “cobra head” or “spring onion” appearance. A radiolucent halo is produced by the wall of the ureter outlined both inside and outside by contrast. - US demonstrates a cystic mass at the ureteral orifice. Peristalsis of the ureter causing alternate filling and emptying of the ureterocele is seen on real-time US.
- - “Cobra head” or “spring onion” appearance - Radiograph from an excretory urogram demonstrates mild dilation of the right ureter associated with a simple ureterocele (u) that protrudes into the lumen of the bladder (B). The radiolucent wall of the ureterocele (arrowhead) is outlined by contrast within the ureterocele and contrast within the bladder lumen.
- - Usually associated with ureteral duplication. - Females with ectopic ureters are prone to urinary incontinence because the ureter may insert distal to the external sphincter into the vestibule, uterus, or vagina. - In males, the ectopic ureter usually inserts proximal to the external sphincter; no incontinence results. - Large ectopic ureteroceles may obstruct the opposite ureter or cause bladder outlet obstruction because of their mass effect.
- - Most common urinary tract neoplasm - Risk factors for bladder urothelial tumors include tobacco use, arsenic ingestion, cyclophosphamide treatment, schistosomiasis, and recurrent urinary tract infections and stones - Urothelial carcinomas are classified as superficial (papillary tumors confined to the mucosa and associated with a high likelihood of multiplicity and recurrence following resection) or invasive (penetrates the bladder wall resulting in local extension and metastases). The hallmark of TCC is multiplicity and recurrence CT and MR are approximately equal in capability of staging this carcinoma - Bladder carcinoma spreads by direct invasion through the bladder wall, by lymphatic spread to regional lymph nodes, and by hematogenous spread most commonly to bones, liver, and lung. Approximately 5% of patients have distant metastases at initial diagnosis.
- - Intraluminal papillary or nodular mass - Longitudinal US image of the bladder shows a large, hypoechoic urothelial carcinoma (arrow) within the bladder.
- Axial CT image shows a large, lobular mass within the bladder.
- Contrast-enhanced CT imaging shows an enhancing area of focal wall thickening (arrow), which represents a urothelial carcinoma. - Flat lesions are more difficult to detect with radiologic studies, especially if the bladder lumen is not well distended.
- - Constitutes 4% of bladder neoplasms and are highly associated with Schistosomiasis. In contrast to urothelial carcinoma which appear as a papillary mass, squamous carcinoma is sessile (attached directly by the base/not raised upon a stalk) May also appear as a diffuse or focal wall thickening. - Muscle invasion is present in 80% of cases and extravesical spread may be extensive, involving surrounding organs and the abdominal wall
- Axial T2-weighted MR image showing soft-tissue mass (straight arrows) filling the pelvis and obliterating the normal bladder lumen. The mass is locally aggressive and has eroded through the abdominal wall (curved arrow)
- - Benign bladder tumors appear as well-defined masses and smooth filling defects. - Include leiomyoma, hemangioma, pheochromocytoma, and neurofibroma.
- Blood clots - usually irregular in shape, - move with changes in patient position, and change in size and appearance over time. Bladder stones - may migrate from the kidney or form primarily within the bladder because of urinary stasis or a foreign body. - Solitary stones are most common. Stones must be removed to cure chronic bladder infection. - Chronic bladder stones increase the risk of developing bladder carcinoma.
- Non-contrast CT demonstrates multiple high-attenuation stones (arrow) seen within the lumen of the bladder. Contrast opacification of the bladder may obscure the presence of bladder stones. This patient has a neurogenic bladder resulting in chronic urine stasis within the bladder.
- Delayed phase image from a CT urogram shows a bladder diverticulum ( arrow ) partially filled with contrast-opacified urine. The narrow neck of the diverticulum is apparent. - Bladder diverticula are herniations of the bladder mucosa between interlacing muscle bundles. Most are located posterolaterally near the UVJ. Diverticula may contain stones or tumor and occasionally do not fill on cystograms. - Complications of bladder diverticula include urinary stasis, infection, stone formation, vesicoureteral reflux, and bladder outlet obstruction.
- Axial plane image through the bladder (B) shows a urine-filled diverticulum (arrows) with a narrow neck (long arrow) connecting it to the bladder.
- Vesicocolonic fistula - most commonly occurs as a complication of diverticulitis. Additional causes include colon or bladder carcinoma, ulcerative colitis, and Crohn disease. The - - bladder is chronically infected - the patient may complain of pneumaturia and fecaluria. The diagnosis is often made clinically. - Barium enema and cystography detect only 35% of vesicocolonic fistulae. The fistulous tract is occasionally demonstrated by CT. Vesicovaginal fistula - usually a complication of gynecologic surgery, especially for cervical carcinoma. Obstetric injury is an occasional cause. Vesicoenteric fistula is almost always attributable to Crohndisease.
- Image from a CT cystogram performed in a patient with a pelvic fracture reveals contrast extravasation (arrowheads) from the bladder into the retropubic space of Retzius indicating bladder rupture into the extraperitoneal compartment. Contrast has also tracked into the subcutaneous tissues (curved arrow). Contrast was instilled into the bladder through a Foley catheter (arrow). Extraperitoneal bladder rupture (80% of bladder ruptures) - Results from puncture of the bladder by a spicule of bone from a pelvic fracture. - Contrast extravasates into extraperitoneal compartments, most commonly the retropubic space of Retzius. Contrast extravasation may extend into the anterior abdominal wall, thigh, and scrotum. Conventional or CT cystography with distension of the bladder to atleast 250 mL is required to exclude bladder rupture.
- Image from a CT cystogram demonstrates extravasation of contrast from the bladder into the intraperitoneal space. Contrast ( arrowheads ) enveloping loops of bowel confirms its intraperitoneal location. This finding on a CT cystogram is diagnostic of intraperitoneal bladder rupture. A fracture (arrow) of the ilium is evident. Intraperitoneal bladder rupture (20% of bladder ruptures) - results from blunt trauma applied to a distended bladder. - The sudden rise in intravesical pressure results in rupture of the bladder dome and extravasation into the peritoneal space. - Contrast material flows into the paracolic gutters and outlines the loops of the bowel. - Intraperitoneal bladder rupture may clinically mimic acute renal failure. Urine output is decreased or absent, and serum creatinine is increased because of absorption of urine by the peritoneal surface