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Large urinary bladder calculus

This 50 yr. old male patient complained of hematuria. Sonography reveals a large

echogenic,oval object of 4.4 cms. in the urinary bladder. As the ultrasound images

reveal, it is freely mobile with change in position, occupying the dependent part of the bladder. Diagnosis: large stone in the urinary bladder. Urinary bladder calculi are

usually formed by migration of stones from the kidney or ureter. It may also be caused

due to stasis of urine in the bladder, due to bladder outlet obstruction  . Ultrasound

images taken using Pie Scanner 100 Falco system. 

Multiple calculi in urinary bladder

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Urinary bladder- multiple large stones 

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Transrectal Ultrasound image - calculi in bladder  

This patient was an elderly male with moderate prostatic symptoms. Transrectalsonography showed a severely enlarged prostate (benign prostatic hypertrophy). But

at least part of the symptoms were due to multiple large stones in the urinary bladder.

Both transabdominal and transrectal sonography show the bladder calculi gravitating

to the dependent part of the urinary bladder. The cause of these multiple bladder

calculi is obviously the persistent urinary tract obstruction due to the enlarged

 prostate, resulting in incomplete evacuation of the urine. The urinary bladder

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stones varied in size from 15 to 27 mm., and I could count at least 4 of them. The

 patient had severe urgency and incontinence. 

View the videos of this case: Ultrasound video clip of multiple, large bladder stones 

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IUCD in urinary bladder

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(Intrauterine contraceptive device in Urinary bladder) 

Sonography of the pelvis in this female patient revealed an echogenic linear object

with posterior acoustic shadowing in the urinary bladder. X-ray images reveal theobject to be a T-shaped structure. Ultrasound and X-ray images are diagnostic of a

Copper-T (IUCD or intrauterine contraceptive device) which migrated to the urinary

 bladder. A snap of the specimen after removal is also seen. It appears to be coated

with urinary sediment. Images courtesy of Dr. Ravi Kadasne, UAE. 

Urinary bladder wall trabeculation in a case of Lower urinary tractobstruction

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 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 (image

top right). The cause of Lower urinary tract obstruction appears to the enlarged

 prostate (benign prostatic hypertrophy) with intravesical enlargement of the medianlobe (image on lower left). The fourth image shows significant post-voiding residual

urine in the urinary bladder (Ultrasound image on lower right). 

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. 

All images by Joe Antony, MD, using a Toshiba Nemio-XG ultrasound system. 

References: 

http://www.ncbi.nlm.nih.gov/pubmed/23452803 

Ureterocele

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Sonography of the urinary bladder done on this patient, revealed a saccular

outpouching of the distal end of the left ureter, into the distended urinary bladder. The

left ureter also appears dilated (left hydroureter). These ultrasound images are

diagnostic of left ureterocele. Ureteroceles are caused due to congenital obstruction ofthe ureter during the embryonic stage. Here the left kidney also shows back-pressure

changes (left hydronephrosis). Observation of the orifice shows gradual distension of

the membrane of the ureterocele sac and then collapse of the sac after evacuation of

the contained urine into the bladder lumen. Ultrasound images courtesy of Dr. Ravi

Kadasne, UAE. 

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Reference: 

http://emedicine.medscape.com/article/451105-overview(free article) 

http://radiographics.rsna.org/content/20/1/155.full(free article and images) 

Ureterocele seen on TRUS (Transrectal ultrasound) imaging

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The above ultrasound images show transrectal imaging of the urinary bladder with a

small left ureterocele visible. The left ureter also appears mildly dilated (hydroureter).

The ureterocele is seen partially distended and also seen in the collapsing stage as the

 pressure builds up within the sac (of the ureterocele) with resultant evacuation of the

urine into the bladder (seen on Power Doppler image- lower right). The jet of urine isseen emanating from the ureterocele sac. All 4 ultrasound images taken via TRUS

study using Toshiba Nemio-XG system. 

Ureterocele with calculus

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 This patient underwent sonography of the abdomen for suspected calculus disease.

Ultrasound images show left hydroureter with calculus within the left ureterocele. The

image on left shows the dilated left ureter in long section. Ultrasound image on right

shows the urinary bladder with the calculus impacted within the ureterocele. Both

images are courtesy of Ravi Kadasne, MD, UAE. 

Ureterocele - 3D ultrasound image

3D Ultrasound image (using Philips Matrix probe) showing left ureterocele (arrows).

The Philips Matrix 3D system shows color coded 3D real time images. This image is

courtesy of Dr. Ravi Kadasne, MD, UAE. 

Carcinoma of Urinary Bladder

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This elderly male patient presented with hematuria. Sonography of the urinary bladder

showed: 1) a large cauliflower shaped mass producing thickening of the bladder wall

(the lower half of the urinary bladder was affected). 2) Power Doppler images (top

row) show considerable vascularity of the mass (arrows). Sonography of the kidneysshow bilateral moderate hydronephrosis with bilateral hydroureter. This suggests

obstruction of the distal ends of both ureters, probably at the level of both vesico-

ureteric junctions. TRUS (transrectal ultrasound) imaging shows mild prostatic

enlargement (benign prostatic hypertrophy). TRUS study also shows complete

emptying of the urinary bladder with no post-voiding residual urine. However, the

highly vascular mass is seen to involve a large portion of the urinary bladder (lower

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right). These ultrasound and Power Doppler images are suggestive of carcinoma of

the urinary bladder. Images taken using a Nemio-XG ultrasound system by Joe

Antony, MD, India. 

Reference: http://emedicine.medscape.com/article/444061-overview (carcinoma in situ of urinary bladder).. free

article.. 

Case-2: Carcinoma of urinary bladderUltrasound images of urinary bladder (mass) and both kidneys  

Transabdominal ultrasound images show a polypoid mass in the bladder close to the

 bladder neck. Is this a bladder mass or an enlarged median lobe of the prostate? Faced

with this dilemma we decided to perform a transrectal ultrasound scan (TRUS). The

kidneys were almost normal but for a small calculus in left kidney. 

Back to top 

TRUS ultrasound images of the prostate and bladder: 

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Coronal image Sagittal color Doppler images shows bladder

mass: TRUS image showing relation of the masses to the prostate 

Transrectal ultrasound showed not one but two contiguous masses on either side ofthe bladder neck and almost in close contact with the prostate. However, the prostate

appeared non vascular and small in size compared to the irregular, polypoid masses

which were very vascular. There does not appear to be any spread beyond the

confines of the bladder wall. Final diagnosis- these are a pair of malignant masses of

the urinary bladder- carcinoma of urinary bladder. This patient had severe urinary

obstruction- a result of the location of the bladder tumors near the bladder neck. He

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had a history of undergoing surgery for bladder carcinoma. Clearly this was a case of

recurrence of bladder malignancy. The video clip below shows the TRUS scan study

of this patient. Note the clear separate nature of the masses from the prostate.

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TRUS video clip of the bladder masses Back to top 

Diverticulum of urinary bladder

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This elderly male patient had symptoms of lower urinary tract obstruction.

Sonography of the abdomen shows a large sac like structure, communicating freely

with the urinary bladder through a small orifice (6 mm. in size). These ultrasound

images are diagnostic of diverticulum of the urinary bladder. Color Doppler images

show to and fro flow across the orifice between the bladder and the diverticulum.Surprisingly, the kidneys appear normal in structure. 

Reference: 

http://www.medcyclopaedia.com/library/topics/volume_iv_2/d/diverticulum_bladder.aspx 

http://emedicine.medscape.com/article/1015329-overview 

Urostomy / Continent Pouch- Continent urinary diversion:Ultrasound

study of Bladder replacement surgeriesa) Artificial bladder made from small bowel 

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This elderly patient underwent surgical removal of the urinary bladder for malignant

 bladder mass (carcinoma). A urostomy was done with an artificial bladder (pouch)

created using a segment of small bowel. The structure (pouch) is seen fully distended

in the ultrasound images in the top row and bottom-left. The image on bottom rightshows the pouch after evacuation of the urine via catheter inserted via stoma in the

abdominal wall. Note the close relation of the pouch to the right kidney. Such a pouch

is also called a continent cutaneous reservoir. Urine collects in this reservoir within

the abdomen till it is full. Urine is drained via a stoma (opening in the abdomen

connected to the continent cutaneous reservoir). Both kidneys (top-left) show mild

 pelvicalyceal dilation. 

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Anatomy of the continent cutaneous reservoir  

Reference: http://www.kidneyurology.org/Library/Urologic_Health.php/Urostomy_and_Continent_Urinary_Diversion.p

hpBack to top 

b) Sigmoid pouch (sigma pouch) or uretero-sigmoidostomy 

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This male, elderly patient underwent cystectomy (surgical removal of urinary bladder)

for carcinoma of the organ. A bladder replacement surgery in this case was done by

creating an artificial pouch using the sgmoid colon (sigmoid pouch) with the ureters

emptying in to this pouch (uretero-sigmoidostomy). Ultrasound images above show a

 partially (urine) filled sigmoid pouch in this study of the pelvis. It is important to do afollow up ultrasound study of the urinary tract to rule out pyelonephritis in such cases.

Here the kidneys appear normal. 

Reference: 

http://www.ncbi.nlm.nih.gov/pubmed/16336348 

http://www.moffitt.org/moffittapps/ccj/v3n6/a4.html 

Back to top c) Orthotopic neobladder or neobladder to urethra diversion 

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he above ultrasound pictures are those of a middle aged female patient with history of

severe tuberculous infection of the urinary tract. Severe infection of the urinary

 bladder (cystitis) resulted in severe urinary complaints. The patient underwent

surgical removal of the urinary bladder (cystectomy) with an artificial urinary bladdermade out of the terminal ileum and caecum. The outlet of this ileo-caecal neobladder

(artificial bladder) was connected to the patient's urethra. This type of surgery is

called orthotopic neobladder as the new bladder is placed in the normal bladder

location (in the lower pelvis). The ultrasound images of the neobladder to urethra

diversion, show multiple peristaltic waves (arrows) caused by contractions within the

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distended urinary neobladder. This patient has to empty the bladder every 4 to 5 hours

using a simple catheter, due to real possibility of rupture of the distended neobladder. 

References: Article on types of urinary diversions  (free excellent article)

Discussion on types of urinary diversions and neobladder options (for

 patients and laypersons)

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Bilharziasis (Schistosomiasis) of the urinary bladder

This patient presented with lower urinary symptoms, dysuria and hematuria.

Sonography of the pelvis showed thickening of the wall of the urinary bladder with

extensive calcification. These ultrasound images suggest a diagnosis ofschistosomiasis 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. The disease is caused by contact with water infested with

the parasite- schistosoma and is endemic in parts of Africa (Egypt and Sudan). Both

above images are courtesy of Ravi Kadasne, MD, UAE. 

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CT Scan imaging in Bilharziasis 

The above CT (computerized tomography) images (another patient) show

hyperdense, extensive involvement of the urinary bladder suggesting calcification of

the bladder wall. This is a typical appearance of Schistosomiasis of the urinary bladder and is caused by calcification of the dead schistosoma parasites or their eggs.

CAT scan images are courtesy of Nirmali Dutta, MD, UAE.

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Liver/ Spleen involvement in Schistosomiasis 

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his patient is a known case of Bilharziasis and ultrasound showed

hepatosplenomegaly with increased echogenicity of the periportal regions of the portal

veins suggesting periportal fibrosis. Fibrosis of the periportal regions of the liver is a

known complication of hepatic involvement in schistosomiasis. Ultrasound images are

courtesy of Ravi Kadasne, MD, UAE. 

Reference: 

1)http://emedicine.medscape.com/article/377318-overview 

2)http://en.wikipedia.org/wiki/Schistosomiasis 

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Urachal cyst in urinary bladder

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This patient underwent sonography of the urinary bladder which revealed a small

cystic structure with well defined wall and turbid fluid content, protruding into the

lumen of the bladder, from its dome. The ultrasound images at bottom and on top-

right show 3-D display of the cyst (the image at bottom row shows a surface rendering3-D image of the lesion). These ultrasound appearances are suggestive of urachal cyst

involving the urinary bladder. A urachal cyst can occur anywhere between the ends of

the obliterated part of the urachus. Most urachal cysts occur close to the umbilicus, ie:

the upper part of the urachus. Images are courtesy of Ravi Kadasne, MD, UAE.  

Reference: http://emedicine.medscape.com/article/1015329-overview(free article) 

Ultrasound images of polyp (inverted papilloma) in urinary bladder

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This polyp like mass was seen close to the bladder neck on transabdominal ultrasound

imaging (image on top row-left). It measured 14 x 5 mm. and showed considerable

vascularity on color Doppler imaging (see image in bottom -left). The TRUS

ultrasound images (Transrectal ultrasound) show the polyp clearly arising from the

urinary bladder mucosa (lower part of trigone), close to the prostate. Such polyps cangive rise to obstructive voiding symptoms (as in this patient) due to its tendency to

 block the adjacent bladder neck by a valvular mechanism. This patient underwent a

 biopsy of the polyp to rule out malignancy of this mass. This was found to be an

inverted papilloma of the urinary bladder on cystoscopy, and was confirmed by

histopathological study. The sketch (bottom row) shows the trigone of the bladder

with the inverted papilloma arising from the lower part of the trigone, producing

obstruction at the bladder neck. 

Reference: 

http://emedicine.medscape.com/article/1788400-overview 

http://www.ajronline.org/cgi/reprint/159/1/93.pdf( excellent article-free) 

Cystitis cystica-sub mucosal cyst of bladder

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Coronal TRUS Sagittal TRUS

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 ofthe prostate in this TRUS 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. 

The above images are TRUS studies of the prostate; Power Doppler image on right

shows the lack of significant vascularity to the cystic lesion in the submucosal region

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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.

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 cystitiscystica 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. 

See ultrasound video of this case at: 

http://ultrasound-videos.blogspot.com/2011/06/cystitis-cystica-transrectal-ultrasound.html 

References: 

http://www.ispub.com/ostia/index.php?xmlFilePath=journals/iju/vol4n2/cystitis.xml 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2006711/pdf/amjpathol00621-0065.pdf  

http://vet.sagepub.com/content/18/1/113.full.pdf  

Endoscopic Teflon or Deflux gel treatment for Vesico-ureteral reflux

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This patient shows an echogenic mound in the left vesico-ureteric junction. The Color

Doppler image shows a ureteric jet emerging from this region suggesting that the left

distal ureteric orifice is patent. This patient had a history of vesico-ureteric (vescio-

ureteral) reflux. This was corrected by a Teflon gel injected in the submucosal part ofthe left VUJ (vesico-ureteral junction) via the endoscopic route. There are 5 grades of

vescio-ureteral reflux. Grade-1: the VUR reaches below the renal pelvis. Grade-2:

VUR reaches up to the renal pelvis without causing dilation of the pelvis. Grade-3:

There is mild to moderate dilation of the renal pelvis and ureter. Grade-4: Moderate

dilation of renal pelvis, ureter and calyces is present. Grade-5: Gross dilation of

 pelvicalyces with tortuous and dilated ureter. Endoscopic deflux or Teflon gel

injection is used for correcting of VU reflux from grade-2 to grade-5. the gel causes a

small mound to form in the submucosal part of the distal ureteral orifice resulting in a

kind of valve formation preventing the reflux of urine up the ureter. Teflon is now

 being replaced by Deflux gel as the preferred material for this procedure. Ultrasoundimages of endoscopic Teflon gel injection are courtesy of Dr. ravi Kadasne, MD,

UAE. 

References: 

http://urology.ucsf.edu/patientguides/pdf/pedUro/VUR_Endoscopic.pdf(simple article on the basics) 

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http://pednephrology.stanford.edu/secure/documents/Vesicoureteral-Reflux.pdf ( detailed description) 

Urinary bladder herniaUltrasound images of urinary bladder herniation into the right scrotum 

Back to top 3D ultrasound image: Bladder hernia 

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CT scan-sagittal section image- Bladder hernia 

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This 65 year old male presented with right inguino-scrotal swelling. Ultrasound

images of the swelling showed a cystic fluid containing lesion with a prominent

"beak" extending towards the top of the swelling/ lesion. Further, on sonographic

imaging it was possible to show its continuity with the distended urinary bladder

above. The lesion measured 18 x 9 cms. and showed reduction in size on emptying theurinary bladder. This sign is typical of the lesion/ swelling arising from the urinary

 bladder herniating through the inguinal canal into the scrotum. 3D ultrasound imaging

further confirmed the internal surface of the swelling to be of the same texture as that

of the urinary bladder. These images confirm that the swelling in question is an

inguinal hernia of the urinary bladder. CT scan section further adds to the validity of

the diagnosis. This case study is courtesy of Dr. Ravi Kadasne, MD, UAE. These

ultrasound images were taken using a Philips IU 22 ultrasound system.

References: Radiology and sonography of urinary bladder hernia 

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Carcinoma urinary bladder- 3D ultrasound images

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 A case of carcinoma of the urinary bladder studied using 3D and 4D ultrasound imaging. The bladder mass is seen

as a small cauliflower shaped lesion to the right of the bladder neck. 3D ultrasound and 3D color Doppler images

show the surfac features and vascularity of the bladder mass in detail. The color Doppler images show the feeder

vessels supplying the malginant bladder mass.

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normal urinary bladder-3d ultrasound

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what does the normal urinary bladder look like in a 3-D ultrasound image? These two 3-D ultrasound images of the

urinary bladder show the inner surface of a male urinary bladder. The mucosa of bladder presents a fine cobblestone

appearance in 3-D sonography. This can very well be appreciated in these images.

calculus in female urethra

This female patient complained of dysuria for which she underwent routine sonography. This ultrasound image shows

the cause of the dysuria- a calculus lodged in the female urethra. Though calculi are often seen in the male urethra

due to its length, it is very unusual to sonographically image a calculus in the female urethra. Despite its small size,

such a calculus can produce significant dysuria. This ultrasound image is courtesy of Dr. Ravi Kadasne, MD, UAE.

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3D ultrasound- multiple bladder calculi

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Dr. Sanjiv Bhalla, MD managed to capture this wonderful 3D ultrasound image of multiple urinary bladder calculi. It is

rather unusual for a patient to have such a large number of bladder calculi; it is even more unusual to have all the

bladder stones of almost the same size and captured in such breath-taking clarity on 3D sonography.