Male Pelvis

Subject: Radiology Topic: Male Pelvis, Uroradiology Lecturer: Dra. Irene Bandong Shifting /Date: 2nd Shifting/ August__, 2008 Trans group: Den, Bart, Kyth, Karla, Josh MALE PELVIS Testis: measures 3.5-4cm in length and 2-3 cm in width covered by the fibrinous tunica albuginea spermatic cord enters through the posterosuperior margin (mediastinum testes) divided into lobules arrayed radially around the mediastinum testes each lobule is composed of branching seminiferous tubules Epididymis: 6-7cm in length; 7-8mm diameter at the globus major (head of the epididymis at the mediastinum testes); 1-2 cm at the tail where it continues as the vas deferens

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Vas deferens courses through the spermatic cord and exits via the deep inguinal ring. It joins the seminal vesicle at the base of the prostate, forming the ejaculatory duct

o Renal stones o Some degree of obstruction Enlarged prostate may cause a smooth, domelike, indentation along the floor of the bladder MRI: Normal increased signal intensity on T2weighted images and either low or high intensity on T1 with hypertrophic changes in the transitional zone PROSTATE CANCER More common than any other cancer in American men except for non-melanoma skin cancer May produce symptoms like, urinary urgency, nocturia, frequency and hesitancy—all of which are more likely to be caused by benign prostatic hypertrophy

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Prostate Gland: 20-30 ducts form the prostate gland, draining into the prostatic urethra 3 zones of ductular drainage which subdivide the prostate: o Peripheral zone o Central zone o Transitional zone

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PROSTATE

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BENIGN PROSTATIC HYPERTROPHY Affects 50-75% of men over age 60 More common in blacks, diabetics and hypertensives Presenting symptoms include: decreased force of urine stream, dribbling, and incomplete emptying of the bladder, due to uninhibited contractions of a hypertrophied detrusor due to obstruction of the prostatic urethra by enlargement of glandular tissue of the prostate CT- IVU: Enlarged trigone J-hook configuration of distal ureters Common findings include: o Benign renal cysts o Bladder diverticula

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If in DRE, asymmetric areas of induration or nodules are found, SUSPECT prostate cancer evaluate PSA (Prostate Specific Antigen) Gold standard for diagnosis is TRANSRECTAL BIOPSY Spread may occur by direct extension into the seminal vesicles, bladder base, and perivesical fat Extracapsular spread is evaluated with: o TRANSRECTAL PROSTATE ULTRASONOGRAPHY with biopsy or o ENDORECTAL COIL MRI WITH OR WITHOUT SPECTROSCOPY Nodal metastases o may be evaluated with CT or MRI o Biopsy is performed when nodes are >10mm o If nodal disease is present, 80% of patients will have bone metastases within 5years o Most commonly involved: Obturator nodal chain Internal/ external iliac nodal chain Bone metastases o Evaluated by checking PSA levels o Performing bone scan o Prostate specific imaging of distant disease can also be evaluated with nuclear medicine: “prostascint” scan  

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MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY KC JAM CECILLE DENESSE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU RACHE ESTHER JOEL GLENN TONI

Subject: Radiology Topic: Male Pelvis, Uroradiology Page 2 of 8

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Staging System: o T1: microscopic tumor, not palpable o T2: macroscopic tumor, palpa ble (80% 5 year disease free survival) o T3: extracapsular extension (30% 5 year disease free survival) o T4: metastatic disease

TESTIS TORSION Due to abnormal configuration of the testicle on its pedicle (Bell Clapper Deformity), leading top abnormal twisting of the spermatic cord that causes testicular ischemia Common in adolescents and infants less than 12 months old Classified as complete or incomplete. o Complete torsion- >360o Adult males: 80% testicular salvage rate when reversed within 5 hours Incomplete torsion- <360o 

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Relatively longer period before testicle is unsalvageable High resolution ultrasound with color Doppler: Enlarged and diffusely hypoechoic testicle May contain multifocal hypoechoic areas Many have normal testicle findings Epididymis may be enlarged with hypoechoic skin thickening Diagnosis is made if there is no blood flow to the testis (evaluated by Doppler) after 1 minute scanning time or, If there is a single small vessel in the symptomatic testis when contralateral normal testis shows readily detectable diffuse flow 

EPIDIDYMITIS Most common scrotal process in postpubertal age group Nine times more common than the main differential consideration which is TORSION Thought to be caused by retrograde spread of infection from the urethra or prostate 90% with pyuria Ultrasonography: Demonstrates enlarged and hypoechoic epididymis Hydrocele or pyocele Scrotal skin thickening Increased color flow surrounding symptomatic epididymis Associated orchitis may or may not be seen

ORCHITIS Parenchymal infection of the testicle Often seen as a complication of mumps infection (25% of postpubertal male patients with mumps) Other frequent causes include echovirus, group B arboviruses, and lymphocytic choriomeningitis virus Unilateral in 2/3, usually developing within 7-10 days of parotitis associated with mumps Testicle may be secondarily involved by epididymitis VARICOCELE Distension of the pampiniform venous plexus due to incompetent valves of the spermatic vein Standing on valsalva may provoke the distension 95% is left sided and are the most manageable cause of male infertility The compressible tortuous vessels measure more than 2mm in diameter Ultrasound: Multiple serpiginous anechoic spaces of similar size Doppler shows venous flow within these spaces MRI: Reveals multiple serpentine vessels in the left hemiscrotum HYDROCELE Accumulation of fluid between the visceral and parietal tunica vaginalis May occur in isolation or in association with epididymitis, orchitis, torsion, trauma, or tumor TRAUMA Presents with pain, nausea, vomiting and extreme tenderness with scrotal ecchymosis and swelling Surgical exploration and debridement needed if tunica albuginea has been violated and devitalized seminiferous tubules have extruded or if there is a large scrotal hematoma Ultrasound: Finding of testicular injury include: o irregular testicular contour (rupture) o multifocal linear hypoechoic areas (contusion) o complex hydrocele o extratesticular mass caused by hematoma SEMINOMA most common malignancy of males aged 15-30 usually presents as a painless scrotal mass risk factors: o cryptorchidism

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o o

maternal diethylstilbestrol use testicular atrophy

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germ cell tumors comprise 95% of testicular cancer, 40% of these are seminomas, and 40% with mixed histologic pattern. Ultrasound: demonstrates areas of uniformly decreased echogenicity, usually focal but may be diffuse and may cause bulging of the tunica albuginea Computed Tomography (staging): I- tumor confined to testis II- extratesticular spread: o A- minimal nodal metastases, limited to infradiaphragmatic stations o B- bulky retroperitoneal nodal metastases III- lymphatic involvement above diaphragm IV- extranodal metastases (pulmonary, hepatic, osseous, CNS)

URORADIOLOGY CONGENITAL ABNORMALITIES Ureterocele Congenital saccular dilatation of the terminal portion of the ureter Ectopic ureterocele enter the bladder, typically arise from the upper pole moiety of a duplicated collecting system Occur in approximately 1 in every 4,000 children Females are affected 4-7 times more often than males Radiographic findings: Classic: “cobra head deformity” o Resembles a snake’s head bulging into the bladder o Often best detected on IVP Duplicated Collecting System Upper moiety separated by renal parenchyma from the lower moiety There are two ureters on the left draining their respective moieties Renal Agenesis When the ureteric bud fails to reach the metanephric blastema, there is no induction of nephron development Associated ipsilateral abnormalities are almost always present, and include: o Absence of ureter o Hemitrigone o Vas Deferens o Seminal vesicle cyst

Mullerian anomalies such as unicornate uterus Absence of the ipsilateral adrenal gland is seen in 10% of these patients Incidence of renal agenesis is one per 1000 live births, 75% of which are male o

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Bilateral Renal Agenesis Fatal anomaly Occurs in one per 3000 livebirths, and due to oligohydramnios o These newborns present with Potter’s syndrome:  low set ears,  broad flat nose,  prominent skin folds below the lower eyelids  pulmonary hypoplasia  pneumothorax Multicystic Dysplastic Kidney occurs as a result of inadequate induction of maturation of the metanephric blastema by the ureteric bud 2 types o Pelvoinfundibular MCDK Randomly distributed non-communicating cysts replace normal renal parenchyma.  non- functional kidney  artretic ureter is often present Hydronephrotic MCDK  

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Representing a severe, in utero form of uteropelvic junction (UPJ) obstruction Both forms present with an abdominal mass detected during infancy and are associated with contralateral UPJ obstruction UPJ obstruction with associated hydronephrosis is the most common palpable abdominal mass in newborns 

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Medullary Sponge Kidney A.K.A. benign renal tubular ectasia Cystic dilatation of the connecting tubules in one or more renal pyramid Urine stasis in the collecting tubule may lead to stone formation within the ectatic tubules Etiology is unknown Occurs in males more than females More frequently bilateral than unilateral Plain Radiograph Nephrocalcinosis Clustered pyramidal medullary calcifications

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Calculi in renal pelvis, ureter, bladder may be seen Kidney size is usually normal Calyces are broad, shallow, and distorted, with groups of calculi arrayed medially emanating from the renal papilla

Horseshoe Kidney 1 in every 400 livebirths Most common renal anomaly Males are twice likely to have the anomaly as females Associations include UPJ obstruction, duplication, anomalies, and stone formation due abnormal kidney geometry and urine stasis Result of contact between and fusion of the developing metanephros An isthmus develops between the 2 kidneys, consisting of a fibrotic band or functioning renal parenchyma As fused kidneys ascend, the isthmus becomes hooked under the origin of the inferior mesenteric artery, resulting in a lower location and an abnormal rotation, especially at the lower poles where the kidneys deviate medially

Pelvic Kidney Premature arrest of cranial ascent of the kidney a 3:2 male to female predominance Bilateral pelvic kidneys may fuse, forming a discoid single kidney known as “PANCAKE KIDNEY” Major complications: o Trauma- due to decreased protection o Nephrolithiasis- due altered geometry resulting in urine stasis Associated with other urinary tract anomalies , including: o UPJ obstruction o Vesicoureteral reflux o Decreased function RENAL MASSES Renal Cysts 50% of the population older than 50yrs Most are assymptomatic, though a large cyst can cause discomfort and hypertension Ruptured cysts may result in hematuria Infected cysts may result to fever Both infected and hemorrhagic cysts are nonsimple by imaging Ultrasound: Sharp interface between cysts and adjacent renal parenchyma

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Lesion is round or oval, anechoic (black or white without echoes) Has an imperceptibly thin wall Demonstrates increased sound through transmission

CT: Lesions show a sharp interface with adjacent renal parenchyma Water density: <20HU Show no contrast enhancement of wall or cyst contents after IV contrast administration BOSNIAK CLASSIFICATION OF RENAL CYSTS By CT Classifi cation I

Features

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Septated, minimal calcium described as “egg shell” thin high density cysts (>20HU), nonenhancing Multiloculated, hemorrhagic, dense calcifications; non enhancing solid component Marginal irregularity, enhancing solid component

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IV

Simple cyst

Nonoperative Nonoperative

Renalsparing surgery

Radical nephrectom y

Autosomal Dominant Polycystic Kidney Disease (ADPKD) An autosomal dominant disease Prevalence: 0.1% accounting for 10% of patients on chronic dialysis Multiple kidney cysts leading to enlarged, palpable kidneys Progresses slowly, eventually resulting in end stage renal disease and the need for dialysis or transplant Renal Cell Carcinoma A.K.A. renal adenocarcinoma, hypernephroma, clear cell carcinoma, and malignant nephroma 90-95% of primary renal cancers 50-60 y/o Patients present with hematuria (50%), flank pain (40%), palpable mass (35%), weight loss (25%), and paraneoplastic syndrome

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Classic triad of Hematuria, Flank Pain and Palpable Abdominal Mass occurs in ~10% and indicates advanced disease

Subject: Radiology Topic: Male Pelvis, Uroradiology Page 5 of 8

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30% present with metastatic disease with predilection for lung, soft tissue, bone, and liver Risk factors include: o Smoking o Obesity o Male (2:1) o Phenacetin and other analgesics o von Hippel- Lindau disease o chronic dialysis o Family history

CT: Enhancing mass (does not enhance as intensely as normal renal parenchyma) With distortion of parenchyma Collecting system and contour abnormalities Calcifications in 10% Filling defects in collecting system Renal veins and IVC Ultrasound: Small tumors are generally hypoechoic Large tumors: hyperechoic Angiomyolipomas Hamartomas containing fat, smooth muscle and blood vessels Most are assymptomatic, but may hemorrhage if large Larger symptomatic lesions (>4cm) can be resected or embolized 80% of patients with tuberous sclerosis have AML, usually multiple lesions bilaterally Presence of fat: almost PATHOGNOMONIC (hehe goldi ano daw ang meaning ng pathognomonic?!?)

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Calcifications are common findings would lead towards a diagnosis of renal cell carcinoma

o o CT:

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renal enlargement with wedge shaped heterogenous areas of poor enhancement, known as “striated nephrogram” Ultrasound: focal area of increased echogenicity (brightness) in the right upper pole cortex

BLADDER Bladder Carcinoma 90% of bladder carcinomas are TRANSITIONAL CELL CARCINOMAs (TCC) o 75% of TCCs are papillary o 25% of TCCs are Infiltrative Other malignant neoplasms: o Squamous cell carcinoma- after schistosoma infection o Adenocarcinoma o Leiomyosarcoma o Lymphoma o Rhabdomyosarcoma- in ages 2-6 Benign lesions: o Leiomyoma o Fibroepithelial polyp o Hemagioma o Pheochromocytoma o Adenoma Differential diagnosis of focal mural filling defect in the bladder: o Common:

CT:

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Fat hypodense Ultrasound: hyperechoic MRI: Hyperintense (T1 weighted MRI) mass SMALL KIDNEYS Chronic Medical Renal Disease Chronic insult results to a small kidney with uniformly thin renal cortex and marked increased cortical echogenicity LARGE KIDNEYS Pyelonephritis A bacterial infection of the renal parenchyma and collecting system Clinical diagnosis: o flank pain

costovertebral angle tenderness urinary tract infection

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 Neoplasm  Stone  Blood clot  Enlarged prostate Uncommon     

Focal cystitis Ureterocele Benign neoplasm Endometriosis Fungus ball

Cystitis Inflammation of part or the entire urinary bladder wall Common causes include: o Infection- E. coli, Klebsiella, Pseudomonas, Scistosomiasis, viral, fungal o Irritative or Mechanical- indwelling catheter or stone

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o Toxic- cyclophosphamide o Radiation induced o Allergic Radiologic Findings ( I think this was taken from the pics on Dr. bandong’s slides, imagine na lang kayo hehe) : The picture shows (imagine ha…) indwelling nephroureteral catheter sitting in the bladder o Pelvic radiation results to bladder wall thickening, and obstruction of the left ureter at the ureteral orifice into the bladder causing left sided hydronephrosis, thus requiring stenting. o Note: bladder wall thickening from radiation induced cystitis The picture shows a CECT scan of the Pelvis o A mass like lesion on the dependent portion of the bladder may represent a mass o Differential diagnosis: Bladder or prostate mass Bladder Diverticula Occur as a result of focal herniations of the urothelium and submucosa Usually occurs in the setting of chronic elevation of intravesical pressure Tend to occur next to ureteral orifices Important cause of urine stasis, ureteral obstruction and vesicouretral reflux Radiographic Findings: Smooth inner wall with a saccule of 2cm or less Diverticula may occasionally be filled with stones or rarely, carcinoma Cystocele Focal herniations of the urothelium and submucosa Usually occur in the setting of chronic elevation intravesical pressure Tend to occur next to ureteral orifices Occur when small outpouchings of mucosa evaginate between hypertrophied detrusor muscle bundles Do not extend past the bladder wall Important cause of urinary stasis, ureteral obstruction, vesicoureteral reflux Voiding Cystouretethrogram (VCUG): Shows with straining, the patient voids while revealing the bladder floor Relaxes, allowing the bladder base to extend 2cm below the pubic symphisis This is a cystocele anatomically resulting in stress urinary incontinence Bladder Fistulas

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Most common causes of intravesical air incled bladder catherterization or instrumentation Vesicoenteric fistulas: o Difficult to image- only 30-60% seen in cystography and barium enema o Iatrogenic causes, diverticulitis, carcinoma, regional enteritis or Crohn’s disease, VCUG (steep oblique or full lateral views): o Best imaging modality o Findings include air in the bladder o Focal mural irregularity o Extrinsic mass effect CT with oral and rectal contrast: o Air within the bladder, focal bladder wall thickening >2mm o Contiguous bowel wall thickening >3mm o Presence of air containing, paravesical soft-tisuue mass Vesicovaginal fistulas: o Causes: 

Iatrogenic

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cervical or bladder carcinoma  obstetric injury  radiation  foreign body presents clinically with continuous urinary incontinence

Emphysematous Cystitis rare form of bacterial cystitis which occurs in patients with poorly controlled diabetes E. coli is the most common pathogen Urinary stasis is a common feature Radiographic Findings: Gas within the bladder (in the absence of bladder instrumentation) Gas within the wall of the bladder in a linear, streaky or multicystic pattern Contrast Enhanced CT of the pelvis: Low density gas in the bladder wall representative of emphysematous cystitis in the absence of any recent instrumentation Bladder Stones Occurs commonly due to urinary stasis or infection

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In the setting of bladder outlet obstruction (such as BPH), uric acid stones predominate

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In the setting of UTI, magnesium ammonium phosphate and apatite stones tend to occur, especially with proteus infection Most stones are asymptomatic Symptomatic presentations may include:

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Subject: Radiology Topic: Male Pelvis, Uroradiology Page 7 of 8

o Microscopic hematuria o Suprapubic pain o Interruption of urine stream Stones may be seen on plain film if sufficiently calcified Cystograms/IVUs: Appear as filling defects because they are usually less dense than contrast opacified urine CT: Densely calcified foci

TRAUMA KIDNEYS Occur in 15-40% of all patients with abdominal trauma CT examination is only indicated in patients with multi-organ trauma where major renal injuries are suspected CT has been shown to be more sensitive than intravenous urography in the detection of renal injuries, especially in assessing the severity and geometry of injury Most patients with blunt renal injuries can be effectively treated without surgical intervention CT is highly useful for: o Diagnosing and staging renal injuries o Determining the depth of cortical lacerations o The quantity of devascularized renal tissue o The status of the renal collecting system o The extent of peri-renal hemorrhage Grading: o Grade 1  Hematuria with normal imaging studies  Contusions  Nonexpanding subcapsular hematomas o Grade 2  Nonexpanding perinephric hematomas confined to the retroperitoneum  Superficial cortical lacerations less than 1 cm in depth without collecting system injury o Grade 3  Renal lacerations greater than 1cm in depth that do not involve the collecting system o Grade 4  Renal lacerations extending through the kidney into the collecting system  Injuries involving the main renal artery or vein with contained hemorrhage

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Grade   

Segmental infarctions without associated lacerations Expanding subcapsular hematomas compressing the kidney 5 Shattered or devascularized kidney Ureteropelvic avulsions Complete laceration or thrombus of the main renal artery or vein

Bladder - Occurs in blunt pelvic trauma, pelvic fractures or penetrating injuries Gross hematuria almost always accompanies bladder rupture (95% of patients) Susceptibility of bladder to injury is dependent on degree of distention. Distended- more prone to injury - Urine extravasation, whether intraperitoneal or extraperitoneal, is dependent on the location of the bladder tear and its relation to the peritoneal reflections - Extraperitoneal rupture is usually the result of shear injury at the base of the bladder Intraperitoneal rupture often results from a direct blow to a distended bladder Delayed scans may help display extravasated urine END Madadaming space!!! Wala na kong magawa, compressed na yan. Naghanap pa ko ng fillers kaya na late ito. Joke. Pero inayos ko pa talaga to para di kyo maguluhan. Hehe. Sorry late na late ang trans na to.. ayun, happy aral guys Ngayon, magsawa tayo sa comics.. SNOOPY p

ara sa mga tamad at praning… 

Subject: Radiology Topic: Male Pelvis, Uroradiology Page 8 of 8

GARFIELD at ang

Salbaheng weighing scale…

Eto mas salabahe…

Hehehe

That’s all for now… Aral na ulet. 