Question: Describe the radiological anatomy of the male urinary bladder.

Describe in detail the techniques for demonstrating the organ.

Answer - Introduction/Gross - Imaging Modalities: * Cystogram * Pelvic scan * CT scan * MRI * Plain radiography * Angiography * RNI

Introduction/Gross The urinary bladder is situated within the pelvis. It is an extraperitoneal pyramidal muscular organ when empty but as it fills, it becomes ovoid and rises into the abdomen stripping the loose peritoneum off the anterior abdominal wall.
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It has a base/posterior surface, an apex, a superior and two inferiolateral surfaces. The ureters enter the posterolateral angles and the urethra leaves inferiorly at the narrow neck which is surrounded by the involuntary internal urethral sphincter. The trigone is the triangular inner wall of the bladder between the ureteric and the urethral orifices, this part of the wall is smooth while the remainder of the bladder wall is coarsely trabeculated by crisis- cross muscle fibres.

The perivesical fat surrounds the bladder. The bladder is relatively fixed inferiorly via condensations of pelvic fascia, which attach it to the back of the pubis, the lateral walls of the pelvis and the rectum. The obturator internus muscle is anterolateral and the levator ani muscle is inferolateral to this.

The vasa deferentia and seminal vesicle are posterior to the bladder so also is the cul-de-sac and rectum. The bladder neck is fused with the prostate.

Imaging Modalities - Cystogram It localises the bladder within the pelvis cystogram is used to assess the integrity of bladder following trauma or surgery or to investigate fistulas involving the bladder. The bladder is filled with contrast which appear as rounded radio-opacity and demonstrates the corrugation of the bladder wall especially when not well distended.

The bladder wall is seen as the soft tissue density structure separating the perivesical fat and the intravesical contrast Irregular collection of contrast may be trapped between muscles fibres after micturition the prostate may protrude up into the bladder base to produce a prostatic impression the full bladder outline should be smooth and regular

Pelvic US Us is best for demonstrating the internal anatomy. Routine examination of the bladder requires it to be moderately full. The normal bladder has a triangle shape in the sagittal plane and that of a square with the corners rounded off in the transverse plane. The normal wall thickness is 2-3mm when the bladder is moderately full. The bladder wall is slightly echogenic which contrasts against the anechoic urine within it this beautifully demonstrating the internal anatomy.

It is also possible to visualize the lower ureter in young children and the use of colour Doppler allows identification of ureteric jet Relations, Anterior, Anterior abdominal wall (medium level echo), Pubic bone (posterior acoustic shadow) Posterior: Rectum (poorly demonstrated) Lateral: Obturator internus muscle (medium level echo), levator on muscle (medium level echo)

Superior: Loops of bowel (not properly demonstrated because of bowel gas; evidence of peristalsis) Inferior:Prostate (lobuted out homogenous medium level echo) line,

CT The bladder is best appreciated when filled with urine or contrast and it is seen as a thin walled structure between the urine and the periversical fat the wall should not exceed 4-5mm fat. The appearance of the urine depends on the presence or absence of contrast, when present it hyperdense but when absent it is hypodense

The seminar vesicles which lie on the posterior wall of the bladder appear as tubular structure related to the superior aspect of the prostate and posterior to the lower bladder but anterior to the rectum. There is a fat plane between the seminal vesicles and the bladder. In a suprapubic axial slice, the various structures from anterior to posterior are

Anterior abdominal wall [(subcut. fat (hypodence); rectus abdominic (isodense)] ii Urinary Bladder iii Seminal vesicle (isodense) iv Rectum (gas + faeces + contrast => mixed density) v Sacrum (hyperdense) vi Gluteus maximus (isodense) vii Subcuit fat (hypodense) Psoas muscles are demonstrated laterally at higher level but obturator internus muscle at lower levels

MRI
MR is ideal to demonstrate the relationship of the bladder in the coronal and sagittal plane. It is seen as a low/ intermediate signal line on t1 W images, similar to urine hence poor contrast between them but on T2 W1 the bladder wall is seen as a thin low signal intensity line adjacent to the high signal of fat outside and urine inside the bladder

The bladder wall enhances intensity with IV gadolinium.

On T2 W1 the seminal vesicle is hyperintense but it has intermediate intensity on T1 W1. NB- They low intensity bladder wall may be obscured by the chemical shift artifact that result from the difference in resonance frequency between fat and water proton

Plain Radiograph. The bladder may be identified on plain film especially when full. It is seen as a round soft tissue density surrounded by lucent line of perivesical fat. It should be smooth and symmetrical. Angiography This demonstrates the superior and interior vesical artery originating from the internal iliac artery as radio opaque lines

RNI (Radionuclide Cystography) Agent Non absorbable radiotracer e.g. 99M TCMAG3 (Mercaptoacetylglycine)

B.Describe in detail the technique for demonstrating the urinary bladder. - Outline Indications C.I Patient preparation Equipment/materials Techniques proper description After care Complication

(1)
(i) (ii)

(iii)
(iv) (v)

Cystogram Indications Abnormalities of the bladder e.g. fistula mass After bladder trauma After bladder surgery Haematuria Difficulty in micturition

C.I
(a) (b)

Acute urinary tract infection Patient preparation The patient micturates prior to the exam Patient is fasted for about 6hrs prior to exam Contrast medium HOCM or LOCM

 (1) (2) (3) (4) (5)

Equipment/Materials Fluoroscopy unit with spot film device Jaques or foley catheter. In small infants a fine (5-7F) feeding tube. Casettee and film Emergency tray Sunctioning machine Preliminary film Coned view of the bladder

 (a)

Technique The patient lies supine on the x-ray table. Using aseptic technique a catheter, lubricated with Hibitane 0.05% in glycerine, is introduced into the bladder. Residual urine is drained. Contrast medium is slowly dripped in a bladder filling is observed by intermittent fluoroscopy. It is important that initial filling is monitored by fluoroscopy in case the catheter is in the distal ureter (Therapy mimicking vesicoureteric reflux) or vagina.

(b) (c)

(d)

Any reflux is recorded on spot films The catheter should not be removed until the radiologist is convinced that no more contrast medium will drip into the bladder. Film are taken in AP, lateral and oblique.

 (A)

(B)

Aftercare No special aftercare is necessary, but patients and parents of children should be warned that dysuria, possibly leads to retention of urine, may rarely be experienced. In such cases a simple analgesic is helpful and children may be helped by allowing to micturate in a warm both. Antibiotics should be prescribed if reflux is demonstrated.

CX (A) Due to the contrast medium Adverse rxn may result from absoprtion of contrast medium by the bladder mucosa Contrast medium-induced cystitis

(B)

Due to the technique (a) Acute U.T.I (b) Catheter trauma-may produce dysuria, frequency, haematuria urinary retention.

and

(c)

(d) (2) (i) (ii) (iii) (iv)

Complications of bladder filling e.g. perforation from overdistention prevented by using a non-retaining catheter e.g. Jaques. Retention of a foley catheter
U/S * Indications Haematuria Bladder outlet obstruction Bladder tumour and other pelvic masses Post trauma

(a)
(b) (c)

C.I None Patient preparation Full bladder Equipment/material 3.5 SMHz transducer U/S machine Electrolyte/Ultrasound gel

Technique The patient lies supine and the bladder is scanned suprapublically in transverse and longitudinal planes. Measurement taken of three diameters before and after micturition enable an approx. volume to be calculated.

After Care None Cx None 3)Pelvic CT Indications as already stated C.I (i) rxn to contrast medium (ii) Pregnancy

Patient preparation - Bowel preparation - Fast in the day of exam - Give 500ml dilute contrast agent orally the evening preceding exam
Equipment/Materials CT Machine CT Printer Contrast agents Mechanical injector Emergency tray Suctioning machine

(a) (b) (c) (d) (e) (f)

Technique We give 500ml dilute contrast agent orally the evening preceding the exam and repeat the dose 45 to 60min before the exam. The colon and the rectum can be distended by placing a tube in the rectum and insufflating with 20 puffs of air, or the limit of patient comfort. All patients are asked to avoid micturition for 30 to 40min before the exam to allow bladder filling. IV

contrast medium is routinely given by mechanical inject or at 2 to 3ml/sec for a total dose of 150ml of 60% contrast agent. Lie patient supine angulate your gantry. Scanning through the pelvis is performed with contiguous 2-5mm thick slices. We routinely scan the abdomen as well in patients with known or suspected pelvic malign. N.B: A contrast material enema (200ml) occasionally may be necessary to expedite opacification of Rectosigmoid

After Care None Cx Rxn to contrast 4)MRI Indication As previously stated C.I Metallic prosthesis or metals in the body e.g. bullet.

Patient preparation No special preparation Equipment/Materials M.R. machine Gadolinium M.R. printer

(i) (ii) (iii)

Technique Patient are usually examined supine during shallow respiration, with the urinary bladder at least half full before the study is begun. Both T1-W (TR=300-500msec, TE=15 35msec) and T2W (TR = 1,500 2,100 msec, TE = 90-120 msec) spin echo sequences are necessary for complete examination of the pelvis. T2W1 provide clear delineation of the bladder wall, as well as internal morphology of the prostate gland and the uterus.

Transaxial images are obtained in every case; additional views are performed in either the coronal or sagittal plane. Coronal images are useful for evaluating the seminal vesicle and bladder neoplasms that involve the lateral wall while sagittal images are necessary is cases in which a bladder neoplasm is located along the anterior or posterior wall.

After Care None

Cx None