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 o Renal stones

o Some degree of obstruction
Testis: - Enlarged prostate may cause a smooth, dome-
- measures 3.5-4cm in length and 2-3 cm in width
like, indentation along the floor of the bladder
- covered by the fibrinous tunica albuginea
MRI:
- spermatic cord enters through the - Normal increased signal intensity on T2-
posterosuperior margin (mediastinum testes) weighted images and either low or high intensity
- divided into lobules arrayed radially around the on T1 with hypertrophic changes in the
mediastinum testes transitional zone
- each lobule is composed of branching
seminiferous tubules
PROSTATE CANCER
- More common than any other cancer in
Epididymis:
- 6-7cm in length; 7-8mm diameter at the globus American men except for non-melanoma skin
major (head of the epididymis at the cancer
mediastinum testes); 1-2 cm at the tail where it - May produce symptoms like, urinary urgency,
continues as the vas deferens nocturia, frequency and hesitancy—all of which
are more likely to be caused by benign prostatic
- Vas deferens courses through the spermatic
hypertrophy
cord and exits via the deep inguinal ring. It joins
the seminal vesicle at the base of the prostate,
- If in DRE, asymmetric areas of induration or
forming the ejaculatory duct nodules are found, SUSPECT prostate cancer
evaluate PSA (Prostate Specific Antigen)
Prostate Gland: - Gold standard for diagnosis is TRANSRECTAL
- 20-30 ducts form the prostate gland, draining BIOPSY
into the prostatic urethra - Spread may occur by direct extension into the
- 3 zones of ductular drainage which subdivide the seminal vesicles, bladder base, and perivesical
prostate: fat
o Peripheral zone - Extracapsular spread is evaluated with:
o Central zone o TRANSRECTAL PROSTATE
o Transitional zone ULTRASONOGRAPHY with biopsy or
o ENDORECTAL COIL MRI WITH OR
WITHOUT SPECTROSCOPY
PROSTATE - Nodal metastases
o may be evaluated with CT or MRI
BENIGN PROSTATIC HYPERTROPHY o Biopsy is performed when nodes are
- Affects 50-75% of men over age 60
>10mm
- More common in blacks, diabetics and
o If nodal disease is present, 80% of
hypertensives
patients will have bone metastases
- Presenting symptoms include: decreased force of
within 5years
urine stream, dribbling, and incomplete
o Most commonly involved:
emptying of the bladder, due to uninhibited
contractions of a hypertrophied detrusor due to Obturator nodal chain

obstruction of the prostatic urethra by Internal/ external iliac nodal

enlargement of glandular tissue of the prostate chain
CT- IVU: - Bone metastases
- Enlarged trigone o Evaluated by checking PSA levels
- J-hook configuration of distal ureters o Performing bone scan
- Common findings include: o Prostate specific imaging of distant
o Benign renal cysts disease can also be evaluated with
o Bladder diverticula nuclear medicine: “prostascint” scan

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

- 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
o Incomplete torsion- <360o
 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
Subject: Radiology
Topic: Male Pelvis, Uroradiology
Page 2 of 8
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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Topic: Male Pelvis, Uroradiology
Page 3 of 8
o maternal diethylstilbestrol use o Mullerian anomalies such as unicornate
o testicular atrophy uterus
- germ cell tumors comprise 95% of testicular - Absence of the ipsilateral adrenal gland is seen
cancer, 40% of these are seminomas, and 40% in 10% of these patients
with mixed histologic pattern. - Incidence of renal agenesis is one per 1000 live
Ultrasound: births, 75% of which are male
- demonstrates areas of uniformly decreased
echogenicity, usually focal but may be diffuse Bilateral Renal Agenesis
- Fatal anomaly
and may cause bulging of the tunica albuginea
- Occurs in one per 3000 livebirths, and due to
Computed Tomography (staging):
- I- tumor confined to testis oligohydramnios
- II- extratesticular spread: o These newborns present with Potter’s
o A- minimal nodal metastases, limited to syndrome:
infradiaphragmatic stations  low set ears,
o B- bulky retroperitoneal nodal  broad flat nose,
metastases  prominent skin folds below the
- III- lymphatic involvement above diaphragm lower eyelids
- IV- extranodal metastases (pulmonary, hepatic,  pulmonary hypoplasia
osseous, CNS)  pneumothorax

Multicystic Dysplastic Kidney

URORADIOLOGY - occurs as a result of inadequate induction of
maturation of the metanephric blastema by the
CONGENITAL ABNORMALITIES ureteric bud
- 2 types
Ureterocele
- Congenital saccular dilatation of the terminal o Pelvoinfundibular MCDK
portion of the ureter  Randomly distributed
- Ectopic ureterocele enter the bladder, typically  non-communicating cysts
arise from the upper pole moiety of a duplicated replace normal renal
collecting system parenchyma.
- Occur in approximately 1 in every 4,000 children  non- functional kidney
- Females are affected 4-7 times more often than  artretic ureter is often present
males o Hydronephrotic MCDK
Radiographic findings:  Representing a severe, in utero
- Classic: “cobra head deformity” form of uteropelvic junction (UPJ)
o Resembles a snake’s head bulging into obstruction
the bladder - Both forms present with an abdominal mass
o Often best detected on IVP detected during infancy and are associated with
contralateral UPJ obstruction
Duplicated Collecting System
- UPJ obstruction with associated hydronephrosis
- Upper moiety separated by renal parenchyma
is the most common palpable abdominal mass in
from the lower moiety
newborns
- There are two ureters on the left draining their
respective moieties
Medullary Sponge Kidney
- A.K.A. benign renal tubular ectasia
Renal Agenesis
- Cystic dilatation of the connecting tubules in one
- When the ureteric bud fails to reach the
or more renal pyramid
metanephric blastema, there is no induction of
- Urine stasis in the collecting tubule may lead to
nephron development
stone formation within the ectatic tubules
- Associated ipsilateral abnormalities are almost
- Etiology is unknown
always present, and include:
- Occurs in males more than females
o Absence of ureter
- More frequently bilateral than unilateral
o Hemitrigone
Plain Radiograph
o Vas Deferens - Nephrocalcinosis
o Seminal vesicle cyst - Clustered pyramidal medullary calcifications
 Subject: Radiology
Topic: Male Pelvis, Uroradiology
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- Calculi in renal pelvis, ureter, bladder may be - Lesion is round or oval, anechoic (black or white
seen without echoes)
- Kidney size is usually normal - Has an imperceptibly thin wall
- Calyces are broad, shallow, and distorted, with - Demonstrates increased sound through
groups of calculi arrayed medially emanating transmission
from the renal papilla CT:
- Lesions show a sharp interface with adjacent
Horseshoe Kidney renal parenchyma
- 1 in every 400 livebirths - Water density: <20HU
- Most common renal anomaly - Show no contrast enhancement of wall or cyst
- Males are twice likely to have the anomaly as contents after IV contrast administration
females
- Associations include UPJ obstruction, duplication, BOSNIAK CLASSIFICATION OF RENAL CYSTS By CT
anomalies, and stone formation due abnormal
kidney geometry and urine stasis Classifi Features
- Result of contact between and fusion of the cation
I Simple cyst Non-
developing metanephros
operative
- An isthmus develops between the 2 kidneys, II Septated, minimal Non-
consisting of a fibrotic band or functioning renal calcium described operative
parenchyma as “egg shell” thin
- As fused kidneys ascend, the isthmus becomes high density cysts
hooked under the origin of the inferior (>20HU), non-
mesenteric artery, resulting in a lower location enhancing
III Multiloculated, Renal-
and an abnormal rotation, especially at the lower
hemorrhagic, sparing
poles where the kidneys deviate medially dense surgery
calcifications; non
enhancing solid
Pelvic Kidney component
- Premature arrest of cranial ascent of the kidney IV Marginal Radical
a 3:2 male to female predominance irregularity, nephrectom
- Bilateral pelvic kidneys may fuse, forming a enhancing solid y
discoid single kidney known as “PANCAKE component
KIDNEY”
- Major complications: Autosomal Dominant Polycystic Kidney Disease
o Trauma- due to decreased protection (ADPKD)
o Nephrolithiasis- due altered geometry - An autosomal dominant disease
- Prevalence: 0.1% accounting for 10% of patients
resulting in urine stasis
on chronic dialysis
- Associated with other urinary tract anomalies ,
- Multiple kidney cysts leading to enlarged,
including:
palpable kidneys
o UPJ obstruction
- Progresses slowly, eventually resulting in end
o Vesicoureteral reflux
stage renal disease and the need for dialysis or
o Decreased function
transplant
RENAL MASSES
Renal Cell Carcinoma
- A.K.A. renal adenocarcinoma, hypernephroma,
Renal Cysts
- 50% of the population older than 50yrs clear cell carcinoma, and malignant nephroma
- Most are assymptomatic, though a large cyst can - 90-95% of primary renal cancers
cause discomfort and hypertension - 50-60 y/o
- Ruptured cysts may result in hematuria - Patients present with hematuria (50%), flank
- Infected cysts may result to fever pain (40%), palpable mass (35%), weight loss
- Both infected and hemorrhagic cysts are non- (25%), and paraneoplastic syndrome
simple by imaging - Classic triad of Hematuria, Flank Pain and
Ultrasound: Palpable Abdominal Mass occurs in ~10%
- Sharp interface between cysts and adjacent and indicates advanced disease
renal parenchyma
 Subject: Radiology
Topic: Male Pelvis, Uroradiology
Page 5 of 8
- 30% present with metastatic disease with o costovertebral angle tenderness
predilection for lung, soft tissue, bone, and liver o urinary tract infection
- Risk factors include: CT:
o Smoking - renal enlargement with wedge shaped
o Obesity heterogenous areas of poor enhancement,
o Male (2:1) known as “striated nephrogram”
o Phenacetin and other analgesics Ultrasound:
o von Hippel- Lindau disease - focal area of increased echogenicity (brightness)
o chronic dialysis in the right upper pole cortex
o Family history
CT:
- Enhancing mass (does not enhance as intensely BLADDER
as normal renal parenchyma)
Bladder Carcinoma
- With distortion of parenchyma
- 90% of bladder carcinomas are TRANSITIONAL
- Collecting system and contour abnormalities
CELL CARCINOMAs (TCC)
- Calcifications in 10%
o 75% of TCCs are papillary
- Filling defects in collecting system
o 25% of TCCs are Infiltrative
- Renal veins and IVC
- Other malignant neoplasms:
Ultrasound:
- Small tumors are generally hypoechoic o Squamous cell carcinoma- after
- Large tumors: hyperechoic schistosoma infection
o Adenocarcinoma
Angiomyolipomas o Leiomyosarcoma
- Hamartomas containing fat, smooth muscle and o Lymphoma
blood vessels o Rhabdomyosarcoma- in ages 2-6
- Most are assymptomatic, but may hemorrhage if - Benign lesions:
large o Leiomyoma
- Larger symptomatic lesions (>4cm) can be o Fibroepithelial polyp
resected or embolized o Hemagioma
- 80% of patients with tuberous sclerosis have o Pheochromocytoma
AML, usually multiple lesions bilaterally
o Adenoma
- Presence of fat: almost PATHOGNOMONIC (hehe
- Differential diagnosis of focal mural filling defect
goldi ano daw ang meaning ng
in the bladder:
pathognomonic?!?)
o Common:
- Calcifications are common findings would lead
 Neoplasm
towards a diagnosis of renal cell carcinoma
 Stone
CT:
 Blood clot
- Fat hypodense
 Enlarged prostate
Ultrasound:
- hyperechoic o Uncommon
MRI:  Focal cystitis
- Hyperintense (T1 weighted MRI) mass  Ureterocele
 Benign neoplasm
SMALL KIDNEYS
 Endometriosis
Chronic Medical Renal Disease  Fungus ball
- Chronic insult results to a small kidney with
uniformly thin renal cortex and marked increased Cystitis
cortical echogenicity - Inflammation of part or the entire urinary
bladder wall
LARGE KIDNEYS - Common causes include:
o Infection- E. coli, Klebsiella,
Pyelonephritis Pseudomonas, Scistosomiasis, viral,
- A bacterial infection of the renal parenchyma fungal
and collecting system o Irritative or Mechanical- indwelling
- Clinical diagnosis: catheter or stone
o flank pain

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
Subject: Radiology
Topic: Male Pelvis, Uroradiology
Page 6 of 8
- 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
 cervical or bladder carcinoma
 obstetric injury
 radiation
 foreign body
o 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
- In the setting of bladder outlet obstruction (such
as BPH), uric acid stones predominate
- 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:
 Subject: Radiology
Topic: Male Pelvis, Uroradiology
Page 7 of 8
o Microscopic hematuria  Segmental infarctions without
o Suprapubic pain associated lacerations
o Interruption of urine stream  Expanding subcapsular
hematomas compressing the
- Stones may be seen on plain film if sufficiently
kidney
calcified o Grade 5
Cystograms/IVUs:  Shattered or devascularized
- Appear as filling defects because they are kidney
usually less dense than contrast opacified urine  Ureteropelvic avulsions
CT:  Complete laceration or thrombus
- Densely calcified foci of the main renal artery or vein

Bladder
TRAUMA - Occurs in blunt pelvic trauma, pelvic fractures or
penetrating injuries
- Gross hematuria almost always accompanies
KIDNEYS
bladder rupture (95% of patients)
- Occur in 15-40% of all patients with abdominal
- Susceptibility of bladder to injury is dependent
trauma
on degree of distention.
- CT examination is only indicated in patients with
- Distended- more prone to injury
multi-organ trauma where major renal injuries
are suspected - Urine extravasation, whether intraperitoneal or
- CT has been shown to be more sensitive than extraperitoneal, is dependent on the location of
intravenous urography in the detection of renal the bladder tear and its relation to the peritoneal
injuries, especially in assessing the severity and reflections
geometry of injury - Extraperitoneal rupture is usually the result of
- Most patients with blunt renal injuries can be shear injury at the base of the bladder
effectively treated without surgical intervention - Intraperitoneal rupture often results from a direct
- CT is highly useful for: blow to a distended bladder
o Diagnosing and staging renal injuries - Delayed scans may help display extravasated
o Determining the depth of cortical urine
lacerations
o The quantity of devascularized renal END
tissue
o The status of the renal collecting system Madadaming space!!! Wala na kong magawa,
o The extent of peri-renal hemorrhage compressed na yan. Naghanap pa ko ng fillers kaya na
- Grading: late ito. Joke. Pero inayos ko pa talaga to para di kyo
o Grade 1 maguluhan. Hehe. Sorry late na late ang trans na to..
 Hematuria with normal imaging ayun, happy aral guys
studies Ngayon, magsawa tayo sa comics..
 Contusions
 Nonexpanding subcapsular SNOOPY
hematomas p
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 ara sa mga tamad at praning…
 Renal lacerations extending 
through the kidney into the
collecting system
 Injuries involving the main renal
artery or vein with contained
hemorrhage
 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.
