Ultrasound Evaluation Fetal Genitourinary System.

Objectives

• Understand the sonographic evaluation the fetal kidneys and bladder

• Learn how to differentiate renal anatomical changes with gestational age

• Know how to measure renal length correlated with menstrual age

• Learn the assessment of amniotic fluid volume

• Differentiate obstructive and nonobstructive abnormalities of the urinary tract

• Know how to evaluate pylectasis and calyectasis

• Learn the causes of hydronephrosis

• Learn the sonographic findings in ureterovesical junction obstruction and posterior urethral
valves

Introduction
Prenatal ultrasound has been integrated into the obstetrical examination to provide information to
the clinician regarding the development and overall well-being of the fetus. Specifically,
ultrasound has the capability of imaging the genitourinary system as early as the first trimester
with the endovaginal examination; however improved anatomical detail is obtained with
transabdominal ultrasound after eighteen gestational weeks. The sonographer has the
opportunity to assess the presence and amount of amniotic fluid, to clearly visualize the fetal
kidneys and bladder in the early second trimester, as well as the opportunity to demonstrate
many genitourinary system anomalies.

A complete fetal genitourinary examination would include evaluation and measurement of both
kidneys, documentation of the urinary bladder, and assessment of amniotic fluid. Amniotic fluid
volume reflects the prognosis of renal function; early detection of amniotic fluid variations may
influence the management of the obstetrical patient. Abnormal amounts of amniotic fluid should
lead the sonographer to suspect problems with the genitourinary, gastrointestinal, or central
nervous system, premature rupture of membranes, or intrauterine growth restriction. In the
presence of poly- or oligohydramnios the sonographer should carefully image the renal areas and
bladder with ultrasound and to determine if obstruction is present that may be the cause of the
abnormal production of amniotic fluid.

The genitourinary system is the most common site (30%) of all antenatally detected anomalies.
Abnormalities of the genitourinary system may also be discovered incidentally or secondarily if
another anomaly has been detected during the obstetrical ultrasound evaluation.
Development of the Urogenital System

The fetal urinary system begins to develop in the first trimester. The genitourinary system consists
of two kidneys that excrete urine, the ureters which transport urine to the urinary bladder, and
the urethra through which the urine is discharged to the exterior.

Development of the Kidneys. The kidneys begin to develop early in the fifth week of life
although they do not begin to function and produce urine until around the end of the first trimester
to the beginning of the second trimester.

The assessment of amniotic fluid is correlated with gestational age. Prior to approximately sixteen
weeks, the placenta contributes the fluid waste to form the amniotic fluid volume. After the second
half of gestation, the kidneys are the primary contribution of urine waste formation that continues
to fill the amniotic cavity throughout fetal life. Therefore, early in gestation the amniotic fluid is
present in the absence of renal function. After sixteen weeks, normal amniotic fluid implies that at
least one functioning kidney is present.

The fetal kidneys are subdivided into lobes that may be separated by grooves. This lobulation
usually diminishes by the end of the fetal period, but in some cases the lobes may still be
noticible by the end of the neonatal period. In the adolescent and the adult patient, persistent of
the fetal lobulation and groove may be seen on ultrasound as an echogenic "triangular" notch
along the anterior wall of the right kidney.

The arterial vascular supply to the kidneys is supplied by arteries that arise from the aorta.
Usually these vessels disappear as the kidneys ascend from the pelvis into the retroperitoneal
cavity, but some of them may persist to account for the variations in number that the sonographer
may find in the renal arteries. At least 25% of adult kidneys have two to four renal arteries.

Development of the Urinary Bladder. The fetal urinary bladder is derived from the hindgut
derivative known as the urogenital sinus. The caudal ends of the mesonephric ducts open into the
cloaca and parts of them are gradually absorbed into the wall of the urinary bladder. This
development causes the ureters (derived from the ureteric buds) and the mesonephric ducts to
enter the bladder separately.

Development of the Urethra. The epithelium of the female urethra and most of the epithelium of
the male urethra is derived from the endoderm of the urogenital sinus.

The Urachus. Early in development the urinary bladder is continuous with the allantois. The
allantois regresses to become a fibrous cord known as the urachus. This cord, or ligament,
extends from the apex of the bladder to the umbilicus. If the lumen of the allantois persists as the
urachus forms, a urachal fistula develops which causes urine to drain from the bladder to the
umbilicus.1 If only a small part of the lumen of the allantois persists it is called a urachal cyst. If a
larger portion of the lumen persists, it may cause a urachal sinus to develop that may open at the
umbilicus or into the urinary bladder.

Sonographic Evaluation of the Genitourinary Tract

The kidneys should be evaluated by assessing their anatomy, texture, and size. Normal anatomic
structures of the kidney include the relatively homogeneous renal cortex and parenchyma,
hypoechoic pyramids and echogenic calyces, and anechoic renal pelvis. Kidney texture that
appears significantly enhanced or echogenic should be a cause for concern.

Demonstration of the genitourinary tract is best imaged with transabdominal ultrasound after
sixteen weeks gestation. By twenty weeks gestation sonography may clearly define over 90% of
fetal kidneys.2 Transvaginal ultrasound has occasionally demonstrated the renal area as slightly
hyperechoic as compared to the hypoechoic adrenal glands near the end of the first trimester.
However with transabdominal ultrasound the renal area is hypoechoic at fourteen to sixteen
weeks. As the gestation progresses, the retroperitoneal fat increases surrounding the renal area
and thus makes an echogenic border to differentiate the kidneys from the abdominal structures.
By the third trimester, the corticomedullary junction may be distinguished from the renal cortex
and the hypoechoic renal pyramids are well delineated. The renal borders may appear lobulated
on the longitudinal image. These fetal lobulations gradually develop into a smoother border as the
gestation progresses.

The kidneys may be demonstrated on the ultrasound image in the transverse and longitudinal
plane. Transversely, the kidneys are demonstrated as a circular area adjacent to the fetal spine.
(Fig. 1) The sonographer may locate the kidneys in the transverse plane by slowing "sweeping"
the transducer in a cephalic to caudal direction. Locate the fetal heart or fluid-filled stomach and
then slightly angle the transducer inferior toward the area of the fetal kidneys; if the fluid-filled
bladder is seen the sweep was angled too inferior (caudal). (Fig. 2) Analysis of the central renal
sinus and pelvis should be assessed for the presence of fluid.

Fig.1
Fig.2

If the kidneys are difficult to locate, color Doppler may be utilized to locate the fetal vascular
structures that flow in and out of the central renal area. (Fig. 3) The pulse rate frequency should
be reduced and the transducer held still over the renal area to detect vascular flow. Color Doppler
mapping may be especially useful in the presence of oligohydramnios.
Fig.3

Fig.4

Normally, the fetal ureters are too small to image (measuring 1-2 mm). If "cystic" type structures
are seen separate from the kidney, the sonographer should evaluate for the presence of
hydronephrosis, dilated ureters, prominent fluid-filled bowel, or other abnormality. An abdominal
structure (separate from the psoas muscle) or mass that touches the fetal spine most likely
originates within the retroperitoneal urinary tract.2

Once the kidneys have been located on the transverse plane, rotate the transducer 90 degrees to
the longitudinal plane. (Fig. 4) Hold the transducer still over the renal area to watch for respiratory
movement of the kidney and diaphragm. The prominent adrenal gland that caps the superior pole
of the kidney may be demonstrated.

Fetal Urinary Bladder. The fetal urinary bladder is well seen on ultrasound if fluid is present
within. The bladder has a thin wall and may be seen as a triangular sac in the central anterior
position on the transverse image within the fetal pelvis. The bladder becomes more elliptical in
shape with fluid distention. With color Doppler, the umbilical (superior vesical) arteries may be
seen on the transverse plane just lateral to the bladder as they flow towards the umbilicus.

The production of fetal urine increases with gestational age from a mean value of 5 mL/hr at 20
weeks to 56 mL/hr at 41 weeks. The bladder volume at 20 weeks is approximately 1 mL, by term
gestation at 41 weeks the volume has increased to 36 mL.3 The normal bladder fills and empties
(partially or completely) on average every 25 minutes. Therefore, it is a good idea to image the
genitourinary system early in the ultrasound examination. If the bladder is not full, it may be
reassessed at the end of the exam.

Failure to observe the bladder may indicate a severe renal abnormality when accompanied by
oligohydramnios. The bladder wall should be thin in a normal fetus. When obstruction occurs at
the level of the urethra, the bladder wall becomes hypertrophied. The presence of ureteral jets
may be assessed in the fetus to rule out obstruction. Color Doppler is focused over the area of
the bladder, near the base, and the presence of ureteral jets streaming into the bladder over a
period of time indicates the ureter is not obstructed.

The urethra, like the ureters, is usually unidentifiable in the normal fetus. Dilation of the posterior
urethra is highly suspicious for an obstructive process such as posterior urethral valve syndrome.

Assessment of Renal Growth. Normal fetal renal measurements for thickness, width, length,
and volume have been reported as a function of menstrual age. As expected, these
measurements increase with age and correlate with measurements in the postnatal period. The
easiest measurements to obtain are the anterior-posterior and the longitudinal dimensions. A "rule
of thumb" measurement is that the menstrual age in weeks approximates the normal fetal kidney
length in millimeters or twice the anteroposterior diameter in millimeters.2

Normal Fetal Renal Dimensions (mm) Correlated with Menstrual Age*

Gest. Age Thickness Width Length Volume
16 2/6/10 6/10/13 7/13/18 0/0.4/2.6
18 4/8/12 6/10/14 12/17/22 0/0.7/2.9
20 6/10/13 7/11/15 15/21/26 0/1.1/3.3
24 9/13/17 10/14/18 22/28/33 0.3/2.5/4.7
28 12/16/20 13/17/21 28/33/38 2.5/4.7/6.9
32 15/19/23 17/20/24 33/38/43 5.4/7.5/9.7
36 17/21/25 19/23/27 36/41/47 8.1/10.2/12.4
*5th/50th /95th percentile
Adapted from Romero R. Pilu G. Jeanty P. et.al: Prenatal Diagnosis of Congenital
Anomalies. East Norwalk, CT. Appleton & Lange, 1989.
Measurement of the renal length may be difficult to assess the upper pole border because of rib
shadowing or adrenal tissue. The sonographer should observe the kidney movement as the fetus
breathes and the complete renal border may be visually assessed.

Assessment of Amniotic Fluid Volume. The amniotic fluid volume (AFV) provides information
about renal and placental function. It also is an important biophysical assessment tool. The
assessment of amniotic fluid may be may by the single vertical pocket method or the four
quadrant summation method. The single vertical pocket measurement may be made after the
uterine surface has been evaluated for the greatest single vertical pocket of amniotic fluid (without
cord or fetal parts) has been demonstrated.

Single Vertical Pocket Measurement

<2 cm suggests oligohydramnios

2-8 cm is normal fluid

>8 cm suggests polyhydramnios.

The amniotic fluid index (AFI) method divides the uterine cavity into four quadrants. Each
quadrant is measured for the greatest pocket of fluid minus umbilical cord or fetal parts (color
Doppler is useful to assure the cord is not included in the measurement). The four quadrants are
added together to provide one measurement known as the AFI. This method varies with
gestational age and is objective and reproducible. An AFI of less than 5 cm presents
oligohydramnios, 5-20 is normal, 20-25 is upper normal, and >25 cm polyhydramnios.

Obstructive and Nonobstructive Abnormalities of the Urinary Tract

Systematic Approach to Evaluate Genitourinary Anomalies. The sonographer should

determine if the urinary bladder is present and fluid filled during the examination. The kidneys
should be imaged in their normal position and the size and texture evaluated. If the renal pelvis is
dilated, the sonographer should try to assess the level of the obstruction and whether it is intrinsic
or extrinsic. Assessment of the fetal gender will also help to determine the gender specific
anomaly.

The recognition of urinary tract anomalies is of significant clinical concern, since several fetal
conditions are incompatible with life. In unilateral obstructions of the urinary tract, early delivery of
the fetus is often warranted to salvage the normal kidney. Intrauterine decompression of an
obstructed urinary tract (posterior urethral valve syndrome) has been performed to relieve the
obstruction and allow expansion of the lungs to prevent pulmonary hypoplasia.4 Recognition of
lethal or treatable renal anomalies is necessary to ensure appropriate clinical and therapeutic
management. When bilateral, decide if the condition is asymmetric (dissimilar abnormal patterns
for each kidney) or symmetric (same abnormal pattern for both kidneys; this may imply a genetic
condition, such as autosomal-recessive infantile polycystic kidney or multicystic dysplastic kidney
disease).

If the fetus has a known chromosomal defect or if other abnormalities are found, the risk is
greater for the fetus to have a renal anomaly as well. Additional malformations indicate a higher
risk for chromosome anomalies (x30 for multiple defects and x3 for isolated defects).

As discussed earlier, assessment of the amniotic fluid volume is important to evaluate renal
function. If an abnormality of the genitourinary tract is found, normal AFV after twenty weeks
implies at least one kidney is functioning and the fetus has a good prognosis. If oligohydramnios
is seen early in the second trimester, the prognosis is poor because of the development of
pulmonary hypoplasia.
Renal obstructive malformations may be divided into two categories: (1) obstructive and (2) those
resulting from a non- obstructive process. The consequences of renal malformations vary,
depending on the type of lesion and extent of obstruction.

Dilatation of the Urinary Tract. Marked deviations of anatomy should alert the sonographer to
investigate the urinary tract more extensively. It is important to remember that a small amount of
urine may be seen in the renal pelvis in the normal fetus after twenty weeks gestation, measuring
in its anterior-posterior diameter less than 5 mm. Prior to twenty weeks, this measurement should
not exceed 4 mm. This slight dilatation should not be misinterpreted as an abnormal collection of
urine within the renal pelvis, pelviectasis, (5-9mm); or caliectasis, rounded calyces with renal
pelvis dilation (greater than10 mm) which may lead to severe hydronephrosis.

Fig. 5
Fig.6

A renal pelvis diameter, measured in an anteroposterior direction in a transverse plane that

exceeds 10 to 15 mm is considered to be abnormal. (Fig. 5, 6) Follow-up ultrasound evaluation in
six to eight weeks should continue throughout the pregnancy and postnatally to evaluate the
degree of obstruction.

Pylectasis is found in two percent of normal fetuses. An increased number (17-25%) of fetuses
with Trisomy 21 have been reported to have pylectasis. If renal dilatation is the only ultrasound
finding, the risk of having a Trisomy 21 fetus increases only slightly and therefore should be
considered a soft finding for a chromosomal anomaly.

Obstructive Urinary Tract Abnormalities

Obstruction of the urinary system may originate anywhere along the urinary tract. The
consequences of an obstruction depend on the origin of the blockage. For example, in fetuses
with complete posterior urethral valve obstruction, urine is unable to pass through the urethra and
into the amniotic fluid. Consequently, urine backs up in the posterior urethra, bladder, ureters, and
often extends to the kidneys (hydronephrosis).

The urinary tract may be obstructed at the junction of the ureter entering the renal pelvis
(ureteropelvic junction) or at the junction of the ureter as it enters the bladder (ureterovesical
junction) or at the level of the urethra (megacystis).

Hydronephrosis. Fetal hydronephrosis is the most common fetal anomaly. The sonographic
appearance of urinary tract obstruction varies depending on the site and extent of blockage.
Dilation of the renal pelvis (hydronephrosis) occurs in response to a blockage of urine at some
junction in the urinary system. This blocked urine is unable to pass the obstruction, and urine is
continually produced, it will back up into the kidney. Hydronephrosis commonly occurs when there
is an obstruction in the ureter, bladder, or urethra. Hydronephrosis is generally the end result of
an obstruction at a lower level in the urinary tract.

Cause of Hydronephrosis

44% Ureteropelvic Junction Defect

21% Ureterovesical Junction Defect

14% Vesicoureteric Reflux

12% Duplex Collecting System

9% Posterior Urethral Valves

The ultrasound appearance of hydronephrosis varies according to the severity of the underlying
obstruction. The dilated renal pelvis is centrally located and distended with urine, which often
communicates with the calyces (caliectasis). The remaining renal tissue may be identified in all
but the most severe cases of hydronephrosis. Renal dysplasia often occurs and represents cystic
changes within the renal tissue. Several obstructive patterns may be observed. The sonographic
team should attempt to define the severity of the cystic changes affecting the kidney.

Ureteropelvic Junction Obstruction. Fetal hydronephrosis may occur as a unilateral or bilateral

process. Unilateral renal hydronephrosis commonly results from an obstruction at the junction of
the renal pelvis and the ureter. This is called a ureteropelvic junction obstruction (UPJ). The
prognosis of the fetus is good with unilateral UPJ obstruction.

Sonographically, the renal pelvic is dilated, pylectasis. As the dilatation increases in size, a
collection of urine located medially within the renal pelvis communicates with the calyces,
caliectasis. The ureter and bladder are usually normal in size; the amniotic fluid volume may be
normal to slightly increased. When unilateral hydronephrosis is accompanied by oligohydramnios
the contralateral renal pathology should be investigated. With severe chronic obstruction, there
may be marked dilation of the renal pelvis with sonographic findings of a thin renal cortex and a
large unilocular "cystic" mass.

Bilateral UPJ obstruction occurs in 10 to 30% of fetuses. The prognosis is poor with bilateral
obstruction if the hydronephrosis is severe. The sonographer should image the fetal bladder and
amniotic fluid volume to assess renal function. Serial examinations are necessary to monitor the
degree of obstruction and to assess renal function.

Ureteropelvic junction obstruction is the most common reason for hydronephrosis in the neonate.
Only half of these disorders are found during early childhood; therefore early prenatal detection
may improve long-term renal function. The causes of UPJ obstructions include abnormal bends
or kinks in the ureter, adhesions, abnormal valves in the ureter, abnormal outlet shape at the
ureteropelvic junction, or absence of the longitudinal muscle that is imperative to the normal
excretion of urine from the kidney.5
Ureterovesical Junction Obstruction. The second most common cause for hydronephrosis is
the junction where the ureter enters the posterior wall of the bladder, ureterovesical junction
obstruction (UVJ). Ureterovesical junction obstruction commonly presents with dilation of the
ureter, megaureter. Megaureter may result from a primary ureteral defect (stenotic ureteral valves
or fibrosis) or occur secondary to obstruction at another level (causing reflux or backward flow of
urine). UVJ obstruction is usually unilateral.

Sonographic findings include hydroureter and hydronephrosis. The dilated ureter should be
distinguished from bowel. The ureter lies closer to the spine; both bowel and the dilated ureter
may show peristalsis. Bowel may present with more echogenic texture internally than the ureter.

Coexisting anomalies such as vesicoureteral reflux, UPJ obstruction, and multicystic dysplasia
are frequently present.

Duplication Anomalies. Other defects, such as duplication of the renal collecting system, are
common and may be diagnosed prenatally. This anomaly is more common in females When a
dilated upper renal pole is observed with a normal lower pole an obstructed duplicated collecting
system may be indicated. This may result from an ectopic ureterocele (15% have bilateral
ureteroceles) within the bladder causing bladder outlet obstruction and hydronephrosis of the
upper pole of the kidney. The ectopic ureter may be enlarged and tortuous to mimic a septated,
cystic mass.

Lower Urinary Tract Obstruction

Urethral Obstruction. Obstruction at the bladder outlet would cause dilatation of the bladder that
may reflux into the ureters and renal pelvis. The time of onset and severity of the obstruction
would be influential in the amount of obstruction present.

Posterior Urethral Valves. This condition is the most common cause of lower urinary tract
obstruction. Posterior urethral valve obstruction results in hydronephrosis, hydroureters, or
dilation of the bladder and posterior urethra. This entity occurs only in male fetuses and is
manifested by the presence of a valve(s) in the posterior urethra. As a result, urine is unable to
pass through the urethra and into the amniotic fluid. This causes a back-up of urine in the
bladder, ureter, and, in the most severe cases, the kidneys. Severe oligohydramnios is a classic
finding in the complete obstruction form.

Sonographic findings include the classic "keyhole" bladder sign. This occurs secondary to the
outlet obstruction, causing the bladder wall to thicken greater than 2 mm. The ureters are both
dilated and tortuous. Severe dilatation of the bladder may lead to spontaneous rupture of the
bladder to cause urinary ascites or peri-renal urinoma. Hydronephrosis is often present. If the
obstruction is severe, renal fibrosis and dysplasia develop which leads to decreased renal
function. Oligohydramnios occurs and causes pulmonary hypoplasia and compression
deformities of the fetus. When these sonographic signs occur in the female fetus, abnormalities of
the sacrum (caudal regression anomalies) and megacystis-microcolon intestinal hypoperistalsis
syndrome should be considered.

Fetal renal function may be assessed by aspirating urine from an obstructed bladder. Cystic
dysplasia and poor renal function are suggested when sodium, chloride, and osmolality are
unusually elevated.5

Intermittent posterior urethral valve obstruction may occur with a normal amount of amniotic fluid.
Diminishing fluid volume and increased hydronephrosis may prompt early delivery.

The prognosis of posterior urethral valve syndrome is invariably fatal, but in selected fetuses with
documented normal renal function, placement of an in-dwelling bladder shunt to relieve the
obstruction has improved chances for survival in some cases.6 This shunt drains the blocked
urine into the amniotic fluid, allowing the fetal lungs to develop. When the urinary tract is
completely blocked, severe oligohydramnios and the Potter sequence occur.7

Urethral Atresia. Rare disorders, such as urethral atresia, may cause a massively dilated
bladder without evidence of amniotic fluid, (anhydramnios). This is the most severe form of
obstructive uropathy in the lower urinary system. This condition is fatal without treatment as renal
dysplasia develops along with pulmonary hypoplasia.

Fetal Megacystis. Dilation of the ureters may occur as isolated lesions (primary megaureters),
resulting from atresia of the distal ureter.8 The disorders are generally associated with adequate
to increased amounts of amniotic fluid and a normal bladder. Infrequently, renal hydronephrosis
may occur.

Cloacal Malformation. The failure of the urorectal septum to reach the perineum results in
cloacal malformation. This condition occurs in 1/50,000 births and affects phenotypic females.
Other lower urinary tract malformations are common.

Sonographic findings include decreased amniotic fluid volume, normal-to enlarged- to

nonvisulization of the fetal bladder, a retrovesical cystic mass, ascites, hydronephrosis,
ambiguous genitalia, and vertebral anomalies.

Prune-Belly Syndrome. This syndrome may be called the urethral obstruction malformation
complex. The condition consists of: cryptorchidism, agenesis of abdominal wall muscle,
megaureters, bladder outlet obstruction due to urethral anomalies such as atresia, stenosis
valves, or diverticulum.

Sonographic findings in prune-belly syndrome include oligohydramnios, mild to severe bilateral

hydronephrosis, fetal ascites, and hypoplastic lungs. The abdomen is extremely distended as
compared to the small thoracic cavity. The dilated ureters and bladder appear as numerous cystic
lesions within the distended abominal cavity.

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Golbus MS, and Filly RA, editors: The unborn patient: prenatal diagnosis and
management. Orlando, Fla., 1984, Grune & Stratton.
• Berkowitz RL, Glickman MG, Walker-Smith GJ, et al: Fetal urinary tract obstruction: what
is the role of surgical intervention in utero? Am J Obstet Gynecol 144:367, 1982.
• Dunn V and Glasier CM: Ultrasonographic antenatal demonstration of primary
megaureters, J Ultrasound Med 4:101, 1985.