Atlas of

Ultrasonography in
Urology, Andrology,
and Nephrology

Pasquale Martino
Andrea B. Galosi
Editors

123
 Neoplastic and Nonneoplastic
Disease of the Bladder
Luigi Mearini, Elisabetta Nunzi,
and Michele Del Zingaro
35.1 Introduction
The presence of blood in the urine as macroscopic
(visible on gross examination) or microscopic
(invisible, more than 3–5 red blood cells per high-
power field on microscopic urine analysis) hema-
turia is a very common problem that can represent
many different common benign or malignant
underlying diseases. The causes of hematuria can
be broadly categorized into renal (glomerular and
non-glomerular) and/or extrarenal.
Apart from a detailed history, which is essen-
tial in driving the diagnostic process in cases of
hematuria and baseline laboratory evaluations,
further investigation with noninvasive imaging
studies [1] is imperative to confirm or exclude the
presence of malignant disease.
The most common conditions of the bladder
that cause hematuria include infection, inflam-
mation, stones, and malignancy.
Although hematuria’s characteristics and
symptoms are suggestive of underlying disease
(e.g., symptomatic hematuria with frequency
L. Mearini, MD (*) • E. Nunzi • M.D. Zingaro
Urology Department, University Hospital,
Perugia, Italy
Urology Department, Perugia Hospital University
of Perugia, Perugia, Italy
e-mail: luigi.mearini@tin.it
© Springer International Publishing Switzerland 2017
P. Martino, A.B. Galosi (eds.), Atlas of Ultrasonography in Urology, Andrology, and Nephrology,
DOI 10.1007/978-3-319-40782-1_35
35
suggests an infectious or irritative disease), most
bladder cancers are asymptomatic.
Ultrasound scanning (US) is a useful, rela-
tively simple noninvasive imaging modality for
the evaluation of the urinary bladder [2, 3]. The
bladder is an abdominal organ ideally suited to
US [4] for many reasons, including its superfi-
cial location and the acoustic properties of the
fluid (urine) inside. The functions of the blad-
der include urine storage and removal, and
when the bladder is filled with urine, its content
should be anechoic upon US evaluation, thus
permitting the ideal examination of its content
and walls.
Before proceeding with bladder US, it is cru-
cial to remember that upon normal filling, the
bladder wall appears as a typical three-layer
structure with a detrusor muscle of medium
homogeneous echogenicity, while the outer
serosa layer and the inner mucosa (urothelial)
layer are usually hyperechoic compared with
the middle detrusor smooth muscle (muscularis
­propria) layer.
425
426 L. Mearini et al.

35.2 Technology (200–300 ml). Bladder US requires careful and

The most common method used to scan the uri-
nary bladder is an external, suprapubic, abdominal
approach using a convex 2.5−5-MHz probe. Linear
probes with higher frequencies (7.5−16 MHz) can
be used in specific cases. The bladder floor, includ-
ing the distal and intramural part of the ureter, can
be visualized more accurately with a higher fre-
quency transrectal ­ultrasound scan (TRUS) in men
or with a vaginal probe in women. A transurethral
approach into the bladder with high-frequency
miniprobes is an antiquated procedure and is not
currently a standard approach due to its inva-
siveness and limits [5–7], although still promis-
ing with less invasive probe in tumor staging [8]
(Figs. 35.1, 35.2, and 35.3).
The patient is usually examined in the supine
position with a sufficiently full bladder
complete scanning with transverse and longitu-
dinal sections.
The fine regulation of light is essential to obtain
a significantly improved image quality and to cor-
rectly visualize the anterior wall (superficial com-
pared to the skin) and posterior wall (deep). The use
of high-frequency probing or the use of a second
tissue harmonic imaging tool improves the quality
of the imaging by reducing some reverberation arti-
facts. Effectively, abdominal ultrasound is limited in
the evaluation of the anterior bladder wall due to
reverberation artifacts, such as the rain effect.
Echo-Doppler may be useful to assess the ure-
teral jet and make a differential diagnosis of a
bladder lesion.
Table 35.1 briefly resumes the quality of
images obtained by different approaches and
probes.

Fig. 35.1 Historical

image of transurethral
US of the bladder. The
picture demonstrates
two small intraluminal BLADDER CANCER
bladder masses. Bladder
wall is easily identified,
showing that one of the
bladder mass involves a
small diverticulum

BLADDER CANCER

Fig. 35.2 Another

“antique” image of
transurethral US. Note
the integrity of the
echostructural pattern of
bladder wall at tumor’s
base
35 Neoplastic and Nonneoplastic Disease of the Bladder 427

Fig. 35.3 A deep

infiltrating bladder mass
seen at transurethral BLADDER CANCER
US. The echostructural
pattern of anterior
bladder wall is easily
seen, and it
demonstrates a diffuse
interruption

Table 35.1 Synthetic overview of imaging quality according to different probes and approaches to the bladder
Abdominal Transrectal or transvaginal Transurethral
Instrument Convex 3.5–5- Linear biplanar Endoscopic
MHz probe 7.5-MHz probe probe 5–7.5 MHz
Overall view +++ + ++
Bladder wall appearance + + +++
Trigone ++ +++ −
Anterior wall +− − +
Lateral wall ++ − +
Bladder dome + − +
Surrounding organ ++ ++ −
428
35.3 Report
The findings report should [9]:
• Include the name of the physician examiner,
place, and date.
• Include the patient’s name, surname, and date
of birth.
• Briefly include all clinical information and the
indications for the specific investigation.
• Describe type of current ultrasound examina-
tion and the probe.
Example: Bladder Ultrasound Examination
Dr. Samuel Smith; Urology Department, NY
City Hospital; June 26th, 2015
Patient: Richard Doyle; October 23th, 1947
Queries: asymptomatic hematuria
Abdominal bladder ultrasound by convex
5-MHz probe
Ultrasound findings:
Bladder filling volume is sufficient for
exhaustive examination. The bladder wall
thickness is normal. The right and left ureteral
jets are present. Presence of a polypoid
hypoechoic mass in the right bladder wall,
Fig. 35.4 An example of exhaustive US report in case of bladder cancer. The two images describe in detail the
bladder mass with a transverse and longitudinal scan
L. Mearini et al.
• Use standard anatomical and ultrasound
terminology.
• Describe all abnormal findings, includ-
ing number, side, shape, dimension, and
characteristics.
• Try to obviate to any difficulties or lim-
its encountered while performing the
­investigation; underline the diagnostic accu-
racy of current test.
• Suggest types of studies for further investiga-
tion; in case of serious findings, inform the
patient and contact the patient’s doctor.
1.5 × 5 mm; the hyperechoic line of inner
mucosa is not interrupted. Power Doppler
images show considerable vascularity of the
mass. The post-micturition volume is 20 ml.
Urologist consultation and cystoscopy are
strongly suggested since these ultrasound and
power Doppler images are suggestive of carci-
noma of the urinary bladder.
The exams included:
1. Two pictures of the bladder in transverse
and longitudinal scan
2. Two pictures of the mass in transverse and
longitudinal scan (Fig. 35.4)
BLADDER CANCER
35 Neoplastic and Nonneoplastic Disease of the Bladder
35.4 Diagnosis
In the diagnosis of luminal defects of the bladder,
it is of paramount importance to remember the
normal bladder wall anatomy, which consists of
mucosa, detrusor smooth muscle, and adventitia.
This anatomical distinction is easily visualized
by US, as the ultrasound appearance of the blad-
der wall is as a sandwich structure with a
hypoechogenic muscular wall between the
mucosa and adventitial layers, which are slightly
hyperechogenic.
The possibility of distinguishing each compo-
nent of the bladder wall depends upon bladder
wall thickness, which varies with the state of
urine filling; the upper limits are 3 and 5 mm for
a full bladder and empty bladder, respectively.
The trigone represents an important landmark: it
is the triangular area which lies between the two
ureteral orifices and the internal urethral orifice;
in this region, the musculature of the bladder
floor is dense and usually hypertrophied, forming
the interureteric ridge.
All these concepts explain why a bladder
ultrasound scan requires adequate bladder filling
and the limits of US evaluation in cases of detru-
sor hypertrophy or small lesions.
35.4.1 Neoplastic Bladder Disease
Most bladder tumors are transitional cell carcino-
mas, accounting for approximately 90 % of all
primary malignant lesions. They are usually
found in the region of the trigone or bladder base
or on the lateral walls as unique or multiple
lesions. According to their intrinsic characteris-
tics, they show different patterns in growth, with
429
papillary, sessile (or infiltrative), and mixed pap-
illary and sessile shape.
On ultrasound [10], they appear as a papil-
lary (polypoid) or sessile (plaque with large
base) lesions projecting into the lumen, usually
quite echogenic and fixed with changes in the
patient’s position. Ultrasound must describe the
presence of wall alterations (assessment of
lesions >3 mm), number, size, shape, and tumor
staging.
In cases of superficial lesions, the bladder wall
shows no echostructural alterations with a nor-
mal ultrasound appearance of the sandwich pat-
tern (Figs. 35.5, 35.6, 35.7, and 35.8). Endophytic
tumors appear as hypoechogenic, fixed prolifera-
tive lesions; however, they are sometimes hyper-
echogenic due to the presence of superficial
calcifications.
In cases of infiltrating lesions, the bladder
wall shows an interruption [11] or deformation,
and sometimes the bladder tumor extends beyond
the bladder wall. The hyperechoic layer of blad-
der mucosa is interrupted (Figs. 35.9, 35.10, and
35.11).
The diagnostic accuracy of US for bladder
tumor diagnosis and staging [12] is generally
considered to be poor (with a sensitivity ranging
50–94 % [13]) in comparison with other diagnos-
tic modalities such as CT scan or MRI. This wide
discrepancy in sensitivity is related to some
tumor factors (e.g., size, location, macroscopic
aspects), patient factors (gender, body mass
index, bladder filling), and operator-dependent
factors (different levels of experience [14]; more-
over, the type of US device and the technical
modality of performing the ultrasound examina-
tion may explain such a wide variation in results
for the diagnosis and staging of bladder cancer.
430 L. Mearini et al.

Fig. 35.5 A small

exophytic tumor at
bladder neck

BLADDER CANCER

Fig. 35.6 A small,

diffuse hyperechoic
exophytic tumor at
bladder wall. The BLADDER CANCER

normal hyperechoic
internal layer is
continued at tumor’s
base. This is a typical
pattern of superficial
bladder cancer

Fig. 35.7 Another

small exophytic bladder
mass at bladder base BLADDER CANCER

BLADDER CANCER

Fig. 35.8 Bladder scan

by means of transrectal
US. Abdominal US is
negative
35 Neoplastic and Nonneoplastic Disease of the Bladder 431

Fig. 35.9 Small

bladder tumor at bladder
neck. Despite small
size, US shows partial
BLADDER CANCER
interruption of the
hyperechoic mucosa
layer. This is a
histologically confirmed
case of infiltrating
bladder cancer

Fig. 35.10 A
transrectal US showing
an infiltrating bladder
BLADDER CANCER
cancer. The entire
bladder wall is diffusely
interrupted, and the
mass seems to reach the
plane of seminal vesicle

BLADDER CANCER

Fig. 35.11 A
transverse and
longitudinal picture of
an infiltrating bladder
cancer. The mass is
partially exophytic with
a large base, and the
echostructural pattern of
bladder wall is diffusely
interrupted
432 L. Mearini et al.

35.4.1.1 S  ensitivity and False-Negative obstruction (bladder wall hypertrophy, diver-

Findings
The main limits of bladder ultrasound scanning
depend upon spatial resolution and thus on the
size, shape, and side of the bladder tumor.
Moreover, apart from the characteristics of
bladder tumors, the ultrasound scan is limited by:
Bladder filling, which should be suboptimal in
cases of acute or chronic cystitis
Bladder content, which is altered in cases of
bladder catheterization by the balloon itself or
by the presence of an air bubble or the con-
temporary presence of lithiasis
Bladder wall characteristics, such as in cases of
progressive changes in the bladder wall
observed in patients with lower urinary tract
ticulosis, trabeculations)
Size: bladder lesions smaller than 5 mm may
not be identified on ultrasound, especially on the
bladder dome. On the other hand, the ability to
diagnose vegetating/papillary lesions >5 mm is
high.
Shape: flat or slow-growing non-vegetative
tumors, such as carcinoma in situ, are not diag-
nosed by imaging.
Side: during abdominal US, the rain effect at
the anterior bladder wall reduces spatial resolu-
tion [15] (Fig. 35.12), even for tumors >5 mm.
Some small wall defects at the bladder neck or
trigone could be confused with a median lobe
(Fig. 35.13).

Fig. 35.12 A large,

exophytic mass at
anterior bladder wall.
Note the difficulties in
BLADDER CANCER
the correct identification
of tumor’s base, mainly
due to the side of the
tumor

Fig. 35.13 An BLADDER CANCER

infiltrating bladder
tumor at the bladder
neck. At transverse
abdominal US, due to
tumor’s side and
reduced bladder filling,
the ultrasound
appearance of tumor is
confusing. At linear
transrectal US, bladder
tumor is easily identified
and distinctive from the
normal prostate
35 Neoplastic and Nonneoplastic Disease of the Bladder
35.4.1.2 S  pecificity and False-Positive
Findings
A false-positive finding on an ultrasound scan
is particularly frequent in cases of macroscopic
hematuria or in cases of reduced bladder
filling.
The most frequent cause of false-positive find-
ings is represented by bladder wall hypertrophy
caused by lower urinary tract obstruction. Bladder
wall hypertrophy or diverticulosis or trabecula-
tions could be confused with wall defects.
Other false-positive findings are represented
by endovesical clots, which are frequent in cases
of macroscopic hematuria independent from the
primary cause. Clots appear as variably sized
hyperechoic masses, usually on the bladder floor;
they are mobile, depending on decubitus move-
ments. In cases of clot adhesion to the bladder
wall, the use of color Doppler will show the
absence of a color signal.
Fig. 35.14 A typical abdominal US in case of acute cystitis. The bladder filling is markedly reduced, and the irregular
increased thickness of bladder wall is diffused
433
Other common conditions associated with
false-positive findings include acute or chronic
cystitis. In acute conditions (Fig. 35.14), there
is diffuse increased hypoechogenicity and an
increased thickness of the bladder wall at the
mucosa layer, especially at the level of the bladder
floor and at the trigone. Anechoic bladder content
is substituted by fine, mobile echoic pattern.
In chronic conditions, increased hyperecho-
genicity and thickness of the bladder wall at the
mucosa level is more nonspecific, except in cases
of tuberculosis or bilharziasis.
Another common cause of false positives is
the presence of small or irregular prostatic
median lobes.
Another rare condition associated with false-­
positive findings is the presence of urachal remnants.
Table 35.2 shows false-negative and false-­
positive findings related to bladder and tumor
ultrasound scan.
ACUTE CYSTITIS
434 L. Mearini et al.

Fig. 35.15 Another

picture showing an
infiltrating bladder
cancer causing distal BLADDER CANCER

ureteral dilation. Note

the reduced bladder
filling caused by the
tumor LEFT URETER

Table 35.2 Main reasons for false-negative and false-­positive findings at bladder ultrasound scan
False negative False positive
Bladder Filling (low or excessive) Filling (low)

Content (catheter, air, clots, stone) Content (clots, stone)

Detrusor hypertrophy Detrusor hypertrophy
Acute or chronic cystitis
Tumor Size (<5 mm)
Side (anterior bladder wall, bladder neck, or trigone) Side (median lobe)
Shape (flat lesion)

35.4.2 Nonneoplastic Bladder
Disease
There are a number of nonneoplastic and inflam-
matory disorders that can manifest as a focal or
diffuse bladder wall and alterations of bladder
content and can sometimes mimic malignancy;
therefore, ultrasound examination represents one
helpful diagnostic tool.
Diffuse bladder wall thickening can develop sec-
ondary to many nonneoplastic conditions, including
acute or chronic infection or inflammation and
detrusor hypertrophy, while focal bladder wall alter-
ations are derived from extrinsic causes, creating
bladder filling defects, such as ureteral disease, ura-
chal remnants, the median lobe of an enlarged pros-
tate gland, and endometriosis. Alterations of content
include bladder stones or clots.
35.4.2.1 Acute Cystitis
Acute cystitis symptoms often include a strong,
persistent urge to urinate with pelvic discomfort
and the presence of hematuria or strong-smelling
urine.
While all these symptoms strongly suggest the
diagnosis, they influence the ultrasound examina-
tion of the bladder with a reduction in bladder
filling and/or the presence of abnormal bladder
content (clots). Despite this, US is helpful in
excluding secondary causes of cystitis, such as
bladder outlet obstruction and bladder calculi.
A typical ultrasound picture of acute cystitis is
characterized by diffuse and increased hypoecho-
genicity and increased thickness of the bladder
wall accompanied by reduced bladder filling. The
trigone area is frequently altered.
35.4.2.2 Chronic Cystitis
Chronic cystitis symptoms often include a
chronic and persistent urge to urinate with pelvic
pain and discomfort. It is derived from recurrent
infection or other conditions, such as interstitial
cystitis, cystitis cystica, cystitis glandularis,
tuberculosis, schistosomiasis, and radiation and
chemotherapy cystitis. Apart from the underlying
cause, the most typical ultrasound feature of
chronic bladder inflammation is the reduction of
bladder filling.