IMAGING OF THE

GENITOURINARY
SYSTEM
PRESENTER: Dr. Omar Fatuma
FACILITATOR: Dr. Valeria Nabossa
OVERVIEW

• Anatomy

• Different modalities used in imaging

• Indications

• Contraindications

• Questions??
Blood supply to the kidneys
• Arterial blood is received by the kidneys
directly from the abdominal aorta via the left
and right renal arteries.
• The renal veins connect directly to the
inferior vena cava to return the blood to the
right side of the heart. The renal veins are
anterior to the renal arteries.
• Along the medial border of each kidney is a
centrally located, longitudinal fissure termed
the hilum.
• The hilum serves to transmit the renal artery,
renal vein, lymphatics, nerves, and ureter.
Each kidney is generally divided into an upper
part and a lower part, called the upper pole
and the lower pole, respectively.
• The ureters extend from the
kidneys to the urinary bladder
and are approximately 10
inches in length.
• They normally enter the
bladder obliquely in the
posterolateral portion of the
bladder, equidistant from the
urethral orifice in a triangular
fashion.
• A number of variations of this
exist. The function of the
ureters is to drain the urine
from the kidneys to the
bladder
EXCRETORY OR
INTRAVENOUS
UROGRAM
VOIDING CYSTOURETHROGRAM
A. Distal ureter B. Urinary bladder C. Trigone area of bladder
D. Area of prostate gland E. Urethra
Anatomy on CUG
Imaging techniques for the urinary system:

• Ultrasound
• Plain radiograph (KUB)
• Fluroscopy(contrast studies):
Intravenous urogram (pyelogram) - (IVU,IVP)
Cystography
Micturating cystourethrogram (MCUG)
Urethrogram
• Computed tomography (CT)
• Magnetic Resonance Imaging (MRI)
• Nuclear Medicine
 Ultrasound

Indications
 Abnormalities in size/location
 Suspected renal mass
 Suspected renal parenchymal disease
 Possible renal obstruction
 Hematuria
 Renal cystic disease
 Doppler (artetery stenosis, tumours)
 Interventional radiology

Equipment
 3-5 MHZ transducer (curvilinear probe)
Horseshoe kidney Duplex collecting system
 RADIOGRAPHY

INDICATIONS

• Renal stones, or any calcifications within the urinary tract

• Kidney masses with calcification
• Preliminary film before contrast studies

CONTRA INDICATIONS

Early pregnancy (risk-benefit)

RADIATION PROTECTION
• Avoid repeats
• Gonadal shields
• Radiation dose appropriate

LIMITATIONS??
Plain films
Fluoroscopy (Contrast studies)
IVU/IVP
•  Radiographic study of the renal parenchyma, pelvicalyceal system, ureters
and the urinary bladder. 
Indications:
• Check for normal function of kidneys
• Check for anatomical variants or congenital anomalies (e.g. horse-shoe
kidney)
• Check the course of the ureters
• Detect and localize a ureteric obstruction (urolithiasis)
• Assess for synchronous upper tract disease in those with bladder
transitional cell carcinoma (TCC)
IVU/IVP

Patient preparation
• No solid food for 5 hours prior to examination
• Patient should be ambulant for 2 hours prior to exam
• Explain procedure (including CM) and reassure patient to reduce
anxiety
• Sign informed consent
Film sequence
• Immediate
• 5 minutes
• 15 minutes
• Release film
• Post micturation
5 min film

AP of the renal areas

This film is taken to determine if

excretion is symmetrical and is also
used to asses if more contrast is
needed
10-15 minutes

Supine AP abdomen

This film is taken to show the

whole urinary tract

If satisfactory patient is asked to

pass urine

After micturition film

can either be a full length/ or a
coned view of the bladder

Its value is assess bladder

emptying, presence of reflux
Limitations of the IVU

• It depends on kidney function

• Its impossible to differentiate solid or cystic lesions

• It requires contrast medium and radiation

• It has the inconvenience of a long filming sequence

• Quality of the study may be limited by bowel ileus, technician

variability
Retrograde pyelography
Indications
• Demonstration of the site , length, lower limit and if possible the nature of
obstruction
• When urothelial tumors of the upper UT are suspected (biopsy)
• Demonstration of pelvicalyceal system after an unsatisfactory excretion urogram
• Better characterization of ureteral or pelvicalyceal abnormalities seen on IVU or
CTU

Contraindication : Acute UTI

 Micturating/Voiding cystourethrography (MCUG)

• Fluoroscopic study of the lower urinary tract in which contrast is introduced

into the bladder via a catheter.
• The purpose of the examination is to assess the bladder, urethra, postoperative
anatomy and micturition in order to determine the presence or absence of
abnormalities.

Indications:

Vesicoureteric reflux

Abnormalities of bladder

Stress incontinence
Indications…..
• Hydronephrosis and/or hydroureter
• Bladder outlet obstruction
• Hematuria
• Urinary incontinence
• Neurogenic dysfunction of the bladder
• Congenital anomalies of the genitourinary tract
• Postoperative evaluation of the urinary tract
Micturating cystourethrogram reveals
marked dilatation of the prostatic
portion of the urethra consistent
with posterior urethral valves. 
Ascending urethrography in the male

Indications
Strictures
Urethral tears
Congenital abnormalities
Peri urethral or prostatic abscess
Fistulae or false passages
Ascending Urethrography
When contrast medium is infused through the urethral orifice with the
use of a catheter, the test is called 'Ascending Urethrogram'
Indications
• Strictures
• Urethral tears
• Congenital abnormalities
• Peri urethral or prostatic abscess
• Fistulae or false passages
Computed Tomography(CT)
• Suspected urolithiasis (Location of the stone, size, and secondary signs of renal tract obstruction
can then be used to gauge the likelihood of passage and guide further management)

• Assess complications of obstruction

• Hematuria (typically in conjunction with a CT-IVU)

• Flank pain

• Suspected mass

• Abnormal location

• Intervention guided procedures

CTA

• Rapid contrast injection with helical CT during arterial phase

• Soft tissue and bone reduced

• 3D reconstruction

Indications
• Renal artery stenosis
• Exclude other renal vascular abnormalities
• Preparation for donor nephrectomy
Contrast enhanced CT through kidney in nephrogram phase
Contrast enhanced CT 3D coronal reconstruction
showing cobra head deformity Coronal IV contrast CT abdomen showing
right renal agenesis
Contrasted CT axial images showing abnormal right kidney but no left kidney , later found in the pelvis
 MRI
• No iodinated contrast (gadolinium)
• Soft tissue resolution better than CT
Indications
• To evaluate kidneys when CM is contraindicated. (cortex bright on T1)
• Staging of malignancies (T2)
• Urethral- intraluminal coil to evaluate stricture/diverticulum
• MRU- to id obstruction- ureters/collecting system- T2- fluid bright,
tissue dark (can’t distinguish stone from clot/tumor)

• Contraindications
Metal implants that are magnetic (take proper history!!)
??Claustrophobia
Coronal T1 image
Magnetic resonance imaging: T2-weighted
sequence demonstrating the extent of
bilateral pelviureteric junction obstruction,
nondilation of ureters, and normal bladder,
confirming the obstruction to be at the
renal pelvis on both sides
Coronal MRI venogram
 Nuclear scintigrapghy

Nuclear medicine in vivo is the practice of utilizing small amounts

of radioactive substances to diagnose, monitor and treat
disease.

 Static renal scan

 Dynamic renal scan
 Dynamic renal studies are able to assess the perfusion to the kidneys,
extraction of tracer from the blood and excretion of the tracer through the
collecting system. 
Dynamic scan Indications

• Evaluation of mechanical renal tract obstruction (including

pelviureteric and vesicoureteric junction obstruction)

• Perfusional abnormalities

• Investigation of declining renal function

• Assessment of renal transplants

 Static Renal Scan

 The Radiopharmaceutical is Tc99m- DMSA.( Dimercaptosuccinic acid)

 It is given intravenously. Image is obtained in 2 hours.

 It binds sufficiently to the renal tubules and lasts for several hours. This will permit
good renal cortical imaging.

 The main clinical application of DMSA scan is in acute pyelonephritis in children,

 evaluation of renal scarring (e.g. reflux nephropathy, prior trauma
QUESTIONS???
References
• Clark’s Positioning in Radiography
• WHO manual of diagnostic ultrasound vol 1
• Grainger and Allison’s Diagnostic Radiology
• Kidneynet.com
• Radiopedia