GU Sonography of the Urinary Bladder, Scrotum & Prostate. Bladder Capacity. Bladder Wall. Bladder Diverticulum. Urachal Remnant

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1 GU Sonography of the Urinary Bladder, Scrotum & Prostate Bladder Capacity Maximum: cc Post void: < 5-12cc Volume = (π/6) x L x W x H Ethan J. Halpern, MD Director, Jefferson Prostate Diagnostic Center Thomas Jefferson University Bladder Post-void residual Outlet obstruction Neurogenic bladder Bladder Wall Normal bladder wall Smooth Thickness < 5mm Thickened wall Outlet obstruction» Diffuse thickening» Trabeculated bladder Neoplasm» Irregular, masslike Bladder Diverticulum Nidus for infection Early spread of malignancy Urachal Remnant Nidus for infection AdenoCA of bladder 1 1

2 Ureterocele Saccular out-pouching of the distal ureter into the urinary bladder Obstruction infection Ectopic ureteroceles are associated with the upper pole moiety of a duplex system obstructed upper pole & refluxing lower pole Bladder Stones UVJ Stones Ureteral Jet Presence can exclude obstruction 4-6 jets / minute Bladder Mass: Hematoma Bladder Mass: TCC Diffuse wall thickening Focal endophytic mass 2 2

3 Left Sided Bladder TCC Surgical Scar of Bladder sagittal Transverse at dome of bladder Bladder Masses Normal Testicle Stone Clot Tumor Scar 3-5cm long axis 2-4cm short axis Ovoid shape Smooth contour Surrounded anteriorly and laterally by tunica vaginalis Compare both testicles with a view through midline raphe Symmetric appearance Homogeneous echogenicity Testicular Echogenicity Testicular Anatomy Seminiferous tubules Tunica albuginea Radiating septa lobules Mediastinum testis Tubules join efferent ductules Epididymis Vas deferens 3 3

4 Linear echogenic appearance Radiating septa from tunica albuginea converge in mediastinum Seminiferous tubules rete testis Mediastinum Testis Epidydimal Anatomy Head, body, tail Length: 6-7cm Head: 1-1.5cm Isoechoic to testicle, or slightly more echogenic than testicle Appendix Testis & Appendix Epididymis Embryological remnants Toward upper pole of testis Scrotal Pearl Calcification within layers of the tunica vaginalis Inflammation of the tunica vaginalis May represent a remnant of appendix testis or appendix epididymis that has torsed Associated with hydroceles Dilated Rete Testis Parallel tubules in mediastinum Do not confuse with a mass Normal testicular flow Symmetric flow to both testicles Normal branching pattern Little or no flow in epididymis 4 4

5 Hydrocele Serous fluid between the layers of the tunica vaginalis No fluid posterior to testis/epididymis in the bare area» Tunica does not surround testicle at its attachment to the posterior scrotum Congenital» Incomplete closure of processus vaginalis» Resolve by 18 months Acquired» Idiopathic» Infections, infarction, trauma» Torsion, neoplasm Epididymitis Most common cause of acute scrotum Thickened epididymis with increased flow Tenderness on side of increased flow Usually secondary to lower UTI Orchitis Epididymo-Orchitis Tenderness on side of increased flow Heterogeneous gray scale Markedly increased flow Epididymo-orchitis orchitis Increased flow in testis and epididymis Tenderness on side of increased flow Scrotal Abscess Scrotal Edema normal testicle 5 5

6 Scrotal Sarcoidosis Scotal involvement is rare (1%) Epididymis more likely to be involved than testis Small hypoechoic masses may calcify Testicular Torsion Acute scrotum 80% epididymitis / orchitis Testicular torsion must find early to save the testicle Trauma Intra-vaginal torsion bell-clapper deformity» Tunica vaginalis completely surrounds the testicle» Bilateral in 50% of patients Occurs around puberty Extra-vaginal torsion neonates Testicular Torsion with Infarct Torsion: US grayscale Heterogeneous Enlarged Hemorrhage atrophy Doppler: Torsion vs. epididymitis Epididymitis increased flow on side of tenderness Torsion decreased flow on side of tenderness Testicular Contusion p-traumap Testicular Trauma & Rupture Irregular, heterogeneous testis Protrusion of testicular contents Difficult to distinguish from blood Doppler identifies testicular tissue Salvage rate of 90% if surgery is performed within 72 hours Tunica albuginea cysts Small, peripheral Multiple Parenchymal cysts Near mediastinum Associated with epididymal cysts Up to 2.0cm in size Testicular Cysts 6 6

7 Calcification along Tunica Epididymal Cyst vs. Spermatocele Two types of cysts Both may be related to prior trauma or epididymitis Cyst with clear fluid» Anywhere in epididymis Spermatocele» thick milky fluid» Usually in epidydimal head» Incidental in older men» Multiple in 30% Dilated Rete Testis with Spermatocele Dilatation/cysts in these two different parts of the ductal system are often found in association Varicocele Tortuous veins within pampiniform plexus around spermatic cord and epididymis >2-3mm Incompetent valves in testicular veins More common on left side, often bilateral Associated with infertility May be painful Varicocele Intratesticular Varicocele Intratesticular and extratesticular varicoceles are often found in association 7 7

8 Undescended Testicle Inguinal Hernia US appearance small and hypoechoic (like a node) Present in 3.5% of newborns Only 1% persist at 1-year Majority in inguinal canal Associated with infertility and increased risk of testicular cancer usually seminoma Real time US examination Watch for herniation Characterize hernia tissue Val salva maneuver or ask patient to stand up Microlithiasis May be associated with an increased risk of testicular neoplasm controversial Present in 1-5% of population Classic microlithiasis > 5ubo s Risk increases with: number of calcifications Bilaterality infertility Recommend US follow up Microlithiasis with Mass Doppler flow does not help to characterize the type of tumor mass Doppler may help to identify an isoechoic mass Flow tends to be present in masses over 1.5cm Intratesticular vs. Extratesticular masses Most solid intratesticular lesions are malignant (90%) A minority of paratesticular tumors are malignant (16%) Most are from spermatic cord» Lipomas» Mixed mesodermal tumors»fibromas» Sarcomas are most common malignant tumors Intratesticular masses Germ cell tumors (most common) Seminoma (40%)» Usually well marginated» Hypoechoic» Not cystic or calcified Embryonal cell (20-25%)» More aggressive tumor» Inhomogeneous» Poorly marginated» Invades tunica» Cystic areas & calcification Teratomas (25-30%)» Mixture: teratocarcinoma» Inhomogeneous, cystic, calcified Choriocarcinoma (1%) seminoma 8 8

9 Stromal Tumors 5% of all testicular tumors Multiple cell types Leydig (most common)» 15% are symptomatic from androgen production Theca cell Granulosa cell Lutein cell Sertoli cell Fibroblast Hypoechoic foci when small Larger tumor are complex Epididymal Tumors 10 times less frequent than testicular tumors Benign adenomatoid tumor Most common (30% of extratesticular masses) Commonly in tail of epididymis Treated with local excision Leiomyomas (6%) Papillary cystadenoma (4%) Testicular Mass - recurrent lymphoma s/p chemotherapy Scrotal Mesothelioma Gross Anatomy of the Prostate Prostate is under the urinary bladder Seminal vesicles project superiorly, behind the bladder Prostate apex situated behind symphysis pubis Transrectal Ultrasound 6-10 MHz transducer Probe directly on peripheral zone Apex well visualized Anterior fibromuscular zone obscured by BPH Resolution / lesion detection - better 9 9

10 Prostate Ultrasound: Objectives Size of gland Overall echotexture Focal lesions Seminal vesicles Vasa Deferentia Ejaculatory ducts Periprostatic fat Prostate Volume Prolate Ellipse V = (π/6) x L x W x H Weight Volume Normal < 25cc Prostatic Echotexture: : Normal Prostatic Echotexture: : Abnormal Outer gland: isoto hyper-echoic Inner gland: less echogenic Prostatitis Infiltrating Cancer Prostate Imaging: Transverse Lateral gland margin Neurovascular bundle Symmetry Seminal vesicles Biopsy Base and apex Urethra Prostate Imaging - Sagittal Ejaculatory ducts Seminal vesicles Confirm a lesion Biopsy 10 10

11 Neurovascular Bundle Prostatic urethra Angles 35º at verumontanum Ejaculatory ducts empty at colliculus seminalis Preprostatic (internal) Sphincter Internal sphinctor Ends above veru Smooth muscle fibers from bladder Seminal Vesicles Size 27 x 15 mm - Symmetric Taper to base of prostate Vas Deferens Ductal Ectasia Ampullary portion Medial to SV 11 11

12 Seminal Vesicle Cyst Mullerian Duct Cyst Ejaculatory Duct Cyst Prostate Anatomy: Zonal Inner Gland Periurethral tissue Transition zone Outer Gland Central zone Peripheral zone Anterior fibromuscular stroma Surgical Capsule Separates inner gland & outer gland Corpora amylacea deposition Inner vs. Outer Gland Periurethral tissue Transition zone Central zone Peripheral zone BPH Minority of cancers Prostatitis Cancer 12 12

13 Poor bladder emptying Urinary retention Detrusor instability Urinary tract infection Hematuria Renal insufficiency Diagnosis: Clinical BPH Digital rectal exam & ultrasound No precise cutoff value for BPH Marked BPH (median lobe) Classification of Prostatitis Acute & Chronic bacterial (5%) Nonbacterial Prostatodynia Multiple Prostate Abscesses Prostate Cancer: Conventional Ultrasound Diagnostic Criteria Contour Echo-Texture Doppler Flow Gleason 6 with rectal wall invasion on right Gray Scale Features of Prostate Cancer Usually isoechoic - hypoechoic Rarely echogenic Focal contour bulge size cellular differentiation fibrotic reaction Gleason 9 &

14 Doppler of Prostate Cancer Increased flow to the outer gland focally increased flow surrounding increased flow diffusely increased flow Increase sensitivity for detection of cancer Prognostic indicator Doppler Detection of Prostate Cancer Hypervascularity in a Gleason 7 cancer Cancer Along Left Side of Gland A map of tissue stiffness Changes in ultrasound RF speckle pattern with external pressure Speckle displacement depends upon tissue stiffness elastogram Elastography Hypoechoic Nodule Gleason 7 Hard Mass Gleason 9 &

15 Ultrasound Contrast Agents Enhanced acoustic reflectivity Non-linear frequency response: f xmt = f 0 f 0 2f 0 f rcv = f 0 and 2f 0 f 0 Visualization of Neovascularity Intermittent Imaging - Low MI Increased overall enhancement Contrast passes into distal circulation Size selective vascular enhancement longer delay -> smaller vessels Continuous vs. Intermittent Imaging Continuous vs. Intermittent Imaging Continuous Intermittent Gleason 9 lesion left base Continuous Intermittent Gleason 6 lesion left base Visualization of Neovascularity Left Mid: Gleason 6 Short interscan delay flow rate imaging Long interscan delay vascular volume imaging Low MI imaging less contrast destruction Low MI (0.1) continuous Gleason 7 right base Baseline grayscale Baseline color Baseline power 15 15

16 The Future Better Doppler techniques for cancer detection Identification of cancer tissue with elastography Selective enhancement of neovessels with contrast & intermittent imaging of cancers Improved technique will select patients for biopsy, and limit the number of biopsy sites 16 16