Bladder Anatomy

8/6/2019 Bladder Anatomy

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Question:Question:

Describe the radiological anatomy of the male urinaryDescribe the radiological anatomy of the male urinary

bladder. Describe in detail the techniques forbladder. Describe in detail the techniques fordemonstrating the organ.demonstrating the organ.

AnswerAnswer

-- Introduction/GrossIntroduction/Gross-- Imaging Modalities:Imaging Modalities:

** CystogramCystogram** Pelvic scanPelvic scan

** CT scanCT scan** MRIMRI** Plain radiographyPlain radiography** AngiographyAngiography

** RNIRNI


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-- Introduction/GrossIntroduction/Gross

TheThe urinaryurinary bladderbladder isis situatedsituated within within thethe

pelvispelvis.. ItIt isis anan extraperitonealextraperitoneal pyramidalpyramidalmuscularmuscular organorgan whenwhen emptyempty butbut asas itit fills,fills,itit becomesbecomes ovoidovoid andand risesrises intointo thethe

abdomenabdomen strippingstripping thethe looseloose peritoneumperitoneumoffoff thethe anterioranterior abdominalabdominal wallwall..


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ItIt hashas aa base/posteriorbase/posterior surface,surface, anan apex,apex, aa

superiorsuperior andand twotwo ininffereriiolateralolateral surfacessurfaces.. TheTheuretersureters enterenter thethe posterolateralposterolateral anglesangles andand thetheurethraurethra leavesleaves inferiorlyinferiorly atat thethe narrownarrow neckneck

whichwhich isis surroundedsurrounded byby thethe involuntaryinvoluntary internalinternal

urethralurethral sphinctersphincter.. TheThe trigonetrigone isis thethe triangulartriangularinnerinner wallwall ofof thethe bladderbladder betweenbetween thethe uretericureteric

andand thethe urethralurethral orifices,orifices, thisthis partpart ofof thethe wallwall isis

smoothsmooth whilewhile thethe remainderremainder ofof thethe bladderbladder wallwallisis coarselycoarsely trabeculatedtrabeculated byby crisiscrisis-- crosscross musclemusclefibresfibres..


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The The perivesicalperivesical fatfat surroundssurrounds thethe bladderbladder..

The The bladderbladder isis relativelyrelatively fixedfixed inferiorlyinferiorly viavia

condensationscondensations ofof pelvicpelvic fascia,fascia, whichwhich attachattach itit toto

thethe backback ofof thethe pubis,pubis, thethe laterallateral wallswalls ofof thethe

pelvispelvis andand thethe rectumrectum.. TheThe obturatorobturator internusinternus

musclemuscle isis anterolateralanterolateral andand thethe levatorlevator aniani

musclemuscle isis inferolateralinferolateral toto thisthis..


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TheThe vasavasa deferentiadeferentia andand seminalseminal vesiclevesicleareare posteriorposterior toto thethe bladderbladder soso alsoalso isis

thethe culcul--dede--sacsac andand rectumrectum.. TheThebladderbladder neckneck isis fusedfused withwith thethe prostateprostate..


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ImagingImaging ModalitiesModalities

-- CystogramCystogramItIt localiseslocalises thethe bladderbladder within within thethe pelvispelvis

cystogramcystogram isis usedused toto assessassess thethe integrityintegrity ofof

bladderbladder followingfollowing traumatrauma oror surgerysurgery oror totoinvestigateinvestigate fistulasfistulas involvinginvolving thethe bladderbladder.. TheThe

bladderbladder isis filledfilled withwith contrastcontrast whichwhich appearappear asasroundedrounded radioradio--opacityopacity andand demonstratesdemonstrates thethe

corrugationcorrugation ofof thethe bladderbladder wallwall especiallyespecially whenwhennotnot wellwell distendeddistended..


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TheThe bladderbladder wallwall isis seenseen asas thethe softsoft tissuetissue

densitydensity structurestructure separatingseparating thethe perivesicalperivesicalfatfat andand thethe intravesicalintravesical contrastcontrast

IrregularIrregular collectioncollection ofof contrastcontrast maymay bebe

trappedtrapped betweenbetween musclesmuscles fibresfibres afteraftermicturitionmicturition thethe prostateprostate maymay protrudeprotrude upupintointo thethe bladderbladder basebase toto produceproduce aa prostaticprostatic

impressionimpression thethe fullfull bladderbladder outlineoutline shouldshouldbebe smoothsmooth andand regularregular


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PelvicPelvic USUS

UsUs isis bestbest forfor demonstratingdemonstrating thethe internalinternal

anatomyanatomy.. RoutineRoutine examinationexamination ofof thethe bladderbladderrequiresrequires itit toto bebe moderatelymoderately fullfull.. The The normalnormalbladderbladder hashas aa triangletriangle shapeshape inin thethe sagittalsagittal planeplane

andand thatthat ofof aa squaresquare withwith thethe cornerscorners roundedroundedoffoff inin thethe transversetransverse planeplane.. The The normalnormal wallwallthicknessthickness isis 22--33mmmm when when thethe bladderbladder isis

moderatelymoderately fullfull.. The The bladderbladder wall wall isis slightlyslightly

echogenicechogenic whichwhich contrastscontrasts againstagainst thethe ananechoicechoicurineurine withinwithin itit thisthis beautifullybeautifully demonstratingdemonstrating thetheinternalinternal anatomyanatomy..


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ItIt isis alsoalso possiblepossible toto visualizevisualize thethe lowerlower ureterureter inin

youngyoung childrenchildren andand thethe useuse ofof colourcolour DopplerDopplerallowsallows identificationidentification ofof ureteriuretericc jetjet

Relations,Relations, Anterior, Anterior, Anterior Anterior abdominalabdominal wallwall

(medium(medium levellevel echo),echo), PubicPubic bonebone (poster(posterioiorr

acousticacoustic shadow)shadow)

PosteriorPosterior:: RectumRectum (poorly(poorly demonstrated)demonstrated)

LateralLateral:: ObturatorObturator internusinternus musclemuscle (medium(medium

levellevel echo),echo), levatorlevator onon musclemuscle (medium(medium levellevelecho)echo)


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SuperiorSuperior:: LoopsLoops ofof bowelbowel (not(not properlyproperly

demonstrateddemonstrated becausebecause ofof bowelbowel gasgas;;

evidenceevidence ofof peristalsis)peristalsis)

InferiorInferior::ProstateProstate (lobuted(lobuted outout line,line,

homogenoushomogenous mediummedium levellevel echo)echo)


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CTCT

TheThe bladderbladder isis bestbest appreciatedappreciated whenwhen filledfilled withwith

urineurine oror contrastcontrast andand itit isis seenseen asas aa thinthin walledwalled

structurestructure betweenbetween thethe urineurine andand thethe periversicalperiversicalfatfat thethe wallwall shouldshould notnot exceedexceed 44--55mmmm fatfat.. TheThe

appearanceappearance ofof thethe urineurine dependsdepends onon thethepresencepresence oror absenceabsence ofof contrast,contrast, whenwhen presentpresent itit

hyperdensehyperdense butbut whenwhen absentabsent itit isis hypodensehypodense


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TheThe seminarseminar vesiclesvesicles whichwhich lielie onon thethe posteriorposterior

wallwall ofof thethe bladderbladder appearappear asas tubulartubular structurestructurerelatedrelated toto thethe superiorsuperior aspectaspect ofof thethe prostateprostateandand posteriorposterior toto thethe lowerlower bladderbladder butbut anterioranterior

toto thethe rectumrectum.. ThereThere isis aa fatfat planeplane betweenbetween thethe

seminalseminal vesicles vesicles andand thethe bladderbladder.. InIn aasuprapubicsuprapubic axialaxial slice,slice, thethe various various structuresstructures

fromfrom anterioranterior toto posteriorposterior areare


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ii Anterior abdominal wall [(subcut. fat (hypodence);Anterior abdominal wall [(subcut. fat (hypodence);rectus abdominic (isodense)]rectus abdominic (isodense)]

iiii Urinary BladderUrinary Bladder

iiiiii Seminal vesicle (isodense)Seminal vesicle (isodense)

iviv Rectum (gas + faeces + contrast => mixed density)Rectum (gas + faeces + contrast => mixed density)

vv Sacrum (hyperdense)Sacrum (hyperdense)vi vi Gluteus maximus (isodense)Gluteus maximus (isodense)

viivii Subcuit fat (hypodense)Subcuit fat (hypodense)

Psoas muscles are demonstrated laterally at higher levelPsoas muscles are demonstrated laterally at higher levelbut obturator internus muscle at lower levelsbut obturator internus muscle at lower levels


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The The bladderbladder wall wall enhancesenhances intensityintensity with with IVIV

gadoliniumgadolinium..OnOn TT22 WW11 thethe seminalseminal vesiclevesicle isis hyperintensehyperintense butbut

itit hashas intermediateintermediate intensityintensity onon TT11 WW11..

NBNB-- They They lowlow intensityintensity bladderbladder wall wall maymay bebeobscuredobscured byby thethe chemicalchemical shiftshift artifactartifact thatthat resultresult

fromfrom thethe differencedifference inin resonanceresonance frequencyfrequency

betweenbetween fatfat andand waterwater protonproton


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PlainPlain RadiographRadiograph..

The The bladderbladder maymay bebe identifiedidentified onon plaplaiinn ffililmmespeciallyespecially whenwhen fullfull.. ItIt isis seenseen asas aa roundround softsofttissuetissue densitydensity surroundedsurrounded byby lucentlucent lineline ofof

perivesicalperivesical fatfat.. ItIt shouldshould bebe smoothsmooth andandsymmetricalsymmetrical..

AngAngiiographyography

This This demonstratesdemonstrates thethe superiorsuperior andand interiorinteriorvesicalvesical arteryartery originatingoriginating fromfrom thethe internalinternal iliaciliac

arteryartery asas radioradio opaqueopaque lineslines


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RNI (Radionuclide Cystography)RNI (Radionuclide Cystography)

AgentAgent Non absorbable radiotracer e.g. 99Non absorbable radiotracer e.g. 99MMTCTC--

MAG3 (Mercaptoacetylglycine)MAG3 (Mercaptoacetylglycine)


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B.B.Describe in detail the technique forDescribe in detail the technique for

demonstrating the urinary bladder.demonstrating the urinary bladder.-- OutlineOutline

IndicationsIndications

C.IC.IPatient preparationPatient preparation

Equipment/materialsEquipment/materials

Techniques proper descriptionTechniques proper description

After careAfter care

ComplicationComplication


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(1)(1) CystogramCystogram

IndicationsIndications(i)(i) Abnormalities of the bladder e.g. fistulaAbnormalities of the bladder e.g. fistula

massmass

(ii)(ii) After bladder traumaAfter bladder trauma(iii)(iii) After bladder surgeryAfter bladder surgery

(iv)(iv) HaematuriaHaematuria

(v)(v) Difficulty in micturitionDifficulty in micturition


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C.IC.I

Acute urinary tract infectionAcute urinary tract infection Patient preparationPatient preparation

(a)(a) The patient micturates prior to the examThe patient micturates prior to the exam

(b)(b) Patient is fasted for about 6hrs prior toPatient is fasted for about 6hrs prior toexamexam

Contrast mediumContrast medium

HOCM or LOCMHOCM or LOCM


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Equipment/MaterialsEquipment/Materials

(1)(1) Fluoroscopy unit with spot film deviceFluoroscopy unit with spot film device(2)(2) Jaques or foley catheter. In small infants a fineJaques or foley catheter. In small infants a fine

(5(5--7F) feeding tube.7F) feeding tube.

(3)(3) Casettee and filmCasettee and film(4)(4) Emergency trayEmergency tray

(5)(5) Sunctioning machineSunctioning machine

Preliminary filmPreliminary filmConed view of the bladderConed view of the bladder


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TechniqueTechnique

(a)(a) The The patientpatient lieslies supinesupine onon thethe xx--rayray tabletable..

UsingUsing asepticaseptic techniquetechnique aa catheter,catheter, lubricatedlubricatedwithwith HibitaneHibitane 00..0505%% inin glycerine,glycerine, isis introducedintroducedintointo thethe bladderbladder.. ResidualResidual urineurine isis draineddrained..

ContrastContrast mediummedium isis slowlyslowly drippeddripped inin aa bladderbladderfillingfilling isis observedobserved byby intermittentintermittent fluoroscopyfluoroscopy..ItIt isis importantimportant thatthat initialinitial fillingfilling isis monitoredmonitored

byby fluoroscopyfluoroscopy inin casecase thethe cathetercatheter isis inin thethe

distaldistal ureterureter (Therapy(Therapy mimickingmimicking vesicouretericvesicouretericreflux)reflux) oror vaginavagina..


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(b)(b) Any reflux is recorded on spot filmsAny reflux is recorded on spot films

(c)(c) The catheter should not be removed untilThe catheter should not be removed untilthe radiologist is convinced that no morethe radiologist is convinced that no morecontrast medium will drip into thecontrast medium will drip into the

bladder.bladder.

(d)(d) Film are taken in AP, lateral and oblique.Film are taken in AP, lateral and oblique.


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AftercareAftercare

(A)(A) NoNo specialspecial aftercareaftercare isis necessary,necessary, butbut patientspatientsandand parentsparents ofof childrenchildren shouldshould bebe warnedwarned thatthat

dysuria,dysuria, possiblypossibly leadsleads toto retentionretention ofof urine,urine,

maymay rarelyrarely bebe experiencedexperienced.. InIn suchsuch casescases aasimplesimple analgesicanalgesic isis helpfulhelpful andand childrenchildren maymay bebe

helpedhelped byby allowingallowing toto micturatemicturate inin aa warmwarmbothboth..

(B)(B) Antibiotics Antibiotics shouldshould bebe prescribedprescribed ifif refluxreflux isis

demonstrateddemonstrated..


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CXCX

(A)(A) Due to the contrast mediumDue to the contrast medium Adverse rxn may result from absoprtion ofAdverse rxn may result from absoprtion of

contrast medium by the bladder mucosacontrast medium by the bladder mucosa Contrast mediumContrast medium--induced cystitisinduced cystitis

(B)(B) Due to the techniqueDue to the technique

(a)(a) Acute U.T.IAcute U.T.I

(b)(b) Catheter traumaCatheter trauma--may producemay producedysuria,dysuria, frequency, haematuriafrequency, haematuria andandurinary retention.urinary retention.


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(c)(c) Complications of bladder filling e.g.Complications of bladder filling e.g.perforation from overdistentionperforation from overdistention preventedprevented

by using a nonby using a non--retainingretaining catheter e.g. Jaques.catheter e.g. Jaques.(d)(d) Retention of a foley catheterRetention of a foley catheter

(2)(2) U/SU/S** IndicationsIndications

(i)(i) HaematuriaHaematuria

(ii)(ii) Bladder outlet obstructionBladder outlet obstruction(iii)(iii) Bladder tumour and other pelvic massesBladder tumour and other pelvic masses

(iv)(iv) Post traumaPost trauma


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C.IC.I

NoneNone Patient preparationPatient preparation

Full bladderFull bladder

Equipment/materialEquipment/material(a)(a) 3.53.5 SMHz transducerSMHz transducer

(b)(b) U/S machineU/S machine

(c)(c) Electrolyte/Ultrasound gelElectrolyte/Ultrasound gel


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TechniqueTechnique

TheThe patientpatient lieslies supinesupine andand thethe bladderbladder isisscannedscanned suprapublicallysuprapublically inin transversetransverse andandlongitudinallongitudinal planesplanes.. MeasurementMeasurement takentaken ofof

threethree diametersdiameters beforebefore andand afteraftermicturitionmicturition enableenable anan approxapprox.. volumevolume toto bebecalculatedcalculated..


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After CareAfter Care

NoneNone CxCx

NoneNone

3)Pelvic CT3)Pelvic CT IndicationsIndications

as already statedas already stated C.IC.I

(i)(i) rxn to contrast mediumrxn to contrast medium

(ii)(ii) PregnancyPregnancy


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Patient preparationPatient preparation

-- Bowel preparationBowel preparation-- Fast in the day of examFast in the day of exam

-- Give 500ml dilute contrast agent orallyGive 500ml dilute contrast agent orally the eveningthe eveningpreceding exampreceding exam

Equipment/MaterialsEquipment/Materials

(a)(a) CT MachineCT Machine

(b)(b) CT PrinterCT Printer

(c)(c) Contrast agentsContrast agents

(d)(d) Mechanical injectorMechanical injector

(e)(e) Emergency trayEmergency tray

(f)(f)Suctioning machineSuctioning machine


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contrastcontrast mediummedium isis routinelyroutinely givengiven byby

mechanicalmechanical injectinject oror atat 22 toto 33ml/secml/sec forfor aa totaltotaldosedose ofof 150150mlml ofof 6060%% contrastcontrast agentagent.. LieLie patientpatientsupinesupine angulateangulate youryour gantrygantry.. ScanningScanning throughthrough

thethe pelvispelvis isis performedperformed withwith contiguouscontiguous 22--55mmmm

thickthick slicesslices.. WeWe routinelyroutinely scanscan thethe abdomenabdomen asaswellwell inin patientspatients withwith knownknown oror suspectedsuspected pelvicpelvic

malignmalign..

NN..BB::A A contrastcontrast materialmaterial enemaenema ( (200200ml)ml)occasionallyoccasionally maymay bebe necessarynecessary toto expediteexpediteopacificationopacification ofof RectosigmoidRectosigmoid


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NoneNone CxCx

Rxn to contrastRxn to contrast

4)MRI4)MRI IndicationIndication

As previously statedAs previously stated

C.IC.IMetallic prosthesis or metals in the bodyMetallic prosthesis or metals in the bodye.g. bullet.e.g. bullet.


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Patient preparationPatient preparation

No special preparationNo special preparation

Equipment/MaterialsE

quipment/Materials(i)(i) M.R. machineM.R. machine

(ii)(ii) GadoliniumGadolinium

(iii)(iii) M.R. printerM.R. printer


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TechniqueTechnique

PatientPatient areare usuallyusually examinedexamined supinesupine duringduringshallowshallow respiration,respiration, withwith thethe urinaryurinary bladderbladder atatleastleast halfhalf fullfull beforebefore thethe studystudy isis begunbegun..

BothBoth TT11--W W (TR=(TR=300300--500500msec,msec, TE=TE=1515

3535msec)msec) andand TT22WW (TR(TR == 11,,500500 22,,100100 msec,msec,TE TE == 9090--120120 msec)msec) spinspin echoecho sequencessequences arearenecessarynecessary forfor completecomplete examinationexamination ofof thethepelvispelvis.. TT

22

WW11 provideprovide clearclear delineationdelineation ofof thethebladderbladder wall,wall, asas wellwell asas internalinternal morphologymorphology ofofthethe prostateprostate glandgland andand thethe uterusuterus..


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TransaxialTransaxial imagesimages areare obtainedobtained inin everyevery casecase;;

additionaladditional views views areare performedperformed inin eithereither thethecoronalcoronal oror sagittalsagittal planeplane.. CoronalCoronal imagesimages areare

usefuluseful forfor evaluatingevaluating thethe seminalseminal vesicle vesicle andand

bladderbladder neoplasmsneoplasms thatthat involveinvolve thethe laterallateral wallwallwhilewhile sagittalsagittal imagesimages areare necessarynecessary isis casescases inin

whichwhich aa bladderbladder neoplasmneoplasm isis locatedlocated alongalong thetheanterioranterior oror posteriorposterior wallwall..


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NoneNone

CxCx

NoneNone

Bladder Anatomy

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