UROGENITAL

Dr. Achmad Bunyamin Sp.Rad (K)

Department of Radiology, Faculty of Medicine

Padjadjaran University-Hasan Sadikin Hospital
Bandung

URINARY TRACT
ANATOMY
KIDNEY :
I. Normal Size :
Right kidney smaller than left
3 3,5 lumbar vertebral body
Discrepancies of 1,5 cm or greater :
Positive factor in hypertension

II. Normal Position

Retroperitoneal
Upper poles 1 cm closer to midline
Recumbent : Th 12 L3
Max. excursion 5 cm or 1,5 vertebral
body on erect position

III. Internal Architecture

- External cortex : 12 mm thickness
* Renal corpuscle
* Convoluted tubules
* Blood vessels
- Internal Medulla :
* 8 renal pyramids
* Separated by columns of Bertini
* Interlobar, arcuate, and interlobular artery
- Renal Pelvis :

ULTRASOUND OF THE KIDNEY

RLL
SP
RK

Right Kidney

LK

Left Kidney

LK

Left Kidney

URETER
About

25 cm long
Retroperitoneal
In pelvic : Convex posteriorly and laterally
At ischial spine bend forward and medially
> lower portion of bladder
Diameter variable : more or less 6 mm
Three normal constriction :
- Ureteropelvic junction
- Cross external iliac artery
- Uretero vesical junction

URINARY BLADDER
* Lies in pelvic space
* Anterior : Pubic symphysis
* Posterior between bladder and rectum :
- Male : ductus deferens and seminal vesicles
- Female : Uterus and vagina

URETHRA
- Female

- Male

: Short, 4 cm, diameter 6 mm

: Prostatic portion : elongated, 3 cm
Membranous portion
Bulbous portion
Cavernous portion : diameter 6 mm

BLOOD SUPPLY
Renal artery : 1

st

lumbal vertebrae > Dorsal

Ventral
Renal veins : Parallel renal artery

RENAL FUNCTIONS :
Blood

plasma filtration
Selective tubular reabsorption
Tubular synthesis and excretion
Acid base regulation
Fluid volume regulation
Maintenance normal blood regulation
Erythropoiesis

INTRAVENOUS UROGRAPHY
Indications :
1. Elevated creatinin or BUN
2. Flank Pain
3. Pyuria
4. Microscopic / gross hematuria
5. Hypertension
6. Proteinuria
7. Dribbling
8. Frequency
9. Dysuria

DIAGNOSIS
1. Neoplasia
2. Urinary tract obstruction
3. Inflammation
4. Lithiasis
5. Cystic disease
6. Hypertension
PREPARATION
- Clear liquid diet
- Fasting after midnight
- Bowel cleansing
SKIN TEST OF CONTRAST MEDIUM
PLAIN FILM ABDOMEN
COMPRESSED OF ABDOMEN
(by rubber bag / tennis ball)

NORMAL UROGRAM :

Dosage : - 1 cc / pound of 50 % diatrizoate

for patient less than 100 pound BW
- 100 200 pound BW : 100 cc
- More than 200 pound : 150 cc
Nephrographic phase : 1 minute
- Contrast in vascular and renal tubules
- Hypervascular mass : isodens
- Hypovascular, abcess and cyst : luscent

Pelvocalyceal opacification : 2,5 - 3 minute

Delayed opacification :
- overhydration
- decreased renal function
- hypotension
- small contrast volume

FILMING SEQUENCE
1 minute : Nephrogram phase
Ureteral compression
5 minute : collecting system
15 30 minute : ureter
60 minute : bladder
Post voiding > - Passage of contrast agent
- Simptom of lower urinary tract
- Suspected stone
No ureteral compression :
- Suspected stone
- Acute abdomen
- Following abdominal surgery
- Large abdominal mass
- Aortic aneurysm

BNO IVP

5 MENIT

15 MENIT

30 MENIT

FULL BLAST

POST
VOIDING

BNO IVP

5 MENIT

15 MENIT

30 MENIT

FULL BLAST

POST
VOIDING

RETROGRADE UROGRAPHY

Preparation is the same as for intravenous

urography
Catheters introduced into ureters by cystoscopic
manipulation
Tip of catheter introduce into renal pelvis
5 10 ml opaque medium injected through
ureteral catheter to evaluate pyelum ( pyelogram)
Withdraw catheter : to visualization ureter

Retrograde pyelography on left collecting system

shows moderate hydronephrosis and hydroureter with a
tortuous change of ureter. The arrows indicate the site
compressed by the prosthetic reservoir.

RETROGRADE URETRHO CYSTOGRAPHY

150 - 200 ml contrast agent injected into

distal urethra by insertion small catheter to
fill urethra and then to fill bladder
Position postero-anterior, left anterior
oblique and right anterior oblique
Post voiding study demonstrating : bladder
diverticula, filling defect ( neoplasm),
vesico-ureteral reflux

URETHRA :
Stricture : - Post traumatic
- Post intrumentation
- Post inflammation

Figure 1. Retrograde urethrogram shows a focal smooth indentation (arrow) on the anterior
aspect of the proximal bulbous urethra by the compressor nudae muscle

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 2a. Affect of patient positioning on the appearance of the urethra during retrograde
urethrography

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 2b. Affect of patient positioning on the appearance of the urethra during retrograde
urethrography

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 3. Cowper gland and duct

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 4a. Intact but stretched posterior urethra following blunt trauma (type I urethral injury)

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 4b. Intact but stretched posterior urethra following blunt trauma (type I urethral injury)

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 5a. Posterior urethral rupture above the intact urogenital diaphragm following blunt
trauma (type II urethral injury)

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 5b. Posterior urethral rupture above the intact urogenital diaphragm following blunt
trauma (type II urethral injury)

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 5c. Posterior urethral rupture above the intact urogenital diaphragm following blunt
trauma (type II urethral injury)

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 6a. Posterior urethral rupture extending through the urogenital diaphragm to involve the
bulbous urethra following blunt trauma (type III urethral injury)

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 6b. Posterior urethral rupture extending through the urogenital diaphragm to involve the
bulbous urethra following blunt trauma (type III urethral injury)

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 7a. Type IV urethral injury from blunt trauma

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 7b. Type IV urethral injury from blunt trauma

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 8a. (a) Retrograde urethrogram obtained in a 32-year-old man with bladder base injury
following blunt trauma (type IVa urethral injury) shows extraperitoneal contrast material
extravasation that extends from the elevated bladder base and surrounds the proximal urethra

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 8b. (a) Retrograde urethrogram obtained in a 32-year-old man with bladder base injury
following blunt trauma (type IVa urethral injury) shows extraperitoneal contrast material
extravasation that extends from the elevated bladder base and surrounds the proximal urethra

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 9a. Bladder neck urethral injury (type IV) in a 23-year-old woman

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 9b. Bladder neck urethral injury (type IV) in a 23-year-old woman

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 9c. Bladder neck urethral injury (type IV) in a 23-year-old woman

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 10a. Anterior urethral injury following blunt trauma (type V urethral injury)

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 10b. Anterior urethral injury following blunt trauma (type V urethral injury)

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 11. Stricture following traumatic bulbomembranous urethral distraction injury

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 12. Prostatic urethrorectal fistula in a patient who sustained both a urethral disruption
and a rectal injury in an automobile accident

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 13. Penetrating urethral injury from a gunshot wound

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 14a. Urethral injury caused by insertion of a foreign body into the external meatus

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 14b. Urethral injury caused by insertion of a foreign body into the external meatus

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 15. Urethral injury in penile fracture

Kawashima A et al. Radiographics 2004;24:S195-S216

Figure 17. Urethral disruption after pancreas transplantation

Kawashima A et al. Radiographics 2004;24:S195-S216

2004 by Radiological Society of North America

Figure 18. Gonococcal urethral stricture

Kawashima A et al. Radiographics 2004;24:S195-S216

2004 by Radiological Society of North America

Figure 19. Gonococcal urethral stricture with periurethral abscess

Kawashima A et al. Radiographics 2004;24:S195-S216

2004 by Radiological Society of North America

Figure 20a. Stricture of the bulbous urethra with urethrocutaneous fistulas (watering can
perineum)

Kawashima A et al. Radiographics 2004;24:S195-S216

2004 by Radiological Society of North America

Figure 20b. Stricture of the bulbous urethra with urethrocutaneous fistulas (watering can
perineum)

Kawashima A et al. Radiographics 2004;24:S195-S216

2004 by Radiological Society of North America

Figure 21. Condyloma acuminata

Kawashima A et al. Radiographics 2004;24:S195-S216

2004 by Radiological Society of North America

Figure 22. Female urethral diverticulum

Kawashima A et al. Radiographics 2004;24:S195-S216

2004 by Radiological Society of North America

Figure 24a. Calculi associated with urethral stricture

Kawashima A et al. Radiographics 2004;24:S195-S216

2004 by Radiological Society of North America

Figure 24b. Calculi associated with urethral stricture

Kawashima A et al. Radiographics 2004;24:S195-S216

2004 by Radiological Society of North America

Figure 25. Squamous cell carcinoma of the male urethra

Kawashima A et al. Radiographics 2004;24:S195-S216

2004 by Radiological Society of North America

Figure 27. Squamous cell carcinoma of the female urethra

Kawashima A et al. Radiographics 2004;24:S195-S216

2004 by Radiological Society of North America

PATHOLOGY
Renal calsification :
I. Nephrocalcinosis : - cortical
- usualy small, multiple
II. Nephrolithiasis : - collecting system
Densed calculi : - Ca oxalat
- Ca phosphate
- Mg ammonium phosphate
Lucent calculi :
- Cystine
- Uric acid
- Xanthine
Hydronephrosis

Hydronephrosis :
- Calyces markedly club shape
- Dilated pelvis

Etiology :
1.
2.
3.
4.
5.

Stone.
Stricture, bands, adhesion.
Anomalous vessels
a.Reflux from urinary bladder infection
b.Reflux from ureter to renal pelvis infection
Tumor.

Urogram :
-

Club shaped calyces

Distended Renal pelvis
Nonopacified dilated calyces Crescent sign
Ureter may/may not delated.
Vesico ureteral reflux voiding cystography

Hidronefrosis

APG

Renal Calculi With Dilated Calyceas

Obstructed Right Kidney Due To

Distal Calculus

Distal Right Ureteral Calculus

RENAL CYST
- Lucency in nephrogram
- Caliceal system splaying
- Sharp margination

RENAL CYST

Renal Cyst

Polycystic Kidneys

RENAL INFECTION
1. Acute pyelonephritis
- Focal or diffuse attenuation intrarenal collecting system
- Diminished contrast excreation
- Reflex dilatation of either intra / extra renal collecting system
- Transient vesicoureteral reflux

2. Chronic Pyelonephritis
- Pelvic and upper ureter mucosal linear striations
- Renal scarring
- Clubbing and irregularity underlying calyx
- Scarred and constrected infundibular calyx
- Irregularities and thickness of cortex
- Pseudotumor

3. Perirenal abscess
Primary sign :
- Loss of renal outline
- Kidney displacement
- Kidney axial rotation
- Displacement of renal pelvis and proximal ureter
- Kidney fixation
- Perirenal space contrast extravatation
- Perirenal gass
-Contiguous bowel displacement

 Secondary sign :
- Absence of psoas margin
- Scoliosis
- Diaphragmatic motility restriction
- Flank stripe infiltration

Pyelonephritis

Pyelonephritis

Pyelonephritis

Pyelonephritis

Cicatricial change in the infudibular portions

of several of the calyces, with slight
dilatation of the calyces and pelvis.

The changes are predominantly

localized to the superior pole region
of the right kidney

Emphysematous Pyelonephritis

Pyelonephritis Secondary To
Obstructing Stone

RENAL PARENCHYMAL ABSCESS

- Disturbed excretion function
- Kidney fixation
- Fuzzy caliceal outline
- Nephrographic phase : lucent
- Irregularly contrast filled
- Single or multiple calyces pressure defect
- Kidney displacement with lumbar scoliosis

Renal Abscess

RENAL TUBERCULOSIS
- Primary lesion : lungs
- Ocassionaly bone and joint
- Hematogenous spread
- Usually bilateral, involves ureter, bladder
- KUB :
- Irregular kidney shadow
- Punctate calcifications
- IV UROGRAPHY :
- Focal papillary necrosis : earliest
- Caliceal irregular filling : sprayed
- Abscess formation
- infundibular constriction / calyceal amputation
- Calyces calcification
- Autonephrectomy : totally calcified

Ureteral Tuberculosis :
- Pipestem
- Beading
- Irregular / stricture
Bladder Tuberculosis
- Small and contracted
- Irregular outline

Renal TB

CYSTITIS
- Acute
- Chronic :
- Diminution of size
- Edge : Irregular, trabeculation
- Occasionaly associated with
- stone
- diverticle

Cystitis Chronis

NEUROGENIC BLADDER
Distended
- Associated with :
- Chronic infection
- DM
- Tabes dorsalis
- Appearance :
- Pine tree deformation
- Hourglass configuration
- Saccular dilatation
- Contracted hypertonic
- Large hypotonic
- Ellipsoid.
-

NEUROGENIC BLADDER

Pine tree deformation

Pine tree deformation

RENAL TUMOR
- Infant

/ Children : - Wilms tumor

- Adult Grawitz tumor :
- High vascular
- Necrosis and hemorrhage
- Polycytemia, hypercalcemia, fever

Rontgenologic :
- Polar enlargement, rotation

- Displaced ureter
- Irregular renal outline
- Calyces splaying/spreading.
- Calyces destruction/amputation

Wilms Tumor

Renal Lymphoma

Carcinoma of the kidney

Excretory urogram

Retrograde pyelogram.

Upper pole carcinoma invading the perihilar region and

displacing the upper ureter laterally

Carcinoma of the kidney

Carcinoma invading calyx

Transitional cell carcinoma, primary

in the renal pelvis, growing outward
to involve the renal cortex

Cystic Renal Cell Carcinoma

RENAL TRAUMA :
1.

Renal parenchymal injuries :

a. Contusion.
b. Cortical laceration.
c. Calyceal laceration
d. Complete fracture.

2. Pelvicalyceal injuries :
a. Pelvic rupture.
b. Calyceal rupture.

3. Renal vascular injuries :

a. Avulsion of vascular pedicle
1. Artery
2. Vein
3. Both.
b. Renal vessel thrombosis :
1. Artery.
2. Vein
3. Both.

KUB :
- Renal outline indistinct
- Broaded psoas shadow
- Bulging of the flank
- Rib spine/pelvic fractures

Renal Trauma

Excretory urogram following

fracture of the kidney.
The Elongation of the superior pole
calyx at the fracture site

Renal arteriogram

Renal Trauma

Nephrogram phase

Excretory phase showing the escape

of contrast agen

IV UROGRAM :
- None

to complete lack of renal function

- Contrast extravasation
- Renal hydrocele : Increasing density renal cortex

URINARY BLADDER TRAUMA :

Intra/extraperitoneal extravasation
- Intraperitoneal : Dog ears appearance.
- Extraperitoneal : associated with pelvic fracture
-

URETHRAL TRAUMA :
Most common : Membranous and bulbous.
- Membranous : pelvic fracture.
-

URETHRAL TRAUMA

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