Question:

Describe the radiological anatomy of the male urinary bladder. Describe

in detail the techniques for demonstrating the organ.

Answer
- Introduction/Gross
- Imaging Modalities:
* Cystogram
* Pelvic scan
* CT scan
* MRI
* Plain radiography
* Angiography
* RNI
-Introduction/Gross
The urinary bladder is situated within the
pelvis. It is an extraperitoneal pyramidal
muscular organ when empty but as it fills,
it becomes ovoid and rises into the
abdomen stripping the loose peritoneum
off the anterior abdominal wall.
It has a base/posterior surface, an apex, a superior
and two inferiolateral surfaces. The ureters enter
the posterolateral angles and the urethra leaves
inferiorly at the narrow neck which is surrounded by
the involuntary internal urethral sphincter. The
trigone is the triangular inner wall of the bladder
between the ureteric and the urethral orifices, this
part of the wall is smooth while the remainder of the
bladder wall is coarsely trabeculated by crisis- cross
muscle fibres.
 The perivesical fat surrounds the bladder.
The bladder is relatively fixed inferiorly via
condensations of pelvic fascia, which attach it
to the back of the pubis, the lateral walls of
the pelvis and the rectum. The obturator
internus muscle is anterolateral and the levator
ani muscle is inferolateral to this.
The vasa deferentia and seminal
vesicle are posterior to the bladder so
also is the cul-de-sac and rectum.
The bladder neck is fused with the
prostate.
Imaging Modalities
- Cystogram

It localises the bladder within the pelvis cystogram

is used to assess the integrity of bladder following
trauma or surgery or to investigate fistulas
involving the bladder. The bladder is filled with
contrast which appear as rounded radio-opacity
and demonstrates the corrugation of the bladder
wall especially when not well distended.
The bladder wall is seen as the soft tissue
density structure separating the
perivesical fat and the intravesical
contrast
Irregular collection of contrast may be
trapped between muscles fibres after
micturition the prostate may protrude up
into the bladder base to produce a
prostatic impression the full bladder
outline should be smooth and regular
Pelvic US
Us is best for demonstrating the internal anatomy.
Routine examination of the bladder requires it to
be moderately full. The normal bladder has a
triangle shape in the sagittal plane and that of a
square with the corners rounded off in the
transverse plane. The normal wall thickness is 2-
3mm when the bladder is moderately full. The
bladder wall is slightly echogenic which
contrasts against the anechoic urine within it this
beautifully demonstrating the internal anatomy.
It is also possible to visualize the lower ureter in
young children and the use of colour Doppler
allows identification of ureteric jet
 Relations, Anterior, Anterior abdominal wall
(medium level echo), Pubic bone (poster ior
acoustic shadow)
 Posterior: Rectum (poorly demonstrated)

 Lateral: Obturator internus muscle (medium

level echo), levator on muscle (medium level
echo)
 Superior: Loops of bowel (not
properly demonstrated because of bowel
gas; evidence of peristalsis)
 Inferior: Prostate (lobuted out line,
homogenous medium level echo)
CT
The bladder is best appreciated when filled
with urine or contrast and it is seen as a thin
walled structure between the urine and the
periversical fat the wall should not exceed 4-
5mm fat. The appearance of the urine depends
on the presence or absence of contrast, when
present it hyperdense but when absent it is
hypodense
The seminar vesicles which lie on the
posterior wall of the bladder appear as
tubular structure related to the superior aspect
of the prostate and posterior to the lower
bladder but anterior to the rectum. There is a
fat plane between the seminal vesicles and
the bladder. In a suprapubic axial slice, the
various structures from anterior to posterior
are
i Anterior abdominal wall [(subcut. fat (hypodence);
rectus abdominic (isodense)]
ii Urinary Bladder
iii Seminal vesicle (isodense)
iv Rectum (gas + faeces + contrast => mixed density)
v Sacrum (hyperdense)
vi Gluteus maximus (isodense)
vii Subcuit fat (hypodense)
Psoas muscles are demonstrated laterally at higher level
but obturator internus muscle at lower levels
MRI
MR is ideal to demonstrate the relationship
of the bladder in the coronal and sagittal plane.
It is seen as a low/ intermediate signal line on
t1 W images, similar to urine hence poor
contrast between them but on T2 W1 the
bladder wall is seen as a thin low signal
intensity line adjacent to the high signal of fat
outside and urine inside the bladder
 The bladder wall enhances intensity with IV
gadolinium.
On T2 W1 the seminal vesicle is hyperintense
but it has intermediate intensity on T1 W1.
NB- They low intensity bladder wall may be
obscured by the chemical shift artifact that
result from the difference in resonance
frequency between fat and water proton
Plain Radiograph.
The bladder may be identified on plain film especially when
full. It is seen as a round soft tissue density surrounded by
lucent line of perivesical fat. It should be smooth and
symmetrical.
Angiography
This demonstrates the superior and interior vesical artery
originating from the internal iliac artery as radio opaque lines
RNI (Radionuclide Cystography)
Agent – Non absorbable radiotracer e.g. 99 M TC-
MAG3 (Mercaptoacetylglycine)
B. Describe in detail the technique for
demonstrating the urinary bladder.
- Outline

Indications
C.I
Patient preparation
Equipment/materials
Techniques proper description
After care
Complication
(1) Cystogram
 Indications
(i) Abnormalities of the bladder e.g. fistula
mass
(ii) After bladder trauma
(iii) After bladder surgery
(iv) Haematuria
(v) Difficulty in micturition
C.I
 Acute urinary tract infection
 Patient preparation

(a) The patient micturates prior to the exam

(b) Patient is fasted for about 6hrs prior to
exam
 Contrast medium

HOCM or LOCM
 Equipment/Materials
(1) Fluoroscopy unit with spot film device
(2) Jaques or foley catheter. In small infants a fine
(5-7F) feeding tube.
(3) Casettee and film
(4) Emergency tray
(5) Sunctioning machine
 Preliminary film
Coned view of the bladder
 Technique
(a) The patient lies supine on the x-ray table. Using
aseptic technique a catheter, lubricated with Hibitane
0.05% in glycerine, is introduced into the bladder.
Residual urine is drained. Contrast medium is slowly
dripped in a bladder filling is observed by
intermittent fluoroscopy. It is important that initial
filling is monitored by fluoroscopy in case the
catheter is in the distal ureter (Therapy mimicking
vesicoureteric reflux) or vagina.
(b) Any reflux is recorded on spot films
(c) The catheter should not be removed
until the radiologist is convinced that no
more contrast medium will drip into the
bladder.
(d) Film are taken in AP, lateral and
oblique.
 Aftercare
(A) No special aftercare is necessary, but patients
and parents of children should be warned that
dysuria, possibly leads to retention of urine,
may rarely be experienced. In such cases a
simple analgesic is helpful and children may be
helped by allowing to micturate in a warm both.
(B) Antibiotics should be prescribed if reflux is
demonstrated.
 CX
(A) Due to the contrast medium
 Adverse rxn may result from absoprtion of contrast
medium by the bladder mucosa
 Contrast medium-induced cystitis

(B) Due to the technique

(a) Acute U.T.I
(b) Catheter trauma-may produce dysuria,
frequency, haematuria and urinary retention.
(c) Complications of bladder filling e.g. perforation
from overdistention – prevented by using a non-
retaining catheter e.g. Jaques.
(d) Retention of a foley catheter

(2) U/S
* Indications
(i) Haematuria
(ii) Bladder outlet obstruction
(iii) Bladder tumour and other pelvic masses
(iv) Post trauma
 C.I
None
 Patient preparation
Full bladder
 Equipment/material
(a) 3.5 – SMHz transducer
(b) U/S machine
(c) Electrolyte/Ultrasound gel
 Technique
The patient lies supine and the bladder is
scanned suprapublically in transverse and
longitudinal planes. Measurement taken
of three diameters before and after
micturition enable an approx. volume to
be calculated.
 After Care
None
 Cx
None
3)Pelvic CT
 Indications
as already stated
 C.I
(i) rxn to contrast medium
(ii) Pregnancy
 Patient preparation
- Bowel preparation
- Fast in the day of exam
- Give 500ml dilute contrast agent orally the evening preceding
exam

 Equipment/Materials
(a) CT Machine
(b) CT Printer
(c) Contrast agents
(d) Mechanical injector
(e) Emergency tray
(f) Suctioning machine
 Technique
We give 500ml dilute contrast agent orally the
evening preceding the exam and repeat the dose
45 to 60min before the exam. The colon and the
rectum can be distended by placing a tube in the
rectum and insufflating with 20 puffs of air, or
the limit of patient comfort. All patients are
asked to avoid micturition for 30 to 40min
before the exam to allow bladder filling. IV
 contrast medium is routinely given by mechanical
inject or at 2 to 3ml/sec for a total dose of 150ml of
60% contrast agent. Lie patient supine angulate your
gantry. Scanning through the pelvis is performed
with contiguous 2-5mm thick slices. We routinely
scan the abdomen as well in patients with known or
suspected pelvic malign.
N.B: A contrast material enema (200ml) occasionally
may be necessary to expedite opacification of
Rectosigmoid
 After Care
None
 Cx
Rxn to contrast
4)MRI
 Indication
As previously stated
 C.I
Metallic prosthesis or metals in the body e.g.
bullet.
 Patient preparation
No special preparation

 Equipment/Materials
(i) M.R. machine
(ii) Gadolinium
(iii) M.R. printer
 Technique
Patient are usually examined supine during shallow
respiration, with the urinary bladder at least half full
before the study is begun.
Both T1-W (TR=300-500msec, TE=15 – 35msec) and
T2W (TR = 1,500 – 2,100 msec, TE = 90-120 msec)
spin echo sequences are necessary for complete
examination of the pelvis. T2W1 provide clear
delineation of the bladder wall, as well as internal
morphology of the prostate gland and the uterus.
 Transaxial images are obtained in every
case; additional views are performed in either
the coronal or sagittal plane. Coronal images
are useful for evaluating the seminal vesicle
and bladder neoplasms that involve the lateral
wall while sagittal images are necessary is
cases in which a bladder neoplasm is located
along the anterior or posterior wall.
 After Care
None

 Cx
None