====== Contrast Rxn ====== {{reaction.jpg?500|Don't freak out}} ====== Pelvis ====== ===== Anatomy ===== * Extraperitoneal cavity: contiguous with retroperitoneal space * Retropubic space of Retzius: contiguous with posterior pararenal space + extraperitoneal fat * Perineum: below pelvic diaphragm * Parametrium: contained within broad ligament * Denonvillier’s fascia: positioned between prostate and rectum ====== Kidneys ====== * Combination of coritcal & medullary nephrocalcinosis suggests primary oxaluria ===== Grades of Vesicoureteral Reflux ===== {{:gradesofreflux.jpg|Grades of Vesicoureteral Reflux}} ===== Cortical Nephrocalcinosis (COAG) ===== * Cortical Necrosis (Acute) * Oxalosis * Alport Syndrome * Glomerulonephritis (Chronic) ===== Medullary Nephrocalcinosis (MARCH) ===== * Medullary Sponge Kidney * Alkali Excess * RTA (Type 1, Distal), Renal Medullary/Cortical Necrosis * Chronic Glomerulonephritis * Hyperoxaluria, Hypercalcemia (Hyperparathyroidism), Hypercalciuria ===== Papillary Necrosis (POSTCARD) ===== * Pyelonephritis * Obstruction * Sickle Cell * TB/Trauma * Cirrhosis * Analgesic Nephropathy * Renal Vein Thrombosis * Diabetes ===== Diffusely Hyperechoic Kidneys (HIV MAN) ===== * HIV * Inflammation * Glomerulonephritis * HTN, DM * Vascular * SLE / Vasculitis * Multiple Myeloma * Acute Tubular Necrosis / ARPCKD * Nephrocalcinosis * ESRD * Hemolytic Uremic Syndrome ===== Bilaterally Enlarged Kidneys (TIM VPC) ===== * Tumor * Leukemia / Lymphoma * Myeloma * Inflammation (acute) * Glomerulonephritis * Interstitial Nephritis * ATN * Metabolic * Amyloid * Diabetes * Gaucher's * Acromegaly * Vascular * Bilateral renal vein thrombosis * Polycystic Kidney Disease * Collagen Vascular Disease ===== Bilaterally Small Kidneys (IR RAS) ===== * Inflammation (chronic) * Pyelo, Glomerulonephritis, Interstitial Nephritis * Reflux (chronic infection) * Bilateral renal artery stenosis ===== Unilaterally Small Kidney (VOX HS) ===== * Vascular (RAS / RVT) * Obstruction * XRT * Hypoplasia * Subcapsular hematoma (chronic) ===== Urethral Stricture ===== * iatrogenic * post-infectious (gonococcal or non-gonococcal) * non-infectious irritation (chemical or Reiter's) * traumatic injury * neoplasm (long, irregular stricture ± fistula) ===== Bosniak Classification ===== * Category I - No atypical features * US - anechoic without internal echoes, with good thru transmission and a barely perceptible but well defined wall * CT - fluid density, no enhancement and imperceptible wall * Category II - homogeneously hyperdense cyst that is not enhancing, or thin (<1mm) septations or thin wall Ca+ * must be 3 cm or less in diameter, have one quarter of its wall extending outside the kidney so the wall can be assessed, and be nonenhancing after contrast material is administered * Category IIF - minimally complicated cysts that need follow-up * not well defined by Bosniak but consists of lesions that do not neatly fall into category II * have some suspicious features that deserve follow-up up to detect any change in character. * Category III - true indeterminate cystic masses that need surgical evaluation, although many prove to be benign * thicker septations or multiloculated, coarser Ca+ or solid component that is not enhancing * may show uniform wall thickening, nodularity, thick or irregular peripheral calcification, or a multilocular nature with multiple enhancing septa * hyperdense lesions that do not fulfill category II criteria are including in this group. * Category IV - needs nephrectomy * nonuniform or enhancing thick wall, enhancing or large nodules in the wall, or clearly solid components in the cystic lesion * enhancement of at least 10 HU ===== RCC Staging ===== * Stage 1 -> confined by renal capsule (completely in kidney) * Stage 2 -> beyond capsule but confined within Gerota’s fascia * Stage 3A -> extension to renal vein or IVC * Stage 3B -> positive lymph nodes * Stage 3C -> both venous extension and adenopathy * Stage 4A -> grows through gerotas fascia into adjacent organs (other than adrenal) * Stage 4B -> distant mets ===== Grading of Renal Lacerations ===== FIXME ====== Ureter & Bladder ====== ===== DDx Small Bladder (CITRUS) ===== * cystitis cystica * interstitial cystitis * TB * rads * unused bladder * surgery and schistosomiasis ===== DDx Pear-shaped Bladder (CILLI) ===== * Collection - urinoma, hematoma, abscess * IVC obstruction * Lymphoma / adenopathy * Lipomatosis * Iliopsoas hypertrophy ===== DDx for ureteral filling defects ===== * Fungus ball * Ureteritis cystica -> epithelial/ subepithelial cysts due to inflammation or irritation (metaplasia of Brunn’s nests) * Clot * Fibroepithelial polyp * Endometriosis * Stone / Sloughed papilla * Tumor / TB * Leukoplakia: associated with Schistosomiasis; premalignant → squamous cell carcinoma * Malakoplakia: chronic gram (-) infection (E. coli #1); ↑ DM → foamy macrophages (Hansemann) with PAS (+) inclusions (Michaelis-Guttman bodies); raised yellow lesions * looks like ureteritis cystica ===== DDx hemorrhagic cystitis ===== * viral and bacterial infection * drugs - cyclophosphamide (cytoxan) * eosinophilic * cystitis cystica ===== Pseudodiverticulosis ===== * 1-3 mm outpouchings * DDx -> calculi / infections / CA (#1 = TCC) ===== Ureteral TCC ===== * Risks: azo-dyes, cyclophosphamide, phenacetin * Radiographic: * “Wine glass/goblet” deformity (dilated distal ureter) * Bergman sign (coiled retrograde catheter) ===== Ureteral displacement ===== * Distribution: ^ ^ **Medial** ^ **Lateral** ^ |**Above Pelvis**|Retroperitoneal fibrosis\\ Retrocaval ureter \\ (right; at L3)|Psoas hypertrophy\\ LAD\\ AAA\\ Central tumor| |**Below Pelvis**|Pelvic lipomatosis\\ Iliac LAD/ aneurysm\\ Iliopsoas hypertrophy\\ Hutch diverticulum|Fibroids\\ Ovarian masses| * Medial * Retroperitoneal fibrosis: drugs (methylsergide, ergotamine); XRT; prior surgery; malignancy; connective tissue disorders * Retrocaval ureter (right only) * Pelvic lipomatosis: ↑ black males; “tear-drop” or “pear”-shaped bladder; associated with ureteritis cystica * Other: hematoma; iliac LAD or aneurysms; adnexal mass; surgery * Lateral: * AAA * LAD; psoas hypertrophy * Central pelvic mass * Retroperitoneal fat (≠ pelvic lipomatosis) ===== DDx for ureteral stricture ===== * Infection: TB; Schistosomiasis; abscess; fistula * CA: metastases; local extension; TCC; lymphoma * XRT * Inflammation: calculi; instrumentation; stent; endometriosis ===== DDx for ureteral dilatation ===== * Obstruction * Reflux * Primary megaureter (“beak” sign) ===== DDx for bladder filling defects ===== * Tumor: TCC; adenocarcinoma; squamous cell carcinoma; metastases (pheochromocytoma) * Extrinsic masses: BPH; uterus (fibroids); etc. * Other: calculus; thrombus; ureterocele (pseudoureterocele due to inflam/ tumor); foreign bodies ===== Hutch Diverticulum ===== * adjacent to UVJ; ↑ vesicoureteral reflux ===== Bladder Carcinoma ===== * Clinical: transitional cell (90% malignant); risks = azo-dyes; phenacetin; cyclophosphamide; focal thickening of bladder wall; perivesical spread; LAD (> 10 mm) * Staging: * Stage A: limited to mucosa + submucosa * Stage B1: superficial muscular layer * Stage B2: deep muscular layer * Stage C: perivesical fat * Stage D: seminal vesicles, prostate, or rectum ===== Bladder Trauma ===== * Contusion: interstitial * Extraperitoneal: due to pelvic fracture, dissection into retroperitoneum + scrotum + thigh * Intraperitoneal: usually blunt trauma with distended bladder; DX requires adequate bladder distention (> 250 ml) ===== DDx for Bladder Ca2+ (SCART) ===== * Schistosomiasis (↑ squamous cell carcinoma) * CA; cyclophosphamide (cytoxan); calculus * Alkaline encrusting cystitis * Radiation * TB ====== Urethra ====== ===== Urethral Anatomy ===== ==== Anatomy (male) ==== * Anterior = penile + bulbous (penoscrotal junction) * Posterior = membranous (between inferior margin of verumontanum + tip/ cone of bulbous urethra) + prostatic * Cowper’s glands: contained within membranous urethra with ducts entering the bulbous urethra * Glands of Littré: located primarily along dorsal penile urethra → infections (gonococcus; chlamydia) {{urethra.png}} ===== Urethral Injuries ===== * Clinical: risks = pelvic trauma (especially multiple pelvic fractures); absence of blood at meatus does not exclude urethral injury → RUG * Subtypes: * Type I: posterior urethra stretched * Type II: posterior disruption (above urogenital diaphragm) * Type III: anterior + posterior disruption * Type IV: bladder neck injury with extension to urethra * Type IVa: periurethral extravasation with intact urethra * Type V: anterior disruption (“saddle” injury); ↑ bulbous urethra ===== Female Urethral Diverticulum ===== * Clinical: most often acquired due to infection of Skene’s glands; ↑ posterior wall; SXS = dysuria + dribbling + dyspareunia (3 D’s); TX = surgical resection (diverticulectomy) * Radiographic: focal outpouching along posterior urethra; impression along inferior bladder (= “male prostate”); best seen on MRI * Complications: infection; calculi; CA (squamous cell) ===== DDx for Urethral Strictures (TIICB) ===== * Trauma * Inflammatory; infections (prostatitis; phlegmon; etc.) * Calculus * BXO (= balanitis xerotica obliterans): variant of lichen sclerosis et atrophicus (white plaques) → phimosis/ meatal stenosis; premalignant (penile squamous carcinoma) ===== Hypospadias ===== * ↑ cryptorchidism (30%) + inguinal hernias (10%) ===== DDx for Urethral Tumors ===== ==== Benign ==== * Fibroepithelial polyp: solitary; pedunculated; attached near veru montanum; ↑ child/ young adult * Transitional cell papilloma: ↑ prostatic/ bulbomembranous urethra; ↑ bladder papillomas; older adults * Adenomatous polyp: ↑ young men; adjacent to veru montanum * Penile squamous papilloma / condyloma acuminata: verrucous lesion in penile urethra; associated with cutaneous disease ==== Malignant ==== * Squamous cell carcinoma (70%): distal 2/3 of urethra; risks = venereal disease; ↑ stricture (> 80%) * TCC (10-20%): posterior 1/3 of urethra; ↑ multifocal * Adenocarcinoma (10-20%): arise from periurethral glands (Skene; female) and glands of Cowper/ Littré (male) ====== Testes ====== ===== Testicular Cancer ===== * Clinical: seminomas → orchiectomy + XRT; nonseminomas (radioresistant) → orchiectomy + chemotherapy * Staging: * Stage I: limited to testes and spermatic cord * Stage II: lymph nodes below the diaphragm * Stage III: lymph nodes above the diaphragm * A: lymph nodes only * B: extranodal mets * Lymphatic spread: along gonadal veins → renal hilar nodes; external iliac nodes → para-aortic nodes * Hematogenous spread: uncommon except for choriocarcinoma * Cryptorchidism: located from inferior renal pole to superficial inguinal ring; ↑ risk of torsion (↑ 10x) + malignancy (↑ 50x); usually atrophic ===== Extratesticular Mass DDx ===== * Inguinal hernia * Inflammatory mass such as infection, sarcoidosis * Benign neoplastic processes such as adenomatoid tumor, epidermoid inclusion cyst * Malignant processes such as soft tissue sarcomas, mesothelioma of the tunica, lymphoma, and metastatic disease. ===== Peyronie's Disease ===== * Calcification of tunica albuginea of corpora cavernosa * Idiopathic, older men (> 45 yrs old) ====== Prostate ====== ===== Anatomy ===== * U/S → hyperechoic central gland = transitional + central zones * Transition zone (5%): periurethral → BPH * Central zone (25%): ejaculatory ducts * Peripheral zone (75%): carcinoma (> 80%); hypoechoic ===== BPH ===== * periurethral transitional zone; enlarged, lobulated gland; cystic degeneration; Ca2+; elevation of bladder base; bladder wall thickening and trabeculation ===== Prostatic Cysts ===== * Midline: * Mullerian duct: larger; extend superiorly * Utricular cyst: smaller; communicate with urethra; ↑ hypospadias * Ejaculatory duct cyst: acquired; due to obstruction * Eccentric: * Cystic prostatitis/ carcinoma * Cystic BPH * DDX = seminal vesicle cysts → unilateral; ↑ ipsilateral renal agenesis (= Zinner syndrome) > cystic renal disease (APKD), renal ectopia, duplication, ectopic renal insertion ===== Prostate Carcinoma ===== * Clinical: # 2 male CA; enlarged gland with nodules; periprostatic stranding; regional nodes; direct extension to seminal vesicles, bladder; mets to axial skeleton * Radiographic: hypoechoic; ↓ T2 lesions in peripheral gland (DDX = prostatitis; fibrosis; hemorrhage) ==== Staging ==== * Stage A: nonpalpable * Stage B: confined to prostate * Stage C: capsular involvement * 1: invasion * 2: penetration * 3: seminal vesicles * Stage D: metastases * D1: pelvic LN * D2: bone; distant LN * Treatment: Stage A/B → radical prostatectomy +/- XRT; Stage C/D → hormone therapy +/- XRT ====== Peritoneal Cavity, Vessels, and Nodes ====== ===== Fluid in peritoneal cavity ===== * Ascites: serous; due to CHF, cirrhosis, hypoproteinemia, venous obstruction; accumulates in greater peritoneal space; density = 10-15 HU * Exudative ascites: pancreattis → accumulates within lesser sac; peritonitis; bowel perforation * Hemoperitoneum: density > 30 HU; “sentinel bleed” → accumulates at site of hemorrhage * Pseudomyxoma peritonei: due to appendiceal mucocele or mucinous cystadenocarcinoma of the ovary (> urachal/ endometrial CA); peritoneum filled with gelatinous mucin; Ca2+ ===== Pneumoperitoneum ===== * due to bowel perforation, pneumothorax, or mechanical ventilation ===== Peritoneal tumors ===== * Peritoneal carcinomatosis: * Etiologies: ovarian, pancreatic, gastric, and colon carcinoma * Radiographic: malignant ascites; tumor nodules/ Ca2+ → bowel wall nodularity; mesentery; “omental cake”; pouch of Douglas (“Blumer’s shelf); adnexa/ ovaries (Krukenberg tumor) * Peritoneal (cystic) mesothelioma: 20-40% in abdomen; ↑ women 30-40 years; irregular thickening of peritoneal surfaces; multilocular cysts; ascites; bowel compression without obstruction * Mesenteric lipodystrophy (= retractile mesenteritis): fat-density mass with tethering/ kinking/ angulation of adherent bowel loops ===== Abscess ===== * Clinical: complications of trauma or surgery; pancreatitis; bowel perforation; commonly located within pelvis, subhepatic and subphrenic spaces * Radiographic: loculated fluid collection; thickened walls; gas; thickening of fascia; obliteration of fat planes; ascites; pleural effusions ===== DDx for cystic abdominal masses ===== * Abscess * Loculated ascites * Pancreatic pseudocyst * Ovarian cyst/ tumor * Cystic teratoma: fat, water, Ca2+ * Enteric duplication cysts: lined by GI mucosa * Lymphocele: complication of surgery / trauma * Cystic lymphangioma: mesenteric / omental ===== DDx for pelvic cystic masses ===== * Ectopic pregnancy: adnexal/ tubal ring * TOA: tubo-ovarian abscess * Endometrioma * Ovarian neoplasms * Ovarian cysts * Extra-GU origin: abscess; urinoma; duplication/ mesenteric cyst; etc. ===== Lymph nodes ===== * Pathology: lymphadenopathy: > 10 mm in abdomen and pelvis; > 6 mm in retrocrural and porta hepatis regions * Hodgkin’s lymphoma: 40% of total; contiguous spread * Non-Hodgkin’s lymphoma: 60% of total; noncontiguous spread; ↑ GI involvement ===== DDx for hypodense intra-abdominal/ retroperitoneal LAD ===== * Infection: MAI > TB (↑ AIDS), histoplasmosis * Whipple’s disease: glycogen deposition * Tumors: lymphoma (post-therapy); nonseminomatous testicular CA; mucinous adenoCA (rare) ===== Trauma ===== * Hemoperitoneum: density (30-45) HU; (60-80) HU → active bleeding (> 100 HU with contrast); “sentinel clot” → adjacent to injured organ (> 60 HU); free intraperitoneal contrast → bowel/ bladder perforation * Pneumoperitoneum: perforated viscous; PTX; mechanical ventilation; post-op * Subcapsular hematomas: crescentic → flatten parenchyma * Lacerations: jagged, linear low density areas * Intraparenchymal hematomas: rounded, low density areas ====== Retroperitoneum ====== ===== Retroperitoneal fibrosis ===== * ST-encasement of retroperitoneal vessels/ ureters without anterior displacement (DDX = lymphoma); prominent enhancement * Drugs: methylsergide; hydralazine * Lymphoma * Metastases: lung; breast; carcinoid * Other: AAA; trauma; surgery; instrumentation * Ormond’s disease: idiopathic ===== DDx for retroperitoneal masses ===== ==== Malignant ==== * MFH (#1) * Liposarcoma (#2) * Other: leiomyosarcoma; metastases; RCC/ adrenal extension ==== Benign ==== * XGP * Neural tumors * Lymphangioma; hamangioma; lipoma * Teratoma (dermoid) ===== Retroperitoneal Fibrosis ===== * Associated w/ * aortic aneurysms * inflammatory bowel dz * urinomas * retroperitoneal hematomas * aortic and iliac graft procedures * infections * ergot alkaloids * sclerosing cholangitis * fibrosing mediastinitis ===== Waterhouse-Friderichsen syndrome ===== * massive, usually bilateral, hemorrhage into the adrenal glands caused by fulminant meningococcemia ===== Low-density Retroperitoneal Nodes ===== * Neoplastic * Testicular (particularly teratocarcinoma) * Epidermoid carcinoma of GU tract * Lymphoma * Leiomyosarcoma * Infectious * Whipple's Dz * MAI