 Sonography of Urinary Tract Infections The role of ultrasound is in the diagnosis of UTI, follow up and looking for complications of infection and also diagnosing the conditions which predispose for urinary tract infection and intervention in case of predisposition condition or complication. Now predisposition conditions are an anatomical abnormality which causes stasis of the urine which predisposes for the infection. It may be congenital like pelvic erotric junction obstruction, primary obstructive megauretor, horseshoe kidney or vesicoerotric reflex or it may be occurred where it is a cystocene, vesicle diverticulum or a fistula and it may be iotrogenic like an indwelling catheter and also comial infection or following surgery and it can also be the predisposing condition may be avoiding dysfunction which happens in neurological disease pelvic floor dysfunction or a high post void residual urine in enlarged prostate and incontinence. The urinary tract obstruction is also a predisposing condition like any obstruction like bladder outlet obstruction, uretric stricture or calculate and rarely there may be other causes like pregnancy, urolithiasis, diabetes and other immunosuppression. Acute diffuse bacterial infection of the kidney otherwise called the acute pylonephritis is a combination of parenchymal, teletial and pelvic inflammation. It may be a hematogenous seeding not that common causing the infection but usually it is an ascending infection facilitated by an anomaly obstruction, vesicoerotric reflex and the causative organism is usually E. coli and more common in diabetics, pregnancy and after instrumentation or after debilitating disease and in cases of altered host resistance and drug abuse. Acute pylonephritis diagnosis is typically the condition is typically diagnosed on the basis of the clinical symptoms and laboratory findings. Routine radiological imaging is not required for diagnosis and treatment of uncomplicated cases of urinary tract infection. It is a clinical diagnosis made out of abrupt onset of chills, fever of about 100 degrees or more and unilateral or bilateral flank pain with tenderness. Often accompanied by dysuria, urinary frequency and urgency. There may be nonspecific gastrointestinal symptoms like abdominal pain, nausea, vomiting and diarrhea. Add up to this a positive urine culture of infection results in the clinical diagnosis of acute pylonephritis. So ultrasound is required when the patient feels to respond to appropriate therapy within the first 72 hours occurs approximately only in 5% of cases of acute pylonephritis. So its role is also to assess those patients at significant risk for more severe life-threatening complications like diabetes, elderly or immunocompromised patients. And it is also useful to characterize the severity of infection to direct future therapy or interventions, evaluate the extent of organ damage, subsequent to resolved acute infection. So ultrasound is positive in 20 to 25% of acute pylonephritis. Tissue harmonic imaging has improved the sensitivity and specificity. Now this is a coronal scan in the case of right flank pain and fever and the left kidney is normal whereas the right kidney is enlarged. So the characteristic feature of acute pylonephritis is renal enlargement as seen in the right kidney here. And swollen parenchyma which is appreciated well in the transverse scan and changes in the ecogeneity of the renal parenchyma may be hypochoric due to edema of the parenchyma or hyperechoic due to associated hemorrhage. And there is loss of cortical medullary differentiation due to edema. And the loss of renal sinus fat due to edema of the parenchyma compressing the central ecogenic area. So these are the characteristic features of acute pylonephritis along with the clinical symptoms of fever and pain. The differential diagnosis is renal vein thrombosis. So a color Doppler will rule out renal vein thrombosis as seen here the renal vein flow is normal. The swelling of the parenchyma is better appreciated and transverse scan as seen here the coronal scan the kidneys almost look normal whereas the transverse scan shows the normal right kidney whereas the left kidney the parenchyma is swollen. So this swelling of the parenchyma is better appreciated in a transverse scan. So coming to the ecogeneity of parenchyma we saw previously it was ecopore but here on the right side you see the parenchyma is ecogenic and you see the swollen parenchyma which is appears ecogenic along with the clinical features the diagnosed acute pylonephritis. So again the swelling of the parenchyma is well marked here with compression of the central ecogenic area which is not well seen and there is also loss of cortical medullary differentiation. We don't see the renal medulla. Another feature of acute pylonephritis with other features is subcapsula parenifric fluid and ecogenic parenifric fat as seen here that is ecogenic parenifric fat. There may be in some patients ipsilateral floral fluid as a sign of infection. Now real time scan we can see fixation of the kidney as seen here now this spleen moves over the kidney the left kidney is fixed because of the inflammatory adherence. After treatment you see the difference the left kidney and the spleen move together whereas here the left kidney is fixed so that is another feature of acute pylonephritis on real time. There may be adherence of the adjacent organ either liver or spleen to kidney which is showing acute pylonephritis as seen here you see the parking movement of the liver over the kidney because the liver is adherent to the right kidney here the rest of the liver moves around. So that is another feature of acute pylonephritis may be present not always present. Now pylitis component of acute pylonephritis can be seen as ureothelial thickening in the calisthenics and pelvis as seen here that is the ureothelial thickening in the renal pelvis. Another form of acute bacterial infection of the kidney is focal that is acute focal bacterial infection otherwise also called acute focal lobar nephronium. It is an inflammatory mass without drainable pus it is the causative organism is E. coli. Some patients presents with fever chills, flank pain more common in females diabetes. On ultrasound we see it as a poorly defined ecopolar mass absent corticometallary differentiation associated with the clinical features of fever and flank pain. So here you see the left kidney you see a poorly defined ecopolar mass in the lower pole and in the transverse scan in the posterior parenchyma and the absent corticometallary differentiation you see the renal medulla here but here you are not able to appreciate the medulla. So that is acute focal lobar nephronium another case where you see a poorly defined ecopolar mass and absent corticometallary differentiation you see the medulla here but you don't see the medulla. Another case of acute focal lobar nephronium better appreciated on high frequency scan this is the conventional you see the ill-defined mass on high frequency transverse scan you see compared with the normal you will see the echogenicity of the parenchyma and the loss of corticometallary differentiation these are the medulla pyramids in normal which are not appreciated in the acute focal lobar nephronium. Another feature of acute focal lobar nephronium is seen on color Doppler because of the edema compression of the vessels in so you see sparse vessels or no vessels in the ill-defined mass. Now here that is the ill-defined mass loss of corticometallary differentiation and if you put on color so the vessels are not seen in the in the particular area confirming that they are compressed. Now acute parenchyma and focal lobar nephronium what is the course so most of them result with treatment and some because of destruction of parenchyma it results in a scar or it can progress to an abscess a complication of an abscess anal abscess which can rupture either into the perinephric space collecting system or both. So this is a case of renal abscess which is seen as a hypercoic mass in the renal parenchyma with acoustic enhancement indicating fluid pus in the mass and debris may be seen as internal echoes and on color Doppler there will not be any flow within the mass so these are features of renal abscess with of course the clinical features. Now there are multiple renal abscesses seen in the kidney in the parenchyma you see one abscess another abscess another abscess here here so multiple abscesses. Our complication of the abscess is a subcapsular abscess as seen here and coronals can on the periphery and it may be large as seen here the rest of the parenchyma is compressed by the subcapsular abscess which is due to rupture of the renal abscess. Renal abscess can rupture into the perinephric space you see a renal abscess which is ruptured into the perinephric space with a perinephric abscess and here in a child of six months use a high frequency scan which shows clearly the kidney the small renal abscess which has ruptured and produced by concave perinephric abscess which is brought on very well with the high frequency scan. Now there are the renal abscess can rupture into the collecting system as seen here that is the renal abscess which is ruptured with the the collecting system you can see the communication between the renal abscess and the callix brought on with the color Doppler by press release movement red and blue alternatively which is seen on the real time you can see grayscale there is a communication with the abscess and the callix which is shown by color Doppler by alternating red and blue with the compression it can rupture both into the collecting system and the perinephric space and which is also seen on real time as the movement of debris from the perinephric space into the collecting system and the abscess so this is rupture of renal abscess both into the collecting system as well as perinephric abscess or it can extend further outside the kidney as a perinephric abscess here you see the kidney the abscess is extended into the sova's muscle as a perinephric abscess. Then we come to condition of acute emphysematis pylonephritis which is a life-threatening condition of necrotizing infection of the kidney characterized by gas formation within or surrounding the kidneys most common in diabetes in 90 percent case seen in diabetes rarely in obstruction and the causative organisms are E. coli, Klebsiella and Proteus and anaerobic gas production within the parenchyma results in the gas it's most often unilateral it is rapidly progressive to fulminant sepsis and septicemia carries a high mortality rate because of septicemia now this is a ultrasound of a case of acute emphysematis pylonephritis where you see gas within the renal parenchyma or collecting system or both and with or without gas in the perinephric space so here you see dirty shadowing deep to the gas in the kidney and in the severe case we see gas in the renal area and the kidney is not seen separate from the gas when there is the amount of gas is very high so that is one of the classical appearances or you may see an enlarged kidney as seen here with the gas within the renal parenchyma and collecting system and perinephric space with the dirty shadowing typical of acute emphysematis pylonephritis a little milder form you see the swollen ecopower kidney with the pockets of gas both in the parenchyma collecting system and the perinephric space very rarely acute emphysematis pylonephritis may be bilateral as seen in the gas in the right kidney and the left kidney and when it is bilateral patient will be sick and patient may be in renal failure the variation of emphysematis pylonephritis is emphysematis pylite is where the gas is localized to the renal collecting system more common in women associated with diabetes and urinary tract obstruction mortality rate is significantly less than that of all the emphysematis pylonephritis when the presence of gas in the collecting system it has to be differentiated from calculus because both appear as a cogenic spots in the collecting system with shadowing whereas in gas it will be dirty shadowing at times it may not be so marked and so in that case when you can change the position of the patient here you see the axial scan of the kidney when supine position you see gas in the chelises whereas when you turn the patient to left lateral decubitus the gas from the chelises moves into the pelvis so the gas is seen in the pelvis confirming that it is gas and not calculus then we move on to the chronic pylonephritis as a result of multiple recurrent infections or a remote single severe infection the which has resulted in scarring of the parenchyma which is often associated with vesicoeriatric reflex or chronic obstruction or calculate now vesicoeriatric reflex is cause of chronic pylonephritis reflex when papilla reductors are incompetent more common in compound papillae so in the poles begins in childhood because of the reflex and more common in females chronic pylonephritis is often unilateral if it is bilateral it is asymmetrical in involvement and feature of chronic pylonephritis is scarring due to fibrosis which results in loss of parenchyma, cortical thinning, depression on the surface, retraction of the papilla resulting in a dilatation or clubbing of the calyx and the scars may be multiple if there are multiple it results in decrease in renal size and irregularity of the contour this is chronic pylonephritis you see cortical thinning and because of thinning there is depression on the surface and retraction of the papilla results in clubbed calyx or dilatation of the calyx deep to the cortical thinning now the scar and here a typical case of chronic pylonephritis with multiple scars of thinning parenchyma and dilated kinesis which with hypertrophied intervening normal tissue normal parenchyma which mimics a mass and as a result overall asymmetry of the contour of the kidney and because of multiple scars or trophy it results in decrease in the renal size so visecarytric reflex as a cause of chronic pylonephritis has to be evaluated ultrasound of the urethral vesicle junction will show the jet in red and reflex in blue which is seen in the real time you see the jet followed by reflex visecarytric reflex that is the jet followed by visecarytric reflex in blue so ultrasound can pick up visecarytric reflex next condition of infection is xanthogranometer pylonephritis a rare form of chronic destructive granulometous process from an atypical incomplete immune response to subacute bacterial infection renal parenchyma is ultimately replaced with lipid laden or foamy macrophages most cases occur in association with the renal pelvic calculus which is usually a staghorn calculus and the height of the process is thought to be a contributing factor the accostative organisms are rotis mirabilis and e coli symptoms are often nonspecific no-grade fever and malice flank pain and hematuria. Anthogranometer pylonephritis is rare more common in female diabetes in four to five decades now this is a ultrasound of typical xanthogranometer pylonephritis it shows an enlarged kidney of normal shape but heterogeneous parenchyma normal renal architecture of the parenchyma is lost you may see multiple cavities with debris but the classical feature is a large calculus in the renal pelvis is a very characteristic picture of xanthogranometer pylonephritis so xanthogranometer pylonephritis with fatty replacement appears as a fatty mass in the renal fossa as shown by the arrows I have replaced in the kidney and a large calculus in the center that is the renal pelvic calculus and the entire renal parenchyma has been replaced with fat then we pass on to fungal infection usually due to candida albicans usually occurs in premature infants females and advanced age diabetics and immunocompromised patients with obstruction and indwelling catheter and patients are usually asymptomatic now this is a premature infant term shows hydronephrosis and fungal balls in the dilated chelises and pelvis and with parenefric abscess also containing fungal balls that is a fungal infection of premature infant and this is a diabetic with obstruction and hydronephrosis and the dilated chelises and pelvis are filled with multiple large fungal balls that is very characteristic of fungal infection and our case of hydronephrosis with fungal balls in the dilated chelises and pelvis and also in the upper ureter now fungal infection can result in abscess rupture into the collecting system which will show as fungal balls in the dilated chelises pelvis and ureter then we pass on to pionephrosis pionephrosis is simply an infected and obstructed collecting system untreated a rapid off and permanent decline in renal function will result her patient may develop septic shock two cases of pionephrosis the dilatation of the pelvic lacyl system ecogenic collecting system you see debris fluid fluid levels within the collecting system these features give rise to a sensitivity of 90% and accuracy of 96% in diagnosis of pionephrosis and then both the cases you see calculate causing the obstruction so features are dilatation of the pelvic lacyl system debris as indicated by a course within the collecting system and the fluid fluid level shown in the calyx by the arrow another case of pionephrosis dilatation of the collecting system ecogenic walls of the collecting system debris in the pelvis and fluid fluid level a large pionephrosis serviced by dilated chelises and pelvis with third debris and also multiple fluid levels in the collecting system the pionephrosis may be due to obstruction by ureterocene as seen here you see that the hydronephrosis of the left kidney and in the dilated ureter you see the debris in the ureter and because of the infection there is total obstruction so no efflux from the ureterocene when we move on to parasitic infestation of the urinary tract the rear renal hydrated disease is rare two to three percent your patient is usually asymptomatic or they may present as flank mass pain and dysuria and the way complicated with assist rupturing into the collecting system are causing acute renal colic and hydrated urea urinal hydrated disease with two types type one is unilocular or it may be with multiple dot assist type three is completely calcified and represent the depth of the parasite now here you see the type one unilocular assist the thick bilated wall and hydrate its hand seen within the cyst or it may be type two with the spoke wheel appearance with because of multiple dot assist separated by fluid matrix so that is a typical appearance of spoke wheel in renal hydrate now here there is a assist in the parenchyma with internal debris which is ruptured into the collecting system with the dilatation of the achillesis and pelvis with the debris in the collecting system that is the hydrate sand filling the collecting system in which can result in acute renal colic and under urine examination there will be hydrate urea then we come to condition of papillary necrosis which may be due to analgesic abuse common in diabetics it may be due to urinary tract infection obstruction dehydration or sickle cell disease or hemophilia now in diabetics papillary necrosis occurs with poor control it may be due to over super added fungal infection now features of papillary necrosis the swelling of the papilla it sloughs and gets passed away which may obstruct cause some hydranoproses or it may get calcified now here this is the high frequency scan of a normal papilla that is the cortex and that is the medulla with the papilla this is the calyx so here you see the swollen papilla of papillary necrosis and papilla gets sloughed off and produces a papillary cavity which is seen as a clubbed calyx and filled with sloughed papilla or it can be passed out and it may get calcified in the place of the papilla itself or when it passed out it can cause obstruction so this is the papillary necrosis this is normal calyx normal papilla in tuberculosis you see the calyx and that is the medulla there is a papillary cavity communicating with the pelvis that is the typical appearance of tuberculosis whereas here in papillary necrosis you see the entire papilla necrosis sloughed off and lying within the clubbed cavity that is in the cavity so there is sloughed papilla remaining in the papillary cavity and see that is the sloughed off necrosis papilla in the cavity and when this gets passed out you see only the cavity communicating with the calyx and you do not see the sloughed papilla inside so that is the different appearance of papillary necrosis now here this is a coronal scan coronal scan of the kidney showing multiple papillary necrotic cavities all the papilla have been passed out sloughed papilla have been passed out here you see cavities filled with sloughed papilla and another in the lower calyx which is communicating and part of the sloughed papilla passed out and filling the pelvis and the ureter passed out sloughed papilla can cause obstruction to the ureter with high frequency you see the dilated ureter proximal and the sloughed soft tissue papilla causing the obstruction in the upper ureter and in the lower ureter and that is the ureterscopy showing the sloughed papilla in the ureter in the calyx you see the sloughed papilla after removal of the sloughed papilla you see the papillary necrotic cavity and that is the removed sloughed papilla now here you see the papillary necrotic cavity communicating with the dilated calyx because there is hydronephrosis there is also some soft tissue there and you see distally in the lower ureter you see the soft tissue filling the ureter indicating that it is sloughed papilla which is causing the obstruction that is the real time you can see the hydronephrosis you see the cavity in the upper pole parenchyma that is the papillary necrotic cavities another case you see hydronephrosis and you see upper ureter there is a calculus but it is the case of poorly controlled diabetes and if you watch carefully you see the hydronephrosis and you see actually they are communicating with the cavities in the parenchyma so that is papillary necrotic cavities multiple cavities you can see in real time you see the multiple papillary cavities in the parenchyma how to differentiate so here papillary necrotic cavities with the echogenic mass causing obstruction it is actually calcified sloughed papilla which got passed out and causing the obstruction and not a calculus so how to differentiate papillary necrotic cavity versus hydronephrosis so here these are dilated calisthenes and the parenchyma this is dilated calisthenes and the cavities so in the dilated calisthenes are confined to the central echogenic area and there is symmetric dilatation whereas in papillary necrosis the cavities are seen in the parenchyma outside the central echogenic area in the parenchyma and they are asymmetric they are not of the same I hear the calisthenes are of same size symmetric whereas here it will be asymmetric you can see the cavities in the parenchyma whereas dilated calisthenes is confined to the central echogenic area so hydronephrosis progression if you see this is mild this is moderate so the calisthenes are confined dilated calisthenes are confined to the central echogenic area however much the dilatation is these are the renal pyramids in the parenchyma that is the parenchyma confined to the central echogenic area gross again symmetric there is parenchyma thinning again very gross with high frequency you see the parenchyma made out and very gross very thin parenchyma and finally no parenchyma they slay it's just a bag of fluid so however much is the dilatation the cavities are not seen in the parenchyma whereas in papillary necrosis you see them in the parenchyma necrosis papilla you see as ring like calisfications in the region of the renal medulla and two cystitis that is the infection of the bladder more in women coronation of the urethra by rectal flora because in women the urethra is short it is common in men usually in case of bladder obstruction or prostratitis positive organism is E. coli the symptoms will be bladder irritability in the form of dysuria frequency or hematuria on ultrasound you see diffuse mucosal thickening or it may be focal mucosal thickening here you see diffuse mucosal thickening of bladder and then color you see hyperemia typical of cystitis and another case you see diffuse mucosal thickening and there is peri vesicle fat inflammation in a severe case of cystitis with treatment all of this will disappear there may be focal mucosal thickening as seen here in a case of cystitis now emphysemitic cystitis is acute urinary infection which threatens patients life characterized by gas in bladder wall or in the lumen of course in diabetes or in urinary tract obstruction causative organism is E. coli and clebsiella pneumonia so here you see a case of emphysemitic spiline apparatus where you see thick gold bladder with gas in the wall as soon as in the lumen and when it is in the wall you will see alderone in the wall that is typical appearance of emphysemitic cystitis a rare form of cystitis is cystitis glandularis or cystitis cystica it is a proliferative disorder of urinary bladder glandular metoplasia of the transitional cells lining the urinary bladder it occurs due to chronic irritation from infection or calcule here this case you see focal polypoidal wall thickening of the urinary bladder in the region of the trigone and there may be mild obstruction with hydronephrosis or may not be there and here another case you see the polypoidal thickening of the base in the region of the trigone with tiny cystic areas so that is the typical of cystitis glandularis the cystitis or the infection of bladder may be extension of adjacent infection like appendicular abscess here you see an appendicular abscess which is extending into the wall of the urinary bladder it can even rupture so you can see with high frequency the abscess extending into the wall of the urinary bladder or it may be a diverticular abscess you see an abscess near the dome of the bladder mimicking a uraical mass but in the sigmoid colon you see diverticular we have to think of an abscess due to diverticular so because of the uninflamed diverticular so it is confirmed after three months the abscess is ruptured into the bladder resulting in a colo vesicle fistula which is with evidence of gas in the urinary bladder let me pass on to the last component recurrent urinary tract infection the uti follows the complete resolution of a previous uti then you call it recurrent urinary tract infection a threshold of three uti's in 12 months is used to signify a recurrent uti the role of ultrasound in recurrent uti is to pick up predisposing conditions like anatomical abnormality which may be congenital, acute or voiding dysfunction or obstruction so those can be picked up or just one example of a role of ultrasound in recurrent uti in this patient you see the bladder you see a gas in the urinary bladder and careful scan you see a gas filled attract from the urinary bladder to the colon with a suspicion of colo vesicle fistula which is confirmed by water enema you see gush of fluid from the colon by enema into the bladder confirming colo vesicle fistula as the cause of recurrent urinary tract infection due to diverticular so you see an influent diverticular in the colon confirming that it is due to diverticulosis. Now ultrasound is also useful in guided interventions in correction of predisposing anatomical abnormality like Pugab's Fiction or vesicle retric reflex and also in intervening complications like renal abscess or perinephric abscess. Thank you for your patient listen.