 Sonography of the Urinary Tract, Technique, Normal Appearance and Variations, Part 2 covering the ureter and urinary bladder. In Part 1, I have covered the kidney and the renal pelvis. Now, ureter when it is dilated can be traced to the level of cause of obstruction. As seen here, you can see from the kidney the chelises are dilated, you see the upper ureter is dilated and then you trace it and you see the mid ureter, the pelvic crossing, lower ureter dilated and when you see the ureter ending up to the bladder and there is a calculus at the UVJ. So, that is how a dilated ureter can be traced. But when the ureter is non-dilated, can it be seen and can it be traced? Yes, is the answer. How to start with it? To start with, it is better to start with a dilated ureter. You see the course and how we have to move the transducer to trace the different parts of the ureter and also you can try with ureter with a stent in place and then see the stent in the renal pelvis in the upper ureter, you can see the stent. So you know now by tracing the stent a non-dilated ureter, so you can memorize the transducer movement to see the non-dilated ureter, upper ureter, the mid ureter, the level of pelvic crossing and then the lower ureter you see the stent in place and it see the stent actually entering the urinary bladder through the ureter vesicle junction. So then you can see the stent in the bladder. So with the stent in the ureter which is not dilated, you can use the stent as a guide to trace the non-dilated ureter. That will be shown in the video. You can see the stent in the pelvis upper ureter and you can then move the transducer as it was described in the basic lectures for tracing the iota. So you see the stent and you see the non-dilated ureter various parts, UVJ and enter the bladder. So this is the way to learn tracing and looking for a non-dilated ureter. So here you see a non-dilated ureter, the upper part you see the ureter and how to identify the ureter by the peristals. You will see the ureter emptying, collapsing. So similarly the mid-urator, you see the ureter and it collapses. So the peristals confirms that you are definitely seeing the ureter. So that was the mid-urator and you see the lower ureter filling up and then collapsing. So filling up and collapsing. So this helps us to identify and confirm that it is the ureter and you see the ureter, low distal most ureter collapsing and then you can put on color to see the jet which will follow the collapsing of the lower ureter, distal most ureter. So this is how you can trace the non-dilated ureter confirmed by the occurrence of peristalsis. So by this you can see the helices, the pelvis, the ureter there which is collapsed and it is filling up after some time. You confirm that that is the ureter. Similarly the mid-urator collapsed and then it is filling up and similarly the lower ureter it is collapsed and it is filling up. So the peristalsis of filling up and collapsing confirms that we are looking at the various parts of the ureter and this is the distal most ureter with the color Doppler you see the ureteric jet from the ureterovesicle junction. So now you can see the ureter and you see the peristalsis the various parts. So it is now better for you to appreciate that is the ureter it will collapse. You see the mid-urator that is the lower ureter you see filling up and collapsing. Now similarly you can see the upper ureter which went away fast we will see again and then you see that is the upper ureter collapsing. So this is how you trace the ureter. So now you all will agree that you can see the non-dilated ureter and also trace it. Now coming to the urinary bladder the protocol is with the patient supine and with the full bladder so that only we can see the bladder and make a sagittal sweep the sagittal scan and then make a side to side sweep and then turn the transducer 90 degrees make a trans-scan and make a up and down trans-sweep so that you scan the entire volume of the bladder. So that is the sagittal sweep in the suprapubic region and you see the corresponding video and the trans-sweep you can see the corresponding video in a male patient. So full bladder is required now you see the empty bladder so you cannot study the empty bladder. So the bladder has to be filled to study the bladder as well as structures posterior to the bladder. So this is the sagittal scan. So in the male you see the sagittal scan and the trans-sweep scan and you see the bladder as a fluid filled pyramidal or oval structure and it is filled with a copuap fluid and the prostate you see in the male and prostate also is pyramidal in shape with medium level uniform echoes and then trans-scan you see the when you make a trans-sweep you also see the prostate and the seminal vesicles. Now seminal vesicle depending upon the abstinence stage and the age it may be thin like this in a child and it may be empty and then it is filled with abstinence. So that is the normal seminal vesicles and normal urinary bladder. Seminal vesicles are seen as linear or long oval ecopore structures of variable size depending upon the age and abstinence and there may be some compartments. So urinary bladder measurement is done by using the volume 2 taking the length that is cafellocardial and then api diameter and the width in the trans-sweep scan. So the length and api diameter taken in the sagittal scan and width in the trans-sweep scan and using the volume 2 you will get the volume and the residue urine normally is taken to be 20 to 30 cc. Prostate measurement again using the volume 2 the length and api thickness in the sagittal scan and width in the trans-sweep scan and you get the volume normally is 20 to 30 cc. The size increases with age and when you want to study prostate and seminal vesicles in detail it has to be by trans rectal ultrasound. So this is the female sagittal sweep from side to side you see the bladder and the uterus and the transverse sweep from above downwards you will see the bladder, uterus and the ovaries. So that is the sagittal sweep and the transverse sweep to see the entire volume of the bladder. Now coming to the ureter vesicle junction on either side you can see the ureter vesicle junction. Now you see the distal ureter and so obliquely to join the bladder. So to see the ureter vesicle junction you must see the distal most ureter by taking an oblique scan along this plane and when you do that so that should be the placement of the transducer to look at the ureter vesicle junction and you see the bladder the distal ureter and that is the ureter vesicle junction. Similarly when you put a color Doppler you can see the distal most ureter with the jet from the ureter vesicle junction which identifies the ureter vesicle junction then turn the probe for the left side ureter vesicle junction. So this is the technique for the ureter vesicle junction with color Doppler with color power anjo and color Doppler both. So you can see the collapse of the distal most ureter with the ureteric jet which is normal. So ureteric jet visualizing the ureter jet is useful in certain situations which we will be dealt with in the pathology lectures. Now coming to the trigon of the urinary bladder how to identify the trigon. So trigon is the triangular part of the base of the urinary bladder between the ureter vesicle junctions of both sides and the internal urethral meiasis. So this is the triangular area of the urinary bladder which has special tissue and special origin embryologically. So that is the trigon. So how to identify the trigon you identify the internal urethral meiasis in the main in the female and the ureter vesicle junction. So the area between the two and that is two ureter vesicle junctions and the internal urethral meiasis the triangular area is the trigon. Then urinary bladder besides sagittal and transverse scans and many situations a coronal scan or a high frequency scan are also necessary not to miss a diagnosis. So coronal scan high frequency scan using a high frequency linear proof helps us to see the anterior wall of the urinary bladder better. The coronal scan is done by placing the transducer in the right if suppose you want to see the left lateral wall of the bladder you have to put that probe in the right iliac fossa and parallel to the body and then make a sweep to look at the now this is the probe in the right iliac fossa the beam is almost coronal to see this part of the bladder left lateral wall of the bladder better and make an anterior posterior sweep so that you see the entire wall. So this is the video showing the same movement so from the right iliac fossa you make a coronal sweep so that you see here this will be the left lateral wall of the urinary bladder. So this is useful in certain situations I will show one illustration of this now this is a patient presenting with hematuria you see the sagittal scan transverse scan the urinary bladder is normal and the high frequency scan also shows that the anterior wall of the bladder is normal so here you see the coronal scan shows mass in the epsilon side so this is from the same side when you do a coronal scan you see the mass or you may see a mass here in the opposite wall so that is brought out only by a coronal scan but it is also brought out well with in a post void scan so post void scan is also important not only for residual urine some mass lesions or some pathology become obvious either on a coronal scan or in a post void scan or in some anterior wall lesions in the high frequency scan. Now one warning regarding the bladder in a female particularly now here this is a sagittal scan in a patient with acute suprapubic pain and you see the with suprapubic tenderness so this is a urinary bladder but here in transverse scan sagittal scan and transverse scan it looks like bladder but if you have a doubt because it is tender and you have a doubtful bladder here when you have a doubt repeat after some time or you catheterize and repeat the scan so that if it is bladder it would have emptied and you will think that this is a cyst and the clue here is the bladder the thin bladder seen here so when you have a doubt then you can repeat after some time where we see the increase in volume of the bladder or catheterize to empty the bladder and see so this is a transverse scan you see the bladder on either side better and this is actually a cyst it is not a urinary bladder and cyst ovarian cyst which is resulted in torsion now individual scan in a lady and a trans rectal scan in unmarried women and males can be used to our advantage to look at the distal most part of the ureter but it is not seen well on abnormal scan and you can identify by the ureteravisical junction by the jet also so here you see the individual scan and you see the ureter distal most ureter and which is slightly dilated and you see the calculus better seen by individual scan or trans rectal scan and here another example of a dilated slightly dilated distal most ureter the obstruction is due to a soft tissue mass in diabetic patient it is a sloughed papilla causing obstruction in the lower ureter so that is well seen by either individual scan or breast another example of a lower ureteric stricture you see the dilated ureter and the narrowing smooth narrowing of the distal most ureter indicating a stricture whereas here you see the dilated ureter and you see an irregular mass filling the distal most ureter indicating that it is a lower ureteric tumor carcinoma now individual scan or trans rectal scan can also be used to evaluate the base of the bladder and in here three examples of carcinoma of urinary bladder you can look for the infiltration of the serosa here it is not infiltrated here it is infiltrated I mean infiltration of the mural infiltration which is seen here and here but still the serosa is intact here if there is a serosome involvement that will be seen better so level of innovation of tumor can be better assessed by either individual scan or a trans rectal scan another example you see the endometriosis of the LSCS car in involving the urinary bladder at the interface which is better seen by individual scan you see the uterus and bladder and you see the irregular mass at the level of LSCS car with loss of interface between the uterus and the bladder and actually irregular mass protruding into the bladder giving a diagnosis of endometriosis of the urinary bladder now then coming to the perineal scan now before going for the perineal scan the wall of the urinary bladder thickness can be assessed when a partially or a moderately full urinary bladder where we have to measure the volume of the urinary bladder it should be around 150 cc at that time you measure the bladder wall thickness it should maximum it should be two to three millimeters then coming to the perineal scan to study the urethra so this is the schematic of the pelvis and perineum in a female so when you place the probe here and do a scan the scan will be like this so that is the probe and you see the pubic symphysis and you see the bladder and the urethra so that is the bladder and the urethra and then you see the vagina so that is the vagina and this is the rectum so that is in a child and in an adult you see the pubic symphysis and you see the urethra it's an ecopore structure just beneath the pubic symphysis from the urinary bladder and the vagina the mucus in the vagina gives it an ecogenic appearance with a copore walls and finally the anal canal so this is the normal appearance of perineal scan of urethra and vagina in a female and here some examples of abnormalities so this is the urethra and adjacent you see a cystic area urethral diverticulum and approximate urethral diverticulum filled with milk of calcium as seen here as an ecogenic mass and peri urethral abscess is seen that is the urethra and this is the vagina in between you see a tender fluid collection with enhancement so that is a peri urethral abscess and we can do a 3d to look at how far the peri urethral abscess encircles the urethra now this is a perineal scan in a female with stress incontinence and you can see the scan at rest and with valsalva you see that the bladder generates collapses into the vagina that is a sister seal and this is the video showing the collapse of the bladder into the vagina so that is a sister seal and there is a rotatory descent of the urethra so this is assessment of pelvic floor is a separate lecture so perineal scan in the urethra in a male so that is how you place the probe and so the image will be like this it will be returned like this where you will see the pubic symphysis bladder the posterior urethra and the anterior urethra so that is the posterior urethra anterior urethra in a child and here you see the bladder and you see the structures that is the pubic symphysis bladder the rectum the urethra the posterior and the penile urethra marked in the image and you can actually do the sonographic mixed urethra and you will see the bladder contracting and you see the urethra being filled with urine distended with the fluid which is seen on ultrasound so this is sonographic mixed urethra which is useful in the diagnosis of posterior and anterior urethral valves that we will see in the abnormal section the penile urethra also can be seen by high frequency scan now this is the scan of the penis from the dorsal aspect you see the corpus spondiosum here so the urethra will be in the corpus spondiosum this is the axial scan of the penis these are the two corporeal cavernosa and the single corpus spondiosum on the ventral aspect the urethra will be within the corpus spondiosum we can do turn the from the ventral aspect also we will see that now this is a patient with dysuria and bladder and urinary tract was normal and when you do because of the severe dysuria scan of the penis from the ventral aspect you see the corpus spondiosum with the urethra and in the urethra you see a calculus impact in there which was the cause of dysuria so there is a calculus in the penile urethra the scan is done from the ventral aspect now this is a patient represented with again dysuria and hematuria and here you see a linear echogenic lesion from the bladder it enters the urethra and that is the transverse scan and when you do a scan of the penis you see the linear echogenic structure in the urethra so that is the darsal scan you see the lesion and this is the axial scan this is the corpus spondiosum inside you see the lesion this was a foreign body it was a blade of a leaf of a plant which was introduced by the patient himself that is a foreign body. Penile urethra can also be studied by gel urethragram distending it with gel so we place the nozzle of the lubricating gel on the antiretral meatus and then squeeze the tube so that the gel will enter the urethra and distend it this is a normal urethra so that is the lumen and you see the walls seen very well and this is the longitudinal scan and the axial scan you can see the video showing the procedure you see the gel moving and distending the urethra so very well seen so what are the pathologies we can pick up you can pick up a stricture that is the urethra and you see the narrowing with the wall thickening that is the stricture of the urethra as seen on the retrograde urethragram on x-ray and here this is the patient who had total cystectomy for carcinoma of the urinary bladder presented later with urethra bleeding and the gel urethragram shows the distended urethra and an irregular mass from the ventral wall of the urethra in which a color showed flow indicating that it is a recurrent tumor in the urethra. Another case of urethra bleeding that is the tarcell scan the two copper covenosa and the corpus pongeosum in the place of urethra you see multiple cystic areas in the axial scan in the longitudinal scan again you see linear tubular structures which on jelly urethragram again ventral scan confirms the same which on color showed flow indicating that it is a hemangioma the same which on jelly urethragram is better seen you see the urethra and you see the hemangioma of the balls so this is a hemangioma of the pineal urethra which has resulted in urethra bleeding thank you for your attention