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Transabdominal Pelvic Ultrasound

R. Ernest Sosa and Pat F. Fulgham

Introduction

Indications

Transabdominal pelvic ultrasound provides


instant noninvasive imagery of the lower
urinary tract for the assessment of urologic
conditions. It is useful in evaluating patients
with lower uri- nary tract symptoms. The
examining physician gains valuable information
about the anatomy and function of a patients
bladder and prostate. In the female patient,
bladder
hypermobility can be assessed.
Urologists performing and interpreting bladder
ultrasound will have a specic clinical question
in mind as a reason for performing the scan. In
order to obtain a good- quality diagnostic image
and render an interpre- tation of the ultrasound
ndings, it is important to have an
understanding of ultrasound machine settings,
patient positioning, probe manipula- tion,
normal ultrasound anatomy, and common
artifacts.

Ultrasound of the bladder is performed for a


variety of clinical indications (Table 8.1). When
the bladder is full, it provides information about
bladder capacity as well as bladder wall
thickness. The presence of bladder wall
pathology such as tumors, trabeculations, and
diverticula and the presence of bladder stones or
of a foreign body can also be ascertained.
Imaging of the ureteral orices using Doppler
can conrm the presence of ureteral efux of
urine. The presence of a ure- terocele or a stone
in the distal ureter or the pres- ence of distal
ureteral dilation may also be appreciated. In the
male patient, prostate size and morphology may
be evaluated. In the female patient, bladder
hypermobility can be assessed. In male and
female patients, the proper position of a urethral
catheter in the bladder can be conrmed (Fig.
8.1). The presence of blood clot and tumor in the
bladder can also be determined (Fig. 8.2).
Pelvic ultrasound may also be useful to guide
procedures such as deation of a retained
catheter balloon or for guiding the placement of
a supra- pubic catheter [1].

R. Ernest Sosa, MD
Chief, Division of Urology, Veterans
Administration Healthcare System, New York
Harbor, Manhattan, NY, USA
P.F. Fulgham, MD, FACS (*)
Department of Urology, Texas Health Presbyterian
Dallas,
8210 Walnut Hill Lane Suite 014, Dallas, TX 75231,
USA
e-mail: pfulgham@airmail.net; patfulgham@yahoo.com

Patient Preparation and Positioning


The patient should have a full bladder but should
not be uncomfortably distended. A bladder volume of approximately 150 cc is optimal. The
patient is placed in the supine position on the

P.F. Fulgham and B.R. Gilbert (eds.), Practical Urological Ultrasound, Current Clinical
Urology, DOI 10.1007/978-1-59745-351-6_8, Springer Science+Business Media New York
2013

129

813 Transabdominal Pelvic Ultrasound


01
Table 8.1 Indications for bladder ultrasound
1. Measurement of bladder volume
2. Measurement of post-void residual
3. Measurement of prostate size and morphology
4. Assessment of anatomic changes associated with
bladder outlet obstruction
a. Bladder wall thickness
b. Bladder wall trabeculation
c. Bladder wall diverticula
d. Bladder stones
5. Documentation of efux of urine from the ureteral
orices
6. Evaluation of pediatric posterior urethral valves
7. Assessment of correct position of a urethral catheter
8. Guidance for placement of a suprapubic tube
9. Assessment for completeness of the evacuation of
bladder clots
10. Evaluation of hematuria
11. Evaluation for bladder tumors
12. Evaluation for distal ureteral dilation
13. Evaluation for foreign body in bladder
14. Evaluation for distal ureteral stone
15. Evaluation for ureterocele
16. Evaluation for complete bladder emptying
17. Assessment for bladder neck hypermobility in women
18. Evaluation of pelvic uid collections
19. Guidance for transperineal prostate biopsy
20. Imaging of prostate when the rectum is absent or
obstructed

examining table. The abdomen is exposed from


the xiphoid process to just below the pubic bone.
The patient may place their arms up above their
head or by their side on the table. The room
should be at a comfortable temperature. The
lights are dimmed. A paper drape placed over the
pelvic area and tucked into the patients clothing
will protect the clothing and allow for easy
cleanup after the procedure. The examiner
assumes a comfortable position to the patients
right.

Equipment and Techniques


The appropriate mode for performing pelvic
ultrasound is selected on the ultrasound equipment, and the patients demographics are entered
into demographic elds. A curved-array transducer is utilized for the pelvic ultrasound study

R.E. Sosa and P.F. Fulgham


13

01

(Fig. 8.3). The advantage of the curved-array


transducer is that it requires a small skin surface
for contact and produces a wider eld of view. In
the adult patient, a 3.55.0 MHz transducer is
uti- lized to examine the bladder. For the
pediatric patient, particularly for a small, young
child, a higher frequency transducer is desirable,
partic- ularly for a small, young child.
An even coating of warm conducting gel is
placed on the skin of the lower abdominal wall
or on the probe face. Prior to beginning the
ultrasound examination the transducer is most
often held in the examiners right hand. The
orienting notch on the transducer is identied
(Fig. 8.3). The orientation of the transducer may
be conrmed by placing a nger on the contact
surface near the notch. The image produced by
contact with the nger should appear on the left
side of the screen indicating the patients right
side in the transverse plane and the cephalad
direction in the sagittal plane.
Various techniques for probe manipulation
are useful in ultrasound (Fig. 8.4). The
techniques of rocking and fanning are nontranslational, mean- ing the probe face stays in
place while the probe body is rocked or fanned
to evaluate the area of interest. The techniques
of painting and skiing are translational,
meaning the probe face is moved along the
surface of the skin to evaluate the area of
interest. All four techniques are useful for
avoiding obstacles like the pubic bone or bowel
gas and for performing a survey scan.
Ultrasound of the bladder may be started in
the transverse view with the notch on the
transducer to the patients right (Fig. 8.5). The
transducer is placed on the lower abdominal wall
with secure but gentle pressure. If the pubic bone
is in the eld of view, the bladder may not be
fully visualized. The pubic bone will reect the
sound waves resulting in acoustic shadowing
which obscures the bladder. The pubic bone may
be avoided by varying the angle of insonation
using the fanning technique until a full transverse
image is obtained. In the transverse view of the
bladder, the right side of the bladder should
appear on the left side of the screen. The
machine settings may be adjusted until the bestquality image is obtained.

Fig. 8.1 (a) The tip of the balloon catheter is seen in the bladder (arrow). (b) Image of the inated balloon in the
blad- der (arrow)

Fig. 8.2 Residual blood clot in the bladder after irrigation for clot retention

Fig. 8.3 Curved-array transducer with orienting notch (arrow)

Fig. 8.4 Various techniques for probe manipulation

Fig. 8.5 (a) Position of transducer for obtaining a transverse image. Notch (arrow) is directed toward patients
right. (b) Transverse image of the bladder with measure-

ments of the width (1) and height (2) of the bladder. SV


seminal vesicles

Fig. 8.6 (a) Position of the transducer with the notch to the patients head. (b) Sagittal image of the bladder with
length of the bladder (3) from the dome on the left to the bladder neck (BN) at the right

Survey Scan of the Bladder

then the sagittal view, the length. When starting


with a transverse view, the sagittal view is
A survey scan should be conducted prior to obtained by rotating the transducer 90 clockwise
address- ing specic clinical conditions to with the probe notch pointing toward the patients
determine if any additional or incidental head (Fig. 8.6). The rocking technique may be
pathology is present. The survey scan is used to facilitate viewing the bladder in the
performed in the transverse view
sagittal view.

Fig. 8.7 The formula for calculating bladder volume = width (1) height (2) length (3) 0.625

Measurement of Bladder Volume


The bladder volume is obtained by rst locating
the largest transverse diameter in the mid-transverse view (Fig. 8.7). The width and the height
are measured. The transducer is then rotated 90
clockwise to obtain the sagittal view. In the
mid- sagittal view the length of the bladder is
mea- sured using the dome and the bladder
neck as the landmarks. These measurements
may be made using a split screen so that both
measure- ments are on the same screen. These
images are printed or saved electronically. The
bladder vol- ume is calculated by multiplying
the width, height, and length measurements by
0.625. When the specied measurements are
obtained, the calculated bladder volume will
usually be automatically displayed. When
measuring urine volume in the bladder, the
report should indicate whether the volume is a
bladder volume mea- surement or a post-void
residual urine volume measurement.

measured at a number of different locations. In


this case the bladder wall thickness is measured
along the posterior wall on the sagittal view
(Fig. 8.8). If the bladder wall thickness is less
than 5 mm when the bladder is lled to 150 cc,
there is a 63% probability that the bladder is not
obstructed. However, if the bladder wall
thickness is over 5 mm at this volume, there is
an 87% probability that there is bladder outlet
obstruc- tion. Nomograms are available to
calculate the likelihood of urodynamically
demonstrated bladder outlet for bladder wall
thickness at vari- ous bladder volumes [2].

Evaluation of Ureteral Efux

The efux of urine from the distal ureters can


be appreciated using power or color Doppler.
By positioning the probe in the sagittal view
(orienting notch toward the patients head) and
then twisting the probe approximately 15 to
one side or the other, the probe is aligned with
the direction of urine efux from the ureteral
Measurement of Bladder Wall
orice. This will often demonstrate efux.
Thickness
Ureteral jets of urine can be seen on gray
scale but are more easily seen using Doppler.
Measurement of bladder wall thickness is taken, These jets are seen as a yellow/orange streak
by convention, when the bladder is lled to at when power Doppler is used (Fig. 8.9). These
least 150 cc. Bladder wall thickness may be jets would appear red on color Doppler.