GENITOURINARY RADIOLOGY 1 (Normal: X-Ray, CT, MRI, Ultrasound)

Ma. Cartrini O. Cruz, M.D.

Department of Radiological Sciences
UST Faculty of Medicine and Surgery
(Transcribed from the Powerpoint Presentation. Side notes from: DALM and MinionNotes. Photos from: DRJCSRN and Netters Atlas)

INTRODUCTION
Before requesting any imaging modalities:
Good History and PE = Working
Diagnosis
Choose appropriate imaging modalities
Questions
Is the modality going to affect my diagnostic
certainty about the differential diagnosis I am
considering?
Will the information I expect to receive from this
imaging modality change my diagnostic thinking
enough to affect my choice of Treatment?

NORMAL RADIOGRAPHIC ANATOMY

KIDNEYS
Retroperitoneal between T11-L3
Visualized radiographically because of perirenal
fat

Renal axis parallel to psoas muscles

Fat appears to be black (radiolucent) in

X-ray
Axis is directed laterally and
downwards

RIGHT is lower than the LEFT

This is due to the presence of the head

of the liver (on the right side)

Anatomy

Retroperitoneum (3 compartments):
Anterior pararenal
o Pancreas, duodenum (2nd, 3rd , 4th),
ascending and descending colon,
vascular supply to spleen, liver,
pancreas and duodenum
Perirenal
o Kidneys and adrenal glands, renal
vessel, proximal tubules
Posterior pararenal
o Smallest
o Fat, vessels and nerves

Renal Fascia

These spaces communicate caudally near the pelvic brim

Renal Size:
Adult: 11-15cm (Length) 3.7+0.37 x L2 vertebral
body height
o

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Locate for the last floating rib

Children: height of L1-L4 vertebral bodies

including disc spaces + 1cm

Renal Shape Variations:

Fetal lobulations
o Right or Left Kidney
o Indentation along lateral border
Dromedary hump
o Left Kidney

Due to pressure from spleen

Focal bulge or convexity along mid

border

Contrast material is excreted through the cup-shaped fornices

CALYCEAL PATTERNS

NEPHRON
Outer Renal Cortex
o Glomeruli, proximal and distal
convoluted tubules
Inner medulla
o Collecting tubules and loops of
Henle
CALYCEAL COMPLEX
Major Calyx
o Base infundibulum
Minor Calyx
o Body/calyx proper, fornix
Usually 2 major calyces & 6-14 minor calyces
Note: on IV urogram Cup-shaped fornices -> calyx -> pelvis ->
ureter

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Normal Variations

(A)

(B)

(C)

(A) Blunting of the calyces (i.e. Hydronephrosis)

(B) Attenuated/narrowed infundibulum
(several blunted calyces)
(C) Moth-eaten appearance of the calyces
(i.e. Pyelonephritis)

RENAL PELVIS
Usually triangular with base parallel to long axis
of kidney
Partially intrarenal and partially extrarenal
Types:
(A) Intrarenal type short and small
(B) Extrarenal type large with long major calyces

Prostatic Enlargement

URETERS
Course downward, turn postero-laterally and
course in an arch downward and inward then
anteriorly to enter Urinary Bladder
Ureteral peristalsis
o

Entire ureter is not usually visible due to

peristalsis

KUB (KIDNEYS, URETERS, URINARY BLADDER)

Visualization of:
Renal shadows
Psoas muscle shadow
Calcification
o stones, vascular, lymph node or
tumor
Urinary Bladder shadows
o

Appear distended when filled with

urine

3 Normal Narrowings
Ureteropelvic Junction
Bifurcation of Iliac Vessels
o

From the Aorta

Ureterovesical Junction

Note: these are the common sites where renal calculi would
lodge

Staghorn Calculi

URINARY BLADDER
Transversely oval or round, 5-10mm above
symphysis pubis
o <5mm cystocoele
Male: rounded dome
Female: flat or slightly concave dome
o

The presentation is brought about by the

uterus
(A)
(B)
Plain KUB without contrast
(A) - nephrolithiasis/cystolithiasis (RUQ)
(B) - calcification overlying the vertebral body (Lateral
view)

A. Female

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B. Male

Nephrocalcinosis: Appendicolith

Indications
Urinary stones
Neoplasia
Urinary inflammations
Urinary trauma and obstruction
Miscellaneous: congenital anomalies, GUT
fistula formation, patent urachus, etc.

Appendicitis (RLQ)
Multiple mottled/rounded calcific densities (typical presentation
of nephrocalcinosis)

Phleboliths

IUD

Patient preparation
NPO
Bowel cleansing
o

Presence of fecal materials can be mistaken

as lithiasis/stones

Some cases: adequate hydration (MM, IDDM

and renal failure)

Cystolithiasis
(A)

(B)

(A) Without preparation: presence of fecal material

(B) With preparation: abnormal calcifications are seen
clearly

Urinary Bladder stones presents with egg-shaped density

(radiopaque)

EXCRETORY UROGRAPHY (EXU) OR INTRAVENOUS

UROGRAPHY (IVU)
Assessment of GUT requiring IV injection of
contrast to visualize renal collecting systems,
ureters and Urinary Bladder

Contrast Material
Organic iodides: radiopacity depends on its
iodine content
2 types
o Ionic
o Non-ionic: lower osmolality
Advantages: less toxicity and
reactions
Disadvantages: more
expensive
Mechanism of excretion
o Almost entirely by glomerular filtration
o Little or no tubular resorption
Contraindications:
o Hypersensitivity to contrast
o Combined hepatic and renal disease
o Oliguria
o Serum creatinine >2.5-3.0 mg/dl
o IDD with renal insufficiency (serum
creatinine > 1.5 mg/dl)
o Multiple myeloma

o
o

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Bence Jones protein

Hx of severe allergy
Use of metformin (within previous
48hrs)
value of information obtained must be weighed
against the risk
Adverse contrast reactions
o Minor: urticaria, sweating , nausea,
vomiting
o Major: laryngeal edema, hypotension,
bradycardia, shock, seizure,

anaphylactoid reaction, such as cardiorespiratory arrest

Nephrogram
o Diffuse opacification of the renal parenchyma
o Reflects the ability of proximal tubules to
reabsorb water and concentrate the contrast
o Visualize renal outline
Note:
o
o
o

Postvoiding or postmicturation
Visualize residual urine if present
Upright view: show significant descent of kidney

Kidneys appear more white than plain radiographs

At this phase, kidney size can be measured
Collecting structures are not visualized

Delayed x-ray films

Requested in Patients with abnormal renal
function (poorly or non-functioning)
Used to localize level of obstruction
o

Pyelogram
o Visualization of the pelvocalyceal complex and
ureters
o Contrast has reached the collecting tubules and
excretory passages
o Information on architecture and function of
kidney

Proximal, distal or mid-ureter

Delayed films are taken up to 24-48 hrs after

injection of contrast (case to case basis)

Triplication of Collecting System: Hydronephrosis

(A)

(B)

(A) three sets of ureters seen on the left side

(B) dilated pelvocalyceal complex; bilateral dilatation of
ureters; Hydronephrosis

Obstructive Uropathy

Cystogram
Visualization of the lower part of ureters and
Urinary Bladder
Note:
o
o

Well distended contrast field

Note for abnormal filling defects
(A)

(B)

(C)

(A) Plain KUB, without peristalsis (seen due to obstruction)

(B) Blunting of calyces, Right ureter is visualized (arrow)
(C) Presence of residual urine (arrow)

RETROGRADE PYELOGRAPHY
Visualization of urinary collecting system
achieved via cystoscope, ureteral catherization
and retrograde injection of contrast
Used when IVU failed to opacify renal collecting
system and ureters
Note: Retrograde introduction of contrast material

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Note:

CYSTOGRAPHY
Visualization of the Urinary Bladder wherein a
urethral catheter is inserted and the Urinary
Bladder is filled with contrast
Indicated for suspected Urinary Bladder rupture
in trauma patients and suspected Urinary
Bladder tumors, diverticula and calculi

Post Void volume

o Urinary retention
o Patients with BPH

Female Urethra

Note: Fistulous connection between the urethra and rectum

ULTRASOUND
Indications
Congenital anomalies
Infections
GUT stones
GUT masses
Vascular
Medical diseases
Renal transplant
Ultrasound-guided interventions

VOIDING CYSTOGRAPHY OR CYSTOURETHROGRAPHY

Filling Urinary Bladder with contrast to the point
of urge to void, so that voiding process can be
imaged
o

To visualize the urethra

Indicated for suspected lower urinary tract

obstruction and suspected vesicoureteral reflux

Note:

KIDNEYS
Echogenic central renal sinus
(white; collecting structures)

Note: Indicated in patients with vesicoureteral reflux

Male Urethra
o Urinary Bladder
o Prostatic
o Veromuntanum
o Membranous
o Bulbar
o Pendulous
o Fossa navicularis

o Fat
Normal calyces
o Usually not visible (unless dilated)

Echogenic central renal sinus

(where collecting ducts are located)

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Absence of radiation, therefore, indicated in pediatric

patients
Thinning cortical areas:
o Renal parenchymal disease

Low level echoes in peripheral cortex

o Glomeruli
Hypo or anechoic pyramids
o Renal tubules, supporting tissues, blood
vessels

Tumor detection (unknown primary),

metastasis search, GUT involvement in
lymphoma, treatment planning, followup
Infection
o Acute, chronic, abscess, XGP, TB,
cystitis
Trauma
o Exlude/detect and characterize GUT
injury
Calculus disease (CT STONOGRAM)
o
o

Hydronephrosis: Black

Renal cortex is less echogenic than the adjacent

liver and spleen
o Signify renal parenchymal disease if
same echogenicity

No preparation
lithiasis

Renal failure
o Hydronephrosis, parenchymas disease
Miscellaneous
o Congenital anomalies, vascular,
transplants

CT: Kidneys
Elliptical or round soft tissue structures of soft
tissue density with central renal sinus
predominantly composed of fat density
Renal outline is visible and smooth because of
perirenal fat

Normal ureter
o Usually not visible (unless dilated)
Urinary bladder

(Patient must take fluid to distend the Urinary Bladder)

Anechoic with thin walls

Filled with water

Thickened wall signify Cystitis
Low-level echoes are
abnormal

Kidneys are surrounded by perinephric fat.

Fat appears dark in CT.
Anterior pararenal space: pancreas
Thinning of cortex (Renal Parenchymal Disease)

CT AND MRI
Indications
GUT masses
o Cyst, tumor, psuedotumor,
calcifications, AV malformation,
evaluate lesions that are indeterminate
on US and IVU, state solid masses
Oncologic management

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Cortex and medullary portions

o Cannot be distinguished on
unenhanced scans, but can be
demarcated with rapid IV bolus

Collecting system
o Best seen on contrast study

Note: Delayed contrast - contrast is seen in the renal pelvis

Ureters
o Note relationship of ureters to psoas
and the transverse process
(anterolateral to psoas muscle)

Venous: Inferior Vena Cava (IVC)

Delayed: Contrast media in the collecting structures

CT Stonogram

Stones are hyperdense

Superior pole down to Urinary Bladder

Urinary bladder
o Best seen on contrast study

Renal Vasculature

GUT CT Scan

Nephrolithiasis

Ureterolithiasis

Nephrolithiasis:

Small hyperdense structure in right middle pole

Ureterolithiasis:

Hyperdense at the area of right proximal ureter

Plain: without contrast
Arterial:

Contrast media with renal parenchyma

Cant visualize collecting structures

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UVJ Stone

Horseshoe with Nephrolithiasis

UVJ Stone: calcific density at right UVJ, dilatation of PCC

Horseshoe with nephrolithiasis:

Hyperdensities nephrolithiasis

Dilated PCC
Hydronephrosis

Hydronephrosis at the right

with

Hyperdensity at ureter
Ureterolithiasis

Hydronephrosis due to ureterolithiasis

MAGNETIC RESONANCE IMAGING (MRI)

Most useful in:
Evaluation of renal masses in patients with
contraindication to IV contrast
Contrast enhanced CT has been inadequate for
diagnosis and staging
Detection of renal vascular disorder
Appearance of specific structures varies with the
IMAGING SEQUENCE

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Gadolinium-enhanced T1-weighted SE
o Early cortical enhancement within 1st
minute of contrast
o Then, diffuse parenchymal
enhancement (uniformly hyperintense)