INFLAMMOTRY URINARY BLADDER CONDITIONS Acute bacterial cystitis This disease is present when more than 100,000 bacteria are present in 1mL of fresh urine. Patients with acute cystitis may present with disease of varying degrees of severity; In women, associated haemorrhage is common. IVU results are typically normal. However, in severe cases, generalized bullous mucosal edema may cause the bladder wall to have a cobblestone appearance. This appearance is more pronounced on radiographs, which show a partially filled bladder, or on post voiding images, if residual contrast material is still present. Cystitis is common in sexually active women; it may occur 2-3 times per year and responds well to antibiotics. For patients with more frequent episodes of cystitis or for those with antibiotic resistance, the possibility of an underlying cause should be considered so the entire urinary tract should be imaged to exclude conditions such as calculus disease, bladder diverticula, colovesical fistula, and perivesical abscess. Contrast-enhanced study of the lower bowel shows a post irradiation colovesical fistula CT : For patients who have frequent episodes of cystitis or in the presence of antibiotic resistance, the possibility of an underlying abnormality should be considered; in such cases, the entire urinary tract should undergo imaging. CT scanning is useful when calculus disease, bladder diverticula, colovesical fistula, or perivesical abscess is under consideration. MRI is useful for evaluating colovesical fistula and perivesical abscess. US :Ultrasonography is useful when an underlying cause of recurrent cystitis is being considered. Such causes include associated renal disease, renal and bladder calculus disease, bladder diverticula, colovesical fistula, and perivesical abscess. Interstitial cystitis Interstitial cystitis is a rare, idiopathic disease that is pathologically characterized by fibrosis of the deeper layers of the bladder wall. The disease predominantly affects middle-aged women. Urinary tract infection (UTI) is not thought to be responsible for bladder wall fibrosis, because urine is usually sterile. In advanced disease, the ureterovesical junction becomes dysfunctional, and reflux develops. The bladder ultimately becomes thinned; ulceration and bleeding may occur. IVU results are usually normal unless reflux has developed, in which case non obstructive hydroureteronephrosis may be present. Cystography demonstrates a bladder with a small volume and a smooth or irregular wall. Reflux may also be seen. The main role of radiology in interstitial cystitis is in the exclusion of other diagnoses. US :In interstitial cystitis, the bladder is of small capacity, often 30-50mL. No associated conditions are described. The disease is extremely debilitating because of the limited bladder capacity and because of pain associated with overfilling. Ultrasonography is an accurate means of calculating bladder capacity and of excluding cystitis in association with an underlying pathology, such as calculi. The presence of any one of the following criteria excludes the diagnosis of interstitial cystitis. Bladder capacity of greater than 350 cm3 on awake cystometry using either a gas or liquid filling medium. Duration of symptoms of less than 9 months. Absence of nocturia. Symptoms relieved by antimicrobials, urinary antiseptics, anticholinergics, or antispasmodics. A frequency of urination, while awake, of less than eight times per day. A diagnosis of bacterial cystitis or prostatitis within a 3-month period. Bladder or ureteral calculi. Active genital herpes. Uterine, cervical, vaginal, or urethral cancer. Urethral diverticulum. Cyclophosphamide or any type of chemical cystitis. Tuberculous cystitis. Radiation cystitis. Benign or malignant bladder tumours. Vaginitis. Age less than 18 years. Eosinophilic cystitis Eosinophilic cystitis, also known as pseudo tumoral cystitis, is an uncommon inflammatory process seen in children and adults. In children, it is a selflimiting condition that resolves spontaneously and that usually requires no treatment. Therefore, its recognition is important. Predisposing factors for eosinophilic cystitis include asthma, allergies, and eosinophilic gastroenteritis. Bladder biopsy reveals pancystitis and the presence of eosinophils, among other inflammatory cells. Radiographic findings are non specific and include bladder wall thickening Ureteral obstruction and vesicoureteral reflux are seen. Some authors consider eosinophilic cystitis to be a mild, relatively self-limiting form of interstitial cystitis CT ; The cystitis manifested itself as a submucosal, elevated lesion of the bladder that mimicked a tumor. The submucosal, tumorous lesions were clearly demonstrated on 3D CT cystography; with that modality, it was possible to evaluate the mucosae of the lesions. The scans especially showed the bridging, fold like appearance of the submucosal tumorous lesions. US :Sonographic features of eosinophilic cystitis include the following: 1-A broad-based intravesical mass with a smooth or irregular outline 2-A mass confined to the bladder mucosa with preservation of the muscle layers 3-Trigone primarily involved with variable extension 4-Generalized bladder wall thickening with mucosal irregularity 5-Unilateral or bilateral hydronephrosis occurring as a result of mucosal thickening or obstruction at the vesicoureteral junction Cystic eosinophilic cystitis. (a, b) Axial (a) and sagittal reconstructed (b) contrastenhanced CT images show a thick-walled cystic mass (arrow) arising from the anterior dome of the bladder Cystitis cystica Cystitis cystica, cystitis follicularis, and bullous cystitis are names for the same disorder. This condition usually affects the lamina propria; expected findings include large cysts that resemble cobblestones; multiple, rounded filling defects at the bladder base; or both. These may closely resemble bladder carcinomas. The condition is potentially malignant. Cystitis cystica and cystitis glandularis. Oblique view of the bladder obtained during intravenous urography shows a lobulated contour of the bladder, with a nodular filling defect (arrow). Chemotherapy-related cystitis The incidence of bladder carcinoma is significantly increased in patients who undergo treatment with cyclophosphamide. Cyclophosphamide-induced cystitis is characterized by marked bladder edema and hemorrhage. IVU or cystography shows bladder wall thickening and irregularity, with intraluminal filling defects caused by blood clots. In late stages, the bladder may become fibrotic and have a small volume. Irregular bladder wall calcification may develop, but this is rare. During the acute phase of chemotherapy-induced cystitis, CT scan findings include thickening of the bladder wall and irregularity with intraluminal filling defects, caused by blood clots. In late stages, the bladder may become fibrotic; on imaging, such fibrosis manifests itself as a small-volume bladder. Irregular calcification of the bladder wall may develop. The incidence of bladder carcinoma may be markedly increased in patients who undergo treatment with cyclophosphamide. Bladder carcinoma may be readily identified on CT scans. Chemotherapy cystitis from cyclophosphamide. (a) Longitudinal US image shows diffuse wall thickening (arrows). (b) Axial contrast-enhanced CT image shows enhancement of the mucosal surface (arrow), as well as diffuse wall thickening. The hyperemic mucosa may ulcerate and cause hematuria Emphysematous cystitis Emphysematous cystitis is nearly always associated with diabetes mellitus ٌ ◌Rarely, emphysematous cystitis is seen in long-standing outlet obstruction, neurogenic bladder, or bladder diverticulum. Conventional radiographs demonstrate irregular, streaky lucencies in the bladder wall. Gas may also be seen in the bladder or the ureters. . On contrast-enhanced studies, these gas-filled vesicles may resemble submucosal filling defects produced by inflammatory or neoplastic processes. With the progression of disease, a ring of gas bubbles surrounding the bladder and separated from the bladder lumen may become obvious. On IVU, gas in the bladder may be evident as a horizontal air-contrast level on images obtained with the patient erect. Contrast-enhanced studies of the bladder may show thickened, irregular, or nodular bladder mucosa. CT : For patients with emphysematous cystitis, CT scan findings are usually diagnostic. Intraluminal gas, however, must be differentiated from gas entering the bladder iatrogenically or from an enteric fistula. US : On ultrasonography, air in the bladder wall appears as intramural echogenic foci with dirty shadowing. CT of 76-year-old woman with urosepsis shows cancer of urinary bladder causing bilateral hydronephrosis. CT scan shows that bladder wall thickening and enhancement (black arrowhead) are more prominent on left. Nondependent intravesicle air (white arrowhead) raises question of emphysematous cystitis or recent instrumentation. Arrows show bladder cancer causing obstruction and thereby dilatation of both ureters. Schistosomiasis Calcification in the wall of the bladder or distal ureters may be identified on plain radiographs. On IVU , findings in the bladder and distal ureters and the kidneys remain normal until late in the disease. Mucosal irregularity, inflammatory pseudopolyps, ureteritis cystica, ureteral dilatation and stricture, and reduced bladder capacity may be found The ureters may be dilated , persistent filling in the lower segment commonly occurs. Ureteral strictures may be found, and, as the disease progresses, beading of the lower ureteral segment may be observed. Subsequent ureteral fibrosis leads to calcifications of the distal ureter; on plain radiographs, these calcifications have a characteristic linear or parallel pattern. About 80% of the strictures occur in the bladder wall near the junction with the ureters. Ureteral dilatation is often caused by vesicoureteric reflux, stenosis of the ureter, or an edematous ureteral wall that causes deficient peristalsis. An intense granulomatous reaction to the ova occurs, and fibrosis eventually develops in the tunica propria, which is the site of the calcification visible radiologically. . The calcification spreads around the bladder wall and may completely encircle the bladder, appearing as a curvilinear ring. The bladder wall becomes fibrotic, but it is still distensible and maintains a normal capacity . KUB images often reveal the pathognomonic eggshell calcification of the bladder walls and the ureters. Changes in the motility of the ureter and ureteric strictures may cause hydronephrosis and reflux nephropathy. Patients are at increased risk for sone formation and squamous cell carcinoma of the kidney and bladder. A bladder carcinoma should be considered when follow-up imaging shows an absence of wall calcification in areas that were previously calcified. CT scanning is the best modality for delineating the extent of the calcifications associated with schistosomiasis. In cases of schistosomiasis, bladder calcifications are characteristically linear, coarse, or floccular. The calcifications are usually first seen in the base of the bladder on plain radiographs; they most commonly appear in the anterior wall of the bladder on CT scans. The thickness of the ureteral wall is better evaluated with CT scanning than with any other modality. Schistosomiasis may affect the prostate and urethra; in rare case, it causes destructive urethral fistula formation similar to tuberculosis. The fistulas may drain into the perineum, scrotum, suprapubic skin, or buttocks. MRI provides the best images of fistulous communications. US : Granuloma formation within the wall may produce sonographic findings of polypoid like thickening of the wall. curvilinear calcification in the bladder wall (arrowheads), which also extends to the distal left ureter (arrow). Calcification, representing an abundance of calcified ova, is typically seen in the chronic phase of the infection Plain abdominal radiograph in a 26-year-old man shows a curvilinear ring of bladder wall calcification Tuberculous cystitis Tuberculous cystitis is characterized by a gradual increase in the thickness of the bladder wall and increasing diminution of the volume the bladder. Bladder trabeculation may develop. The vesicoureteric orifices are affected by progressive fibrosis, with subsequent hydronephrosis and hydroureters. Or become fixed and patulous, resulting in vesicoureteral reflux. Bladder calcification is unusual; when it occurs, it is patchy. Fistulae or sinus tract formation may complicate bladder tuberculosis, though these complications are rare. They are best demonstrated on CT and MRI scans. When bladder calcification is seen on a plain abdominal radiograph, schistosomiasis is the diagnosis until proven otherwise. Tumor calcification must also be considered Bladder tuberculosis. Intravenous urogram demonstrates a thickened, contracted, lowcapacity bladder (thimble bladder) (arrowhead) with minimal dilatation of both ureters.
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