We present different cases of our institution,
which works together with the area of urology where we show some of the most representative cases in our experience and timely help in the diagnosis.
NEPHROLITHIASIS:
It is the presence of stones in the urinary system,
being the main cause of emergency urological visit.
As the first diagnostic method,
ultrasound is used,
which has a high sensitivity of up to 90%,
to detect hydronephrosis and ureteropelvic and ureterovesical junction stones, but it has limitations for visualizing ureteral stones in the middle and distal third due to gas interposition.
The ultrasonographic findings that we can find are:
• A hyperechogenic image that generates the posterior acoustic shadow.
Fig. 2 Fig. 3
Fig. 3
Fig. 3: RENAL CALCULI. Hyperechogenic foci with acoustic shadowing.
Fig. 4
Fig. 4
Fig. 4: STAGHORN CALCULUS, also called coral calculi, are renal calculi that obtain their characteristic shape by forming a cast of the renal pelvis and calyces, thus resembling the horns of a stag.
• Dilation of the renal pelvis and proximal ureter.
Fig. 8
• Increased echogenicity of peri-renal fat.
• Twinkling artifact on color Doppler.
Fig. 6
Fig. 6
Fig. 6: TWINKLING ARTIFACT is an artifact seen with Color Doppler that is the result of intrinsic machine noise. It occurs as a focus of alternating colors on Doppler signal behind a reflective object (such as calculi), which gives the appearance of turbulent blood flow.
Fig. 7
CT is more sensitive and is useful for the identification of ureteral stones in any part of the urinary tract and acute urinary obstruction.
The technique is used without oral or intravenous contrast that goes from the upper part of the kidneys to the symphysis pubis.
Fig. 5
DEGREES OF HYDRONEPHROSIS:
O.
Normal kidney.
1.
Renal pelvis with mild dilatation without calcitic ectasia.
2.
Moderate dilatation of the renal pelvis with calcitic ectasia.
3.
Great dilatation of pelvis and renal chalices with normal renal parenchyma.
Fig. 10
4.
Great dilatation of pelvis and renal chalices with slimming renal parenchyma. Fig. 9 Fig. 11
OVER DISTENDED BLADDER:
Produced by the complete or almost complete inability to urinate,
which leads to severe bladder distension accompanied by pain.
BLOOD MOLD:
Blood clots inside the bladder lumen can mold the shape of it and can be confused with tumors,
but differ in that the latter present color Doppler signal and decubitus changes remain attached to the wall.
By Ultrasound the mold is characterized by being a mass of solid appearance,
mobile,
without color Doppler signal,
of variable size,
which reduces after the bladder wash treatment.
Fig. 12
Fig. 12
Fig. 12
Fig. 12: BLOOD MOLD
ACUTE PYELONEPHRITIS:
Kidney-interstitial renal infection,
very common in the urology department.
It usually does not require diagnostic tests,
except in cases of atypical presentation or comorbidities,
such as diabetes.
In these cases,
ultrasound is used to analyze the renal architecture,
and CT,
the method of choice,
for the complications that can be generated.
The most relevant ultrasound findings are:
- Increase in kidney size.
Fig.
- Poorly defined hypoechoic parenchymal areas as signs of edema.
Fig. 13
- Loss of cortico-medullary differentiation.
Fig. 14
- An increase in the color Doppler signal as inflammatory signs.
Fig. 15
In CT we can find:
- Striated nephrogram: alternating linear bands hypo and hyperdense in a phase without intravenous contrast,
these may be due to parenchymal hemorrhage and ischemia respectively.
- A mottled decrease in enhancement after administration of EV contrast,
which is produced by inflammation and edema within the renal parenchyma.
- Nephromegaly.
- Recirculation of peri-renal fat.
- Thickening of the pyelocalyceal wall.
- Delay in the excretion of the affected side.
RENAL ABSCESS:
Complication of pyelonephritis.
In CT,
it is identified as a hypodense area,
with ring enhancement after contrast,
there may or may not be gas inside,
and associated signs such as edema of perirenal fat.
Fig. 17
Fig. 17
Fig. 17
Fig. 17: RENAL ABSCESS. Hypodense area, with ring enhancement after contrast.
EMPHYSEMATOUS PYELONEPHRITIS:
Severe acute and necrotizing renal parenchymal infection usually due to large negative organisms that behave like anaerobic gas generators.
Frequent in the elderly,
diabetics and immunocompromised.
The echographic findings show echogenic foci in the renal parenchyma that generate gas reverberation artifact.
CT is the study of choice. It can be found enlarged kidneys of size,
with alternation of parenchyma,
collections,
abscesses and air bubbles.
FOURNIER GANGRENE:
It is necrotizing fasciitis that affects the region of the external genitalia, more frequent in men between 50 and 70 years,
more frequent in diabetics.
It is a urological emergency due to its high mortality rate.
Ultrasound is used to identify the extent of the injury and possible underlying cause.
Rotiform echogenic images that generate artifact in Ring Down compatible with gas are recognized, a pathognomonic finding of this condition.
Fig. 18
Fig. 18
Fig. 18
Fig. 18: FOURNIER GANGRENE.
a. y b. Echogenic gas foci in cavernous bodies of the penis.
c. y d. Echogenic gas foci in the scrotal wall that generate artifact in Ring Down. Respected testicles.
The CT findings include subcutaneous emphysema,
an extension of the infection and probable cause as abscess or collections.
Fig. 19
Fig. 19
Fig. 19
Fig. 19: FOURNIER GANGRENE: Subcutaneous emphysema is visualized
ORCHIEPIDIDYMITIS:
The sonographic findings are usually similar to those of testicular torsion.
It usually affects the epididymis at first and extends to the testicle and scrotal sac.
Ultrasound is visualized:
- Associated orchitis,
hypoechoic testicle,
enlarged.
If the enlarged and painful testicle is hypoflowed before the color Doppler signal,
it may be a testicular torsion; On the other hand,
if it has hyperflow,
it would be an orchiepididymitis.
TESTICULAR TORSION:
It occurs as a result of a weak insertion of the testicles to the wall of the scrotum.
Testicular Doppler ultrasound is used as the diagnostic method of choice,
although in initial cases there may not be many alterations.
US Findings:
- Hypoechoic testicles.
- Reactive hydro-reels.
- Thickened tunics.
- Spermatic cord twisted and thickened.
- An absence of color Doppler signal in the affected testicle.
Color Doppler is effective in detecting testicular ischemia because it may show absence or asymmetric decrease in vascularization.
The findings found early are: Fig. 22
Fig. 22
Fig. 22
Fig. 22: TESTICULAR TORSION.
Left testicle enlarged, hypoechoic, without vascularization to color Doppler and power angio.
Right testicle with normal flows and normal echostructure.
- Absent venous flow.
- Absent or decreased arterial flow.
- The inflammatory reaction of soft tissues around the testicle.
TRAUMA TESTICULAR:
The third cause of acute testicular pain.
The function of ultrasound is to evaluate the condition of the tunica albuginea, whether it is intact or not since treatment depends on this.
Fig. 23
Fig. 23
Fig. 23
Fig. 23: TRAUMA TESTICULAR:
a. Testicle with a not well defined lesion, heterogeneous, hypo-echoic, compatible with a parenchyma contusion. Discontinuity in the tunica albuginea.
b. The lesion does not show Color Doppler signal.
c. Hematocele partitioned with septa (thin arrow).
d. Discontinuity in the tunica albuginea (thick arrow).
The deformed testicle can be found,
with irregular areas of increased or decreased echogenicity, thickening of the scrotal wall and rupture of the albuginea.
Fig. 24
Fig. 24
Fig. 24
Fig. 24: TESTICULAR TRAUMA.
Testicular heterogeneous parenchyma with loss of the structure and lack of definition of the tunica
PENILE FRACTURE:
It is due to the rupture of the tunica albuginea of the corpus cavernosum,
usually during the sexual act.
Ultrasonography should show the continuity solution of the tunica albuginea associated with a hematoma in the affected cavernous body.
Fig. 25: PENILE FRACTURE: Rupture of tunica albuginea (arrow) associated with a hematoma in the corpus cavernosum.
WUNDERLICH SYNDROME:
Spontaneous non-traumatic renal hemorrhage is a rare and very serious pathology.
Among the main causes is the presence of a pre-existing tumor,
angiomyolipoma is the most frequent,
and vascular causes.
Clinically manifested by the Lenk triad: sudden and intense pain in the flank,
palpable flank mass,
and hypovolemic shock.
Ultrasound is used initially in the patient's clinic,
finding perirenal collections of heterogeneous appearance.
The CT is the method of choice to detect occupation of the perirenal or subcapsular space by the hematoma and the underlying cause of it.
In the phase with contrast,
signs of active bleeding can be identified.
Fig. 26
Fig. 26
Fig. 26
Fig. 26: WUNDERLICH SYNDROME.
RENAL TRAUMA:
A grading scale of kidney injuries (AAST).
Fig. 29 Fig. 30 Fig. 31 Fig. 32
Fig. 28: DEGREES OF INJURY ACCORDING TO AAST
Fig. 27: GRADING SCALE OF KIDNEY INJURIES