Ultrasound signs of bladder pathology

Bladder pathology

It is important to determine the presence of:

1. Changes in wall thickness and trabecularity.
2. Asymmetries of the urinary bladder.
3. Cystic structures in the bladder cavity (ureterocele or diverticula).
4. Tumor structures in the bladder cavity or at the base of the bladder.

General thickening of the bladder wall

• In men, general thickening of the bladder wall occurs most often in the presence of obstruction at the level of the prostate gland. If obstruction at this level is suspected, examine the prostate gland; it is also necessary to exclude hydronephrosis, for this it is necessary to examine the ureters and kidneys. Also look for diverticula of the bladder: they protrude outward, but at the same time, visualization of the diverticulum is possible only if its diameter is at least 1 cm. Diverticula are usually anechoic, with good sound conduction. In some cases, the neck of the diverticulum is visualized: the diverticulum may collapse or enlarge during urination.
• Severe chronic inflammatory processes/cystitis. The bladder wall may be thickened and have an irregular outline. Examine the rest of the urinary tract for dilations.
• Schistosomiasis. The bladder wall may be thickened, its echogenicity may be increased with local hyperechoic inclusions due to the presence of calcifications. Calcification of the wall may be local or general, the thickness of the calcification zone may also vary. Calcification usually affects the intramural spaces and does not interfere with normal contraction of the bladder.

Poor bladder emptying indicates the presence of an acute inflammatory process, as well as a long-standing or recurrent infection. The prevalence of calcification does not correlate with the activity of schistosomiasis infection, and calcification may decrease in the late stages of the disease. However, the bladder wall remains thickened and poorly stretchable. Hydronephrosis may be detected.

• A very thick trabecular wall of the bladder in children is determined as a result of external obstruction due to a posterior urethral valve or the presence of a urogenital diaphragm.
• A very thick wall can be determined in the presence of a non-irogenic bladder, and this is usually combined with ureterohydronephrosis.

Localized thickening of the bladder wall

If there is a suspicion of local thickening of the bladder wall, it is necessary to perform multipositional sections, especially to exclude a tumor. Changing the patient's body position or additional filling of the bladder will help differentiate pathology from normal bladder folding. (The folds disappear when the bladder is stretched.) If there is any doubt, repeat the examination in 1-2 hours: do not allow the patient to urinate until the repeat examination.

Thickening of the bladder wall? Give the patient more fluids

Local thickening of the bladder wall can be determined by:

1. Wrinkles due to insufficient filling.
2. Tumors: broad-based or pedunculated, single or multiple.
3. Damage to the bladder due to tuberculosis or schistosomiasis (with the formation of granulomas).
4. Acute reaction to schistosomiasis infection in children.
5. Hematoma resulting from trauma.

Differential diagnosis of local thickening of the bladder wall

1. Most bladder tumors are multiple but localized in one area. Some tumors cause only localized wall thickening, but most also contribute to the development of polypous growths. It is important to determine whether or not there is bladder wall invasion. Calcification of the tumor-like structure or wall as a result of schistosomiasis causes hyperechoic structures.
2. Bladder polyps are often mobile and have a thin stalk, but there are polyps on a thick base, especially those that develop against the background of inflammation, which are difficult to differentiate from malignant tumors.
3. Granulomas (e.g., tuberculous) cause multiple localized wall thickenings. Often a small bladder is formed with pain when stretched, which leads to frequent urination. Tumor lesions of the bladder are not accompanied by pain when stretched. Schistosomiasis can result in the formation of multiple flat plaques or polypous structures. Any chronic infection reduces the capacity of the bladder.
4. Trauma. If localized thickening of the bladder wall is detected after trauma, perform a pelvic examination to rule out fluid (blood or urine from the bladder) outside the bladder. Repeat the examination in 10-14 days. If the thickening is due to a hematoma, the swelling will decrease.
5. Schistosomiasis. Reinfected children may have an acute "urticarial" reaction, causing a sharp localized thickening of the bladder mucosa. This resolves with appropriate therapy or spontaneously after a few weeks.

Blood clots and swelling appear identical; both may be associated with hematuria.

Echogenic formations in the bladder

1. Wall bound
   • Polyp. A polyp on a long stalk may be mobile. Reposition the patient and repeat the examination.
   • "Soldered" stones. Stones can be single or multiple, small or large: they usually have an acoustic shadow, some of them are "soldered" to the mucous membrane, especially against the background of inflammation: scan in different positions in order to detect the displacement of stones.
   • Ureteroceles. Ureteroceles are cystic structures in the bladder cavity, in the projection of the ureteral orifice. Ureteroceles can change their shape. In children, ureteroceles sometimes reach such sizes that the contralateral ureter can also be blocked. Ureteroceles can be bilateral, but are usually not symmetrical. If you suspect a ureterocele, examine the kidneys and ureters for asymmetric hydronephrosis and ureteral duplication.
   • Enlarged prostate gland. The appearance of an echogenic, non-displaceable structure located centrally at the bottom of the bladder in men is most likely due to an enlarged prostate gland. In women, an enlarged uterus can also displace the bladder.
2. Movable echogenic formations in the bladder cavity
   • Stones. Most stones will move in the bladder unless they are giant stones. However, stones may be lodged in a diverticulum or be so large that they seem to fill the bladder completely: the bladder's ability to hold urine is reduced by the presence of large stones. When in doubt about the presence of stones, change the patient's position and repeat the examination. Small and medium-sized stones will move, but large stones may not move.
   • Foreign body. Catheters are most commonly visualized. Very rarely, foreign bodies inserted into the bladder are visualized. If foreign bodies are suspected, a thorough history should be taken. Radiography may be helpful.
   • Blood clot. A blood clot may look like a stone or foreign body: not all blood clots move freely.
   • Air. Air introduced into the bladder through a catheter or formed during inflammation, or entering the bladder through a fistula appears as echogenic mobile floating structures.

Enlarged (overstretched) bladder

In an overfilled bladder, the walls will be smooth and even overstretched, with or without diverticula. Take measurements to confirm the presence of an overfilled bladder.

Always examine the ureters and kidneys for hydronephrosis. Ask the patient to empty the bladder and repeat the examination to determine how completely the bladder empties.

The most common causes of bladder overdistension are:

1. Enlargement of the prostate gland.
2. Strictures of the urethra in men.
3. Stones in the urethra in men.
4. Trauma to the female urethra (so-called "newlywed urethritis").
5. Neurogenic bladder in spinal cord injury.
6. Urethral valves or diaphragm in newborns.
7. Cystocele in some patients.

Small bladder

The bladder may be small in cystitis, and the patient cannot hold urine for a long time, and is bothered by frequent painful urination. The bladder may also be small as a result of damage or fibrosis of the wall, which significantly reduces the capacity of the bladder. Urination will be frequent, but not painful.

If you have any doubts, give the patient more fluid and ask him or her not to urinate; repeat the test in 1-2 hours.

A small bladder can be a result of:

1. Schistosomiasis (late stage): Typically, there are bright hyperechoic structures due to calcification of the wall.
2. Recurrent cystitis, especially common with tuberculosis. Thickening of the wall will be determined.
3. Rarely occurring infiltrating tumors. When a tumor is present, the bladder is always asymmetrical.
4. Radiation therapy or surgery for malignant tumors. Collect anamnestic data.

Before diagnosing a small bladder, ask the patient to drink more water and repeat the examination in 1-2 hours.