4/7/2017. Ultrasound of the Urinary Bladder. Indications for Bladder Ultrasound. Patient Preparation. Transition Adjustments.

Transcription

1 Indications for Bladder Ultrasound Ultrasound of the Urinary Bladder Hematuria, pyuria, or other UA abnormality Abnormal transitional cells Pollakuria, dysuria, stranguria, periuria History of urinary crystals and/or stones Overgrooming at the caudal abdomen in the cat Caudal abdominal pain Urinary obstruction Bladder is a nice acoustic window for the colon, uterus and sublumbar (iliac) lymph nodes Wendy Blount, DVM Patient Preparation Try linear array probe if you have one Gain and Contrast may need to decrease TGC top levers left If you forget to do this, you might not visualize the ventral bladder wall very well Landmarks for Bladder Depth varies according to size of pet and of bladder Frequency higher MHz Don t allow dogs outside Carry small dogs Remove litter box access for cats Place in dorsal recumbency Lateral recumbency for compromised patients Transition Adjustments Avoid urination for several hours prior to exam Image Views Sagittal Views (4) Place probe on the caudal abdomen Start at the pubis and slide cranially until you find the bladder Use a light touch, if the bladder is small If you can t find it, try rocking the probe caudally under the pubis, in case of pelvic bladder Lateral, right Mid-Sagittal, cranial - apex Mid-Sagittal, caudal trigone (2 distal ureters, proximal urethra), prostate Bounce bladder to look for 4. Lateral, left debris Transverse Views (3) 1. Cranial - apex 2. Mid-Transverse 3. Caudal Pole trigone, prostate 1

2 Image Views Bladder Wall Layers Sagittal Views (4) Lateral, right Mid-Sagittal, cranial - apex Mid-Sagittal, caudal trigone (2 distal ureters, proximal urethra), prostate Bounce bladder to look for 4. Lateral, left debris Transverse Views (3) 1. Cranial - apex 2. Mid-Transverse 3. Caudal Pole trigone, prostate Outer Serosa hyperechoic (white) Smooth Muscle Layers (3) hypoechoic (black) Submucosa/Lamina Propria hyperechoic (white) Mucosa hypoechoic (black) May not always see the layers on ultrasound, without high frequency probe Saggital Cranial Bladder (Apex) Right to Left Saggital Cranial Bladder (Apex) Right to Left Incidental Finding Soft tissue mass tail of spleen Saggital Cranial Bladder (Apex) Right to Left Saggital Cranial Bladder (Apex) Right to Left Saggital Neck of Bladder Right to left Look for the point to make sure you go through Incidental Finding Soft tissue mass neck of the bladder (prostate) 2

3 Saggital Cranial Bladder (Apex) Right to Left Saggital Neck of Bladder Right to left Look for the point to make sure you go through Saggital Cranial Bladder (Apex) Right to Left Saggital Neck of Bladder Right to left Look for the point to make sure you go through A single saggital video may be adequate for a small Transverse Cranial to caudal empty urinary bladder Saggital Cranial Bladder (Apex) Right to Left Saggital Neck of Bladder Right to left Look for the point to make sure you go through A single saggital video may be adequate for a small Transverse Cranial to caudal Saggital Cranial Bladder (Apex) Right to Left Saggital Neck of Bladder Right to left Look for the point to make sure you go through A single saggital video may be adequate for a small Transverse Cranial to caudal Soft tissue mass (spleen) colon artifact Too much pressure on probe missing left side of the bladder Saggital Cranial Bladder (Apex) Right to Left Saggital Neck of Bladder Right to left Look for the point to make sure you go through A single saggital video may be adequate for a small Transverse Cranial to caudal Saggital Cranial Bladder (Apex) Right to Left Saggital Neck of Bladder Right to left Look for the point to make sure you go through A single saggital video may be adequate for a small Transverse Cranial to caudal Too much pressure on probe missing neck of the bladder Gel deficiency 3

4 Lynn Foster Tyler TX Saggital Cranial Bladder (Apex) Right to Left Saggital Neck of Bladder Right to left Look for the point to make sure you go through A single saggital video may be adequate for a small Transverse Cranial to caudal Video Academy of Veterinary Imaging: dorsal recumbency Search for masses attached to the wall (FNA??) Distinguish from clots in the lumen Try different patient positions to assess gravitational effect Search for masses attached to the wall (FNA??) Search for masses attached to the wall (FNA??) Distinguish from clots in the lumen Try different patient positions to assess gravitational effect Trigone Mass Distinguish from clots in the lumen Try different patient positions to assess gravitational effect Bilateral Hydroureter Polypoid cystitis 4

5 Search for masses attached to the wall (FNA??) Search for masses attached to the wall (FNA??) Scan for bladder wall diverticula Assess the distal ureters for enlargement (hydroureter) Scan for bladder wall diverticula Assess the distal ureters for enlargement (hydroureter) Distinguish from clots in the lumen Try different patient positions to assess gravitational effect Distinguish from clots in the lumen Try different patient positions to assess gravitational effect Can sometimes visualize pulses of urine entering the bladder at the ureteral papillae Normal ureter width is <2mm Ectopic ureters are often dilated Can sometimes visualize pulses of urine entering the bladder at the ureteral papillae Normal ureter width is <2mm Ectopic ureters are often dilated Assess the retroperitoneal area for abnormalities Assess the retroperitoneal area for abnormalities Fluid, mass Fluid, Bladder debris Assess contents of the bladder mass Assess contents of the bladder Normal is anechoic Smoke can indicate cellular exudate or normal mucus Sparklies can indicate crystalluria, debris or mucus Normal is anechoic Smoke can indicate cellular exudate or normal mucus Sparklies can indicate crystalluria, debris or mucus Assess the retroperitoneal area for abnormalities Assess the retroperitoneal area for abnormalities Assess contents of the bladder Assess contents of the bladder Search for stones Search for stones Fluid, mass Fluid, mass Normal is anechoic Smoke can indicate cellular exudate or normal mucus Sparklies can indicate crystalluria, debris or mucus Normal is anechoic Smoke can indicate cellular exudate or normal mucus Sparklies can indicate crystalluria, debris or mucus will be resting on the dorsal bladder wall will be resting on the dorsal bladder wall 5

6 Assess the retroperitoneal area for abnormalities Light pressure if the bladder is small If you can t find the bladder, try finding the pelvic brim, and rocking caudally to find a pelvic bladder Fluid, mass Assess contents of the bladder Normal is anechoic Smoke can indicate cellular exudate or normal mucus Sparklies indicate crystalluria, debris/mucus (snow globe) Pelvic brim will produce a strong If you see echoic debris in the urine, be sure to get a urinalysis if not already done Pay careful attention to the cranioventral bladder wall Search for stones will be resting on the dorsal bladder wall Urachal diverticulum will be here Thickening due to cystitis often thickest here Normal bladder wall thickness is <3mm in the dog and <2mm in the cat Light pressure Urachalif the bladder is small If you can tdiverticulum find the bladder, try finding the pelvic brim, and rocking caudally to find a pelvic bladder If you have trouble visualizing the near field, try a linear array probe or a stand-off pad A problem especially in small/underweight patients If you are getting drop-out of the apex on the sagittal view, try sliding the probe caudally and rocking cranially Pelvic brim will produce a strong If you see echoic debris in the urine, be sure to get a urinalysis if not already done Pay careful attention to the cranioventral bladder wall Eliminates edge artifact parallel to beam Penile urethra outside os penis can be interrogated using a stand-off pad Look for the caudal point to find the proximal urethra Urachal diverticulum will be here Thickening due to cystitis often thickest here If you have trouble visualizing the near field, try a linear array probe or a stand-off pad To hasten filling of a small bladder for a better exam: Water bowl + time Subcutaneous fluids furosemide + water bowl Filling with sterile fluids via urethral catheter (take care not to introduce air) A problem especially in small/underweight patients If you are getting drop-out of the apex on the sagittal view, try sliding the probe caudally and rocking cranially Eliminates edge artifact parallel to beam Penile urethra outside os penis can be interrogated using a stand-off pad Look for the caudal point to find the proximal urethra 6

7 Take care not to over-interpret wall thickness or bulges in a small bladder Remember stones may or may not be seen on an x-ray Take care not to mistake dorsal pressure from a full colon for a stone Take care not to mistake a hyperechoic bladder wall Stone will produce an *Caveat* - tumors and colon contents can be mineralized, and thus produce an Stone will usually move due to gravitational effect as Both produce a nice If you are not sure, walk dog to defecate and try again Try lateral recumbency, or even standing/sternal to assess gravitational effect on stones Take care not to mistake a hyperechoic bladder wall Take care not to mistake a hyperechoic bladder wall Stone will produce an *Caveat* - tumors can be mineralized, and thus produce an Stone will usually move due tothickened gravitational effect as Colon Wall Side Lobe Artifact can mimic urine sediment in the far field Stone will produce an *Caveat* - tumors can be mineralized, and thus produce an Stone will usually move due to gravitational effect as Side Lobe Artifact can mimic urine sediment in the far field Small bowel dorsal to the bladder Take care not to mistake a hyperechoic bladder wall Take care not to mistake a hyperechoic bladder wall Stone will produce an *Caveat* - tumors can be mineralized, and thus produce an Soft tissue masseffect as Stone will usually move due to gravitational Side Lobe Artifact can mimic urine sediment in the far field Stone will produce an *Caveat* - tumors can be mineralized, and thus produce an colon Stone will usually move due to gravitational effect as Side Lobe Artifact can mimic urine sediment in the far field 7

8 Take care not to mistake a hyperechoic bladder wall clot Take care not to mistake a hyperechoic bladder wall mass for a stone Stone will produce an *Caveat* - tumors can be mineralized, and thus produce an Stone will usually move due to gravitational effect as Side Lobe Artifact can mimic urine sediment in the far field Stone will produce an *Caveat* - tumors can be mineralized, and thus produce an Stone will usually move due to gravitational effect as pseudosludge pseudosludge Side Lobe Artifact can mimic urine sediment in the far field Take care not to mistake a hyperechoic bladder wall mass for a stone Cannot tell malignant from benign mass based on ultrasound Add harmonics to resolve pseudosludge Take care not to darken the screen to much Stone will produce an *Caveat* - tumors can be mineralized, and thus produce an Stone will usually move due to gravitational effect as Side Lobe Artifact can mimic urine sediment in the far field You could miss debris or wall lesions Decrease the gain as needed pseudosludge Mike Nance Lufkin, TX Summary PowerPoint Urinary Bladder Ultrasound.pdf of PowerPoint Ultrasound of the Urinary Bladder (1 and 6 slides per page) Bladder Ultrasound TIPs Sheet Videos Case Examples Animated PowerPoint Bladder Scanning Hidden Slides Indications, Patient Preparation, transition adjustments, filling the bladder 8

9 Acknowledgments Stephanie Lisciandro, ACVIM (Internal Medicine) Chapter 6: Focused or COAST 3 Urinary Bladder Focused Ultrasound Techniques for the Small Animal Practitioner Editor Greg Lisciandro Bob Cole, ACVR Auburn University The Academy of Veterinary Imaging 2409 Avenue J, Suite C Arlington, TX (800) Acknowledgments John Mattoon, Danelle Auld, Thomas Nyland Chapter 4: Abdominal Ultrasound Scanning Techniques Small Animal Diagnostic Ultrasound Editors Nyland and Mattoon 3 rd Edition 2014 Thomas Nyland, John Mattoon, Eric Herrgesell. Erik Wisner Chapter 9: Urinary Tract Small Animal Diagnostic Ultrasound Editors Nyland and Mattoon 3 rd Edition 2014 John P. Graham, MVB, MSc, DVR, MRCVS Diplomate, ECVDI, Diplomate, ACVR Diagnostic Imaging in Dogs and Cats Nestle Purina Clinical Handbook Series Acknowledgments Sara Hunt, LVT Idexx Abdominal Ultrasound Scanning Protocol 9