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Bladder Disorders: An Ultrasonographic Approach
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The bladder should be scanned with high resolution transducer, from left to right in the longitudinal plane and cranial to caudal in the transverse plane. The bladder should be moderately distended for complete evaluation. This fluid-filled structure can be a useful acoustic window for evaluating adjacent structures such as ureters, lymph nodes, vessels, uterus and colon.
The normal distended bladder is a pear-shaped structure with a thin wall and anechoic contents, extending in the caudal abdomen. It is located on midline in the caudal abdomen ventral to the descending colon, aorta and caudal vena cava. Normal urinary bladder wall thickness can range between 1-3 mm in dogs and 1-2 mm in cats depending on the degree of filling. With increasing filling the wall thickness decreases. The urinary bladder is a common location to encounter side-lobe and pseudo-sludge artifacts, mimicking echogenic sediments in urine.
Bladder disorders can be divided into 2 categories: wall abnormalities and content abnormalities.
Wall abnormalities can appear as focal or diffuse thickening, mural nodules or masses, or rupture. It is important that the bladder be sufficiently distended to evaluate its thickness. Cranio-ventral thickening is most commonly seen in cystitis. Gas will be seen within the bladder wall in cases of emphysematous cystitis. Nodules/masses are seen with neoplasia (TCC) or polypoid cystitis. Biopsy is needed for definitive diagnosis.
Urinary bladder rupture is a challenging diagnosis to make via ultrasonography. In some cases of known uroabdomen, ultrasonographic findings of a small bladder with a mural defect will lead to the diagnosis; however, it is difficult to find the defect in most cases. Not finding the defect does not rule out bladder rupture.
Also, edge shadowing artifact may give the impression of a bladder wall defect that is not actually present. A positive contrast cystourethrogram is a less technically challenging method for evaluating cases of suspected rupture. Content abnormalities include: gas, calculi, blood clots, sediment, or foreign bodies. Calculi and mineralized sediment are found in the dependent portion of the bladder and are most commonly associated with strong far shadowing, whereas gas is found in the nondependent portion of the bladder and is associated with “dirty” (gray) shadowing/reverberation. Gas in the bladder is often iatrogenic (cystocentesis, catheter placement). Blood clots are often echogenic without acoustic shadowing. They may be adherent to the bladder wall, therefore it may be difficult to distinguish them from neoplasia or polyps. Color flow Doppler examination may assist to distinguish blood clot (no flow) from a mass.
Transitional cell carcinoma is the most common neoplasm of the urinary bladder. It is commonly an irregular bladder wall mass with a broad-based attachment. The echogenicity is often mixed and has an overall appearance that can be hyperechoic, isoechoic or hypoechoic compared to the bladder wall. The masses are most commonly located at the bladder trigone region and dorsal bladder wall. Due to the location of the ureteral papilla in this region, unilateral or bilateral hydroureter can occur. It is common for the mass to extend into the proximal urethra. A wide variety of other bladder tumor types are possible including epithelial (squamous cell carcinoma) and mesenchymal tumors (botryoid rhabdomyosarcoma, chemodectoma, leiomyosarcoma, leiomyoma, fibroma, fibrosarcoma, hemangioma, hemangiosarcoma, lymphoma, mast cell tumor). Ultrasonographic differentiation of tumor type and differentiating from non-neoplastic disease is often impossible without a biopsy. However, a mass with a smooth luminal surface is more likely to have a mesenchymal origin. Uncommonly, bladder tumors can diffusely invade the bladder wall. [...]
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