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INTRAVENOUS UROGRAPHY
Radiologic examination that may be used to help diagnose urinary tract disorders. To evaluate the suspected or continued presence of ureteral obstruction.
ANATOMY & PHYSIOLOGY
Kidneys – are a pair of bean-shaped organs on either side of your spine, below your ribs and behind your belly. Hilum - the entry and exit site for structures servicing the kidneys: vessels, nerves, lymphatics, and ureters. Renal Capsule - The fibrous connective tissue that surrounds each kidney. Renal cortex - outer portion of the kidney. Renal columns- a medullary extension of the renal cortex in between the renal pyramids. Renal medulla- inner portion of the kidney Renal pyramids- small structures that contain strings of nephrons and tubules. Renal papilla - the areas where the openings of the collecting ducts enter the kidney and where urine flows into the ureters Renal vein- The main blood vessel that carries blood from the kidney and ureter to the inferior vena cava Renal artery- large blood vessels that carry blood from your heart to your kidneys. Minor calyces - surround the apex of the renal pyramids. Major calyces - surrounds the apex of the malpighian pyramids. Renal pelvis - The area at the center of the kidney URINARY BLADDER - is a temporary storage reservoir for urine. Apex - is at the anterosuperior aspect and is adjacent to the superior aspect of the pubic symphysis Base - is the posteroinferior part of the bladder. Neck - most fixed part of the bladder Trigone - a smooth, triangular area Rugae - folds of tissue URETHRA- Narrow, musculo-membranous tube with a sphincter type of muscle at the neck of the bladder.
- Arises at the internal urethral orifice in the urinary bladder and extends about 1 ½ inches (3.8 cm) in the female and 7 to 8 inches (17.8 to 20 cm) in the male.
- Female urethra passes along the thick anterior wall of the vagina to the external urethral orifice
- Male urethra extends from the bladder to the end of the penis URETERS- convey the urine from the renal pelvis to the bladder by slow, rhythmic peristaltic contractions.
- 10 to 12 inches (25 to 30 cm) long
PATHOLOGY
Abdominal masses - a growth or swelling in a part of your abdomen. Renal cysts - round pouches of fluid that form on or in the kidneys. Renal tumors - abnormal growth in the kidney that can be benign or malignant. Urolithiasis - calculi or stones of the kidneys or urinary tract. Pyelonephritis - infection of the upper urinary tract, which can be acute or chronic.
Hydronephrosis - abnormal dilation of the pelvicaliceal system. Renal Hypertension - increased blood pressure to the kidney.
PREPARATION
Before
Patient is advised to follow a low-residue diet for 1-2 days prior to the examination to prevent gas formation caused by the excessive fermentation of the intestinal contents. Have the patient eat a light evening meal on the day before the examination. When indicated by costive bowel action, administer a non-gas-forming laxatives the evening before the examination. Have the patient take nothing by mouth after midnight on the day of the examination. The patient should not be dehydrated, however. Patients with multiple, high uric acid, or diabetes must be well hydrated before IVU is performed During Before the procedure begins, the patient should be instructed to empty the bladder. Check the patient's clinical history, allergic history, and blood creatinine levels should be reviewed. Normal creatinine: 0.6 to 1.2 mg/100mL. All radiopaque material should be taken out from the region of the study and patient should be dressed in an appropriate radiolucent gown. Explain to the patient and patient party to what could possibly happen during and after the procedure and make sure that the consent is signed.
MATERIALS
Side marker Time interval marker Tourniquet Gloves Syringe
CONTRAST MEDIA
Water-Soluble Iodinated Omnipaque
Procedure
Patient is placed in supine position with pelvis at cathode side of the tube A support is placed under patients’ knees to reduce lordotic curvature of lumbosacral spine and provide comfort A scout film is taken including the Kidneys, Ureters, Bladder, and Urethral region on a large size film Contrast media is injected intravenously into a prominent vein in the arm Test injection of 1 ml of contrast is given and patient is observed for 1 minute to look for any contrast reactions. Then the rest of the contrast is rapidly injective within 30-60 seconds
LATERAL PROJECTION
R or L position Image Receptor: 14×17 inch (35×43 cm) lengthwise Position of the patient Turn the patient into a lateral recumbent position on the right or left side, as indicated Position of part Flex the patient’s knee to a comfortable position; elbow flexed; hands placed under patient’s head; center IR at the level of iliac crest Central ray Perpendicular to the IR, entering the midcoronal plane the level of the iliac crest. Structures Shown A lateral projection of the abdomen shows the kidneys, ureter, and bladder filled with contrast material. Lateral projections are used to show conditions such as rotation or pressure displacement of a kidney and to localize calcareous areas and tumor masses LATERAL PROJECTION Dorsal decubitus position Image receptor: 14×17 inch (35×43 cm) Position of patient Supine position; ensure that the wheels are locked; patient’s arms across the upper chest (to ensure that they are not projected over any abdominal contents) or place them behind the neck; flexed knees (to relieve strain on the back) Position of part Adjust the height of the vertical grid device so that the long axis of the IR is centered to the midcoronal plane of the patient's body. Iliac crest is centered to the IR Adjust the patient to ensure that no rotation from the supine or prone position is present. Central ray Horizontal and perpendicular to the center of the IR, entering the midcoronal plane at the level of the iliac crests. Collimation Adjust to 14×17 inches(35×43 cm) on the collimator. Structures shown Rolleston and Reay recommended the ventral decubitus position to show the UPJ in the presence of hydronephrosis. Cook, et al. advocated this position to determine whether an external mass in the flank is intraperitoneal or extraperitoneal, and they stated that the position makes it easy to screen kidneys and ureters for abnormal anterior displacement.
INFUSION IVU (DRIP)
Contrast is given in 500 ml normal saline Now this procedure is not widely used. Drip infusion is used as the initial pyelographic procedure whenever complete visualization of the ureters is desired.
Advantages: *Nephrogram persists for longer time. *Enhanced dieresis from the additional contrast media and water volume will distend the collecting system *Collecting system is visualized for long times *No significant increase the contrast reactions *Administration is easy Disadvantages: *Overloads the patient with more iodine than necessary *Calyceal blunting may be produced. Suggesting abnormal dilation *May lead to pyelosinus extravasations and pain in patients with partial obstruction *An initial vascular nephrogram is not obtained
CYSTOURETHROGRAM / MICTURATION CYSTOURETHROGRAM
it is the radiographic examination of urethra, bladder by injecting contrast media through
catheter.
ANATOMY & PHYSIOLOGY
Urinary bladder – a musculomembranous sac that serves as a reservoir for urine. Apex - the anterosuperior aspect and is adjacent to the superior aspect of the pubic symphysis. Base/ fundus – the posteroinferior part of the bladder. Neck – a group of muscle that connects the bladder to the urethra. Trigone – a triangular area between the three orifices Rugae – a folds in the stomach lining. Urethra – a narrow, musculomenbranous tube with sphincter type of muscle at the neck of the bladder Female urethra – widest at bladder neck Male urethra – extends from bladder neck till the meatal opening at penis It has four regions Prostatic urethra – passes through the prostate gland. Membranous urethra – passes through the urogenital diaphragm Bulbar urethra – from inferior aspect of urogenital diaphragm to penoscrotal junction. Spongy urethra – passes through the length of the penis
PATHOLOGY
Vesicoureteric reflux – abnormal flow of urine from your bladder back up the tubes(ureters) that connect your kidneys to your bladder. Abnormalities of bladder Dysuria – pain or discomfort when urinating. Chronic urinary tract infection – are infections of the urinary tract that either don’t respond to treatment or keep recurring Suspected urethral diverticulum – a localized outpouching of the urethra into the anterior vaginal wall. Urinary tract infection – an infection involving the kidneys, ureters, bladder or urethra. These are structures that urine passes through before being eliminated from the body. Dysfunctional voiding – refer to daytime voiding disorders in children who do not have neurologic, anatomic, obstructive or infectious abnormalities of the urinary tract. Hydroureter – refers to distension and dilation of the renal pelvis and calyces. Bladder outlet obstruction – a blockage at the base of the bladder. Hematuria – is the presence of red blood cells in the urine Incontinence – also known as involuntary urination, is any leakage of urine
Position of Part: The supine patient is adjusted in an oblique position so that the bladder neck and the entire urethra are delineated as free of bony superimposition as possible. Rotate the patient’s body 35 to 40 degrees, and adjust it so that the elevated pubis is centered to the midline of the grid. The superimposed pubic and ischial rami of the down-side and the body of the elevated pubis usually are projected anterior to the bladder neck, proximal urethra, and prostate. The patient’s lower knee is flexed only slightly to keep the soft tissues on the medial side of the thigh as near to the center of the IR as possible. The elevated thigh is extended and retracted enough to prevent overlapping. With the patient in the correct position, the physician inserts the contrast medium–loaded urethral syringe or the nozzle of a device such as the Brodney clamp into the urethral orifice. The physician extends the penis along the soft tissues of the medial side of the lower thigh to obtain a uniform density of the deep and cavernous portions of the urethral canal. At a signal from the physician, instruct the patient to hold still; make the exposure while injection of contrast material is continued to ensure filling of the entire urethra. The bladder may be filled with a contrast material so that a voiding study can be performed. This is usually done without changing the patient’s position. When a standing upright voiding study is required, the patient is adjusted before a vertical grid device and is supplied with a urinal.
Female cystourethrogram
AP PROJECTION
INJECTION METHOD
Image Receptor : 8 x 10 inch ( 18 x 24 cm) or 10 x 12 inch ( 24 x 30 cm ) lengthwise. Position of the patient : The patient is adjusted in the supine position on the table. Position of part:
- Oblique projections may be required in addition to the AP projection. For oblique projections, the patient is rotated 35 to 40 degrees so that the urethra is posterior to the pubic symphysis. The uppermost thigh is extended and abducted enough to prevent overlapping.
- For an AP projection, the patient is maintained in the supine position, or the head of the table is elevated enough to place the patient in a semi-seated position.
- A lateral voiding study of the female vesicourethral canal is performed with the patient recumbent or upright. In either case, the IR is centered at the level of the superior border of the pubic symphysis.
EPIDIDYMOGRAPHY
radiographic examination of the epididymis ANATOMY & PHYSIOLOGY ● Epididymis - narrow, tightly-coiled tube connecting rear of the testicles to the deferent duct ❖ Regions of Epididymis a. head (caput epididymidis) - largest and most prominent part and is found at the superior pole of the testis b. body (corpus epididymidis) - found at the inferior pole of the testis c. tail (cauda epididymidis) - sperm mature in this section of the epididymis PATHOLOGY
● Epididymal masses - also known as a spermatic cyst or epididymal cyst, spermatocele is a typically painless, noncancerous (benign), fluid-filled sac in the scrotum ● Epididymal leiomyomas - are uncommon smooth muscle tumors that do not have malignant potential ● Epididymal Abscess -an uncommon complication of epididymitis wherein the scrotum is usually inflamed and painful ● Epididymitis -refers to inflammation of the epididymis and may be associated with inflammation extending to the testis itself ● Epididymo-orchitis- originates in the bladder or prostate gland spreads through the ductus deferens and the lymphatics of the spermatic cord to the epididymis, and finally reaches the testis ● Epididymal Calcification - hyperechoic foci within the epididymal head ● Ductus deferens calcification - chronic infection/inflammation tends to be irregular (unilateral and segmental) PREPARATION
- Informed consent.
- Indication for the examination and specifically the use of contrast media.
- Investigation into the medical history.
MATERIALS
● Gloves ● Catheter ● Syringe
CONTRAST MEDIA
**1. Water-soluble iodinated compound
- Gas iodinated compound**
Procedure
1. The seminal vesicles are sometimes opacified directly by urethroscopic catheterization of the ejaculatory ducts. 2. The entire duct system is inspected introducing contrast solution into the canals via the ductus deferens. 3. Small bilateral incisions in the upper part of the scrotum are required for exposure and identification of these ducts. 4. The needle that is used to inject the contrast medium inserted into the duct in the direction of the portion of the tract under investigation.
Administration of Contrast Media
- Injected proximally for examination of extra pelvic ducts
- Injected distally for intra pelvic ducts
POSITION/PROJECTIONS
AP Projection Image Receptor: 8x10 inch (18x24 cm) 10x12 inch (24x30 cm)
- IR centered at the level of the superior border of the pubic symphysis.
- No rotation of patient.
- Exposure sufficient to demonstrate all structures of interest. Oblique Projection Image receptor: 8x10 inch (18x24 cm) 10x12 inch (24x30 cm)
EPIDIDYMIS - an oblong structure that is attached to the superior and latero posterior aspects of the testis. The ductules leading out of the testis enter the head of the epididymis to become continuous with the coiled and convoluted ductules that make upthis structure.
PATHOLOGY
Adhesion – Union of two surfaces that are normally separate
Cryptorchidism – Condition of undescended testis
Endometrial polyp – Growth or mas protruding from endometrium
Epididymis – Inflammation of the epididymis
Uterine tube obstruction – Condition preventing normal flow through uterine tube
Fistula – Abnormal connection between two internal organs
Testicular torsion – Twisting of the testis at its base, causing acute ishemia
Tumor – New tissue growth where cell proliferation is uncontrolled
Dermoid cyst – Tumor of the ovary filled with sebaceous material and hair
Prostate cancer – Second most common type of testicular tumor
Seminoma – Most common type of testicular tumor
Uterine fibroid – Smooth muscle tumor of then uterus
ULTRASOUND OF THE SCROTUM INDICATIONS CONTRAINDICATIONS
- Suspected testicular tumor NONE
- Suspected epididymo-orchitis
- Hydrocoele
- Acute torsion. In boys or young men in whom this clinical diagnosis has been made and emergency surgical exploration is planned, ultrasound should not delay the operation. Although color Doppler may show an absence of vessels in the ischemic testis, it is possible that partial untwisting resulting in some blood flow could lead to a false negative examination
- Suspected varicocele
- Scrotal trauma. MALE RADIOGRAPHY Seminal Ducts EPIDIDYMOGRAPHY Radiologic examinations of the seminal ducts are performed to investigate certain genitourinary abnormalities, such as cysts, abscesses, tumors, information, and sterility. The regional terms applied to these examinations are vesiculography, epididymography, and when combined, “epididymovesiculography” MATERIALS -Needle -Catheter PROCEDURE The seminal vesicles are sometimes opacified directly by urethroscopic catheterization of the ejaculatory ducts. The entire duct system is inspected introducing contrast solution into the canals via the ductus deferens. Small bilateral incisions in the upper part of the scrotum are required for exposure and identification of these ducts. The needle that is used to inject the contrast medium inserted into the duct in the direction of the portion of the tract under investigation. Distally: study of extra pelvic ducts Proximally: study of intrapelvic ducts.
CONTRAST MEDIA
The water-soluble, iodinated compounds used for intravenous urography are also employed as contrast media for these procedures.
A gaseous contrast medium can be injected into each scrotal sac to improve contrast in the
examination of extra pelvic structures
A nongrid exposure technique is used to delineate extrapelvic structures. A grid technique is
used to show the intrapelvic ducts.
POSITION/PROJECTIONS
AP PROJECTION
IR centered at the level of the superior border of the pubic symphysis
No rotation of the patient
Exposure sufficient to demonstrate all structures of interest
OBLIQUE PROJECTION
Region of interest in the center of the collimated field
No superimposition of the seminal ducts by the iliac
No overlap of the region of the prostate or urethra by the uppermost thigh.
IMAGE RECEPTOR AND COLLIMATION
AP and Oblique Projections are made using 8 × 10-inch (18 × 24-cm) or 10 × 12- inch (24 × 30-
cm) lengthwise IR's or collimated field sizes and centered at the level of the superior border of the pubic symphysis.
HYSTEROSALPINGOGRAPHY
hystero - uterus salpingo - fallopian tubes graphy - to record or take picture performed to determine the size, shape, and position of the uterus and uterine tubes. ANATOMY & PHYSIOLOGY Vagina - elastic tube that connects the uterus and cervix to the vulva. Cervix - lower, narrow end of the uterus that forms a canal between the uterus and vagina. Uterus - hosts the developing fetus
- produces vaginal and uterine secretions - passes the anatomically male sperm through the fallopian tubes Ovaries - produce the anatomically female egg cells - produce and secrete estrogen and progesterone Fallopian tubes/Uterine tubes - are bilateral conduits between the ovaries and the uterus in the female pelvis Fimbriae - finger-like projections on the ends of the fallopian tubes closest to the ovaries. PATHOLOGY Uterine Polyps - overgrowing of cells in the lining of the uterus (the endometrium). Hydrosalpinx - fallopian tubes is enlarged with fluids. Salpingitis - acute inflammation of the fallopian tubes Asherman's syndrome - scar tissue on the uterus Leiomyomas or Uterine myomas - a benign smooth muscle tumor, usually in the uterus or gastrointestinal tract. Adenomyosis - the inner lining of the uterus breaks through the muscle wall of the uterus Congenital Anomalies in Uterus Bicornuate - heart-shaped uterus, appearing to have two sides instead of being one hollow cavity.
Near the vaginal opening and cervix is the Bartholin’s glands which provides vaginal lubrication. The vagina’s primary functions are sexual arousal and intercourse as well as childbirth, thereby providing a channel for the baby’s delivery due to its elasticity. Thus, the vagina is referred to as the birth canal in the context of pregnancy and childbirth.
PATHOLOGY
Vaginitis Inflammation of the vagina, commonly from a “yeast infection” or bacterial overgrowth. Typical symptoms: Itching, discharge, and change of odor Vaginismus Involuntary spasm of the vaginal muscles during sexual intercourse. Genital warts It may affect the vulva, vagina, and cervix Treatments can remove vaginal warts, which are caused by human papillomavirus (HPV) Trichomoniasis Infection of the vagina by a microscopic parasite called “trichomonas” It is transmitted by sex and is easily curable Bacterial Vaginosis (BV) A disruption in the balance of healthy bacteria in the vagina. Symptoms: Discharge and change of odor Herpes Simplex Virus (HSV) The herpes virus can infect the vulva, vagina, and cervix causing small, painful, recurring blisters and ulcers. Having no noticeable symptoms is common. The virus is transmitted sexually and it can be treated, but not cured. Gonorrhea This sexually transmitted bacterial infection most often infects the cervix. Half the time, there are no symptoms, but vaginal discharge and itching may occur. It can cause pelvic inflammatory disease and infertility. Chlamydia The bacterium chlamydia trachomatis causes this sexually transmitted infection. Only half of women will have symptoms, which include vaginal discharge or pain in the vagina or abdomen. It can cause pelvic inflammatory disease and infertility. Vaginal cancer Cancer of the vagina is extremely rare. Symptoms: Abnormal vaginal bleeding or abnormal discharge Vaginal prolapse Due to weakened pelvic muscles (usually from childbirth), the rectum, uterus, or bladder pushes on the vagina. In severe cases, the vagina protrudes out of the body. Vaginal Fistula The presence of an unusual opening that connects the vagina to another organ which includes the bladder, ureters, urethra, rectum, colon and small intestine. Causes range from childbirth, abdominal surgery, pelvic cancer, cervical cancer, colon cancer, bowel disease, infection, traumatic injury and many more that results to tissue damage.
Symptoms of vaginal fistula include: fever, pain in the tummy area, diarrhea, dramatic loss of weight, nausea, vomiting.
PREPARATION
Informed consent.
Examination of the patient's medical history
Explain to the patient the procedure and any potential side effects before, during, and after
the procedure.
MATERIALS
Gloves Foley Catheter Atraumatic clamp Rectal retention tube Iodinated organic compound
CONTRAST MEDIA
Thin Barium Sulfate
Procedure
Vaginography is performed on a combination fluoroscopic radiographic table. Contrast medium is injected under fluoroscopic control and spot images are exposed as indicated during the filling. The perineum and vagina are cleansed (pHisoHex) and examination is carried out with sterile preparation. The examination is performed by introducing a contrast medium into the vaginal canal. Lambrie et al., recommended using a thin barium sulfate mixture to investigate fistulous communications with the intestine. A Foley catheter, with a 30-c.c. balloon attached, is inserted into the vagina. From between 10 and 30 c.c. of air or water is inserted into the long neck of the balloon, and the neck is clamped. The patient is then placed supine on the table, with lower extremities in adduction. A 50-c.c. syringe containing 20 to 50 per cent hypaque is connected to the catheter via an adapter, and under fluoroscopic control injection is started. The patient is examined in supine, both posterior oblique, and lateral positions. The lateral position is vital for antero-posteriorly directed fistulas (rectovaginal and vesicovaginal). Spot-films are obtained during active injection. For other investigation of other conditions, Coe advocated the use of an iodinated organic compound. At the end of the examination, the patient is instructed to expel as much of the barium mixture as possible, and the canal is cleansed by vaginal irrigation.
POSITION/PROJECTIONS
VAGINOGRAPHY SPOT IMAGE
o PA OBLIQUE PROJECTION LAO POSITION
SIGMOID FISTULA AND TWO ILEUM FISTULAE ARE SHOWN.
VAGINOGRAM AP OBLIQUE PROJECTION
