Atlas of

Ultrasonography in
Urology, Andrology,
and Nephrology

Pasquale Martino
Andrea B. Galosi
Editors

123
 Neoplastic and Nonneoplastic
Disease of the Bladder 35
Luigi Mearini, Elisabetta Nunzi,
and Michele Del Zingaro

35.1 Introduction suggests an infectious or irritative disease), most

bladder cancers are asymptomatic.
The presence of blood in the urine as macroscopic Ultrasound scanning (US) is a useful, rela-
(visible on gross examination) or microscopic tively simple noninvasive imaging modality for
(invisible, more than 3–5 red blood cells per high- the evaluation of the urinary bladder [2, 3]. The
power field on microscopic urine analysis) hema- bladder is an abdominal organ ideally suited to
turia is a very common problem that can represent US [4] for many reasons, including its superfi-
many different common benign or malignant cial location and the acoustic properties of the
underlying diseases. The causes of hematuria can fluid (urine) inside. The functions of the blad-
be broadly categorized into renal (glomerular and der include urine storage and removal, and
non-glomerular) and/or extrarenal. when the bladder is filled with urine, its content
Apart from a detailed history, which is essen- should be anechoic upon US evaluation, thus
tial in driving the diagnostic process in cases of permitting the ideal examination of its content
hematuria and baseline laboratory evaluations, and walls.
further investigation with noninvasive imaging Before proceeding with bladder US, it is cru-
studies [1] is imperative to confirm or exclude the cial to remember that upon normal filling, the
presence of malignant disease. bladder wall appears as a typical three-layer
The most common conditions of the bladder structure with a detrusor muscle of medium
that cause hematuria include infection, inflam- homogeneous echogenicity, while the outer
mation, stones, and malignancy. serosa layer and the inner mucosa (urothelial)
Although hematuria’s characteristics and layer are usually hyperechoic compared with
symptoms are suggestive of underlying disease the middle detrusor smooth muscle (muscularis
(e.g., symptomatic hematuria with frequency ­propria) layer.

L. Mearini, MD (*) • E. Nunzi • M.D. Zingaro

Urology Department, University Hospital,
Perugia, Italy
Urology Department, Perugia Hospital University
of Perugia, Perugia, Italy
e-mail: [email protected]

© Springer International Publishing Switzerland 2017 425

P. Martino, A.B. Galosi (eds.), Atlas of Ultrasonography in Urology, Andrology, and Nephrology,
DOI 10.1007/978-3-319-40782-1_35
426 L. Mearini et al.

35.2 Technology (200–300 ml). Bladder US requires careful and

complete scanning with transverse and longitu-
The most common method used to scan the uri- dinal sections.
nary bladder is an external, suprapubic, abdominal The fine regulation of light is essential to obtain
approach using a convex 2.5−5-MHz probe. Linear a significantly improved image quality and to cor-
probes with higher frequencies (7.5−16 MHz) can rectly visualize the anterior wall (superficial com-
be used in specific cases. The bladder floor, includ- pared to the skin) and posterior wall (deep). The use
ing the distal and intramural part of the ureter, can of high-frequency probing or the use of a second
be visualized more accurately with a higher fre- tissue harmonic imaging tool improves the quality
quency transrectal ­ultrasound scan (TRUS) in men of the imaging by reducing some reverberation arti-
or with a vaginal probe in women. A transurethral facts. Effectively, abdominal ultrasound is limited in
approach into the bladder with high-frequency the evaluation of the anterior bladder wall due to
miniprobes is an antiquated procedure and is not reverberation artifacts, such as the rain effect.
currently a standard approach due to its inva- Echo-Doppler may be useful to assess the ure-
siveness and limits [5–7], although still promis- teral jet and make a differential diagnosis of a
ing with less invasive probe in tumor staging [8] bladder lesion.
(Figs. 35.1, 35.2, and 35.3). Table 35.1 briefly resumes the quality of
The patient is usually examined in the supine images obtained by different approaches and
position with a sufficiently full bladder probes.

Fig. 35.1 Historical

image of transurethral
US of the bladder. The
picture demonstrates
two small intraluminal BLADDER CANCER
bladder masses. Bladder
wall is easily identified,
showing that one of the
bladder mass involves a
small diverticulum

BLADDER CANCER

Fig. 35.2 Another

“antique” image of
transurethral US. Note
the integrity of the
echostructural pattern of
bladder wall at tumor’s
base
35 Neoplastic and Nonneoplastic Disease of the Bladder 427

Fig. 35.3 A deep

infiltrating bladder mass
seen at transurethral BLADDER CANCER
US. The echostructural
pattern of anterior
bladder wall is easily
seen, and it
demonstrates a diffuse
interruption

Table 35.1 Synthetic overview of imaging quality according to different probes and approaches to the bladder
Abdominal Transrectal or transvaginal Transurethral
Instrument Convex 3.5–5- Linear biplanar Endoscopic
MHz probe 7.5-MHz probe probe 5–7.5 MHz
Overall view +++ + ++
Bladder wall appearance + + +++
Trigone ++ +++ −
Anterior wall +− − +
Lateral wall ++ − +
Bladder dome + − +
Surrounding organ ++ ++ −
428 L. Mearini et al.

35.3 Report • Use standard anatomical and ultrasound

terminology.
The findings report should [9]: • Describe all abnormal findings, includ-
ing number, side, shape, dimension, and
• Include the name of the physician examiner, characteristics.
place, and date. • Try to obviate to any difficulties or lim-
• Include the patient’s name, surname, and date its encountered while performing the
of birth. ­investigation; underline the diagnostic accu-
• Briefly include all clinical information and the racy of current test.
indications for the specific investigation. • Suggest types of studies for further investiga-
• Describe type of current ultrasound examina- tion; in case of serious findings, inform the
tion and the probe. patient and contact the patient’s doctor.

Example: Bladder Ultrasound Examination 1.5 × 5 mm; the hyperechoic line of inner
Dr. Samuel Smith; Urology Department, NY mucosa is not interrupted. Power Doppler
City Hospital; June 26th, 2015 images show considerable vascularity of the
Patient: Richard Doyle; October 23th, 1947 mass. The post-micturition volume is 20 ml.
Queries: asymptomatic hematuria Urologist consultation and cystoscopy are
Abdominal bladder ultrasound by convex strongly suggested since these ultrasound and
5-MHz probe power Doppler images are suggestive of carci-
Ultrasound findings: noma of the urinary bladder.
Bladder filling volume is sufficient for The exams included:
exhaustive examination. The bladder wall 1. Two pictures of the bladder in transverse
thickness is normal. The right and left ureteral and longitudinal scan
jets are present. Presence of a polypoid 2. Two pictures of the mass in transverse and
hypoechoic mass in the right bladder wall, longitudinal scan (Fig. 35.4)

BLADDER CANCER

Fig. 35.4 An example of exhaustive US report in case of bladder cancer. The two images describe in detail the
bladder mass with a transverse and longitudinal scan
35 Neoplastic and Nonneoplastic Disease of the Bladder 429

35.4 Diagnosis papillary, sessile (or infiltrative), and mixed pap-

illary and sessile shape.
In the diagnosis of luminal defects of the bladder, On ultrasound [10], they appear as a papil-
it is of paramount importance to remember the lary (polypoid) or sessile (plaque with large
normal bladder wall anatomy, which consists of base) lesions projecting into the lumen, usually
mucosa, detrusor smooth muscle, and adventitia. quite echogenic and fixed with changes in the
This anatomical distinction is easily visualized patient’s position. Ultrasound must describe the
by US, as the ultrasound appearance of the blad- presence of wall alterations (assessment of
der wall is as a sandwich structure with a lesions >3 mm), number, size, shape, and tumor
hypoechogenic muscular wall between the staging.
mucosa and adventitial layers, which are slightly In cases of superficial lesions, the bladder wall
hyperechogenic. shows no echostructural alterations with a nor-
The possibility of distinguishing each compo- mal ultrasound appearance of the sandwich pat-
nent of the bladder wall depends upon bladder tern (Figs. 35.5, 35.6, 35.7, and 35.8). Endophytic
wall thickness, which varies with the state of tumors appear as hypoechogenic, fixed prolifera-
urine filling; the upper limits are 3 and 5 mm for tive lesions; however, they are sometimes hyper-
a full bladder and empty bladder, respectively. echogenic due to the presence of superficial
The trigone represents an important landmark: it calcifications.
is the triangular area which lies between the two In cases of infiltrating lesions, the bladder
ureteral orifices and the internal urethral orifice; wall shows an interruption [11] or deformation,
in this region, the musculature of the bladder and sometimes the bladder tumor extends beyond
floor is dense and usually hypertrophied, forming the bladder wall. The hyperechoic layer of blad-
the interureteric ridge. der mucosa is interrupted (Figs. 35.9, 35.10, and
All these concepts explain why a bladder 35.11).
ultrasound scan requires adequate bladder filling The diagnostic accuracy of US for bladder
and the limits of US evaluation in cases of detru- tumor diagnosis and staging [12] is generally
sor hypertrophy or small lesions. considered to be poor (with a sensitivity ranging
50–94 % [13]) in comparison with other diagnos-
tic modalities such as CT scan or MRI. This wide
35.4.1 Neoplastic Bladder Disease discrepancy in sensitivity is related to some
tumor factors (e.g., size, location, macroscopic
Most bladder tumors are transitional cell carcino- aspects), patient factors (gender, body mass
mas, accounting for approximately 90 % of all index, bladder filling), and operator-dependent
primary malignant lesions. They are usually factors (different levels of experience [14]; more-
found in the region of the trigone or bladder base over, the type of US device and the technical
or on the lateral walls as unique or multiple modality of performing the ultrasound examina-
lesions. According to their intrinsic characteris- tion may explain such a wide variation in results
tics, they show different patterns in growth, with for the diagnosis and staging of bladder cancer.
430 L. Mearini et al.

Fig. 35.5 A small

exophytic tumor at
bladder neck

BLADDER CANCER

Fig. 35.6 A small,

diffuse hyperechoic
exophytic tumor at
bladder wall. The BLADDER CANCER

normal hyperechoic
internal layer is
continued at tumor’s
base. This is a typical
pattern of superficial
bladder cancer

Fig. 35.7 Another

small exophytic bladder
mass at bladder base BLADDER CANCER

BLADDER CANCER

Fig. 35.8 Bladder scan

by means of transrectal
US. Abdominal US is
negative
35 Neoplastic and Nonneoplastic Disease of the Bladder 431

Fig. 35.9 Small

bladder tumor at bladder
neck. Despite small
size, US shows partial
BLADDER CANCER
interruption of the
hyperechoic mucosa
layer. This is a
histologically confirmed
case of infiltrating
bladder cancer

Fig. 35.10 A
transrectal US showing
an infiltrating bladder
BLADDER CANCER
cancer. The entire
bladder wall is diffusely
interrupted, and the
mass seems to reach the
plane of seminal vesicle

BLADDER CANCER

Fig. 35.11 A
transverse and
longitudinal picture of
an infiltrating bladder
cancer. The mass is
partially exophytic with
a large base, and the
echostructural pattern of
bladder wall is diffusely
interrupted
432 L. Mearini et al.

35.4.1.1 S  ensitivity and False-Negative obstruction (bladder wall hypertrophy, diver-

Findings ticulosis, trabeculations)
The main limits of bladder ultrasound scanning
depend upon spatial resolution and thus on the Size: bladder lesions smaller than 5 mm may
size, shape, and side of the bladder tumor. not be identified on ultrasound, especially on the
Moreover, apart from the characteristics of bladder dome. On the other hand, the ability to
bladder tumors, the ultrasound scan is limited by: diagnose vegetating/papillary lesions >5 mm is
high.
Bladder filling, which should be suboptimal in Shape: flat or slow-growing non-vegetative
cases of acute or chronic cystitis tumors, such as carcinoma in situ, are not diag-
Bladder content, which is altered in cases of nosed by imaging.
bladder catheterization by the balloon itself or Side: during abdominal US, the rain effect at
by the presence of an air bubble or the con- the anterior bladder wall reduces spatial resolu-
temporary presence of lithiasis tion [15] (Fig. 35.12), even for tumors >5 mm.
Bladder wall characteristics, such as in cases of Some small wall defects at the bladder neck or
progressive changes in the bladder wall trigone could be confused with a median lobe
observed in patients with lower urinary tract (Fig. 35.13).

Fig. 35.12 A large,

exophytic mass at
anterior bladder wall.
Note the difficulties in
BLADDER CANCER
the correct identification
of tumor’s base, mainly
due to the side of the
tumor

Fig. 35.13 An BLADDER CANCER

infiltrating bladder
tumor at the bladder
neck. At transverse
abdominal US, due to
tumor’s side and
reduced bladder filling,
the ultrasound
appearance of tumor is
confusing. At linear
transrectal US, bladder
tumor is easily identified
and distinctive from the
normal prostate
35 Neoplastic and Nonneoplastic Disease of the Bladder 433

35.4.1.2 S  pecificity and False-Positive Other common conditions associated with

Findings false-positive findings include acute or chronic
A false-positive finding on an ultrasound scan cystitis. In acute conditions (Fig. 35.14), there
is particularly frequent in cases of macroscopic is diffuse increased hypoechogenicity and an
hematuria or in cases of reduced bladder increased thickness of the bladder wall at the
filling. mucosa layer, especially at the level of the bladder
The most frequent cause of false-positive find- floor and at the trigone. Anechoic bladder content
ings is represented by bladder wall hypertrophy is substituted by fine, mobile echoic pattern.
caused by lower urinary tract obstruction. Bladder In chronic conditions, increased hyperecho-
wall hypertrophy or diverticulosis or trabecula- genicity and thickness of the bladder wall at the
tions could be confused with wall defects. mucosa level is more nonspecific, except in cases
Other false-positive findings are represented of tuberculosis or bilharziasis.
by endovesical clots, which are frequent in cases Another common cause of false positives is
of macroscopic hematuria independent from the the presence of small or irregular prostatic
primary cause. Clots appear as variably sized median lobes.
hyperechoic masses, usually on the bladder floor; Another rare condition associated with false-­
they are mobile, depending on decubitus move- positive findings is the presence of urachal remnants.
ments. In cases of clot adhesion to the bladder Table 35.2 shows false-negative and false-­
wall, the use of color Doppler will show the positive findings related to bladder and tumor
absence of a color signal. ultrasound scan.

ACUTE CYSTITIS

Fig. 35.14 A typical abdominal US in case of acute cystitis. The bladder filling is markedly reduced, and the irregular
increased thickness of bladder wall is diffused
434 L. Mearini et al.

Fig. 35.15 Another

picture showing an
infiltrating bladder
cancer causing distal BLADDER CANCER

ureteral dilation. Note

the reduced bladder
filling caused by the
tumor LEFT URETER

Table 35.2 Main reasons for false-negative and false-­positive findings at bladder ultrasound scan
False negative False positive
Bladder Filling (low or excessive) Filling (low)

Content (catheter, air, clots, stone) Content (clots, stone)

Detrusor hypertrophy Detrusor hypertrophy
Acute or chronic cystitis
Tumor Size (<5 mm)
Side (anterior bladder wall, bladder neck, or trigone) Side (median lobe)
Shape (flat lesion)

35.4.2 Nonneoplastic Bladder While all these symptoms strongly suggest the
Disease diagnosis, they influence the ultrasound examina-
tion of the bladder with a reduction in bladder
There are a number of nonneoplastic and inflam- filling and/or the presence of abnormal bladder
matory disorders that can manifest as a focal or content (clots). Despite this, US is helpful in
diffuse bladder wall and alterations of bladder excluding secondary causes of cystitis, such as
content and can sometimes mimic malignancy; bladder outlet obstruction and bladder calculi.
therefore, ultrasound examination represents one A typical ultrasound picture of acute cystitis is
helpful diagnostic tool. characterized by diffuse and increased hypoecho-
Diffuse bladder wall thickening can develop sec- genicity and increased thickness of the bladder
ondary to many nonneoplastic conditions, including wall accompanied by reduced bladder filling. The
acute or chronic infection or inflammation and trigone area is frequently altered.
detrusor hypertrophy, while focal bladder wall alter-
ations are derived from extrinsic causes, creating 35.4.2.2 Chronic Cystitis
bladder filling defects, such as ureteral disease, ura- Chronic cystitis symptoms often include a
chal remnants, the median lobe of an enlarged pros- chronic and persistent urge to urinate with pelvic
tate gland, and endometriosis. Alterations of content pain and discomfort. It is derived from recurrent
include bladder stones or clots. infection or other conditions, such as interstitial
cystitis, cystitis cystica, cystitis glandularis,
35.4.2.1 Acute Cystitis tuberculosis, schistosomiasis, and radiation and
Acute cystitis symptoms often include a strong, chemotherapy cystitis. Apart from the underlying
persistent urge to urinate with pelvic discomfort cause, the most typical ultrasound feature of
and the presence of hematuria or strong-smelling chronic bladder inflammation is the reduction of
urine. bladder filling.