Bladder wall thickness in normal adults and men with mild lower urinary tract symptoms and benign prostatic enlargement

There is evidence that increased bladder wall thickness can be a useful parameter in the evaluation of men with clinical benign prostatic hyperplasia (BPH). However, normal values for bladder wall thickness (BWT) in adults have not been established. BWT was measured by suprapubic ultrasonography. Bladder volume was calculated as the product of the ultrasonographic measurements of bladder height, width and depth, and a correction factor (0.6). Three groups were assessed: men with normal lower urinary tracts (n = 172; mean age, 39.9), women with normal lower urinary tracts (n = 166; mean age, 37.8), and men with mild lower urinary tract symptoms (LUTS) and clinical benign prostatic enlargement (BPE) (n = 150; mean age, 66.4). For the whole group of men and women with normal bladders, mean BWT was 3.35 mm, and BWT appeared normally distributed. There were a weak negative correlation with bladder volume (r = -0.12, P < 0.003) and a weak positive correlation for BWT and age for both men (r = 0.12, P < 0.014) and women (r = 0.17, P < 0.013). Mean BWT was 3.04 mm in healthy women, 3.33 mm in healthy men, and 3.67 mm in men with LUTS and BPE. Sub-dividing normal men into different age groups showed an increasing mean BWT of 3.08 mm (<20 years, n = 27), 3.25 mm (21-40 years, n = 75), 3.42 mm (41-60 years, n = 39), and 3.57 mm (>60 years, n = 31) for those sub-groups. BWT in normal adult women is 3.0 +/- 1 mm and 3.3 +/- 1. 1 mm in normal adult men. A small increase in BWT with age is seen for both genders, and BWT tends to be greater in men than in women. Men with LUTS and BPE show a moderate increase in BWT. Adjustments for bladder volume are for practical purposes negligible, although there is a small decrease in BWT with increasing volume.

Bladder Wall – an overview

Microscopic anatomy

The bladder wall is formed of four layers: the serosa (outermost, formed from the peritoneum), the muscular layer, the submucosa and the mucosa. The muscular layer (detrusor muscle) comprises three bands of smooth muscle fibres arranged variously in longitudinal and circular array. The layers cannot be distinguished on ultrasound. The muscle fibres form the involuntary internal sphincter at the bladder neck.

The deep muscle fibres are bound by the submucosa to the mucosa, in the most part a loose affiliation so that the mucosa can ‘ruck up’ when the bladder is empty, becoming stretched and smooth as the bladder distends. The mucosa is continuous with that of the ureters (and therefore with the mucosa of the collecting systems of the kidneys) and with that of the urethra. Transitional cell epithelium lines the mucosa.

The base is the most complex part of the bladder, the sensitive trigone being triangular in shape and receiving the left and right ureter posteriorly, and opening to the urethra anteriorly. The mucosa over the trigone is always smooth, even when the bladder is empty because uniquely it is firmly attached to the muscular layer. The distal ureters pass obliquely through the bladder wall, the ureteric openings marking the posterior border of the trigone. Their course is visible on ultrasound.

The urothelium is not just a barrier, but is active in bladder function, having an afferent innervation with an important role in the reflex responses to bladder filling and distension. Within the urothelium, there is a dense muscarinic receptor population, which mediates the release of a diffusible inhibitory factor that inhibits smooth muscle contraction.¹

The bladder derives its blood supply from the internal iliac arteries, predominantly via the superior, middle and inferior vesical arteries, supplemented by the obturator and inferior gluteal branches of the internal iliac arteries. The venous drainage forms a rich plexus of vessels around the inferior and fundal surfaces.

What is Bladder Trabeculation? How Bladder Trabeculation Can Be a Sign of a More Serious Health Condition

Bladder trabeculation happens when the walls of the bladder thicken, making them harder to contract. When that happens, it’s harder for people to completely empty their bladder when they urinate. 

Bladder trabeculation can occur in both men and women. The leading cause is an obstruction to the urethra. 

Causes of Bladder Trabeculation

The bladder is a hollow, triangle-shaped organ in your lower abdomen. Other organs and ligaments attached to the bones in your pelvis hold it in place. Your bladder walls typically expand to store urine, then contract to push urine out through your urethra and expel it from your body.

When something blocks the urethra, like a kidney stone, it can slow down or stop urine from getting out. Your bladder walls must work harder as your bladder tries to force out urine. This causes the bladder walls to thicken. That thickening of the bladder walls is called trabeculation. 

When your bladder walls get too thick, they lose the ability to expand and contract, making it hard for your body to expel urine. 

Bladder trabeculation can be caused by other health conditions, such as blood clots. People who have blood clots may have trouble urinating when the clots harden. This puts pressure on the bladder walls, causing them to thicken.  ‌

Bladder trabeculation in children. Bladder trabeculation in children can be caused by congenital bladder conditions (conditions that they are born with). Certain valves within the urethra can narrow or block the ureter or urethra, causing bladder trabeculation. 

Bladder trabeculation can also be caused by other conditions, including:

• Polyps (large, benign growths found on body tissues)
• Tumors (abnormal tissue mass)
• Muscle or nerve disorders
• Ureter (the tube carrying urine from the kidneys to the bladder) bulging into the bladder
• Fecal impaction (large mass of hard stool trapped in the colon)‌

Bladder trabeculation in men. Benign prostatic hyperplasia (BPH) in men can block the flow of urine. That can eventually cause trabeculation in the bladder.  

The condition typically affects men over 50 years old. Problems urinating are often the first sign men experience when they have trabeculation caused by BPH.

Men can also develop bladder trabeculation after having laser treatment for an enlarged prostate. This procedure can cause blood clots to form within the bladder.   

Bladder trabeculation in women. Women can experience a severe form of pelvic organ prolapse, which can cause lower urinary tract issues. Many women who have this disorder end up developing bladder trabeculation and other problems. This keeps them from experiencing normal urine flow. 

Older women may have a greater risk of developing bladder trabeculation because they more often have severe pelvic organ prolapse.

Women can also develop hydronephrosis, or swelling, of the kidneys during pregnancy when the growing uterus puts pressure on their ureter. Other hormonal changes during that time can also cause hydronephrosis. 

Hydronephrosis lowers the number of muscle contractions that typically help move urine out of the body.  

While these conditions usually clear up after pregnancy, they can both put pressure on the bladder walls and potentially lead to bladder trabeculation.

Diagnosing Bladder Trabeculation

Your doctor will typically diagnose bladder trabeculation by measuring the thickness of your bladder walls. A bladder that measures more than three millimeters when swollen and greater than five millimeters when normal is considered trabeculated.

‌Treating a trabeculated bladder typically involves treating the cause of the obstruction. For men who have BPH, that starts with getting a diagnosis from a doctor. The doctor typically will do a physical exam that includes: 

• A digital rectal exam
• Urine and blood tests
• A prostate-specific antigen (PSA) blood test‌

Your doctor may also test your urinary flow and have you track how often you urinate in 24 hours. 

Diagnosing the cause of a urinary tract blockage as soon as possible is important to prevent other complications besides bladder trabeculation. Your doctor may perform a bladder catheterization or other imaging tests to figure out why you have trouble urinating. They will likely ask you about other symptoms you may be having, including:

• Pain in the lower abdomen
• Discomfort in the back
• Blood or pus in the urine
• Fever
• Kidney pain‌

‌Your doctor may also perform an endoscopy to view your urethra, prostate, and bladder. They may also insert a long, flexible endoscope, called a ureteroscope, to examine your kidneys for potential obstructions. 

Treating Bladder Trabeculation

If your doctor diagnoses you with BPH, they may recommend medication to reduce the size of your prostate. If that doesn’t work, they may recommend minimally invasive prostate surgery.‌

If a cancerous tumor or another blockage is causing your bladder trabeculation, your doctor may recommend other medical procedures to treat your obstruction. 

If your bladder trabeculation is caused by pregnancy, then you may not need treatment after you deliver your baby.

Ultrasound Thickness of Bladder Wall in Continent and Incontinent Women and Its Correlation with Cystometry

Objective. To compare bladder wall thickness in two kinds of urinary incontinent women—stress urinary incontinence (SUI) and overactive bladder (OAB) with urodynamic detrusor overactivity (DO), and to compare them with continent patients by ultrasound, also, correlate with cystometric results in incontinent women. Methods. 91 women were divided into the following groups: continent , SUI , and DO groups after clinical evaluation and urodynamic test (only in incontinent women). Transvaginal ultrasound was performed to the bladder wall thickness (BWT) measurement. The mean of BWT was calculated and data were analyzed with ANOVA and Turkey’s multiple comparison tests. Pearson’s correlation coefficient () was used to compare two variables. Receiver operating characteristic (ROC) curve was performed to study BWT as a diagnostic parameter. Results. BWT in DO group was significantly higher than that in the other groups . A moderate positive correlation was found between BWT and maximum bladder pressure during involuntary bladder contraction. There was no difference in BWT between SUI and continent groups. DO group had lower first desire to void and cystometric capacity. Maximum bladder pressure at detrusor contraction had a moderate positive correlation with BWT. The ROC revealed an area under the curve of 0.962 (95% CI, 0.90–1.01). Conclusions. DO patients have increased bladder wall thickness, lower first desire to void, and lower cystometric capacity. There was a moderate correlation between BWT and maximum bladder pressure during involuntary bladder contraction.

1. Introduction

Urinary incontinence is a common health problem associated with poor perception of personal health, impairment of quality of life, social isolation, and symptoms of depression [1]. The most common subtypes of urinary incontinence are stress urinary incontinence (SUI), with leakage of urine during effort or physical exertion, and urgency urinary incontinence with the complaint of involuntary loss of urine associated with urgency (OAB) [2]. The diagnosis in primary care can be done just based on patient’s complaints, or exams may be requested to further investigate the symptoms.

Urodynamic test tries to reproduce the situation in which patients’ complaints occur and therefore is considered an extension of patient history and physical examination in a controlled setting; however, it is not a mandatory exam for incontinence diagnosis [3]. Detrusor overactivity (DO) is an urodynamic observation defined by involuntary detrusor contractions during the filling phase, which may be spontaneous or may be provoked. It is detectable in about half of the patients with OAB submitted to urodynamic test [4].

Ultrasound is a diagnostic method that is very much a part of general practice in obstetrics and gynecology and its role in urogynecology has increasing importance [5, 6]. When compared to other imaging exams, it is less invasive, nonradioactive, inexpensive, and widely available. In addition, ultrasound is the gold standard for measuring bladder volume and postvoiding residue, and it allows dynamic assessment of pelvic structures [7, 8].

Bladder wall thickness (BWT) has been studied in incontinent patients and those with OAB especially those with DO who show higher values [9]. Farag and Heesakkers [10], in a literature review, compared the various pathways of ultrasound to measure the BWT and they concluded that the study of BWT by transvaginal transducer is more appropriate. Oelke et al. [11] compared the measurement of BWT obtained by conventional ultrasound with the automatic measurement performed by the BVM 6500 device. Although both show good reproducibility, the conventional measurement showed the smallest variation and it was more reliable. Kuhn et al. [12], comparing different ways to perform ultrasound to measure the BWT, found that vaginal measurement was more reliable than abdominal or perineal assessment.

The objective of this study was to compare the BWT in two kinds of urinary incontinent women, SUI and OAB with DO, and compare them with continent patients by transvaginal ultrasound, also, correlate with cystometric results in incontinent women.

2. Material and Methods

In a tertiary referral ambulatory, we selected women who were continent or with SUI or OAB. The study was approved by the Research Ethics Committee of Federal University of São Paulo (UNIFESP), and the volunteer women who agreed to participate gave consent form.

We included continent women with gynecological diseases or conditions other than urinary incontinence like miomas or adnexial cists.

Patients with mixed urinary incontinence, lower urinary tract diseases, bladder outlet obstruction, previous surgery for urinary incontinence, and current or recurrent urinary tract infection were not included. All patients were examined and pelvic organ prolapse quantification (POP-Q) was determined. Urodynamic test was performed before inclusion in this study and it followed the International Continence Society (ICS) recommendations using Dynapack MPX 816 four-channel urodynamic system (Dynamed, Sao Paulo, Brazil). The clinical diagnosis had to match the urodynamic test result.

Women were asked to void. Then, in supine position, ultrasound exam was performed using a SA-9900 (Samsung, Seoul, Korea) ultrasound machine equipped with a multifrequential transvaginal transducer (4–9 MHz). Using the method described by Haylen et al. [13], the residual volume was calculated to ensure that it was <50 mL. The bladder was visualized in the sagittal plane and then the probe was laterally moved 1 cm to achieve a clear view of the bladder and directed cranially to image the bladder in the parasagittal plane. At maximal magnification, the measurements were made perpendicular to the luminal surface of the bladder in the thickest part of trigone, dome of the bladder, and anterior wall of the bladder (Figure 1). BWT was considered the mean value of these three measurements. All exams were performed by the same physician (ENO, urogynecologist) who was also blinded to the incontinence diagnosis.

The data were transferred to the spreadsheet program Excel 2007 (Microsoft Corp. , Redmond, WA, USA) and the statistical analysis was performed with GraphPad Prism version 5.0 for Windows (GraphPad Software, San Diego, CA). Analysis of variance (ANOVA) or Student’s -test was used to compare continuous variables. Post hoc multiple comparisons were performed using the Tukey’s multiple comparison tests. Pearson’s chi-squared test () was used to compare categorical variables. Mann-Whitney test was applied to compare two independent random samples. Pearson’s correlation coefficient () was used to compare linear dependence between two variables. In all analyses, we used a significance level of .

3. Results

A total of 91 patients with age between 18 and 81 were included in this study. Of these, 31 were continent, 30 had SUI, and 30 had urgency urinary incontinence (OAB with DO).

Clinical characteristics of the groups are listed in Table 1. There was no difference in age (), hormonal status (), body mass index (), parity (), or POP-Q () among the groups. Postvoid residual ranged from 0 to 40 mL.

BWT was higher in detrusor overactivity group and significantly different compared to SUI and continent groups (). There was no difference between SUI and continent groups (Figure 2).

In Table 2, urodynamic findings are listed. In SUI group, 3 patients had intrinsic sphincter deficiency. In DO group, first desire to void and maximum cystometric capacity were significantly lower compared to SUI results.

Variable SUI ( = 31) DO ( = 30) value* Volume at first desire to void (mL) 157.7 ± 60.8 124.4 ± 56.27 0.002* Maximum cystometric capacity (mL) 471.6 ± 100.5 339.2 ± 135.6 <0.001* Valsalva leak point pressure (cmH2O) 87.7 ± 28.93     Volume at leakage (mL) 301.8 ± 164.7     Cystometric volume at first IDC (mL)   242. 2 ± 117.1   Maximum vesical pressure at IDC (cmH2O)   34.96 ± 19.8

Data presented as mean ± SD; data in parenthesis are percentages. IDC: involuntary detrusor contraction. *Student’s -test.

The linear dependence in SUI group between BWT and first desire to void (, ), volume at leakage (, ), and maximum cystometric capacity (, ) was not significant.

Concerning OAB group, there was a moderate positive correlation between BWT and maximum vesical pressure at involuntary detrusor contraction (, ) (Figure 3). There was no significant correlation between BWT and first desire to void (, ) and maximum cystometric capacity (, ).

4. Discussion

The diagnosis of the type of incontinence only with the clinical assessment of patients can mislead to the right treatment. It is not uncommon that patients with OAB have involuntary detrusor contractions triggered by stress maneuver such as coughing or sneezing. In these cases, particularly, Giarenis et al. [14] observed worse efficacy with tolterodine than women with involuntary detrusor contractions during cystometric filling phase of urodynamic test. It takes a good amount of self-perception to tell if the urinary loss is caused by sudden increase in intraabdominal pressure or by a detrusor contraction. Also, different diseases share common lower urinary tract symptoms and many times a consistent diagnosis is not reached [3, 15, 16]. Questionnaires of quality of life, bladder diaries, and visual analog scales are valuable to expand the understanding and bothersome of the symptoms but provide only subjective data.

Currently, when clinical assessment of urinary incontinence is compared to urodynamic test, there is lack of a gold standard [17]. Clarke [18] considered the urodynamic test inappropriate to diagnose and introduced treatment based only in symptoms, as he found DO in 64% of the patients with SUI. Urodynamic test can provide valuable information of the underlying pathophysiology, but its intra- and interobserver reproducibility is not good [19, 20].

Healthy patients have BWT measurement ranging from 3 to 5 mm [21]. Conditions such as infection, pelvic radiation, pelvic surgery, neurological disease, cancer, and bladder outlet obstruction can cause thickening of the bladder wall associated to other sonographic signals [22]. The study of BWT has brought the question if it is possible to diagnose OAB by a “cut-off” value measured by ultrasound. Khullar and Cardozo [23] proposed 5 mm as a cut-off value to discriminate detrusor overactivity, while Robinson et al. [5] considered 6 mm to the diagnose of OAB in patients without evidence of SUI. Kuhn et al. [24] with a cut-off value of 5.6 mm found sensitivity of 83.3% and specificity of 87.5% in distinguishing between OAB and bladder obstruction. Serati et al. [25] compared BWT in different forms of incontinence and concluded that a “cut-off” value of 6. 5 mm could distinguish patients with detrusor overactivity, pure or associated with SUI, but it could not replace urodynamic test.

An important question is if we are looking to the right point. The diagnosis of DO is controversy. DO is present in only 40–60% of the OAB patients [26]. Although urodynamic test is the only method to its diagnosis, the interobserver variation in evaluation of the same exam is high [27]. DO is not exclusive of OAB patients; asymptomatic patients may present DO during urodynamic test when the saline solution is instilled very fast or too cold.

It is unknown if involuntary detrusor contraction is the cause of urgency at storage phase or that other types of lower urinary tract dysfunction can cause OAB complaints [28]. Normal bladder physiology includes phasic contractions of low magnitude with frequency of dozens per minute, thus promoting a better adjustment of the bladder surface to urine filling [29]. The detrusor of OAB patients presents biochemical changes, which have different cellular ultrastructure and tissue macrostructure leading to more contractility and resulting in hypertrophy of the detrusor muscle [30].

Using ICS’s definition of OAB syndrome, based only on symptoms, can lead to a heterogeneous group, as women with different physiopathologies present with the core complaint of urinary urgency. In a different approach, we aimed to study a homogeneous group only including women who not only complained of urgency, but were also incontinent and with presence of DO at urodynamic test. Women with DO experience more significant impairment to their quality of life and have a greater degree of bladder dysfunction [31]. Our finding of higher values of BWT associated with higher vesical pressure at involuntary detrusor contraction concurs with the background of OAB. Also, there was a moderate positive relation between intensity of OAB and BWT.

We decided not to include patients with mixed urinary incontinence because of the difficulty to determine the “amount” of troublesome of each component of this group.

The time lapse necessary to increase the BWT from normal values is a question that remains without response. To our knowledge, it is not demonstrated yet.

According to the definition of OAB suggested by the ICS, the need to detect DO loses importance. On the other hand, it seems that increased BWT, as a result of repeated DO, is linked to clinical symptoms, as Panayi et al. [32] observed that women with BWT greater than 5 mm had a visual analog scale of urgency significantly higher when compared to controls. In a recent article, Abou-Gamrah et al. [33] found 4.78 mm of BWT the best cut-off value for prediction of OAB in patients with lower urinary tract symptoms.

As a diagnostic tool of urinary incontinence, we agree that BWT cannot replace urodynamic test. Nonetheless, our findings encouraged us to consider it as an “index” of detrusor activity.

One of the strengths of this paper is the observation that the BWT of the SUI patients and that of normal women are similar and significantly thinner than that of the DO patients, the most severe form of OAB. For our knowledge this is the first study that observed the BWT in SUI. The urodynamic evaluation in incontinent women and correlation with ultrasound findings are also the strengths of this paper. On the other hand, the weakness of this paper was that we did not investigate BWT of mixed urinary incontinence patients.

In summary, we believe that the thickening of the bladder wall is itself an important hallmark in OAB patients mainly when the clinic is not compatible with urodynamic test or in women not responsive to anticholinergics.

Conflict of Interests

The authors declare that there is no conflict of interests regarding the publication of this paper.

Comparison of Bladder Wall Thickening and Presence of Internal Echoes Within the Bladder for the Diagnosis of Cystitis in Infants | Iranian Journal of Pediatrics

Control group (N) consisted of 713 patients whose ultrasound examination was normal (no bladder wall thickening and no echoes in the lumen of bladder and no perivesical fluid). Among these 713 patients, 98 had pathological urinalysis results. The pathological urinalysis rate was 13.7%. In this group sensitivity was 0.597, and specificity was 0.723 for pathological urinalysis results.

Perivesical fluid group (P1) consisted of 43 patients whose ultrasound examination revealed only perivesical fluid without either bladder wall thickness or echoes in the lumen of bladder. Among these 43 patients, 8 had pathological urinalysis results. The pathological urinalysis rate was 18.6%. When compared with control group, pathological urinalysis rate was higher but it was not statistically significant. In this group sensitivity was 0.033, and specificity was 0.959 for pathological urinalysis results.

Bladder wall thickness group (P2) consisted of 170 patients whose ultrasound examination detected only thickened bladder wall (≥ 3.9 mm) without either perivesical fluid or echoes in the lumen of bladder. Among these 170 patients, 62 had pathological urinalysis results. The pathological urinalysis rate was 36.5%. When compared with control group (N) pathological urinalysis rate was higher and this difference was statistically significant (P < 0. 05). In this group, sensitivity was 0.255 and specificity 0.873 for pathological urinalysis results.

The lumen group (P3) consisted of 116 patients whose ultrasound examination showed only echoes within the bladder lumen without either perivesical fluid or thickened bladder wall. Among these 116 patients, 48 had pathological urinalysis results. The pathological urinalysis rate was 41.4%. When compared with control group (N) pathological urinalysis rate was higher and this difference was statistically significant (P < 0.05). In this group, sensitivity was 0.198 and specificity 0.920 for pathological urinalysis results.

Fluid or thickened wall or echoes group (P4) consisted of 319 patients whose ultrasound examination detected perivesical fluid or thickened bladder wall or echoes in the lumen of bladder. Among these 319 patients, 118 had pathological urinalysis results. The pathological urinalysis rate was 37.0%. When compared with control group (N) pathological urinalysis rate was higher and this difference was statistically significant (P < 0. 05). In this group, sensitivity was 0.481 and specificity 0.764 for pathological urinalysis results.

Fluid and thickened wall group (P5) consisted of 11 patients whose ultrasound examination detected perivesical fluid and thickened bladder wall without echoes in the lumen of bladder (Figure 1). Among these 11 patients 5 had pathological urinalysis results. The pathological urinalysis rate was 45.5%. When compared with control group (N) pathological urinalysis rate was higher and this difference was statistically significant (P < 0.05). In this group, sensitivity was 0.021 and specificity 0.993 for pathological urinalysis results.

Figure 1.
Bladder wall thickening (5, 7 mm) and perivesical fluid (arrows) are seen

Fluid and echoes group (P6) consisted of 9 patients whose ultrasound examination detected perivesical fluid and echoes in the lumen of bladder without thickened wall of bladder (Figure 2). Among these 9 patients, 4 had pathological urinalysis results. The pathological urinalysis rate was 44.4%. When compared with control group (N) pathological urinalysis rate was higher and this difference was statistically significant (P < 0.05). In this group, sensitivity was 0.016 and specificity 0.994.

Figure 2.
Internal echoes within the bladder which has normal wall thickness (3.0 mm). Perivesical fluid is seen (arrows)

Thickened wall and echoes group (P7) consisted of 22 patients whose ultrasound examination detected thickened bladder wall and echoes in the lumen of bladder without perivesical fluid (Figure 3). Among these 22 patients, 12 had pathological urinalysis results. The pathological urinalysis rate was 54.5%. When compared with control group (N) pathological urinalysis rate was higher and this difference was statistically significant (P < 0.05). In this group sensitivity, was 0.049 and specificity 0.988 for pathological urinalysis results.

Figure 3.
Internal echoes in the lumen of bladder with thickened wall (4. 5 mm)

Thickened wall and echoes and fluid group (P8) consisted of 10 patients whose ultrasound examination detected thickened bladder wall and echoes in the lumen of bladder and perivesical fluid (Figure 4). Among these 10 patients, 6 had pathological urinalysis results. The pathological urinalysis rate was 60.0%. When compared with control group (N) pathological urinalysis rate was higher and this difference was statistically significant (P < 0.05). In this group sensitivity was 0.025 and specificity 0.995 for pathological urinalysis results. Statistical analysis results of all groups are detailed in Table 1.

Figure 4.
Internal echoes in the lumen of bladder with thickened wall (4.1 mm). Also perivesical fluid is seen (arrows)Table 1.
The Detailed Statistical Results of All Groups

Finding	N	P1	P2	P3	P4	P5	P6	P7	P8	Total
	Control Group	Perivesical Fluid	Thickened Bladder Wall	Echoes in the Lumen	Fluid or Thickened Wall or Echoes In the Lumen	Perivesical Fluid and Thickened Bladder Wall	Perivesical Fluid and Echoes in the Lumen	Thickened Bladder Wall and Echoes in the Lumen	Thickened Wall and Echoes in Lumen and Perivesical Fluid
Patients	713	43	170	116	319	11	9	22	10	1094
Pathological urinalysis	98	8	62	48	118	5	4	12	6	253
Pathological urinalysis ratio, %	13. 7	18.6	36.5	41.4	37.0	45.5	44.4	54.5	60.0	23.1
Sensitivity	0.597	0.033	0.255	0.198	0.486	0.021	0.016	0.049	0.025
Specificity	0.723	0.959	0.873	0.920	0.764	0.993	0.994	0.988	0.995
False negative rate	0.403	0.967	0.745	0.802	0.514	0.979	0.984	0.951	0.975
False positive rate	0.277	0.041	0.127	0.0080	0.236	0.007	0.006	0.012	0.005
Accuracy	0.695	0.753	0.736	0.760	0.702	0.777	0.777	0.780	0.780
Positive predictive value	0. 381	0.186	0.365	0.414	0.370	0.455	0.444	0.545	0.600
Negative predictive value	0.863	0.776	0.804	0.801	0.839	0.780	0.780	0.785	0.781
Positive hjlikehood ratio	2.152	0.800	2.010	2.472	2.056	2.918	2.802	4.202	5.253
Negative likehood ratio	0.558	1.009	0.853	0.872	0.673	0.986	0.989	0.962	0.980

Also patients in thickened wall group (P3) were classified to 3 subgroups according to their bladder wall thicknesses. The first subgroup (SG1) consisted of 92 patients whose ultrasound examination detected a bladder wall thickness between 3.9 and 4.9 mm. Among these 92 patients 31 had pathological urinalysis results. The pathological urinalysis rate was 33.6%. When compared with control group (N) (13.7%) pathological urinalysis rate was significantly higher (P < 0.05).

The second subgroup (SG2) consisted of 54 patients whose ultrasound examination detected a bladder wall thickness between 5.0 and 6.0 mm. Among these 54 patients, 19 had pathological urinalysis results. The pathological urinalysis rate was 35.1%.When compared with control group (N) (13.7%) pathological urinalysis rate was significantly higher (P < 0.05). However when compared with subgroup 1, pathological urinalysis rate was higher but this difference was not statistically significant (P > 0.05).

The third subgroup (SG3) consisted of 24 patients whose ultrasound examination detected a bladder wall thickness > 6 mm (Figure 5). Among these 24 patients, 12 had pathological urinalysis results. The pathological urinalysis rate was 50.0%.When compared with control group (N) (13.7%) pathological urinalysis rate was higher and this difference was statistically significant (P < 0. 05). Also when compared with both subgroups 1 and 2, pathological urinalysis rate of subgroup 3 was higher and these differences were statistically significant (P < 0.05 for both). Pathological urinalysis rates of subgroups are summarized in Table 2.

Figure 5.
Markedly thickened bladder wall (9.1 mm) (subgroup 3) is seenTable 2.
Pathological Urinalysis of Three Subgroups of Group P3 (Thickened Bladder Wall Group)

Also we compared the pathological urinalysis rates of males and females for each group. In all the groups pathological urinalysis rates of females was found to be higher than rates of males. The pathological urinalysis results of males and females are documented in Table 3.

Table 3.
Comparision of Pathological Urinalysis Rates of Male and Female Patients for Each Groups

	N	P1	P2	P3	P4	P5	P6	P7	P8
	Control	Perivesical fluid	Thickened bladder wall	Echoes in the lumen	Fluid or thickened wall or echoes in the lumen	Perivesical fluid and thickened bladder wall	Perivesical fluid and echoes in the lumen	Thickened bladder wall and echoes in the lumen	Thickened wall and echoes in lumen and periveical fluid
Pathological male urinalysis	23	2	13	13	28	1	1	3	2
Total male patients	371	12	75	39	126	4	4	8	4
Pathological male urinalysis rate, %	6. 2	16.7	17.3	33.3	22.2	25.0	25.0	37.5	50.0
Pathological female urinalysis	75	6	49	35	90	4	3	9	4
Total female patients	342	31	95	77	193	7	5	14	6
Pathological female urinalysis rate, %	21.9	19.4	51.6	45.4	46.6	54.5	60.0	64.3	66.7

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Gall bladder wall thickening as non-invasive screening parameter for esophageal varices – a comparative endoscopic – sonographic study | BMC Gastroenterology

Patients with compensated liver cirrhosis have a chance of up to 40% to develop EV [8]. To avoid hemorrhage from EV, it is recommended to perform an upper endoscopy as soon as there are signs for the presence of liver cirrhosis in patients [9, 10]. Therefore, many patients undergo upper endoscopy although they do not require treatment of EV (e.g. ligation) according to endoscopic classifications. While diagnostic gastroscopy itself is of low risk, low platelet counts as well as impaired coagulation parameters increase the risk of complications. Most patients prefer sedation during the procedure which is associated with additional risks. Therefore, more accurate non-invasive parameters for the presence of EV could be a valuable and clinically relevant tool. We based our study on non-invasive, standard diagnostic tests, which are routinely performed in patients with chronic liver disease: ultrasound, clinical and laboratory results were evaluated in terms of prediction of EV.

Because of its portal-venous blood supply, we assumed that the GBWT may predict the presence of portal hypertension and EV. An interesting study by Maruyama et al. also reported a lower sensitivity of 62% regarding the detection of large esophageal varices using the platelet count to spleen diameter ratio in 229 cirrhosis patients. In this study, the authors showed that a diameter of the left gastric vein -as a non-variceal collateral- of more than 5.35 mm had a sensitivity of 90% and a specificity of 62% for presence of large esophageal varices. Its sonographic detection was associated with a sensitivity of 84% for any esophageal varices and a sensitivity of 100% for large varices [11]. However, further prospective studies are required to assess the value of portal vein velocity as non-invasive parameter for the presence of esophageal varices.

A small Chinese study showed a correlation between portal vein velocity and GBWT supporting the hypothesis that GBWT could also predict the presence of EV [12]. From a pathophysiological point of view, GBWT may be a microcirculatory driven event caused by impaired portalvenous outflow before significant changes in portal vein velocity occur. However, the development of GBWT may also be caused by other factors such as the serum-ascites albumin gradient (SAAG) [13].

Several studies have investigated non-invasive parameters as predictors for the presence of EV. A platelet count to spleen diameter ratio of 909 and less was associated with EV [7]. The enlarged spleen is caused by portal hypertension and low platelets were also associated with a lowered thrombopoetin serum level due to reduced liver function [14]. Chen performed a meta-analysis to confirm the usefulness of this ratio and calculated a summative sensitivity of the ratio of 84% with a specificity of 78% to predict EV. The sensitivity of this ratio was also influenced by etiology of the liver disease with a sensitivity of 92% in viral liver cirrhosis [15]. Using the platelet count to spleen diameter ratio as previously described [7], the sensitivity was somewhat lower with our dataset. The reasons might be the greater variety of causes for liver disease in our cohort than in previous evaluations. Another non-invasive method is the use of computed tomography (CT) imaging with a sensitivity of 90% and a specificity of 72% for the detection of EV [16]. The higher sensitivity is traded against higher costs, exposure to irradiation, and the use of contrast agents. Other non-invasive measurements such as liver stiffness measurements are promising but further studies need to be performed. Meta-analysis of data so far collected by using transient elastography (FibroScan®) showed lower prognostic values for liver stiffness [17]. A meta-analysis of studies using different modes of elastography techniques to measure spleen stiffness showed heterogeneous results to detect EV [18]. The sensitivity of liver stiffness was 84% in predicting any varices, compared to 78% using the stiffness of the spleen as parameter. The specificity of the spleen stiffness was higher when compared to liver stiffness (76% versus 62%) [18] [16]. The use of capsule endoscopy to detect EV is also discussed in the literature [19] but high costs and its semi-invasive nature need to be kept in mind. Because of those limitations of the aforementioned non-invasive methods, the use of GBWT could represent a novel and feasible clinical marker for the detection of EV.

Alcantara previously published a cut-off value of 4.35 mm for a thickened gall bladder wall and found a sensitivity of 60% and a specificity of 90% regarding the presence of EV in pediatric patients [20]. The sensitivity was higher than in our study, although a higher value was used as cut-off. Other reasons for this difference might be the different patient cohorts, since de Alcantara based his study on data from children with various causes of cirrhosis such as biliary atresia and autoimmune hepatitis [20]. In our study we used data from adult patients with chronic liver disease and common causes for cirrhosis in Western Europe, but lack of histological confirmation in almost half of them. The cut-off-value of 4 mm was arbitrarily set for univariate analysis and seems reasonable since a lower value could be measured in individuals that did not fast overnight with a higher rate of falsely positive cases. A higher cut-off value would lower sensitivity.

In addition, a lowered velocity within the portal vein seems reasonable in the presence of portal hypertension and esophageal varices, but existing data are still conflicting. An Indian study of sonographic parameters predicting esophageal varices in 56 patients showed a significant difference of mean portal vein velocity. In presence of esophageal varices the mean velocity was 14.77 cm/s and in absence of varices 17.66 cm/s [21]. However, Li et al. did not report a significant difference in portal vein velocity between patients with and without esophageal varices. The mean velocity was 15.3 cm/s in healthy individuals, 14.2 cm/s in patients with first degree varices, 13.1 cm/s in second degree varices and 12.0 cm/s in third degree varices [22]. In our study there was no difference in average portal vein velocity with 18.0 cm/s in both groups.

Our study has several limitations. First, ultrasonography and endoscopy were not always performed within a few days and may have biased results in case of rapidly changing endoscopy or ultrasonography findings. Furthermore, retrospective data collection could not establish a clear cause for chronic liver disease in almost 20% of patients. Secondly, although performed by experienced Gastroenterology trainees and consultants, GBWT measurements were performed by only one examiner, and inter-observer variability could thus not be accounted for. Third, we could not detect significant differences between small and large EV most likely due to the relatively low number of 3° EVs (n = 9) in the EV cohort.

90,000 Bladder cancer – symptoms, stages, prognosis and natural treatment

Bladder cancer: what is it?

Statistics say that more than 2% of people in the world (every fiftieth) are diagnosed with bladder cancer. In the United States of America, more than 696,000 people were diagnosed with the disease in 2014, and another 68,000 cases are diagnosed each year.Most often men suffer from bladder cancer.

What are the first signs of bladder cancer? Usually, the first symptom is blood in the urine (hematuria). Depending on the stage and severity of the disease, treatment may include chemotherapy, radiation therapy, immunotherapy, and lifestyle adjustments to prevent cancer recurrence. Unfortunately, cancer treatments come with a number of side effects that can even make the disease worse. Natural therapies (diet, supplementation, and exercise) can help facilitate the healing process.

What is bladder cancer?

As the name suggests, this type of cancer affects the bladder, the hollow organ in the lower abdomen that collects urine before being excreted from the body. There are several types of bladder cancer:

• Transitional cell carcinoma. The US National Cancer Institute says it is the most common cancer (also called urothelial carcinoma). It appears in the urothelial cells located on the inner surface of the bladder.These cells help the bladder to change shape and size depending on the degree of filling. Transitional cell carcinoma can also affect other parts of the urinary tract.
• squamous cell carcinoma. This cancer first affects the flat cells found in the bladder. Their appearance is often caused by irritation or infection in the organ. This type of cancer is quite rare in Russia.
• adenocarcinoma. This cancer affects cells that make and secrete mucus and other fluids.Compared to transitional cell carcinoma, this disease is less common.

What is the life expectancy of a diagnosis of bladder cancer? It depends on the stage and degree of neglect of the disease at the time of diagnosis. Treatment early on in the disease greatly increases the chances of recovery. Research suggests that in 2013, 77% of patients with bladder cancer lived for more than five years after diagnosis.

Signs and Symptoms

How to recognize bladder cancer? The first signs of the disease may be as follows:

• Blood in urine (hematuria).The urine may turn pink, bright red, burgundy, or even brown. Blood can appear and disappear for a while (even weeks), then reappear.
• Pain when urinating, which only gets worse over time.
• Signs of cancer may include frequent urination, kidney and bladder stones; the disease can also develop from irritation caused by a catheter in the bladder.

In a more advanced state, the disease can cause the following health problems:

• Pelvic pain and / or sometimes pain in the lower back and abdomen.
• Frequent urination due to overactive bladder. You may feel a sharp and sudden urge to use the toilet, difficulty controlling your bladder.
• Inability to control the pressure of the jet and the process of urination.
• Nausea, loss of appetite and weight.
• Feeling tired and weak.
• Swelling in the legs.
• Pain and aches in the bones.

Symptoms of bladder cancer may differ in men and women.In men, it can affect the prostate gland, which is located between the bladder and the penis. This organ produces prostatic fluid to aid in the flow of urine. In the United States, bladder cancer is the fourth most common malignant disease diagnosed in men, and is three times less common in women. Men usually experience a burning sensation when urinating, frequent urge to use the toilet and observe blood in the urine. Both sexes are characterized by the presence of infections of the genitourinary system as a symptom of cancer.If any of the listed symptoms appear, you should consult a doctor.

Causes of occurrence and risk factors

Why does bladder cancer appear? The disease occurs as a result of abnormal cell growth, the development of mutations and the formation of neoplasms. It is not always clear why this is happening. However, experts identify many possible causes that contribute to the development of cancer, including genetic and environmental factors.

The risk group for developing bladder cancer includes:

• People over the age of 40, as aging provokes the development of disease. 9 out of 10 patients with bladder cancer are over 55 years old.
• Men, as they are diagnosed with this disease more often than women.
• Smokers. Cigarette smoke is one of the main causes of bladder cancer, as it contains toxins that enter the kidneys and urine, from where they affect the bladder surface.
• Fair skinned / Caucasians. People with white skin are twice as likely to have this condition compared to Africans and Hispanics.
• People who are exposed to chemicals and toxins that can damage the kidneys (eg at work). These compounds include arsenic, benzidine, beta-naphthylamine, as well as substances used in the production of paints, rubber, leather, textiles. The American Cancer Society states that “Workers at increased risk of bladder cancer include painters, mechanics, printers, hairdressers (due to hair dye and curling products) and drivers (due to exposure to fuel fumes).Arsenic is found even in tap water, but this is quite rare in industrialized countries.
• Persons with chronic infections and inflammations of the bladder. Such diseases can occur due to a genitourinary infection, kidney stones, or an infection of the prostate gland.
• People with a family history of cancer, especially if there is a case of hereditary non-polyposis colon cancer (Lynch syndrome). Genetic mutations in the retinoblastoma gene ( RB 1 ), or Cowden’s disease, also increase the risks.
• People who have received chemotherapy or have been exposed to radiation.
• Persons suffering from parasitic infections. For example, a parasitic infection called schistosomiasis (also known as bilharziasis), which occurs mainly in Africa and the Middle East, provokes the development of bladder cancer.
• Persons with a rare birth defect affecting the urinary tract and bladder (eg exstrophy or urachus).
• Patients with diabetes mellitus and taking pioglitazone for more than one year.

Diagnostics

Fortunately, bladder cancer is often diagnosed early, which means the likelihood of recovery is high. The Mayo Clinic in the United States states that “7 out of 10 cases of bladder cancer are detected early in the course of development, when the disease is easily treatable.”

Early diagnosis makes it easier to cope with the disease

To diagnose bladder cancer, your doctor may suggest a number of tests, including urinalysis and urine cytology.Blood in urine can be seen with the naked eye; under a microscope, a specialist is able to see changes in chromosomes, antigens and proteins called NMP 22 .

Stages

The stage of the disease indicates the progression of the cancer and the spread in the body. The purpose of this cancer classification is to help determine the most effective treatment. Most specialists use the TNM system (tumor, nodes, metastases) to determine the stage of the disease, which describes the presence of primary tumors, the location and presence of metastases.Bladder cancer is divided into four diagnosed stages:

• Stage 0a or 0b: This is the early stage when the cancer is on the inside of the bladder and has not yet invaded muscle or connective tissue.
• Stage I: Cancer has spread through the inner surface of the organ into the lamina propria ( lamina propria ) , a loose layer of connective tissue under the base of the membrane surface of the epithelium.
• Stage II: The cancer has spread to the thick muscular wall of the bladder, but is not present in the lymph nodes or other organs.
• Stage III: the cancer has entered the fatty tissue surrounding the bladder through the muscle wall.
• Stage IV: The tumor has spread to the pelvic or abdominal wall and possibly to one or more adjacent lymph nodes. Metastases to other areas of the body are likely.

Stages of bladder cancer

Also, bladder cancer can be classified by degrees:

• Pappiloma – may recur, very rarely progresses.
• Poorly differentiated cancer – may recur and progress
• Highly differentiated cancer – often recurs and progresses.

Standard Treatment

Can bladder cancer be cured? It all depends on the stage and degree of the disease. As a rule, several specialists of different profiles are involved in the treatment under the guidance of a urologist (a doctor specializing in the genitourinary system, which includes the kidneys, bladder, prostate gland and testicles) and an oncologist (a doctor specializing in the treatment of cancer).

Treatments for bladder cancer include:

• Operation. The operation is the removal of the tumor and surrounding tissues. For patients with muscle-invasive cancer, the entire bladder is removed during surgery (called a radical cystectomy). Surgery to remove the lymph nodes is called pelvic lymph node dissection. When the bladder is removed, the surgeon leaves an opening to which a bag is attached where the urine flows.
• Chemotherapy. It helps to stop the growth and division of cancer cells. Chemotherapy can be local or systemic (whole body).
• Radiation therapy. It uses high-energy X-rays or other particles to destroy cancer cells. This treatment is usually not the primary treatment, but is sometimes used in combination with chemotherapy.
• Immunotherapy. It stimulates the immune system to fight cancer cells.This method can be used by a microorganism called bacillus Calmette-Guerin (BCG).
• A healthy lifestyle can help reduce the risk of breast cancer recurrence.

Natural Ways to Facilitate Recovery and Relieve Symptoms

Treatment for bladder cancer, such as with chemotherapy and radiation therapy, usually has side effects that are uncomfortable. So, the adverse effects of surgery, radio- and chemotherapy include: fatigue, mild skin irritation, bowel upset, loss of appetite, nausea, depression, weight loss, pain in the pelvic region and abdomen, bladder irritation, frequent urination, blood from the urinary bladder or rectum.Below we will talk about how you can deal with these symptoms and speed up the recovery process:

1.

Get more rest and sleep

Your body is throwing all its strength into coping with cancer and getting used to aggressive treatments, so it’s no surprise that you might feel tired, weak, and even depressed. You may not have the energy to exercise, but if you still find the energy in you, try to enjoy walks in the fresh air, stretching or swimming.Adequate amount of sleep (at least 7 hours a day) will give you strength. During the day, give yourself some rest, maybe even sleep.

2. Consume more nutritious foods

Research has found that fruits and vegetables high in antioxidants reduce cancer risk and promote recovery. Include more anti-cancer foods in your diet, such as:

• Leafy and dark green vegetables. Greens and cruciferous vegetables are known for their high concentration of vitamin C and their ability to fight cancer cells.
• Berries (blueberries, raspberries, cherries, strawberries, goji, camu camu and blackberries), kiwi, citrus fruits, melon, mango and pineapples, oranges, yellow vegetables and fruits (sweet potatoes, pumpkin and others) contain many carotenoids necessary to strengthen immunity and eliminate toxins.
• Organic meat, wild fish, eggs, fermented dairy products are rich in protein and nutrients such as selenium, zinc and B vitamins.
• Healthy fats (coconut, olive and ghee, avocado).
• Nuts and seeds (almonds, walnuts, chia and flax seeds).
• Complex carbohydrates found in sweet potatoes, carrots, beets and other root vegetables and grains. They provide energy and raise serotonin levels, which improves sleep.
• Fresh herbs and spices (ginger, turmeric, garlic, cumin, cayenne pepper, oregano, basil, rosemary, cinnamon and parsley).
• Bone broth, fresh vegetable juices and herbal infusions enrich the body with vitamins, minerals and antioxidants.

3. Drink plenty of water

Research suggests that in addition to quitting smoking and adjusting your diet, it is very important to consume enough fluids to protect both the bladder, thai and urinary tract. If you do not have any contraindications, try to drink 2 liters of water every day to relieve the symptoms of bladder cancer. Limit alcohol and caffeine, which are diuretic and can irritate the urethra.

Scientists have also found that drinking enough fluids lowers the risk of developing colorectal cancer. According to a study published in the European Journal of Clinical Nutrition, “liquid reduces the risk of colon cancer by improving bowel permeability and reducing mucosal contact with carcinogens. An insufficient amount of fluid in the body negatively affects the concentration of cells, affects the work of enzymes in the regulation of metabolism and slows down recovery. “

4. Relieve the symptoms of nausea

If you are experiencing symptoms of bladder cancer or medication side effects (nausea, upset stomach, loss of appetite, weakness, fatigue), try the following remedies:

• Drink ginger tea or apply ginger essential oil to your chest and abdomen. To make ginger tea, cut the ginger root into slices and place in the teapot for 10 minutes.
• Take vitamin B6 supplements.
• Make a stomach calming drink with chamomile and lemon juice.
• Inhale or rub peppermint oil on the neck and chest area.
• Breathe fresh air, ventilate the room more often and take walks.
• Try alternative treatments such as meditation or acupuncture.
• Eat more often, but in small portions. Avoid lying down for an hour after eating to keep things from getting heavy. The last meal should be no later than three hours before bedtime.

5. Practice relaxation techniques

Very often, patients undergoing cancer treatment experience anxiety, depression, feelings of hopelessness and even anger. Relaxation techniques can help you calm down and find the strength to cope with this difficult situation:

• Yoga, meditation and breathing exercises.
• Walking outdoors will increase your vitamin D levels from sunlight.
• Adaptogenic herbs will strengthen the nervous system.
• Support from relatives, relatives and friends.
• Vera and support groups.
• Essential oils of lavender, chamomile and holy basil.
• Epsom salt bath before bed will help relieve muscle tension.

6. Frankincense oil

Internal and topical intake of Indian Frankincense Oil (Boswellia serrata) is believed to contribute to the natural fight against cancer.Frankincense oil is made from the aromatic resin of the tree. The main anti-cancer component of this plant, boswellic acid, has anti-tumor properties.

One study published by the Department of Urology at the University of Oklahoma Center for Health Sciences claims that “Frankincense oil is able to distinguish cancer cells from healthy bladder cells, suppressing the vitality of the former … Frankincense oil can activate cancer cell death in several ways.It may also provide an alternative intravesical agent in the treatment of bladder cancer. ”

Preventive measures

Cancer cannot always be avoided or prevented, but studies have shown that a healthy lifestyle can significantly reduce the risks of developing cancer. To do this, we advise you to follow the following guidelines:

• Stop smoking, tobacco and other drugs.
• Parasitic diseases, recurrent urinary tract infections and other comorbid conditions must be treated.Fermented foods rich in probiotics and supplementation with probiotics help digestion and boost immunity.
• Plenty of magnesium-rich vegetables and good water prevent kidney stones from forming.
• Safe sex minimizes the risk of sexually transmitted diseases.
• Avoid foods that cause inflammation. Eat more unprocessed foods (especially brightly colored fruits and vegetables).
• An active lifestyle strengthens the immune system. There is evidence that exercise protects against enlargement of the prostate gland.
• Avoid exposure to toxins, chemicals and hazardous substances both at home and at work.
• Monitor your intake of the optimal amount of all nutrients. If you are deficient in key vitamins and minerals, include nutritional supplements in your diet.
• Review your family’s medical history.Regular screening will help catch the disease at an early stage.

Precautions

Be sure to see your doctor if you notice blood in your urine, especially if you notice other symptoms of bladder cancer. Blood in the urine may not be a symptom of cancer, but it must be ruled out anyway. Symptoms can be caused by a urinary tract infection (UTI), bladder stones, organ hyperactivity, kidney stones, or an enlarged prostate.

If you have had bladder cancer and are cured of the disease, you should still see your doctor regularly and get tested. Bladder cancer can return at a later stage, so it is so important to monitor your health. High risk factors for bladder cancer include personal and family history of cancer, birth defects of the bladder, and exposure to chemicals and toxins.

Final conclusions

• Bladder cancer affects the bladder, the hollow organ in the lower abdomen that contains urine before being excreted from the body.
• Symptoms of bladder cancer include: blood in the urine, pain when urinating, pain in the pelvic or abdominal cavity; in more advanced cases, weakness, nausea, bone and joint pain, loss of appetite.
• Risk factors for bladder cancer include: male gender, age over 40, personal or family history of cancer, smoking, alcohol addiction, frequent urinary tract infections.

You can make an appointment with an oncologist on our website.

Hypertrophic cardiomyopathy / Diseases / Clinic EXPERT

What is hypertrophic cardiomyopathy?

Hypertrophic cardiomyopathy (HCM) is an autosomal dominant disease characterized by hypertrophy (thickening) of the wall of the left and / or (occasionally) right ventricle. This leads to stiffness of the walls of the heart and aorta and contributes to the fact that the anterior cusp of the mitral valve is close to the surface of the septum and the flow of blood pulls it to it due to the Venturi effect, thus creating an obstacle to the release of blood.

Symptoms of Hypertrophic Cardiomyopathy

Many people with HCM have either no signs of illness or only mild symptoms and live normal lives. In other patients, symptoms may progress and worsen, thereby impairing heart function. Symptoms of hypertrophic cardiomyopathy can occur at any age and include:

• chest pain or pressure (usually occurs with exertion, but can also occur during rest or after eating)
• shortness of breath (shortness of breath)
• fatigue (feeling excessively tired)
• fainting (due to irregular heart rhythms, malfunctioning of the blood vessels, or for no reason at all)
• heart palpitations (due to irregular heart rhythms, usually ventricular extrasystoles, paroxysms of ventricular tachycardia , supraventricular rhythm disturbances are also frequent)
• sudden death (approximately 30% of patients do not present any complaints at all, sudden death may be the first and only manifestation of the disease.

Causes of hypertrophic cardiomyopathy

HCM can be both hereditary disease associated with mutations in genes encoding the synthesis of contractile proteins, and a disease that appears during aging or due to high blood pressure. In some cases, the reasons remain unknown.

Diagnosis of hypertrophic cardiomyopathy

HCM is diagnosed both on the basis of medical history (symptoms and family history) and on the basis of physical examination and clinical tests, such as blood tests, ECG, chest X-ray, echocardiography (ultrasound of the heart), stress test, cardiac catheterization, CT and MRI.

Treatment of hypertrophic cardiomyopathy

Treatment of HCM is indicated only in the presence of a clinic or risk factors for sudden death. Treatment is aimed at preventing symptoms and complications, and includes identifying risks, lifestyle changes, and medication. Also, as needed, your cardiologist can prescribe various procedures for you.

Recommendations

Diet

Drinking plenty of fluids is very important. Drink at least 6 to 8 glasses of water a day. In hot weather, you should increase your fluid intake. Fluid and salt restrictions are essential for patients with heart failure. Talk with your healthcare professional about how specific liquids and diet drinks affect your body, including information about the effects of alcohol and caffeine.

Exercise

Your doctor will advise whether you are advised to exercise or not.Most people with cardiomyopathy are offered light aerobics. However, your doctor may ask you to refrain from any physical activity based on your symptoms and the severity of your illness. As with dilated cardiomyopathy, lifting weights is not recommended

Regular visits to a doctor

Patients with HCM should visit a cardiologist at least once a year and monitor their condition. Doctor visits may be more frequent when hypertrophic cardiomyopathy is first diagnosed.

What drugs are used to treat hypertrophic cardiomyopathy?

Drugs used to treat symptoms and prevent further complications of HCM relieve stress on the heart and reduce obstacles to effective blood circulation in the body. In the treatment of hypertrophic cardiomyopathy, drugs are also used, which are based on beta-blockers, which can reduce the load on the heart by reducing pressure and pulse, reducing myocardial hypertrophy.Also, beta-blockers have antiarrhythmic effects, including the ability to reduce the risk of fatal arrhythmias and sudden death.

Your doctor may ask you to avoid taking certain medications, such as nitrates (which lower blood pressure) or digoxin (which increases the strength of the heart).

Your doctor will advise which medications are best for you.

Surgical procedures used to treat hypertrophic cardiomyopathy

Surgical techniques used to treat HCM include:

Transaortic septal myectomy.This technique involves reducing obstruction by reducing the thickness of the interventricular septum.

Transcatheter septal alcohol ablation. The introduction of sclerosing substances such as alcohol solutions, the creation of infarction zones in the interventricular septum.

Implantation of an artificial mitral valve of the heart. This type of surgery is offered to patients at high risk of life-threatening arrhythmias and sudden cardiac death. The mitral valve constantly monitors the heart rate.When it detects an abnormal, very fast heart rate, supplying energy to the heart muscle, it makes the heart beat at a normal rate.

Sudden death and endocarditis in hypertrophic cardiomyopathy

A small number of people with HCM are at increased risk of sudden cardiac death. People who belong to this risk group:

• relatives of those who died from sudden cardiac death
• young people with HCM with several episodes of loss of consciousness
• patients with high blood pressure and arrhythmia
• patients with severe symptoms and heart failure

If you have two or more risk factors for sudden cardiac death, your doctor will prescribe medication to prevent arrhythmias.In most patients with HCM, the risk of sudden cardiac death is low. Talk to your doctor about any problems you may have with hypertrophic cardiomyopathy.

How to prevent endocarditis?

People with obstructive HCM may be at increased risk of infective endocarditis, a potentially life-threatening condition. To protect yourself, tell any doctor, including your dentist, that you have heart disease.

Call your doctor if you develop symptoms of an infection (sore throat, weakness, fever).

Take care of your teeth and gums to protect against infections.

Take antibiotics before undergoing any procedure that may cause bleeding, such as dental care, tests (any tests that may involve collecting blood or may cause bleeding), surgery. Talk to your doctor about the type and amount of antibiotic you should take.

Procedure for ultrasound of the bladder in children, or how to stop being afraid of doctors

How is bladder ultrasound done in children?

Ultrasound of the bladder when prescribed to children is not much different from the procedure carried out for adult patients.This method of diagnosing diseases associated with the work of the urinary system remains one of the most effective and at the same time completely safe for the child’s body and psyche. The specialist receives an accurate picture of the state of the organ without causing discomfort to the child.

Indications for the procedure

Indications for the appointment of an ultrasound scan can be:

• Disorders associated with infections, inflammation (cystitis) or damage to the bladder;
• problems with urination, pain, blood or a noticeable sediment in the urine;
• suspected diseases of the urinary tract and kidneys;
• results of clinical analyzes;
• control over the process of bladder treatment;
• the presence of developmental anomalies;
• increased body temperature.

If a child has residual urine on an ultrasound of the bladder, as well as a burning sensation, such symptoms should cause concern for the parents, in which case the ultrasound procedure will painlessly and accurately determine the possible disease. Ultrasound diagnostics of the bladder for the smallest patients (newborns and children under 1 year old) is prescribed for a much wider range of indications, and each case is considered by the doctor individually. Diagnostics for children is carried out only by a non-invasive method.

Preparation for ultrasound of the bladder in children

In order to properly prepare the child for the ultrasound procedure and ensure a high-quality diagnosis, it is necessary to follow a number of mandatory recommendations. One of the most important requirements is the mandatory filling of the bladder with fluid shortly before the start of the diagnosis. To do this, the child drinks from 200 to 500 ml of liquid (still water, compote, tea), depending on age, filling the organ under study and keeping the liquid in it during the entire ultrasound procedure.It is allowed to use the toilet before the child has consumed liquids. You should also refrain from eating milk, food products that can cause the formation of gas in the intestines (honey, fruits, legumes and bread) and thereby make it difficult to accurately diagnose. Do not forget about a good mood, because conducting an ultrasound scan is not painful at all and is very interesting.

Conducting a survey

After the preparation for the ultrasound scan is completed, the specialist puts the young patient on a couch and, having treated the abdominal area with gel, begins the diagnosis using a special scanner.The specialist moves the device over the entire area smoothly, with light pressure, and the image immediately appears on the screen of a small monitor located nearby. Young patients have the opportunity to observe the examination process. Ultrasound results are formed 15-20 minutes after diagnosis and then the patient’s parents are transferred to the doctor for diagnosis.

Interpretation of results

The final conclusion on the results of ultrasound is made by a qualified doctor who is able to give a detailed interpretation of the data obtained and make a diagnosis.He can prescribe a re-examination if there are doubts about the diagnosis or insufficient data. Ultrasound does not do any harm to the child’s body, so parents do not have to worry about the need to re-examine the child.

Norms of ultrasound of the bladder in children under 1 year old

A full bladder that makes you feel like it

The bladder normally has a rounded shape, its contours are clear, even, the wall thickness is up to 3 mm.The contents in the bladder are anechoic. There is no expansion of the distal ureters.

Norms of ultrasound of the bladder in children 1-3 years old

A full bladder that makes you feel like it

Indicators of the norm for the bladder: clear, even contours, rounded shape, non-thickened walls – 3 mm.The distal ureters are not dilated. The content is anechoic.

Norms of ultrasound of the bladder in children 3-7 years old

The fact that the ultrasound standards depend on the child’s age and gender is a medical fact, and an experienced diagnostician can quickly compare the data obtained by ultrasound with the standards. In case of detection of diseases or pathologies, the doctor chooses the appropriate treatment, gives the necessary recommendations and prescribes mandatory procedures. A full bladder that makes you feel like it

Normally, the bladder has a wall thickness of 3 mm, a rounded shape, smooth and clear contours.Its contents are anechoic, the distal parts of the ureters are not dilated.

Pathology on ultrasound

Ultrasound is the most informative modern diagnostic method, therefore, pathologies and diseases are detected with a fairly high accuracy. Pathologies include the formation of cysts and tumors, a noticeable thickening of the bladder walls, and an asymmetric position of the bladder. It should be remembered that even a minor disruption in the work of this important organ in a child can cause serious consequences, and in this case, his health will depend on the timely diagnosis and the optimally chosen treatment.

90,000 MRI diagnostics of diseases of the bladder | MRI Expert

MRI of the small pelvis in the diagnosis of diseases of the bladder

With the introduction of MRI into clinical practice, work is constantly being carried out on a comparative characteristic of the prospects for using this method in the diagnosis of both diseases of the bladder and the surrounding tissues and organs. At the moment, most authors convincingly prove that the accuracy, sensitivity and specificity of MRI in the diagnosis of bladder tumors is maximally high.It is especially important to use MRI to assess the stage of the tumor process and differential diagnosis of superficial and invasive cancer. At the moment, it has been established that intravenous contrasting significantly increases the diagnostic capabilities of the method.

Also, the overwhelming majority of researchers have come to the conclusion that MRI is much more informative in assessing extravesical tumor invasion.

Tumors of the bladder

A volumetric mass on the pedicle (papillary urothelial tumor) growing exophytically into the lumen of the bladder is visualized.

In order to assess the depth of tumor invasion into the bladder wall, MRI uses dynamic intravenous contrasting.

Non-invasive papillary urothelial tumor. Coronal T2-weighted MR imaging shows the tissue signal intensity of the tumor (arrow) growing into the bladder lumen. With a non-contrast study, the impression is created that the adjacent sections of the hypointense bladder wall are preserved. However, it is possible to reliably judge the degree of invasion depth only by postcontrast scans.

In this case, it is important to carry out precisely dynamic intravenous contrasting (in the arterial phase, only the tumor tissue is strengthened, but the intact wall of the bladder has not yet been strengthened). The presented contrast T1-WI image (arterial phase) against the background of the accumulation of CV by the tumor tissue, the submucosa, shows the absence of invasion of the adjacent bladder wall.

a) T2-axial image b) DW-axial plane

Male, 49 years old, urothelial carcinoma.

a) T2-weighted image shows tumor with tissue-intensity MR signal on the posterior-left bladder wall. At the same time, a slight increase in the intensity of the MR signal from the normally hypointense bladder wall is visible (arrows). (b Diffusion-weighted imaging shows the tumor (thin arrow) and its spread into the submucosal layer (arrowheads), without signs of invasion into the muscle layer.

a) T2-tra b) T1-sag c) T2-diffusion (DW)

Male, 72 years old.In the posterior-left bladder, a space-occupying mass (urothelial carcinoma), stage 3b is visualized.

(a) Axial T2-weighted image shows a large tumor with muscle wall invasion and the development of a hydroureter (arrow). The invasion of the muscle layer is visible, but it is impossible to judge about paravesical spread.

(b) Dynamic contrasting on a scan passing perpendicular to the base of the tumor reveals a total lesion of the bladder wall, indistinctness of the posterior contour of the tumor.

(c) Transverse diffusion-weighted image shows a large tumor with signs of transmural growth and invasion of paravesical tissue (arrow).

a) T2 cor FS b) T2-tra

Woman, 56 years old. Clinically – hematuria, morphologically verified tumor of the bladder. The presented non-contrast T2-weighted images in the coronal (a) and axial (b) planes show asymmetric infiltrative thickening of the left bladder stack, rigidity and flattening of the left wall against the background of normal bladder filling.In this case, the outer contour of the infiltratively thickened wall has fuzzy contours.

Intravenous dynamic contrasting, T1-WI, early (arterial phase). A pronounced diffuse contrast enhancement of the entire thickness of the infiltratively altered left (and partially posterior) walls of the bladder is seen, with an indistinctness of its outer contour and signs of minimal extravesical spread.

Metastases of bladder cancer

Axial T1-weighted image (a), T2-weighted image with fat (b) in a patient with bladder cancer.A small volumetric mass of the left femoral neck is determined (arrows). With intravenous contrast enhancement (c) – T1 c FS, the enhancement of this small formation is determined, which allows confirming the secondary, metastatic nature of this focus, despite its small size.

Thus, the value of an MRI study lies in the possibility of a polypositional study, the choice of any scanning planes; numerous MR sequences complementing each other to increase the diagnostic value of the results obtained.Dynamic contrast enhancement as well as diffusion-weighted sequences are invaluable in diagnosing the depth of invasion of the bladder wall, assessing extravesical spread. At the same time, it becomes possible to study paravesical tissues and organs; assessment of the condition of the pelvic, inguinal, paraortal lymph nodes, bone structures at the level of visualization.

MRI should precede any surgical intervention for a bladder tumor, being by far the most informative of the non-invasive diagnostic methods.Diagnosis of a non-invasive form of bladder tumor makes it possible to transurethral resection of the formation, i.e. allows you to properly plan a radical operational aid.

Bladder diverticula.

This is a local protrusion of the bladder wall. They predominate in men, the frequency of their occurrence increases with age.

Diverticulum develops, as a rule, against the background of a prolonged increase in intravesical pressure with bladder outlet obstruction (benign hyperplasia, prostate cancer, urethral strictures).There is a high risk of developing urothelial cancer in the bladder diverticulum due to the retention of carcinogenic substances in it.

Surgical treatment is indicated for large diverticula. According to MRI data, the localization, size and complications of the diverticulum (inflammation or tumor development) are determined.

a) T2-sagittal image b) T2-axial image.

Thinning of the wall and an increase in the volume of the bladder against the background of chronic bladder outlet obstruction (due to BPH).Trabecularity of the bladder wall is visible, diverticulum of the posterior wall of the bladder on the left (b), arrow; bilateral ureterectasia.

Non-clogging of the urinary duct

Urachus is a cystic or tubular structure located in the midline, at the level from the navel to the apex of the bladder. If the urinary duct is not closed, an umbilical fistula, a vesicoumbilical fistula, or a urachus cyst may occur.

a) T1-axial image b) T2-sagittal image

a) T1-axial image shows weakly hypointense inclusion adjacent to the anterior wall of the bladder (arrow).b) sagittal T2-WI shows a hyperintense oval (fluid) formation along the midline in the projection of the apex of the bladder. There was no evidence of a connection between this fluid formation and the bladder cavity (urachus cyst).

90,000 Bladder cancer – Docrates

Most often, bladder cancer is superficial and does not extend beyond the mucous membrane. However, this type of cancer can spread to the bladder wall and metastasize, for example, to the liver, lungs, or bone.The incidence of cancer invading the muscle layer accounts for only 20-25% of all malignant tumors of the bladder. The risk of recurrence of the disease is high, so the patient should undergo regular check-ups throughout his life.

Risk factors for bladder cancer

With age, the risk of bladder cancer, like many other types of malignant tumors, increases. The main risk group includes people whose body is exposed to chemicals (aromatic amines), as well as smokers.In modern industrial plants, effective protective equipment is used, which significantly reduces the risk of illness. Also, careful monitoring is carried out to ensure that the limit values ​​of carcinogens do not exceed the permissible norm. In Finland, the cost of bladder cancer treatment can be paid for by insurance that covers the treatment of occupational diseases, provided that the dependence of the disease on the working conditions is confirmed. This type of cancer can also be hereditary.

Bladder cancer symptoms

Typical symptoms of bladder cancer are blood in the urine and pain when urinating.If the tumor blocks the passage of urine from the kidneys to the bladder, it can lead to kidney dysfunction, which in turn results in pain in the kidney area. If the tumor blocks the urethra, then the process of urination can be very difficult.

Diagnosis of bladder cancer

If a bladder tumor is suspected, basic examinations are done: a urinalysis is taken to confirm the presence of blood in it, a urinalysis for cytology and an internal examination of the bladder (cystoscopy) is performed.Typically, an x-ray of the urinary tract (urography) and an ultrasound scan are done. Often, CT urography (a visual examination on a computer) is done to determine if the tumor has spread locally.

Then an ultrasound scan is performed, which allows you to see large neoplasms in the bladder and changes in the kidneys. At the initial stage, the kidneys are also examined with a contrast agent (urography). This helps to confirm that there are no tumors in the upper urinary tract and that the ureters are not blocked.In addition, the doctor performs an internal examination of the bladder.

In the case of a bladder resection, the patient usually undergoes a full-body CT scan if there is a suspicion that the cancer has invaded muscle tissue.

Bladder cancer treatment

Bladder cancer is treated with different methods – either separately or in combination. Due to the multifaceted nature of bladder cancer and the difference in prognosis of the disease, in order to choose the optimal treatment, it is necessary to determine the extent of the tumor as accurately as possible and correctly classify the type of tissue determined by the pathologist (histology).

If the tumor is superficial and has not spread beyond the bladder mucosa into muscle tissue, transurethral resection of the bladder (TUR) is performed. During the operation, with the help of a resectoscope inserted through the urethra, the tumor is resected and the bleeding vessels are cauterized (coagulation).

If cancer invades muscle tissue or there is a risk of it, radical surgery (total cystectomy), i.e. complete or partial removal of the bladder and removal of the prostate gland, can be performed as a treatment.In this case, urine is diverted into a reservoir, which is created from the intestinal area and performs the function of the bladder, or the urine reservoir can be discharged outside, through a special opening, of the stoma.

Depending on the type of tumor, its size and the presence of metastases, radiation therapy and intravenous treatment with cytostatic drugs are also possible. Chemoradiation therapy gives the same good results as traditional surgery.

In superficial bladder cancer with a good prognosis, the tumor is removed through the urethra using a resetoscope.To reduce the risk of recurrence during the procedure or immediately after it, a single rinsing of the bladder with cytostatics is performed. After drug treatment of superficial cancers with a high risk of recurrence, repeated flushing of the bladder with cytostatics is performed.

As a rule, the prostate gland is also removed during surgery for men, but the urethra is usually preserved today. For women, the urethra, uterus and including related organs are most often removed.If, due to poor general condition or difficult localization of the tumor, the operation is impossible, they resort to radiation therapy.

At the time of diagnosis of the disease, metastases are found in only about 5% of patients. In these cases, radiation or chemotherapy is used instead of removing the bladder. If the tumor has metastasized, radiation therapy is used to relieve symptoms such as pain, incontinence caused by a large tumor and a blockage of the urinary tract.To treat metastases, chemotherapy is used, with the help of which they decrease, and the symptoms of the disease become less pronounced.

Paid ultrasound of the internal organs of the abdominal cavity at a low price Es Class Clinic Ulyanovsk

Ultrasound of internal organs is a modern method that allows you to accurately determine the state of organs, to identify the presence of pathology or inflammation. Ultrasound examination of the abdominal cavity in Ulyanovsk can be performed at the medical center “Es Class Clinic Ulyanovsk”.

Here ultrasound examination is carried out on the latest equipment by doctors with many years of experience.

It is necessary to understand that there are no people with the same structure of internal organs. What is normal for some will be a sign of illness for others. Only an experienced and competent specialist can accurately decipher the results of ultrasound, to distinguish the norm from pathology. Doctors of this level practice in the diagnostic center “Es Class Clinic Ulyanovsk”.

Advantages of the method

• During ultrasound of the abdominal cavity, neither organs nor the skin are disturbed.This non-invasive method avoids pain and infection.
• The radiation received by the patient during the examination is minimal and does not in any way affect health.

Soft tissue ultrasound can be used to:

• to determine the size of internal organs and their congenital anomalies;
• find out their location;
• to investigate the structure of tissues;
• to identify neoplasms, polyps, stones.

Ways of conducting ultrasound of internal organs

There are two main methods of performing ultrasound examination:

• external when the sensor scans organs from the outside;
• internal (transvaginal and transrectal), when the sensor is inserted into the body.

Doppler sonography is also used, in which, thanks to the reflection of waves from a moving organ, the heartbeat, blood flow, and vascular work are determined.

How to prepare for the procedure

In order for the ultrasound to show the most accurate results, there is not enough good equipment and the doctor’s experience – it is necessary to properly prepare for the procedure.

It must be remembered that:

• Ultrasound is performed on an empty stomach, preferably in the early morning hours;
• the last meal should be at least 3 hours before the examination;
• no smoking before the procedure;
• 5 days before the procedure, you must give up alcohol;
• it may be necessary to abandon some drugs – which ones, the doctor recommends;
• during the previous 3 days, you should refrain from products that contribute to gas formation;
• if there is a tendency to flatulence, resort to a medicine that reduces the level of gas formation;
• in the presence of constipation, take a mild laxative or make an enema 10 hours before the examination;
• it is necessary to drink at least 1.5 liters of water daily for 3 days before the procedure;
• it is impossible to combine ultrasound with gastroscopy and some other examinations – with which ones, it is better to consult a doctor.

What organs are examined and when is it needed

• Ultrasound of the liver is prescribed when the symptoms indicate a violation in the activity of this organ, and other methods do not reveal its causes. Also, with its help, it is possible to establish the exact focus of the disease. The examination reveals tumors, abscesses, hepatitis, cirrhosis.
• May show irregularities in structure, uneven edges, indurations and growths, changes in size, increased connective tissue.
• Ultrasound of the gallbladder is prescribed for abdominal pain, with the appearance of bitterness in the mouth. It is recommended for those who suspect the presence of stones in this organ. The study shows the presence of a tumor, dyskinesia, cholecystitis, the presence of stones.
• Structural changes are visible in the thickening of the bladder walls, the existence of neoplasms, a change in the diameter of the organ and the tone of its walls.
• An ultrasound scan of the pancreas shows a change in its size, structural heterogeneity, tissue destruction, enlarged lymph nodes, the presence of seals and neoplasms, as well as stones.An ultrasound examination of the pancreas allows you to detect pancreatitis, oncological diseases, track the condition in diabetes mellitus, and clarify the causes of jaundice.
• Kidney ultrasound is prescribed for changes in urine tests and back pain, increased urination, nocturnal enuresis, after transplantation and injuries. It shows the presence of stones, neoplasms, inflammatory diseases, purulent lesions. Simultaneously with the study of the kidneys, the state of the ureters is assessed and, accordingly, the function of urine outflow.
• Ultrasound of the bladder is recommended for pain in the lower abdomen, increased frequency or retention of urination, painful urination, blood in the urine. The procedure is prescribed at the same time as a kidney examination in order to identify the exact cause of the dysfunction. The study shows the size and shape of the organ, its contours, the presence of neoplasms, stones and cysts. It can help identify hematomas, blood clots and pus.
• Ultrasound of female genital organs is performed transvaginally, transrectally and externally.It is indicated for all pregnant women, as well as women who are suspected of having diseases or abnormalities of the internal genital organs. With its help, pregnancy (uterine and ectopic), fibroids, cysts, inflammation of the uterus and appendages, endometriosis and much more are determined. It is prescribed for pain, extramenstrual bleeding, heavy menstruation. A routine examination of the genitals is recommended in the first half of the cycle. In the second half, the lining of the uterus thickens, and neoplasms are less visible.In addition, an egg cell matures in the ovary, forming a cyst. It is almost impossible to distinguish it from pathological.
• Genital ultrasound in men is performed in two ways. The first way is transabdominal. In this case, an ultrasound probe is used, which is pressed against the abdomen. The bladder should be full. The second way is transrectal. With this method, a special rectal device is inserted into the rectum. Often, an ultrasound of the prostate gland is performed in this way, when the patient, for some reason, cannot wait for the bladder to fill.But in many other cases, TRUS (this is the name of this method) gives more effective results.

How much does this or that examination cost? You can find out from our operators by the phone number indicated on the website.

Ultrasound of the abdominal organs in the “Es Class Clinic Ulyanovsk”

In the medical center “Es Class Clinic Ulyanovsk” each patient is provided with an individual approach. All conditions have been created here to make visitors feel as comfortable as possible.The price of an ultrasound of the kidneys, liver, pancreas and other organs is available even to those who need a study on a regular basis, in particular, patients with diabetes, renal failure, chronic pancreatitis, and pregnant women.

90,000 Bladder and urethral abnormalities in cats and dogs

Bladder volume

In humane medicine, the measurement of urine volume by ultrasound is widely used, with particular attention to the accumulated volume of urine and the residual volume after urination.When calculating the volume of urine in humans, the following formula is used: volume = length X width X height X 0.523. In dogs, the latter coefficient has been changed to 0.625, which more accurately determines the estimated volume of urine.

In the practice of small pets, ultrasound calculation of urine volume by ultrasound can be used to assess conditions such as: bladder contractility, neurogenic bladder, obstruction of urine outflow. In dogs and cats, urine volume measurements may also be helpful in assessing the degree of bladder dysfunction during medical or surgical treatment.Also, ultrasonic measurement of residual urine volume is used to assess canine dysuria and the success of surgical treatment for herniated lumbosacral intervertebral discs.

Position of the bladder neck

Ultrasound identification of the location of the bladder neck can provide the veterinarian with some data that are somewhat contradictory in meaning and content (the usefulness of these measurements remains unclear). Displacement of the bladder into the pelvic canal is established when> 10% of the organ is there, and this deviation may require colposuspension (at the discretion of the doctor).

In the practice of small pets, ultrasound is used to determine the change in the position of the bladder neck in healthy dogs and in dogs against the background of the sphincter mechanism of urinary incontinence, which often develops during rest or relaxation of the animal. On analysis of the data, it was found that dogs with urinary incontinence had a greater degree of caudal bladder movement under anesthesia. The theory has been hypothesized that incontinence may be related to a deficiency in a vesicourethral support mechanism.Also, with this form of incontinence, the bladder may also be abnormal and not constrict normally at the junction with the urethra.

So, ultrasound of the urinary bladder for incontinence can exclude visible causes (eg ectopia of the ureter, see above), and helps in the diagnosis of sphincter incontinence by assessing dynamic changes in the position of the bladder neck. It should be noted that with caudal displacement of the bladder neck, it is very difficult to exclude other causal incontinence due to poor visualization of the bladder trigone umbrellas (difficulties in diagnosing ureteral ectopia).

Also, when a comparison was made between stress urinary incontinence in women and sphincter incontinence in bitches, scientists found a lot in common between them. It was noted that both in women and in bitches with these diseases, a shortening, compared to the norm, of the functional urethra area is determined, as well as a low maximum pressure in the urethra.

Urachus anomalies and acquired diverticula

Contrast radiographic examination is the best method for assessing the position and extent of diverticula (congenital and acquired) and fistulas.Ultrasound in these cases plays an auxiliary role, but some pathologies of the urachus, diverticula and fistula may be suspected during ultrasound of the bladder (which is often performed before radiography) and serves as a reason for further diagnosis.

Urachus plays an important role in the period when the animal fetus is in the uterus, it connects the bladder with the allantoic sac. After the birth of an animal, the urachus undergoes regression and transformation into fibrous masses. In case of violation of the reverse development of the urachus, the development of the following pathologies is likely: persistent (open) urachus; urachus diverticulum; urachus cyst.

Persistent (open) urachus – preservation of the connection of the bladder with the external environment in the navel area. It is clinically expressed in urine leakage in the navel area (only wetted hair can be observed), with the supine position, the formation of dotted leaks is likely. The main diagnostic method is contrast cystography, ultrasound is an auxiliary method. On ultrasound examination against the background of an open urachus, it is determined between the cranioventral part of the bladder wall and the umbilicus, and is suspected in cases of a change in the contour of the apex of the bladder (unusually raised, pointed appearance).The very wall of the bladder with persistent urachus is often thickened. The main method of treatment for persistent urachus is surgical correction (direct indications), it leads to a complete cure.

Urachus diverticulum (s) – weak protrusion of the bladder tissue at the apex, with incomplete closure of the urachus of the fetus. Probably the development of a secondary urachus diverticulum secondary to urethral obstruction or idiopathic feline cystitis. The urachus diverticulum predisposes the animal to the development of bacterial colonization of the urinary bladder, and may contribute to the development of signs of idiopathic cystitis.The main diagnostic method, as well as with persistent urachus, are contrast radiographic imaging methods; An ultrasound scan only helps to suspect a diverticulum. Ultrasound examination of urachus diverticula usually reveals fluid-filled structures extending from the bladder lumen. Diverticula can vary significantly in size, and the wall can thicken in chronic cystitis with prolonged course. Removal of diverticula (diverticulectomy) is indicated only if there are clinical signs, i.e.,Because a urachus diverticulum may predispose the bladder to recurrent infection, asymptomatic animals are not treated.

It should be remembered that urachus abnormalities are localized in the cranioventral wall of the bladder, between the bladder itself and the umbilicus, while acquired diverticula can develop at any location. Diverticula in the bladder wall can form due to trauma or cystitis.

Urachus cyst forms under the condition of continued secretion of an isolated part of the urachus epithelium, while the remaining urachus undergoes fibrosis and regression.Typically, on ultrasound, urachus cysts appear as thin-walled, anechoic structures cranial to the bladder. Probably infection of the cyst and the formation of an abscess (with a corresponding appearance on ultrasound). Contrast cystography also remains the main diagnostic method, and surgical excision of the urachus cyst is the treatment of choice.

Also described is such a pathology as preserved urachus ligament , it pulls the bladder cranially to the umbilicus and prevents adequate emptying in cats, leading to lengthening of the bladder and the formation of a pointed apex.Surgical dissection of this ligament leads to the animal’s recovery.

Ultrasound of the bladder can detect herniation (hernia) of intact mucosa through a tear in the muscle layer of the bladder wall after traumatic exposure. But the diagnosis must also be confirmed by contrast cystography. Also, with ultrasound of the bladder, deformation of the lumen and adhesion of the bladder may be suspected; confirmation of the diagnosis of these pathologies requires a contrast radiographic examination.

Bladder duplication

Duplication of the bladder is a rare condition described in dogs. Ultrasound allows us to suspect this pathology, the final diagnosis is carried out by means of plain and contrast radiography. Duplication of the bladder can predispose an animal to urinary tract infection and urinary incontinence, and surgical correction is the main treatment.

Bladder rupture

If you suspect a ruptured urinary tract (pr.in trauma), expert means of assessing their integrity are various methods of contrast imaging (excretory urography, contrast cystography and urethrography). Ultrasound in these cases can only play an auxiliary, and far from the main, role. Also, with ultrasound of the bladder, wall rupture may be mistakenly suspected due to interruption of the curved wall signal (marginal or refractive artifact). In addition, small wall defects may not be visualized by ultrasound and lesions in other parts of the urinary tract are likely to be missed.

Cystitis

During ultrasound examination of the bladder against the background of cystitis, asymmetric thickening of its walls is most often noted, this phenomenon is most pronounced in the cranioventral section, but, in severe cases, generalized thickening may be noted. The normal wall thickness of a distended bladder is in the order of 1–2 mm. When the bladder collapses, a subjective assessment of the wall thickness is required, based on the degree of stretching.In many cases of cystitis, the bladder wall is normal, this may be true even in the presence of sediment or stones. Ultrasonic thickening of the bladder wall (hypoechoic, hyperechoic, or stratified) is often combined with other findings such as stones, debris, or blood clots. And again, ultrasound data for cystitis are often auxiliary, and a combined use of other examination methods is required to establish the final diagnosis.

Polypoid cystitis is a rare form of cystitis described in dogs.Ultrasound examination of the bladder, with this form of cystitis, reveals hyperechoic masses (polypoid or pedunculated) protruding into the lumen of the bladder, as well as diffuse thickening of the walls (the latter is not always the case). Polypoid masses are characterized by a certain localization, more often they are located on the cranioventral wall of the bladder, in rare cases they can be located craniodorsally.

The main differential diagnosis in polypoid cystitis is a neoplasm of the urinary bladder (usually transitional cell carcinoma of dogs), in case of any doubts, a catheter biopsy (suction biopsies) should be performed, followed by cytological examination of the samples.It should be remembered that neoplasms of the bladder are much more common than wall polyps.

Emphysematous cystitis is a separate form of cystitis, characterized by the formation of gas by bacteria such as: Escherichia coli, Aerobacter aerogenes, Proteus mirabilis, and Clostridium sp. This type of cystitis is more often observed in animals against the background of diabetes mellitus, during the fermentation of urine glucose by bacteria. The ultrasound view in emphysematous cystitis is characterized by the detection of a multifocal, hyperechoic surface of the bladder of irregular shape with a reverberation artifact and the formation of a dirty shadow.

The free gas of the bladder lumen (often observed during catheterization) is differentiated by changing the position of the patient and / or the sensor (free gas moves with the change in the position of the patient). Radiography of the abdominal cavity acts as an auxiliary method for diagnosing emphysematous cystitis, it reveals the glow of the bladder wall.

Pseudomembranous cystitis has mainly been described in humane medicine, but can also occur in cats. This type of cystitis is associated with severe diffuse ulceration, necrosis and hemorrhage in the bladder wall, as well as with intraluminal necrosis, and the formation of free fibrinous and geromrhagic septa and debris in the lumen.The accumulation of tissue and debris in the lumen predisposes to obstruction of the flow of urine through the urethra. The ultrasound picture in pseudomembazous cystitis reveals a thickening of the walls of the bladder, the presence of echogenic debris and septa that break up the bladder into small sections.

Cystitis with inversion of the bladder walls is a rather rare condition, it can be asymptomatic, and can cause signs of inflammation of the bladder. The ultrasound picture reveals a thickening at the tip of the bladder in the form of masses, or a fold of the bladder protruding into the bladder.Inversion leads to the formation of incised serous borders of the bladder. The thickening of the inverted wall retains the layering, leading to the formation of a characteristic mixed (hyper- and hypoechoic) species. This condition can also occur after long-term placement of a urinary catheter.

Blood clots in the lumen and hemorrhages of the bladder walls

Blood clots in the lumen of the bladder and wall hematomas can form for the following reasons: trauma, hemostasis disorders, infection, neoplasia.Blood clots are expected findings with appropriate medical history and clinical signs. Clots with ultrasound are usually hyperechoic, without a shadow, irregular in shape, displaced according to the law of gravity. In the presence of large clots or their adhesion to the wall of the bladder, their vernal appearance may be more echogenic with less mobility, which leads to an erroneous diagnosis of mural masses. To differentiate between neoplasms of the urinary wall and blood clots (or hematomas), Doppler can be used; in the formations, it reveals some vascularity of the lesions.Manipulation of intermittent pressure of the transducer on the bladder temporarily suspends small clots in the urine (lifts), this phenomenon is not observed in the presence of mural masses or large uroliths.

Ultrasound examination of intramural hematoma reveals masses of different echogenicity (more often hypoechoic) inside the thickened wall, they can be linear or round. A Doppler study helps to distinguish a hematoma from formation by a lack of blood flow in the hemorrhage focus.Also, repeated research helps to differentiate neoplasia and inflammatory diseases of the urinary wall secondary to hemostasis disorders, with appropriate successful treatment – the hematoma resolves at a rate of about 1 mm / day. With trauma, there may be concomitant bladder lesions in the form of free fluid around the outer wall, and a suitable medical history or accompanying signs of recent trauma may help in making a diagnosis.

Intramural hematoma gradually resolves if it does not lead to the formation of necrosis of the bladder wall and urine leakage into the abdominal cavity.

Bladder stones

A typical ultrasound view of radiolucent and radiopaque bladder stones are hyperechoic foci, with an artifact of shading in the dependent part of the bladder lumen (lower, facing the ground). Bladder stones are heavier than urine and tend to migrate into the dependent part of the lumen, in rare cases, they are likely to stick to the wall against the background of severe inflammation. Uroliths usually have a spherical shape, their surface is hyperechoic and curvilinear, their number and size are varied.

Photo. Typical ultrasound appearance of a cat’s urinary bladder urolith.

Ultrasound identification of uroliths in the bladder using modern equipment has the same accuracy as contrast radiographic examination. However, compared to other imaging techniques, ultrasound tends to increase the true dimensions of uroliths by a few millimeters.

The degree of shading of bladder stones varies considerably and depends on such factors as: composition and density of uroliths; their location in the focal zone of the sensor; the frequency of the ultrasound used.The presence of shading correlates poorly with the composition of stones, the shading becomes most pronounced when using a higher frequency of ultrasound, with the location of uroliths in the focal zone of the sensor. In the presence of small stones (not exceeding the width of the ultrasound beam along the x or Z axis), the shading artifact usually does not appear. Ultrasound identification of suspect bladder stones facilitates the use of color Doppler; the presence of uroliths is determined by the presence of a twinkling artifact.

Difficulties in identifying stones may arise in the presence of sediment; it is more often localized in the dependent part of the lumen of the bladder and can give shading. However, the sediment is easily suspended when exposed to the bladder, and if there are no stones, there is no way to observe the discrete echogenic foci of uroliths. The accumulation of small stones or mineralized sediment in the dependent part of the bladder is capable of creating a linear surface with a shade of varying severity.The presence of a dependent sediment without a shadow indicates the presence of non-mineral substances (eg cellular debris) or a small amount of salts in crystalluria. Less echogenic pyuria may appear on ultrasound as an echogenic accumulation in the dependent part of the bladder. Unlike sediment and stones, gas bubbles rise up in the bladder, but they also create a shadow, and must be differentiated from the near field reverberation artifact. Both sediment and gas bubbles change their localization with the change in the position of the patient’s body.

Fibrosis or calcification of the bladder wall can form mural hyperechogenicity and shading. In most cases, repositioning or visualizing the transducer in multiple planes (together or separately) helps to distinguish fibrosis or calcification from stones, blood clots, sediment, or gas bubbles.

For the newcomer to ultrasound diagnostics, the colon has a hyperechoic surface, creates a shading artifact and can mimic large bladder stones.To differentiate this phenomenon, the movement of the transducer in the longitudinal plane defines the colon as a linear surface along the entire length of the image, while the stones must remain spherical. In addition, a change in position of the animal (standing or on its side) should lead to a change in the position of stones in the lumen of the bladder, while the colon remains in one position.

Foreign bodies of the urinary bladder

Examples of foreign bodies in the bladder are pathologies such as: an abandoned catheter, an awn of cereals, suture material.The catheter is presented in the form of parallel echogenic lines when the ultrasound beam is perpendicular to the wall, the parallel lines represent the catheter walls. The awns of cereals have a different appearance, but they can be presented as hyperechoic structures without shading. In case of reaction to the suture material of the walls – the site of the operation appears to be thickened, it is likely to determine the suture pattern.

Neoplasms of the bladder

Transitional cell carcinoma (TCC) of the bladder is the most common type of tumor in this location.Most often affects dogs, almost never occurs in cats. There is a possibility of detecting other types of bladder tumors; they can be epithelial in origin (squamous cell carcinoma, adenocarcinoma) and mesenchymal (uviform rhabdomyosarcoma, tumors of the peripheral nerve sheath, leiomyoma, leiomyosarcoma, fibroma, fibrosarcoma, osteosarcoma, lymphoma, mycodonitis). By means of ultrasound, it is impossible to distinguish the type of tumor, as well as to distinguish it from a benign formation, however, neoplasms of epithelial origin have an intraluminal protrusion of an irregular shape, while mesenchymal tumors give a smooth surface (both mucous and serous).Due to the fact that transitional cell carcinoma of the bladder is the only type of tumor often found in the veterinary practice of small pets, we will talk about it further. In case of various doubts, it is better to send an animal with education to a reference veterinary clinic.

The characteristic localization of transitional cell carcinoma of the bladder is the trigone zone and the dorsal wall of the bladder; in rare cases, any other localization or diffuse involvement of the wall can be noted.An ultrasound view of this tumor is usually presented as its thickening and change in shape with the formation of masses protruding into the lumen of the bladder with a wide attachment. The echogenicity of the lesions is often mixed, and the general appearance may be weak or echogenic. With tumor mineralization (there is a possibility of development), differentiation of intramural lesions from intraluminal uroliths is required. With diffuse involvement of the bladder wall and the absence of local masses, the appearance of the thickening should be differentiated from thickening in severe and chronic cystitis.

With the localization of transitional cell carcinoma of the bladder in the papillae of the ureter, the development of obstruction and expansion of the ureter (unilateral and bilateral) is likely. With this type of neoplasm, invasion of the tumor into the proximal urethra often occurs. However, the transfer of the tumor from the prostate and ureter to the bladder is possible. Dogs with transitional cell carcinoma often have concurrent urolithiasis, urethritis, cystitis, and / or blood clots.

As mentioned above, differentiation of the type of tumor is possible only through cytology and / or pathomorphology. But performing a percutaneous biopsy in dogs with transitional cell carcinoma is controversial (rather contraindicated). promotes the spread of cells along the canal of the needle (more often the development of a secondary tumor on the ventral wall of the abdominal cavity). Therefore, for the diagnosis of this type of tumor, the preferred method of establishing a definitive diagnosis is catheter biopsy (possibly under ultrasound guidance).

For tumor staging, ultrasound is used to assess the sub-lumbar (iliac) lymph nodes, and ureteral obstruction is excluded by visualizing both the ureter itself and the degree of filling of the renal pelvis. The operator must remember that tumors of the ureter or prostate can extend into the bladder, depicting a urinary tumor. To complete the complete staging of the tumor, in addition to microscopic examination of the samples, radiographic examination of the thoracic and abdominal cavities (metastasis to the lungs, assessment of the iliac lymph nodes, pelvis and lumbar spinal cord) is required.Complete staging of transitional cell carcinoma of the bladder can affect the prognosis of the disease.

Urethral pathology

The value of ultrasound evaluation of the urethra in dogs and cats is difficult and anatomically limited. The most beneficial is the evaluation of the proximal urethra in bitches and the prostatic urethra in males. The use of modern intraluminal high-frequency equipment makes it possible to assess the entire length of the urethra (determination of urethral tumor, assessment of metastases, localization of stones), but this type of study is still out of reach and remains the domain of reference veterinary clinics.