Filling Defect in Urinary Bladder



Filling Defect in Urinary Bladder


Michael P. Federle, MD, FACR



DIFFERENTIAL DIAGNOSIS


Common



  • Bladder Carcinoma


  • Bladder Calculi


  • Ureterocele


  • Blood Clot


  • Benign Prostatic Hypertrophy


  • Diverticulitis


  • Bladder Fistulas


  • Foreign Body, Bladder


  • Extravesical Pelvic Mass



    • Prostate Carcinoma


    • Rectal Carcinoma


    • Cervical Carcinoma


    • Endometrioma


  • Cystitis



    • Emphysematous Cystitis


Less Common



  • Urachal Carcinoma


  • Inverted Papilloma, Bladder


  • Inflammatory Pseudotumor or Sarcoma


  • Mesenchymal Tumors, Bladder


  • Pheochromocytoma


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • Mobility, location, and shape of lesion suggest the diagnosis or limit the differential



    • Enhancement of lesion = neoplastic or inflammatory, excludes calculi, blood clot, debris


    • Cystoscopy and biopsy often necessary


    • Chronic inflammation of bladder leads to clinical and imaging features that are difficult to distinguish from neoplastic disease without cystoscopy & biopsy


Helpful Clues for Common Diagnoses



  • Bladder Carcinoma



    • Sessile or pedunculated soft tissue mass projecting into the lumen


    • Similar density to bladder wall on CECT


    • Can never exclude cancer by imaging



      • Patient with unexplained hematuria requires cystoscopy


  • Bladder Calculi



    • Smooth round or ovoid; can be spiculated (“jack stone”), laminated or faceted


    • US: Mobile, echogenic, shadowing foci


    • Most are radiopaque on plain films; all on CT


  • Ureterocele



    • Orthotopic: “Cobra-head” or “spring onion” deformity of distal ureter with surrounding radiolucent halo


    • Ectopic: Smooth, radiolucent intravesicular mass near bladder base


  • Blood Clot



    • US: Mobile mass, does not cast an acoustic shadow


    • Attenuation value in the range of 50-60 HU, no enhancement on CECT


  • Benign Prostatic Hypertrophy



    • Displaces the floor of the bladder cephalad


    • Classic finding on urography is upward deviation of distal ureters



      • “J-shaped” ureters


    • Often accompanied by clinical symptoms of dysuria and hematuria, raising concern for bladder cancer



      • Trabeculation of bladder wall from chronic outlet obstruction may also simulate signs of bladder cancer


      • Cystoscopy usually necessary for definitive diagnosis


  • Diverticulitis



    • Commonly causes inflammatory thickening of adjacent wall of bladder


    • Abscess arising from sigmoid diverticulitis especially prone to involve bladder


    • May give rise to colovesical fistula (most common cause in industrialized countries)


  • Bladder Fistulas



    • Enterovesical: Gas in bladder; bladder ± adjacent bowel wall thickening



      • Diverticulitis most common cause


      • Other causes include Crohn disease, radiation (cystitis &/or enteritis), carcinomas of bladder, bowel or other pelvic viscera, especially after radiation therapy


    • Vesicovaginal: Contrast-opacified urine opacifies vagina


  • Foreign Body, Bladder



    • Bladder catheter (“Foley”) is extremely common in hospitalized patients


    • Next most common cause is introduction during autoeroticism or child abuse



      • Pieces of catheters, hairs, sutures, and other causes are recognized



    • Can become a nidus for calcification


  • Extravesical Pelvic Mass



    • Any neoplastic (or inflammatory) process arising in pelvis can indent or invade the bladder



      • Neoplastic examples: Carcinoma of prostate, rectum, cervix


      • Inflammatory: Endometriosis, pelvic abscess


  • Prostate Carcinoma



    • Mass effect of tumor may indent bladder floor similar to BPH


    • Tumor may invade bladder, causing intramural or even intraluminal mass


  • Cystitis



    • Many causes



      • Infectious: Bacterial, viral, fungal, parasites (Schistosoma hematobium)


      • Medication induced: Chemotherapy, especially with cyclophosphamide (Cytoxan); antibiotics


      • Interstitial (idiopathic); urine is sterile


      • Eosinophilic: May cause “pseudotumoral cystitis”, especially in children


      • Radiation therapy


  • Emphysematous Cystitis



    • Most commonly seen in patients with long standing & poorly controlled diabetes mellitus


    • Caused by bacterial fermentation of glucose in urine or uroepithelium



      • Can release gas (carbon dioxide) within bladder lumen and/or wall


      • Gas limited to lumen is difficult to recognize on radiography, & cause is more often iatrogenic (catheterization)


Helpful Clues for Less Common Diagnoses



  • Urachal Carcinoma



    • Mass ± calcification extending up from dome of bladder toward umbilicus


    • Infected urachal cyst may have similar appearance


  • Inverted Papilloma, Bladder



    • May arise in bladder (or ureter or renal pelvis)


    • Usually small sessile or pedunculated mass


  • Inflammatory Pseudotumor or Sarcoma



    • Pseudotumor is also known as myofibroblastic tumor


    • Sarcoma has worse prognosis, but difficult to distinguish between these lesions on imaging or pathology (gross or microscopic)


    • Usual appearance is vascular, bulky mass in patient with gross hematuria


  • Pheochromocytoma



    • May arise in pelvis, even within wall of bladder


    • May be accompanied by symptoms of headache & palpitations on urination






Image Gallery









Axial CECT shows a large mass image in the bladder near the trigone that was causing hematuria and ureteral obstruction in this 69 year old man.






Coronal CECT shows the large mass image in the bladder near the trigone with right-sided hydronephrosis image in the same patient.







(Left) Frontal radiograph shows multiple calcified bladder stones, some rounded image and others irregular in shape image. This young woman had paraplegia and repeated, chronic bladder infections. (Right) Axial CECT shows multiple calcified stones image and gas image within the urinary bladder of the same patient. Repeated urinary infections are a predisposing cause for calculi.
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Aug 2, 2016 | Posted by in GENERAL | Comments Off on Filling Defect in Urinary Bladder
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