Practical Recommendations for Performing Ultrasound Scanning in the Urological and Andrological Fields

Parameter

Pattern

Acute cystitis

Wall thickness and

echogenicity

Increased hypoechogenicity, increased thickness of the bladder wall, between the serosa and mucosa

Chronic cystitis

No characteristic pattern, assessment of post-micturition residue, search for foreign bodies in the bladder

Bullous cystitis

Wall thickness,

echogenicity

Increased bladder wall thickness, anechogenic areas

Wall hypoechogenicity

Diverticuli

Presence/absence

Formation of anechogenic paravesical areas with the presence of asonic funneling to the bladder (diverticular neck)

Transrectal scanning can better reveal the diverticular neck

Color Doppler can enable DD between tumors and endodiverticular clots, although it is not the ultimate test

In doubtful cases CEUS or other radiological or endourological imaging should be done

Detrusor hypertrophy

Thickness detrusor wall (calculated at ≥ 250 ml of filling, as mean of three measurements, the hypoechogenic tissue included between two lines of hyperechogenic tissue: mucosa and bladder serosa)

Increased (>3 mm) with irregularities

(trabeculatures or even pseudodiverticuli) low-level evidence, recommendations need to be verified on vast scale, evidence levels based on opinions of experts and case series Parameter to be assessed, advised by experts. For use in clinical studies

Ureterocele

Anechogenic formation (cyst) at the level of the ureteral meatus with evidence at color Doppler of ureteral jet

Juxtavesical ureter lesion

Juxtavesical ureter obstructive lesion (stone or vegetating lesion)

Hyperechogenic image with posterior shadow included in the thickness of the ureteral wall (between hyperechogenic serosa)

Eco-color Doppler: useful to identify color signals (artifacts) in the shadow area and in DD of vegetating lesions also with eco-power Doppler

Evidence or not of urethral jet at color Doppler

Stones

Hyperechogenic images with shadow, mobile depending on decubitus movements

Hyperactive bladder

Bladder weight

(UEBW, ultrasound-estimated bladder weight)

No consensus in literature as to standardized cutoff values to be used in clinical studies

59.3.7.2 Neoplastic Diseases

Although staging is not currently approved on the basis of the ultrasound findings, we report indications for a possible interpretation.

	Parameter	Pattern
Superficial lesions	Bladder wall structure	Generally no echostructural alterations of the wall Endophytic tumors appear as hypoechogenic, fixed proliferative lesions, but sometimes they are hyperechogenic due to the presence of superficial calcifications. At color Doppler hypervascularization is observed
Infiltrating lesions	Bladder wall structure	Interruption/deformation of the wall that appears thickened, sometimes extension beyond the bladder wall

59.3.7.3 Ultrasound of the Pelvic Floor (19, 22–24, 26–30, 32, 34–38)

	Trans-perineal	Introital	Trans-vaginal	Transrectal
Instruments	Convex 3.5–5 Mhz probe	Sector end-fire 5–7.5 Mhz probe	Linear biplanar 7.5 Mhz probe	Linear biplanar 7.5 Mhz probe
Patient position		Lithotomic	Lithotomic Orthostatic	Lithotomic Orthostatic
Quality of image	+	+	+++	+++
Measurement of mobility	++	++	+++	+++
Invasiveness	+	+	++	+++
Artifacts in 3–4 grade cystocele	++	++	+++	+

Addendum: possible use of 3D studies, especially for postsurgical assessment (sling). Clinical studies to assess the presence of funneling of the neck, hypermobility of the neck-urethra complex, cystocele, and ureteral fixity. No standards have yet been established for mobility parameters (among proposals see Schaer et al. Int Urogynecol J Pelvic Floor Dysfunc 1996, Pajoncini C. in Atlante di ecografia uro nefrologica ed andrologica 1996 ed.CIC, Merz et al. Ultraschall Med 2004, Tunn R. et al. Update recommendations on ultrasonography in urogynecology. Int Urogynecol J 2005 16, 236–241).

59.3.8 Reference Texts

A literature search of guidelines and reviews on the use of ultrasound in bladder studies published in the last 10 years was made:

AIUM Practice Guideline for Documentation of an Ultrasound Examination – 2008 American Institute of Ultrasound in Medicine
AIUM Official Statements Training Guidelines for Physicians Who Evaluate and Interpret Diagnostic Ultrasound Examinations American Institute of Ultrasound in Medicine 2011
Standards and Guidelines for the Accreditation of Ultrasound Practices. 2011 American Institute of Ultrasound in Medicine
Documento SIUMB per le linee guida in Urologia

Giornale Italiano di ecografia I.R. al vol.8 n.4 2005
EAU Guidelines on Urinary Incontinence

Eur Urol 59 (2011) 387–400
Guidelines on Non–muscle–invasive Bladder Cancer (TaT1 and CIS)

EAU 2012
Guidelines on Pain Management

EAU 2012

59.4 Prostate and Seminal Vesicles

59.4.1 Prostatic Ultrasound Scanning with the Suprapubic Technique

59.4.1.1 Method

The prostate must be analyzed on two orthogonal planes: transverse and longitudinal. In this study it is essential to examine:

Juxtavesical ureters
Bladder
Prostate
Seminal vesicles

The prostate diameters to be assessed are latero-lateral, anteroposterior, and cranio-caudal.

In cases of an obstructive lesion of the juxtavesical ureter (stone or vegetating lesion), oblique scans must be made.

Images to be included (not all are always indispensable, depending on the clinical picture)

1.

One image of the bladder in longitudinal/transverse scan
2.

One image of the prostate in transverse scan showing the bladder
3.

One image of the prostate in longitudinal scan showing the bladder
4.

One image of the right juxtavesical ureter in oblique scan
5.

One image of the left juxtavesical ureter in oblique scan
6.

One or more images of any anomalies

Report of the findings

1.

Date and place of performance of the investigation
2.

Patient data (including birth date)
3.

Mention of clinical history and diagnostic purpose
4.

Value of the last total PSA blood test
5.

Comparison with previous tests if available

Both the images and findings must be easy to read by other operators and at later dates. The findings must therefore be reported as unambiguously as possible. In cases of any diagnostic doubt, this must be pointed out, indicating possible hypotheses and suggesting any further instrumental investigations that may help to solve any doubts.

59.4.1.2 Terminology

1.

Identification of the medial lobe and its size and relations with the pelvic floor

Any picture of cervico-ureteral obstruction due to prostatic hypertrophy causing severe detrusor impairment and any presence of bladder stones [Table 59.1].

Table 59.1

Stones and hyperechogenic prostatic images

Pathologic mechanism	Size	Macroscopic evidence	Number	Site
(Increased intraprostatic pH and increased precipitation of calcium salts)
Endogenous Amyloid bodies Reaction to foreign body in intra-acinar site	Macrolithiasis (max. diameter ≥ 2 mm)	Disseminated ±posterior shadow	Single	Periureteral
Exogenous Stasis of prostatic secretion Intraprostatic Reflux Prostatitis	Microlithiasis (max. diameter ≤ 2 mm)	Thickened ± posterior shadow	Multiple	Lobar Perinodular Ejaculatory ducts

59.4.1.3 Indications

1.

To assess the size and volume of the prostate gland before medical, surgical, or radiation treatment (in particular, to assess the volume displacement caused by the third lobe and correlations with detrusor hypertrophy and the presence of bladder pseudodiverticuli and diverticuli)
2.

To assess the patient with lower urinary tract symptoms
3.

To assess congenital anomalies

59.4.1.4 Essential Parameters to Be Specified in the Final Report

Prostate

1.

Presence or absence of the prostate
2.

Orthotopic or heterotopic site
3.

Shape
4.

Size
5.

Presence or absence of a third lobe (if present, volume and/or size of protrusion into the bladder: intravesical prostatic protrusion)
6.

Presence and size of any gross calcifications (diameter >5 mm)
7.

Presence and size of any gross abscesses/cysts (diameter >5 mm)
8.

Presence of the ureters and any dilation or anomalous outlet
9.

Quantification of post-voiding residue

Note

Lesions of any nature with a diameter of ≤ 5 mm are not identifiable with suprapubic ultrasound scanning. The suprapubic technique cannot visualize the echostructure of the peripheral zone of the prostate due to technical image resolution limitations.

Seminal Vesicles

1.

Presence or absence
2.

Site
3.

Symmetry

Bladder

An accurate description of the bladder is essential; see previous chapter.

59.4.1.5 Preparation for Investigation and Patient Position

1.

The patient does not need to be fasting.
2.
The bladder must be repleted with at least 300 cc; to ensure this it is necessary:
(a)

For the patient to drink at least 500 cc of fluids during the three hours before the investigation

(b)

For the patient to refrain from urinating within two hours before the investigation

(c)

For the patient to feel the urge to urinate (this latter parameter is extremely subjective and not always reliable)

The investigation is normally performed with the patient in supine position. Lateral right or left decubitus may rarely be necessary, in cases where a lesion, likely of prostatic origin, extends into the lumen, and its mobility must be checked.

In cases requiring oblique scanning, this is done by rotating the probe by about 40° to its longitudinal axis, taking care that the bladder filling is not more than 250–300 cc (otherwise the ureters would appear crushed by the bladder volume itself).

59.4.1.6 Facsimile of the Final Report

Mention of clinical history:_________________

Diagnostic purpose: ____________________

Last total PSA value

The bladder…

Yes/no hyperechogenic bladder images depicting stones, nor dilation of the juxtavesical and intramural bilateral ureters

The prostate is shown in orthotopic/heterotopic site and is grossly triangular, size within normal limits (more/less), (LL × AP × CC), having a theoretical calculated volume of about ___ml.

Presence of third lobe protruding into the bladder by ____cm

Post-voiding residue is about cc.

Mild/fair/marked tenderness or pain on palpation of the hypogastrium at the start/throughout the duration of the investigation

59.4.1.7 Diagnostic Accuracy

It is important to note that the elective method for the study of the prostate gland includes the use of endocavitary probes (see relative chapter). In fact, suprapubic ultrasound scanning is not contemplated in the guidelines for the study of the prostate drawn up by the main scientific societies due to its limited diagnostic power (see references).

In particular, it is thought that prostate ultrasound results in an overestimation by more than 30–50 % of the true prostate volume.

According to some authors, moreover, the use of the ellipsoid formula to calculate the prostate gland volume with the aid of suprapubic ultrasound leads to an error of about 20 %.

59.4.1.8 Notes on Clinical Practice

A.

Attention must be paid to the degree of distension of the bladder that can affect the visualization of the juxtavesical ureters and seminal vesicles.
B.

Use the tissue harmonic imaging tool to reduce reverberation artifacts and obtain better detail.
C.

Indicate any difficulties encountered while performing the investigation (patient’s collaboration and constitution, presence of bowel gas), underlining any limits of the test and so its diagnostic value.
D.

Remember that if the prostate is larger than normal, its morphology may vary, especially in cases of prostatic hyperplasia.

59.4.1.9 Devices and Transducers Used

Convex transducer with a frequency of 3.5 MHz or multifrequency 5–2 MHz probes depending on the patient’s constitution and how deeply the gland is located

59.4.2 Transrectal Prostatic Ultrasound

59.4.2.1 Method

The investigation is dynamic, and apart from longitudinal and transverse scans, with the probe inclined more cranio-caudally than for the study of the bladder, oblique scans will also be performed to study the seminal vesicles that generally lie on the transverse/oblique plane.

The prostate must be analyzed on two orthogonal planes: transverse and longitudinal, from the apex to the base of the gland.

At the same time, it is essential to study:

The urethra sphincter, Cowper’s glands
The seminal vesicles
The juxtavesical tract of the ureters
The deferens ducts
The bladder (insofar as it is explorable)

Additionally, any gross alterations of the rectal wall should be pointed out and referred to the competent specialist colleague.

The diameters to be assessed are latero-lateral, anteroposterior, and cranio-caudal, to calculate the total volume and also the volume of the transition zone (periureteral hypertrophy).

For the seminal vesicles, the diameters assessed are anteroposterior. The apparent size of the latter may be affected by the degree of distension of the bladder, by ejaculation and by forms of obstruction.

Images to be included (not all are always indispensable, depending on the clinical picture)

1.

One image of the prostate in transverse scan (indicating the diameters of both the entire gland and adenoma)
2.

One image of the prostate in longitudinal scan (indicating the diameters of both the entire gland and adenoma)
3.

One image of the prostate in transverse scan showing the bladder
4.

One image of the prostate in longitudinal scan showing the bladder
5.

One image of the seminal vesicles in transverse scan
6.

One or more images of any anomalies
7.

Any images of the juxtavesical ureter in longitudinal scan

Calculation of total prostatic volume and transition zone volume

It is important to note that all latest generation ultrasound devices automatically calculate the volume of the prostate, bladder, and seminal vesicles. If this is not possible, multiply the three diameters by 0.52 according to the ellipsoid formula. Data on the volume of the entire gland and adenoma are clinically essential for therapeutic and surgical workup purposes.

Orientation of the ultrasound images

The ultrasound probe always appears at the bottom of the image. In transverse scans: the patient’s right side is conventionally on the left side of the image (as also in CT and MR images). In longitudinal scans: the superior/proximal part/patient’s head is conventionally on the left side (as in abdominal ultrasound imaging) and the distal part on the right side.

Documenting the findings

1.

Date and place where the investigation was performed
2.

Patient data (including birth date)
3.

Mention of clinical history and diagnostic query
4.

Value of the last total PSA blood test
5.

Outcome of rectal exploration that should always be done before the investigation
6.

Comparison with previous examinations, if available

Both the images and findings must be easy to read by other operators and at later dates. The findings must therefore be reported as unambiguously as possible.

In cases of any diagnostic doubt, this must be pointed out, indicating possible hypotheses and suggesting any further instrumental investigations that may help to solve any doubts.

59.4.2.2 Terminology

1.

Hypoechogenic pars adenomatosa, as compared to pars peripherica of the prostate
2.

Identification of medial lobe and its size and relationships with the bladder floor
3.

Presence of calcifications (diameter ≥3 mm) that appear hyperechogenic with a posterior shadow (possibly showing signs of previous inflammation)
4.

Presence of focal hyperechogenic areas with no posterior shadow (diameter ≥3 mm) (possibly showing signs of previous inflammation)

Presence of abscesses of hypo-/anechogenic areas (diameter ≥ 3 mm) that appear prevalently with a fluid anechogenic or dyshomogeneous component, possibly showing inflammation processes in active phase. Anechogenic/echogenic areas of inflamed abscesses [Table 59.2]

Table 59.2

Definition of ultrasound characteristics of different disease pictures

Disease picture	Morphology	Echogenicity	Vascularization	Margins	Peculiarities	Differential diagnosis
Prostatic hypertrophy	Increased size due especially to enlarged pars adenomatosa	Showing pars peripherica separate from pars adenomatosa, thanks to an evident cleavage plane and different echogenicity (pars adenomatosa is hypoechogenic and dyshomogeneous as compared to pars peripherica)	No variation	Free	Shows pars peripherica separate from pars adenomatosa, thanks to a cleavage plane and different echogenicity (pars adenomatosa is more hypoechogenic than pars peripherica) There may be nodular oval or rounded areas, with distinct margins, and an isoechogenic appearance to the surrounding parenchyma, expressing prostatic hyperplasia intra-adenomatous areas or focal prostatitis areas	Abscess areas, in very hypoechogenic images Calcification areas, in very hyperechogenic images Tumoral areas (possible only with biopsy)
Acute prostatitis	Increased gland size	Less than normal	Increased Doppler signal, correlated to increased vascularization due to inflammatory processes	Normally free, sometimes blurred in cases of subcapsular abscess and direct involvement of the margins	In cases of abscess, this will show distinct margins and a highly hypo-/anechogenic content. Hyperechogenic lesions may be present within the abscess area, showing an irregular morphology demonstrating partial colliquation of such abscesses	Neoplasia, especially in cases of suspected abscess colliquation
Chronic prostatitis	Increased size or no change	Tendency to be increased, in cases with calcifications as inflammatory outcomes	Variable	Free	In cases of inveterate chronic prostatitis, there may be a dyshomogeneous appearance, with alternating hypo-isoechogenic and hyperechogenic areas	Neoplasia, especially in cases of granulomatous prostatitis observed in subjects with a history of endovesical chemo-immunoprophylaxis with BCG

6.

In a picture of cervico-ureteral obstruction due to prostatic hypertrophy causing severe detrusor impairment, any presence of bladder stones [Table 59.1]
7.

Dilation/cysts of the ejaculatory ducts
8.

Perviousness and funneling of the cervical or anastomotic region in surgical scars

59.4.2.3 Indications

1.

To assess the size and volume of the gland for medical/surgical workup, regardless of the type of treatment or underlying disease
2.

Prostatic biopsy guidance
3.

Suspected prostatitis and/or prostatic abscess
4.

To examine congenital anomalies
5.

In infertility of the couple (morphological study of the seminal tracts)
6.
Study of the bladder neck
Functional diseases of the bladder neck (sclerosis, iatrogenic stenosis, or ndd)

Neurological bladder

Outcome of surgery of the cervico-prostatic region (prostatic trans-vesical adenomectomy, endoscopic resection or enucleation of prostatic adenoma, endoscopic incision of the bladder neck)

Identification and examination of cysts of the bladder neck or third prostatic lobe
7.

Postoperative controls (post-disobstructive surgery or radical prostatectomy)
8.

Posttreatment controls for prostatic tumors (radiotherapy, HIFU, cryotherapy)

59.4.2.4 Essential Parameters That Must Be Specified in Final Report

For All Types of Report

Preliminarily, transrectal exploration must be performed, indicating the presence, size (X2–3), surface, consistency, margins, presence or absence of a medial groove, any nodules, their characteristics and localization, and tenderness or pain on palpation of the gland.

Prostate

1.

Presence or absence of the prostate
2.

Orthotopic or heterotopic site
3.

Symmetry
4.

Size/volume of the gland (latero-lateral, anteroposterior, and cranio-caudal, to be multiplied by 0.52, according to the ellipsoid formula, if the device does not make an automatic calculation)
5.

Size/volume of the transition zone/adenoma
6.

Presence or absence of a third lobe (if present, volume and/or measurements of protrusion into the bladder)
7.

Presence and size of calcifications (diameter ≥3 mm) [Table 59.1]
8.

Presence and size of abscesses/cysts (diameter ≥3 mm)
9.

Presence and size of intraprostatic cysts or bladder neck cysts (diameter ≥3 mm)
10.

Echostructure of the peripheral portion
11.

Integrity of the prostatic capsule
12.

Presence of the ureters and any dilation or anomalous outlet
13.

Any pain elicited during the investigation [Table 59.2]

59.4.2.5 Addendum in Particular Cases

Presence of the deferens and any dilation

Urethra

Any lesions evident at ultrasound. Morphology and function of the internal urethral sphincter (only in cases of ultrasound performed for functional purposes)

Seminal Vesicles

1.

Presence or absence
2.

Site
3.

Symmetry
4.

Morphology
5.

Any dilation (>12 mm in anteroposterior site)

Bladder

1.

Morphology of walls
2.

Morphology of content
3.

Presence of vegetation and description
4.

Presence of stones

Prostatic Biopsy Guidance

1.
In cases of suspected tumor areas, describe:
Site

Size

Morphology

Ultrasound appearance

Margins

Relations of lesion with the capsule, bladder neck, and seminal vesicles in cases of basal nodules with extracapsular extension

If several nodules are present, each must be detailed as described above.
2.
In cases of multiple prostatic biopsy sampling, indicate:
Type of patient preparation

Antibiotic prophylaxis administered

Results of preliminary rectal exploration (and any agreement between increased consistency areas at palpation and suspicious ultrasound images)

Type of anesthesia (site, drug, and dosage)

Number of samples, specifying the scheme adopted

Course of procedure

Indications for patient care in days after the maneuver

Any home antibiotic therapy

Assessment of Congenital Anomalies

In particular, apart from studying alterations of the course of the juxtavesical ureters, transrectal prostatic ultrasound is able to demonstrate intraprostatic cysts. Cystic lesions appear as round or oval, with distinct margins and asonic content. The definition of the site is particularly important, namely:

1.

Vesical
2.

Medial posterior: mullerian/prostatic utricle
3.

Paramedial/lateral: ductal dilatation/cysts of the ejaculatory duct
4.

Due to retention

Morphologic Study of the Seminal Tract

Ejaculatory ducts:

1.

Presence or absence
2.

Presence or absence of calcifications and any obstruction caused
3.

Any dilation

Deferens ducts:

1.

Presence or absence
2.

Presence or absence of calcifications or lesions and any obstruction caused
3.

Any dilation

Seminal vesicles:

1.

Diameters (latero-lateral, anteroposterior, and cranio-caudal)
2.
Any dilation

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