Abnormal Fetal GU Tract – Part 2 PDF

ULTR‐3014 OBGYN Sonography 3 Module O.13: Abnormal Fetal Genitourinary Tract 2 Abnormal Fetal GU Tract – Part 2 1 2 Fetal Urogenital Tract textbook reference Module O.13 Abnormal Fetal Genitourinary Tract • • Curry 5th Edition Chapter 22 (p. 406‐409) Abnormal GU Tract – Part 2 • • 3 Rumack...

ULTR‐3014 OBGYN Sonography 3 Module O.13: Abnormal Fetal Genitourinary Tract 2 Abnormal Fetal GU Tract – Part 2 1 2 Fetal Urogenital Tract textbook reference Module O.13 Abnormal Fetal Genitourinary Tract • • Curry 5th Edition Chapter 22 (p. 406‐409) Abnormal GU Tract – Part 2 • • 3 Rumack 5th Edition Chapter 39 4 Abnormal GU Tract – Part 1 Abnormal GU Tract – Part 2 • Basic assessment • Ureters • Kidneys • Bladder • Obstruction and rupture • Genital tract 5 6 Ureters Ureters • Hydroureter • UVJ obstruction 1 ULTR‐3014 OBGYN Sonography 3 Module O.13: Abnormal Fetal Genitourinary Tract 2 Abnormal Fetal GU Tract – Part 2 7 8 Hydroureter AKA megaureter, ureterectasis Definition Pathologically distended ureter Hydroureter Causes • Distal urinary obstruction • Nonobstructive dilatation • Reflux 9 10 Bilateral hydronephrosis and hydroureters Hydroureter – sonographic features • Abnormal tubular structure that connects with kidney and bladder • No colour Doppler flow seen NB: differentiate from fluid filled bowel 11 12 Hydroureter • Fetus also demonstrated hydronephrosis Ureterovesical Junction (UVJ) Obstruction FB: bladder 2 ULTR‐3014 OBGYN Sonography 3 Module O.13: Abnormal Fetal Genitourinary Tract 2 Abnormal Fetal GU Tract – Part 2 13 14 UVJ Obstruction Unilateral hydronephrosis and hydroureter • Obstruction at the right UVJ Definition Obstruction at the junction of the ureter and bladder • Usually unilateral Arrow: UVJ Causes • Congenital stenosis • Ureterocele 15 16 Right UVJ obstruction UVJ obstruction – sonographic features • Renal pyelectasis / hydronephrosis • ± Caliectasis • Dilated ureter • Normal renal contour • Normal bladder • Normal AFV Posterior axial kidneys if unilateral 17 long right kidney/prox ureter right ureter 36 weeks GA; enlarged right ureter and hydronephrosis 18 Bilateral UVJ obstruction • Coronal fetal abdomen • Bilateral hydronephrosis (P) • Dilated, tortuous ureters (U) Hydroureter vs Fluid‐filled Bowel Hydroureter FF Bowel Appearance Anechoic, tubular Anechoic, tubular Kidneys & bladder Often dilated Usually normal Location Posterior Anterior Communication Renal pelvis Other loops Peristalsis Yes Yes Intraluminal particles No Yes Sex Usually male Either 3 ULTR‐3014 OBGYN Sonography 3 Module O.13: Abnormal Fetal Genitourinary Tract 2 Abnormal Fetal GU Tract – Part 2 19 20 Bladder Bladder • Nonvisualization • Posterior urethral valves • Bladder exstrophy • Prune belly syndrome • Cloacal exstrophy • Ureterocele • Megacystis • Vesicoamniotic shunt • Bladder outlet obstruction Exstrophy To turn inside out 21 22 Nonvisualization of Bladder Associated anomalies • Renal • Agenesis • UPJ obstruction must be bilateral • MCDK • ARPKD • Bladder • Bladder/cloacal exstrophy Nonvisualization of Bladder 23 24 Nonvisualization of bladder – amniotic fluid volume • Normal, increased, or decreased • Depends on cause of nonvisualization Bladder Exstrophy 4 ULTR‐3014 OBGYN Sonography 3 Module O.13: Abnormal Fetal Genitourinary Tract 2 Abnormal Fetal GU Tract – Part 2 25 26 Bladder Exstrophy Bladder exstrophy cord Definition Bladder and related structures are turned inside out • Skin absent at lower anterior abdominal wall • Inside of bladder exposed to amniotic fluid Exstrophy Eversion of a part or organ bladder Eversion Turning inside out 27 genital tissues 28 Bladder exstrophy – sonographic features • Non‐visualization of bladder • Soft tissue mass in lower anterior abdominal wall • Inferior to normal cord insertion Sagittal Transverse 33 week GA female fetus – bladder exstrophy • Soft tissue mass anterior to area of unseen bladder Textbook of Diagnostic Sonography, 7th Edition (Hagen‐Ansert fig 63‐16) 29 30 Bladder exstrophy Cloacal Exstrophy Transverse at area of bladder • • Transverse at cord insertion Anterior lower pelvic‐abdominal mass No bladder seen and normal cord insertion 5 ULTR‐3014 OBGYN Sonography 3 Module O.13: Abnormal Fetal Genitourinary Tract 2 Abnormal Fetal GU Tract – Part 2 31 32 Cloacal Exstrophy Technically not exstrophy, but it does show the cloaca Cloacal exstrophy AKA Omphalocele‐exstrophy‐imperforate anus‐spinal defects (OEIS) Definition Failure of development of primitive cloaca – convergence of GI and GU tracts • • • Single opening on perineum (inferior to UC insertion) Both systems empty Very Varying associated abnormalities rare 33 34 Cloacal exstrophy Cloacal exstrophy – sonographic features omphalocele bladder • Non‐visualization of bladder • Soft tissue mass in lower anterior abdominal wall • Omphalocele • Spinal defects bowel 35 36 Cloacal exstrophy Megacystis • • Mass containing bowel and bladder tissues (arrow) Cord arose from mass 6 ULTR‐3014 OBGYN Sonography 3 Module O.13: Abnormal Fetal Genitourinary Tract 2 Abnormal Fetal GU Tract – Part 2 37 38 Megacystis • Causes of megacystis Posterior urethral valves Most common Urethral diaphragmatic membrane Urethral atresia (agenesis) Urethral stricture Persistent cloaca Megacystis‐microcolon‐intestinal hypoperistalsis syndrome Most common cause is posterior urethral valves • Obstruction of the prostatic urethra in males posterior urethral valves 39 40 6 cases of megacystis • All associated with prune belly syndrome (discussed later) • Fetuses in left column had normal AFV • Fetuses in right column had oligohydramnios Megacystis caused by urethral atresia 41 Fetal megacystis: Diff Dx, Osborne et al., JUM, June 1, 2011 vol 30 no 6 (833‐841) 42 Bladder Outlet Obstruction Bladder Outlet Obstruction Definition Obstruction (varying degrees) or complete atresia at level of bladder and urethra • Posterior urethral valves (PUV) most common cause in males • Prognosis poor if obstruction complete and oligohydramnios severe 7 ULTR‐3014 OBGYN Sonography 3 Module O.13: Abnormal Fetal Genitourinary Tract 2 Abnormal Fetal GU Tract – Part 2 43 44 Bladder outlet obstruction – sonographic features • Megacystis, ± bladder wall thickening • Bilateral hydroureters • Bilateral renal pyelectasis / hydronephrosis • Oligohydramnios (severe: pulmonary hypoplasia) • Usually male Urethral obstruction (atresia) Radiograph hydronephrosis 45 46 Posterior urethral valves • Coronal fetal abdomen (16 weeks GA) • Grossly dilated fetal bladder • Oligohydramnios 47 Posterior Urethral Valves 48 Posterior Urethral Valves Prostatic urethra Definition Redundant tissue flap obstructing the prostatic (proximal) portion of the male urethra • Wide range of severity 8 ULTR‐3014 OBGYN Sonography 3 Module O.13: Abnormal Fetal Genitourinary Tract 2 Abnormal Fetal GU Tract – Part 2 49 50 Posterior urethral valves Posterior urethral valves – sonographic features 51 • Bilateral renal pyelectasis / hydronephrosis • Bilateral hydroureter • Megacystis with “keyhole sign” • ± Oligohydramnios 52 Are PUV lethal? “Keyhole sign” • Megacystis (BL) and proximal urethra (U) 53 • With PUV, the urethra has a narrow, slit‐like opening that partially impedes urine outflow • The degree of urinary outflow obstruction will determine the severity of the urinary tract problems • Neonatal death may occur for varying reasons Treatment: • Pulmonary hypoplasia vesicoamniotic • Renal failure shunt 54 Prune Belly Syndrome Prune Belly Syndrome AKA Eagle‐Barrett syndrome Definition Underdeveloped abdominal muscles, bilateral cryptorchidism, and an abnormal urinary tract • Abdominal skin wrinkles like a prune • Associated PUV (males) causes severe megacystis, dilated ureters, and hydronephrosis Cryptorchidism Undescended testes 9 ULTR‐3014 OBGYN Sonography 3 Module O.13: Abnormal Fetal Genitourinary Tract 2 Abnormal Fetal GU Tract – Part 2 55 56 Prune belly syndrome CT scan Neonate – prune belly syndrome (abdominal laxity) 57 58 Prune belly syndrome – sonographic features • Megacystis – may have keyhole sign • Bilateral renal pyelectasis / hydronephrosis • Bilateral hydroureters • Urinary ascites (if ruptured) AC enlarged and • Oligohydramnios (if long standing) not included in estimation of gestational age • Empty scrotum (undescended testes) 59 A Prune belly syndrome • 16 weeks LNMP • Megacystis (with keyhole sign) • Severe oligohydramnios 60 B C Posterior urethral valves – resulted in prune belly syndrome A: Subtle pyelectasis (atypical) and megacystis B: Megacystis C: Empty scrotum (undescended testes) – male fetus Prune belly syndrome Bilateral hydronephrosis, oligohydramnios, thick‐walled bladder 10 ULTR‐3014 OBGYN Sonography 3 Module O.13: Abnormal Fetal Genitourinary Tract 2 Abnormal Fetal GU Tract – Part 2 61 62 Ureterocele Ureterocele 63 • Simple • Ectopic 64 Simple Ureterocele • Simple Ureterocele Prolapse and cystic dilatation of distal ureter into bladder ureterocele 65 66 Simple ureterocele • Cystic dilatation seen in bladder at a distal UVJ (arrow) Simple ureterocele – bladder obstruction • A ureterocele may block the urethra • Bladder cannot empty 11 ULTR‐3014 OBGYN Sonography 3 Module O.13: Abnormal Fetal Genitourinary Tract 2 Abnormal Fetal GU Tract – Part 2 67 68 Ectopic Ureterocele Definition Prolapse and cystic dilatation of distal ureter at insertion into bladder distal to the normal insertion Ectopic Ureterocele • 69 Associated with duplication of collecting system, hydroureter, and obstruction of upper pole of affected kidney 70 Ectopic ureterocele Ectopic ureterocele – sonographic features • Complete ureteral duplication • Pyelectasis in upper pole of kidney • Ureter from upper pole inserts distally forming a ureterocele • Dilated ureter • Ureterocele within bladder • Normal kidney contour • Dilatation of the upper pole collecting system ureterocele Ultrasonography in Obstetrics and Gynecology, 5th Edition (Callen fig 16‐21) 71 72 Ectopic ureterocele Vesicoamniotic Shunt normal kidney (2) kidney with pyelectasis (1) bladder with ureterocele (arrows) 12 ULTR‐3014 OBGYN Sonography 3 Module O.13: Abnormal Fetal Genitourinary Tract 2 Abnormal Fetal GU Tract – Part 2 73 74 Vesicoamniotic Shunt Definition Shunt from fetal bladder to amniotic fluid for treatment of fetal bladder outlet obstruction • Vesicoamniotic shunt – treatment • Critical factors in prognosis: • Timing of diagnosis • Severity • Onset of oligohydramnios Initial steps in a bladder shunt procedure Textbook of Diagnostic Sonography, 7th Edition (Hagen‐Ansert fig 63‐33) 75 76 Vesicoamniotic shunt Vesicoamniotic shunt – sonographic features Shunt Functioning Non‐functioning Bladder Normal size, shunt seen Megacystis, shunt seen Amniotic fluid volume Normal Decreased 77 Megacystis (before shunt) Normal bladder (after shunt placement) 78 Obstruction and Rupture of GU Tract Obstruction and Rupture of the GU Tract • Rupture may be renal, ureteral, or vesicular • Results in urinary ascites or urinoma • Suspect rupture when ascites seen with oligohydramnios • Possibility of intra‐abdominal calcification (chemical peritonitis) Urinoma Encapsulated urine collection 13 ULTR‐3014 OBGYN Sonography 3 Module O.13: Abnormal Fetal Genitourinary Tract 2 Abnormal Fetal GU Tract – Part 2 79 80 Rupture of GU tract • Fetal urinoma • Axial fetal abdomen shows a large abdominal cyst Genital Tract U: urinoma Sp: spine goo.gl/52WglJ 81 82 Genital Tract • Hydrocele • Hypospadias • Hydrocolpos / hydrometrocolpos • Ovarian cysts • Ambiguous genitalia Hydrocele Rare Covered in Gyne PowerPoints 83 84 Hydrocele Definition Fluid accumulation between the two layers of tunica vaginalis (cavum vaginale – sac surrounding testes) Normal scrotal anatomy A: parietal layer of tunica vaginalis B: visceral layer of tunica vaginalis A • Common 3rd trimester finding C: testis B • Usually a physiologic finding which resolves spontaneously (in the absence of other abnormalities) D: skin of scrotum C D Atlas of Human Anatomy, 7th Edition (Netter plate 369) 14 ULTR‐3014 OBGYN Sonography 3 Module O.13: Abnormal Fetal Genitourinary Tract 2 Abnormal Fetal GU Tract – Part 2 85 86 Hydrocele Bilateral hydroceles coronal 87 lateral axial 88 Bilateral hydroceles • 33 weeks GA • CMV infection 89 Unilateral hydrocele 90 Hypospadias Hypospadias Definition Urethral meatus of penis abnormally positioned • Opens (in varying degrees) onto ventral surface of penile shaft proximal to normal location • Penis appears shorter and broadened 15 ULTR‐3014 OBGYN Sonography 3 Module O.13: Abnormal Fetal Genitourinary Tract 2 Abnormal Fetal GU Tract – Part 2 91 92 Hypospadias Normal penis 93 Hypospadias 94 Hypospadias • Penis appears somewhat shortened and broadened Module O.13 Abnormal Fetal Genitourinary Tract Abnormal GU Tract – Part 2 END Ultrasonography in Obstetrics & Gynecology, 5th Edition (Callen fig 16‐58) 16