Imaging of Urinary

System
LECTURED BY : DR. RAISA MAHMUDAH
Modalitas Radiologi

 Ultrasonography
 Plain kidney, ureter and bladder (KUB)
 Fluoroscopy (contrast media)  BNO IVP, Antegrade Pyelography,
Retrograde Pyelogrphy, Cystography, Uretrocystography
 Non Contrast Enhanced CT scan (NECT) for non tumoral mostly for
stone detection/obstruction, Contrast E Enhanced CT scan (CECT)
for tumor evaluation
 MRI (anatomical)
 Nuclear (function)
Plain BNO to evaluate KUB
What To Look For?
 A: air - where it should and
shouldn't be
 B: bowel - position, size and wall
thickness
 D: dense structures, calcification
and bones
 O: organs and soft tissues
 X: eXternal objects and artifacts
Fluoroscopy
Intravenous pyelography (IVP)

 Good modality
to evaluate
urinary system
 Can evaluate 
Anatomical and
functional
abnormality
 Indication 
Urinary tract
obstruction,
Urinary leak
from trauma or
post operation,
urothelial tumor
Procedure of IVP

 “ Plain radiographs along phases of the renal function and

excretion”
 Plain radiographs on
1. Pre-contrast (Scout film)  to detect stone, renal shadow, psoas
shadow
2. 1 minute after contrast administration  evaluate nephrogram
3. 3 minutes after contrast administration  evaluate excretory
function
Procedure of IVP

4. 10 minutes after contrast administration  evaluate pelvocaliceal

system and ureter
5. 25-30 minutes after contrast administration  evaluate lower part of
ureter and urinary bladder
6. Full bladder  evaluate urinary bladder
7. Post voiding  residual urine
IVP device
Principle of IVP
Scout film
1 minute
3-5 minutes
10 minutes
 25-30
minutes
Both oblique views
Full bladder
Retrograde pyelography

 Retrograde injection of the contrast material into ureters 

extending to pelvocaliceal system
 Use to evaluate collecting system of the patient who has poor renal
function
 Quality of the imaging can be controlled by concentration of the
contrast material and rate of injection
 Left
retrograde
pyelography
Intraluminal
filling defect
within right
upper pole
calyx
Cystography/Voiding
cystourethrography
Cystography/voiding
cystourethrography (VCUG)

 Input contrast material into urinary bladder

 Imaging of the urinary bladder on AP, lateral and both
oblique views
 Evaluate urothelial tumor, diverticulum or leakage from
trauma or surgery
Cystography/voiding
cystourethrography (VCUG)

 Voiding cystourethrography  take pictures while voiding

 Indication for VCUG  to rule out vesicoureteral reflux
(VUR) ; use in urinary tract infection of the children,
evaluation of the urethra
Contrast
leakage
Normal anatomy on VCUG
Imaging of VCUG
Abnormal VCUG
Hysterosalpingography
Definition

 Hysterosalpingography (HSG) is the radiographic evaluation of the

uterus and fallopian tubes with the use of radiographic contrast
medium.
 Injection of the contrast material into uterine cavity, via cervix
 Indication: in infertility (primaryy, secondary), spontaneous abortion,
recurrent preterm delivery, evaluation of the uterus and fallopian
tubes post tubal surgery, preoperative evaluation to tubal
anastomosis.
 To evaluate tubal pantency and anatomical variation of uterus
Information obtained from HSG
includes
 the width of the cervical canal
 the contour of the uterine cavity
 the orientation of the uterus - anteverted(fig. 4) on page /
retroverted
 an outline of the lumen of the fallopian tubes and cornua
 the presence or abscence of spillage of contrast from the
fimbriated ends of the tubes.
 an outline of peritoneal structures.
Hysterosalpingography

Contraindication Compliaction
- Pregnancy  Bleeding and infection (<3%)
antibiotic therapy
- Active menstrution
 Light spotting after the procedure
- Acute pelvic inflammatory disease/
 Contrast media reaction is very rare
pelvic infection
especially with the use of low-osmolar
- Recent undergo uterine or tubal nonionic contrat agents.
surgery  Perforation of the uterus or fallopian
tubes is extremely rare and usually
presents with increasing abdominal
pain.
 sepsis (if has intravastion of the
contrast material)
HSG Technique
 The examination is scheduled for days 6-10 of the menstrual cycle.
 The patient is instructed to abstain from sexual intercourse from the day 1
of the menstrual cycle to avoid irradiating a potential pregnancy.
 The patient is placed supine on the fluoroscopy table in the lithotomy
position.
 The area is prepared with povidone-iodine solution(betadine) and
draped with sterile towels.

 A speculum is placed into the vagina and the cervix is localised.

 A 5-F HSG catheter is positioned into the cervical os and canal and the
balloon is inflated.
 Water-soluble contrast material is slowly instilled under fluoroscopic
guidance with intermittent images obtained to evaluate the uterus and
fallopian tubes.
 Normal anatomy on
hysterosalpingography
Cases

Spot radiograph of HSG showing vascular Spot radiograph shoiwng lymphatic

intravasation of contrast(yellow arrows). intravasation(yellow arrow). There is also a
left fallopian tube clip(blue arrow)
Cases

Spot radiograph of HSG demonstrating Spot radiograph of HSG showing a

an intrauterine pregnancy septate uterus
 Cases

Spot radiograph of HSG Bicornuate uterus. Spot Unicornuate uterus. Spot

demonstrating a didelphys radiograph shows two markedly radiograph demonstrates a
uterus splayed uterine horns. The single uterine horn with an
fallopian tubes are not visualized irregular medial contour. A single
at this imaging stage fallopian tube is also visualized.
Cases

 Cornual spasm. (a) On an HSG spot radiograph obtained during the early filling stage of the uterus, the right
fallopian tube does not opacify beyond the cornual portion (arrow), whereas the left fallopian tube
opacifies to the ampullary portion. Arrowheads indicate amorphous calcifications on the right side of the
pelvis. These calcifications were also present on the scout image (not shown). (b) On a spot radiograph
obtained after the instillation of additional contrast material, the right fallopian tube opacifies to the
ampullary portion. Right-sided SIN and a leftsided hydrosalpinx are also noted. Amorphous calcifications
(arrowheads) are again seen on the right side of the pelvis.
 Cases

Tubal occlusion. (a) Spot radiograph demonstrates abrupt cutoff of the left fallopian tube. (b) Spot
radiograph demonstrates cutoff of contrast material in the isthmic portions of both fallopian tubes,
with bulbous dilatation of the distal aspects of the opacified portions. These findings can be seen
with postsurgical occlusion (eg, following tubal ligation).
USG
CASES
THANK YOU

REFERENCES:

1. SIMPSON WL JR, BEITIA LG, MESTER J. HYSTEROSALPINGOGRAPHY: A REEMERGING STUDY. RADIOGRAPHICS. 2006 MAR-APR;26(2):419-31. DOI: 10.1148/RG.262055109. PMID: 16549607.

2. JOHNSON N, VANDEKERCKHOVE P, WATSON A, ET AL. TUBAL FLUSHING FOR SUBFERTILITY. COCHRANE DATABASE SYST REV 2005; CD003718.

3. BORHANI, AMIR & TUBLIN, MITCHELL & FURLAN, ALESSANDRO & HELLER, MATTHEW. (2015). DIAGNOSTIC IMAGING: GENITOURINARY.