ULTRASONOGRAPHIC FEATURES OF PYONEPHROSIS IN DOGS

JIHYE CHOI, JAEYONG JANG, HEEYEON CHOI, HYUNWOOK KIM, JUNGHEE YOON

Pyonephrosis refers an infected hydronephrotic kidney which arise from pyelonephritis followed by exudate
accumulation in a dilated renal pelvis or hydronephrosis followed by ascending infection. Pyonephrosis may
cause serious systemic complications, making prompt and reliable diagnosis critical. Clinical and ultrasono-
graphic findings are used for the diagnosis of pyonephrosis in humans, but these findings have not been
investigated in dogs. We reviewed ultrasonographic features in pyonephrosis in 18 dogs. Ten dogs with
hydronephrosis were also evaluated to compare with the pyonephrosis patients. In most dogs with pyonephrosis,
hyperechoic contents completely filled the dilated renal pelvis (n ¼ 8) or a fluid-debris level was observed (n ¼ 8).
Hyperechoic contents were dispersed in renal pelvis in only two of the 18 dogs. Hyperechoic, edematous
mesentery, and peritoneal and retroperitoneal effusion, which represented peritoneal and retroperitoneal in-
flammation, were observed in the perinephric region in 11 dogs. Compared with pyonephrosis, and as expected,
hydronephrosis was characterized by anechoic contents within the urine-filled collecting system and there were
no definitive findings to suspect peritonitis. Thus, there is a distinct difference in the sonographic appearance of
pyonephrosis vs. hydronephrosis in dogs. r 2010 Veterinary Radiology & Ultrasound, Vol. 51, No. 5, 2010,
pp 548–553.

Key words: dog, fluid-debris level, hydronephrosis, pyelonephritis, pyonephrosis, ultrasonography.

Introduction sonographic features of pyonephrosis have not been inves-

tigated in dogs, because it is rare, with only a few examples
P YONEPHROSIS IS A collection of sloughed urothelium and
inflammatory cells in a dilated renal collecting system.1
It is a serious complication of hydronephrosis that may
described.4–6 Herein we characterize the comparative clinical
and ultrasonographic features of pyonephrosis vs.
develop as a direct consequence of urinary stasis and sec- hydronephrosis in dogs.2
ondary infection.2–6 As the bacteria and purulent exudate
increase in renal pelvis, renal function decreases, and even- Materials and Methods
tually renal function is partially or completely destroyed.7,8
The sonograms and the medical records of 18 dogs with
Calculi in the renal collecting system are the most com-
pyonephrosis and 10 dogs with hydronephrosis were re-
mon cause of obstruction, although other causes such as
viewed. Pyonephrosis was confirmed via laparotomy
tumors, fibrosis, prostatic disease, and urinary bladder
(n ¼ 17) or percutaneous ultrasound-guided pyelocentesis
disease can also cause obstruction.1,8 The underlying mech-
(n ¼ 1). Hydronephrosis was due to calculi in six dogs, ia-
anism resulting in conversion from simple hydronephrosis
trogenic ureteral stricture in two dogs, or a neoplasm of the
to pyonephrosis have not been identified.1
lower urinary tract in two dogs; absence of pyonephrosis
Prompt recognition of pyonephrosis and its differentia-
was confirmed in seven via a laparotomy and three via
tion from hydronephrosis is important because pyonephro-
percutaneous ultrasound-guided pyelocentesis.
sis should be treated immediately to avoid pyrexia and septic
Ultrasonography was performed without sedation or
shock and/or prevent loss of renal parenchyma.3,8,9 Using
anesthesia with the dog in lateral and dorsal recumbency.
either computed tomography or magnetic resonance imag-
Sagittal, transverse, and dorsal images of the kidney were
ing, pyonephrosis could not differentiate from hydronephro-
obtained with 10.0 MHz linear and 7.5 MHz convex trans-
sis.3,8,10 In humans, pyonephrosis is traditionally diagnosed
ducers. The characteristics of the renal pelvis, renal paren-
by clinical and ultrasonographic findings.1,10,11 The ultra-
chyma, and perinephric region were investigated. Gain
settings and transducer selection were individualized, and
From the Haemaru Referral Animal Hospital, Seongnam 463-050, particular care was taken to avoid artifactual echogenicity
South Korea (Choi, Jang, Choi, Kim), and the College of Veterinary
Medicine, Seoul National University, Seoul 151-742, South Korea (Yoon). within the collecting system.1 Factors such as obesity, and
This study was partially supported by the Research Institute for Vet- bowel gas likely to produce artifacts were taken into con-
erinary Science at Seoul National University. sideration in the interpretation of the sonograms.12,13 The
Address correspondence and reprint requests to Dr. Junghee Yoon, at
the above address. E-mail: heeyoon@snu.ac.kr internal echogenicity in the renal pelvis was categorized
Received November 17, 2009; accepted for publication April 1, 2010.
doi: 10.1111/j.1740-8261.2010.01702.x Prosound SSD 4000 sv, Aloka, Tokyo, Japan.

548
Vol. 51, No. 5 ULTRASONOGRAPHIC FEATURES OF PYONEPHROSIS IN DOGS
into five types, modified from a system used in humans
(Table 1).2,11 Renal parenchyma and perinephric changes
were compared between dogs with pyonephrosis vs.
hydronephrosis.
Survey abdominal radiographs were available from all
18 dogs with pyonephrosis and eight of 10 dogs with
hydronephrosis. Excretory urography had been performed
in six of 18 dogs with pyonephrosis and six of 10 dogs with
hydronephrosis. If excretory urography had been per-
formed, it was always after ultrasonography. For excretory
urography, lateral and ventrodorsal radiographs were
made at immediately after and then at 5, 15, 30, and
45 min after intravenous injection of 880 mgI/kg Iohexol).w
All diagnostic examinations were performed and inter-
preted by one radiologist (J.H.C.).
The association between pyonephrosis and gender or
breed was assessed with the Binomial Test. A cross
tabulation analysis (P)w2 was used to assess whether
there was a difference in the clinical signs between
pyonephrosis vs. hydronephrosis. Differences in clinical
laboratory data between dogs with pyonephrosis vs.
hydronephrosis were assessed using a t-test. For all an-
alyses a P-value o0.05 was considered statistically sig-
nificant. Statistical analyses were performed using
SPSSWIN 1.2 software.z
Results
The mean age of dogs with pyonephrosis was 7.6 years
(range 1–12 years) while the mean age of dogs with
hydronephrpsis was 9.1 years (range 4–15 years). Both
conditions affected primarily small breed dogs (Table 2)
but there was no statistically significant breed predilection.
Pyonephrosis was significantly more common in female
(n ¼ 14) than male (n ¼ 4) dogs (Po0.05), but there was
no gender predilection of hydronephrosis. Dogs with
pyonephrosis or hydronephrosis had many nonspecific
signs including anorexia, vomiting, and urinary signs such
as hematuria, oliguria, or polyuria, and there was no sig-
nificant difference of clinical signs between two renal con-
ditions (Table 3).
Leukocytosis (25.76  18.71  103/ml; reference range,
6–17.0  103/ml) was identified in 11 of 18 dogs pyonephro-
sis and zero of 10 dogs with hydronephrosis. Serum urea
nitrogen and creatinine were normal in 18 of 18 dogs with
pyonephrosis. Six of 10 dogs with hydronephrosis had el-
evated serum urea nitrogen and creatinine; four dogs had
bilateral renal calculi and two dogs had lower urinary tract
obstruction.
Bacteriuria was found in 15 of 18 dogs with pyonephro-
sis; the three pyonephrosis dogs without bacteriuria had
wOmnipaque, Nycomed, Amersham Health, Cork, Ireland.
zSPSS Inc., Chicago, IL.
549
Table 1. Pyonephrosis and Simple Hydronephrosis Classified by Internal
Echogenicity in Renal Pelvis
Type Internal Echogenicity in the Renal Pelvis
1 Anechoic contents
2 Dispersed hyperechoic contents
3 A fluid-debris level with dependent echogenicity that shifted
with repositioning
4 Hyperechoic contents that completely filled in a dilated
collecting system
5 Coarse, very strong echogenicity with dirty acoustic shadowing
resulting from air within the collecting system
previous antibiotics administration. Bacterial cystitis was
detected in four of 10 dogs with hydronephrosis.
Fourteen of 18 dogs with pyonephrosis had unilateral
(n ¼ 13) or bilateral (n ¼ 1) renomegaly on survey radio-
graphy and the mean renal size was 4.6 times the length of
the second lumbar vertebra. One of the 18 dogs had nor-
mally sized kidneys and in the other three renal size could
not be measured because of poor abdominal detail. Over-
all, the radiographic abdominal detail was decreased in 14
of the 18 dogs with pyonephrosis; this was perinephric
(n ¼ 3) or generalized (n ¼ 11). Thirteen of 18 dogs with
pyonephrosis had radiopaque stones in the renal pelvis
(n ¼ 5), ureter (n ¼ 3), or both (n ¼ 5); stones were more
common in right collecting system (n ¼ 12) than the left
(n ¼ 5).
In hydronephrosis, unilateral renomegaly was observed
in five of eight dogs. Only one dog had radiographically
decreased abdominal detail. Radiopaque stones in renal
collecting system were observed in two dogs.
Based on excretory urography, the affected kidney in six
of 18 dogs with pyonephrosis and three of 10 dogs with
hydronephrosis was nonfunctional or very poorly func-
tional. In one dog with pyonephrosis there was leakage of
contrast medium from the renal pelvis.
In dogs with pyonephrosis, three ultrasonographic pat-
terns of internal pelvic echogenicity were observed (Fig. 1);
dispersed hyperechoic contents, dependent hyperechoic
contents with a fluid-debris level, or completely filling the
collecting system (Table 4). Anechoic contents or gas bub-
bles were not detected in pyonephrosis. The mean sagittal
length of the affected kidney was 5.02 cm. Renal paren-
Table 2. Breed Distribution in Pyonephrosis and Hydronephrosis
Pyonephrosis Hydronephrosis
(n ¼ 10) (n ¼ 18)
Shihtzu 6 (33%) 4 (40%)
Maltese 6 (33%) 3 (30%)
Miniature Schnauzer 4 (22%) 0
Yorkshire Terrier 1 (6%) 1 (10%)
Poodle 1 (6%) 0
Miniature Pinscher 0 1 (10%)
Mixed 0 1 (10%)
550 CHOI ET AL. 2010

Table 3. Clinical Signs in Dogs with Pyonephrosis or Hydronephrosis Table 4. Ultrasonographic Features in Renal Collecting System in Dogs
with Pyonephrosis and Hydronephrosis
Pyonephrosis Hydronephrosis
(n ¼ 18) (n ¼ 10) Dogs with Pyonephrosis Dogs with Hydronephrosis
Type (n ¼ 18) (n ¼ 10)
Anorexia 17 (94%) 5 (50%)
Vomiting 13 (72%) 3 (30%) 1 0 10 (100%)
Urinary signs 12 (67%) 3 (30%) 2 2 (11%) 0
Abdominal pain 12 (67%) 2 (20%) 3 8 (44%) 0
Hyperthermia 12 (67%) 0 4 8 (44%) 0
Abdominal distension 5 (28%) 2 (20%) 5 0 0
Palpated mass 4 (22%) 3 (30%)
Respiratory distress 3 (17%) 0

chyma was diminished with a severely dilated renal pelvis
in seven dogs; in these dogs the kidney has the appearance
of a thick-walled cyst. In other dogs with pyonephrosis,
renal parenchyma was conserved but there was indistinct
internal structure with focal distortion or irregular margin.
Sonographically, calculi were observed in the renal collect-
ing system in 15 of 18 dogs with pyonephrosis; these were
located in the renal pelvis in 11 dogs and in the ureter in 12
dogs. In 14 of 18 dogs with pyonephrosis, the adjacent
mesentery appeared hyperechoic and edematous due to
peritoneal inflammation (Fig. 2). The abnormal mesentery
was especially conspicuous in 11 dogs, in which anechoic or
mild hyperechoic perirenal fluid was identified. The
amount of fluid was small in all dogs and was retroperi-
toneal in four dogs, peritoneal in five dogs, and both in two
dogs. A renal tear was suspected in 11 of the 18 pyonephro-
sis dogs, based on irregularity and focal distortion of
the renal parenchyma (n ¼ 4) or on the basis of focal
mesenteric adhesion into the renal pelvis (n ¼ 7) with
peritoneal or retroperitoneal effusion. Furthermore, fluid
around the affected kidney was due to a septic exudate
in these dogs. In two of these dogs with perirenal fluid, it
was difficult to conclude whether the fluid was due
to pyonephrosis or recent laparotomy.
In hydronephrosis, anechoic fluid filled the renal pelvis
in all dogs (Fig. 3) (Table 4). The mean length of the
hydronephrotic kidney was 4.1 cm. Two dogs with an
iatrogenic ureteral stricture had a mildly edematous
mesentery and a small amount of anechoic, but no dog
had evidence of a renal tear or rupture. The peritoneal fluid

Fig. 1. Ultrasonographic features of pyonephrosis. (A) Scattered hypoechoic contents (arrow) represent purulent debris. (B) and (C) Renal pelvis with a
fluid-debris level (arrowheads). (D) Renomegaly with hyperechoic contents filling the dilated renal pelvis.
Vol. 51, No. 5 ULTRASONOGRAPHIC FEATURES OF PYONEPHROSIS IN DOGS 551

Fig. 2. Ultrasonographic features of the perinephric region in dogs with pyonephrosis. (A) Small amount of retroperitoneal effusion (long arrow) adjacent the
affected renal pelvis. Focal hyperechoic renal parenchyma (short arrow) at the renal pelvis are assumed to be due to adhesions with the mesentery. (B) Anechoic
fluid around the kidney (K) in the retroperitoneal space (arrow) and hyperechoic fluid in peritoneal cavity (dotted arrow). (C) Peritoneal fluid (arrows) with weak
echogenicity is adjacent to a dilated ureter (U) containing a stone (arrowhead). (D) Anechoic fluid (F) between the abdominal wall and hyperechoic mesentery (M).

was confirmed as a septic exudate in one dog, but there was In 10 of the pyonephrosis dogs, pyonephrosis was not
no pus in the renal pelvis with percutaneous ultrasound- suspected until pyelocentesis was performed; fluid in these
guided pyelocentesis. Modified transudate was detected in dogs ranged from a thin cloudy fluid to thick purulent
the other dog. material that varied in color from bright to dark brown.

Fig. 3. Ultrasonography of hydronephrosis. (A) Sharply marginated anechoic pelvis with good sound transmission. (B) Renal pelvis (arrow) and dilated
ureter (arrowheads) are filled with artifactual weak echogenicity due to a high gain setting.
552 CHOI ET AL.
In the other eight pyonephrosis dogs, pyonephrosis was
suspected based on the sonographic findings of echogenic
contents in the renal pelvis and perinephric inflammation.
Nephrectomy was the first method for treatment for
pyonephrosis because of the loss of renal parenchyma and
severe perinephric inflammation or multiple calculi in the
renal collecting system. In one dog with left pyonephrosis
and right end-stage renal disease, pyelolithotomy and ure-
teroneocystostomy were performed. Exudate leaked from
the renal parenchyma or renal pelvis of 11 dogs and severely
congested mesentery and blood clots adhered to the dam-
aged kidney. The renal pelvis was filled with a large amount
of dark brown-colored exudates. Bacteria were isolated
from 15 of 16 kidneys; Staphylococcus aureus and Escheri-
chia coli were identified most commonly. Calculi were the
cause of obstruction in 14 dogs, and iatrogenic ureteral
stricture was found in three dogs. All dogs recovered well.
Discussion
Pyelonephritis is interstitial inflammation, often most
severe in the renal pelvis and adjacent medullary tissue.
When pyelonephritis leads to obstruction of the renal col-
lecting system, or obstruction accompanies ascending in-
fection, pyonephrosis occurs. In this study, all dogs with
pyonephrosis had distinct obstructive lesions in the renal
collecting system suggesting that the hydronephrotic kid-
ney subsequently became infected.
A noninvasive and reliable way to discriminate between
pyonephrosis and hydronephrosis is important, because
pyonephrosis may cause septic shock and loss of renal
function.3
Hydronephrosis has traditionally been diagnosed with
abdominal radiography, ultrasonography, and excretory
urography. In humans, pyonephrosis is traditionally diag-
nosed by clinical signs and ultrasonographic findings.10 In
this study, radiographs provided information about renal
size and calculi in the renal collecting system but there were
no radiographic findings that enabled identification of
pyonephrosis.2,8 Some information on renal function was
obtained from excretory urography, but nuclear scinti-
graphy, or other methods to assess glomerular filtration,
are preferable14–16 and excretory urography was not help-
ful in distinguishing between pyonephrosis and hydro-
nephrosis.
The human pyonephrosis sonographic classification cri-
teria, based on the contents of the renal collecting system,
was applied to dogs in this study.1,8,17,18 Pyonephrosis was
characterized by hyperechoic collecting system contents.2,19
while hydronephrosis findings were anechoic contents in
the renal collecting system.2
A hydronephrotic kidney with a severely dilated renal
pelvis may appear to have mild echogenicity in the depen-
dent part of the collecting system, which may be confused
2010
with type 2 pyonephrosis, but this echogenicity can be cre-
ated by electronic noise.1,2,20 At high gain settings, elec-
tronic noise within an obstructed collecting system
appeared as fine, low-level echogenicity that conforms to
the renal collecting system.2 To avoid this confusion, dogs
should be scanned meticulously at various gain settings and
in different positions.
In this study, the amount of peritoneal and retroperi-
toneal fluid was small and focal; therefore, it had no in-
fluence on the ultrasonographic appearance of a dilated
renal pelvis. However, with larger amounts of peritoneal
or retroperitoneal fluid, acoustic enhancement should be
considered during interpretation of the internal echogeni-
city of renal pelvis. On the other hand, pyonephrosis in
humans can occasionally have predominantly anechoic
contents.20 In this study, all dogs with pyonephrosis had
echogenic contents in the renal pelvis and anechoic con-
tents were only found in dogs with hydronephrosis. In
humans, the positive predictive value of ultrasonography
for pyonephrosis was 100%, but the negative predictive
value was only 85%.20 Thus, pyonephrosis could not be
excluded with anechoic renal collecting system contents. In
other work also in humans, ultrasonography had a sen-
sitivity of 90%, a specificity of 97%, and an overall ac-
curacy of 96% for differentiating pyonephrosis from
simple hydronephrosis.1
In human pyonephrosis where similar evaluation criteria
were used, seven of 14 patients (50%) had a disperse shift-
ing echo pattern (type 2).2 A fluid-debris level (type 3) was
detected in five patients and only two patients had a com-
pletely filled collecting system (type 4).2 Gas formation
(type 5) was identified in one patient.2 In our study, only
two of 18 (11%) dogs had type 2 change, while the re-
maining 89% had type 3 or type 4 change. Working from
the assumption that the echogenicity of the dilated collect-
ing system in pyonephrosis depends on the amount of cel-
lular debris, we inferred that canine pyonephrosis is
characterized by more cellular debris.1
Some dogs with hydronephrosis had abdominal fluid,
but this was uncommon. In pyonephrosis, perinephric in-
flammation and fluid were caused by exudate from the
inflamed kidney; we documented this sonographically and
at laparotomy in 11 dogs. Exudate leakage from the renal
collecting system is rare in humans with pyonephrosis. The
reason for this difference is not known, but the duration of
the disease may be contributory.
Clinical findings and percutaneous pyelocentesis can sup-
port the diagnosis of pyonephrosis.1,2,8,20,21 Even though
percutaneous ultrasound-guided drainage of the renal pelvis
is widely accepted as a safe and effective method of treating
pyonephrosis in humans, puncture-related sepsis developed
in one of two dogs undergoing pyelocentesis in a previous
study.4,7,19–21 Bleeding is also suggested as a contraindica-
tion of ultrasound-guided percutaneous drainage.7,8,19
Vol. 51, No. 5 ULTRASONOGRAPHIC FEATURES OF PYONEPHROSIS IN DOGS
In summary, there were two major sonographic patterns
of canine pyonephrosis (1) echogenicity dispersed or filling
the renal collecting system, or (2) a fluid-debris level due
to layered purulent exudate. Sonography can allow
pyonephrosis to be distinguished from hydronephrosis.
Additionally, ultrasonographic detection of perinephric in-
flammation and fluid can provide useful diagnostic infor-
REFERENCES
1. Subramanyam BA, Raghavendra BN, Bosniak MA, Lefleur AS,
Rosen RJ, Horii SC. Sonography of pyonephrosis: a prospective study. Am
J Roentgenol 1983;140:991–993.
2. Coleman BG, Arger PH, Mulhern CB, Pollack HM, Banner MP.
Pyonephrosis: sonography in the diagnosis and management. Am J Roent-
genol 1981;137:939–943.
3. Chana JHM, Tsuia EYK, Luka SH, et al. MR diffusion-weighted
imaging of kidney: differentiation between hydronephrosis and pyonephro-
sis. Clin Imaging 2001;25:110–113.
4. Szatmári V, Ösi Z, Manczur F. Ultrasound-guided percutaneous
drainage for treatment of pyonephrosis in two dogs. J Am Vet Med Assoc
2001;218:1796–1799.
5. Madewell BR, Creed JE, Hopkins JB. Hydronephrosis and pyelone-
phritis in a dog. J Am Vet Med Assoc 1975;167:377–379.
6. Crow SE, Lauerman LH, Smith KW. Pyonephrosis associated
with Salmonella infection in a dog. J Am Vet Med Assoc 1976;169:1324–
1326.
7. Yoder IC, Lindfors KK, Pfister RC. Diagnosis and treatment of
pyonephrosis. Radiol Clin North Am 1984;22:407–414.
8. Yoder IC, Pfister RC, Lindfors KK, Newhouse JH. Pyonephrosis:
imaging and intervention. Am J Roentgenol 1983;141:735–740.
9. Schneider K, Helmig FJ, Eife R, et al. Pyonephrosis in childhood—is
ultrasound sufficient for diagnosis? Pediatr Radiol 1989;19:302–307.
10. Geoghegan T, Govender P, Torreggiani WC. MR urography de-
piction of fluid-debris levels: a sign of pyonephrosis. Am J Roentgenol 2005;
185–560.
553
mation for pyonephrosis. Percutaneous ultrasound-guided
pyelocentesis can be performed to confirm pyonephrosis.
Ultrasonography is expected to be sufficiently reliable to
establish or exclude the diagnosis of pyonephrosis solely on
the basis of the appearance of the renal collecting system
and perinephric lesions.
11. Van Kirk OC, Go AT, Wedel VJ. Sonographic features of
xanthogranulomatous pyelonephritis. Am J Roentgenol 1980;134:1035–
1039.
12. Goldstein A, Madrazo BI. Slice-thickness artifacts in gray-scale
ultrasound. J Clin Ultrasound 1981;9:365–375.
13. Laing FC, Kurtz AB. The importance of ultrasonic side-lobe arti-
facts. Radiology 1982;145:763–768.
14. Powers TA, Stone WJ, Witt WS, Killion LT, Patton JA.
Glucoheptonate measurement of differential renal function. J Urol
1984;132:175–178.
15. Kerl ME, Cook CR. Glomerular filtration rate and renal scinti-
graphy. Clin Tech Small Anim Pract 2005;20:31–38.
16. Heuter KJ. Excretory urography. Clin Tech Small Anim Pract
2005;20:39–45.
17. Vehmas T, Päivänsalo M, Taavitsainen M, Suramo I. Ultrasound in
renal pyogenic infection. Acta Radiol 1988;29:675–678.
18. Jeffrey RB, Laing FC, Wing VW, Hoddick W. Sensitivity of sono-
graphy in pyonephrosis: a reevaluation. Am J Roentgenol 1985;144:71–73.
19. Schwerk WB, Durr HK. Ultrasound gray-scale pattern and guided
aspiration puncture of abdominal abscesses. J Clin Ultrasound 1981;9:
389–396.
20. Watson RA, Esposito M, Richter F, Irwin RJ Jr, Lang EK. Per-
cutaneous nephrostomy as adjunct management in advanced upper urinary
tract infection. Urology 1999;54:234–239.
21. St.Lezin M, Hofmann R, Stoller ML. Pyonephrosis: diagnosis and
treatment. Br J Urol 1992;70:360–363.