ULTRASONOGRAPHY 0195-5616/98 $8.00 + .

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ULTRASONOGRAPHY OF
URINARY BLADDER DISORDERS
Renee Leveille, DVM

The urinary bladder is superbly suited for ultrasonographic evalua-

tion because of the excellent acoustic properties of fluid and its superfi-
cial location? Ultrasonography can provide information relative to the
capacity of the bladder, changes in bladder outline, changes in wall
thickness, identification of mural and luminal masses, and identification
of extrinsic lesions that may displace the bladder wall, causing changes
in its shape. 1• 3 • 10• 19• 35 It also allows the evaluation of the retroperitoneal
region for lymphadenopathy.

TECHNIQUE AND NORMAL ULTRASONOGRAPHIC

APPEARANCE

Technique

Dogs and cats are positioned and imaged in either dorsal or lateral
recumbency. Occasionally, the examination can be performed with the
animal in the standing position. The urinary bladder is examined in
both the sagittal and transverse planes. A moderate distention of the
urinary bladder is recommended and will facilitate evaluation of muco-
sal detail and wall thickness. 1• 10• 15 When minimally distended, the uri-
nary bladder may show a nodular undulating mucosal surface represent-
ing mucosal folding. On the other hand, a complete distention may hide
mucosal irregularities and mild to moderate bladder wall thickening; it
also may potentially cause ischemia, hemorrhage, cystitis, and rupture. 15

From the Department of Clinical Sciences, College of Veterinary Medicine, The Ohio State
University, Columbus, Ohio

VETERINARY CLINICS OF NORTH AMERICA: SMALL ANIMAL PRACTICE

VOLUME 28 • NUMBER 4 • JULY 1998 799

800 LEVEILLE

Catheterization of the urinary bladder and injection of saline may help

distend the urinary bladder, but care must be taken not to simultane-
ously inject air bubbles which may significantly impair interpretation.
An alternative is to perform the examination early in the morning; this
also decreases the risk of infection introduced by retrograde procedures.
Complete visualization of the superficial structures may be difficult.
Irregularity in the shape of the skin surface makes contact scanning
difficult and can cause a loss of needed information. Another problem
is the generation of intense echoes in the most superficial zone of the
near field due to transducer reverberation. The use of a stand-off pad

Figure 1. Longitudinal scan of a normal urinary bladder without a standoff pad (A); with a
standoff pad (B). Note the loss of details in the near field. * = standoff pad.
 ULTRASONOGRAPHY OF URINARY BLADDER DISORDERS 801

will improve image resolution by moving the area of interest into the
focal zone of the transducer (Fig. 1).9

Normal Urinary Bladder

Ultrasonographically, the normal urinary bladder is an echo-free

structure cranial to the pelvis, surrounded by an echogenic structure
that represents an acoustic interface of urine, bladder wall, and serosal
fat.l The wall appears as two thin, parallel, hyperechoic lines separated
by a hypoechoic line15 : (1) the hyperechoic serosa/ perivascular fat inter-
face, (2) the hypoechoic muscularis, and (3) the hyperechoic line of the
lamina propria submucosa paralleling the mucosal surface. The mucosal
and submucosal layers are well defined only when the bladder is nearly
empty with no tension deforming the wall (Fig. 2).14
The shape of the bladder varies among dogs and changes with the
degree of distention and the amount of pressure applied to the abdomen
by the ultrasonographer. 15 Bladder wall thickness varies with the degree
of distention and the dog's body weight. Mean bladder wall thickness
in dogs is 2.3 mm in minimally distended bladders (0.5 mL/ kg of saline)
and 1.4 mm in moderately distended bladders (4 mL/kg of saline). 15 In
the normal cat, the bladder wall thickness is about 1.7 mm. 14

Ureterovesicular Junctions

The ureterovesicular junctions may be visible ultrasonographically

as small elevations of mucosa on the dorsal surface of the bladder

Figure 2. Longitudinal scan of a normal urinary bladder wall. (1) the hyperechoic serosal
interface (black arrow), (2) the hypoechoic muscularis (*), (3) the hyperechoic line of the
mucosal surface (white arrow).
802 LEVEILLE

corresponding to the ureteral orifices (Fig. 3). 12• 28 Caudal displacement

of the bladder neck prevents them from being identified. 28 Anatomic
variation, degree of bladder distention, inappropriate image plane, or
low image quality can also be responsible for the lack of their identifica-
tionY The peristalsis of the distal ureters and the flow of urine into the
bladder may be observed in real time when using a high-resolution
transducer; the jet echoes emanate in a caudal direction and are best
seen when the bladder is full. Each ureter functions independently of
the other. After a few seconds, the low-intensity echoes become distrib-
uted within the bladder and lose their intensity until they are no longer
visualized. Several potential mechanisms have been proposed for the
formation of ultrasonographically detectable ureteral jets. Among these
are microbubbles of particulate matter in the urine, turbulence or cavita-
tion at the ureteral orifice, and temperature or density differences be-
tween ureteral and bladder urine. The latter mechanism is primarily
responsible for the detection of fluid jets in vitro. 2 In order to avoid
catheterization, Lamb and Gregory28 suggest allowing the dog to urinate,
then withholding water for several hours to ensure that the bladder
urine is concentrated, and finally allowing the dog access to water so
that more dilute ureteral urine is produced. This technique increases the
frequency of ureteral jets and thus facilitates comparison of the normal
and abnormal sides; it also shortens the amount of time needed for
examination.2 Although ureteral jets are visible in real-time, two-dimen-
sional images, the flow of urine from ureters can sometimes be detected
during color-flow Doppler ultrasonographic scanning (Fig. 4).I2

Figure 3. Longitudinal scan of a normal urinary bladder wall. The ureterovesicular junction
is visible ultrasonographically as a small elevation of mucosa on the dorsal surface of the
bladder corresponding to the ureteral orifice (arrow).
 ULTRASONOG RAPHY OF URI NA RY BLADDER DISORDERS 803

Figure 4. Longitudinal scan of a normal urinary bladder, using color flow Doppler. The jet
echoes are emanating from the ureterovesicular junction.

Reflux

Vesicoureteral reflux is a common urinary tract abnormality in chil-

dren.32 It has been reported in up to 50% of normal dogs less than 6
months of age but usually disappears as the animal matures. Secondary
vesicoureteral reflux is nonspecific and may occur as a result of inflam-
mation, a neurogenic disorder, an obstructive lesion, or surgical damage
to the trigone or ectopic ureter.38 In humans, ultrasonographic examina-
tion is performed while the bladder is filled to capacity with a drip
infusion of 0.9% saline. Before infusion, the saline is shaken vigorously
to provide a suspension of air microbubbles. Vesicoureteral reflux is
suggested by dilatation or the appearance of bubbles in the upper renal
tracts. Saline-containing microbubbles reflux freely into the anechoic
fluid-filled conduit. 9

Bladder Volume

Formulas to measure the volume of the urinary bladder have been

reported in the human literature. To my knowledge, no efficient formulas
have been described in the veterinary literature.32
804 LEVEILLE

ARTIFACTS

It is essential to recognize the ultrasonographic imaging artifacts

commonly encountered during the routine evaluation of the urinary
bladder and to interpret them correctly to obtain accurate diagnostic
information.

Slice Thickness Artifact

Slice thickness or reverberation artifact may occasionally simulate

intraluminal or mural abnormalities. The width of the beam causes
echoes that have originated outside the lumen to appear within the
bladder. Reverberation echoes from the transducer, skin, or adjacent gas-
filled bowel may also cause confusing echogenicities within the bladder.
These artifacts can usually be eliminated, or at least recognized, by
changing the position of the transducer and imaging the bladder in
multiples planes (Fig. 5). 33

Acoustic Shadowing

Distinct shadowing is a useful artifact that can be seen if a calculus

or other calcified tissue is equivalent to or greater in size than the beam
width at the point of the sound beam-calculus interface. Calculi outside

Figure 5. Longitudinal scan of a normal urinary bladder wall. Reverberation artifacts in the
near field may occasionally simulate intraluminal or mural abnormalities. Side-lobe artifacts
appear as echogenic material on the deep portion of the urinary bladder known as pseu-
dosludge.
 ULTRASONOGRAPHY OF URINARY BLADDER DISORDERS 805

the focal zone or that are very small but located within the focal zone
may have no shadow or will tend to have backscattered echoes within
the shadow, resulting in indistinct margins. 26

Side Lobe Artifacts

Artifacts produced by secondary lobes are due to ambiguity in the

direction of the ultrasound beam. In the urinary bladder, side lobes can
be produced by adjacent gas in the colon and by the reflective interface
between urine and the bladder wall.26 They participate in the formation
of apparent echogenic material on the deep portion of the urinary
bladder known as "pseudo-sludge." Side lobes may occur with any type
of transducer and have been called "grating lobes" when occurring
with array transducers. 26 These artifacts result in an increase in noise,
deteriorating image quality by reducing contrast resolution. They can be
reduced in brightness from the display image by lowering the gain and
decreasing the dynamic range (see Fig. 5). 4

Hypoechoic Pseudolesion

When examining an animal with peritoneal effusion, a portion of

the urinary bladder wall may be hypoechoic and may appear as a wall
defect. There may also be a hypoechoic line distal to the bladder edge
in a plane that intersects the edge. Both artifacts probably result from
acoustic shadowing caused by beam refraction, although lack of beam
reflection back to the transducer may also contribute to the hypoechoic
bladder wall image segment. Based on the above, the author assumes
that the peritoneal effusion has a higher sound propagation speed than
does the urine (Fig. 6). 13

Other Artifacts

Some structures such as a paraprostatic cyst or a fluid-filled uterus

can be mistaken for the urinary bladder if the bladder is empty during
the examination. Passing a urinary catheter and infusing saline will help
identify the bladder when doubt exists. A fluid-filled uterus is often
tortuous and tubular, and it can be followed to a perirenal location. 14 If
there is gas or fecal material within the colon, artifacts result in an image
similar to what one would see in a patient with cystic calculi. The
artifact is more apparent when one is imaging a patient in dorsal recum-
bency and in a transverse scan plane. Simple techniques of repositioning
the transducer so that the colon can be traced in the sagittal imaging
plane as a longitudinal structure that may be seen to extend beyond the
bladder and of standing the patient and imaging from the ventral or
lateral abdomen can be used to differentiate the colon filled with gas or
806 LEVEILLE

Figure 6. Longitudinal scan of a normal urinary bladder wall demonstrating the hypoechoic
pseudo lesion artifact in which a portion of the urinary bladder wall appears as a wall defect.

feces from true calculi. On ventral scan images, the colon will remain
dorsal, whereas gravity-dependent cystic calculi will fall to the ventral
aspect of the bladder. The dorsal wall of the urinary bladder contacts
the colon and, in fact, the walls of the colon and urinary bladder may
appear confluent (Fig. 7). 5

Figure 7. Longitudinal scan of a urinary bladder. The hyperechoic structure at the dorsal
urinary bladder wall corresponds to the adjacent colon, which may mimic reverberation
from a calculus. An blood clot adherent to the ventral urinary bladder wall is noted in the
near field .
 ULTRASONOCRAPHY OF URINARY BLADDER DISORDERS 807

ABNORMALITIES OF THE URINARY BLADDER

Urachal Anomalies

The urachus connects the apex of the bladder with the allantoid
through the umbilical cord. Normally, it fibroses at birth and atrophies.
Depending on the type of defective obliteration during downward pro-
gression of the bladder, various types of congenital urachal anomalies
can occur, including (1) patent urachus, (2) umbilical sinus, (3) urachal
cyst, and (4) vesicourachal diverticulum. 42
When present, the postnatal urachal remnant is found at the crania-
ventral surface of the distended bladder. 21 The remnant can be found
between the peritoneum and the transversalis fascia. If an anomalous
urachal remnant becomes infected, there could be enlargement of the
structure, drainage from the fistula, soft tissue swelling, erythema, and
localized pain. 8

Patent Urachus
With a patent urachus, a vesicocutaneous fistula persists throughout
from the bladder to the umbilicus. There is a significant fundamental
difference between the remnant of the urachus in man and that of some
domestic animals. In man, the urachus normally persists after birth as a
fibrous cord extending from the umbilicus to the vertex of the bladder.
This cord is usually called the "median umbilical ligament," but it is
sometimes referred to as the "urachus." In horses, cattle, dogs, and cats,
however, the fetal urachus usually atrophies to a greater degree so that
only a scar at the vertex of the bladder remains. Occasionally, a fibrous
cord extending from the vertex of the bladder to the umbilicus persists.
If the urachal canal remains patent from the bladder to the umbilicus,
urine may be voided to the exterior by this route. 36 This congenital
anomaly is rare in the dog and cat. Greene and Bohning20 reported a cat
with persistent urachus which was associated with a cystic liver and
diagnosed by exploratory laparotomy. It was hypothesized that the
persistent urachus became patent due to an increased vesicular pressure
caused by urethral blockage. The obstruction causes increased vesicular
pressure which converts the closed urachal canal into a patent urachus.
Ultrasonographically, the patent urachus may be evident or the bladder
vertex may have an unusual pointed appearance. 33

Urachal Sinus
With a urachal sinus, the cranial portion of the urachus is patent,
opening into the umbilicus.

Urachal Cyst
With a urachal cyst, the midportion of the urachus is patent with
both cranial and caudal ends closed. The cyst can sometimes spontane-
808 LEVEILLE

ously drain its contents into the bladder or the umbilicus with increased
pressure. Urachal cysts form when secretions continue from an isolated
section of urachal epithelium while the remainder of the urachus under-
goes fibrosis.
On ultrasound examination, a urachal cyst is seen as a thin-walled
and anechoic tubular structure in the ventral abdomen. It sometimes
becomes infected in later life and takes on the appearance of an abscess. 33

Vesicourachal Diverticulum
A vesicourachal diverticulum represents the caudal segment of the
urachus that fails to close, opening into the bladder. Diverticula of the
urinary bladder may be congenital urachal remnants or they may be
acquired defects owing to partial obstruction of urine outflow or mural
trauma. 14 Diverticula are of clinical significance because they appear to
be a predisposing factor for recurrent urinary infections. 42 Sixty percent
of male and female cats evaluated for signs of lower urinary tract disease
had vesicourachal diverticula, however, only 40% of these cats had
bacterial urinary tract infections. Whereas urachal diverticula may pre-
dispose affected cats to feline urology syndrome, the mechanism by
which the condition induces this disease remains unclearP, 18
Ultrasonographically, a diverticulum appears as a fluid-filled struc-
ture extending from the bladder lumen. 33 On ultrasound'•examination,
diverticula vary greatly in size. They are seen as round, well-defined,
thin-walled, distinctly fluid-filled masses with acoustic enhancement. In
many cases, clear demarcation of the communication with the bladder
can be seen on the caudal or lateral wall with a straight transverse or
longitudinal scan. The diverticulum should disappear when the patient
voids (Fig. 8).
An acquired diverticulum may result from trauma or infection.
Herniation of intact mucosa through a tear in the muscular layers of the
bladder wall has been identified with frauma. Acquired diverticula or
fistulas between the bladder and other organs may form as a result of
inflammation in the bladder wall or adjacent organs. Persistent defor-
mity of the lumen with masses or adhesions may be noted with ultraso-
nography, but the diagnosis is better confirmed with contrast cystogra-
phy.33

Exstrophy

Exstrophy of the bladder is a condition in which there is an absence

of the ventral abdominal wall and ventral bladder wall. The dorsal wall
of the bladder becomes the ventral body wall and the ureters discharge
urine directly to the exterior. Genital anomalies usually accompany the
condition. 22 Some of the complications of a patent urachus reported in
humans are exstrophy of the bladder, benign and malignant neoplasms,
 ULTRASONOGRAPHY OF URINARY BLADDER DISORDERS 809

Figure 8. Longitudinal scan of a urinary bladder wall demonstrating a well-defined, thin-

walled, distinctly fluid-filled structure cranial to the urinary bladder corresponding to a
diverticulum.

and abscesses.36 There is no report on the ultrasonographic appearance

of this condition in animals.

Other Abnormalities

Rupture
Urinary bladder injuries resulting from blunt trauma are classified
as contusions, extraperitoneal ruptures, intraperitoneal ruptures, or a
combination of all three. 41 Although the diagn osis of bladder rupture
can be established by retrograde positive cystography, real-time ultraso-
nography can be an initial diagnostic procedure in suspected cases of
rupture (Fig. 9). The inflation of air or injection of saline into the urinary
bladder may aid in determining whether the perivesical lesions commu-
nicate with the urinary bladder. The ultrasonographic detection of micro-
bubbles or turbulent flow through the visualized defect, and shortly
thereafter in the extravasated fluid collection, is diagnostic of extraperito-
neal rupture of the bladder.41 The "hypoechoic pseudo-lesion" may
mimic a bladder rupture. Partial rupture of the urinary bladder wall
with subserosa! accumulation of urine can be easier to detect as a focal
anechoic halo associated with a portion of the wall. 14

Cystitis
Cystitis usually produces diffuse thickening of the bladder wall,
decreased echogenicity, and a smooth outline of the mucosal surface.
810 LEVEILLE

Figure 9. Transverse scan of a urinary bladder. A defect (arrow) is noted at the cranial
aspect of the urinary bladder where urine could be seen leaking within the peritoneal cavity.

The transition from edematous to normal mucosa is usually graduaP

Although cystitis may manifest itself as a rounded intraluminal mass, it
is clearly mucosal in origin. 27 It is usually most pronounced cranioven-
trally but can become generalized in severe cases (Fig. 10). In a nondis-
tended bladder, subjective evaluation of wall thickness limits the inter-
pretation. Mucosal lesions of the bladder occur in a variety of locations
and require the use of various transducer positions and image planes
for optimal identification.29

Figure 10. Longitudinal scan of a urinary bladder with cystitis. It usually appears as a
diffuse bladder wall thickening.
 ULTRASONOGRAPHY OF URINARY BLADDER DISORDERS 811

In polypoid cystitis, wall thickening is accompanied by multiple

small masses that project into the bladder lumen. Occasionally, large
polyps with a pedunculated attachment may be seen (Fig. 11). If the
attachment is sessile, neoplasia is more likely.31 Because neoplasia is
much more common than polyps, the diagnosis of a polyp must be
confirmed with a biopsy.33
Granulomatous cystitis sometimes is seen as an irregular bladder
internal surface. The ultrasonographic findings of granulomatous cystitis
are indistinguishable from those of carcinoma.
The ultrasonographic appearance of emphysematous cystitis is one
of multifocal hyperechoic areas of intramural gas w ith variable acoustic
shadowing and reverberation (Fig. 12). Emphysematous cystitis can be
differentiated from urinary catheter-introduced gas within the lumen by
the involvement of bladder walls other than the uppermost wall. The
hyperechoic foci of emphysematous cystitis are also fixed in location
unlike intraluminal gas. Intraluminal gas may, however, be present with
emphysematous cystitis. 14

Blood Clots
Blood clots may occur secondary to trauma, bleeding disorders,
infection, or neoplasia. Clots are commonly hyperechoic nonshadowing
echogenicities with an irregular shape, which settle to the dependent
portion of the bladder lumen on positional studies (Fig. 13). The lumen
of the bladder may be filled with a lacy cob-like material (Fig. 14).14• 33
Blood clots usually move when the bladder is agitated. When they are
adherent to the bladder wall, they may produce an irregularity along
the mucosal surface. This appearance may be similar to that of tumor.

Figure 11. Longitudinal scan of a urinary bladder. A polyp is seen projecting within the
lumen of the urinary bladder.
812 LEVEILLE

Figure 12. Longitudinal scan of a urinary bladder with emphysematous cystitis. Multifocal,
hyperechoic areas of intramural gas (arrows), with variable acoustic shadowing and rever-
beration are noted on multiple bladder walls.

Figure 13. Transverse scan of a urinary bladder. A hyperechoic blood clot has settled to
the dependent portion of the urinary bladder.
 ULTRASONOGRAPHY OF URINARY BLADDER DISORDERS 813

Figure 14. Transverse scan of a urinary bladder with hematuria. The lumen of the bladder
is filled with a lacy material, representing a blood clot.

Agitation of the transducer temporally resuspends small clots and

sediment if adequate urine is present. This does not occur with mural
masses or larger calculi.33

Calculi
Radiopaque or radiolucent cystic calculi appear as curvilinear, hy-
perechoic, focal echogenicities creating a distal acoustic shadow in the
dependent portion of the bladder (Fig. 15). Calculi often change position
as the animal's position is changed? If the mobility of a calculus is not
easy to demonstrate while the p atient is recumbent, standing the patient
up will cause gravitation of an intraluminal calculus to the ventral
bladder wall. 14 The degree of acoustic shadowing or the echogenicity
correlates with the chemical composition of the calculi, the focal zone,
and the ultrasound frequency used. 33
Solitary or multiple uroliths produce intense acoustic shadowing;
therefore, the parts that are far from the transducer are often not visual-
ized. Small calculi do not always produce acoustic shadowing; however,
reverberation, the repeated reflection of ultrasound waves from the same
echogenic structure closest to the transducer, is often seen. 40 Urolithic
sand particles can be detected along the dorsal wall with the patient in
dorsal recumbency and along the ventral wall in a standing patient (Fig.
16). After some movement, however, these small particles will scatter in
the anechoic black lumen. Depending on the resolution of the transducer,
0.1 to 0.2 em is the minimum size detected.
False-positive diagnoses should be considered under the following
circumstances:
814 LEVEILLE

Figure 15. Longitudinal scan of a urinary bladder. The curvilinear hyperechoic focal echo-
genicity creating distal acoustic shadow in the dependent portion of the bladder represents
a cystic calculus.

Figure 16. Longitudinal scan of a urinary bladder. Urolithic sand particles are detected
along the dorsal urinary bladder wall in dorsal recumbency.
 ULTRASONOGRAPHY OF URINARY BLADDER DISORDERS 815

1. Urinary sludge (probably cellular debris, mucin, and blood).

Urinary sludge is quite similar to urolithic sand, as they are both
gravity dependent; however, sludge does not produce reverbera-
tion.
2. Gas (air) bubbles. Gas can be produced by bacteria in cystitis and
air can be injected via catheterization. Gas bubbles may shadow
or create reverberations, but they rise to the top of the bladder
on positional views.
3. Blood clots. Blood clots are relatively large structures, but they
do not have acoustic shadowing as do calculi of similar size.
4. Bladder tumors and polyps. Bladder tumors and polyps can be
differentiated from calculi because they are fixed to the wall of
the bladder and do not produce acoustic shadowing.
False-negative diagnoses can also be made. These primarily result
from (1) an empty bladder, (2) urolithic particles (sand) being too small,
and (3) an ultrasonographic examination not being performed systemati-
cally utilizing several different scans. 40 A commonly encountered ultra-
sound artifact is the convex-shaped colon, located adjacent to the dorsal
wall of the urinary bladder (see Fig. 7). Fibrosis or calcification of the
bladder wall may cause mural hyperechogenicity and shadowing. In
most cases, repositioning the animal and imaging the bladder in multiple
planes distinguishes fibrosis or calcification from calculi, blood clots,
sediment, or gas bubbles. 33

Primary Urinary Bladder Tumors

Tumors of the urinary bladder comprise about 1% of all canine
tumors. 37 Transitional cell carcinoma is the most common malignant
tumor of the urinary bladder in the dog. Squamous cell carcinoma,
adenocarcinoma, undifferentiated carcinoma, and rhabdomyosarcoma
have also been reported but occur less frequently (Fig. 17).34• 37
The size of the lesion is an important factor in the rate of detection
in ultrasonography. In humans, the rate of detection of tumors less than
0.5 em in diameter is less than 33.0% compared with 83.3% for tumors
larger than 1.0 em and 95.0% for those larger than 2.0 cm. 25 In my
experience, lesions 3.0 mm or greater in diameter can be identified
within a moderately distended urinary bladder. 31 Tumors of the ventral
wall can be missed or more difficult to image because they may lie
outside the focal zone of the transducer or be covered by superficial
reverberation artifact. A stand-off pad applied between the transducer
and abdominal wall may decrease the likelihood of missing a ventral
mass.
There are several entities that may mimic the ultrasonographic
appearance of urinary bladder tumors. These include blood clots, cysti-
tis, and calculi. The observation of pedunculated masses is more consis-
tent with a diagnosis of polypoid cystitis. 31 If a focal hypoechoic mass is
seen, it is most likely a tumor. 32 In humans, suture material and sur-
816 LEVEILLE

Figure 17. Longitudinal scan of a urinary bladder with transitional cell carcinoma, located
along the dorsal wall. Note the loss of distinction of the different layers of the wall.

rounding tissue reactions in the urinary bladder wall have been reported
as mimicking a tumor. 11
The intrapelvic location of the urethra may sometimes compromise
its evaluation by transabdominal ultrasonography because of overlying
bone. 31 In humans, transrectal ultrasonography allows visualization of
lesions obscured by the pubic symphysis. 11 In small animals, retrograde
urethrography and positive-contrast vaginography remain the only alter-
native imaging techniques to evaluate the urethra for neoplastic exten-
sion at the present time.
During the ultrasonographic examination, the kidney and ureter
should be examined for hydronephrosis and hydroureter resulting from
obstructive uropathy. The sublumbar (iliac) lymph nodes should be
evaluated for metastasis (Fig. 18).33
Ultrasonography has also been used to stage bladder tumors with
an accuracy ranging from 67% to 83%.24 The prognosis and treatment of
transitional cell carcinoma and other uroepithelial neoplasm s depend on
the stage of the tumor. Color-flow Doppler ultrasonography and the
measurement of the resistive index are not clinically helpful in the
evaluation of transitional cell carcinoma. The vascularity cannot predict
whether an individual tumor has become invasive. 24

Secondary Urinary Bladder Tumors

Metastatic bladder tumors usually develop from direct extension by
implantation from a primary lesion of the upper tract or by lymphatic
or hematogenous spread. A thickening of the wall or a focal mass at the
 ULTRASONOGRAPHY OF URINARY BLADDER DISORDERS 817

Figure 18. Longitudinal scan of a urinary bladder. Multiple hypoechoic masses are noted
dorsal to the urinary bladder representing sublumbar (iliac) lymphadenopathy in a dog with
transitional cell carcinoma.

bladder neck suggests a tumor originating from the urethra or prostate

with extension to the bladder.32• 33

ULTRASOUND-GUIDED BIOPSY AND FINE NEEDLE

ASPIRATION

The differentiation between a granulomatous lesion, tumor type,

and polypoid cystitis cannot be determined by ultrasonographic appear-
ance alone. A biop sy is needed to confirm the diagnosis.33 There have
been some reports regarding the potential for tumor seeding along a
biopsy needle tract or in the surgical field. Gilson and Stone 16 described
surgically induced tumor seeding of the urinary tract as the most com-
mon tumor type seeded. Others have reported no evidence of tumor
seeding after transcutaneous ultrasound-guided fine needle aspiration
or tissue core biopsy; however, the number of cases was small and no
long-term follow-up was available.30• 31
More recently, Lamb et aF9 have described a technique of ultra-
sound-guided catheter biopsy of lesions affecting the bladder or urethra.
This is a m odification of a technique previously described by Holt et
al/3 which consists of obtaining a biopsy from the lower urinary tract
using a urinary catheter. Saline is infused to increase bladder distention
and to provide an optimal acoustic window. A urinary catheter is placed
in the bladder w hich is identified on transverse ultrasound images, and
the position of the catheter tip relative to the lesion is monitored as the
catheter is manipulated. Rather than attempting to steer the catheter to
818 LEVEILLE

the lesion, Lamb et aF3 attempt to displace the lesion towards the
catheter. This is achieved by repositioning the transducer on the abdomi-
nal wall adjacent to the lesion and, while observing the catheter, pushing
the lesion towards it by indenting the abdominal wall with the trans-
ducer; a full bladder may have to be partially drained to facilitate this
movement. The biopsy is obtained by applying suction with a 20-mL
syringe when the side of the catheter tip is in contact with the lesion.
This technique offers certain advantages. There is limited risk for either
perforation of the bladder wall or peritoneal hemorrhage when using a
urethral approach, and any urinary hemorrhage is monitored by urinaly-
sis. Disadvantages of this technique include small sample size which
may limit the accuracy of the pathologic diagnosis and the inability to
obtain submucosal tissue or to biopsy extraluminal lesions such as
enlarged regional lymph nodes. 29

ULTRASOUND CONTRAST MEDIUM

Bladder instillation with an echo-enhancing agent has been reported

in humans. This agent provides good echogenic speckles for identifying
the bladder neck and urethra. In addition, the dynamic evaluation ac-
quired during the processes of pressing and coughing in urinary stress-
incontinent women shows bladder neck funneling and the entire urethra
as a sign of urine loss. If the contrast medium is injected too high or too
fast, the suspension is distributed instantly in the bladder liquid and
dissolves immediately. The combination of the dynamic properties of
ultrasonography and the optimized visualization of bladder neck behav-
ior provides new possibilities for investigating urinary incontinence. 39

MISCELLANEOUS

Catheters

Catheters can be easily defined within the bladder on ultrasound

examination. If the Foley balloon is distended with saline, it is seen as
an anechoic mass with the catheter walls identified as parallel hypere-
choic lines. When possible, it is best to examine the bladder without the
catheter in place. 14

Foreign Bodies

Foreign bodies within the urinary system are reported infrequently

in veterinary medicine. Iatrogenic bladder foreign bodies (urinary cathe-
ters) have been reported as a cause of cystitis. Precisely how the object
arrived within the bladder is not always known; several possibilities
include entrance via the external urethral orifice, migration from the
 ULTRASONOGRAPHY OF URINARY BLADDER DISORDERS 819

vaginal cavity into the urethra and subsequently through the urinary
bladder, and migration following cutaneous penetration or from an
internal site such as the intestinal tract. 43
The ultrasonographic appearance of a metallic foreign body is simi-
lar to that of a calculus, except that it is circular, smooth, and extremely
hyperechoic at the urine-foreign body interface. Sound reverberation can
be seen distal to the metal foreign body within the acoustic shadow of
the highly reflective metal. A grass awn can appear as a mildly echogenic
small branching structure within the lumen. 14

Gas

Intraluminal gas bubbles introduced by urinary catheterization or

produced by a gas-forming infection can also appear as small, floating,
hyperechoic foci in the bladder lumen. These foci rapidly gravitate to
the uppermost bladder wall, however, and accumulate under the muco-
sal surface as a reverberating, curvilinear, hyperechoic interface. 14

CONCLUSIONS

Ultrasonography is often recommended as the first diagnostic im-

aging modality in patients with hematuria or dysuria as it is more
sensitive and specific than double-contrast cystography in detecting
urinary bladder disorders. Its clinical value is its ability to evaluate the
entire urinary tract (except the distal urethra) in both female and male
dogs. If the extent of the disease cannot be adequately evaluated, con-
ventional radiographic modalities should be used as a diagnostic com-
plement.

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Address reprint requests to

Renee Leveille, DVM
Department of Clinical Sciences
College of Veterinary Medicine
The Ohio State University
601 Vernon L. Tharp
Columbus, OH 43210