Sorin M.

Dudea, MD, PhD

EM ER G EN C Y IM A G IN G
U R IN A R Y TR A C T
R ETR O P ER ITO N EU M
P ELV IS

Course objectives
Imaging approach for the most

common emergency situations

encountered in the:
Urinary tract
Retroperitoneum
Pelvis

U R IN A R Y TR A C T

RenalTraum a
Classification
American Association for the Surgery of
Trauma (AAST)
depth of damage
involvement of the urinary collecting system and
renal vessels

RenalTraum a
grade I
Hematuria with normal imaging studies
contusion
non enlarging subcapsular haematoma, but no laceration

grade II superfical laceration <1cm depth and does not involve the

collecting system;
non expanding perirenal haematoma

grade III laceration >1cm, without extension into the renal pelvis or

collecting system and withno evidence of urine extravasation

 grade IV
laceration extends to renal pelvis / urinary extravasation
vascular : injury to main renal artery or vein with contained

haemorrhage
Segmental infarctions without associated lacerations
Expanding subcapsular hematomas compressing the kidney

grade V
shattered kidney
avulsion of renal hilum -devascularisation of kidney due to hilar

injury
Ureteropelvic avulsions
Complete laceration or thrombus of the main renal artery or vein

Im aging ofRenalTraum a
WHEN?
Blunt abd. trauma + gross hematuria
Blunt trauma, microscopic hematuria +
hemodyn. Instability
Penetrating flank or in line w. kidney
trauma + hematuria
Pediatric trauma + mico / gross
hematuria
Flank ecchymosis, Fx. Vertebra, transverse
process, lower ribs

Im aging signs
Indirect
Intraperitoneal fluid
Subcapsular hematoma
Retroperitoneal hematoma
Bladder clot

Direct
contusion
Intraparenchymal hematoma
Renal fracture / deep laceration
Urinoma

G rade 1

G rade 2

G rade 3

G rade 4

G rade 5

RenalTraum a
WHAT?
CT
Contrast enhanced
MDCT, multiphase

US
FAST
Direct assessment, variable sensitivity

N ontraum atic renal

em ergency
Acute pyelonephritis
CT wedge shaped streaks of delayed
enhancement
US focal hyper / hypoechogenicity,
reduced Doppler signal

Em physem atous
pyelonephritis
CT gas in the collecting system
- no recent catheterization

RenalAbscess
CT nonenhancing mass with perirenal
stranding
US impure fluid intrarenal mass with
debris

RenalInfarction
Focal / Global
Acute / chronic (no emergency)
CT no uptake of CM

RenalVein Throm bosis

Nephrotic syndrome / dehydration

(children)
CT large kidney, delayed contrast

kinetics
Direct visualization
US direct visualization / very high

impedance

Renalcolic
KUB stone (opaque)
US hydronephrosis, obstruction site
CT if previous inconclusive

H em aturia
Malignancy
R.a.aneurysm
A-V malformation
Benign / vascular tumors
Infection
Coagulopathies
stones

 US anatomy
CT contrast enhanced, source of

hemorrhage
Arteriography - pretreatment

Renalfailure - acute onset

Prerenal
Hypovolemia / shock
R.A.occlusion / AO dissection
R.V. thrombosis

Renal intrinsic
Glomerulonephritis
Acute interstitial nephritis
Acute tubular necrosis

Postrenal
Obstruction

Renalfailure - acute onset

Imaging US
Prerenal normal + cause
Renal sometimes specific, large kidneys
Postrenal obstruction dilatation
(bilateral)

Retroperitoneum

Retroperitoneum
Aorta
Inferior Vena Cava
Fluid collections

Aorta
Dissection
Aneurysm
Clot / occlusion

Aortic dissection
Flap dual lumen
US / CT

Aortic aneurysm -

rupture /leakage

Throm bosis /occlusion

IVC - acute throm bosis

IVC - acute throm bosis

Fluid collections
Hematoma
Abscess

Pelvis
Urinary bladder
Male
Testis

Female
Uterus / pregnancy
ovary

U rinary bladder traum a

Clinicalindicators ofbladder rupture

Suprapubic pain or tenderness
Inability to void, low urine output, clots in urine
Signs of major perineal trauma: swelling or
hematoma, blood at the urethral meatus
Unresponsiveness, intoxication, altered
sensation
Free intraperitoneal fluid on CT scan or
ultrasound
Preexisting bladder outlet obstruction, bladder
surgery or bladder abnormality
Abdominal distension, hypoactive bowel
sounds
Morey AF, Iverson AJ, Swan A, et al. Bladder rupture after blunt trauma: Guidelines for diagnostic imaging. J Trauma
2001;
51:683-686.
Increased serum BUN and/or creatinine

Im aging ofbladder traum a

Cystography immediate if
Gross hematuria + pelvic fracture
The presence of clinical indicators
Relative: Microhematuria + pelvic fracture

CT cystography

Intraperitonealleak

Extraperitonealleak

Delayed prone
CT

Intraperitonealrupture

Acute urinary retention

Causes
Obstructive prostate / stones
Infectious / inflammatory
Pharmacologic antidepressants,
antihistaminic, anticholinergic,
antiarrhythmics, etc
Neurologic
Other
Post-op
Pregnancy
Trauma

Acute urinary retention

Imaging
US bladder size + walls + content

Testis
Epididymo-orchitis
Torsion
Only US + Doppler

Epididym o-orchitis
Clinical

presentation
Pain +

hypersensitivity
Swelling
Fever

2D US
Testis
Large
Hypoechoic

Epididymis
Large
Inhomogenous

Acute torsion
Clinical

presentation
Pain +

hypersensitivity
Swelling
Fever

2D US
Testis
Large
Hypoechoic

Epididymis
Large
Inhomogenous

D iff
erential= D oppler
Epididymo-orchitis
HYPER FLOW

(inferno)

Torsion
NO FLOW

(silentium)

Fem ale pelvis

Ovarian torsion US (endovaginal)
Pelvic mixed mass, peripheral follicles
No flow (Doppler)
CT confirm if doubt

Ectopic pregnancy
US
Normal uterus
Gestational sac outside uterus
Peritoneal fluid

Thank you !