Imaging prostatitis ,urethritis Dr Ahmed Esawy
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Transcript of Imaging prostatitis ,urethritis Dr Ahmed Esawy
Dr Ahmed Esawy
Prostatitis
Imaging
Dr. Ahmed Esawy
MBBS M.Sc MD
Dr Ahmed Esawy
Anatomy of Urethra
• Extends from bladder neck to the membranous urethra
• Divides the prostate into anterior FMS and posterior glandular structures.
• Veromontanum
• Prostatic utricle. • Ejaculatory duct openings.
• Internal urethral sph. at the bladder neck
• External urethral sph. at the prostatic apex
Dr Ahmed Esawy
Orientation of images
Dr Ahmed Esawy
Seminal Vesicles, Vas
deferences
Dr Ahmed Esawy
Prostatic base-TS
Dr Ahmed Esawy
Dr Ahmed Esawy
Mid prostate-TS
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Dr Ahmed Esawy
Prostatic apex-TS
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Dr Ahmed Esawy
Mid prostate-LS
Dr Ahmed Esawy
Dr Ahmed Esawy
Periprostatic structures
• Urinary bladder
• Obturator internus&
levator ani
• Anterior periprostatic fat
• Pubic bone
• Neurovascular bundles
• Rectal wall
Dr Ahmed Esawy
Normal MRI of the
Prostate
Dr Ahmed Esawy
Dr Ahmed Esawy
category III prostatitis, also known as chronic pelvic pain syndrome
(CPPS)
is a common condition of unclear etiology and few validated effective
therapies.
It is even controversial whether all patients with CPPS have prostatic
pathology
Prostatitis infection or inflammation of the prostate gland
Acute prostatitis
Chronic focal prostatitis
symptomatic
oligo or asymptomatic
Typical pelvic or perineal pain lasting more than 3 month can be
bacteria or non infectious
Dr Ahmed Esawy
The National Institutes of Health (NIH) classified prostatitis into four distinct
syndromes
I: acute bacterial prostatitis
II: chronic bacterial prostatitis
III: chronic prostatitis and chronic pelvic pain syndrome (CPPS); further
classified as inflammatory or noninflammatory)
IV: asymptomatic inflammatory prostatitis
Dr Ahmed Esawy
Prostatitis
• Diffuse or focal.
• Involve inner or outer gland.
• Acute, chronic or granulomatous.
.
Dr Ahmed Esawy
Ultrasonographic findings in prostatitis
Enlarged prostate
diffuse enlargement
focal
high-density and mid-range echoes represent corpora amylacea concretion ,
Calcifications
Focal hypoechoic region in the peripheral zone of the gland the mid-range echoes
represent inflammation, fibrosis, or both
echo-lucent zones Discrete fluid collection suggests abscess formation.
capsular irregularity and thickening, ejaculatory duct echoes, and periurethral-zone
irregularity.
Colour Doppler ultrasound demonstrates increase flow in the periphery of the
abscess
Granulomatous prostatitis: * Focal hypoechoic lesion
Dr Ahmed Esawy
TRUS findings
Edema of the verumontanum
Edema of the prostatic lobes (peripheral zone)
Dilated Ejaculatory Ducts
Changes of the Seminal Vesicles
Median prostatic cysts (utricular cysts, Mülleriancysts)
Dr Ahmed Esawy
MRI The prostate will be diffusely enlarged, often with associated inflammatory
changes of periprostatic fat and of the seminal vesicles
Acute prostatitis
T1: peripheral zone iso- or hypo-intense to transitional zone
T2: hyperintense
T1 C+ (Gd) diffusely enhancing
CT abscess is present it is seen as a rim-enhancing, unilocular or
multilocular, hypodensity in the peripheral zone
Infection can extend through capsule into periprostatic tissues, seminal
vesicles, and peritoneum
Chronic prostatitis: * heterogenous gland DD cancer * Ca in PZ
Dr Ahmed Esawy
Group I. Prostatic calculi associated with prostatitis
Group II. Prostatic calculi associated with hypertrophy of the gland
Group III. Prostatic calculi that simulate carcinoma
Group IV. Calculi in both the prostatic urethra and the urinary tract
Prostatic Calculi
Calcification formed within prostate gland. It is mainly composed of calcium
carbonate and/or calcium phosphate.
They are usually asymptomatic. These calculi can be well demonstrated by
Plain X-ray, CT scan,
Dr Ahmed Esawy
small multiple concretions corresponding to the corpora amylacea.
Prostatic parenchymal calculi are usually incidental findings
Small, multiple calcifications are a normal, often incidental ultrasonographic
finding in the prostate and represent a result of age rather than a pathologic entity.
However, larger prostatic calculi may be related to underlying inflammation and
require further evaluation and possibly, treatment
Dr Ahmed Esawy
Prostatic concretions ( corpora amylacea [starch bodies)
1. Small spherical or ellipsoid bodies
2. Number increases with age
3. May become calcified as male ages
4. May simulate carcinoma
Dr Ahmed Esawy
Prostatic calculi
• Occur in conjunction of BPH
• Concretion of corpora
amylacia
• Localized in PUG
• As gland enlarge-calculi at
surgical capsule
• May dystrophic calcifications
Dr Ahmed Esawy
Dr Ahmed Esawy
Longitudinal transrectal ultrasound image of the left lobe of the
prostate demonstrating extensive concretions.
Dr Ahmed Esawy
Dr Ahmed Esawy
This middle aged patient underwent TRUS imaging (transrectal ultrasound) of the
prostate for prostatism (symptoms related to the prostate). TRUS images show
multiple hyperechoic foci (arrows), each of 4 to 7 mm. in the inner gland of the
prostate and also along the prostatic urethra. Power Doppler image (bottom)
shows normal flow in the prostate. These ultrasound images suggest prostatic
calcification or calculi. Calcific foci in prostate are associated with normal aging
process in the male and may be the result of formation of corpora amylacea.
These are formed by calcification of secretions of the gland. It is also seen in
chronic inflammation of the prostate (chronic prostatitis).
Dr Ahmed Esawy
Power Doppler TRUS image (on right above), shows no significant changes in
vascularity of the prostate and suggesting absence of prostatitis at present. The
calcification of the walls of this midline utricle cyst of the prostate may be the result of
dystrophic changes
Dr Ahmed Esawy
Micturating cystourethrogram (MCUG)
showing huge prostatic cavity Plain pelvic X-ray showing prostatic
urethral calculus
Dr Ahmed Esawy
Multiple, small prostatic calculi (type A) in a young patient.
Dr Ahmed Esawy
Coarse echoes representing larger, discrete prostatic calculi
Dr Ahmed Esawy
The above TRUS ultrasound and color doppler images in a young male patient
show a) hypoechoic prostate b) gross augmentation of vascularity in the prostatic
tissue. These ultrasound findings suggest presence of acute prostatitis
Dr Ahmed Esawy
Note the markedly hypoechoic patches in the inner zone of the prostate (arrowed),
which appear overtly vascular on color doppler imaging
Dr Ahmed Esawy
acute-bacterial-prostatitis-and-abscess
Dr Ahmed Esawy
Acute bacterial prostatitis and abscess
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
T2 T1 fat sat
severe urinary tract infection with complicating prostatic abscess
Dr Ahmed Esawy
• Chronic prostatitis. CT revealed multiple, coarse, ring like calcification inside the normal-sized prostate, which is sharply marginated. The prostate clearly absorbs contrast medium as an expression of current prostatitis.
Dr Ahmed Esawy
Chronic Prostatitis
heterogenous gland
Dr Ahmed Esawy
Chronic Prostatitis-MRI
Dr Ahmed Esawy
Prostate abscess-TRUS
Dr Ahmed Esawy
Prostatic Abscess-MRI
C C
Dr Ahmed Esawy
Prostatic Abscess-MRI
Dr Ahmed Esawy
Prostatic abscess in a 48- year-old man with perineal pain and abnormally
ncreased CRP. Axial unenhanced (a) and postcontrast (b) CT images showed
mild asymmetric prostatic enlargement, occupied by a 4-cm septated fluid-like
Collection (arrowheads) with peripheral and septal enhancement. Note
displacement of periurethral calcifications (thick arrows) from midline.
Ultrasound-guided transperineal drainage confirmed Escherichia coli infection
Dr Ahmed Esawy
Large prostatic abscess from ESBL-positive
Escherichia coli infection in a 61-year-old
man with previous chemo- and radiotherapy
for non-Hodgkin lymphoma, fever (38 °C),
dysuria, pelvic pain and enlarged tender
prostate at digital rectal examination.
Multiplanar CT images (a–d) showed marked
prostatic enlargement by confluent
nonenhancing hypoattenuating (17–19 HU)
regions, with peripheral and septal
enhancement (arrowheads). The prostatic
infection also involved the left seminal vesicle
(arrows in b, d),
displaced upwards of the urinary bladder,
with mild circumferential mural thickening and
mucosal hyperenhancement (thin arrows)
consistent with UTI.
After transperineal evacuation (e),
follow-up CT urography (f) confirmed
persistent resolution of the abscess
Dr Ahmed Esawy
Dr Ahmed Esawy
PROSTATIC CANCER ON TRUS
Dr Ahmed Esawy
Dr Ahmed Esawy
PROSTATITIS ON MRI
Dr Ahmed Esawy
PROSTATITIS ON TRUS
Dr Ahmed Esawy
PROSTATIC ABSCESS ON TRUS
Dr Ahmed Esawy
urethritis
Dr Ahmed Esawy
Acute uncomplicated
urethritis in a 30-year-old
man
with neurogenic bladder
treated by intermittent
selfcatheterisation.
Physical examination
revealed induration and
tenderness of the corpus
spongiosum and purulent
urethral
secretions. Unenhanced T2-
weighted MRI images (a)
revealed a diffuse, uniform
hypersignal in the corpus
spongiosum (*) with
corresponding intense
homogeneous enhancement
on post-gadolinium T1-
weighted sequences (b, c).
The infection did not appear
to interrupt the tunica dartos
or Buck’s fascia, and did not
involve the corpora
cavernosa, scrotum or
ischioanal
spaces. Note Foley catheter
in
place (thick arrows). The
patient successfully
recovered with temporary
suprapubic catheter and
intravenous and topical
antibiotics
Dr Ahmed Esawy
Urethral infection
complicated by penile and
perineal abscess in a 53-year-old
man with tender, inflamed
perineal swelling despite
antibiotics. Infection was initially
detected at contrast-enhanced CT
(a) as an elongated midline
abscess with peripheral
enhancement (arrowheads) and
internal fluid. MRI showed
corresponding inhomogeneous
fluid-like content on T2-weighted
sequences (b–d), with
surrounding inflammatory
stranding (+) and strong contrast
enhancement in the abscess walls
(arrowheads in e, f). The infected
corpus spongiosum (*) showed
similar signal features. Surgical
evacuation was required to relieve
the abscess
Dr Ahmed Esawy
Dr Ahmed Esawy
This middle aged male patient presented with a history of hemospermia (passage of
blood in semen) with mild pain during ejaculation. Sonography of the abdomen was
normal. Transrectal ultrasound (TRUS) of the prostate and seminal vesicles showed
multiple echogenic foci/ lesions in the terminal (proximal) part of the seminal vesicles,
bilaterally. The ultrasound images show multiple seminal vesical calculi bilaterally, each
measuring 2 to 4 mm. in size. Studies suggest that such stones are related to
inflammation, obstruction or diabetes mellitus. The ultrasound image on bottom right
shows Power Doppler study of the prostate; no abnormal flow was found. Calculi in this
case can cause poor flow of semen during ejaculation, hemospermia and painful
ejaculation.
Dr Ahmed Esawy
This late middle aged male patient presented with lower urinary tract symptoms.
TRUS ultrasound shows a 9 mm. midline cyst of the prostate; what is interesting
is the markedly hyperechoic rim of the prostate cyst suggesting calcification of
the cyst walls. This is an unusual appearance for what is obviously a cyst of the
prostatic utricle with almost no literature available.