Nice links on kidney stones:

My last blog was on kidney stones (renal calculi and urinary calculi). Here are some really good links on urinary stone disease:
http://emedicine.medscape.com/article/437096-workup#aw2aab6b5b6
As usual emedicine has done some really good work up on kidney stones, from symptoms to treatment. But on ultrsonography of kidney stones visit: http://www.ultrasound-images.com/renal-calculi/
For the patient and layman visit:
http://www.medicinenet.com/kidney_stone/article.htm
For information on medullary sponge kidneys visit:
http://emedicine.medscape.com/article/379323-overview#a22

Kidney stones- renal calculi- urinary stones

Renal stones or Kidney stones:
(This article is meant for both the layperson and those new to the science and art of sonography).
Most urinary stones or calculi as they are called in medical parlance, originate in the kidneys. Some are also known to form in the urinary bladder due to stasis of urine or collection of urine within the urinary bladder. Kidney stones in the urinary system pass from the kidney (renal calculi) to the ureter and thence, down to the urinary bladder.
One of the simplest and most inexpensive methods of diagnosing renal stones (kidney stones) is ultrasound imaging.
The symptoms of kidney stone include- passage of blood in the urine, or hematuria or pain in the side of the abdomen, along the flanks. Pain is usually the first symptom and may be the only sign of kidney stone. However, I have come across many patients who have absolutely no symptoms at all and kidney stone disease may be found only incidentally during an ultrasound scan. With phosphate stones in the kidney, the stone or kidney calculus may actually reach a very large size over a period of time (many years) and yet the patient may be unaware of the disease.
  Here are some ultrasound images of kidney stones:

Case 1: Left kidney stone- in the renal pelvis:

The urinary bladder in this lady appears normal as are the uterus and adenxae (ovaries).

The above ultrasound images show a large stone in the left kidney. The right kidney appears normal. The renal stone/ calculus is within the central part of the kidney called the renal pelvis, within which the urine from the kidney enters or collects. From here the urine passes to the ureter or muscular tube from the renal pelvis to the urinary bladder. The kidney stone here measures 1.8 cms., and has not produced any significant obstruction to the passage of urine to the left ureter below- this despite the large size of the left renal calculus. We can say this because there is no hydronephrosis of the left kidney. We shall discuss this term in detail below:

Case-2: Kidney stone causing moderate hydronephrosis of the left kidney

This patient shows a typical kidney stone location called PUJ calculus or stone located at the pelvi-ureteric junction, in the left kidney. The PUJ or UPJ is the junction between the renal pelvis and the ureter and is pretty narrow. The large kidney stone (shown above) is unable to pass down into the left ureter, and has become stuck at the narrow junction causing partial flow of urine downwards through this bottle-neck.

This has resulted in back pressure due to collection of urine within the collecting system of the left kidney causing the left kidney to "balloon up". This condition is called hydronephrosis and we can see this change in the obstructed left kidney above. If not treated quickly (meaning within a few months), this kidney could pass to a stage of severe hydronephrosis and ultimately become non functional or result in what is called renal failure.
Case-3: Hydronephrosis due to left PUJ calculus:

This is yet another case of left PUJ/ UPJ calculus with a relatively small kidney stone stuck at the narrow left uretero-pelvic junction with resulting left kidney swelling or hydronephrosis.(Note :-) kidney stones shown here are from 3 different patients and there is no evidence that the left kidney has a greater chance of being affected by stone disease).

The above ultrasound video clip shows the left PUJ stone in a better perspective with the resultant left hydronephrosis.
From the above ultrasound case studies of kidney stones, it is obvious that small stones can produce more trouble for the patient if located in a critical location, and that the size of the kidney stone alone is not the only factor that causes symptoms and clinical complaints and complications.
In case 1 above despite the large size of the kidney stone, its location above the narrow bottle neck called the pelvi-ureteric junction, has resulted in absence of any hydroneprhosis in the affected left kidney.
In cases 2 and 3, there is significant ballooning of the kidney as a result of the kidney stone being located at the PUJ (the bottle neck). In case -3 the kidney stone is less than half the size of the stone seen in case-1.

Case-4: Right mid ureteric calculus with right hydronephrosis:

This patient shows  moderately severe hydronephrosis of the right kidney. This is seen as collection of urine (dark space within the right kidney- image on left side). However there is no stone visualized in this ultrasound image. The left kidney appears normal (image on right half of the picture above).

We tried to trace the dilated (distended) right ureter (called hydroureter) downwards and this is what we found. There is a stone (ureteric calculus) in middle third of the right ureter, and it is pretty large (at 1.7 cms.). Tracing stones in the ureter can be a very cumbersome task and much of this depends on displacing gas distended bowel away from the front of the ureter. This is done by gently pressure with the ultrasound probe. This ureteral stone originated in the right kidney and has managed to pass down the right renal pelvis and right PUJ down to the middle of the ureter. This patient has experienced severe pain (called ureteric colic) as the stone irritates the soft muscle of the ureter. The next task for the stone is to negotiate the next major bottle neck in its passage downwards- the right VUJ (vesico-ureteric junction). This is the narrowest point in the urinary tract and is the point of entry of the ureter into the urinary bladder. We shall next see what happens when a stone gets impacted at the VUJ (vesico-ureteric junction).

Have a look at the ultrasound video clip of this case:

Case-5: Right vesico-ureteric Junction calculus:
The next destination that the kidney stone has to reach on its way out in the urinary system is the urinary bladder. But unfortunately for the patient, things are not so easy, and the narrow bottle-neck called the vesico-ureteric junction (VUJ) being the narrowest point in the urinary tract, most stones lodge here for some time before being expelled into the urinary bladder.
This is one such case-

This young adult male shows a small stone impacted in the right VUJ (ultrasound image of urinary bladder above). At 5 mm. size this urinary stone has transited successfully all the way from the right kidney, down the right ureter, and has almost made it to the bladder! But it has not quite made it. The stone is stuck in this narrow point, despite its small size. What is its effect on the right kidney? See the ultrasound image below:

 

Even a stone as small as 5 mm. is able to wreak havoc on the right kidney, which shows moderate hydronephrosis with right hydroureter. The left kidney appears relatively normal in this ultrasound image of the kidneys.

Case-6: Left VUJ calculus:

 

This is another patient with severe left flank pain. The ultrasound image of the urinary bladder above shows a suspicious looking areas in the left VUJ (vesico-ureteric junction). Most probably this is a stone in the left VUJ.

 

When in doubt, I switch on the color Doppler ultrasound button, and the result was a little twinkling (the blue color- arrow)  around the left VUJ. This is a clear sign of a stone here.

When we examined the left kidney, this is what we saw (ultrasound image of left kidney- below):

There is clear evidence of left hydronephrosis in this image above. The final diagnosis was- left VUJ calculus with resultant left hydronephrosis.

Final destination- the Urinary bladder:
Case-7: bladder sediments and debris:

 

What this image shows is transrectal ultrasound imaging (TRUS) study of the prostate (the triangular soft tissue structure in upper part of image). But what is even more striking is the particulate matter within the urinary bladder below (this is an upside down ultrasound image of the bladder). This is common finding in elderly male patients with urinary tract infection- the debris (particles) within the bladder being a sign of that.

Have a look at the TRUS ultrasound video clip of this patient:

The motion of the particles within the urinary bladder can be fully appreciated in this ultrasound video clip. particulate matter of this type can often result in colloid gel like matter forming the nidus (precursor) for stone formation in the urinary bladder. Thus elderly male patients with chronic difficulty in urination can sometimes develop urinary bladder stones. See: http://www.ultrasound-images.com/urinary-bladder/#Large%20urinary%20bladder%20calculus

Case-8: Urinary bladder stones:
As said earlier there are various causes for the formation of bladder stones. Chronic obstructive conditions in the lower urinary tract such as patients with benign prostatic hypertrophy can often develop urinary bladder stones.
These ultrasound images are of an elderly male with benign prostatic enlargement. There is a stone of 1.5 cms. seen in the urinary bladder in both transabdominal and transrectal ultrasound images (see below).

Transabdominal ultrasound image of stone in urinary bladder (arrow). Also seen is a Foley catheter bulb within the bladder.

Transrectal ultrasound image showing urinary bladder stone (above)....arrow.
Shown below is the TRUS ultrasound video clip of the bladder stone:

Bulky uterus

The above ultrasound images show what is called a bulky uterus. This term is used when the uterus is larger than normal for the age of the patient. The common causes include -1) the post partum stage (after delivery/ childbirth), when the uterus is still large in size after delivery (the process of shrinking in size of the uterus to its normal size is called involution), 2) fibroids, 3) adenomyosis etc. These patients often complain of discomfort in the pelvic region and menstrual problems. Another cause of enlarged or bulky uterus in middle aged women is increase in the BMI (body mass index). Higher the BMI and obesity are associated with larger or bulkier uterus. See this link: Bulky uterus and obesity The ultrasound images above show a diffusely enlarged uterus with no evidence of masses (tumors) or other pathologies.

The above is an ultrasound video clip of a case of bulky uterus seen in sagittal section. Observe the increased size of the liver without any other pathology. This was a middle aged (52 year) old female patient with back pain. Bulky uterus is a common finding among middle aged menopausal women.

This middle aged lady with the bulky uterus (same case as above) also has a significant deposition of fat within the liver, resulting in moderate fatty change. Many middle aged Asian women present with both bulky uterus and fatty liver.

Causes of intertility in men and women:

Among the causes of infertility in women are diseases of the uterus and ovaries:
This middle aged lady has a very small uterus (called hypoplasia of the uterus). Such a uterus is incompatible with the ability to conceive and have a child. The ultrasound video clip below shows a sagittal (midline) section through the uterus. It was obtained via the transvaginal route. The vagina itself was sufficiently large enough to insert the transvaginal probe.

 

The inner lining of the uterine cavity- the endometrium appears markedly thinned, and again this is incompatible with conceiving a child. 

 

The ultrasound video clip below is a transverse section through the uterus of the same patient:

For more on this case study visit: http://www.ultrasound-images.com/uterus.htm#Hypoplastic_uterus

See: http://www.medscape.com/viewarticle/471012_6

In men, similarly, absence of or hypoplasia (very small) of parts of the reproductive system can result in infertility:

This male patient underwent sonography of the prostate and seminal vesicles via the transrectal route:

Ultrasound video clip shows normal sized prostate-

Observe the TRUS video clip as we pan the probe from the upper most part of the prostate showing the clear absence of the seminal vesicles and the vas deferens (agenesis) on both sides. This type of congenital absence of an important part of the route through which sperms pass from the testes to the penile urethra will result in total absence of spermatozoa in the ejaculated semen. This condition is called a azoospermia in the male.

See: http://www.ncbi.nlm.nih.gov/pubmed/3379704 

Also: http://en.wikipedia.org/wiki/Azoospermia

Other and more common causes of infertility in men-

Perhaps one of the commonest cause of male infertility is a condition called varicocele.

Here, there is a dilatation of the veins around the testes, inside the scrotum. These veins are called the Pampiniform veins, and are responsible for draining blood from the testes. Due to decreased efficiency of the draining process, these veins swell and blood collects within these vessels resulting in increased temperature within the scrotum and the testes. The testes then lose some of their spermatogenic (sperm producing) functions. Depending on the degree of varicocele (grade of varicocele), the man may suffer from infertility.  

Color Doppler Ultrasound can help in diagnosing this condition; see this link for more on this topic:

http://ultrasound-images.blogspot.com/2010/09/color-doppler-ultrasound-video-clips-of.html

Also: http://www.ultrasound-images.com/scrotum.htm

Diseases of the testes and the epididymis (a small structure next to the testis) can cause poor or impaired production of sperms. This can result in infertility. One such common condition is an inflammatory disease called orchitis and epididymo-orchitis. (see: http://www.ultrasound-images.com/scrotum.htm#Epididymitis

and http://www.ultrasound-images.com/scrotal-infections.htm )  

Another cause of impaired spermatogenesis (sperm formation) is chronic or past infection of the testes resulting in atrophy (shrinking) of the testes. This happens in mumps inflammation of the testes, a condition called mumps orchitis. See : http://www.ultrasound-images.com/scrotum.htm#Atrophy_of_testis

This condition causes decreased function of the testes with small shrunken testes. Atrophy of the testes is usually irreversible.

Another condition that involves another part of the male reproductive system is prostatitis or inflammation of the prostate. The prostate helps to form a bulk of the fluid in the semen. Inflammation of the prostate is common and can impair the production of semen and its release during ejaculation. This color Doppler video clip shows a severely inflamed prostate:

This prostate was visualized via the transrectal route. The color Doppler mode shows massively increased blood flow in the prostate (hyperemia), a hall mark of prostatitis. This condition of the prostate can be corrected to a large extent using medical treatment.

The above still color Doppler image shows the TRUS (transrectal ultrasound) view of the same prostate.

Fibroids of the uterus (leiomyoma):

Fibroids are the commonest tumors of the uterus and have a reported incidence of at least 25 to 30 % in the female population. Uterine fibroids are benign tumors (lumps) of the uterine musculature (called smooth muscles) and have varying prognosis from slowly growing tumors to those that may actually regress (become smaller). A small percentage of fibroids of the uterus may actually undergo malignant transformation (become cancerous); these cancerous tumors are called leiomyosarcoma. Another aspect about a fibroid is that this uterine tumor may be single or it may be multiple.
What are the symptoms of a uterine fibroid?
The earliest symptoms of a fibroid can be pain the lower abdomen (the pelvis) of the woman (usually after the age of 30). The other symptoms of uterine fibroids include dysmenorrhea (pain during menses), increased frequency or amount of bleeding during menses (polymenorrhea or menorrhagia) and other menstrual abnormalities. Other symptoms include those produced by pressure of the fibroids of the uterus on the adjacent organs in the female pelvis including the urinary bladder (increased frequency of urination and obstructed urination). Pressure on the rectum may cause constipation in women where the uterine mass (tumor/ fibroid) arises from the posterior (back) of the uterus. Fibroids are also a common cause of infertility in women.
 So how does one diagnose fibroid of the uterus?
If a woman has one or more of the symptoms mentioned above, she should consult the doctor/ gynecologist immediately. Per abdominal examination (palpation) of the pelvis can sometimes help detect a relatively larger fibroid. In addition, a per vaginal examination may also help to detect a lump of the uterus. In any case, the safest and best method to diagnose a fibroid of the uterus is ultrasound examination. The sonologist or radiologist conducts a transabdominal examination of the pelvis (on a full bladder) to visualize the uterine mass. The uterine tumor is seen from various angles to determine its size, number, location and pressure effects on the adjacent bladder or rectum.
Here is some examples of what a uterine fibroid looks like on ultrasound imaging:
There are commonly three types of fibroid based on ultrasound imaging:
a) Intramural- the fibroid is within the wall of the uterus.
b) Subserosal- the fibroid is just below the outer covering serosa of the uterus.
c) Sub mucous- the fibroid is just below the inner lining of the uterus (the endometrium).

  

Image below shows multiple fibroids:

This ultrasound image shows a fibroid extending from the subserous to the intramural location of the uterus-

What does the sonologist or radiologist see in this ultrasound image of the subserosal fibroid? The uterine fibroid is pressing upon the anteriorly (front) located urinary bladder. The mass or tumor is located to the right side of the uterus and extends from the intramural to the subserosal location of the upper part of the uterus (called the fundus).
See another ultrasound picture of the same case:

 












The uterine fibroid also appears to compress upon the inner lining of the uterus (EM= endometrium).(FIB= fibroid; BL= bladder; UT= uterus). Thus this patient is likely to have a number of complaints- from bladder compression to irritation of the inner lining (endometrium) of the uterus with resultant menstrual problems.
Broad ligament fibroid:
In rare cases the uterine fibroids may be located to either side of the uterus- the so called broad ligament fibroids- see the ultrasound pictures/ ultrasound video clips of one such case of broad ligament fibroid:

The uterine tumor in this case is seen in the left broad ligament of the uterus. Such a broad ligament fibroid may interfere with the function of the left fallopian tube (the duct that transmits the ovum from the left ovary to the uterine cavity). Hence such a patient might have problems conceiving or may be infertile.
See this ultrasound video clip of the same case (left broad ligament fibroid):

Pedunculated fibroid:
The next case we shall discuss is another relatively rare entity called the pedunculated fibroid of the uterus. Here, the fibroid in the uterus is connected to the uterus by a short or sometimes long pedicle or stalk. See the ultrasound images of one such case of pedunculated fibroid of the uterus:

  

In this patient, the uterine fibroid is seen extending just above the fundus (top) of the uterus and is connected to it by a short stalk. It is almost like a floating tumor suspended from the main body - the uterus by a stalk or cord. Such pedunculated uterine fibroids can cause severe pain due to torsion of the uterine tumor mass (twisting of the stalk) resulting in cutting off of the blood supply to the tumor from the uterus.

Have a look at these ultrasound video clips of the pedunculated fibroid described above:

Such an event resulting in twisting of the stalk of the pedunculated fibroid can be a medical emergency and urgent surgery might be required to remove the mass immediately.

This color Doppler ultrasound video clip shows the stalk is very vascular (ie: a number of blood vessels are seen between the pedunculated uterine fibroid and the fundus of the uterus. For more details of the various other types of fibroids of the uterus and ultrasound images of each case, visit:

http://www.ultrasound-images.com/uterus/#Types%20of%20fibroid 

Case-2 (pedunculated fibroid of uterus):

This is another example of a large fibroid with a stalk connecting the tumor (6 x 7 cms.) to the fundus of uterus via a stalk or peduncle. The peduncle measures about 2 cms. in thickness. I managed to visualize the peduncle by applying pressure onto the area between the fibroid and the fundus of the uterus. See the ultrasound video below:

 

Color Doppler video clip (above) shows multiple blood vessels within the short and relatively thick pedicle connecting the fundus to the fibroid.

This is how the mass (fibroid) and pedicle appeared on still images (see below):

 Observe the presence of a second fibroid within the lower part of body of the uterus in these sagittal sections of the uterus. This fibroid appears intramural in location.

It is beyond the scope of this article to describe in detail the other methods of diagnosing tumors of the uterus. However, it must be added that CT (CAT) scan imaging and MR imaging can also offer additional information on  fibroids of the uterus, in certain cases.

For information on treatment of fibroid of the uterus visit:

http://www.emedicinehealth.com/uterine_fibroids/page5_em.htm

Degenerative changes in fibroid:

This case of a large fibroid with a most unusual appearance:

   

This is a sagittal section of the huge mass in the uterus. Note the markedly inhomogenous appearance of the mass. The ultrasound video clip below shows a transverse section of the mass:

Now, the color doppler video of the tumor (fibroid) of the uterus:

For more images and details of this case see:
http://www.ultrasound-images.com/uterus/#Types%20of%20fibroid

Multiple fibroids:
Uterine fibroids can very often be multiple. This middle aged lady has 3 fibroids seen in this sagittal section ultrasound video clip of the uterus:

Of these, the one labeled as (1)- towards the fundus, shows degenerative changes- it is hypoechoic, inhomogenous, suggesting possible cystic changes within it.
Another video clip shows the presence of all 3 fibroids in this uterus:

Ultrasound Imaging of the head of neonatal femur and humerus

High resolution Ultrasound images of the normal head of femur in neonate:

 The above image shows the head of the left femur in a 3 day old neonate. Note the full ball of the head of the femur in this transverse section of the femoral head inside the left hip joint. 

 Another neonate- the head of femur is seen a round, hypoechoic structure due to its cartilaginous nature. Note the coarse appearance of the femoral head.

Ultrasound image of the right femoral head (hip joint) - all the above images show the normal head within the acetabulum (socket of the hip joint).                                                                                                                                 

 

This (above) ultrasound image shows the normal head of the left humerus (in neonate). As in the case of the femoral head images, the head of the humerus is cartilaginous at this young age- hence the hypoechoic, grainy or coarse echotexture. But the humerus shows one major difference- the head forms a "half ball" -a shallow ball and socket joint (the shoulder joint). In infective arthritis of these joints, there would be widening of the joint space with collection of synovial fluid within the joint cavity. Ultrasound is an excellent method of imaging the neonatal hip and shoulder joints.

 The above 3 high resolution (7- 8 Mhz transducer frequency) show the normal right neonatal shoulder joint, from different angles. The transverse section image shows the shallow nature of the glenoid cavity. Sonography of the shoulder joint in the neonate is useful in detecting tendency for dislocation in a baby and ruling out conditions like shoulder dysplasia in infants. By detailed ultrasound imaging one can detect glenoid dysplasia in infant shoulder (a clear indicator of potential shoulder dislocation). This condition is coomon in neonates/ infants with obstetric brachial plexus injury.  

Read more at: http://proceedings.jbjs.org.uk/cgi/content/abstract/90-B/SUPP_III/521-a 

and also: http://www.ultrasoundpaedia.com/USP%20neonatal%20hips%20winner.html

 Also: http://www.ultrasound-images.com/pediatric.htm

and also Musculoskeletal Ultrasound imaging