Ureters and Bladder
Speaker: Suzanne Johnson, Gynecologist from Southampton
Resources
- Paper from the idea group (2016) on terms definitions and measurements in women with endometriosis
- Specific book (Chapter 8)
- Two recent papers on urinary tract endometriosis
Introduction to Endometriosis
- Types of Endometriosis: Superficial, Ovarian, Deep
- Deep Endometriosis: Affects anterior (bladder & ureters) or posterior compartments
- Urinary Tract Endometriosis: Rare, mostly affects bladder; ureteral involvement in up to 1/3 of cases
Bladder Anatomy (by the idea group)
- Urethra, Bladder, Cervix
- Trigon: Within 3 cm of bladder neck, up to ureteric orifice
- Base: Part in contact with vagina and cervix
- Dome: Above the peritoneal reflection
Examination Techniques
Bladder Nodules
- Conduct at the end of a pelvic scan
- Check for sliding sign, nodule measurement (length, depth, width), color Doppler signals
- Assess location: trigon, base, dome
Ureteral Endometriosis
- Caused by fibrosis from deep endometriosis nodules or actual tissue within muscularis
- Can lead to silent hydronephrosis; always check kidneys
Normal Ureter Path
- Described in detail: descends pelvis, passes iliac artery, uterine artery, paracervical tissue, enters bladder at trigon
Examination Areas
- Lower Ureters: Between bladder and torus; note rarity of deep endometriosis here
- Middle Ureters: Between torus and pelvic brim; common site for stenosis
- Upper Ureters: Viewed transabdominally
Locating the Torus
- Described process for longitudinal and transverse imaging
- Essential for assessing nearby endometriosis involvement
Examination Techniques (Detailed)
- Trigon & Bladder Base: Follow in longitudinal view
- Middle Ureters: Look for dilation behind the torus; transverse perineum view can show water under the bridge sign
- Upper Ureters: Look transabdominally near iliac vessels
Hydronephrosis (Kidney Check)
- Mild Hydronephrosis: Dilated renal pelvis
- Moderate Hydronephrosis: Dilated pelvis and calyces
- Severe Hydronephrosis: Cystic dilation, thin rim of renal parenchyma
Bladder/Ureter Images
- Example clips and descriptions provided for normal and abnormal findings
- Normal Bladder: Freely mobile muscularis layer
- Abnormal Findings: Nodule sizes, locations, movements with sliding sign
Ureter Endometriosis Examples
- Several cases illustrated with nodules near bladder
- Demonstrating ureter tracking techniques in different planes
Different Conditions
- Bladder Nodules: Discussed differences from malignancy
- Ureter Seal: Ballooning during urine entry
- Ureteral Stones: Identified by bright reflection and shadowing on scans
Important Takeaways
- Areas to Examine: Ureter at bladder entry, torus, near iliac vessels
- Timing: Check bladder at the end of the scan
- Kidney Checks: Always important in deep endometriosis cases
- Educational Resources: Mention of online resources for hydronephrosis scanning techniques
Conclusion
- Emphasized the importance of checking the bladder, ureters, and kidneys during scans and specified areas to look for endometriosis-related changes.