Ureters and Bladder

this is a video about the ureters and bladder my name is Suzanne Johnson and I'm a gynecologist from Southampton the resources I've used to help me make this video include this paper from the idea group published in 2016 talking about terms definitions and measurements in women with endometriosis other resources are this book particularly chapter 8 and these two recent papers about urinary tract endometriosis endometriosis can be superficial or ovarian or deep and when deep endometriosis is present it can affect the anterior compartment consisting of the bladder and ureters which is what this video is about or the posterior compartment where it affects the posterior vaginal fornix the torus in neutral sacral ligaments and the rectum and sigmoid urinary tract endometriosis is quite rare but it's mostly bladder endometriosis however endometriosis affecting the ureters can be seen in up to a third of women with endometriosis the idea group has given different areas of the bladder different names so this is a bad cartoon I'm sorry about that that's the urethra and the bladder and the cervix and here you can see where the ureter enters the trigon this area is the trigon and it's defined as being within three centimeters of the bladder neck and up to the uro Taric orifice the part of the bladder that's in contact with the vagina and cervix is called the base and then the area above that is called a dome and this is intra-abdominal and it's above the peritoneal reflection as you can just see here reflection of the peritoneum and it's in the base that you see most endometriosis cystoscopy is often normal the way I examine a blood and nodule I do this at the end of a systematic pelvic scan because I ask people to empty their bladder at the beginning of the scan but by the time I finished there will be some urine in the bladder and it's a good time to look at the bladder then I look for the sliding sign of the bladder on the uterus look for adjacent utrom adenomyosis I measure a nodule in three planes lengths depth and width and look for color Doppler signals I measure the distance between the nodule and the ureter ik orifice and describe where it is is it in the triger and the base or the dome of the bladder urethral endometriosis mostly is caused by fibrosis near a nodule of deep endometriosis which then constricts the ureter rarely it is actually endometriosis in the muscularis layer and it's very hard to tell the difference on ultrasound however the ureter is affected this can cause silent hydronephrosis and it's essential to check the kidneys in all patients with deep endometriosis so where is the ureter well the normal path of the ureter is nicely described in this paper it descends into the pelvis and then it travels medially into the internal iliac artery it then passes underneath uterine artery into parts of Michael tissue and at this level you're one to two centimeters lateral to the cervix immediately by the utero sacral ligament the ureter then courses medially over the anterior vaginal fornix and enters the bladder at the Trigon so you can examine the ureters in three areas you can look at the lower ureters between the bladder and the torus and you really rarely see deep end the meteos is here but bladder endometriosis in or near the Trigon can affect the ureters here the middle ureters between the torus and pelvic brim this is the important bit and because near the torus is a common location for stenosis and the upper ureters you can look transept on but this is less relevant to us so where is the Taurus you'll have seen this before in previous talks but this is how I do it this is a longitudinal section of the cervix the cervix is here and the uterus is here it's a longitudinal view and because deep endometriosis centers on the Taurus you get an longitudinal view of the internal us and then you rotate to the transverse plane so there is where the bladder attaches to the uterus in a straight line back you've got the internal cervical off and then here is where you've got the Taurus so this is to orientate you so I start longitudinal and then I rotate to the transverse that's longitudinal now rotating anti-clockwise to a transverse view the Taurus is here this is one uterus a polygamist and then toward the other side is the other utero sacral ligament so the level of the Taurus is an important plane for you to look for your toes and this is the Taurus seen at laparoscopy of course we're looking into the pelvis this way so the patient's right is here this is the back of the uterus and this area here is the Taurus those are the uterus sacral ligaments and this all of this is the planche of Douglas so we want to look near the level of the Taurus because this is more or less the area where the ureter could be visible on ultrasound so how to examine the year it is well when you're looking at the lower year it is between the bladder and the Taurus and you can look in the longitudinal view of the bladder and move the probe andr laterally from the Tri going and just follow the ureter more importantly the middle section of ureter between Taurus and pelvic brim you find the Taurus and then in the longitudinal view you'll see the ureter if it's dilated behind the Taurus but in the transverse view you can look at the perineum which is lateral to the Taurus you may be able to see water under the bridge sign - this is very rare near the pelvic brim you can see the ureter in the longitudinal section the medial to the iock vessels and I'll show you some examples of all of these and then the upper ureters you can see those transit only so where to look a quick guide you can see the ureter as it enters the bladder base there just by the try go you can see it at the Taurus if you look near the cervix at the level of the Taurus go either posteriorly or laterally and if you look for the Ilia vein and iliac artery there's the ovary and that's another place where you'll be able to see the ureter medial to the internal iliac vessels near the ovary so three places where I routinely look for a hydro ureter you'll know if you see a tubular structure you have to decide is it dilated and the normal diameter of your tour is three millimeters is there color flow in which case it will more likely to be a blood vessel and vermiculite is the telltale sign of something being the ureter and then if we go a bit higher still kidneys we want to know is there any hydronephrosis this is obviously dumb trans abdominally and mild hydronephrosis is where you have a dilated renal pelvis only so that would be just this area here in moderate you get a dilated pelvis and calluses and in severe you get cystic dilatation with only a very thin rim of renal parenchyma or it may not be visible at all so what does normal look like here we've got the bladder there's the urethra this is where the we're going in this longitudinal view from left to right so this happens to be the left ureter and then the uterus a bit of it is just there so if we follow we're going for in the longitudinal plane from left to right and that was the ureter there it goes into the bladder at the bottom of the try go I'm going out the other side and there is the right ureter you can see that's the bit where it's just entering the bladder so again that's the left ureter coming into bladder I'm going over toward the right side now and then there's the right ureter coming into the bladder - this is what normal bladder wall looks like here this lady's got a bit of retrograde menstruation so there's some blood in her pelvis and you can see when if I play the video I'm just doing the sliding sign there's the uterus there's a bit of free fluid and you can see the bladder wall this is normal bladder wall it's freely mobile onto the cervix at the top there so this is what normal bada looks like and in this clip you can just see normal muscularis the muscular layer of the bladder normal muscularis so when you see the bladder you can if it's done immediately after mature ition you can do a residual volume but this is the the length and the depth and the width of this ladder and then here I've got a longitudinal view this is the bladder neck and this is where the ureter enters and then this is the transverse view so you see one ureter and another ureter in the transverse and if somebody has been drinking a lot of fluids then you'll be able to see the this is the transverse playing the ureter emptying into the bladder transverse view if the you retrieve cycle Junction so this area here would be part of the Trigon so what does it look like if you compare trans abdominal and trans vaginal so in the trans abdominal view this is uterus this is vagina and if you look just there and it's a bit better seen there you can just see urine coming into the bladder you can see this the nice jet with color Doppler and there you can just see is where the ureter comes in this is the Tri going this is the bladder neck just there and then the area that's equivalent on TV it's just there there's the bladder neck there's the Tri going and this is where the ureter enters the bladder so sometimes you might say you retry seal and this is where the ureter as it inserts into the bladder and balloons as urine comes into the bladder that's it on longitudinal view and in transverse view you can see that on the left it's worse but on the right there's a small ureter seal too and this is a nought we're going up slightly now slightly higher level normal lower ureter you can see the vermiculite in here as this ureter is squeezing urine into the bladder it's completely normal so how to track a ureter now you know how where to find it we have the bladder neck up there this is where the ureter enters the bladder you can now track it in the longitudinal plane or the transverse plane there it goes if you just wiggle your probe in the longitudinal plane you can follow there it goes past that ovary so and then we're going back up there it goes follow it follow it into the bladder so I'll just let it play again you can see the ureter coming out of the bladder I'm just tracking it as it snakes up toward this ovary and then it's going to go back again so I move my probe medially back toward the bladder so as you can see it's a bit tricky you can track the ureter in the transverse plane to the perineum I'll play this video there it comes the ureter track track track down and then back up again so you can find these lower your toes but I'm not sure how useful it is really because this area is lower than the area where the ureter is normally affected by endometriosis which is higher so at this level you can see the ureter in the upper pelvis this is a longitudinal plane those are the internal iliac vessels and there you see a little tubular structure if you put color Doppler on there's no flow so it's beginning to look like a ureter and then if you're patient and just hold your probe still look at there some vermiculite so this is the ureter as a high-level so we know it's a ureter because it's by the I lack vessels there was no Doppler signal and there was vermiculite so what does endometriosis then look like we've seen normal now waters endometriosis look like so this is the bladder and here you can see this very large nodule and it could be malignancy so of course we're going to put color on and there is some vascularity and it does not look malignant but this was proven to be endometriosis on out on land biopsy and here you can see the uterus just behind and this is a little video clip I'm going in the longitudinal playing from side to side and you can see this the entire posterior wall of the bladder really actually is completely in occupied by endometriosis so try going the base part of the dome but this is a very rare case and normally it's a lot smaller so in this case here we can see a longitudinal view there's the section scar this is a retroflex uterus there's the small nodule and you can see that there's not much color in it it's not suspicious of the malignancy though it doesn't exclude it of course and this is a little video clip you can see the thickening there I'm just in the longitudinal plane going from one side of the bladder to the other showing how it's just focally abnormal in that central area there and then when I do the sliding sign you can see that that area is actually fixed to her section scar you can see that there the section scars there you can see how there's no movement another example of bladder endometriosis is this tiny nodule seen in the longitudinal plane and in the transverse plane and then this is the nodule this is the distance to where the ureter comes into the bladder this is the try going because you've got blood and neck hair this is where you're at enters so this nodule is this far away from the ureter and this is important information for surgeons and again looking at color making sure it's not an obvious malignancy and this is what it looks like in the longitudinal playing going from side to side you can see that nodule very clearly and you can see there that it slides reasonably well against the uterus it's not entirely free maybe but it's it's quite quite good sliding and here's just a view of the uterus often people think that it's only when you have Adnan myiasis kind of growing into the bladder you can see there is no adenomyosis then this is just bladder deep endometriosis sometimes you see a nodule of deep into me ptosis near the bladder like here we've got an empty bladder here there's little nodule and you'll be a bit more obvious when I play the video longitudinal playing the uterus at the back and there's this nodule offended me ptosis but the bladder is just there you can see it's not in the bladder but it's very near the bladder and in fact this was a nodule of deep endometriosis near the insertion of the round ligaments they're just playing it again so it's not blood or endometriosis but it's very near to the bladder there's a bit of an ovarian endometrium oh okay so this is a case where there's a bladder nodule and I could see an abnormal ureter near it the ureter discharges nicely into the bladder but at the level of the Taurus just there I can see a Hydra ureter and I could prove it was a hydrator by looking for vermiculite so the bladder nodule the urine does go into the bladder it's not entirely obstructed but is causing Hydra ureter nicely seen at the level of the Taurus and sometimes you can see bilateral hydrators this is the ureter on the left this is the air Terron the right and then this is a tourist this is a transverse view that's right and that's left not shown in that clip you can see the right one better than the left but it just demonstrates again there's the uterus oka ligaments this patient didn't actually have endometriosis but she did have bilateral hydrators so it's just nice to see how they vermiculite and where you can see them at the level of the torus is a good place and this the same same case we could see that this is the ovary these the iliac vessels and then there is the Hydra ureter again so in this case I could see the Hydra artists at the level of the torus and by the early acts so in this case this year or so you can you can track it to track it track it track it me it was all nice and thin till it came to the ovary you can see I'm going back up now so that your is normal between the try going and the ovary and then if you look here there's the ovary and if you increase your field of view you can see above the ovary and you suddenly see that above the ovary it's dilated whereas below the ovary between the ovary and the bladder is completely normal and on 3d particularly got a nice view of a little nodule of deep endometriosis and when I put in when I put collar on you can see here that there is a dilated ureter it doesn't have a color signal like this this is the vessel and this is the ureter that's the end of me choices and there's no table okay so then if we're going to look a little bit higher still this is illustrated in this case and this uterus is an T verted you can see the ovary is attached to the uterus there here you can see some deep endometriosis and if you look here you'll be able to see some vermiculite in this tubular structure so you can see that this is the ureter it's being pinched here had some deep endo at the level of the torus and then when I went trans abdominally I could see the ureter on the right-hand side there and then when I looked at the kidney you can see she's got motorists hydronephrosis sometimes it's even worse this is a nodule of deep endometriosis seen again at the torus and you can see this big hydrator above and thinner below that's the deep end Demetrios this is what it looks like on 3d sometimes you just get a better view longitudinal plane this is the ureter above this level of the torus and this is below this is going to the bladder so demonstrating that that looks normal as it enters the bladder is pretty pointless really need to look above the level of the torus and when I looked at her kidney that's what it looked like so if you find it difficult to look for ureters just look at the kidney in this case is lady had a lump of deep endometriosis close to the ureter and here you can see the right ovary this is the lump of deep and demetrius here is the longitudinal view of the ilyich vessels and then if you look when I do a bit of gentle pushing you can see it's close to the ureter it's not attached to it's not constricting it but maybe slightly prominent sometimes you can see you're at our extent so this is a bladder view and you can see the stent as it enters the bladder through the ureter and this is a little video clip just following that stent there you can see it entering the ureter but you win even with that stent in it's difficult to follow that ureter from bladder to torus so I wouldn't worry too much about that it's more important to learn how to look for the ureter at the level of the Taurus and sometimes you find something are different as well so here are the i-league vessels the ilac vein and the artery and the longitudinal plane and when I looked a little bit medially I could see this tubular structure and then I could see a very echo bright structure with dense shadowing behind it this is a stone in the ureter and if I play this little video I'm looking above it and below it and you can see that this is a year etre containing a little stone it seems to be fairly well wedged kidneys really important look at them trans abdominally routinely at the end of the pelvic scan I don't do this in every case but I do it in every case with endometriosis you're looking to exclude hydronephrosis you're not going to say whether the kidneys normal or not probably takes a lot of training but you're looking to exclude hydronephrosis and you can actually learn this online there's some excellent videos on youtube like these ones from radiology nation where they show you exactly how to hold the probe they show you what it looks like and they even show you how to adjust your settings to get a better view and they annotate the images so it's a very nice way to learn how to exclude hydronephrosis and these are some of my images that's a normal kidney and this is some fat there there's no fluid this is moderate hydronephrosis where you can see that there's fluid within the calluses and here you can see crows hydronephrosis where you can't even tell anymore where the renal parenchyma is so the take-home messages are you can look in three places for a dilated G return you can look where it enters the bladder look at the torus and look by the i'li accent look at the bladder toward the end of the scale it's much easier and always check the kidneys in women with any endometriosis thank you

this is a video about the ureters and bladder my name is Suzanne Johnson and I&#39;m a gynecologist from Southampton the resources I&#39;ve used to help me make this video include this paper from the idea group published in 2016 talking about terms definitions and measurements in women with endometriosis other resources are this book particularly chapter 8 and these two recent papers about urinary tract endometriosis endometriosis can be superficial or ovarian or deep and when deep endometriosis is present it can affect the anterior compartment consisting of the bladder and ureters which is what this video is about or the posterior compartment where it affects the posterior vaginal fornix the torus in neutral sacral ligaments and the rectum and sigmoid urinary tract endometriosis is quite rare but it&#39;s mostly bladder endometriosis however endometriosis affecting the ureters can be seen in up to a third of women with endometriosis the idea group has given different areas of the bladder different names so this is a bad cartoon I&#39;m sorry about that that&#39;s the urethra and the bladder and the cervix and here you can see where the ureter enters the trigon this area is the trigon and it&#39;s defined as being within three centimeters of the bladder neck and up to the uro Taric orifice the part of the bladder that&#39;s in contact with the vagina and cervix is called the base and then the area above that is called a dome and this is intra-abdominal and it&#39;s above the peritoneal reflection as you can just see here reflection of the peritoneum and it&#39;s in the base that you see most endometriosis cystoscopy is often normal the way I examine a blood and nodule I do this at the end of a systematic pelvic scan because I ask people to empty their bladder at the beginning of the scan but by the time I finished there will be some urine in the bladder and it&#39;s a good time to look at the bladder then I look for the sliding sign of the bladder on the uterus look for adjacent utrom adenomyosis I measure a nodule in three planes lengths depth and width and look for color Doppler signals I measure the distance between the nodule and the ureter ik orifice and describe where it is is it in the triger and the base or the dome of the bladder urethral endometriosis mostly is caused by fibrosis near a nodule of deep endometriosis which then constricts the ureter rarely it is actually endometriosis in the muscularis layer and it&#39;s very hard to tell the difference on ultrasound however the ureter is affected this can cause silent hydronephrosis and it&#39;s essential to check the kidneys in all patients with deep endometriosis so where is the ureter well the normal path of the ureter is nicely described in this paper it descends into the pelvis and then it travels medially into the internal iliac artery it then passes underneath uterine artery into parts of Michael tissue and at this level you&#39;re one to two centimeters lateral to the cervix immediately by the utero sacral ligament the ureter then courses medially over the anterior vaginal fornix and enters the bladder at the Trigon so you can examine the ureters in three areas you can look at the lower ureters between the bladder and the torus and you really rarely see deep end the meteos is here but bladder endometriosis in or near the Trigon can affect the ureters here the middle ureters between the torus and pelvic brim this is the important bit and because near the torus is a common location for stenosis and the upper ureters you can look transept on but this is less relevant to us so where is the Taurus you&#39;ll have seen this before in previous talks but this is how I do it this is a longitudinal section of the cervix the cervix is here and the uterus is here it&#39;s a longitudinal view and because deep endometriosis centers on the Taurus you get an longitudinal view of the internal us and then you rotate to the transverse plane so there is where the bladder attaches to the uterus in a straight line back you&#39;ve got the internal cervical off and then here is where you&#39;ve got the Taurus so this is to orientate you so I start longitudinal and then I rotate to the transverse that&#39;s longitudinal now rotating anti-clockwise to a transverse view the Taurus is here this is one uterus a polygamist and then toward the other side is the other utero sacral ligament so the level of the Taurus is an important plane for you to look for your toes and this is the Taurus seen at laparoscopy of course we&#39;re looking into the pelvis this way so the patient&#39;s right is here this is the back of the uterus and this area here is the Taurus those are the uterus sacral ligaments and this all of this is the planche of Douglas so we want to look near the level of the Taurus because this is more or less the area where the ureter could be visible on ultrasound so how to examine the year it is well when you&#39;re looking at the lower year it is between the bladder and the Taurus and you can look in the longitudinal view of the bladder and move the probe andr laterally from the Tri going and just follow the ureter more importantly the middle section of ureter between Taurus and pelvic brim you find the Taurus and then in the longitudinal view you&#39;ll see the ureter if it&#39;s dilated behind the Taurus but in the transverse view you can look at the perineum which is lateral to the Taurus you may be able to see water under the bridge sign - this is very rare near the pelvic brim you can see the ureter in the longitudinal section the medial to the iock vessels and I&#39;ll show you some examples of all of these and then the upper ureters you can see those transit only so where to look a quick guide you can see the ureter as it enters the bladder base there just by the try go you can see it at the Taurus if you look near the cervix at the level of the Taurus go either posteriorly or laterally and if you look for the Ilia vein and iliac artery there&#39;s the ovary and that&#39;s another place where you&#39;ll be able to see the ureter medial to the internal iliac vessels near the ovary so three places where I routinely look for a hydro ureter you&#39;ll know if you see a tubular structure you have to decide is it dilated and the normal diameter of your tour is three millimeters is there color flow in which case it will more likely to be a blood vessel and vermiculite is the telltale sign of something being the ureter and then if we go a bit higher still kidneys we want to know is there any hydronephrosis this is obviously dumb trans abdominally and mild hydronephrosis is where you have a dilated renal pelvis only so that would be just this area here in moderate you get a dilated pelvis and calluses and in severe you get cystic dilatation with only a very thin rim of renal parenchyma or it may not be visible at all so what does normal look like here we&#39;ve got the bladder there&#39;s the urethra this is where the we&#39;re going in this longitudinal view from left to right so this happens to be the left ureter and then the uterus a bit of it is just there so if we follow we&#39;re going for in the longitudinal plane from left to right and that was the ureter there it goes into the bladder at the bottom of the try go I&#39;m going out the other side and there is the right ureter you can see that&#39;s the bit where it&#39;s just entering the bladder so again that&#39;s the left ureter coming into bladder I&#39;m going over toward the right side now and then there&#39;s the right ureter coming into the bladder - this is what normal bladder wall looks like here this lady&#39;s got a bit of retrograde menstruation so there&#39;s some blood in her pelvis and you can see when if I play the video I&#39;m just doing the sliding sign there&#39;s the uterus there&#39;s a bit of free fluid and you can see the bladder wall this is normal bladder wall it&#39;s freely mobile onto the cervix at the top there so this is what normal bada looks like and in this clip you can just see normal muscularis the muscular layer of the bladder normal muscularis so when you see the bladder you can if it&#39;s done immediately after mature ition you can do a residual volume but this is the the length and the depth and the width of this ladder and then here I&#39;ve got a longitudinal view this is the bladder neck and this is where the ureter enters and then this is the transverse view so you see one ureter and another ureter in the transverse and if somebody has been drinking a lot of fluids then you&#39;ll be able to see the this is the transverse playing the ureter emptying into the bladder transverse view if the you retrieve cycle Junction so this area here would be part of the Trigon so what does it look like if you compare trans abdominal and trans vaginal so in the trans abdominal view this is uterus this is vagina and if you look just there and it&#39;s a bit better seen there you can just see urine coming into the bladder you can see this the nice jet with color Doppler and there you can just see is where the ureter comes in this is the Tri going this is the bladder neck just there and then the area that&#39;s equivalent on TV it&#39;s just there there&#39;s the bladder neck there&#39;s the Tri going and this is where the ureter enters the bladder so sometimes you might say you retry seal and this is where the ureter as it inserts into the bladder and balloons as urine comes into the bladder that&#39;s it on longitudinal view and in transverse view you can see that on the left it&#39;s worse but on the right there&#39;s a small ureter seal too and this is a nought we&#39;re going up slightly now slightly higher level normal lower ureter you can see the vermiculite in here as this ureter is squeezing urine into the bladder it&#39;s completely normal so how to track a ureter now you know how where to find it we have the bladder neck up there this is where the ureter enters the bladder you can now track it in the longitudinal plane or the transverse plane there it goes if you just wiggle your probe in the longitudinal plane you can follow there it goes past that ovary so and then we&#39;re going back up there it goes follow it follow it into the bladder so I&#39;ll just let it play again you can see the ureter coming out of the bladder I&#39;m just tracking it as it snakes up toward this ovary and then it&#39;s going to go back again so I move my probe medially back toward the bladder so as you can see it&#39;s a bit tricky you can track the ureter in the transverse plane to the perineum I&#39;ll play this video there it comes the ureter track track track down and then back up again so you can find these lower your toes but I&#39;m not sure how useful it is really because this area is lower than the area where the ureter is normally affected by endometriosis which is higher so at this level you can see the ureter in the upper pelvis this is a longitudinal plane those are the internal iliac vessels and there you see a little tubular structure if you put color Doppler on there&#39;s no flow so it&#39;s beginning to look like a ureter and then if you&#39;re patient and just hold your probe still look at there some vermiculite so this is the ureter as a high-level so we know it&#39;s a ureter because it&#39;s by the I lack vessels there was no Doppler signal and there was vermiculite so what does endometriosis then look like we&#39;ve seen normal now waters endometriosis look like so this is the bladder and here you can see this very large nodule and it could be malignancy so of course we&#39;re going to put color on and there is some vascularity and it does not look malignant but this was proven to be endometriosis on out on land biopsy and here you can see the uterus just behind and this is a little video clip I&#39;m going in the longitudinal playing from side to side and you can see this the entire posterior wall of the bladder really actually is completely in occupied by endometriosis so try going the base part of the dome but this is a very rare case and normally it&#39;s a lot smaller so in this case here we can see a longitudinal view there&#39;s the section scar this is a retroflex uterus there&#39;s the small nodule and you can see that there&#39;s not much color in it it&#39;s not suspicious of the malignancy though it doesn&#39;t exclude it of course and this is a little video clip you can see the thickening there I&#39;m just in the longitudinal plane going from one side of the bladder to the other showing how it&#39;s just focally abnormal in that central area there and then when I do the sliding sign you can see that that area is actually fixed to her section scar you can see that there the section scars there you can see how there&#39;s no movement another example of bladder endometriosis is this tiny nodule seen in the longitudinal plane and in the transverse plane and then this is the nodule this is the distance to where the ureter comes into the bladder this is the try going because you&#39;ve got blood and neck hair this is where you&#39;re at enters so this nodule is this far away from the ureter and this is important information for surgeons and again looking at color making sure it&#39;s not an obvious malignancy and this is what it looks like in the longitudinal playing going from side to side you can see that nodule very clearly and you can see there that it slides reasonably well against the uterus it&#39;s not entirely free maybe but it&#39;s it&#39;s quite quite good sliding and here&#39;s just a view of the uterus often people think that it&#39;s only when you have Adnan myiasis kind of growing into the bladder you can see there is no adenomyosis then this is just bladder deep endometriosis sometimes you see a nodule of deep into me ptosis near the bladder like here we&#39;ve got an empty bladder here there&#39;s little nodule and you&#39;ll be a bit more obvious when I play the video longitudinal playing the uterus at the back and there&#39;s this nodule offended me ptosis but the bladder is just there you can see it&#39;s not in the bladder but it&#39;s very near the bladder and in fact this was a nodule of deep endometriosis near the insertion of the round ligaments they&#39;re just playing it again so it&#39;s not blood or endometriosis but it&#39;s very near to the bladder there&#39;s a bit of an ovarian endometrium oh okay so this is a case where there&#39;s a bladder nodule and I could see an abnormal ureter near it the ureter discharges nicely into the bladder but at the level of the Taurus just there I can see a Hydra ureter and I could prove it was a hydrator by looking for vermiculite so the bladder nodule the urine does go into the bladder it&#39;s not entirely obstructed but is causing Hydra ureter nicely seen at the level of the Taurus and sometimes you can see bilateral hydrators this is the ureter on the left this is the air Terron the right and then this is a tourist this is a transverse view that&#39;s right and that&#39;s left not shown in that clip you can see the right one better than the left but it just demonstrates again there&#39;s the uterus oka ligaments this patient didn&#39;t actually have endometriosis but she did have bilateral hydrators so it&#39;s just nice to see how they vermiculite and where you can see them at the level of the torus is a good place and this the same same case we could see that this is the ovary these the iliac vessels and then there is the Hydra ureter again so in this case I could see the Hydra artists at the level of the torus and by the early acts so in this case this year or so you can you can track it to track it track it track it me it was all nice and thin till it came to the ovary you can see I&#39;m going back up now so that your is normal between the try going and the ovary and then if you look here there&#39;s the ovary and if you increase your field of view you can see above the ovary and you suddenly see that above the ovary it&#39;s dilated whereas below the ovary between the ovary and the bladder is completely normal and on 3d particularly got a nice view of a little nodule of deep endometriosis and when I put in when I put collar on you can see here that there is a dilated ureter it doesn&#39;t have a color signal like this this is the vessel and this is the ureter that&#39;s the end of me choices and there&#39;s no table okay so then if we&#39;re going to look a little bit higher still this is illustrated in this case and this uterus is an T verted you can see the ovary is attached to the uterus there here you can see some deep endometriosis and if you look here you&#39;ll be able to see some vermiculite in this tubular structure so you can see that this is the ureter it&#39;s being pinched here had some deep endo at the level of the torus and then when I went trans abdominally I could see the ureter on the right-hand side there and then when I looked at the kidney you can see she&#39;s got motorists hydronephrosis sometimes it&#39;s even worse this is a nodule of deep endometriosis seen again at the torus and you can see this big hydrator above and thinner below that&#39;s the deep end Demetrios this is what it looks like on 3d sometimes you just get a better view longitudinal plane this is the ureter above this level of the torus and this is below this is going to the bladder so demonstrating that that looks normal as it enters the bladder is pretty pointless really need to look above the level of the torus and when I looked at her kidney that&#39;s what it looked like so if you find it difficult to look for ureters just look at the kidney in this case is lady had a lump of deep endometriosis close to the ureter and here you can see the right ovary this is the lump of deep and demetrius here is the longitudinal view of the ilyich vessels and then if you look when I do a bit of gentle pushing you can see it&#39;s close to the ureter it&#39;s not attached to it&#39;s not constricting it but maybe slightly prominent sometimes you can see you&#39;re at our extent so this is a bladder view and you can see the stent as it enters the bladder through the ureter and this is a little video clip just following that stent there you can see it entering the ureter but you win even with that stent in it&#39;s difficult to follow that ureter from bladder to torus so I wouldn&#39;t worry too much about that it&#39;s more important to learn how to look for the ureter at the level of the Taurus and sometimes you find something are different as well so here are the i-league vessels the ilac vein and the artery and the longitudinal plane and when I looked a little bit medially I could see this tubular structure and then I could see a very echo bright structure with dense shadowing behind it this is a stone in the ureter and if I play this little video I&#39;m looking above it and below it and you can see that this is a year etre containing a little stone it seems to be fairly well wedged kidneys really important look at them trans abdominally routinely at the end of the pelvic scan I don&#39;t do this in every case but I do it in every case with endometriosis you&#39;re looking to exclude hydronephrosis you&#39;re not going to say whether the kidneys normal or not probably takes a lot of training but you&#39;re looking to exclude hydronephrosis and you can actually learn this online there&#39;s some excellent videos on youtube like these ones from radiology nation where they show you exactly how to hold the probe they show you what it looks like and they even show you how to adjust your settings to get a better view and they annotate the images so it&#39;s a very nice way to learn how to exclude hydronephrosis and these are some of my images that&#39;s a normal kidney and this is some fat there there&#39;s no fluid this is moderate hydronephrosis where you can see that there&#39;s fluid within the calluses and here you can see crows hydronephrosis where you can&#39;t even tell anymore where the renal parenchyma is so the take-home messages are you can look in three places for a dilated G return you can look where it enters the bladder look at the torus and look by the i&#39;li accent look at the bladder toward the end of the scale it&#39;s much easier and always check the kidneys in women with any endometriosis thank you

Transcript for:Ureters and Bladder

Transcript for:
Ureters and Bladder