Abdominal Radiology

https://doi.org/10.1007/s00261-019-02276-w

REVIEW

Bladder cancer and its mimics: a sonographic pictorial review with CT/
MR and histologic correlation
Andrew L. Wentland1 · Terry S. Desser1 · Megan L. Troxell2 · Aya Kamaya1

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Bladder cancer is the most common cancer of the urinary system and often presents with hematuria. Despite its relatively
high incidence, bladder cancer is often under-recognized sonographically. Moreover, even when bladder abnormalities
are identified, numerous other entities may mimic the appearance of bladder cancer. Given the incidence and prevalence
of bladder cancer, it is important to recognize its variable appearance sonographically and distinguish it from its common
mimics. We review the sonographic appearance of bladder cancer and its mimics, providing correlative CT/MR imaging as
well as pathology. We stress the importance and advantage of ultrasound as a dynamic imaging modality, with the ability to
optimize distinguishing bladder cancer from similar-appearing entities.

Keywords Ultrasound · Sonography · Bladder cancer · Bladder mass · Bladder tumor

Introduction bladder may not be the focus of the examination, incidental

bladder lesions may be inadvertently overlooked especially
Focused evaluation of the urinary tract is often performed if hematuria is not one of the explicit indications given for
in the initial evaluation of hematuria. Many urologic enti- the examination. A fluid-distended bladder provides an
ties cause hematuria, including urinary stones, renal and acoustic window for sonographic evaluation of the pelvic
urothelial tumors (including bladder cancer), urinary tract organs, but while looking through it, one should carefully
infections, and glomerulonephritis. Imaging studies per- inspect the bladder itself so as to not miss bladder pathol-
formed for the evaluation of hematuria inevitably prompt ogy. The aim of this review is to heighten awareness of the
inspection of the kidneys and ureters. Such evaluation is findings of bladder cancers on imaging studies, particularly
commonly performed by CT urography, although a recent ultrasound, with the hope that radiologists will resolve to
study by Tan et al. demonstrated that renal and bladder ultra- give it as much attention as the structures whose visuali-
sound can safely replace CT urography in the evaluation of zation it facilitates. The imaging appearance of urothelial
patients with microscopic hematuria [1]. Perhaps because it carcinoma of the bladder will first be discussed, followed by
is well-accepted that direct visualization with cystoscopy is mimics of urothelial carcinoma, including other malignant
the best method for detecting bladder cancer, [1] radiologic masses, and benign conditions that may mimic malignancy.
evaluation of the bladder is often underemphasized in most
imaging modalities. Nonetheless, the bladder is typically
included in ultrasound studies of the male and female pelvis, Background
kidneys, and gravid uterus. In these situations, while the
The bladder is a muscular sac for the collection, storage,
and expulsion of urine from the ureters, located in the extra-
* Aya Kamaya
[email protected] peritoneal compartment of the anterior pelvis. Figure 1
illustrates the gross anatomy of the bladder, as well as the
1
Department of Radiology, Stanford University School relevant layers of the bladder wall. Bladder cancer is most
of Medicine, H‑1307, 300 Pasteur Dr., Stanford, CA 94305, commonly found along the posterior wall and the trigone [2],
USA
the latter of which is important for sensing distention and
2
Department of Pathology, Stanford University School instigating micturition. The innermost layer of the bladder
of Medicine, Stanford, CA, USA

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and non-invasive, muscular invasive, or metastatic, and have

different etiologies, treatments, and prognoses.
Patients with bladder cancer typically present with micro-
scopic or macroscopic hematuria [4]. Flank pain may be
another presenting symptom especially in patients in whom
bladder masses involve and obstruct the ureterovesical junc-
tion, leading to hydroureteronephrosis. Bladder cancers are
typically diagnosed with cystoscopy and transurethral resec-
tion of the bladder tumor (TURBT) and staged using the
standard TNM system. As with other hollow organs, bladder
cancer is staged based on the depth of invasion through lay-
ers of the wall. Non-invasive carcinomas include papillary
non-invasive urothelial carcinoma, staged as pTa, which can
present as mass lesions. These are distinguished from flat
urothelial carcinoma in situ, which are staged as pTis. In
stage T1 lesions, the carcinoma invades the lamina propria.
A stage T2 tumor invades into the muscularis propria—the
detrusor muscle. Thereafter, tumors invade into the perivesi-
cal fat (T3) or surrounding organs (T4). Stage T1 tumors
are typically treated with TURBT and adjuvant intravesical
therapy. Stage T2 and above tumors require more aggressive
management, typically including radical cystectomy. Tumors
are also classified histologically as low grade or high grade
using a system devised by the World Health Organization
(WHO) and the International Society of Urologic Patholo-
gists (ISUP), with higher-grade tumors having greater poten-
tial for invasion and a more aggressive course [5].
Approximately 95% of bladder cancer is urothelial (tran-
sitional-cell) carcinoma [6]. Squamous cell carcinoma is
the second most common type, with less-common varieties
including adenocarcinoma, small-cell carcinoma, and sar-
coma. Extremely rare varieties of bladder tumors include
well-differentiated neuroendocrine tumors (‘carcinoid’),
Fig. 1  a Diagram of the bladder. Two ureters enter the bladder poste- rhabdomyosarcoma, paraganglioma, leiomyosarcoma, and
riorly to transmit urine from the kidneys; urine exits through the ure- lymphoma. Metastases to the bladder are rare but can origi-
thra. The trigone, the region between the ureteric orifices and the ure- nate from any primary site, particularly the gastrointestinal
thra, is sensitive to distention and signals the need to micturate. Inset tract cancers, breast carcinoma, or melanoma.
image of the bladder wall layers includes the innermost layer (urothe-
lium), from which most bladder cancers arise. As cancer advances, Bladder cancer most frequently metastasizes to the pel-
tumor invades through the lamina propria into the bladder wall mus- vic and retroperitoneal lymph node stations [7]. Bone is the
culature (detrusor muscle), and eventually progresses through the most common site for distant bladder cancer metastases;
adventitia and serosa and into surrounding organs. Diagram designed most appear sclerotic but can also be lytic or mixed lytic-
in Adobe Illustrator and adapted from the article on Bladder Anat-
omy from Medscape (emedicine.medscape.com/article/1949017- sclerotic. For solid organs, the liver and lung are the most
overview). b Histology of the bladder wall, corresponding to inset in frequent sites of metastasis [7], with involvement of other
a. Urothelium lines the lumen, supported by underlying lamina pro- organs occurring far less frequently.
pria (double-headed arrow) containing numerous vessels and incon- Males are three times more likely to develop bladder
spicuous muscularis mucosa (small arrow). The detrusor muscle, or
muscularis propria, consists of large bundles of smooth muscle (M). cancer than females. Smoking is associated with 50–65%
Adventitia and serosa are deep to the muscularis and not represented of cases of bladder cancer in men, and 20–35% in women
here. H&E, original magnification ×20 [8]. Most bladder cancers occur in people over the age
of 60 years [9]. In addition to age, additional risk factors
include occupational or environmental exposure to chemi-
wall is the urothelium, the cell type from which most blad- cal carcinogens such as aniline dyes—benzidine and beta-
der cancers arise [3]. Bladder cancers may be superficial naphthylamine [10]—chronic bladder stones, chronic cys-
titis, analgesic (phenacetin) abuse [11], cyclophosphamide

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use [12], and a history of radiation therapy to the pelvis [13,

14]. In developing countries, bladder cancer may be caused
by schistosomiasis infection.

Sonographic technique

The bladder is optimally evaluated under moderate disten-

tion, as underdistention markedly limits evaluation of blad-
der wall thickening and focal masses, while overdistention
leads to patient discomfort. The patient should be placed in
a supine position, with lateral decubitus positioning used
ad hoc to assess for lesion mobility, which can help to dis-
tinguish potential mimics of bladder cancer such as bladder
stones or fungus balls. The time-gain compensation (TGC)
may need adjustment to reduce reverberation artifact from
the anterior bladder wall. If a focal mass is seen, careful
evaluation with color and power Doppler can help identify
internal vascularity, which would distinguish potential mim-
ics such as blood clots or fungus balls from tumor. Spectral
Doppler interrogation in areas of detectable blood flow can
help demonstrate arterial or venous blood flow, which would
be suspicious for bladder cancer. Newer flow sensitive Dop-
pler techniques may increase sensitivity to detect internal
vascularity, now available on many ultrasound machines.
A 3.5–6 MHz transducer is most commonly used for blad-
der evaluation. Findings along the anterior bladder wall can
be assessed with greater spatial resolution using higher-fre-
quency linear transducers (> 9 MHz). During the ultrasound
examination, the bladder should be centered within the field
of view; the bladder can be fully assessed by placing the
probe immediately superior to the symphysis pubis and
angling the probe laterally, inferiorly, and superiorly in both
the transverse and longitudinal orientations. The posterior
wall at the bladder base should be carefully interrogated, as
transitional-cell carcinoma often resides in this region. In
females, the bladder may be assessed using a transvaginal
probe for improved spatial resolution if needed; a transrectal
approach can be used in males if visualization of the bladder
is limited transabdominally. Identification of a single lesion
should prompt the search for additional lesions, as 30–40%
of bladder cancers are multifocal [15].

Imaging and pathology findings of bladder

cancer
Fig. 2  72-year-old male with high-grade urothelial carcinoma. a Longitudinal
Most urothelial cell cancers are located along the posterior ultrasound scan shows a large bladder mass arising from the posterior bladder
wall at the base of the bladder [15]. Sonographically vis- wall with invasion and posterior extension of tumor. b Sagittal CT of the blad-
der shows a polypoid heterogeneously enhancing mass arising from the poste-
ible bladder cancer most commonly manifests as a poly- rior bladder wall. Pathology c demonstrates polypoid fragments of exophytic
poid mass arising from the bladder wall (Fig. 2). On sono- high-grade urothelial carcinoma in the transurethral resection of bladder tumor
graphic evaluation, bladder masses are typically immobile (TURBT) specimen. Image shows considerable squamous differentiation and
focal lamina propria invasion by cancer (arrows). H&E, original magnification
with changes in patient position and often heterogeneous ×20. M mass, L bladder lumen

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in echotexture. The presence of flow detected on color

Doppler helps to distinguish the solid tissue of a tumor
from blood clot or debris. Bladder cancer typically appears
as a lesion with soft-tissue attenuation on CT but is often
better identified as a filling defect within a contrast-
filled bladder on CT urography. When visualized by MR,
bladder cancers typically are T1 isointense and mildly
T2 hyperintense compared to the bladder wall. If large
enough, bladder cancers can be identified as enhancing
bladder masses on post-contrast CT or MRI.
In high-grade urothelial carcinoma, the mass may invade
through the bladder wall musculature and can extend beyond
the bladder into the abdominal wall, prostate, or uterus
(Fig. 3). In particular, carcinomas arising in bladder diver-
ticula may have early transmural extension related to the
underlying bladder wall defect, conferring a worse prog-
nosis. Lesions near the ureterovesical junctions may cause
ureteral obstruction and result in hydroureteronephrosis.
Occasionally, bladder cancer may be sessile and only
appear as focal bladder wall thickening with or without
extension into the bladder lumen. While such focal thicken-
ing can be appreciated on ultrasound, CT, or MR, it may also
be quite subtle and difficult to recognize depending on the
degree of bladder distention. A focal area of bladder wall
thickening > 3 mm for a well-distended bladder, and > 5 mm
for a poorly distended bladder, is suggestive of pathology
[16].
Focal calcifications are seen in 5% of urothelial cell can-
cers [15]. Idiopathic focal bladder wall calcifications are
unusual, and thus the presence of focal calcifications in the
bladder wall should raise suspicion for an underlying bladder
tumor. Calcifications can also be seen in cystitis, schisto-
somiasis, tuberculosis, and after radiation treatment of the
pelvis; however, in these entities calcifications are typically
more diffuse than focal. Calcifications can be recognized
on ultrasound as echogenic foci with or without shadowing,
or as hyperattenuating foci on CT. Calcifications are more
difficult to appreciate on MR, but are best seen as low signal
foci on T1 or GRE acquisitions.
Sonography is reported to be 63% sensitive and 99% spe-
cific for the detection of bladder cancer [17]. Sonographic
sensitivity may be limited in identifying tumors within a
non-fluid-filled diverticulum and in detecting tumors of the
bladder base in the setting of prostatomegaly, which may Fig. 3  72-year-old male with high-grade urothelial carcinoma. a Lon-
cause irregular impressions upon the bladder base. How- gitudinal ultrasound scan shows a large bladder mass arising from the
ever, of note, imaging can be particularly beneficial in the posterior bladder wall with invasion and posterior extension of tumor.
b Sagittal CT of the bladder shows the mass arising from the poste-
detection of cancer within diverticula, as cystoscopy cannot rior bladder wall. Pathology c demonstrates high-grade urothelial car-
evaluate diverticula with a narrow neck. cinoma with papillary architecture (asterisks). Some of the malignant
On pathology, urothelial carcinoma typically demon- epithelium is degenerating in this TURBT specimen (above the black
strates papillary architecture. The degree of nuclear anapla- line). The tumor in the lower left represents involvement of a von
Brunn nest (red circle). The prostatic invasion is not represented in
sia denotes whether the tumor is low or high grade. Invasion this TURBT specimen. H&E, original magnification ×100. M mass,
into the lamina propria, muscularis propria, or vasculature L bladder lumen, P prostate
can also be assessed histologically.

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Fig. 4  36-year-old pregnant female with urachal carcinoma. a Longi- ▸

tudinal grayscale ultrasound of the pelvis shows a large mass supe-
rior to the bladder and anterior to the gravid uterus. b Sagittal MR of
the pelvis shows the heterogeneous mass superior to the bladder and
extending to the umbilicus. c Histologic sections of the urachal tumor
demonstrate invasive mucinous carcinoma, a common histologic vari-
ant of urachal carcinoma. At bottom, there is malignant epithelium
with surface villous structures. Elsewhere, invasive pools of pale gray
mucin (arrows) are partially lined by tumor cells. H&E, original mag-
nification ×20. L bladder lumen, M mass, F fibroid, U gravid uterus

Mimics of primary bladder urothelial

carcinoma

Neoplasms mimicking urothelial carcinoma

Urachal carcinoma

The urachus is a remnant of the embryologic cloaca and

allantois. The urachus extends from the anterosuperior
surface of the bladder to the umbilicus. Of note, urachal
remnants are seen in nearly 100% of newborns, but eventu-
ally the remnant regresses to become the median umbilical
ligament. A urachal remnant is present in 3% of the general
population at autopsy [18].
Carcinoma of the urachus is rare, representing < 1% of
bladder cancers [19, 20]. It most often presents as an adeno-
carcinoma (69% of cases), with the remaining cancers attrib-
uted to urothelial, squamous, and sarcomatoid subtypes [18].
In 90% of cases, urachal carcinoma begins in the urachus
adjacent to the bladder dome [18]; as the cancer grows, it
extends cranially towards the umbilicus (Fig. 4).
Urachal carcinoma is most often seen in middle-aged and
elderly men. It is often undetected until symptoms arise from
local invasion or systemic spread. Urachal carcinoma can
cause abdominal pain, hematuria, mucosuria, and purulent
or bloody discharge from the umbilicus [18]. Furthermore,
as the mass is typically extravesical in location, the patient
is often asymptomatic initially, resulting in a late presenta-
tion. Urachal carcinoma is highly malignant, which often
necessitates an en bloc resection of the mass as well as the
umbilical ligament for long-term disease-free survival [21].
Urachal carcinoma will appear sonographically complex
and heterogeneous in echotexture. Calcifications are present
in 70% of cases [18], often along the periphery of the mass.
Early urachal carcinomas, limited to the bladder dome, can
look identical to invasive bladder cancer. The presence of
a mass at the bladder dome that extends to the umbilicus
is more easily appreciated on sagittal CT and MRI. Cystic
components of the mass, when present, are hypo- or ane-
choic on ultrasound, near water attenuation on CT, and T2
hyperintense on MRI. are mucin-producing [22], with prominent lakes of mucus.
On pathology, urachal carcinomas are seen in the set- There is often invasion of the muscularis or deeper tissues.
ting of a urachal remnant. Most commonly these tumors

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Lymphoma

Lymphoma of the bladder is rare. By definition, primary

lymphoma of the bladder occurs in the absence of known
lymphoma elsewhere. More commonly, the bladder is sec-
ondarily involved with a known extravesical primary lym-
phoma [23].
Bladder lymphoma is most commonly seen in middle-
aged women [22]. Patients may present with hematuria. Mar-
ginal zone lymphoma of mucosa-associated lymphoid tissue
(MALT lymphoma) and diffuse large B-cell lymphoma are
the most frequent types identified (Fig. 5). Bladder lym-
phoma presents most commonly as a solitary submucosal
bladder mass (70%) (Fig. 5), with 20% occurring multifo-
cally, and 10% presenting as diffuse bladder wall thickening
[23]. There are no known distinct imaging characteristics
to distinguish bladder lymphoma from other types of blad-
der cancer. Thus, bladder lymphoma typically appears as
a lobular mass along the bladder wall with vascularity on
color Doppler and enhancement on post-contrast CT or MRI.
Pathology of bladder lymphoma reveals a proliferation
of large cells with a high nuclear:cytoplasmic ratio. Immu-
nostains, such as for CD20, can be used to identify a pro-
liferation of B cells in the setting of a diffuse large B-cell
subtype of lymphoma.

Paraganglioma

A paraganglioma is a pheochromocytoma outside the adre-

nal gland. Of pheochromocytomas, 18% are paraganglio-
mas, 10% of which are located in the bladder [24]. Para-
gangliomas account for 0.06% of all bladder tumors [25].
An interesting and classic presentation of patients with
bladder paragangliomas is acute hypertension during mic-
turition due to the release of catecholamines. This transient
release of catecholamines may manifest as headache, blurred
vision, or flushing with micturition [26]; however, 27% of
patients may not have any symptoms associated with bladder
paraganglioma.
Bladder paragangliomas appear as a soft-tissue mass aris-
ing from the bladder wall that protrudes into the bladder
lumen [27] (Fig. 6). These tumors are often indistinguish-
able from urothelial cell or other bladder cancers. Potential
distinguishing features from other bladder tumors include Fig. 5  85-year-old male with diffuse large B-cell lymphoma of the
bladder. a Transverse grayscale ultrasound of the bladder shows a
intense enhancement on post-contrast CT or MRI, or the large heterogeneous mass along the right posterolateral bladder wall.
presence of necrosis or hemorrhage within the lesion. If a b Axial CT in the same patient shows similar asymmetric thickening
bladder paraganglioma is suspected given the history and of the right bladder wall. No additional site of lymphoma was identi-
imaging appearance, further evaluation with an iodine-123- fied on subsequent staging studies. Of note, patient had a history of
prostate cancer and pelvic radiation therapy. c Histologic section of
MIBG nuclear medicine study can be performed [27]. bladder demonstrates effacement by sheets of large cells with high
On pathology, a paraganglioma is epithelioid in appear- nuclear:cytoplasmic ratio. Inset shows immunostain for B-cell protein
ance. The architecture is characteristically nested. Immuno- CD20, highlighting all tumor cells (brown-positive). H&E original
histochemistry can be used to confirm the neuroendocrine magnification ×200, inset CD20 immunostain. L bladder lumen, M
mass
origin of the mass.

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Fig. 6  60-year-old female with bladder wall paraganglioma. a Trans-

verse grayscale ultrasound of the bladder shows a mass arising from
the right posterior bladder wall. Internal vascularity was present on
color Doppler (not shown). b Axial contrast-enhanced CT images
show that the right posterior bladder wall mass is avidly enhancing.
c Histologic section in a different patient with bladder paraganglioma
shows epithelioid tumor within the detrusor muscle with vaguely
Fig. 7  65-year-old male with bladder abscess confirmed on pathol-
nested architecture. Higher-power inset (upper right) highlights neu-
ogy. a Longitudinal ultrasound image shows a rounded mass with
roendocrine chromatin and pink-purple cytoplasm. Immunohisto-
several echogenic foci, consistent with gas (arrows). b Sagittal CT in
chemical stains (not shown) confirm the diagnosis of paraganglioma.
the same patient shows a hyperdense mass with corresponding foci of
H&E, original magnifications ×100, inset ×200. L bladder lumen, M
gas. c Pathology confirms bacterial infection, which walled off in the
mass
bladder wall, forming an abscess. Sections show neutrophils (between
red arrows) with abundant bacterial overgrowth (black arrows). H&E,
original magnification ×400. L bladder lumen, M mass

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Fig. 8  64-year-old female with radiation-induced cystitis after radia- change. The lamina propria is edematous (long arrows), with scat-
tion treatment of cervical carcinoma. a Transverse ultrasound image tered chronic inflammatory cells throughout. Vessels are congested
of the bladder shows diffuse marked thickening of the bladder wall. with red blood cells and neutrophils. Stromal and endothelial cells are
Radiation cystitis often prevents full distension of the bladder, as enlarged and atypical (short arrows), which are characteristic features
seen in this patient. b Coronal contrast-enhanced T1W MR and c of radiation. H&E, original magnification ×100. W bladder wall, L
coronal contrast-enhanced CT images confirm the bladder wall is bladder lumen
diffusely thickened. d H&E stain shows the urothelium with reactive

Metastases spreads hematogenously, the route via which renal cell car-
cinoma metastasizes to the bladder is unknown; proposed
The bladder may be involved secondarily due to transmu- mechanisms of the latter include hematogenous, lymphatic,
ral extension of tumors in contiguous pelvic organs, or via and canalicular routes (i.e. along the urinary tract) [29].
drop metastases in peritoneal carcinomatosis. Metastases Bladder metastases often appear as vascular nodular lesions
to the bladder most often arise from primary malignancies along the bladder wall and can be solitary or multifocal.
such as gastric carcinoma, breast carcinoma, or melanoma While bladder metastases can look identical to primary blad-
[28]. Lung cancer and renal cell carcinoma are less-common der cancers, a multifocal appearance and/or patient history
sources of bladder metastases. While lung cancer typically can help to distinguish between the two entities.

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Fig. 9  50-year-old male with history of chronic lymphocytic leuke-

mia and cyclophosphamide-induced cystitis. Transverse ultrasound
image of the bladder shows severe bladder wall thickening, which
results in marked restriction of bladder distension, resulting in a small
bladder lumen. W bladder wall; L bladder lumen

Benign entities that can mimic urothelial carcinoma

Cystitis

Cystitis is a general term for inflammation of the bladder.

Cystitis typically presents with dysuria, pyuria, frequency,
and urgency, but can also present with hematuria, similar
to bladder cancer. Common risk factors for development of
cystitis include female gender (the shorter urethra in females
may facilitate retrograde bacterial reflux into the bladder),
sexual intercourse, spermicide use, bladder outlet obstruc-
tion, catheterization, or the presence of foreign bodies. Anti-
bacterial properties of prostatic fluid may also be protective
against cystitis in men [30].
Acute cystitis typically causes bladder wall thickening.
Although bladder wall thickening can be appreciated on all
imaging modalities, it can be challenging to determine if Fig. 10  52-year-old male with cystitis glandularis. a Transverse gray-
the thickened appearance is simply due to underdistention scale ultrasound view of the bladder shows mass-like buds along the
posterior bladder wall, which were confirmed via cystoscopy to rep-
of the bladder versus true wall thickening. In these situa- resent areas of glandular hypertrophy. b Histologic sections from a
tions, ultrasound may be advantageous. First, the bladder different patient with cystitis glandularis show numerous glandular
may be imaged serially and if not optimally distended, repeat structures with open lumens below the mucosa. These have colum-
imaging may be performed after the bladder is optimally nar cells, rather than urothelial epithelial lining, an example of cys-
titis glandularis. The arrow denotes a focus of intestinal metaplasia,
filled. Secondly, bladder wall edema may be better appreci- with mucin-filled goblet cells; small blue nuclei in the lamina propria
ated with ultrasound and appear hypoechoic and thickened. below are lymphocytes. H&E, original magnification ×100. L bladder
Hyperemia of the bladder wall may be appreciated on color lumen, B buds
or power Doppler imaging. Finally, perivesical inflammatory
changes may be appreciated as echogenic fat on ultrasound,
analogous to fat stranding seen on CT or MRI. Chronic cys-
titis also leads to thickening of the bladder wall, but can

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Fig. 12  83-year-old male with chronic bladder outlet obstruction and

a bladder diverticulum. a Transverse ultrasound view shows a dis-
tended bladder with irregular trabeculations along the bladder wall as
well as a thin-necked bladder diverticulum containing layering debris.
b Axial CT in the same patient confirms a diverticular outpouching
with layering calcifications. A Foley catheter has now been placed,
resulting in partial decompression of the bladder. D debris, O out-
pouching, L bladder lumen
Fig. 11  89-year-old male with chronic bladder outlet obstruction and
bladder wall thickening. a Longitudinal grayscale ultrasound view of
the bladder shows a large prostate, which results in nodular indenta- lumen (Fig. 7). On pathology, bacterial cystitis will reveal
tion of the inferior bladder margin. Chronic bladder outlet obstruction abundant bacterial overgrowth and the presence of neutro-
often leads to bladder wall thickening, trabeculations, and diverticula.
b Non-contrast sagittal CT of the pelvis shows a corresponding thick-
phils. Cystitis can also be secondary to an adjacent inflam-
walled bladder and an enlarged prostate, which results in irregularity matory process, such as prostatitis, diverticulitis, colitis, or
of the inferior bladder contour. L bladder lumen, P prostate salpingitis. In cystitis due to Schistosomiasis haematobium,
an inflammatory response is elicited by the deposition of ova
within the bladder lamina propria. Non-infectious causes of
appear more contracted or irregular on sonography than is cystitis include chronic irritation from bladder stones or an
seen in acute cystitis. Infrequently, bladder cancer can cause indwelling catheter or external beam radiation (Fig. 8). On
diffuse bladder wall thickening as well as hyperemia, and pathology, radiation-induced cystitis is distinguished by the
the imaging appearance may overlap with chronic cystitis. presence of enlarged and atypical stromal and endothelial
Correlation with symptoms and patient demographics is cells. The chemotherapy agents ifosfamide or cyclophos-
often helpful in distinguishing cystitis from bladder can- phamide can also cause cystitis [31] (Fig. 9).
cer, particularly favoring the former over the latter when Another iatrogenic source of cystitis is intravesical ther-
the patient is female, has dysuria, and has an identifiable apy with bacillus Calmette-Guerin (bCG), used in the treat-
causative agent, as discussed below. ment of non-muscular invasive bladder cancer. bCG-induced
Infectious cystitis most commonly occurs secondary to cystitis is a frequent complication of this therapy, seen in up
bacteria present on the skin entering the bladder in a retro- to 91% of patients [32]. Given that bladder wall thickening is
grade fashion via the urethra. In severe cases, phlegmonous seen in the setting of cystitis, it can be difficult to distinguish
tissue or an abscess can develop within the bladder wall and

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Fig. 13  44-year-old female with a large bladder calculus. a Trans-

verse grayscale ultrasound view of the bladder shows the anterior
bladder wall and a large round calcified intraluminal mass with
marked posterior acoustic shadowing. b Axial non-contrast CT shows
a large calcified bladder mass, confirmed to represent a large bladder
calculus. Note the presence of a left ureteral stent fragment (C) sur- Fig. 14  87-year-old male with large bladder thrombus. a Transverse
rounded by calcification. The bladder calculus may have formed sec- ultrasound view of the bladder shows a heterogeneous lobulated
ondarily to the presence of this retained distal ureteral stent fragment. mass, confirmed to represent a thrombus on cystoscopy. b Transverse
L bladder lumen, S stone, C calcified ureteral stent ultrasound view of the bladder with color Doppler overlay. Scattered
blue foci over the lesion are artifactual. No vascularity was present
within the mass. L bladder lumen, T thrombus
bCG-induced cystitis from residual/recurrent bladder cancer
in follow-up imaging. multifocal bladder cancer [33, 34] (Fig. 10). A biopsy is nec-
essary to differentiate these entities. While cystitis cystica
Cystitis cystica and cystitis glandularis and glandularis are considered non-neoplastic, there is a
small risk of degeneration to adenocarcinoma, and follow-
Cystitis cystica/glandularis is a non-neoplastic condition that up imaging is therefore warranted [35].
may be a normal variant, or related to chronic infection,
bladder calculi, or chronic bladder outlet obstruction [22]. Bladder outlet obstruction
Cystitis cystica/glandularis can occur at any age, although
there is a slight male predominance. Patients with cystitis Bladder outlet obstruction often presents with urinary reten-
cystica/glandularis typically present with hematuria but can tion and discomfort. Outlet obstruction is often secondary to
also be asymptomatic. benign prostatic hyperplasia (BPH), and is therefore more
When florid, cystitis cystica and glandularis may appear common in males, but can also be secondary to urethral
radiologically or cystoscopically as polypoidal, mass-like strictures or periurethral masses [36].
lesions within the bladder. These lesions most often appear Chronic bladder outlet obstruction commonly pro-
at the bladder trigone [33]. Cystitis cystica and glandula- duces diffuse bladder wall thickening without hyperemia
ris can be indistinguishable from inverted papilloma and/or as well as bladder wall trabeculations (Fig. 11), which

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can be appreciated on ultrasound, CT, or MR. A post-void

residual volume greater than 200 ml, as measured during
sonographic evaluation, is indicative of inadequate empty-
ing of the bladder [37]. Moreover, urinary retention can
cause bladder wall irritation and, when chronic, may also
lead to cystitis.

Bladder diverticulum

Bladder diverticula are focal outpouchings of the blad-

der and are often seen in the setting of chronic bladder
outlet obstruction. The muscularis propria is either absent
or markedly attenuated around the diverticulum. Diver-
ticula are often fluid-filled, clearly communicate with the
bladder lumen, and are therefore easily distinguished from
bladder cancer. Although bladder diverticula are in com-
munication with the bladder lumen, stasis of urine within
the diverticulum may lead to infection, stone formation,
or the accumulation of debris (Fig. 12). This in turn can
lead to chronic irritation, which is again a risk factor for
the development of bladder cancer. Therefore, diverticula
should be scrutinized, particularly in exams ordered for
the workup of hematuria.
Diverticula are easily identified on ultrasound given the
superior spatial resolution, with the ability to identify the
communication of the diverticulum with the bladder lumen.
Identification of a diverticulum on CT or MRI can be dif-
ficult if the neck of the diverticulum is narrow; as a result,
the diverticulum can appear as a cystic mass adjacent to the
bladder. Filling of the diverticulum with contrast on delayed
excretory phase imaging can aid in identification.
The presence of vascularity within the diverticulum, best
evaluated with color Doppler, can help distinguish cancer
from debris. Well-formed stones within a diverticulum are
typically more echogenic than a solid mass, will lack vas-
cularity, and may shadow posteriorly. Twinkling artifact is
often seen associated with layering debris and can be a help-
ful clue to the presence of debris. Twinkling artifact should
not be mistaken for true vascularity however and spectral
Doppler interrogation may be performed to distinguish
Fig. 15  63-year-old male with large bladder thrombus. a Transverse between the two entities. Layering debris within a diver-
grayscale ultrasound view of the bladder shows a large, hypoechoic, ticulum may be hyperattenuating on CT; on MRI, the layered
well-circumscribed mass within the bladder. b Transverse ultrasound debris is best appreciated as hypointense layered material on
view of the bladder with color Doppler overlay shows no vascular-
T2-weighted images. The debris will not enhance on post-
ity within the mass. c Axial contrast-enhanced CT confirms a large
rounded mildly hyperdense intraluminal mass confirmed to represent contrast CT or MRI.
large thrombus on cystoscopy. The patient had a history of clear cell
renal cell carcinoma status post partial nephrectomy complicated by Bladder stones
a pseudoaneurysm, which caused hematuria and led to the bladder
thrombus. L bladder lumen; T thrombus
Bladder stones, or calculi, are often seen in the setting of
bladder outlet obstruction, a neurogenic bladder, or in the
presence of a foreign body. The resulting urinary stasis leads
to the precipitation of stones. Stones within the bladder
lumen can cause irritation and lead to cystitis; such irritation

13
Abdominal Radiology

Fig. 16  46-year-old female with an endometriosis implant in the blad- the anterior bladder wall. d Histologic section shows endometriosis
der wall. a Transverse grayscale ultrasound shows a rounded hetero- as evidenced by endometrial gland with a cuff of endometrial stroma
geneously hypoechoic mass indenting the anterior bladder wall. b within the detrusor muscle. Histocytes and acellular debris are seen
Axial contrast-enhanced CT and c axial contrast-enhanced T1W MR in the lumen. H&E, original magnification ×200. L bladder lumen,
of the bladder similarly show a heterogeneous enhancing mass along M mass

and inflammation increase the risk of developing bladder and their migration to a dependent location between supine
cancer. Patients with bladder stones can be asymptomatic, or and lateral decubitus positions.
may present with pain, urinary tract infections, or hematuria.
Bladder stones are typically highly echogenic in appear- Thrombus
ance and have associated posterior acoustic shadowing
(Fig. 13). On CT, the stones will be hyperattenuating and, Thrombus, or blood clot, within the bladder presents with
on MR, will have very low signal on T1 or GRE sequences. gross hematuria. Bladder thrombus has a myriad of causes.
On occasion, bladder stones may be mistaken for a calcified Most commonly patients have a history of anticoagulation
bladder cancer. As previously mentioned, calcifications are use or may present with renal or bladder trauma, such as
present in approximately 5% of bladder cancers [15]. To recent traumatic Foley catheter placement.
distinguish bladder stones from bladder cancer, ultrasound Thrombus within the bladder lumen can mimic bladder
is an ideal imaging modality to show the mobility of stones cancer (Fig. 14), particularly when polypoid in appearance.
A chronic bladder thrombus can appear well-circumscribed

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 Abdominal Radiology

(Fig. 15). However, unlike bladder cancer, intraluminal

thrombus is often mobile and will lack internal blood flow.
The lesion will not enhance with contrast on CT or MR
imaging. Unlike stones, the thrombus will not exhibit pos-
terior acoustic shadowing.

Endometriosis

Endometriosis is defined as ectopic endometrial glands,

located anywhere outside of the uterine cavity. Approxi-
mately 10% of reproductive age women have endometrio-
sis, typically between the ages of 30 and 45 years [38]. The
urinary tract is involved in 1% of women with endometrio-
sis, and bladder involvement is the most frequent site of
urinary tract endometriosis [39]. Women may present with
suprapubic pain and a unique clinical presentation of hema-
turia occurring only during menstruation, also known as
“catamenial hematuria.”
On ultrasound, a bladder endometrioma can appear as a
hypoechoic area of bladder wall thickening but more com-
monly appears as a hypoechoic spherical or comma-shaped
mass [40]. The lesion can have an irregular border and
appear similar to bladder cancer. The lesion is often out-
lined by the echogenic layers of the bladder wall (Fig. 16),
whereas bladder cancer often lacks such a boundary.
Depending on the time of the patient’s menstrual cycle, the
degree of vascularity and size of the lesion may fluctuate.
On T1-weighted MRI imaging, hyperintense foci within the
mass can help confirm chronic blood products, which may
help to distinguish an endometrioma from other bladder
tumors [41]. Bladder endometriomas are most commonly
present along the posterior aspect of the bladder, extending
directly from the uterus, but can occur anywhere along the
bladder wall (Fig. 16).
On pathology, a bladder endometrioma is evidenced by
the presence of endometrial glands. Involvement of the det-
rusor muscle may be seen.

Tuberculosis

Tuberculosis of the urogenital tract is the third most com-

mon form of extrapulmonary tuberculosis after nodal and
pleural involvement [42]. Tuberculosis affects the urogeni-
tal tract in 2–20% of patients with pulmonary tuberculosis
Fig. 17  48-year-old female with bladder tuberculosis. a Transverse [42, 43], and has a 2:1 male predominance with a mean age
grayscale ultrasound of the bladder shows asymmetric irregular of 40 years [44]. Risk factors for bladder tuberculosis are
thickening of the posterior bladder wall. b Axial non-contrast CT in the same as for pulmonary tuberculosis, and includes indi-
the same patient shows irregular thickening of the left posterolateral viduals from developing nations, as well as immunocompro-
bladder wall. c Pathologic specimen of the bladder confirms bladder
tuberculosis, with florid granulomatous inflammation and a central mised patients, particularly those inflicted with HIV/AIDS.
multinucleated giant cell (arrow). Acid-fast stain in inset (bottom left) Bladder tuberculosis most often causes an irregular asym-
shows several AFB-positive organisms (red). Original magnification metric bladder wall (Fig. 17); in advanced cases, extreme
H&E ×200, AFB inset ×630. L bladder lumen, T thickening of the fibrosis of the bladder walls results in marked contraction
bladder wall
and small capacity of the bladder lumen, the so-called

13
Abdominal Radiology

“thimble bladder,” which results in urinary frequency and 9. Bladder cancer: diagnosis and management of bladder cancer:
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On pathology, tuberculosis of the bladder is denoted by org/10.1111/bju.14045​
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Acid-fast stain reveals AFB-positive organisms of Mycobac- tality among racial and ethnic minorities in 21 states. Am J Ind
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Heaney J, Kelsey KT, Karagas MR (2007) Analgesic and anti-
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