Urinary bladder

Question 1

4. Infltrating papillary TCC is diagnosed from a mass at the renal pelvis. Which is the single best answer?

A. 50% of TCC are infltrating papillary tumours

B. Have a broad base and frond-like morphology

C. On CT have a density lower than urine and higher than renal parenchyma

D. CT value of TCC is around 50-60 HU

E. Demonstrate avid enhancement post-contrast

Answer 1

B. Have a broad base and frond-like morphology

Over 85% of TCCs are infltrating papillary tumours.

CT density is 8-30 HU, slightly higher than urine and lower than renal parenchyma.

Post-contrast there is mild to moderate enhancement to 18-55Hu

Question 2

5. Which of the following favours a diagnosis of infiltrating papillary TCC rather than ureteral endometriosis?

A. Age 35 years

B. An intramural nodule

C. Soft tissue component outside ureter larger than in it

D. High signal intensity on T1 and ‘shading’ on T2

E. Location in proximal third of ureter

Answer 2

E. Location in proximal third of ureter

Ureteral endometriosis is usually in childbearing age and in the lower third of ureters, often co-existent with other
sites of abdominal and pelvic disease.

Question 3

42. Regarding retroperitoneal fbrosis(RPF):

A. Is common in females in the primary form

B. Beta-blockers are a common cause

C. Desmoplastic response to malignancy is the most common case in secondary RPF

D. Causes lateral deviation of the mid ureter

E. In the primary form responds to steroids

Answer 3

E. In the primary form responds to steroids

Two thirds of cases of RPF are primary and one third are secondary.

Both forms are more common in males.

Secondary causes include drugs such as methysergide, beta-blockers, phenacetin.

Medial deviation of the ureter occurs in the mid third.

Question 4

8. Which of the following indicates T3 disease in a 66-year-oldman with bladder cancer?

A. Tumour size 2.5cm

B. Tumour invading inner half or superfcial muscle

C. Invasion of perivisical fat

D. Tumour invading deep muscle

E. Invasion of the rectum

Answer 4

C. Invasion of perivisical fat

Invasion of perivesical fat indicates T3 disease.

Invasion of surrounding organs, pelvic or abdominal wall is T4 disease.

T1-T2b tumours are treated with a conservative approach including TURB and local chemotherapy,
whereas radical cystectomy and urinary diversion are reserved for invasive cancer.

Question 5

48. A 40-year-old diabetic presents with Urinary Tract Infection (UTI). Abdominal radiograph demonstrates
    small rounded curvilinear lucencies outlining the bladder wall. What is the diagnosis?

A. Emphysematous cystitis

B. Enterovesical fstula

C. Penetrating trauma

D. Post-cystoscopy

E. Pneumatosis intestinalis

Answer 5

A. Emphysematous cystitis

Emphysematous cystits occurs more commonly in females and is usually due to E.coli. Gas is present in the
bladder mucosal lumen. On ultrasound there is a thickened bladder wall with echogenic foci and acoustic
shadowing.

Question 6

14) A 60-year-old male, treated long term for hypertension with hydralazine, develops bilateral hydronephrosis.
On CT KUB, the ureters are deviated medially and obstructed by a large, plaque-like, para-aortic, soft-tissue
density. The aorta appears ‘taped-down’ to the vertebral column rather than elevated by the para-aortic tissue.
Which of the following is the most likely diagnosis?

a. enlarged retroperitoneal lymph nodes due to Hodgkin’s disease

b. enlarged retroperitoneal lymph nodes due to non-Hodgkin’s lymphoma

c. retroperitoneal fibrosis

d. bilateral ureteral transitional cell carcinoma

e. metastatic lymph node enlargement from testicular embryonal cell carcinoma

Answer 6

c. retroperitoneal fibrosis

Retroperitoneal fibrosis can cause extrinsic compression of both ureters and retroperitoneal vascular structures such as the aorta, inferior vena cava and iliac vessels.

It can be idiopathic or secondary to inflammatory aortic aneurysm, retroperitoneal metastases, haemorrhage, abscess, urinoma, diverticulitis, appendicitis, Crohn’s disease, and drugs such as ergot alkaloids and hydralazine.

Malignant retroperitoneal lymphadenopathy causing ureteric obstruction tends to encircle the aorta, elevating it off the vertebral column.

In contrast, retroperitoneal fibrosis rarely extends between the aorta and the vertebrae, therefore appears to tape the aorta down to the spine.

Question 7

16) On CT performed for staging purposes, a primary bladder tumour involves bladder muscle without perivesical
extension. Malignant enlarged lymph nodes of 4 cm greatest dimension in the ipsilateral internal iliac and 1.5 cm
greatest dimension in the common iliac lymph node groups are present. Which of the following is the most
accurate TNM stage?

a. T1 N1 M0

b. T2 N1 M0

c. T2 N2 M0

d. T2 N1 M1

e. T3 N1 M0

Answer 7

c. T2 N2 M0

Bladder cancer achieves the T3 status by perivesical involvement.

The N status is determined by the greatest dimension of the regional nodes.

When the greatest dimension is less than or equal to 2cm, the nodal status is N1.

N2 is for regional nodes measuring 2–5cm.

N3 is achieved when the greatest dimension of the largest regional node is more than 5cm.

Inguinal and retroperitoneal nodes are staged as metastases

Question 8

21) A patient is found to have a renal pelvis transitional cell carcinoma. The cancer invades adjacent renal
parenchyma and extends into perinephric fat. No significantly enlarged lymph nodes and no metastases are seen
on CT of the chest, abdomen and pelvis. Which of the following is the overall stage for this patient’s disease?

a. I

b. II

c. III

d. IV

e. V

Answer 8

d. IV

In the TNM staging of urothelial malignancies, T1 refers to invasion of the subepithelial connective tissue,
whereas a T2 tumour invades the muscularis. T3 tumours in the renal pelvis invade the peripelvic fat or renal
parenchyma, whereas those in the ureter invade the periureteric fat. T4 tumours invade adjacent organs or
perinephric fat, as in this case. For renal and ureteric transitional cell carcinoma, the group stages I–III are
determined by the T status, all these stages having no involved nodes and no metastases. T4 primaries or any
involved nodes or metastases give stage IV disease. There is no stage V.

Question 9

@# 41) A patient with a lower ureteric transitional cell carcinoma has an MRI for locoregional staging purposes and a CT of the abdomen and pelvis for lymph node involvement and metastases. An 8 mm short axis node is recorded. In which of the following abdominopelvic groups would this be significant by size criteria?

a. inguinal

b. common iliac

c. external iliac

d. internal iliac

e. retroperitoneal

Answer 9

d. internal iliac

A short axis measurement of 7mm or greater represents significant enlargement of internal iliac nodes.

Regarding other nodal regions, significant enlargement

for inguinal nodes is 10mm,

for common iliac 9mm,

for external iliac 10mm,

for obturator 8mm

and for retroperitoneal nodes between renal arteries and the aortic bifurcation 12mm.

In addition to size, there may be morphological clues to nodal involvement by cancer.

Clustering of nodes, round nodes, nodes with irregular capsules, and nodes sharing CTor MRI characteristics of the primary tumour (attenuation, signal, cystic or necrotic changes, and contrast-enhancement pattern) are features suggesting lymph node involvement

Question 10

48) A CT KUB is performed on a 55-year-old South African man with unilateral loin pain. This demonstrates
moderate ipsilateral hydroureteronephrosis with a stricture in the distal ureter. There is also widespread bladder
calcification and bilateral distal ureter calcification. The responsible organism is most likely to be which of the
following?

a. Escherichia coli

b. Schistosoma mansoni

c. Schistosoma haematobium

d. Schistosoma japonicum

e. Mycobacterium tuberculosis

Answer 10

c. Schistosoma haematobium

Schistosomiasis (bilharzia) is a parasitic infection that, worldwide, is the commonest cause of bladder wall
calcification. Schistosoma japonicum and S. mansoni cause gastrointestinal tract infection, while S. haematobium
affects the genitourinary tract. Schistosomiasis is endemic in South Africa, Egypt, Nigeria, Tanzania, Zimbabwe
and Puerto Rico. The calcification spreads proximally up the ureters. In contrast, tuberculosis begins in the
kidneys and spreads distally. Transitional cell carcinoma and cyclophosphamide-induced cystitis also cause
bladder wall calcification. Causes of calcification within the urinary bladder lumen include stones and encrusted
foreign bodies such as catheter balloons

Question 11

53) An 80-year-old man undergoes cystoscopy for macroscopic haematuria. He is found to have a 6 cm bladder
tumour, biopsy of which confirms small-cell bladder cancer. He is considered suitable for radical treatment.
Which of the following is the most appropriate staging strategy?

a. whole-body PET/CT

b. MRI of the bladder

c. MRI of the bladder plus CT of the abdomen and pelvis with intravenous contrast

d. MRI of the bladder plus CT of the chest, abdomen and pelvis with intravenous contrast

e. MRI of the bladder plus CT of the brain, chest, abdomen and pelvis with intravenous contrast

Answer 11

d. MRI of the bladder plus CT of the chest, abdomen and pelvis with intravenous contrast

MRI is indicated for local (in fact locoregional) staging. CT of the chest is required in addition to the abdomen
and pelvis because of the histological tumour type. 18FDG PET is not useful for staging urothelial tumours
because of the urinary excretion of this radiotracer

Question 12

57) Cystoscopy is attempted on a 65-year-old female for persistent microscopic haematuria, but the scope cannot
be advanced along the urethra. A biopsy is taken and MRI is performed. Axial T2W images show a mass of high
signal intensity disrupting the normal, target-like, zonal anatomy of the urethra. Which of the following cell types
is the most likely histology from the biopsy?

a. squamous cell

b. transitional cell

c. adenocarcinoma

d. clear cell

e. mastocyte

Answer 12

a. squamous cell

Urethral tumour is rare and occurs more in women than in men. Squamous cell carcinoma is the most common
histological type followed by transitional cell carcinoma and then adenocarcinoma. MRI is the technique of choice
for local staging.

Question 13

19 An 80 year old woman presents with vague lower abdominal pain. AXR shows translucent linear streaky areas
in the pelvis. USS shows a thickened bladder wall with echogenic foci within it. CT demonstrates areas of gas
within the bladder wall. Which of the following is not consistent with the described condition?

(a) Diabetes mellitus

(b) The patient’s demographics

(c) Staphylococcal infection

(d) Tuberculosis

(e) Bladder outlet obstruction

Answer 13

(d) Tuberculosis

Emphysematous cystitis is usually seen in women over the age of 50 with poorly controlled diabetes mellitus.
Other risk factors include neurogenic bladder and recurrent UTls. Causes other than infection include trauma, recent instrumentation and enterovesical fistula. Classically the organism is E. coli, but a variety of organisms including Staphylococcus, Streptococcus, Klebsie/la and Clostridium perfringens have been described.

TB causes an irritable hypertonic low capacity bladder and occasionally calcification of the bladder wall is seen.

Question 14

25 A 30 year old patient is admitted with multiple stab wounds to the lower abdomen. His pulse is 110/ min and
his blood pressure 80/40 mm Hg after fluid resuscitation. He has frank haematuria. A urethral catheter is passed
freely and a normal cystogram performed in the emergency department. Initial CT in the portal venous phase with
shows free fluid in the pelvis towards the right side but no major injury to the solid viscera. A ureteric injury is
suspected. Which imaging investigation would you recommend next?

(a) Single shot IVU

(b) Full IVU with delayed phase imaging

(c) Ultrasound kidneys

(d) Retrograde ureterogram

(e) Nephrostomy insertion followed by nephrostogram

Answer 14

(a) Single shot IVU

Traumatic ureteric injury is extremely rare. In this situation with an unstable patient who will imminently require
emergency surgery, a one shot IVU to localize the injury should be performed. If the patient was clinically stable,
either CT with delayed phase imaging or a full IVU could be performed.

Question 15

26 A 60 year old man presents with frank haematuria. Cystoscopy demonstrates a transitional cell carcinoma of
the bladder. Which of the following statements is true regarding his staging investigations?

(a) CT has no role

(b) Extension of the tumour into the outer half of the muscle layer is stage T2a disease

(c) At MRI tumour is isointense to muscle on T1W and hyperintense on T2W

(d) T2W is the optimal sequence to detect extension into perivesical fat

(e) T1W is the optimal sequence to assess depth of muscle invasion

Answer 15

(c) At MRI tumour is isointense to muscle on T1W and hyperintense on T2W

MRI is the local staging investigation of choice.

T2W is good for assessment of degree of muscle invasion and differentiating tumour from fibrosis, whilst T1 W is good for assessing invasion into the perivesical fat.

T2a disease involves the inner half of the muscle layer; T2b the outer half and T3 describes invasion of the perivesical fat.

Question 16

4 A 46 year-old woman presents with abdominal pain, .dysuria and abdominal distension. A plain AXR is
performed, which shows air within the right ureter and renal pelvis. Which of the following is the least likely
aetiology?

(a) Caecal tumour

(b) Urinary tract infection with Clostridium spp.

(c) Meckel’s diverticulum

(d) Pelvic actinomycosis

(e) Small bowel MALT

Answer 16

(e) Small bowel MALT

The finding of air within the right ureter and pelvis implies either a colovesical fistula, or UTI by a gas-producing organism.

Diverticulitis is the commonest cause of a colovesical fistula (of which Meckel’s diverticulum can be
a rare cause).

Colorectal tumour, Crohn’s disease, ulcerative colitis, previous radiotherapy, and pelvic infection/infective colitis are other causes.

Lymphoma typically encases bowel and blood vessel and is cause fistulation.

Question 17

@# 14 A 50 year old woman is found to have multiple, round, well defined filling defects in her left ureter on IVU.
Which of the following is the least likely diagnosis?

(a) Emphysematous ureteritis

(b) Ureteritis cystica

(c) Malakoplakia

(d) Leukoplakia

(e) Cervical carcinoma

Answer 17

(a) Emphysematous ureteritis

The differential diagnosis for ureteric filling defects also includes TCC and radiolucent calculi. Emphysematous
ureteritis typically causes streak like filling defects on IVU.

Question 18

19 A 48 year old man presents with urinary frequency, urgency and dysuria. A cystogram demonstrates superior
and anterior displacement of the bladder with a ‘teardrop’ appearance. IVU shows medial displacement of the
distal ureters with mild bilateral hydronephrosis. What is the likeliest diagnosis?

(a) Liposarcoma

(b) Lipoblastoma

(c) Pelvic lipomatosis

(d) Hibernoma

(e) Teratoma

Answer 18

(c) Pelvic lipomatosis

A ‘teardrop’ or ‘pear’ shaped bladder on cystography is the classic finding of pelvic lipomatosis.

CT shows symmetrical abundant intrapelvic fat.

Lipoblastomas are rare soft tissue neoplasms derived from foetal adipose tissue, seen in children.

Hibernomas are rare benign, soft tissue tumours composed of brown fat, that present in adult as a firm, painless, slowly growing mass.

Question 19

22 Regarding traumatic urethral injury, which of the following statements is true?

(a) It occurs in 1 % of all pelvic fractures

(b) The posterior urethra is more commonly injured than the anterior

(c) It is equally common in males and females

(d) It is associated with bladder rupture in 50% of cases

(e) At urethrography, the AP view provides most information

Answer 19

(b) The posterior urethra is more commonly injured than the anterior

Urethral trauma is common in the presence of pelvic fractures (up to 24%) and typically presents with haematuria,
meatal blood, perinea! swelling or a high riding prostate on DRE in men and labial oedema, vaginal bleeding or
urinary leak PR in women. It is more common in men and the posterior urethra, particularly the distal membranous
urethra is most commonly injured. It is associated with bladder rupture in 20%. At urethrography, if the patient
is able, a right or left anterior oblique view is commonly employed.

Question 20

38 A 35 year old man is involved in a high speed RTA and sustains a Malgaigne’s type pelvic fracture. A small
urethral catheter is successfully passed in the emergency department. The patient subsequently develops dark
haematuria. Which of the following statements is true?

(a) The haematuria is most likely to be related to catheter trauma

(b) 70% of patients with pelvic fractures have a bladder rupture

(c) At cystography, widening of fat planes of obturator internus on control film suggests intraperitoneal rupture

(d) Extraperitoneal rupture accounts for 40% of traumatic bladder injuries

(e) 10% of ruptures can only be detected after emptying the bladder of contrast medium at cystography

Answer 20

(e) 10% of ruptures can only be detected after emptying the bladder of contrast medium at cystography

High velocity trauma with a significant pelvic fracture means that bladder injury must be excluded. 70% of
traumatic bladder ruptures are associated with pelvic fracture. On control film at cystography, widening of the fat
planes of obturator internus along with a homogeneous soft tissue density and displacement of ileal loops suggest
extraperitoneal rupture. Overall, extraperitoneal ruptures account for 80% of ruptures. 10% of ruptures are
detected on post micturition imaging only.

Question 21

48 A 70 kg, 55 year old man undergoes a CT KUB for suspected ureteric colic. Reviewing the study, with the
patient on the table, an opacity is identified on the side of the pain which lies approximately 5 cm from the VUJ,
however it is difficult to be certain whether or not the opacity lies within the ureter. Which of the following is the
next best step?

(a) Repeat unenhanced examination with the patient prone

(b) Repeat examination post i. v. contrast medium, acquiring at 50s post administration

(c) Repeat examination post i. v. contrast medium, acquiring at 100s post administration

(d) Repeat unenhanced examination in 24 hours

(e) Repeat examination with post i.v. contrast medium, acquiring at 300s post administration

Answer 21

(e) Repeat examination with post i.v. contrast medium, acquiring at 300s post administration

Although exact techniques vary from department to department, the principles remain the same. In this situation,
an excretory phase image is required to determine whether or not the opacity is in the ureter. This phase begins
at 240 secs post contrast administration. The nephrographic phase (80-120 secs) provides homogeneous
enhancement of the parenchyma and is best for identifying parenchymal lesions. Turning the patient prone can
be useful in delineating VUJ calculi and is performed routinely in some centres.

Question 22

56 A 50 year old man presents with chronic dull flank pain. US shows normal sized kidneys with mild prominence
of their calyces. IVU shows ureterectasis above L4, medial displacement of the ureters bilaterally in their middle
thirds and subsequent distal tapering. CT shows a retroperitoneal periaortic mass of attenuation similar to muscle.
What is the most likely diagnosis?

(a) Retroperitoneal fibrosis

(b) Lymphoma

(c) Liposarcoma

(d) Leiomyoma

(e) Amyloid

Answer 22

(a) Retroperitoneal fibrosis

Retroperitoneal fibrosis may be primary (2/3 of cases) where it may be associated with fibrosis in other organ
systems, or secondary to drugs, radiation therapy or a desmoplastic reaction to local tumours.

Question 23

57 A 52 year old woman presents with a suprapubic mass. CT shows a 6 cm mass lying anterosuperior to the
bladder extending along the course of the urachus. The mass demonstrates heterogeneous enhancement and has
peripheral stippled psammomatous calcifications within it. Which of the following is the likeliest histological
subtype?

(a) Transitional cell carcinoma

(b) Papillary cell carcinoma

(c) Adenocarcinoma

(d) Squamous cell carcinoma

(e) Teratoma

Answer 23

(c) Adenocarcinoma

Urachal carcinoma is a relatively rare tumour characterized by a midline suprapubic mass that may or may not
invade the bladder. 10% lie at the umbilical end. Peripheral curved or stippled calcifications are pathognomonic
of the mucinous adenocarcinoma subtype which may be complicated by pseudomyxoma peritonei.

Question 24

58 A 50 year old recent immigrant from Tanzania presents with a history of vague flank pain. CT KUB shows
coarse calcification in a thickened bladder wall with extension of the calcification into the walls of the distal
ureters. What is the least likely diagnosis?

(a) Tuberculosis

(b) Transitional cell carcinoma

(c) Schistosomiasis

(d) Lymphoma

(e) Histoplasmosis

Answer 24

(c) Schistosomiasis

Although schistosomiasis is rare in the west, it is the commonest cause of mural calcification worldwide. TB
causes calcification relatively rarely. TCC can cause mural calcification but this is usually thin curvilinear
calcification outlining a normal sized bladder

Question 25

59 A 60 year old diabetic woman presents with a history of recurrent coliform UTls. CT urogram shows multiple smooth dome shaped filling defects within the bladder and both distal ureters. At ureteroscopy the lesions have a yellow appearance and biopsy demonstrates the presence of Michaelis-Gutmannbodies. What is the likely diagnosis? (a) Polureteritis cystica (b) Actinomycosis (c) Squamous cell carcinoma (d) Malakoplakia (e) Leukoplakia

Answer 25

(d) Malakoplakia A rare condition characterised by altered host response to infection (E. coli in 94%) at the macrophage level. It is multifocal in 75% and bilateral in 50%. Renal involvement is less common, is usually unilateral, and is characterised by diffuse renal enlargement with displacement and distortion of the pelvi-calyceal system

Question 26

8. An 84 year old diabetic female is investigated for recurrent E. coli urinary tract infections and microscopic haematuria. An intravenous urogram is performed, which shows numerous small filling defects in the ureter and small mural plaque-like defects within the bladder. Which one of the following is the most likely diagnosis? a. Malakoplakia b. Leukoplakia c. Emphysematous cystitis d. Emphysematous pyelonephritis e. Pyeloureteritis cystica

Answer 26

8. a. Malakoplakia Malakoplakia is the most likely diagnosis based on the history provided. This is a rare granulomatous infection affecting elderly females with a history of E. coli infections. It primarily affects the bladder, and affects the remainder of the renal tract with decreased incidence as one progresses proximally. Leukoplakia may have similar appearance, but is more common in males with bladder involvement, and is characterised by the passage of gritty soft-tissue flakes. Pyeloureteritiscystica typically produces multiple round filling defects rather than plaques.

Question 27

16. A 36 year old man suffers pelvic fracture following a road traffic accident. On examination, blood is noted at the urethral meatus and the patient has urinary retention. Regarding urothelial injuries: a. Associated bladder injuries are seen in 50% of patients b. Anterior urethral injuries are commoner with pelvic fractures c. They are more commonly associated with pelvic fractures in females rather than males d. Posterior urethral injuries can be seen in up to 20% of pelvic fractures in males e. Impotence is a rare complication of male urethral injury

Answer 27

16. d. Posterior urethral injuries can be seen in up to 20% of pelvic fractures in males Urethral injuries are seen in up to 20% of male patients following pelvic fractures. They are much less common in women. The posterior urethra is the commonest site; impotence can develop in up to 40% of these patients.

Question 28

20. A 31 year old male is involved in a road traffic accident. The patient was catheterized immediately in A&E and the bladder was found to be empty. A trauma series CT is requested and a left-sided pelvic fracture is noted. A CT cystogram is therefore performed and bladder rupture is diagnosed. Which of the following signs would be an unexpected finding with this history? a. Contrast extravasation into the paracolic gutters b. Contrast extravasation into the perivesical fat c. Contrast extravasation into the anterior abdominal wall d. Flame-shaped contrast extravasation e. Contrast extravasation into the upper thigh

Answer 28

20. a. Contrast extravasation into the paracolic gutters Extraperitoneal rupture of the bladder is associated with pelvic fractures following trauma and cystography should be performed if this is suspected. The injury is usually at the base of the bladder, anterolaterally. Contrast is seen to extravasate with a streaky or flame-shaped appearance and collects in the space of Retzius, upper thighs, inguinal regions, perivesical fat and anterior abdominal wall. Contrast in the paracolic gutters suggests intraperitoneal rupture of the bladder. This is associated with a different method of injury, typically rupture at the bladder dome following blunt trauma with a distended bladder or secondary to iatrogenic injury such as cystoscopy.

Question 29

28. A 60 year old female presents with a large abdominal mass. CT demonstrates a large retroperitoneal fatcontaining mass. Which of the following is true about the different fat-containing retroperitoneal masses? a. Predominantly low signal on T1-weighted and a high signal on T2-weighted images preclude a diagnosis of liposarcoma b. Calcification within a liposarcoma is usually associated with a better prognosis c. Lipomas are rare in the retroperitoneum d. An extremely FDG-avid retroperitoneal fat-containing tumour is almost certainly a liposarcoma e. Given time, most lipomas will dedifferentiate into liposarcomas

Answer 29

28. c. Lipomas are rare in the retroperitoneum Liposarcomas are the most common sarcomas in the retroperitoneum. Whilst welldifferentiated liposarcomas are the commonest, myxomatous and dedifferentiated liposarcomas can have varying appearances and so low T1- weighted signal does not preclude a diagnosis of liposarcoma. Lipomas, whilst exceedingly rare in the retroperitoneum, almost undergo malignant changes. Whilst liposarcomas can have minimal-to-increased FDG uptake, a very FDG-avid fat-containing retroperitoneal tumour is quite likely a hibernoma.

Question 30

33. A 29 year old male has microscopic haematuria and symptoms suggesting left ureteric colic. An unenhanced CT abdomen and pelvis is requested. A 4 mm calcific density is seen near the bladder in the left hemi-pelvis. Which one of the following signs may be useful to help differentiate between a phlebolith and ureteric calculi? a. Lobster claw sign b. Soft-tissue rim sign c. Signet ring sign d. Nubbin sign e. Drooping lily sign

Answer 30

33. b. Soft-tissue rim sign The soft-tissue rim sign is thickening of the ureteric wall around the calculus due to oedema. It has a reported specificity of up to 92% for renal calculi. Other signs that mayfavour a diagnosis of ureteric calculi include asymmetrical perinephric fat stranding, periureteral oedema, hydronephrosis and unilateral renal enlargement. The lobster claw and signet ring signs concern papillary necrosis on intravenous urogram. The nubbin and drooping lily signs both refer to ureteral duplication.

Question 31

43. A 49 year old African male presents to the outpatient urology clinic with a five-month history of macroscopic haematuria. A plain KUB X-ray is requested, which reveals thin arcuate calcification outlining the bladder and the distal ureters. Which one of the following causes is most likely? a. Transitional cell carcinoma b. Squamous cell carcinoma c. Schistosomiasis d. E. coli cystitis e. Proteus cystitis

Answer 31

43. c. Schistosomiasis The differential for bladder calcification includes tuberculosis, post-radiotherapy cystitis, urachal carcinoma, TCC, and squamous cell carcinoma. However, schistosomiasis is the commonest cause, especially in the African population, where it is often endemic. The bladder is usually a normal size and shape, with thin curvilinear calcifications. Ureteric strictures, inflammatory pseudopolyps and vesicoureteric reflux are seen in addition to bladder and ureteric calcification

Question 32

52. A 58 year old man presents with haematuria and suprapubic pain. Ultrasound reveals the presence of an area of bladder wall thickening and a mobile avascular mass within the urinary bladder. A degree of right hydronephrosis is also demonstrated. Which of the following is true regarding transitional cell carcinoma (TCC)? a. The ureter is the second commonest site of TCC after the urinary bladder b. TCC is the most common tumour of the urinary tract c. In the ureter, the lower ureter is the commonest site d. It is the commonest tumour arising in the urachus e. Previous schistosomiasis is a well-recognised risk factor

Answer 32

52. b. TCC is the most common tumour of the urinary tract TCC is the commonest cancer in the urinary tract. Whilst a predominant majority of them develop in the bladder, the renal pelvis is the second commonest site. In the ureter, the upper ureter is the commonest site. Adenocarcinoma is the commonest tumour in urinary tract. Schistosomiasis is associated with SCC.

Question 33

53. A 60 year old patient with a history of previous urinary tract interventions presents with right hydronephrosis and deranged renal function. Imaging suggests a mid-ureteric stenosis. An MR urogram is planned. Which of the following is true? a. A static-fluid MR urography is performed using gadolinium-enhanced T1-weighted imaging b. Excretory MR urogram is preferred in patients with severe renal impairment c. T1-weighted imaging is useful in differentiating between clot and calculi d. Renal sinus cyst can be differentiated from dilated intrarenal collecting system on T1-weighted imaging e. Smaller filling defects are better seen on the MIP images rather than the source data

Answer 33

53. c. T1-weighted imaging is useful in differentiating between clot and calculi A static-fluid MR urogram is a heavily T2-weighted technique similar to MRCP. Excretory urogram is a postgadolinium injection T1-weighted technique. A static-fluid MR urogram is preferred in patients with renal failure. Renal sinus cysts cannot often be differentiated from dilated intrarenal collecting systems on T1-weighted and T2-weighted images. They are better appreciated on the excretory urogram. Source data should be reviewed to ensure that small filling defects are not missed.

Question 34

QUESTION 2 A 65-year-old man with transitional cell carcinoma of the bladder undergoes a pelvic MRI. On Tlw sequences, there is a 2-cm papillary bladder wall growth that returns signal intensity higher than that of the surrounding urine and extends into the bladder wall. On T2w sequences, an uninterrupted low signal intensity line clearly separates the tumour from the surrounding perivesical fat. No perivesical stranding is seen. Which one of the following options best describes the staging of the tumour? A T2a B T2b C T3a D T3b E T4a

Answer 34

C T3a MRI is the most accurate imaging modality to differentiate T3a from T3b carcinoma. On T2w sequences, an uninterrupted low signal intensity bladder wall seen between the tumour and the surrounding fat excludes extension into the perivesical fat, limiting the tumour to stage T3a.

Question 35

QUESTION 14 A 58-year-old man recently migrated to the UK from Kenya. He has been experiencing haematuria, weight loss and dysuria for several months. A series of imaging investigations are requested by the urologists and reveal evidence of renal tract TB. Which one of the following statements best describes the likely radiological findings in renal tract tuberculosis? A A chest radiograph is normal in 75—80% of cases. B Bladder calcification is more commonly seen than renal or ureteric calcification. C Free vesicoureteric reflux into a widely dilated upper renal tract is frequently seen. D Tramline calcification is seen within the seminal vesicles. E Findings usually present as bilateral renal tract disease.

Answer 35

C Free vesicoureteric reflux into a widely dilated upper renal tract is frequently seen.

Question 36

QUESTION 18 A 37-year-old man presents with right flank pain, fever and tenderness. On a contrast-enhanced CT abdomen, there is a ring-enhancing mass just anterior to Gerota's fascia but posterior to the parietal peritoneum on the right. In which fascial compartment does the abnormality lie? A Anterior pararenal space B Anterior perinephric space C Anterior subcapsular space D Posterior pararenal space E Posterior perinephric space

Answer 36

A Anterior pararenal space The anterior pararenal space lies between the posterior parietal peritoneum anteriorly and Gerota's fascia posteriorly. This space is only partially closed; medially by fusion of the fascial planes along the aorta and IVC and laterally by the lateroconal fascia.

Question 37

QUESTION 33 A 22-year-old woman is kicked in the abdomen during an attempted robbery. She presents with haematuria and a triple-phase CT abdomen (arterial, portal venous and delayed phases) shows a left ureteric injury. What level is the ureteric injury most likely to be at? A At the level of the ischial spines B Lower third of the ureter C Middle third of the ureter D Pelviureteric junction E Vesicoureteric junction

Answer 37

D Pelviureteric junction Ureteric injury associated with blunt trauma typically occurs at the pelviureteric junction. Hyperextension with overstretching of the ureter or compression of the ureter against the lumbar transverse processes is the likely mechanism.

Question 38

@#e QUESTION 34 A 68-year-old man is involved in a traffic accident and sustains a pelvic fracture, head and limb injuries. Attempted urethral catheterisation in the Emergency Department is unsuccessful and a cystourethrogram is requested to exclude urethral injuries. Regarding urethral injuries, which one of the following statements is correct? A Anterior urethral injury is more commonly due to iatrogenic or penetrating trauma than to blunt traiima. B Cystography should precede a retrograde urethrogram in a patient with suspected urethral injury. C In men, on digital rectal examination the prostate is lower than normal in patients with urethral trauma. D Urethral injuries occur in 50% of major pelvic fractures. E Urethral injury due to blunt trauma more commonly affects the penile urethra.

Answer 38

A Anterior urethral injury is more commonly due to iatrogenic or penetrating trauma than to blunt traiima.

Question 39

QUESTION 36 A 54-year-old man attends the Radiology Department for an ascending urethrogram. He has a past histoiy of previous urethral stricture and urethroplasty at a different hospital and has now developed recurrent lower urinary tract symptoms. Which one of the following statements regarding urethral strictures is true? A Inflammatory strictures most commonly occur within the penile urethra, the site of the periurethral glands. B Most inflammatory strictures occur in the prostatic urethra. C The urethral strictures due to transurethral retrograde prostatectomy (TURP) are typically long segment, irregular strictures. D Traumatic strictures usually take longer to develop than inflammatory strictures. E Ultrasound is more accurate than conventional urethrography in the assessment of urethral strictures.

Answer 39

E Ultrasound is more accurate than conventional urethrography in the assessment of urethral strictures.

Question 40

QUESTION 41 A 32-year-old man involved in a high-speed traffic accident is found to have blood at the urethral meatus and a high riding prostate during the secondary clinical survey. The examining doctor suspects a urethral injury. Which part of the urethra is most likely to be involved? A Bulbar urethra B Membranous urethra C Penile urethra D Penoscrotal urethra E Prostatic urethra

Answer 40

B Membranous urethra

Question 41

QUESTION 52 On a T2w MRI pelvis of a normal patient, the wall of the urinary bladder has an apparent dark band along its lateral wall on one side, with a bright band on the opposing lateral wall. Which one of the following accounts for this radiological appearance? A A large flip angle B Beam hardening artefact C Chemical shift artefact D Movement artefact in the phase-encoding direction E Movement artefact in the slice select gradient

Answer 41

C Chemical shift artefact On T2w sequences, the normal bladder wall is of low signal intensity compared with high signal urine. Chemical shift artefact—which in this case is due to the difference in resonant frequencies of the hydrogen nuclei in fat and urine—appears as a dark band on one side wall and a bright band on the opposing wall.

Question 42

QUESTION 55 Which one of the following statements best describes the course of the normal ureter within the pelvis? A Anterior to the inferior pubic ramus, the ureter runs posteromedially to enter the urinary bladder. B In females, the ureter lies within the broad ligament where it is intraperitoneal for a short portion of its length and runs inferomedially to enter the urinary bladder. C In males, the ureter runs anterior to the cremasteric artery and turnsmedially to enter the urinary bladder. D In the region of the ischial spine, the ureter turns medially, anteriorly and inferiorly to enter the bladder. E ureter enters the pelvis by crossing bifurcation of the CIA and runs medially to enter the urinary bladder.

Answer 42

D In the region of the ischial spine, the ureter turns medially, anteriorly and inferiorly to enter the bladder.

Question 43

@#e QUESTION 56 An immunosuppressed 24-year-old man presents with left renal colic. He is referred for an IVU. The control film shows a gas containing, round lamellated mass within the urinary bladder. Postcontrast, there are multiple filling defects within the urinary bladder. What is the most likely cause of these appearances? A Blood clot B Bladder calculi C Cystitis D Fungal ball E Schistosomiasis

Answer 43

D Fungal ball

Question 44

QUESTION 57 A 67-year-old man with a history of transitional cell carcinoma of the bladder now presents with several episodes of haematuria. A cystoscopy and biopsies performed 4 weeks ago were negative and he now attends for an MRI pelvis. On sagittal T2w images, there is an area of thickening in the bladder wall with low signal change in the surrounding perivesical fat. Which one of the following findings would suggest a diagnosis of postbiopsy change, rather than recurrent transitional cell carcinoma? A On dynamic contrast-enhanced Tlw images, the area of low signal shows early and avid contrast enhancement. B On fat-suppressed proton density sequences, this area returns a high signal. C On post-gadolinium Tlw images, inflammatory change avidly enhances whilst transitional cell carcinoma does not. D The area shows delayed enhancement on Tlw post-gadolinium images. E There is signal loss on gradient echo images, due to tissue inhomogeneity

Answer 44

D The area shows delayed enhancement on Tlw post-gadolinium images. On dynamic contrast-enhanced MRI, bladder cancer shows earlier enhancement than post-biopsy/surgical tissue and is therefore helpful in distinguishing between bladder cancer and post biopsy change.

Question 45

QUESTION 59 Which of the following best describes the radiological findings of urinary tract malakoplakia? A Intramural bladder wall gas B Multiple filling defects in the pelvicalyceal systems and proximal ureters on IVU, with sparing of the urinary bladder C Multiple small oval filling defects at the bladder base D Plaque-like thickening of the pelvicalyceal urothelium E Tram-track calcification within the bladder wall

Answer 45

C Multiple small oval filling defects at the bladder base Malakoplakia is a benign, inflammatory condition that predominantly affects the bladder and lower urinary tract.

Question 46

QUESTION 66 A 62-year-old patient with transitional cell bladder carcinoma has an MRI scan to locally stage the disease. Which of the following MRI findings would indicate invasion of the seminal vesicles? A Decreased signal of the seminal vesicles on Tlw images B Increased signal of the seminal vesicles on Tlw images C Increased signal of the seminal vesicles on T2w images D Obliteration of the angle between the seminal vesicles and the posterior bladder wall E Reduction in size of the seminal vesicles

Answer 46

D Obliteration of the angle between the seminal vesicles and the posterior bladder wall Invasion of the seminal vesicles is demonstrated by an increase in size of the gland, decrease in signal intensity on T2w images and obliteration of the angle between the seminal vesicles and the posterior bladder wall.

Question 47

QUESTION 67 A 64-year-old woman with bladder cancer is discussed in the urology multidisciplinary meeting. A recent CT suggested the possibility of tumour extension into the perivesical fat and the urologists request an MRI pelvis to assess whether the bladder wall is breached (as this would upstage the tumour). Which one of the following MRI sequences is best for assessing bladder wall integrity? A Gradient echo sequences with a long flip angle B Postcontrast STIR C Proton density fat saturation D Tlw (precontrast) E T2w

Answer 47

E T2w Postcontrast STIR sequences are pointless as gadolinium shortens T1 and STIR removes signal from tissue with a short Tl.

Question 48

QUESTION 72 A 24-year-old man sustains blunt trauma to the lower abdomen during a traffic accident. After initial resuscitation, he is haemodynamically stable but there is clinical suspicion of urinary bladder rupture. Which one of the following radiological findings on a retrograde cystogram would support intraperitoneal rather than extraperitoneal bladder rupture? A Contrast extravasation which spreads out in a streaky, irregular manner B Elliptical extravasation adjacent to the bladder neck C Gas within the bladder D Pelvic fracture E Tear at the bladder dome

Answer 48

E Tear at the bladder dome Intraperitoneal bladder rupture tends to be due to a tear at the bladder dome. Cystography shows accumulation of contrast at the dome with extravasation laterally outlining bowel loops.

Question 49

QUESTION 76 A 65-year-old man is referred by his GP ro the urologists for investigation of chronic macroscopic haematuria. The patient is a teacher and has recently returned to the UI< after 15 years working in Malawi. He suffered an episode of dysuria and haematuria several years ago and a local doctor diagnosed schistosomiasis. You are asked to supervise and report a CT urogram for this patient. Which one of the following statements is true regarding the radiological features of schistosomiasis? A Cortical nephrocalcinosis is characteristic. B In late stage disease, a 1- to 3-mm band of calcification surrounding the bladder wall is seen. C In the late stage, the bladder is dilated, thin walled and calcified, giving an egg-shell appearance. D Narrowed ‘pipe-stem’ ureters are evident. E ‘Tram-line’ calcification within the seminal vesicles is found in the majority of cases

Answer 49

B In late stage disease, a 1- to 3-mm band of calcification surrounding the bladder wall is seen. In schistosomiasis, the ureters become grossly dilated and tortuous and may have multiple filling defects due to either granulomata or ureteritis cystica. The urinary bladder becomes small and fibrosed.

Question 50

QUESTION 77 A 25-year-old man is seen in the Emergency Department following a fall from a height of 20 feet. Plain radiographs reveal a fractured pelvis and a cystogram is performed by the on-call radiology SpR. This demonstrates contrast extravasation from the urinary bladder in an irregular streaky fashion. Which one of the following is the most likely diagnosis? A Bladder wall contusion B Extraperitoneal bladder rupture C Intraperitoneal bladder rupture D Mixed intra- and extraperitoneal bladder rupture E Subserosal bladder rupture

Answer 50

B Extraperitoneal bladder rupture Extraperitoneal bladder rupture is more common (50—85%) than either intraperitoneal (15—45%) or mixed intra- and extraperitoneal bladder rupture (0—12%). Extraperitoneal bladder rupture is frequently associated (89—100%) with pelvic fractures.

Question 51

QUESTION 78 A 70-year-old man with urinary frequency and urge incontinence is referred to the urology outpatient clinic. On digital rectal examination, his prostate is enlarged and the serum prostate specific antigen (PSA) level is elevated. What is the most likely finding on IVU? A A beaded appearance of the distal urethra B A smooth rounded filling defect at the dome of the bladder C J-shaped (‘fish-hook’) appearance of the distal ureters D Inferior displacement of the ureters by the prostate E Narrowing of the distal ureters

Answer 51

C J-shaped (‘fish-hook’) appearance of the distal ureters When the prostate enlarges, it pushes up into the base of the urinary bladder. As a result the trigone is elevated which pushes up the distal ureters (giving a characteristic ‘fish-hook’ appearance).

Question 52

@#e QUESTION 80 Which one of the following statements best describes the characteristic radiological features of retroperitoneal fibrosis? A A plaque-like mass that encases the aorta and displaces it laterally, most commonly to the left B A plaque-like mass that displaces the kidneys and ureters laterally at the Ll-2 level C A plaque-like mass that displaces the aorta and iliac arteries anteriorly D A plaque-like mass that narrows and displaces the ureters laterally at the L4-5 level E A plaque-like mass that narrows and medially displaces the ureters at the L4-5 level

Answer 52

E A plaque-like mass that narrows and medially displaces the ureters at the L4-5 level

Question 53

3. A 50-year-old male patient on long-term analgesia presents with a history of macroscopic haematuria. An intravenous urogram is requested. The preliminary film is unremarkable. Following intravenous contrast administration, there is a delay in excretion on the right side. Subsequent images demonstrate a filling defect in the distal ureter with proximal dilatation. The ureter immediately distal to the filling defect is also mildly dilated, but normal in calibre further down. What is the diagnosis? A. Non-radioopaque calculus. B. Transitional cell carcinoma (TCC). C. Blood clot. D. Sloughed papilla. E. Pyeloureteritis cystica

Answer 53

3. B. Transitional cell carcinoma (TCC). The appearance of ureteral dilatation around and below an intraluminal filling defect is described as the ‘goblet’ sign. This sign indicates that the filling defect is caused by a chronic process, which allows dilatation of the ureter immediately below to accommodate the lesion. In addition to TCC, this appearance may rarely be seen with metastatic disease or endometriosis. Chronic analgesic use is a risk factor for TCC. Pyeloureteritis cystica appears as multiple small filling defects in the renal pelvis and ureter, typically seen in diabetics.

Question 54

10. A 46-year-old woman has an incidentally discovered large mixed echogenicity mass in the left flank on an ultrasound examination. A follow-up CT examination is performed and this shows a predominantly fatty lesion exophytic to the left kidney, measuring approximately 12 cm in maximum diameter. Which of the following findings would make the diagnosis of large renal angiomyolipoma more likely than a perirenal well-differentiated retroperitoneal liposarcoma? A. The presence of mass effect with displacement of the left kidney. B. The presence of aneurysmal blood vessels within the lesion. C. The presence of soft-tissue density areas within the lesion. D. The presence of ill-defined margins. E. The presence of fluid density components

Answer 54

10. B. The presence of aneurysmal blood vessels within the lesion. Both well-differentiated retroperitoneal liposarcomas and exophytic renal angiomyolipomas can be very large in size and thus size is not a discriminating factor. Both contain large amounts of mature lipid, thus significant portions of the lesion will have negative Hounsfield attenuation values on CT imaging. Aneurysmal blood vessels are commonly seen in large angiomyolipomas, whereas welldifferentiated liposarcomas are generally rather hypovascular lesions. Both angiomyolipomas and retroperitoneal liposarcomas may contain areas of soft tissue density. Liposarcoma is probably more likely to have an irregular margin and may contain areas of fluid density.

Question 55

20. A 56-year-old female diabetic patient presents to urology with a history of microscopic haematuria. There is a past history of multiple UTIs. The standard urology investigative process in your hospital consists of ultrasound, intravenous urogram (IVU) and cystoscopy. Ultrasound is normal. Cystoscopy has found a number of yellowish raised lesions in the bladder. You are reviewing the IVU with this information. The IVU shows multiple small filling defects in the distal left ureter and bladder which are 3–8 mm in size. What is the diagnosis? A. Malakoplakia. B. Leukoplakia. C. Pyeloureteritis cystica. D. Multifocal TCC. E. Cystitis with distal ureteric reflux

Answer 55

20. A. Malakoplakia. This is an inflammatory response to chronic E. coli infection. It is more common in females and in diabetic/immunocompromised patients. It most commonly occurs in the bladder and distal ureter and is multifocal in 75% of cases.

Question 56

38. A 50-year-old man attends his GP feeling generally lethargic. The GP organizes blood tests and these reveal renal impairment. A subsequent ultrasound examination shows bilateral hydronephrosis without obvious cause. A CT scan of the abdomen then demonstrates that the hydronephrosis is secondary to bilateral ureteric obstruction from abnormal retroperitoneal soft tissue, intimately related to the aorta and IVC. Which of the following features on CT would suggest that the soft tissue is more likely due to retroperitoneal fibrosis, rather than a malignant cause? A. Nodular contour to the soft tissue. B. Contrast enhancement of the soft tissue. C. More severe hydronephrosis in the kidneys. D. Close application of the soft tissue to the adjacent vertebrae. E. Soft-tissue extension above and below the level of the renal hila.

Answer 56

38. D. Close application of the soft tissue to the adjacent vertebrae. Unfortunately attempts to consistently distinguish benign retroperitoneal fibrosis (RPF) from malignancy are fraught with danger, but there are certain CT findings which are more commonly seen in one or other of these conditions. Malignancy tends to be larger and bulkier, displaying mass effect and displacing the aorta and IVC anteriorly from the spine and the ureters laterally. The purely fibrotic process of benign RPF tends to tether these structures to the adjacent vertebrae. Malignancy is more likely to extend cephalad to the renal hila, with benign RPF remaining caudal to the hila. Neoplasia also more typically has a nodular outline, whereas benign RPF usually manifests as a plaque-like density. There are, of course, exceptions to both these features. Contrast enhancement is not a reliable feature for distinguishing benign RPF from malignancy, as both malignancy and active RPF can enhance with contrast. Similarly, the degree of hydronephrosis caused is not a good distinguisher.

Question 57

55. A 55-year-old female patient presents to your hospital with a history of recurrent UTIs and gross haematuria. Repeated urine cultures are negative, but analysis reveals copious white and red cells in the urine. The patient fails to improve with antibiotics. A CT scan of renal tracts is carried out, which shows an atrophic right kidney containing calcification. There is also an area of increased density on the unenhanced portion of the scan noted in the upper pole of the kidney, with overlying cortical thinning. There are multiple strictures noted in the ureter, with intervening areas of dilatation, giving a corkscrew appearance. There is extensive coarse calcification noted in the wall of the bladder. A CXR is carried out and is normal. Early morning urine collections finally identify mycobacterium tuberculosis in the urine, confirming the suspicion of renal and urinary tract TB. Which of these features is atypical of renal TB? A. High-density material in the calyceal system. B. Bladder calcification. C. Renal calcification. D. Normal CXR. E. Corkscrew appearance to the ureter.

Answer 57

55. B. Bladder calcification Whilst this can be seen in TB, it is more typically associated with schistosomiasis. TB usually causes scarring and a reduced capacity bladder. Renal calcification is typical. The areas of increased attenuation within the calyceal system represent areas of coalescing caseating granulomas, and may have associated calcification. Scarring can also cause stenosis of calyces, causing focal obstruction. Occasionally a small calcified kidney is found, evidence of autonephrectomy. Passage of the infection via the urine into the ureters causes focal stenoses, which can coalesce to cause a long stricture, or give a beaded or corkscrew appearance to the ureter. Whilst renal TB results from spread from a primary pulmonary infection, the CXR is only abnormal in 25–50% of cases and is therefore not helpful.

Question 58

63. A 22-year-old male front seat passenger is admitted following a RTA. On examination in A&E, blood is noted at the external urethral meatus and there is swelling of the penis. An urethrogram is performed which demonstrates contrast extravasation below the urogenital diaphragm only. What type of urethral injury does this represent? A. Anterior urethral injury. B. Disruption of the membranous urethra. C. Bladder neck injury extending into the proximal urethra. D. Bladder base injury. E. Penile fracture.

Answer 58

63. A. Anterior urethral injury. Urethral injuries are rarely life-threatening but have significant long-term morbidity. Complications include stricture, incontinence, and impotence. The male urethra extends from the bladder base to the external meatus and is divided into the posterior (prostatic and membranous) and anterior (bulbous and penile) urethra. The anterior and posterior urethra are separated by the urogenital diaphragm. The Goldman classification of urethral injury emphasizes anatomic location.

Question 59

70. An 18-year-old male fractures his pelvis following a motorcycle accident. He is suspected of sustaining a bladder injury and undergoes CT cystography. This reveals ill-defined contrast medium within the perivesical space with a ‘molar-tooth’ appearance. What is the significance of this finding? A. Interstitial bladder injury. B. Intraperitoneal rupture. C. Extraperitoneal rupture. D. Combined intra- and extraperitoneal rupture. E. Bladder contusion

Answer 59

70. C. Extraperitoneal rupture. Over 70% of patients with traumatic bladder injury have a coexisting pelvic fracture. CT cystography is considered to be as accurate as conventional cystography. Extraperitoneal rupture accounts for 80% of all cases of traumatic bladder injury. It occurs as a result of shearing forces or penetrating injury from bony fragments at the base of the bladder. Contrast can also track down into the scrotum or thigh. Intraperitoneal rupture (15% of cases) follows a direct blow to a distended bladder, with the tear involving the bladder dome. Contrast will be seen to outline small bowel loops. Combined injuries occur in 5%. Interstitial injuries are rare and are detected by contrast dissecting into the bladder wall. Imaging is frequently normal in the setting of bladder contusion

Question 60

48 A 26-year-old male is involved in a motor vehicle accident and sustains a pelvic fracture. On ultrasound `a bladder within a bladder' appearance is seen; that is, a bladder surrounded by a fluid collection. A diagnosis of extraperitoneal bladder rupture is made. Where is the bladder most likely to have ruptured? a The dome of the bladder b The left ureteric orifice C The right ureteric orifice d Anterior aspect of the base of the bladder e Diagnosis is more likely to be urethral transaction

Answer 60

48 Answer D: Anterior aspect of the base of the bladder The site of rupture is usually close to the base of the bladder anterolaterally. On contrast examination a flameshaped contrast extravasation into perivesical fat (best seen on post-void films), which may extend into the thigh or anterior abdominal wall. Eighty per cent of bladder ruptures are extraperitoneal. It is usually caused by penetration of the bladder by a bony spicule from a pelvic fracture or an avulsion tear at the fixation points of the puboprostatic ligaments. Plain film may demonstrate a `pear-shaped bladder'. Other signs of extraperitoneal bladder rupture are loss of obturator fat planes, paralytic ileus and upward displacement of ileal loops on plain film. Intraperitoneal bladder rupture usually occurs as a result of an invasive procedure (cystoscopy), a stab wound or surgery; or due to blunt trauma.

Question 61

55 A 21-year-old male from Nigeria presents with haematuria and urgency. A plain KUB radiograph shows bladder wall calcification. Which of the following is the most likely cause? a Guinea worm infection (Dracunculiasis) b Histoplasmosis infection c Taenia solium infection (Cysticercosis) d Schistosomiasis infection (Bilharziasis) e Candiru fish infestation

Answer 61

55 Answer D: Schistosomiasis infection (Bilharziasis) Schistosoma haematobium is a trematode endemic in parts of Africa. Eggs are deposited in the submucosa of the bladder and ureters leading to granulomas, oedema and strictures. This can result in a fibrotic bladder, with mural calcification, and ureteric dilatation. Squamous cell carcinoma is a recognised complication. The Candiru fish is found in the Amazon basin and may be able to enter the urethra where it becomes lodged.

Question 62

58 A 45-year-old male is crushed by a forklift truck palette. He complains of failure to pass urine and lower abdominal pain. A pelvic radiograph shows bilateral pubic rami fractures. Passage of a urethral catheter shows gross haematuria and the clinicians suspect a bladder injury. What investigation would you recommend to assess his injuries? a CT abdomen and pelvis with intravenous contrast, a clamped urinary catheter and delayed scans through the bladder b CT abdomen and pelvis with intravenous contrast and instilled intravesical contrast c Unenhanced CT pelvis d Pelvic ultrasound e Retrograde standard cystography

Answer 62

58 Answer B: CT abdomen and pelvis with intravenous contrast and instilled intravesical contrast CT cystography is equivalent or better than standard cystography for detection of bladder injury and should be performed in patients already undergoing CT for pelvic fractures. 400mL of 4% contrast can be instilled via a drip bladder infusion, and scans performed before and after bladder emptying.

Question 63

37 A 50-year-old man presented with difficulty passing urine and had a retrograde urethrogram as part of his work-up. This demonstrates a urethral stricture. What is the most likely cause? a Secondary to previous trauma b Secondary to previous gonococcal infection c Congenital d Malignant stricture e Secondary to previous tuberculous infection

Answer 63

37 Answer B: Secondary to previous gonococcal infection Approximately 40% of urethral strictures in males in the USA

Question 64

39 A 60-year-old female with poorly controlled diabetes presents with urinary frequency, dysuria and offensive urine. She has also noticed pneumaturia. On examination she is unwell and is tender in the suprapubic region. On plain film an air-fluid level is noted within the bladder lumen. What is the most likely causative agent? a Actinornycosis b Klebsiella C Tuberculosis d Escherichia coli e Salmonella

Answer 64

39 Answer D: Escherichia coli M:F = 1:2. CT is the most specific modality. The common causative organism is E. coli but a wide range of organisms may be responsible: Candida albicans, E. aerogenes, P mirabilis, S. aureus, Streptococci, Clostridium perfringens and Klebsiella. Gas may extend up the ureter giving an air pyelogram.

Question 65

40 A 35-year-old man was involved in a road traffic accident and sustained chest and pelvic injuries. An enhanced CT scan was performed which shows pelvic fractures and an elliptical extravasation of contrast adjacent to the bladder. Which is the most likely diagnosis? a Extraperitoneal bladder rupture b Intraperitoneal bladder rupture c Subserosal bladder rupture d Retroperitoneal bladder rupture e Intraluminal bladder rupture

Answer 65

40 Answer C: Subserosal bladder rupture This is a rare form of bladder rupture, which is recognised as an elliptical extravasation adjacent to the bladder on contrast-enhanced CT.

Question 66

41 A 42-year-old man who has recently returned from holiday to Egypt presents to the genito-urinary clinic with dysuria and a urethral discharge. He also gives a history of joint pains and intermittent eye pain and irritation. While awaiting the result of penile swab microbiology, a retrograde urethrogram is performed which shows stricture formation and luminal irregularity in the penile urethra. What is the most likely diagnosis? a Gonococcal urethritis b Sarcoidosis C Reiter's syndrome d Schistosomiasis e Escherichia coli infection

Answer 66

41 Answer C: Reiter's syndrome Reiter's syndrome classically presents with the triad of conjunctivitis, urethritis and arthritis.

Question 67

44 A 30-year-old male mountain biker sustained a `straddle injury' during a race. He noticed some blood in his urine for a few days subsequently but decided against consulting a doctor. A few months later he noticed increasing difficulty in passing urine. His urinary stream was weak and he had started suffering from dysuria, urgency and suprapubic discomfort. Which of the following appearances are most likely to be seen on retrograde urethrography? a An abrupt short segment of narrowing in the bulbous urethra b A short segment of narrowing in the membranous urethra C A long segment of narrowing involving the junction of the membranous and prostatic urethra d A long segment of narrowing of the penile urethra e A short segment of narrowing involving the posterior urethra

Answer 67

44 Answer A: An abrupt short segment of narrowing in the bulbous urethra A saddle injury tends to result in injury to the bulbous urethra, with subsequent development of a urethral stricture being a common complication. Abrupt short segment strictures tend to be posttraumatic. Long segment strictures may be either traumatic or inflammatory. Traumatic injury to the posterior urethra occurs in about 10% of pelvic fractures, with the junction between the prostatic and membranous urethra being the most common site of injury.

Question 68

50 A 75-year-old man presents with haematuria and is found to have transitional cell carcinoma of the bladder. Which of following would it be possible to confirm on contrast-enhanced CT chest, abdomen and pelvis alone? a T1 (lamina propria invasion) NO MO b T2 (superficial muscle invasion) NO MO c T3a (deep muscle invasion) NO MO d T3a (deep muscle invasion) Ni (single node <2 cm) MI e T3b (perivesical fat invasion) N1 Ml

Answer 68

50 Answer E: T3b (perivesical fat invasion) N1 MI CT is not able to distinguish between layers of the bladder wall. The role of CT is to differentiate between T3a and T3b tumours (although MRI is better at this), invasion of adjacent organs (T4a), extension to the pelvic side wall (T4b), and to stage pelvic nodal and metastatic disease.

Question 69

54 A 67-year-old man has a carcinoma of his bladder diagnosed on cystoscopy. In which of the following situations is MRI the imaging modality of choice for staging? a Multiple pulmonary nodules are visible on his chest radiograph b Possible obstructive uropathy; for assessment of upper tract disease C He complains of passing urine per rectum d Further assessment of markedly abnormal liver function tests e Further assessment during consideration of a cystectomy

Answer 69

54 Answer E: Further assessment during consideration of a cystectomy MRI is the imaging modality of choice for those patients considered suitable for radical treatment (cystectomy or radical radiotherapy) because of its ability to demonstrate muscle wall invasion or penetration. CT is suitable for patients with clinical suspicion of advanced local disease, or distant metastases, or those not suitable for radical treatment.

Question 70

55 A 23-year-old male with acute ureteric colic undergoes intravenous urography. Two days later he has an unenhanced CT-KUB for further delineation of renal calculi. CT shows vicarious excretion of contrast medium within the gallbladder. What is the most likely cause for this appearance? a Use of high osmolar ionic contrast medium b Iodinated impurities in the injected contrast medium c Unilateral acute ureteric obstruction d Pre-existing renal impairment e Disturbed enterohepatic circulation of bile salts

Answer 70

55 Answer C: Unilateral acute ureteric obstruction Vicarious excretion of intravenous iodinated contrast medium is commonly associated with unilateral renal disease such as acute obstruction, although it may be a normal variant. It is also associated with contrast extravasation.

Question 71

57 An adult diabetic woman who is a surgical inpatient is demonstrated to have gas within the urinary bladder on CT performed for investigation of suspected intra-abdominal collection. What is the most likely cause for this finding? a Vesicointestinal fistula b Recent bladder catheterisation c E. coli urinary tract infection d Emphysematous cystitis e Ureteric diversion

Answer 71

57 Answer B: Recent bladder catheterization latrogenic introduction of air is the commonest cause of incidental gas in the bladder. If the patient has not had recent catheterisation, the causes are more serious and all the choices may result in gas within the urinary tract.

Question 72

(MSK) 23 A 32-year-old motorcyclist presented with blood at the urethral meatus. What is the most effective examination to exclude urethral trauma? a Multi detector CT b Pelvic angiography c MRI d Retrograde urethrography e Ultrasound

Answer 72

23 Answer D: Retrograde urethrography Retrograde urethrography is still widely advocated for excluding urethral trauma. Advanced trauma and lifesupport guidelines consider any of the following as indicators of possible urethral injury: 1 blood at the urethral meatus; 2 perineal ecchymoses; 3 blood in the scrotum; 4 inability to void; 5 elevation of prostate on DRE ; 6 pelvic fracture

Question 73

34 A 40-year-old South African male presents with painless haematuria. On IVP, control films demonstrate thin curvilinear, floccular calcification outlining a bladder of normal size and shape, as well as calcification of the distal ureters. There is an area of discontinuous calcification noted, which corresponds to an irregular filling defect seen on cystography. On cystoscopy, this corresponded to an area of abnormal-appearing mucosa on the posterior bladder wall. On physical examination, he has signs of portal hypertension. He describes episodes of haematemesis in the past. What is the most likely diagnosis? a Transitional cell carcinoma (TCC) of the bladder b Uncomplicated schistosomiasis c Squamous cell carcinoma (SCC) of the bladder d Neurofibromatosis of the bladder wall e Bladder tuberculosis

Answer 73

34 Answer C: Squamous cell carcinoma (SCC) of the bladder There are features of schistosomiasis on the control films, but this patient has developed a complication in the form of SCC of the bladder following childhood infection (latency period of 20- 30 years). SCC often involves in the posterior wall and rarely involves the trigone. A second complication of schistosomiasis is portal hypertension due to ova migrating into the portal venous system and inciting a fibrosing granulomatous reaction within presinusoidal portal veins. Consequently, the haematemesis is likely to relate to oesophageal varices. Neurofibroma of the bladder wall tends to cause smooth filling defects and is not associated with bladder calcification. Tuberculosis tends to begin in the kidney and spread distally, usually resulting in a scarred, contracted bladder of diminished capacity. Multiple granulomas can give rise to filling defects

Question 74

41 A 65-year-old man, who used to work in a rubber manufacturing plant and has a strong smoking history, presents with frank painless haematuria. An IVP demonstrates an irregular filling defect with a broad base, situated at the base of the bladder. Cystoscopy demonstrates a papillary, frondlike tumour and endoscopic biopsies are taken for histological analysis. What sequence would be best for detection of extension of the tumour through the bladder wall? a T1-weighted images b T2-weighted images c T2 -weighted images with fat saturation d STIR images e Diffusion weighted images

Answer 74

41 Answer A: T1-weighted images MRI is the staging modality of choice for TCC, with an accuracy of 72-96%. T1-weighted images are optimal for detecting invasion of perivesical fat and metastases to lymph nodes and bone. TCC of the bladder is the most common tumour of the genital tract and is 30-50 times more common than upper urinary tract urothelial cancer. Approximately 30% will have an additional histologically similar bladder tumour. Staging CT should be delayed for up to seven days postinstrumentation as it can result in overstaging and is best used for staging of advanced disease as it is poor at differentiating superficial non-invasive tumours from those invading the bladder wall muscle. Adenocarcinoma of the bladder is rare (<1%) and most cases are associated with bladder extrophy and urachal remnants. Treatment options for early-stage disease include cystoscopic resection and intravesical mitomycin C.?

Question 75

43 A 43-year-old woman with a renal transplant presented with recurrent urinary tract infections. An ultrasound revealed no abnormality of the transplanted kidney but a thickened section of the bladder wall was noted. She then had a pelvic MRI which confirmed the thickening which was of intermediate signal on T1-weighted and T2- weighted images. She finally had a cystoscopy and a yellowish plaque-like area was found and biopsied. What is the most likely diagnosis? a Histiocytosis X b Malakoplakia C Haemangioma d Chagas disease (South American trypanosomiasis) e Actinornycosis

Answer 75

43 Answer B: Malakoplakia This is an inflammatory condition that usually presents in the immunosuppressed and most often affects the genito-urinary tract. It is rare and biopsy is necessary for diagnosis but the imaging features described are typical.

Question 76

49 A 65-year-old man complained of several months of progressively worsening left flank pain and swelling. CT demonstrated a heterogeneously enhancing soft-tissue density mass arising from the perirenal space, displacing the kidney and containing internal foci of calcification. The MR appearances were of a predominantly low intensity mass on T1-weighted images, with internal areas of high signal thought to represent haemorrhage. On T2-weighted images there was predominantly very high signal intensity with a `bowl of fruit appearance' of intermixed low and intermediate signal. There was early heterogeneous enhancement with slow washout following contrast. High T2/low T1-weighted lesions within the vertebral bodies are also present. What is the most likely diagn sis? a Lymphoma b Well-differentiated liposarcoma C Malignant fibrous histiocytoma d Desmoid tumour e Malignant rhabdomyosarcoma

Answer 76

49 Answer C: Malignant fibrous histiocytoma Malignant fibrous histiocytoma is the most common soft-tissue sarcoma in adults, and approximately 15 % occur in the retroperitoneum. It is one of the few tumours to have a myxoid stroma, the imaging characteristics of which are low T1-weighted signal and very high T2-weighted signal. The admixture of solid components, cystic necrosis, haemorrhage, calcification (in 7-20%), myxoid stroma and fibrous tissue gives the bowl of fruit appearance. The enhancement pattern described is common in malignant tumours and bone metastases are present. Desmoid tumours are typically low on both T1- and T2-weighted images and display delayed enhancement - this is typical of dense collagen fibres.

Question 77

53 A 33-year-old male pedestrian is hit by a car. His pelvic trauma radiograph demonstrates an anterior compression fracture pattern. He complains of dysuria, gross haematuria and has a swollen bruised perineum and scrotum. Retrograde urethrography does not show urethral injury and he undergoes retrograde CT cystography. What type of bladder injury is he most likely to have sustained? a Type 1: Simple bladder contusion b Type 2: Intraperitoneal bladder rupture c Type 3: Partial thickness bladder wall laceration with intact serosa d Type 4: Extraperitoneal bladder rupture e Type 5: Combined intraperitoneal and extraperitoneal bladder rupture

Answer 77

53 Answer D: Type 4: Extraperitoneal bladder rupture Extraperitoneal bladder rupture is the commonest type (80-90%) of bladder rupture and usually occurs from penetrating trauma (from pelvic fractures) or blunt trauma (disruptions of ligamentous attachments to the pelvic floor), in which case rupture occurs at the anterolateral aspect near the neck. Intraperitoneal bladder rupture frequently occurs at the dome with blunt trauma to a distended bladder. Accurate diagnosis is important as types 1, 3 and 4 are treated conservatively but types 2 and 5 require immediate surgery.

Question 78

58 A 54-year-old female with a history of chronic urinary tract infection undergoes excretory urography that demonstrates multiple nodular filling defects of the bladder mucosa. Which of the following conditions does not belong in the differential diagnosis for this appearance? a Malakoplakia b Cystitis cystica c Bullous oedema d Ureterocoele e Transitional cell carcinoma

Answer 78

58 Answer D: Ureterocoele The classic appearance of a ureterocoele is likened to that of a cobra's head due to a dilated distal ureter surrounded by a thin radiolucent line of ureteric wall and prolapsed bladder mucosa.

Question 79

59 A 40-year-old male motorcyclist sustained a straddle injury and blood was noted at his urethral meatus. A urethrogram was performed, which confirmed a urethral injury. What part of the urethra is he most likely to have injured? a Pre-prostatic urethra b Prostatic urethra C Membranous urethra d Penile urethra e Fossa navicularis

Answer 79

59 Answer C: Membranous urethra Retrograde urethrography shows the anterior urethra, VCUG shows the posterior urethra: 300-350mL is required for reliable voiding. US may be useful in assessment of length and thickness of bulbar strictures.

Question 80

63 A 50-year-old man presents with chronic progressive back pain, lower extremity swelling and mild renal impairment. A renal US demonstrates mild bilateral hydronephrosis. Excretory urography is performed which shows abnormal peristalsis in the upper ureter with medial deviation of the middle third of both ureters associated with gradual tapering. What is the most likely diagnosis? a Retroperitoneal fibrosis b Aorto-caval fistula c Retroperitoneal sarcoma d Aortic aneurysm e Schistosomiasis

Answer 80

63 Answer A: Retroperitoneal fibrosis The findings on IVP are typical. The sensitivity and specificity of CT tissue characteristics are poor for the differentiation of benign from malignant disease. US can be helpful in demonstrating additional features such as bile duct dilatation, portal hypertension and sclerosing pancreatitis. The high T2- weighted signal, and radionuclide uptake within the retroperitoneal soft tissue, reduce with successful treatment and these can be used as markers of response

Question 81

65 An 82-year-old male with bilateral ureteric stents in situ for localised prostate cancer for which he was treated with radiotherapy presents with intermittent gross haematuria. What condition would be the most immediately life threatening? a Stent migration irritating bladder mucosa b Local disease progression c Chronic urinary tract infection secondary to stent presence d Radiation cystitis e Ureteral erosion

Answer 81

65 Answer E: Ureteral erosion Ureteral erosion is a rare but serious complication of stent insertion. Fistulation may occur between the ureter and an adjacent vessel, particular an artery, due to ischaemia in the ureter and pulsations from the vessel. Presentation is with intermittent, or occasionally life threatening, haematuria. Demonstration with imaging may be difficult and angiography may be both diagnostic and allow therapeutic embolisation.

Question 82

67 A 19-year-old man presents with a suprapubic mass and haematuria. After investigation he is found to have a tumour originating within a patent urachus. What is the most likely diagnosis? a Adenocarcinoma b Sarcoma c Transitional cell carcinoma d Squamous cell carcinoma e Lymphoma

Answer 82

67 Answer B: Sarcoma Overall 75% of urachal tumours are adenocarcinomas but in young patients 75 % are sarcomas

Question 83

19. A 45-year-old migrant from South Africa with history of recently treated oesophageal varices presents with haematuria. Plain radiograph of abdomen and pelvis shows curvilinear calcifcation in the wall of urinary bladder. There is bilateral hydroureters and hydronephrosis. What is the most likely diagnosis? (a) Bladder carcinoma (b) Portal hypertension (c) Tuberculosis of urinary bladder (d) Schistosomiasis (e) Rhabdomyosarcoma of bladder

Answer 83

19. (d) Schistosomiasis Schistosomiasis is endemic in southern and east Africa and is a result of infection by Schistosoma haematobium. Ova are laid into the submucosa of the lower urinary tract, causing an extensive fbrosing with later calcifcation. Ova migrating into the portal venous system result in a fbrosing granulomatous reaction leading to portal hypertension and oesophageal varices.

Question 84

21. A 65-year-old man with known abdominal aortic aneurysm and under follow up for lymphoma, presents with backache. Contrast-enhanced CT shows a doughnut shaped soft tissue mass surrounding the lower part of aneurysmal abdominal aorta and the ureters are pulled medially with bilateral hydronephrosis. What is the most likely diagnosis? (a) Retroperitoneal fbrosis (b) Lymphoma recurrence (c) Aneurysm leak (d) Radiation injury (e) None of the above

Answer 84

21. (a) Retroperitoneal fibrosis This is hard fbrous tissue enveloping the retroperitoneum, including the great vessels, ureters and the lymphatics. The plaque typically begins around the aortic bifurcation and extends cephalad to the renal hilum, and it rarely extends below the pelvic brim.

Question 85

49. A 25-year-old male driver was admitted to the Accident & Emergency Department after a road trafc accident. Plain radiography shows a fractured pelvis and the patient is unable to pass urine. Te registrar notes blood at the urethral meatus.What is the appropriate management for this condition? (a) Foley’s catheter insertion to drain urine (b) Retrograde urethrogram to exclude urethral injury (c) Micturating cystourethrogram (d) Cystography (e) Antegrade urethrography

Answer 85

49. (b) Retrograde urethrogram to exclude urethral injury In patients with pelvic fractures, bloody meatus and inability to void should raise the possibility of urethral injury. A retrograde urethrogram should be performed to exclude urethral injury before inserting a Foley’s catheter or cystography for bladder ruptures.

Question 86

6. Which of the following are correct regarding retroperitoneal fibrosis? (a) When the ureters are involved, there is typically only mild pyelocalyectasis. (b) The fibrotic plaque usually originates around the aortic bifurcation. (c) On CT, the aorta is typically enveloped and anteriorly displaced by a fibrotic mass. (d) An increase in signal intensity on T2 weighted imaging indicates a good response to steroid treatment. (e) It is associated with primary sclerosing cholangitis.

Answer 86

Answers: (a) Correct (b) Correct (c) Not correct (d) Not correct (e) Correct Explanation: On CT, the aorta is engulfed by the fibrotic mass but not displaced. Displacement is seen in malignancy. Steroid treatment causes a decrease in signal intensity on T2WI indicating a good response.

Question 87

25. Which of the following are correct regarding schistosomiasis: (a) Calcification is the most important single imaging feature. (b) The bladder usually has a reduced capacity in the early stages. (c) Is endemic in parts of the Eastern Mediterranean. (d) Ureteral calculi are rarely seen. (e) In the earliest stage, dilatation of the ureter is confined to the upper third.

Answer 87

Answers: (a) Correct (b) Not correct (c) Correct (d) Not correct (e) Not correct Explanation: Schistosomiasis is commonly associated with ureteric calculi, dilatation of lower ureter in early stage and reduced bladder capacity in advanced stages

Question 88

(GIT) 41. Which of the following are correct regarding bladder cancers? (a) Urachal abnormalities are most frequently associated with squamous cell carcinomas. (b) MRI can identify muscle invasion. (c) The presence of low signal within the seminal vesicles on T2 weighted MRI is specific for tumour involvement. (d) Tumour extension to the cervix is common. (e) Bladder cancer enhances early following intravenous gadolinium- diethylenetriaminepentaacetic acid (DTPA).

Answer 88

Answers: (a) Not correct (b) Correct (c) Not correct (d) Not correct (e) Correct Explanation: About 90% of the bladder cancers are transitional cell tumour. Squamous cell carcinoma is associated with chronic infection and leukoplakia. Transitional cell tumour may extend to the perivesicle fat, seminal vesicles and prostate in Males but extension to the uterus and cervix is uncommon in females The seminal vesicles are high signal on T2-weighted images. Low signal changes may be seen with atrophy, tumour extension and fibrosis.