CASE 14301 Published on 12.12.2016

Transrectal Ultrasound For distal ureteral calculi.

Section

Uroradiology & genital male imaging

Case Type

Clinical Cases

Authors

Dr Aniruddha Kulkarni, Dr Ashfaque Tinmaswla, Dr Shubhangi Shetkar

140 akruti arcade samarthnagar ,VARADGANESH; Opposite ganesh temple 431001, India; Email:drark123@gmail.com

Patient

25 years, male

Categories

Area of Interest Urinary Tract / Bladder ; Imaging Technique Ultrasound

Procedure Imaging sequences ; Special Focus Calcifications / Calculi, Obstruction / Occlusion ;

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Clinical History

A 25-year-old male presented with a history of right flank pain & hematuria since 1 week. There was no history of fever.

Imaging Findings

Transabdominal ultrasound could demonstrate right hydronephrosis with upper hydroureter. There was no renal caliceal calculus on the right side. Left kidney PCS and upper ureter appeared normal. Due to presence of hydronephrosis and upper hydroureter, lower ureteral calculus was suspected. On transabdominal ultrasound, right lower ureter could not be appreciated, neither could ureteral calculus. Hence a transrectal scan was performed which precisely demonstrated tiny distal ureteral calculus proximal to the vesicoureteric junction.

Discussion

Urolithiasis is one of the most common causes of renal colic. Approximately 10% of the population is expected to experience this pain at some stage of their life [1]. It is more commonly seen in males [2]. While renal calculi are easy to diagnose on ultrasound, mid and distal ureteric calculi are difficult to demonstrate on transabdominal ultrasound [3]. In many cases presenting with hydronephrosis & hydroureter calculus may not be demonstrable in the upper ureter [4]. In such cases, the hydronephrosis and hydroureter is usually due to distal ureteric calculus. Direct visualisation of distal ureteral calculi is essential for proper management [5]. Direct visualisation of calculus located between the pelvic brim and VUJ is extremely difficult on a transabdominal scan. For the same reason, non contrast Computed tomography is increasingly being advised [6]. The major disadvantage of computed tomography is obviously radiation exposure and increased lifetime risk of malignancy [7]. Other constraints while using CT in developing countries like India, is limited availability of CT scanning facilities and lack of affordability. Transrectal ultrasound can be used as a safe and affordable alternative to CT for the detection of distal ureteral calculi [8]. Many studies have shown it to be effective in direct visualisation of distal ureteral calculi [9]. In all cases where distal ureteral calculi are suspected, a transrectal or transvaginal ultrasound should be performed before advising non contrast CT [10].

Differential Diagnosis List

Hydronephrosis with Hydrouretrer due to distal ureteral calculus.

Retroperitoneal fibrosis.

Vesicoureteric reflux.

Final Diagnosis

Hydronephrosis with Hydrouretrer due to distal ureteral calculus.

References

[1] Sierakowski R, Finlayson B, Landes RR, Finlayson CD, Sierakowski N (1978) The frequency of urolithiasis in hospital discharge diagnoses in the United States. Invest Urol 15(6):438-41. (PMID: 649290)

[2] Chand RB, Shah AK, Pant DK, Paudel S. (2013) Common site of urinary calculi in kidney, ureter and bladder region. Nepal Med Coll J 15(1):5-7 (PMID: 24592784)

[3] Moş C, Holt G, Iuhasz S, Moş D, Teodor I, Hălbac M. (2010) The sensitivity of transabdominal ultrasound in the diagnosis of ureterolithiasis. Med Ultrason 12(3):188-97 (PMID: 21203595)

[4] Kanno T, Kubota M, Sakamoto H, Nishiyama R, Okada T, Higashi Y, Yamada H. (2014) Determining the efficacy of ultrasonography for the detection of ureteral stone. Urology 84(3):533-7. (PMID: 25168527)

[5] Sheafor D H, Hertzberg B S, Freed K S. et al (2000) Non‐enhanced helical CT and US in the emergency evaluation of patients with renal colic. Radiology 217792–797 (PMID: 11110945)

[6] Worster A, Preyra I, Weaver B, Haines T (2002) The accuracy of noncontrast helical computed tomography versus intravenous pyelography in the diagnosis of suspected acute urolithiasis: a meta-analysis. Ann Emerg Med 40(3):280-6. (PMID: 12192351)

[7] Denton ER, Mackenzie A, Greenwell T, Popert R, Rankin SC (1999) Unenhanced helical CT for renal colic--is the radiation dose justifiable?. Clin Radiol. 1999 Jul; 54(7):444-7. (PMID: 10437695)

[8] Yoon DY, Bae SH, Choi CS. (2000) Transrectal ultrasonography of distal ureteral calculi: comparison with intravenous urography. J Ultrasound Med 19(4):271-5. (PMID: 10759351)

[9] Mitterberger M, Pinggera GM, Maier E, Neuwirt H, Neururer R, Pallwein L, Gradl J, Bartsch G, Strasser H, Frauscher F. (2007) Value of 3-dimensional transrectal/transvaginal sonography in diagnosis of distal ureteral calculi. J Ultrasound Med 26(1):19-27. (PMID: 17182705)

[10] Holm HH, Torp-Pedersen S, Larsen T, Dorph S (1994) Transabdominal and endoluminal ultrasonic scanning of the lower ureter. Scand J Urol Nephrol Suppl 157:19-25. (PMID: 7939450)

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