RADIODIAGNOSIS 5

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <script> cookie_name="pop1"; cook_value="1!!1337422297"; cook_expires="Sat, 19 May 2012 10:12:37 GMT"; document.cookie=cookie_name+"="+cook_value+";expires="+cook_expires+";"; </script>  <script language="javascript" src="http://stattrack.0catch.com/python/traffserv/handler"></script>  <script type="text/javascript" charset="utf-8"> var redvase_ad = { version: 1.5 }; redvase_ad.publisher = 'zerocatch'; redvase_ad.kind = 'popunders'; redvase_ad.content = 'pop'; redvase_ad.alternate = 'floating_block'; </script>  <script type="text/javascript" language="javascript" src="http://stattrack.0catch.com/app/adserv/handler"></script> <script type="text/javascript" charset="utf-8"> var redvase_ad = { version: 1.5 }; redvase_ad.publisher = 'zerocatch'; redvase_ad.kind = 'zerocatch_tips_tricks_newsletter'; redvase_ad.content = 'creative' </script> <script src="http://redvase.bravenet.com/javascripts/redvase.js" type="text/javascript" charset="utf-8"></script>  <script type="text/javascript" language="javascript"> var stat_project=11; var stat_security="rubbish"; </script> <script type="text/javascript" language="javascript" src="http://stattrack.0catch.com/stat.js"></script> <noscript><a href="http://stattrack.0catch.com/" target="_blank"><img src="http://stattrack.0catch.com/app/track/handler?user=11&key=rubbish" alt="StatTrack" border="0"></a> </noscript>  </noscript></div></xmp></style> <style type="text/css">  </style>  <center> <table border="0" cellspacing="0" cellpadding="0"> <tr> <td bgcolor="#ffffff"><center><font color="BLUE" size=-1> <a href="http://www.0catch.com" target="_blank" rel="nofollow">web space</a> | <a href="http://www.0catch.com" target="_blank" rel="nofollow">free hosting</a> | <a href="http://www.0catch.com" target="_blank" rel="nofollow">Web Hosting</a> | <a href="http://submitsolution.com/freesitesubmission.php" rel="nofollow">Free Website Submission</a> | <a href="http://www.qccart.com" rel="nofollow">shopping cart</a> | <a href="http://www.bluehost.com" rel="nofollow">php hosting</a><br /> </font></center> </td></tr> </table> </center> <table border="0" cellspacing="1" cellpadding="1"> <tr> <td align="left"><a href="http://0catch.com" target="_blank"><img src="http://0catch.com/freewebsite.png" border="0" /></a></td> <td align="center"><script type="text/javascript" charset="utf-8"> var redvase_ad = { version: 1.5 }; redvase_ad.publisher = 'stormpages'; redvase_ad.kind = 'popunder'; redvase_ad.content = 'pop' redvase_ad.refurl = encodeURI('http://00freehost.com'); redvase_ad.alternate = 'floating_block'; </script> <script src="http://redvase.bravenet.com/javascripts/redvase.js" type="text/javascript" charset="utf-8"></script><center><DIV STYLE="text-align: center; width: 600px;"> <script type="text/javascript" charset="utf-8"> var redvase_ad = { version: 1.5 }; redvase_ad.publisher = 'stormpages'; redvase_ad.kind = 'leaderboard'; redvase_ad.content = 'creative' redvase_ad.refurl = encodeURI('**URL_HERE**'); </script> <script src="http://redvase.bravenet.com/javascripts/redvase.js" type="text/javascript" charset="utf-8"></script></center></div> <script type="text/javascript" src="http://www.00freehost.com/sideAd.js"> </script> <div id="sideAdObj" style="position:absolute; width:120px; visibility:hidden; z-index: 999 "> TEST </div> </td></tr><tr><td colspan="2" align="center"><script type="text/javascript"> rnd = (new String(Math.random())).substring(2,8) + (((new Date()).getTime()) & 262143); ad_par = 13100; sb_size = ''; sb_button = ''; sb_image = ''; rs_logo = 'http://www.armadasearch.com/arm_logos/logo-blue.jpg'; rs_theme = 'coolSteel'; rs_tmp = ''; rs_type = 'basic'; document.write('<scri' + 'pt type="text/javascript" src="http://adunit.adrevmedia.com/search.js?' + rnd + '"></scr' + 'ipt>'); </script> </td></tr></table><!POP YES 1 0catch 1337422297-0 ><table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=110 BGCOLOR="#666699" TEXT="#080000" bgproperties="fixed" background="04a00840erlcjm.gif"> <div> <B>RADIODIAGNOSIS 5</B></div> <bR> <div> </div> </td> </tr><tr> <td valign="top" width=190 BGCOLOR="#CCCCFF" TEXT="#080000" background="04411c00egdysm.gif"> <div> <B>DANIL HAMMOUDI.MD</B></div> <div> <A HREF="http://SINOEMEDICALASSOCIATION.COM" TARGET="_top" TITLE="http://SINOEMEDICALASSOCIATION.COM"><U><B>SINOE MEDICAL ASSOCIATION</B></U></A></div> <bR> <bR> <bR> </td> <td valign="top" height=370 BGCOLOR="#FFFFFF" TEXT="#080000"> <bR> <bR> <div> <A HREF="id18.htm" TARGET="_top" TITLE="CASES"><U>CASES</U></A>   |   <A HREF="id19.htm" TARGET="_top" TITLE="SOME PICTURES"><U>SOME PICTURES</U></A>   |   <A HREF="id20.htm" TARGET="_top" TITLE="PICTURES"><U>PICTURES</U></A>   |   <A HREF="id17.htm" TARGET="_top" TITLE="Contact Me"><U>Contact Me</U></A></div> <bR> <div> GU RADIOLOGY RENAL </div> <bR> <bR> <div> <B><U>EXCRETORY UROGRAM (IVP, IV Pyelogram, IV Urogram, IVU)</U></B> </div> <div> <B><U>Definition:</U></B><B> </B>The radiographic study of the anatomy and function of the kidney and urinary collecting systems using radiopaque contrast material excreted by the kidneys.</div> <div> <B><U>1. Contrast Material </U></B>(Never say dye!)</div> <div> Contrast is water soluble and contains iodine </div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="627" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 38 ><NOBR><div> Examples: </div> </NOBR></tD> <tD VALIGN=TOP WIDTH="560"><div> Meglumine and sodium diatrizoate (Renografin 60)</div> <div> Iopamidol (Isovue 300 low osmolar contrast) </div> </tD> </tR> </TABLE></div> <div> Dose in Adults: Approx. 0.5cc/lb up to 100 ccs given rapidly I.V.</div> <div> Physiology</div> <div> Excreted by glomerular filtration </div> <div> Rate of excretion altered by anything decreasing renal perfusion </div> <div> Concentration (density) depends primarily on the amount of tubular water resorption </div> <div> Contrast toxicity</div> <div> Minor side effects are very common (flushing, metallic taste, nausea, faintness, tingling) </div> <div> Acute reactions (about 1-2 %) </div> <div> Hives and erythema most common </div> <div> Periorbital edema, nasal stuffiness </div> <div> Cardiovascular (about 1/1300, Mayo clinic data) Includes syncope, shock, cardiac arrest </div> <div> Respiratory (about 1/2000, Mayo clinic data)</div> <div> Includes asthma, laryngeal edema </div> <div> Death (about 1/75,000, Mayo clinic data) </div> <div> Reactions are unpredictable. A prior reaction is not an absolute contraindication.</div> <div> Low osmolar contrast agents now available decrease the incidence of some contrast reactions but cost about ten times as much. </div> <div> <B><U>2. Contraindications</U></B><B> </B>(most are relative)</div> <div> Exam not indicated </div> <div> Absence of facilities to treat an acute reaction (absolute) </div> <div> Other diseases </div> <div> Renal failure with dehydration </div> <div> Multiple myeloma- avoid dehydration - protein may precipitate in tubules if dehydration is present. </div> <div> Diabetes mellitus with renal insufficiency - a worsening of renal failure that at times is permanent is not rare. IVPs should only be done in these pateints for a strong indication. </div> <div> Prior severe reaction - A prior reaction does not reliably indicate that another will occur but prudence would dictate a strong indication should exist and facilities for therapy be ready. </div> <div> <B><U>3. Patient Preparation</U></B></div> <div> Withhold food for 4 - 6 hours. </div> <div> Avoid dehydration especially in the presence of renal failure, diabetes and multiple myeloma. </div> <div> Avoid overhydration and diuresis since it dilutes the contrast material and decreases the density of contrast in the renal collecting system. </div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="627" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 38 ><NOBR><div> <B><U>4. Filminq Sequence</U></B><B> - </B></div> </NOBR></tD> <tD VALIGN=TOP WIDTH="435"><div> Always individualized depending on the patient, the indication and findings during the course of the study. </div> </tD> </tR> </TABLE></div> <div> Plain (Scout) film. Look especially for any calculi which may be later obscured by contrast material </div> <div> Nephrogram phase (about 1 minute after injection). Contrast concentrated in the renal tubules makes the kidney appear dense. Initial films after injection are most often nephrotomograms. If these films are done at one minute intervals renal function (contrast in the <U>collecting system</U>) should be seen at two to three minutes. These films are good for identifying differential function (late function on one side) and for delineation of the renal margins to evaluate for cortical masses. </div> <div> 5 minute KUB (large film including kidneys, ureters and bladder) then abdominal compression is applied to fully distend the collecting systems. </div> <div> 10 minute compression film should show fully distended collecting systems to the level of ureteral compression. </div> <div> 15 minute film just after release of compression to visualize the distal ureters and the urinary bladder. In some patients (eg.- follow-up of a patient with a recently passed ureteral stone) not all of these films would be necessary and the exam could be completed in 5 or 10 minutes. In other patients additional views over possibly much more time might be necessary. All exams are monitored by physicians during progress. </div> <div> <B><U>5. Interpretation of the excretory urogram</U></B> </div> <div> Always look at the scout film - contrast may obscure abnormalities. Look at everything on the film, even areas other than the GU tract, such as bowel gas pattern, bones and soft tissues. The psoas muscle shadows, if they are indistinct, can indicate retroperitoneal fluid or inflammation. </div> <div> If the entire renal outlines are not visualized then the exam is incomplete. </div> <div> Two kinds of information are displayed on an IVP: function and anatomy. An IVP is a good indicator of comparative function of the two sides (especially with rapid sequence filming). Except for gross abnormalities, it is a poor measure of overall renal function. Morphologically the two kidneys are generally symmetrical. </div> <DIV ALIGN="LEFT"></DIV> <div> <B><U>RENAL ULTRASOUND</U></B></div> <div> Ultrasound (US) examination of the kidneys and bladder is a rapid, non-invasive method for evaluation of the morphology of the GU tract.</div> <div> <B><U>1. Indications:</U></B></div> <div> Ultrasound is invaluable in renal failure where an IVP would not visualize the kidneys or when there is concern that contrast could worsen renal failure. In this situation the exam is performed to evaluate renal size and to look for evidence of obstruction. </div> <div> Ultrasound should rapidly be performed when a non-functioning kidney is found on IVP. If the kidney is dilated (hydronephrosis) then obstruction may be the reason and delayed IVP films are warranted. If the kidney is not dilated then other causes of non-function must be considered such as lack of blood flow to or from the kidney, unilateral intrinsic renal disease, and ectopic or congenitally absent kidney. </div> <div> Evaluation of a renal mass found on IVP. If a mass on IVP is shown to be a simple renal cyst on ultrasound examination, no further evaluation of the lesion is necessary. However, if a lesion is solid then malignancy must be considered and further radiographic examination is needed (such as CT for tumor staging). </div> <div> <B><U>2. Contraindications:</U></B></div> <div> There are no true contraindications to renal ultrasound but remember that while Doppler ultrasound can detect flow in the renal arteries and veins, even the best renal ultrasound exam will relate no information regarding renal function, will almost never visualize the mid ureters due to overlying bowel gas, and will not show the urinary bladder unless it is well distended. In addition small renal masses in the cortex of the kidney may be difficult or impossible to visualize. For these reasons, the IVP remains the method of choice for visualization of the urinary tract in most patients.</div> <div> <B><U>3. Patient Preparation:</U></B></div> <div> No special preparation is necessary. Since the kidneys can be visualized by ultrasound through the flanks, intervening gas rarely interferes. If the bladder is to be seen then bladder distension is necessary.</div> <div> <B><U>4. Ultrasound Examination:</U></B></div> <div> Renal ultrasound is usually performed with the patient supine and the ultrasound transducer placed against the posterior flank angled somewhat anteriorly. All of each kidney must be visualized both longitudinally and transversely for a complete examination. The exam should include evaluation of the region of the urinary bladder. Photographs of the examination are taken and may be taken either with white echo writing (where a fluid containing structure with no echoes would be black) or with black echo writing (where a fluid containing structure would be white). The choice of method of photography is merely a matter of personal preference. All sonographic images today are photographed with white echo writing.</div> <div> <B><U>The Normal Renal Ultrasound:</U></B></div> <div> The echogenic central portion of a normal kidney (central echo complex) anatomically contains most of the renal medulla including the major branches of the renal vein and renal artery as well as the collecting system of the kidney. This portion of the kidney is very echogenic both because it contains fat (which is echogenic on ultrasound) and because of all the irregularities of the other contained structures. The ultrasonic renal cortex is of much more uniform structure and contains very few echoes. The renal margin should be smooth and the cortex should be of uniform echogenicity.</div> <div> <B><U>6. The Abnormal Renal Ultrasound:</U></B></div> <div> Obstruction</div> <div> When there is renal dilatation (pelvocalyectasis, hydronephrosis) then obstruction should be suspected. This is manifest by separation of the central echo complex - the appearance of an echo free central zone which represents urine in the dilated collected system. Many things may cause renal dilatation including renal obstruction, vesicoureteral reflux, high urine flow states such as chemical diuresis and diabetes insipidus, and congenital dilatation without obstruction. </div> <div> Calculi</div> <div> Stones (if large enough to be seen) within the kidney will be found in the central echo complex and will be very brightly echogenic and often show a shadow because sound waves are unable to penetrate the stone substance. </div> <div> Masses</div> <div> Renal cysts are easily seen by ultrasound and appear as smooth, echo- free lesions most often in the cortex of the kidney. Renal cysts are very commonly incidentally found in the adult population. Other renal masses including malignancies are most often seen because of an abnormality of renal contour, but the echoes within a neoplasm may differ from those of the normal cortex, especially if central necrosis is present. </div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="626" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 251 WIDTH="622"><div> <B><U>CYSTOGRAMS</U></B></div> <div> <B>Technique </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bladder filled with 30% water soluble iodinated contrast (such as cystoconray) through urethral catheter or supra-pubic catheter. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Films taken in frontal and both oblique positions and then a post- drainage frontal projection. </div> <div> <B>Indications </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lower abdominal and pelvic trauma with hematuria. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Urinary tract infections-particularly in infants and children-usually done as part of a voiding cystourethrogram.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Clinical suspicion of fistula to bowel or vagina. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Evaluation of bladder calculi </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Evaluation of bladder diverticula </div> </tD> </tR> </TABLE></div> <div> <B>URETHROGRAMS</B></div> <div> <B><U>Anatomy </U></B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Male </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Prostatic Urethra-from bladder to urogenital diaphragm traverses the prostate </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Membranous Urethra-that portion that traverses the external sphincter (urogenital diaphragm) - about 1cm. in length </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bulbous urethra-from external sphincter to penile scrotal junction </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Penile or Pendulous urethra-from penile scrotal junction to external meatus </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Prostatic Urethra + Membranous Urethra = Posterior Urethra</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">bulbous Urethra + Penile Urethra = Anterior Urethra </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Female: not divided into segments radiographically because of short length</div> <div> <B>Technique of Exam </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Male </B></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Retrograde </U></B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Best for examining anterior urethra </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Foley catheter with balloon inflated in fossa navicularis (just inside glans penis) - preferred </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Brodny clamp - cumbersome </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Catheter tip syringe in external meatus - discouraged - radiation exposure to examiners hands </B></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Antegrade (voiding) </U></B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Best for examining posterior urethra</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fill bladder with foley catheter, remove catheter, have patient void </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Can be done at conclusion of excretory urogram with contrast in bladder from the intravenous injection - problem because of dilute contrast </B></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Antegrade (voiding) against resistance </U></B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fairly good look at entire urethra</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Resistance provided with Zipser clamp on glans penis or manual compression of glans </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Requires cooperative patient </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Female </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Antegrade (voiding) - same as above </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Retrograde "double balloon" technique - very cumbersome </B></div> <div> <B>Contrast </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Water soluble iodinated contrast </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">50% for retrogrades - example: Hypaque 50 </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">30% for antegrade after filling bladder with foley catheter - example: Cystoconray </div> <div> <B>Indications </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Urinary tract infections in infants and children - voiding cystourethrogram followed by excretory urography - looking for vesical - ureteral reflux or bladder outlet obstruction </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Trauma - evidence of perineal injury in males </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Clinical suspicion of stricture or other obstruction - mostly males </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Clinical suspicion of urethral diverticulum - mostly females </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Relative contraindications - not very useful for evaluating benign prostatic hypertrophy (BPH) or stress urinary incontinence. </div> <DIV ALIGN="LEFT"></DIV> <div> <IMG SRC="06184230.jpg" border=0 width="644" height="291" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Most renal masses are found with an excretory urogram </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ultrasound next step to determine if solid or cystic </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Solid or complex masses then further evaluation with CT or angiography </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Most surgeons want an angiogram before operating on a solid mass. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Preoperative tumor embolization may also be done to decrease blood loss at surgery </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ultrasound usually definitive for most simple cysts but in complicated cases further evaluation such as cyst puncture, CT or Angiography may be indicated </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Above diagram is only a generalization. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Each case has to be individualized according to the clinical circumstance. </div> <bR> <bR> <bR> </td> </tr></table></body>