Dr Ahmed Esawy

Prostatitis

Imaging

Dr. Ahmed Esawy

MBBS M.Sc MD

Dr Ahmed Esawy

Anatomy of Urethra

• Extends from bladder neck to the membranous urethra

• Divides the prostate into anterior FMS and posterior glandular structures.

• Veromontanum

• Prostatic utricle. • Ejaculatory duct openings.

• Internal urethral sph. at the bladder neck

• External urethral sph. at the prostatic apex

Dr Ahmed Esawy

Orientation of images

Dr Ahmed Esawy

Seminal Vesicles, Vas

deferences

Dr Ahmed Esawy

Prostatic base-TS

Dr Ahmed Esawy

Dr Ahmed Esawy

Mid prostate-TS

Dr Ahmed Esawy

Dr Ahmed Esawy

Prostatic apex-TS

Dr Ahmed Esawy

Dr Ahmed Esawy

Mid prostate-LS

Dr Ahmed Esawy

Dr Ahmed Esawy

Periprostatic structures

• Urinary bladder

• Obturator internus&

levator ani

• Anterior periprostatic fat

• Pubic bone

• Neurovascular bundles

• Rectal wall

Dr Ahmed Esawy

Normal MRI of the

Prostate

Dr Ahmed Esawy

Dr Ahmed Esawy

category III prostatitis, also known as chronic pelvic pain syndrome

(CPPS)

is a common condition of unclear etiology and few validated effective

therapies.

It is even controversial whether all patients with CPPS have prostatic

pathology

Prostatitis infection or inflammation of the prostate gland

Acute prostatitis

Chronic focal prostatitis

symptomatic

oligo or asymptomatic

Typical pelvic or perineal pain lasting more than 3 month can be

bacteria or non infectious

Dr Ahmed Esawy

The National Institutes of Health (NIH) classified prostatitis into four distinct

syndromes

I: acute bacterial prostatitis

II: chronic bacterial prostatitis

III: chronic prostatitis and chronic pelvic pain syndrome (CPPS); further

classified as inflammatory or noninflammatory)

IV: asymptomatic inflammatory prostatitis

Dr Ahmed Esawy

Prostatitis

• Diffuse or focal.

• Involve inner or outer gland.

• Acute, chronic or granulomatous.

.

Dr Ahmed Esawy

Ultrasonographic findings in prostatitis

Enlarged prostate

diffuse enlargement

focal

high-density and mid-range echoes represent corpora amylacea concretion ,

Calcifications

Focal hypoechoic region in the peripheral zone of the gland the mid-range echoes

represent inflammation, fibrosis, or both

echo-lucent zones Discrete fluid collection suggests abscess formation.

capsular irregularity and thickening, ejaculatory duct echoes, and periurethral-zone

irregularity.

Colour Doppler ultrasound demonstrates increase flow in the periphery of the

abscess

Granulomatous prostatitis: * Focal hypoechoic lesion

Dr Ahmed Esawy

TRUS findings

Edema of the verumontanum

Edema of the prostatic lobes (peripheral zone)

Dilated Ejaculatory Ducts

Changes of the Seminal Vesicles

Median prostatic cysts (utricular cysts, Mülleriancysts)

Dr Ahmed Esawy

MRI The prostate will be diffusely enlarged, often with associated inflammatory

changes of periprostatic fat and of the seminal vesicles

Acute prostatitis

T1: peripheral zone iso- or hypo-intense to transitional zone

T2: hyperintense

T1 C+ (Gd) diffusely enhancing

CT abscess is present it is seen as a rim-enhancing, unilocular or

multilocular, hypodensity in the peripheral zone

Infection can extend through capsule into periprostatic tissues, seminal

vesicles, and peritoneum

Chronic prostatitis: * heterogenous gland DD cancer * Ca in PZ

Dr Ahmed Esawy

Group I. Prostatic calculi associated with prostatitis

Group II. Prostatic calculi associated with hypertrophy of the gland

Group III. Prostatic calculi that simulate carcinoma

Group IV. Calculi in both the prostatic urethra and the urinary tract

Prostatic Calculi

Calcification formed within prostate gland. It is mainly composed of calcium

carbonate and/or calcium phosphate.

They are usually asymptomatic. These calculi can be well demonstrated by

Plain X-ray, CT scan,

Dr Ahmed Esawy

small multiple concretions corresponding to the corpora amylacea.

Prostatic parenchymal calculi are usually incidental findings

Small, multiple calcifications are a normal, often incidental ultrasonographic

finding in the prostate and represent a result of age rather than a pathologic entity.

However, larger prostatic calculi may be related to underlying inflammation and

require further evaluation and possibly, treatment

Dr Ahmed Esawy

Prostatic concretions ( corpora amylacea [starch bodies)

1. Small spherical or ellipsoid bodies

2. Number increases with age

3. May become calcified as male ages

4. May simulate carcinoma

Dr Ahmed Esawy

Prostatic calculi

• Occur in conjunction of BPH

• Concretion of corpora

amylacia

• Localized in PUG

• As gland enlarge-calculi at

surgical capsule

• May dystrophic calcifications

Dr Ahmed Esawy

Dr Ahmed Esawy

Longitudinal transrectal ultrasound image of the left lobe of the

prostate demonstrating extensive concretions.

Dr Ahmed Esawy

Dr Ahmed Esawy

This middle aged patient underwent TRUS imaging (transrectal ultrasound) of the

prostate for prostatism (symptoms related to the prostate). TRUS images show

multiple hyperechoic foci (arrows), each of 4 to 7 mm. in the inner gland of the

prostate and also along the prostatic urethra. Power Doppler image (bottom)

shows normal flow in the prostate. These ultrasound images suggest prostatic

calcification or calculi. Calcific foci in prostate are associated with normal aging

process in the male and may be the result of formation of corpora amylacea.

These are formed by calcification of secretions of the gland. It is also seen in

chronic inflammation of the prostate (chronic prostatitis).

Dr Ahmed Esawy

Power Doppler TRUS image (on right above), shows no significant changes in

vascularity of the prostate and suggesting absence of prostatitis at present. The

calcification of the walls of this midline utricle cyst of the prostate may be the result of

dystrophic changes

Dr Ahmed Esawy

Micturating cystourethrogram (MCUG)

showing huge prostatic cavity Plain pelvic X-ray showing prostatic

urethral calculus

Dr Ahmed Esawy

Multiple, small prostatic calculi (type A) in a young patient.

Dr Ahmed Esawy

Coarse echoes representing larger, discrete prostatic calculi

Dr Ahmed Esawy

The above TRUS ultrasound and color doppler images in a young male patient

show a) hypoechoic prostate b) gross augmentation of vascularity in the prostatic

tissue. These ultrasound findings suggest presence of acute prostatitis

Dr Ahmed Esawy

Note the markedly hypoechoic patches in the inner zone of the prostate (arrowed),

which appear overtly vascular on color doppler imaging

Dr Ahmed Esawy

acute-bacterial-prostatitis-and-abscess

Dr Ahmed Esawy

Acute bacterial prostatitis and abscess

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

T2 T1 fat sat

severe urinary tract infection with complicating prostatic abscess

Dr Ahmed Esawy

• Chronic prostatitis. CT revealed multiple, coarse, ring like calcification inside the normal-sized prostate, which is sharply marginated. The prostate clearly absorbs contrast medium as an expression of current prostatitis.

Dr Ahmed Esawy

Chronic Prostatitis

heterogenous gland

Dr Ahmed Esawy

Chronic Prostatitis-MRI

Dr Ahmed Esawy

Prostate abscess-TRUS

Dr Ahmed Esawy

Prostatic Abscess-MRI

C C

Dr Ahmed Esawy

Prostatic Abscess-MRI

Dr Ahmed Esawy

Prostatic abscess in a 48- year-old man with perineal pain and abnormally

ncreased CRP. Axial unenhanced (a) and postcontrast (b) CT images showed

mild asymmetric prostatic enlargement, occupied by a 4-cm septated fluid-like

Collection (arrowheads) with peripheral and septal enhancement. Note

displacement of periurethral calcifications (thick arrows) from midline.

Ultrasound-guided transperineal drainage confirmed Escherichia coli infection

Dr Ahmed Esawy

Large prostatic abscess from ESBL-positive

Escherichia coli infection in a 61-year-old

man with previous chemo- and radiotherapy

for non-Hodgkin lymphoma, fever (38 °C),

dysuria, pelvic pain and enlarged tender

prostate at digital rectal examination.

Multiplanar CT images (a–d) showed marked

prostatic enlargement by confluent

nonenhancing hypoattenuating (17–19 HU)

regions, with peripheral and septal

enhancement (arrowheads). The prostatic

infection also involved the left seminal vesicle

(arrows in b, d),

displaced upwards of the urinary bladder,

with mild circumferential mural thickening and

mucosal hyperenhancement (thin arrows)

consistent with UTI.

After transperineal evacuation (e),

follow-up CT urography (f) confirmed

persistent resolution of the abscess

Dr Ahmed Esawy

Dr Ahmed Esawy

PROSTATIC CANCER ON TRUS

Dr Ahmed Esawy

Dr Ahmed Esawy

PROSTATITIS ON MRI

Dr Ahmed Esawy

PROSTATITIS ON TRUS

Dr Ahmed Esawy

PROSTATIC ABSCESS ON TRUS

Dr Ahmed Esawy

urethritis

Dr Ahmed Esawy

Acute uncomplicated

urethritis in a 30-year-old

man

with neurogenic bladder

treated by intermittent

selfcatheterisation.

Physical examination

revealed induration and

tenderness of the corpus

spongiosum and purulent

urethral

secretions. Unenhanced T2-

weighted MRI images (a)

revealed a diffuse, uniform

hypersignal in the corpus

spongiosum (*) with

corresponding intense

homogeneous enhancement

on post-gadolinium T1-

weighted sequences (b, c).

The infection did not appear

to interrupt the tunica dartos

or Buck’s fascia, and did not

involve the corpora

cavernosa, scrotum or

ischioanal

spaces. Note Foley catheter

in

place (thick arrows). The

patient successfully

recovered with temporary

suprapubic catheter and

intravenous and topical

antibiotics

Dr Ahmed Esawy

Urethral infection

complicated by penile and

perineal abscess in a 53-year-old

man with tender, inflamed

perineal swelling despite

antibiotics. Infection was initially

detected at contrast-enhanced CT

(a) as an elongated midline

abscess with peripheral

enhancement (arrowheads) and

internal fluid. MRI showed

corresponding inhomogeneous

fluid-like content on T2-weighted

sequences (b–d), with

surrounding inflammatory

stranding (+) and strong contrast

enhancement in the abscess walls

(arrowheads in e, f). The infected

corpus spongiosum (*) showed

similar signal features. Surgical

evacuation was required to relieve

the abscess

Dr Ahmed Esawy

Dr Ahmed Esawy

This middle aged male patient presented with a history of hemospermia (passage of

blood in semen) with mild pain during ejaculation. Sonography of the abdomen was

normal. Transrectal ultrasound (TRUS) of the prostate and seminal vesicles showed

multiple echogenic foci/ lesions in the terminal (proximal) part of the seminal vesicles,

bilaterally. The ultrasound images show multiple seminal vesical calculi bilaterally, each

measuring 2 to 4 mm. in size. Studies suggest that such stones are related to

inflammation, obstruction or diabetes mellitus. The ultrasound image on bottom right

shows Power Doppler study of the prostate; no abnormal flow was found. Calculi in this

case can cause poor flow of semen during ejaculation, hemospermia and painful

ejaculation.

Dr Ahmed Esawy

This late middle aged male patient presented with lower urinary tract symptoms.

TRUS ultrasound shows a 9 mm. midline cyst of the prostate; what is interesting

is the markedly hyperechoic rim of the prostate cyst suggesting calcification of

the cyst walls. This is an unusual appearance for what is obviously a cyst of the

prostatic utricle with almost no literature available.