Imaging features of chronic cystitis
The diagnosis of chronic nonspecific cystitis using tomographic methods is based on evaluating the condition of the urinary bladder walls. The inflammatory process leads to structural changes that are clearly distinguishable when the appropriate scanning protocol is chosen:
- Computed tomography (CT): When performed with intravenous contrast enhancement in the axial projection, a pathologically altered anterior bladder wall is identified. It appears thickened and is characterized by moderate density.
- Magnetic resonance imaging (MRI): T2-weighted imaging (evaluated in the sagittal plane) reveals uneven thickening of the anterior wall. When using T1-weighted imaging in the axial plane, the early phase after intravenous contrast administration shows marked contrast enhancement of the thickened anterior wall, indicating active inflammation.
General indications for imaging in UTIs
Urinary tract infections (UTIs), which include cystitis, require a differentiated approach to the ordering of imaging studies. According to current criteria, imaging is indicated:
- In men: upon the very first confirmed episode of a urinary tract infection.
- In women: in cases of a recurrent disease course, when 2 to 3 infection episodes are recorded within one year.
Overall, the urinary system is the most frequent localization of extrapulmonary forms of tuberculosis, which also makes diagnostic imaging (CT and MRI) critically important when searching for the causes of chronic inflammation.
Inflammation of adjacent organs: prostatitis
Chronic urinary tract infections in men are frequently accompanied or complicated by involvement of the prostate gland. Chronic prostatitis (both bacterial and non-bacterial) manifests with irritative symptoms, sometimes hematuria, and in rare cases, urinary tract obstruction against the background of recurrent UTIs.
It is clinically impossible to differentiate the bacterial form from chronic pelvic pain syndrome; therefore, quantitative microbiological cultures (localization tests) are required. The main causative agent of the bacterial form is E. coli.
Special attention should be paid to nonspecific granulomatous prostatitis (including eosinophilic and non-eosinophilic variants). It is accompanied by elevated prostate-specific antigen (PSA) levels and presents as a firm mass on digital rectal examination. Clinically and on ultrasound, this form can be mistaken for prostate cancer.
Imaging and complications of prostatitis
MRI is recognized as an excellent method for diagnosing inflammatory diseases of the prostate gland. However, there is the issue of overlapping features between chronic prostatitis and carcinoma.
- On diffusion-weighted imaging (DWI), restriction of diffusion is observed in both pathologies.
- The apparent diffusion coefficient (ADC) helps assess specificity: values below $1.2 \times 10^{-3} \text{ mm}^2\text{/s}$ favor prostatitis.
- On transrectal ultrasound (TRUS), the appearance often remains within normal limits, or nonspecific zones (hypo-, iso-, or hyperechogenic) are detected. The presence of calcifications is not a specific sign. If a palpable mass is detected, a TRUS-guided biopsy is strictly indicated.
Frequent complications of chronic pelvic inflammation include calculogenesis (especially in young patients), inflammation of the vas deferens (ductus deferens) and seminal vesicles. Scarring or compression by adjacent calculi can lead to mechanical obstruction of the ejaculatory ducts and, consequently, male infertility.
Prostatic abscess
A severe purulent complication of pelvic infections is a prostatic abscess. On MRI in T2-weighted mode (coronal projection), it appears as a multilocular cystic lesion that can replace a major part of the prostatic lobe and extend to the pelvic wall. In GRE T1-weighted mode with gadolinium, peripheral rim enhancement as well as septal enhancement are clearly defined. Additionally, uneven enhancement of the seminal vesicles is visualized, confirming their involvement in the purulent-inflammatory process.
Briefly: answers to topical questions
What ultrasound (echographic) signs are characteristic of chronic cystitis?
Bladder ultrasound evaluates:
- Mucosal thickness — normally less than 2 mm with a full bladder and less than 5 mm when empty.
- Residual urine volume.
- Presence of polyps or mass lesions.
Which pathogens, besides E. coli, most commonly cause bacterial urinary tract infections?
In addition to Escherichia coli (E. coli), the main causative agents of bacterial urinary tract infections include:
- Klebsiella species.
- Enterococci.
- Proteus species (P. mirabilis, P. vulgaris).
What MRI findings are characteristic of seminal vesicle inflammation (vesiculitis)?
An MRI sign of seminal vesicle involvement in the inflammatory process is their uneven contrast enhancement.
- MRI in GRE T1-weighted mode with gadolinium demonstrates uneven contrast agent accumulation in the seminal vesicles.
Class and exam questions
In what cases are CT or MRI ordered for urinary tract infections?
Diagnostic imaging is indicated for men upon the very first UTI. For women, the study is prescribed for recurrences if the infection repeats 2–3 times a year.
How to differentiate granulomatous prostatitis from prostate cancer on ultrasound?
This is extremely difficult to do using ultrasound alone: granulomatous prostatitis mimics carcinoma, presenting with focal hypoechoic areas and disruption of the capsule integrity. The definitive diagnosis is established after a TRUS-guided biopsy.
What reproductive system complications are caused by chronic pelvic organ inflammation?
The chronic process can lead to inflammation of the vas deferens and seminal vesicles, as well as mechanical obstruction of the ejaculatory ducts (due to scars or stones), which becomes a cause of infertility.
What else to study on this topic
- CT and MRI findings in acute pyelonephritis
- Diffusion restriction in renal abscesses
- Extrapulmonary manifestations of urinary tract tuberculosis
- Methodology for performing localization bacteriological tests
- Differential diagnosis of granulomatous prostatitis and carcinoma on MRI
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