For each station, you will find:

• Clinical Context
• Modality to Choose (most appropriate first-line or gold standard)
• Possible Imaging Finding (what you might see on the provided image)
• What to Describe (a complete structured description: presentation, criteria, syndrome,
diagnosis, and negative signs)

OSCE Station 1: Acute Pyelonephritis / Focal Nephritis

Clinical Context: Young woman (24 y/o), right lumbar pain for 24h, fever (40.1°C), chills,
tachycardia (125/min), elevated CRP (120) and WBC (18,000). No previous history except right
lumbar pain for 4 months.

Modality to Choose:

• First-line: Renal ultrasound (AUSP + ultrasound)

• Gold standard if ultrasound abnormal or no response to antibiotics: CT with contrast
(Uroscanner)

Possible Imaging Finding (Ultrasound or CT):

• Ultrasound: Localized loss of cortico-medullary differentiation, triangular shape with

peripheral base. Kidney may be enlarged.
• CT (Tubular/Excretory phase): Triangular hypodense areas with peripheral base and
central apex (lobar distribution). Hypodense streaks (banded, radial). Perirenal fat
infiltration.

Complete Description Guide:

Presentation: The image shows [a transverse/coronal] section of the [right/left] kidney on

[ultrasound / CT without contrast / CT with contrast at tubular phase].

Findings (Positive Signs):

• Kidney size: [Normal / Enlarged]

 • Parenchyma: There are [triangular / wedge-shaped] hypodense areas on CT (or
hypoechoic areas on ultrasound) with the base at the renal periphery and apex directed
toward the renal sinus.
• Corticomedullary differentiation: [Preserved / Locally lost]
• Perirenal space: There is [infiltration of perirenal fat / thickening of Gerota's fascia] (seen
on CT as linear stranding).
• Lesion distribution: The abnormalities follow a lobar distribution with pathological areas
extending from the capsule to the papillae

Syndrome / Diagnosis: These findings are consistent with acute pyelonephritis (specifically
focal bacterial nephritis).

Negative Signs (to exclude complications):

• No well-defined rounded fluid collection (no abscess)

• No gas within parenchyma (no emphysematous pyelonephritis)
• No dilation of pyelocaliceal cavities (no obstruction/pyonephrosis)
• No perirenal fluid collection extending to psoas (no perinephric abscess)
Note

Emphysematous pyelonephritis ( the prerogative of diabetic patients in 90% of cases )

shows On ultrasound: hyperechoic zones varying according to the patient's position and
accompanied by a “comet tail” effect.

CTwithout injection of contrast material represents the key examination for diagnosis based on
the presence of air in the renal parenchyma with extension to the peri-renal region and the
presence of intra- or peri-renal fluid collection

OSCE Station 2: Renal Abscess

Clinical Context: Patient with acute pyelonephritis treated with antibiotics but persistent fever
and lumbar pain after 48-72h of appropriate treatment. Diabetic or immunocompromised?

Modality to Choose:

• Ultrasound (first-line to detect collection)

• CT with contrast (to confirm and assess extension)

Ultrasound: It identifies a heterogeneous hypoechoic rounded area.

Possible Imaging Finding (CT with contrast):

• Hypodense rounded mass with a peripheral enhancing shell (rim enhancement). Center
remains hypodense (non-enhancing). May contain air bubbles.

Complete Description Guide:

Presentation: The image shows a [transverse] CT section after IV contrast injection.

Findings (Positive Signs):

• Location: Within the [right/left] renal parenchyma, [peripheral/central].

• Shape: Rounded or oval.
• Borders: [Ill-defined / Well-defined] but with a thick, irregular wall.
 • Density (CT): The center is hypodense (fluid/pus density). After contrast, there is
peripheral rim enhancement (the wall lights up). The center remains non-enhancing.
• Internal content: May contain [no gas / small air bubbles] (if gas present, think
emphysematous or post-drainage).
• Perirenal extension: [No infiltration / There is perirenal fat stranding and thickening of
fascia].

Syndrome / Diagnosis: These findings are characteristic of a renal abscess (suppurative

collection).

Negative Signs:

• No macroscopic fat density (not angiomyolipoma)

• No solid enhancing tissue (not renal cell carcinoma)
• No communication with pyelocaliceal system (not pyonephrosis)
OSCE Station 3: Pyonephrosis

Clinical Context: Febrile renal colic. Patient with known urolithiasis or obstruction, now with
fever and flank pain. Emergency.

Modality to Choose:

• Ultrasound (first-line, fast, bedside)

• CT with contrast (if stable, to confirm cause and extension)

Possible Imaging Finding (Ultrasound):

• Dilated pyelocaliceal cavities with heterogeneous content (debris, fluid-fluid level, or

gas). Thickened pelvic wall. Obstruction (calculus).

Complete Description Guide(ultrasound):

Presentation: The image shows an ultrasound of the [right/left] kidney.

Findings (Positive Signs):

• Pyelocaliceal dilation: The renal pelvis and calyces are dilated (hydronephrosis).
• Content of cavities: The fluid is not anechoic; it is heterogeneous, containing fine
internal echoes (debris, pus). There may be a fluid-fluid level (layering of pus vs. urine)
or even gas bubbles (dirty shadowing).
• Wall: The pelvic/ureteral wall is thickened.
• Obstruction: There is a [calculus at the pyeloureteral junction / distal ureter] visible as a
hyperechoic structure with posterior shadowing.
• Parenchyma: May be thinned (chronic) or normal.

Syndrome / Diagnosis: These findings are consistent with pyonephrosis = infected obstructed
kidney. This is a urologic emergency.

Complete Description Guide (CT):

Presentation: Contrast-enhanced CT, excretory phase (or parenchymal phase if poor excretion).

Positive Signs:

• Dilated pyelocaliceal cavities (hydronephrosis)

 • Content: Not simple fluid – appears heterogeneous or hyperdense (pus, debris). No
contrast mixing in dependent areas (due to thick pus).

• Wall: Pyelic and ureteral walls are thickened and may enhance.

• Obstruction: Stone or stricture at pyeloureteral junction or ureter.

• Perirenal fat stranding (inflammation extends beyond collecting system)

Syndrome / Diagnosis:
This is pyonephrosis – infected obstructed kidney. Requires emergency drainage (nephrostomy
or ureteral stent).

Negative Signs:

• No well-defined parenchymal fluid collection with rim enhancement (no renal abscess –
though abscess can coexist)

• No gas within parenchyma (no emphysematous pyelonephritis)

• No perirenal fluid collection extending to psoas (no perinephric abscess)

A 71 years old septic patient. US longitudinal (a,b) view of left kidney. Severe hydronephrosis, with
extreme cortical thinning. High-grade dilatation and parietal thickening (white arrow) of calico-pelvic
system fluid filled by inhomogeneous fluid with multiple hyperechogenic spots (*). Enlarged and
markedly hyperechogenicity of renal sinus fat with acoustic shadowing due to staghorn calculi
(dashed arrow). Perirenal fat inhomogeneity was detected (dashed line). Axial (c) and MPR coronal
(d) CT with intravenous contrast in cortical-medullary phase after stent placement (white arrow),
showing high-grade hydronephrosis with diffuse parietal thickening of calico-pelvic system (dashed
arrow), staghorn calculi and renal sinus lipomatosis with mild inhomogeneous fat stranding and
suffusion (*).

OSCE Station: Chronic Pyelonephritis (Reflux Nephropathy)

Clinical Context: Child or young adult with history of recurrent urinary tract infections and
vesicoureteral reflux in childhood. Now presents with hypertension or incidental finding of small
kidney on imaging. May have proteinuria or chronic kidney disease.

Modality to Choose:

• First-line: Renal ultrasound

• Gold standard: CT with contrast (Uroscanner) – coronal reconstructions show scars and
calyceal abnormalities best

Possible Imaging Findings (Ultrasound or CT):

Modality Finding

Small kidney, irregular (bumpy) contours, parenchymal thinning, hyperechoic

Ultrasound
cortical notches (scars), loss of corticomedullary differentiation

CT Small kidney, uneven parenchymal thinning, cortical scar retractions (notches),

(contrast) clubbed calyces (flat or convex calyceal fundus)

Complete Description Guide (CT with coronal reconstruction – excretory phase):

Presentation: Contrast-enhanced CT, coronal reconstruction, excretory phase.

Positive Signs:

• Kidney size: The [right/left] kidney is small (reduced in length and volume). Involvement
may be unilateral or bilateral (asymmetrical).
• Renal contours: The outline is irregular and bumpy (bosselated) due to cortical scar
retractions.
• Parenchyma: There is uneven thinning of the renal parenchyma. Cortical notches
(retractions) are present, corresponding to fibrotic scars.
 • Calyces: The affected calyces are clubbed (the calyceal fundus is flat or convex instead of
concave). Calyceal stems (infundibula) remain normal or stretched.
• Corticomedullary differentiation: Lost on ultrasound; on CT, the scarred areas are
hypodense.
• Predilection: Abnormalities often predominate at the upper pole of the kidney.

Syndrome / Diagnosis: These findings are consistent with chronic pyelonephritis (reflux
nephropathy) – sequelae of vesicoureteral reflux in childhood.

Negative Signs:

• No hydronephrosis (unlike obstructive uropathy)

• No calculus (though stones can coexist in chronic stasis)
• No cavitary lesions or calcifications (unlike tuberculosis)
• No mass (unlike tumor)
OSCE Station: Urolithiasis (Renal Colic)
Clinical Context: Acute onset of severe unilateral flank pain radiating to groin, nausea, vomiting.
Hematuria. No fever.

Modality to Choose:

• First-line: AUSP (plain film) + Renal Ultrasound

 • Gold standard: Non-contrast CT (if diagnosis unclear or for surgical planning)

A. Ultrasound Guide (First-line)

Before describing, check:

Positive Signs:

Finding Description

Hyperechoic (bright) focus with posterior acoustic shadowing (dark

Stone cone behind the stone). Located at pyeloureteral junction, crossing of
iliac vessels, or vesicoureteral junction

Dilation of renal pelvis and calyces (anechoic fluid). Grading: Mild

Hydronephrosis (pelvis only), Moderate (pelvis + blunted calyces), Severe (ballooned
calyces + thinned parenchyma)

Dilated ureter seen as a tubular anechoic structure upstream of the

Hydroureter
stone (best seen at vesicoureteral junction with full bladder)

Nephromegaly Kidney may be enlarged (compare to contralateral side)

Absence of ureteral jet on the affected side (at vesicoureteral

Doppler
junction)

Standard description phrase:

"Renal ultrasound shows a hyperechoic focus with posterior acoustic shadowing located at the
[right/left] [pyeloureteral junction / vesicoureteral junction]. Upstream, there is
[mild/moderate/severe] hydronephrosis with dilation of the renal pelvis and calyces. The ureter is
dilated above the stone. The contralateral kidney is normal."

Negative Signs on Ultrasound:

• No debris or fluid-fluid level within dilated collecting system (no pyonephrosis)

• No perirenal fluid collection (no abscess or urinoma)
B. AUSP (Plain Film / KUB) Guide

Before describing, check: Coverage (kidneys to bladder), Centering (midline), Exposure (psoas
visible).

Positive Signs:

Finding Description

90% of stones are radiopaque. Look for a dense opacity projected over
Radiopaque stone
the ureteric course (paraspinal, over sacroiliac joint, or over bladder)

Trace the ureter: renal pelvis → sacral promontory → ischial spine →

Location
vesicoureteral junction

Size and shape Ureteral stones are small, oval, or elongated. May be multiple

Kidney size May see enlarged renal shadow (nephromegaly) on plain film

Standard description phrase:

"AUSP shows a [small/medium] radiopaque opacity measuring [X] mm projected over the
[right/left] ureter at the level of [transverse process of L3 / sacroiliac joint / ischial spine]. The
renal shadow on the affected side is [normal / enlarged]. No other opacities are seen."

Negative Signs on AUSP:

• No staghorn calculus (no large branching stone)

• No bladder stones
• No calcifications over renal parenchyma (no TB or vascular calcifications)
C. Small Note on CT (Gold Standard)

Indication for CT:

• AUSP and ultrasound are negative but high clinical suspicion persists
• Need to confirm stone size and location for surgical planning (ureteroscopy, ESWL)
• Suspected complication (abscess, pyonephrosis, or other differential diagnosis like
appendicitis or diverticulitis)

Key CT finding (non-contrast):

"Non-contrast CT shows a hyperdense stone (measuring [X] mm) at the [level of ureter] with
upstream hydroureteronephrosis and perirenal fat stranding. This is diagnostic of acute ureteral
obstruction due to urolithiasis."

CT advantage:

• Detects all stones (including radiolucent uric acid stones)

• Measures stone density in Hounsfield Units (helps predict composition)
• Identifies alternative diagnoses

When CT is NOT needed:

• Classic renal colic with positive AUSP/ultrasound and no complications

• Pregnancy (use ultrasound or MRI)
• Young patient with first episode and spontaneous stone passage expected
Summary Table for OSCE

Modality Key Finding When to Use

Hyperechoic stone + posterior shadowing

Ultrasound First-line, no radiation, bedside
+ hydronephrosis

AUSP (X- Quick, low radiation, good for

Radiopaque opacity along ureteric course
ray) follow-up

CT (non- Hyperdense stone + hydronephrosis + fat Gold standard for diagnosis and
contrast) stranding surgical planning
OSCE Station 5: Urinary Tuberculosis (Putty Kidney / Autonephrectomy)

Clinical Context: Middle-aged patient (46 y/o), history of pulmonary TB treated 3 years ago. Now
complains of intermittent flank pain, dysuria, recurrent cystitis, total hematuria. Resistant to
standard antibiotics.

Modality to Choose:

• AUSP + IVU or Uroscanner (CT urography)

Possible Imaging Finding (AUSP or CT):

• Dense, amorphous, lobar calcifications occupying the entire kidney (putty kidney). Or
multiple parenchymal calcifications + hydronephrosis + ureteral strictures.

Complete Description Guide (for Putty Kidney):

Presentation: The image is an AUSP (plain abdominal radiograph) or non-contrast CT.

Findings (Positive Signs):

• Calcifications: There is a dense, amorphous, cloud-like calcification projecting over the

[right/left] renal fossa. The calcification is lobar in shape, roughly following the renal
contour.
• Kidney outline: The normal renal outline is not visible; the calcification has replaced the
entire parenchyma.
• Size: The kidney is small (atrophic) or normal-sized but completely calcified.
• Contralateral kidney: Must be examined (TB is often bilateral but asymmetrical). May be
normal or show scars.

Syndrome / Diagnosis: This appearance is called a "putty kidney" or autonephrectomy, which

is the end-stage of renal tuberculosis. The kidney is non-functional and completely calcified.

Negative Signs:

• No hydronephrosis (the kidney is non-functional, no urine output)

• No discrete stone( could be present) (calcification is parenchymal, not intra-cavitary)
Standard description phrase (Putty kidney):

"AUSP shows sparse, amorphous, cloud-like calcifications projecting over the [right/left] renal
fossa, affecting the entire kidney. The kidney is small with irregular contours. These findings are
consistent with a 'putty kidney' – end-stage renal tuberculosis."

B. CT Urography / IVU Guide (Gold Standard)

The two characteristic abnormalities of renal TB:

1. Loss of substance (parenchymal destruction, cavities)

2. Stenoses (strictures)
Positive Signs by Location:

Location Finding Description

Papilla (earliest Papillary Loss of regularity of calyx base; moth-eaten

sign) erosion appearance (rarely seen)

Addition image (filling defect) with irregular, scalloped

contours , which projects opposite the chalice
Tuberculous
Calyx background; connects to calyx by fine port; slower
cave
filling

Dilation of a calyx due to infundibular stenosis, causing

Calyx Hydrocalyx
“the daisy image”

Amputation
Calyx ("thorn Complete exclusion of a calyx stem; irregular borders
image")

Pelvis narrowed or absent; neighboring calyces

Stenosis +
Renal pelvis attracted toward stenosis – "hairpin image"
convergence
(pathognomonic)

Early: blurred
Ureter walls, Ureter too clearly visible; loss of peristalsis
ulcerations

"Necklace of pearls" appearance (alternating

Ureter Late: fibrosis
narrowed and dilated segments)

Early: irregular,
Bladder jagged Thickened mucosa, half-tone appearance
contours

Late: Small, thick-walled, inextensible bladder with high

Bladder
microbladder ureteral implantation (trigonal bladder)

Caverns + Prostate caverns on voiding cystography; urethral

Urethra/prostate
stenosis strictures
Standard description phrase (Classic triad):

"IVU/CT urography shows dilated calyces, an absent or narrowed renal pelvis, and a dilated
ureter. There is convergence of the calyces toward a stenotic infundibulum, producing a 'hairpin'
appearance. The bladder is small and thick-walled (microbladder) giving a double contour image
with high implantation of the ureters: Trigonal bladder. These findings are characteristic of urinary
tuberculosis."
C. Ultrasound Guide (Limited role, but useful)

When used: Non-functional kidney on IVU, renal failure, or to guide puncture.

Positive Signs:

Finding Description
 Dilation of only part of the cavities (localized stenosis), often with
Segmental dilation
debris

Dilated calyces
Calyces dilated but renal pelvis not seen
without visible pelvis

Normal ultrasound +
Strictly normal parenchyma on ultrasound but non-functional on IVU
non-functional
→ highly suggestive of TB (diffuse parenchymal infiltration)
kidney

Summary Table for OSCE (Most Important)

Modality Key Finding Diagnosis

End-stage
AUSP Amorphous, cloud-like calcifications (putty kidney)
renal TB

Stenosis + loss of substance; hairpin image; microbladder; Active urinary

IVU/CT
necklace of pearls TB

Segmental calyceal dilation with debris; normal ultrasound + Suggestive of

Ultrasound
non-functional kidney TB

Quick Mnemonic for TB Signs

"TUBERCULOSIS" – Key imaging features:

Letter Finding

T Thorn image (calyceal amputation)

U Ureteral "necklace of pearls"

B Bladder: microbladder, trigonal bladder

E Erosion of papilla (earliest)

 R Renal pelvis absent or narrowed

C Caves (tuberculous cavities)

U Convergence / hairpin image (pathognomonic)

L Loss of parenchyma

O Obstruction (stenoses everywhere)

S Small kidney (putty kidney end-stage)

I Irregular contours

S Stones (calculi often associated)

OSCE Station 6: Benign Prostatic Hyperplasia (BPH) with Bladder Retention

Clinical Context: Older man (>50 y/o) with dysuria, slow stream, nocturia, feeling of incomplete
emptying. Palpable suprapubic mass.

Modality to Choose:

• Renal and bladder ultrasound (pre- and post-void) + prostate ultrasound (suprapubic or
endorectal).

Possible Imaging Finding (Ultrasound):

• Enlarged prostate, thickened trabeculated bladder wall, post-void residual, possible

diverticula.

Complete Description Guide:

Presentation: The image shows a suprapubic ultrasound of the bladder (pre- and post-void) and
the prostate.

Findings (Positive Signs):

 • Prostate: The prostate is enlarged, volume estimated at [X] grams (normal ~20cc). It is
[homogeneous / heterogeneous] and [hypoechoic / hyperechoic].
• Bladder wall (pre-void): The wall is thickened (>5mm). The inner margin is irregular with
trabeculations (sessile projections) and cellules (sacculations).
• Diverticula: There are [one or more] anechoic pockets communicating with the bladder
lumen through a narrow neck.
• Post-void residual (PVR): After voiding, the bladder contains [X] ml of urine (normal
<50ml, significant >100ml).
• Upper tracts: [No / Mild / Moderate] dilation of the ureters and renal pelvis (if chronic
retention).

Syndrome / Diagnosis: These findings are consistent with bladder outlet obstruction due to
benign prostatic hyperplasia, with stage I (detrusor hypertrophy) or stage II (decompensation
with PVR).

Negative Signs:

• No hypoechoic nodule in peripheral zone (no prostate cancer)

• No bladder mass (no bladder tumor)
• No ureteral stones

OSCE Station 7: Renal Mass (Solid Tumor – Suspicious for Renal Cell
Carcinoma)

Clinical Context: Patient (usually >50 years old) presents with incidental finding on ultrasound,
or less commonly with hematuria, flank pain, or palpable abdominal mass. May have
paraneoplastic syndrome (hypercalcemia, polycythemia) or weight loss (advanced disease).
No signs of infection (afebrile, normal inflammatory markers).

Modality to Choose:

• First-line: Renal ultrasound with Doppler

• Gold standard for diagnosis and staging: Contrast-enhanced CT (Uroscanner) –
corticomedullary and parenchymal phases
• MRI: Reserved for indeterminate masses, contraindication to CT contrast, or to confirm
venous extension (renal vein, IVC)

A. Ultrasound Guide (First-line)

Positive Signs of Malignant Solid Mass (Renal Cell Carcinoma):

On ultrasound, a malignant renal tumor typically appears as a solid mass that may distort the
renal contour. It is isoechoic or discreetly hyperechoic compared to the normal renal
parenchyma, but importantly it is heterogeneous due to internal cystic/necrotic areas
(anechoic spaces) and sometimes fine central calcifications (hyperechoic foci with or without
shadowing). The mass has irregular or poorly defined borders. On color Doppler, there is
central and peripheral intralesional vascularization (numerous color signals representing
tumor neovessels with large draining veins). The mass may be exophytic (extending beyond the
renal contour).

Negative Signs (to suggest benign or infectious etiology):

• No macroscopic fat (no angiomyolipoma)

• No thick, rim-enhancing fluid collection (no abscess – patient is afebrile)
• No simple cyst criteria (not anechoic, no thin wall, no posterior enhancement)

B. CT Guide (Gold Standard)

Before describing: State the phases available (non-contrast, corticomedullary, parenchymal,

excretory). reconstructions (axial, coronal).

Positive Signs of Renal Cell Carcinoma on CT:

Before contrast injection: The mass is isodense or slightly hypodense compared to the normal
renal parenchyma. It is heterogeneous and may contain hypodense areas of necrosis and fine,
clustered, central calcifications.

After contrast injection (arterial or corticomedullary phase): There is heterogeneous

enhancement of the vascularized portions of the tumor. The enhancing areas become
hyperdense relative to the normal parenchyma in the early phase.

In the parenchymal (late) phase: The tumor becomes hypodense compared to the normally
enhancing renal parenchyma. The mass remains heterogeneous with non-enhancing necrotic
areas. The renal contour is distorted or shows a bulge.

Signs of local and regional extension (prognostic assessment):

• Perirenal fat invasion: Stranding or soft tissue nodules in the perirenal space (Stage II)
• Renal vein invasion: Filling defect (low density) within the renal vein, which may be
enlarged (Stage IIIA)
• Inferior vena cava invasion: Low-density thrombus extending into the IVC, sometimes
with vessel expansion (Stage IIIA)
• Lymph node involvement: Enlarged, necrotic, or heterogeneous lymph nodes in the renal
hilum or retroperitoneum (Stage IIIB)
• Invasion of adjacent organs: Liver, spleen, pancreas, or psoas muscle (Stage IVA)
• Distant metastases: Lung, bone, liver, or contralateral kidney (Stage IVB)
Invasion of the pyelocaliceal cavities (on uroscanner/excretory phase): The tumor may cause
erosions (nibbled appearance of calyceal edges), lacunae (filling defects with clear contours
representing tumor budding into the cavity), or amputations (complete obliteration of a calyx).

Syndrome / Diagnosis: These findings are consistent with a malignant solid renal mass, most
likely renal cell carcinoma. The tumor should be staged using the Robson or TNM classification.

Negative Signs:

• No rim enhancement with non-enhancing center – rules out abscess

• No simple cyst features

C. Quick Guide to Benign Renal Masses (Differential Diagnosis)

Angiomyolipoma (AML):

• Ultrasound: Homogeneously hyperechoic (as bright as renal sinus), well-circumscribed,

with clear regular borders.
• CT: Mass contains macroscopic fat – negative Hounsfield units (-10 to -100 HU). May
show vessels within the mass after contrast.
• MRI: Hyperintense on T1 (like fat), signal drops on fat-saturation sequences.

Simple Renal Cyst (most common):

• Ultrasound (3 criteria): Anechoic content, paper-thin imperceptible wall, posterior

acoustic enhancement. Avascular on Doppler.
• No further imaging needed if all 3 criteria are met.
• Atypical cyst (needs CT/MRI): Thick wall, non-transonic content (debris, hemorrhage),
vegetations, or parietal calcifications.

Polycystic Kidney Disease (hereditary, not a tumor):

• Ultrasound/CT: Large kidneys with bumpy contours, containing innumerable cysts of

varying sizes. No normal parenchyma visible. Bilateral and symmetrical (or asymmetrical
but always bilateral). May have cysts in liver, pancreas.

Renal Abscess (infectious):

 • CT: Rim-enhancing hypodense collection (peripheral shell enhances, center does not).
May contain gas bubbles. Associated with perirenal fat stranding. Clinical context: fever,
pyelonephritis not responding to antibiotics.

OSCE Station 8: Bladder Tumor (Urothelial Carcinoma)

Clinical Context: Patient (usually >60 years old, male predominance) presents with painless
total hematuria (gross or microscopic). May have irritative voiding symptoms (dysuria,
frequency) or obstructive symptoms (if tumor at bladder neck or invading ureteral orifices). Risk
factors: smoking, occupational exposures (dyes, chemicals).

Modality to Choose:

• First-line: Suprapubic renal and bladder ultrasound (to detect tumor and rule out upper
tract obstruction)
• Gold standard for diagnosis: Cystoscopy with biopsy (NOT imaging – this must be
stated)
• Role of imaging (CT urography / MRI): Assessment of locoregional extension, lymph
node involvement, upper tract involvement, and distant metastases

A. Ultrasound Guide (First-line for detection)

Before describing: Patient should have full bladder.

Positive Signs of Bladder Tumor on Ultrasound:

The tumor appears as a budding, solid, endoluminal mass projecting into the bladder lumen. It
is most often heterogeneous in echostructure (mixed echogenicity) and may be pedunculated
(on a stalk) or sessile (broad base of implantation). The contours may be lobulated or irregular.
On color Doppler, the mass is vascularized (unlike clot or simple debris). You must describe:

• Location: Anterior, posterior, lateral wall, dome, trigone, or bladder neck

• Relationship to ureteral orifices (if visible) and bladder neck
• Implantation base: Pedunculated (better prognosis) or sessile (more likely invasive)
• Size (measure in cm)

Impact on upper tracts (must check):

 • Examine both kidneys for hydronephrosis (unilateral if tumor invades one ureteral orifice;
bilateral if trigone involved)
• Examine ureters for dilation (hydroureter)

Negative Signs (to differentiate from other endoluminal lesions):

• No hyperechoic focus with posterior shadowing (no bladder stone)

• No mobile, avascular, non-adherent mass (no blood clot – clot moves with patient
repositioning and has no internal Doppler signal)
• No layered debris with fluid level (no infection or chronic retention)

Important disclaimer to state:

"Ultrasound is suggestive of a bladder tumor, but cystoscopy with biopsy is required for definitive
diagnosis and treatment."

B. CT Urography Guide (Gold standard for staging)

Before describing: State phases (non-contrast, corticomedullary, parenchymal, excretory). IV

contrast given. Bladder distended. Patient supine.

Positive Signs of Bladder Tumor on CT:

Before contrast: The tumor is isodense to bladder wall and may be invisible on non-contrast
images. Rarely, mural calcifications may be seen.

After contrast (early phases): The tumor enhances and appears as a hypodense (dark) lesion
against the enhancing normal bladder wall (which appears bright). The mass is solid, irregular,
and may be sessile or pedunculated.
Excretory phase (late): The tumor appears as an intravesical lacuna (filling defect) with
irregular contours, surrounded by dense contrast-opacified urine.

Infiltrative form: Instead of a polypoid mass, the tumor may cause irregular, asymmetric,
circumferential wall thickening with a nibbled or stenotic appearance.

Signs of locoregional extension (staging – critical for management):

• Superficial (non-invasive): Tumor confined to mucosa – cannot be reliably staged on CT

(cystoscopy needed)
• Perivesical fat invasion (≥T3): Stranding, soft tissue nodules, or loss of clear fat plane
between bladder and surrounding structures
• Invasion of adjacent organs (T4): Prostate, seminal vesicles (male), uterus/vagina
(female), rectum, or pelvic wall
• Lymph node metastasis: Enlarged (>10mm short axis), necrotic, or heterogeneous pelvic
lymph nodes (obturator, iliac, presacral)
• Upper tract involvement: Hydronephrosis (unilateral or bilateral) due to ureteral orifice
invasion. Also look for synchronous upper tract urothelial tumors (in renal pelvis or
ureter) – multiple locations are characteristic of urothelial carcinoma.

Distant metastases: Liver, lung, bone, peritoneum.

Syndrome / Diagnosis: These findings are consistent with a bladder tumor, most likely
urothelial carcinoma (transitional cell carcinoma). Imaging suggests [superficial / locally
invasive / locally advanced] disease with [no / evidence of] lymph node or distant metastases.
However, definitive diagnosis and staging of superficial invasion requires cystoscopy with
transurethral resection.

Negative Signs:

• No stone (no hyperdense focus with no enhancement)

• No diverticulum (no sac communicating with bladder lumen through a narrow neck)
• No blood clot (clot does not enhance after contrast)

C. MRI Guide (Problem-solving for local invasion)

When to use: MRI is superior to CT for assessing local invasion into the prostate, seminal
vesicles, vagina, or rectum. Used when CT is equivocal or for surgical planning.

Positive Signs on MRI:

• T2-weighted sequences: Tumor is intermediate to hypointense (dark) against the

hyperintense (bright) normal bladder wall and perivesical fat.
• Post-contrast (T1 with gadolinium): Tumor enhances earlier and less than normal
bladder wall, appearing as a filling defect.
• Invasion: Loss of the dark bladder wall line, tumor extending into perivesical fat or
adjacent organs.

D. Differential Diagnosis for Endoluminal Bladder Lesions (Ultrasound)

Lesion Ultrasound Appearance Doppler

Bladder tumor Budding solid mass, heterogeneous, sessile or

Vascularized
(TCC) pedunculated

Blood clot Mobile with repositioning, avascular, no internal flow Avascular

Hyperechoic focus, posterior shadowing, moves with

Bladder stone Avascular
gravity
Bladder Anechoic sac communicating with bladder via narrow No internal
diverticulum neck mass

Cystic structure at ureteral orifice, collapses with Avascular

Ureterocele
voiding wall

Last-Minute OSCE Summary Table

Key Imaging Don't Miss Don't Miss

Station Gold Standard
Finding (Positive) (Negative)

CT: Triangular
wedge-shaped Perirenal fat NO
1. Acute hypodensities, stranding, loss of hydronephrosis,
CT with contrast
Pyelonephritis base at corticomedullary NO abscess,
periphery, apex differentiation NO gas
at sinus

CT: Rim-
NO solid
enhancing
Thick irregular enhancing
2. Renal hypodense
CT with contrast wall, peripheral tissue (not
Abscess mass, non-
enhancement RCC), NO
enhancing
macroscopic fat
center

NO
US: Dilated
parenchymal
collecting
Thickened pelvic rim-enhancing
3. system with
CT with contrast wall, obstructing collection
Pyonephrosis heterogeneous
stone (abscess), NO
debris (pus),
gas in
fluid-fluid level
parenchyma
 CT: Small
kidney, irregular NO
4. Chronic Uneven
bumpy hydronephrosis,
Pyelonephritis CT with contrast parenchymal
contours, NO cavitary
(Reflux (coronal) thinning, scars at
clubbed lesions (unlike
Nephropathy) upper pole
calyces, TB)
cortical scars

Non-contrast
CT: NO debris in
Hydroureter,
Hyperdense collecting
5. Urolithiasis perirenal fat
stone + Non-contrast CT system (afebrile
(Renal Colic) stranding,
upstream = no
nephromegaly
hydronephrosis pyonephrosis)
+ fat stranding

AUSP:
"Hairpin image"
Amorphous, NO
6. Urinary (convergence),
cloud-like CT Urography / hydronephrosis
Tuberculosis "necklace of
calcifications IVU (non-functional
(Putty Kidney) pearls" (ureter),
replacing entire kidney)
microbladder
kidney

US: Enlarged
prostate + NO hypoechoic
7. Benign Diverticula, PVR
thickened nodule in
Prostatic Ultrasound (pre- >100ml, bilateral
trabeculated peripheral zone
Hyperplasia and post-void) hydronephrosis (if
bladder wall + (not prostate
(BPH) chronic)
post-void cancer)
residual

CT: NO
Renal vein / IVC
Heterogeneous CT with contrast macroscopic fat
8. Renal Cell invasion,
solid mass, (corticomedullary (not AML), NO
Carcinoma lymphadenopathy,
enhances then + parenchymal rim
(RCC) distant
washes out, phases) enhancement
metastases
necrotic areas (not abscess)
 US: Budding CT: Hypodense
9. Bladder NO stone, NO
solid Cystoscopy with filling defect,
Tumor clot (avascular,
vascularized biopsy (NOT perivesical fat
(Urothelial mobile), NO
endoluminal imaging) invasion,
Carcinoma) diverticulum
mass hydronephrosis

Quick Mnemonics (Last Minute)

Pathology Mnemonic

Acute Pyelonephritis Wedge (triangular base at periphery)

Renal Abscess Rim (peripheral enhancement)

Pyonephrosis Debris (heterogeneous content in dilated cavities)

Chronic Pyelonephritis Small + Bumpy + Clubbed (calyces)

Urolithiasis Stone + Dilation + Stranding

Putty Kidney (TB) Cloud-like calcification (amorphous)

BPH Big prostate + Thick bladder + PVR

RCC Heterogeneous + Enhances + Invades vein

Bladder Tumor Budding + Vascular + Filling defect

Imaging Modality First-Line Summary

Clinical Question First-Line Gold Standard

Renal colic
AUSP + Ultrasound Non-contrast CT
(stone)
 Pyelonephritis Ultrasound Contrast CT

Renal mass Ultrasound Contrast CT (staging)

Bladder tumor Ultrasound Cystoscopy + biopsy

BPH with Ultrasound (pre/post

Ultrasound
retention void)

Urinary TB AUSP CT Urography / IVU

Hydronephrosis Non-contrast CT (stone) / Contrast CT

Ultrasound
cause (stricture/tumor)

Good luck!