Good afternoon, everyone, dear colleagues, ladies and gentlemen. First of all, I want to thank my colleague, Professor Evkif from New York, who invited me to give this talk. My name is Oliver Nikolic, I'm professor of radiology from University Clinical Center of Vojvodina in Novi Sad, Serbia. Gynecological emergencies often present with nonspecific symptoms and nonspecific clinical findings. That is why it is very important to choose the best imaging modality to narrow the differential diagnosis. Usually, ultrasound is the first-line imaging modality. And if diagnosis is inconclusive, it is followed by CT. And if the patient is stable and MRI is available, we can perform also MRI because it's superior to CT due to its excellent soft tissue contrast resolution. The group of authors from my department published an article in British Journal of Radiology, and there we described the diagnostic approach to the most common causes of acute pelvic pain. It is very important to know a patient's history, clinical findings, laboratory findings, ultrasound report, to make the conclusion about possible origin of acute pelvic pain. The causes except gynecological pathology can be urinary pathology and gastrointestinal pathology. But if we suspect gynecological pathology, we have to check if the patient is pregnant or not. So pregnancy test is important. And then if the patient is pregnant, we have to think if the pregnancy is intrauterine or if it's ectopic. If it's ectopic, we can perform contrast-enhanced CT if diagnosis is inconclusive. But if we suspect intrauterine pregnancy, then we can perform MRI if diagnosis is inconclusive. In non-pregnant patients who come to emergency room, we usually, after ultrasound, if the diagnosis is inconclusive, we perform contrast-enhanced CT and MRI when available and if patient is stable. There are numerous causes in non-pregnant patients of reproductive age. And some of them I put here. I think that you all know all these causes, rupture of hemorrhage of ovarian cyst, dermatitis torsion or rupture, inflammation, ovarian torsion, myoma degeneration or torsion, endometriosis or ovarian hyperstimulating syndrome in infertility. My case number one today, a young patient, 23 years old, with acute onset of pelvic pain on the right side, vomiting, no signs of inflammation. She was ephemeral and last menstruation three weeks ago. At CT, we found a cystic lesion on the right side with indistinct borders. We found free pelvic fluid, which was dense. So there were signs of hemoperitoneum and peripheral enhancement after contrast injection. The final diagnosis was rupture of ovarian cyst on the right side. Hemoperitoneum is serious complication of ovarian hemorrhagic cyst rupture and it necessitates urgent intervention. At CT, we noticed free peritoneal fluid of high density and sometimes at delayed images, contrast enhanced blood pooling in the pelvis. Limitations of CT are that sometimes it's difficult to identify ovaries from surrounding structures. My case number two, young patient, 30 years old, with acute onset of right-sided pelvic pain. She was ephemeral and she referred to ER. At CT, we found two thick-walled cysts on the right sides. There were signs of hemoperitoneum and you see here after the contrast, there were signs of hemoperitoneum and after the contrast, active bleeding. The final diagnosis was ruptured corpus luteum cysts. The differential of a spontaneous free pelvic fluid in a young female can be ruptured corpus luteum cyst, ruptured ectopic pregnancy, or ruptured ovarian cyst. It is important to perform a pregnancy test because it's an important differentiator. So in our patient, it was negative. We excluded ruptured ectopic pregnancy and then the diagnosis was straightforward because cysts were thick-walled. So corpus luteum after ovulation, why it's thick-walled? Because granulosa cells are luteinized and blood is accumulated inside. So corpus luteum cysts are thick-walled cysts. My case number three, 48-year-old patient with severe left-sided pelvic pain, vomiting, and no signs of inflammation. At MRI, there were two ovarian lesions, T1 hyper-intense, one on both sides, and there were signs of fat suppression at T1 fat set tomograms. At T2, we noticed whirlpool sign on the left side. And the final diagnosis was torsion of the left ovary and bilateral dermoid cysts. Ovarian torsion is torsion of the ovary and a part of the tube around the vascular pedicle. It can be spontaneous, but also it can be caused by ovarian lesions like in my case. Twisted vascular pedicle is specific sign. It is called whirlpool sign. And it is necessary to perform fast and precise diagnosis to preserve the ovary. Case number four, 43-year-old patient with intensive lower abdominal pain and previous history of large uterine myoma. At CT, we found heterogeneous pariuterine mass. It was pedunculated and free pelvic fluid. The diagnosis was torsion of large pedunculated uterine myoma. Here you see a huge myoma with twisted pedicle. Fibroids are the most common gynecological masses accounting 20% to 30%. And in one third of patients, there can be acute pain due to torsion of submucosal pedunculated leiomyoma or acute degeneration. At CT, usually we see enlarged heterogeneous pariuterine mass with twisted pedicle. Case number five, 47-year-old with previous history of uterine myoma and acute onset of pelvic pain. At MR, there is a huge uterine mass with sharp borders. It was T2 hypo-intense with areas of hyper-intensity, no diffusion restriction, and sharp borders. It is important towards the diagnosis to sarcoma. The final diagnosis was large subserosal uterine leiomyoma with cystic degeneration. Acute pain in leiomyomas can be due to degeneration. Degeneration happens when volumetric increase outgrows vascular supply. There are different types of degeneration, hyaline, myxoid, cystic, and hemorrhagic. And it is always important to perform a multi-planar MRI because if fibroid degeneration occurs, it can be a differential diagnosis towards cystic ovarian mass. Case number six, 34-year-old with lower back cramping pain on the left side, irradiating to the inguinal region, nausea, urinary frequency, burning urination, chronic microhematuria, and fever, 39.3. This patient has two previous cesarean sections. At MRI, we found a T2 hypo-intense lesion on the urinary bladder dome. This lesion was T1 hypo-intense with many hyper-intense T1 foci. And after the contrast, no significant enhancement. The final diagnosis was deep pelvic endometriosis. Bladder endometriosis accounts 6% of cases. There is bladder wall involvement with invasion of the detrusor muscle. The symptoms are usually non-cyclic, but in 40% can be cyclic. At MR, there is T2 hypo-intense mass with T1 FETCET hyper-intense foci. There is a theory that endometrial cells are collecting in the anterior cul-de-sac, the most dependent portion of the peritoneal cavity. 22-year-old patient with severe left-sided pelvic pain, fever, and elevated CRP. At MRI, we found dilated tube, thick walls of that tube filled with fluid, enlarged ovary with cystic lesion, free peritoneal fluid, diffusion restriction of the tube, and the diagnosis was tubo-ovarian abscess. Pelvic inflammatory disease is common in sexually active pre-menopausal females due to ascending spread of microorganisms that are not related to pregnancy or surgery. And 25% of all visits to ER are due to pelvic inflammatory disease. If it is untreated, it can lead to tubo-ovarian abscess. And at imaging, thickening and enhancement of the fallopian tube wall, free pelvic fluid in the cul-de-sac, pelvic FET infiltration and edema are noticed. During pregnancy, acute pelvic pain has obstetric etiology, ectopic pregnancy, placental disorders, ovarian cyst rupture or torsion, and myoma degeneration or torsion. My case number 8, 31-year-old patient referred to ER because of mild uterine bleeding for several days. She collapsed earlier that day and pregnancy test was negative. Last menstruation was more than one month ago. At CT, there was a heterogeneous para-uterine mass with signs of hematoperitoneum and peripheral enhancement after the contrast injection. The final diagnosis was extra-uterine tubal pregnancy. Extra-uterine pregnancy is usually tubal in 95% of cases, most commonly ampulla of the fallopian tube. And characteristic imaging findings is that we can see an exocystic mass with peripheral enhancement at CT, like in my case, and signs of hemoperitoneum. Case number 9, 39-year-old patient in 36 gestational week with three previous cesarean sections bleeding during early pregnancy due to placenta previa. And during later course of the pregnancy, placenta percreta was suspected. At MRI, of course, there were signs of placenta previa down to the internal uterine ostium. There are signs of placental bulging, and there are T2 hypointense bands in placenta due to hemorrhage. And here we see that there is invasion of the bladder with placental tissue inside the bladder. The final diagnosis was placenta previa percreta. Placental disorders can be abruption and placental adhesive disorders. Placental adhesive disorders, depending on different degrees of chorionic invasion of myometrium, can be placenta accreta, increta, and percreta. MRI signs of PAT are dark placental bands, placental bulging, interruption of the bladder wall, focal placental tissue inside the bladder. Case number 10, 32-year-old pregnant patient who presented with vaginal bleeding and miscarriage. This is courtesy of my colleague Mila Otero from Hospital Universitario de Vigo, Spain. There were three uterine lesions, T2 heterogeneous with areas of T2 hyperintensity. At T1 fat set, there was a hyper-intense rim of these lesions. And after the contrast, no enhancement. These were leiomyomas with hemorrhagic infarction. Red hemorrhagic degeneration or infarction of uterine myomas is most likely the cause of acute pelvic pain. It can happen during pregnancy or with the use of oral contraceptives. Hemorrhagic infarction is due to venous thrombosis at the periphery. At MRI, there is T1 high signal intensity at the periphery because of methemoglobin effect. At T2, peripheral hypointensity because of hemocidarian formation. And there is post-contrast lack of enhancement. In post-menopausal females with acute pelvic pain, please rule out the malignancy. The malignancy has to be ruled out. And usually, we think of ovarian and uterine cancers. My case number 11, 63-year-old post-menopausal patient with severe uterine bleeding. At MRI, we found heterogeneous endometrial mass with myometrial thinning with signs of diffusion restriction and left ovarian cystic solid mass with diffusion restriction. At DCE, both curves were suspicious, malignant type of curves, type 3. Also, the final diagnosis was endometrial cancer with metastasis to the left ovary, FIGO3A stage. In post-menopausal women with vaginal bleeding, it is always important to exclude malignancy. Usually, in post-menopausal patients, we think of endometrial cancer because it counts 75% of cases. And if there is invasion of myometrial more than 50% and higher tumor grade, the possibility of extra uterine spread rises. Case number 11, my last case, 63-year-old post-menopausal patient with severe uterine bleeding, hysterectomy, and right adnexectomy for cervical cancer several years ago. At MRI, there was dominantly T1 fat set, hyper-intense lesion of the left ovary with one septa and with solid component. And there were signs of lymphadenopathy at T2 and diffusion-weighted imaging. The final diagnosis was metastasis of ductal breast carcinoma to the ovary and differential diagnosis of hemorrhagic ovarian lesion includes hemorrhagic ovarian cyst, endometrioma, endometrioid carcinoma, and metastasis usually of breast cancer and melanoma. Some take-home messages for you, recognizing the cause of acute pelvic pain is very challenging due to wide spectrum of possible origin and overlap of imaging features. Please correlate imaging findings with the clinical presentation. Pay attention to the pregnancy status. In cases of signs of sepsis, think of pelvis inflammatory disease. In post-menopausal patients, exclude malignancy and have in mind that radiologists play the crucial role in establishing the prompt and accurate diagnosis of acute pelvic pain. Thank you very much for your attention. So, hello, everybody, and thank you for the invitation. It's a great pleasure to be here today. I'm Tina Lehtimäki from Helsinki, Finland, and I will talk about penile and scrotal emergencies as a form of, say, a case-based presentation. When we are talking about male genital emergencies, we are basically dealing with three main entities infections, trauma, and acute vascular problems. But today, we will concentrate only on non-traumatic causes, so to say we'll leave out all the trauma cases. This is a case-based lecture, and I will show the cases on the left side of my slides and the findings and the theoretical stuff on the right side. I have a few core cases to show you, and along with them, some companion cases in order to further clarify the findings, pathology, and differentials. All the schematic illustrations which are used in this presentation are from EMIOS, the purchase version, except for one which I have drawn by myself. So, we start with the first case. 62 years old, man, fever, CRP 180, swollen left epididymis. First we start doing ultrasound by placing the linear transverse over the scrotum in order to get both testicles into the same view for comparison. Then we adjust the Doppler settings to be able to evaluate low-flow circulation. And along with that, we orientate ourselves to anatomy, of which I want to highlight the epididymis, which consists of three parts, head, body, and tail, which is actually the direction of the spermatic flow from testicles to vas deferens. So this case, we see here normal and symmetrical testicle parenchyma with symmetrical flow signal. But what we see here is the edema at the tail of epididymis along with increased Doppler signal indicating hyperemia. As a companion case here, we see that in this case, the whole epididymis from tail to head is swollen and hyperemic, while in this case, both the whole epididymis and the testicle are hyperemic, and there is heterogeneity in testicle parenchyma, indicating edema. So of course, these are the signs of infection. You call this inflammatory or infectious fineness according to affected anatomy. It's either epididymitis or epididymopitis, depending on which part is affected. These are ascending infections, and thus, with patients with only mild symptoms, remember to pay special attention to the tail area, which is the first to be affected. Also because of this ascending nature, these are caused by common urinary tract pathogens, and also because of this, isolated orchidis is actually a rare finding. So the next case, 25-years-old male, right scrotal tenderness. We see heterogeneity both in epididymis and testicle, both also with high Doppler signal. But what we also see, we see a focal lesion here with no Doppler signal, but this could be. When we know that this guy also had fever and highly elevated CRB, the finding is suggestive for epididymal orchidis with abscess formation. But keep in mind that there are many other focal findings, from benign to malignant, which may mislead you with a diagnosis. Here you see a bit dilated tubules forming a retiate testis, which is a normal finding, especially in elder men. Here you see an unechoic cystic structure in epididymis, similar in the testicle. This one is epidermoidal cyst, which is a common benign lesion. But then you can also have some more porous findings, such as seminomas or non-seminomas. Here is a testicle with unclear findings at ultrasound. Is this infectious or even tumorous or something else? This was finally operated and the pathological diagnosis was a granulomatous epididymal orchidis. But no other signs of granulomatous infection, for example, tuberculosis, was found in the body CT. So to summarize, if you have a focal lesion, which is suggestive for abscess, please do the follow-up in order to make sure that it disappears or at least decreases in size. This particular patient was followed up and after one and a half month, you see only slight heterogeneity, no hyperemia, no fluid collections. And in six months, only some kind of a remnant was seen. Then third case, 63-year-old man with pylonephritis treated with antibiotics without desired effect. Had fever, right-sided scrotal pain, swelling retinas. And these are the findings at ultrasound. There is some free fluid with septate formation in the scrotum here. And there are these well-defined fluid collections also with septate formation inside. But the testis itself is actually quite okay. So with this kind of large focal findings, it's hard to see the definite anatomy and it may be useful to do the MRI or CT. Here you see that the collections seen at the ultrasound, they are actually located in the epididymis like this. You see the normal testicle here, which are both surrounded by a layer of fluid in the scrotum. And the left testicle is dislocated to the left. He was operated and there was a clear fluid in the scrotum, but pus in both epididymal collections. So to say, this was an epididymal abscess. But what we got to know from patient data, he had previously been diagnosed with epididymal spermatocells, thus in this case, you could also name this as an infected spermatocell. Here you see plenty of fluid, which is not that well-defined as in previous case. Scrotal sac is a potential space between the two layers of tunica faginalis, the parietal and visceral layer. And in this case, the fluid is accumulated there and if that fluid is infected, it is called piocil. But how to differentiate the normal hydrocell from piocil? Of course, the clinical status, but also image-wise. In the piocil, you often see internal echoes caused by depress and septate, which you don't see in hydrocells. Sometimes it's not so easy to define the extent of infection. In this case, there is a collection along the penis here. Again, in order to define the extent of the disease, it would be a good idea to do MRI or CT. In this case, CT was performed, and we see that infection was actually primarily from prostatic area spreading to the penile area here. Next case. Several signs of scrotal infection and ultrasound was performed, which was quite non-informative. Normal testes, normal epididymis. But soon he came back with new acute clinical setting, hypotonia, and extremely rapidly increased CRB. And because of crepitation of the skin and palpation, CT was performed promptly. And what was found? Gas in subcutis spreading down the scrotal area. And actually, to be honest, I think we could have seen that in ultrasound images as well. This is, of course, fernal gangrena, which should be diagnosed and treated promptly because of high mortality rate. CT is the modality of choice when suspecting this kind of necrotizing infections. This requires surgical treatment immediately, so call to your clinician right after you have seen the images. In this companion case, you may also suspect gas-filled soft tissue, for example here. And CT was performed because of this finding. And let's see how it is. What do we see here in the genital area? Yes. We see here a small collection of gas adjacent to penis. But what was also seen was that there is a contrast extravasation also adjacent to penis. This patient had manipulated the catheter himself, causing damage to his penile structures. So not only the imaging, not only the physical examination, not only the medical history, but altogether, they give you the diagnosis. Then we go on to case five, teenager with increasing right-sided pain, right-sided pain. At ultrasound, we see normal testicle parenchyma, but slightly decreased, but not lacking flow on the symptomatic side. The spermatic cord was a bit twisted as well. Radiologists suggested for torsion. But according to clinician, the clinical findings didn't completely fit for the image findings, and this was interpreted as an epididymitis. But what happened? At first, it eased down, but increased heavily after several days. And here you see the ultrasound findings. Patchy heterogeneity, no flow on the symptomatic side, some scrotal fluid as well. Obviously, a torsion. This companion case is more fortunate. Symptomatic side here with heterogeneity and no flow. Ischemia due to torsion was suspected. And he was operated 360-degree torsion, untwisted, and preserved viability. This companion case has instead hyperremia on the symptomatic side with intermittent pain. What is this? Is this infectious with intermittent pain with no clinical signs of infection? We performed contrast-enhanced ultrasound to see the heterogeneous enhancement, such as severe partial ischemia. This, with abundant Doppler signal, could be seen as a torsion-detorsion phenomenon, meaning reperfusion. This patient was operated, and no torsion at that time. The same torsion-detorsion effect is even more clear if there is no hyperremia in the epididymis because of isolated orchidis, which is obviously the alternative diagnosis is rare, as I mentioned earlier. So this hyperremia is due to reperfusion when the patient is having torsion-detorsion. To summarize, in terms of torsion, you may have different kind of flow patterns and findings which relates to torsion-detorsion effect. Remember also to look at the spermatic cord. When you see a rotation, a kind of whirlpool sign, it's suggestive of torsion. At mine, it's rather meandering also normally. 12% of men have an anatomical variant, so-called Belk-Lapper deformity. It means that the reflection of the two layers of tunica vaginalis are located more granularly than normal, allowing the testicle to rotate freely inside the scrotal sac, so to say intra-vaginally. For the same reason, the alignment of the testicle can be more horizontal than normally, which indicates that this testicle is prone to rotate. When to trust this is rotating, the first to happen is that the veins become occluded. That leads to increased testicular pressure, which in turn can be seen in pulse Doppler waveforms. Normal low-resistance waveform changes to more high-resistant curve. This could also be used as a tool for diagnosing testicle torsion. The same vascular phenomena, lack of vascularity, can be seen as a small spot inside the epididymis or between the testicle and epididymis, small rounded area with no flow, and possibly surrounded by reactive hydrocephalus. These are suggestive for appendix testis or appendix epididymis torsion if only the testicle and epididymis themselves are not affected. These are treated conservatively, and that is why they are very rarely verified for the radiologists. Then the last case. This man fell asleep with penile tension ring and is now having pain. The ultrasound showed soft tissue swelling, but when following the continuity of the tunica albuchenia, we see no disruptions, no hematoma inside the corpus cavernosus or spongiosus, so to say, no focal trauma. The testicle is the same. Tunica albuchenia is intact, indicating no focal trauma, but the testicle parenchyma is slightly heterogeneous, and with a closer look, there is also a focal lesion. If that is a hematoma or something else, that remained unclear. This patient was invited to follow up ultrasound, and the focal lesion had increased in size and also a small new one was detected. Contrast-enhanced ultrasound was performed, which showed enhancement in the focal lesion suggesting for tumor instead of hematoma, and in the operation, emperonal carcinoma for swelling. So, if you have some odd focal findings, follow, follow, please follow. Then we have also some penile findings, which are mainly diagnosed by clinicians themselves, at least in our institute. Penile mandor means that there is a term for phlebitis in the superficial dorsal penile way here. If you are asked to do the ultrasound, use your academic common sense and do that the same way that with thrombosis ultrasound in extremities. Now I think we have time for take-to-work messages. Findings, add them to the medical history and clinical findings, note the anatomy, note the anatomical variance, talk to your clinician, remember that there is not only imaging, not only physical examination or medical history, but all that together, and follow up the patient if needed. I'm from Finland, and our neighbor land is Sweden, and by accident, it looks like this. Well, thank you all for attending the session. I'd also like to thank Professor Raffke and all the expert committee for giving me the opportunity to be here with all of you today. We're going to now get started and talk a little bit about the renal emergencies. Renal emergencies encompass a large number of pathological processes with very diverse etiologies, and we generally present with vague symptoms. The cardinal symptoms are analytical alterations, states of only when you are offline pain. All of them can coexist in various underlying processes, and early diagnosis will be key to improving clinical results. So with this brief interaction, we're going to get started with our cases. The first case is a 47-year-old woman with no relevant medical or surgical history. That starts with a sudden onset of intermittent right lung pain that radiates to the mesogastric human right lobe quadrant. She also has pain when percuting the right renal closure, and otherwise she has a complete normal analysis only identifying photoleukocytes in her urine. I think that we would all, in this case, in this young woman with right lung pain, we would all think about an acute pyelonephritis, but is this enough to make our diagnosis? Do we need something more? Okay, it's always been said that acute pyelonephritis is a clinical-based diagnosis, and it's true, but we need to have one of these three scenarios. A patient with symptoms of cystitis along with fever or symptoms of systemic illness, flank pain in the setting of puria and bacteria, or fever or sepsis without localizing symptoms in the setting of filaria and bacteria. We didn't quite have that case. She didn't meet all these criteria, so an ultrasound was performed, and as shown in images A, B, and C, we found a morphologically normal right kidney with good corticomodular differentiation, no hypo- or hyperechoic foci, no alterations on the double color mode, no free fluids surrounding the kidney, no hydronephrosis, so we reported this ultrasound as a normal ultrasound. However, the patient was not improving, and there were some blood tests that were worsening. She started to elevate some subject parameters, so a CT scan was done six hours later, and I think that in this CT scan, we can perfectly depict this wedge-shaped hypotensity with loss of corticomodular differentiation affecting to the upper pole of the right kidney and free fluids surrounding the kidney and the renal foci. These findings are obviously compatible with the clinical suspicion of acute pyelonephritis. Acute pyelonephritis is a bacterial fungal infection resulting in interval interstitial inflammation of the renal parenchyma. It is typically the result of an ascending infection from the bladder by a hematogenous spread kind of cough. Although not routinely indicated in uncomplicated pyelonephritis, radiologic imaging plays a significant role in suspected complicated pyelonephritis in determining the extent of the inflammatory process and depicting complications. Comparing the most accessible techniques, the ultrasound just can make subtle changes, and it is only going to be positive in about 25% of the patients. However, it will be effective in evaluating hydronephrosis or pyelonephrosis, and the contrast agent helps to improve the sensitivity. The CT is just better. It provides a global assessment of the extent of involvement, and it's superior to the ultrasound detecting focal parenchymal abnormalities, defining the true extent of the disease, and detecting perinephric fluid collections and abscesses. I would also recommend to not perform a delayed phase routinely. It doesn't give that much information, and I would only go for the delayed phase whenever we see an abstraction in the portal venous phase. So, according to the mentioned findings, we can have prenatal enlargement, polydermocytic hypo or hypochoic foci, as shown in images A and B. We can have focal or diffuse hyperperfusion and loss of corticomodular layer differentiation. We can also find prenatal extension with fluid collections or abscesses, and also pyelonephrosis, as hydronephrosis, and urine debris level, as shown in this ultrasound and CT scan with this beautiful correlation. In the CT, it's going to be much easier. We can have enlarged septum of the kidneys, persistent nephrogram or viable nephrogram. We could find some wedge-shaped or rounded areas of flow attenuation and renal abscesses with prenatal extension. It's also important to try to depict these inflammatory changes that are mainly characterized by the urethraline thickening and hyperenhancement, and also the inflammatory changes that extend to the fat in the renal foci with the fat stranding, and also to the anterior prenatal fascia with fascial thickening and hyperenhancement. I also recommend to modify the width and length of the window to try to visualize fine hyperentities that might be missed with the default windows. For instance, we have this image, which is the same image in the same patient with the default windows to your left in the A image and with a forced window in the B. And I think that it's obvious how evident the hyperentity becomes when we try to force the window. So for the renal parenchyma, try to force the window. We have this companion case. This is a 67-year-old woman with a stage 1 asepic neoplasia treated by chemotherapy and radiotherapy. She didn't do well. She had multiple complications with radical enteritis and clavicle fistulas repaid with a cystectomy and brachytype reconstruction. She has had multiple admissions for pyelonephrosis, acute renal failure, and hydroelectrolytic alterations. And she's now septic. So we perform a portal planar stage CT scan. And in this axial, oblique, and sagittal image is the fineness that we found. So we can see that there's a huge collection occupying the whole left renal fascia and displacing the remaining kidney anteriorly. Not only that, we can also see some air bubbles, not only within the collection, but also within the respiratory system and the renal parenchyma. It's also obvious a renal parenchyma transfection with a generalized hypotensity and a loss of the corticomodular differentiation. These all findings are suggestive of an emphysema pyelonephritis. So this is a life-threatening necrotizing infection with gas formation and a mortality rate up to 50%. It's almost exclusively seen in immunocompromised patients. And generally, there's an abstraction of the pelvic allele system by a calculus neoplasm or a stricture. It's characterized by gas within the renal parenchyma that may extend into the perineal sub-tissues. There has been a classification with some prognostic implication. And there's type 1 with a collection formation and type 2 with collection formation. In spite of what we could think, the type 2 with collection formation has a much better prognosis since it is thought that the collection formation is a response of the immune system activation. And it also could be treated by percutaneous drainage and antibiotherapy with no nephectomy needed. So before making the diagnosis of an emphysema pyelonephritis, there should be excluded other potential non-infection sources of gas within the collecting system. And it's also important to try to distinguish between emphysema paralytis. Well, there would be gas formation only within the excretory system, but there's no renal parenchyma affection. This is a less aggressive infection and usually does not require a nephrectomy. So whenever you find a thickened gallbladder wall, pre-portal tracking, ascites, peripheral effusion, and thickened interlobular septa, or an increase of the neck glands, hearing uptake, this all could be the systemic result of a sepsis state. So please try to assess carefully the kidneys since they are one of the main sources of sepsis. We're going to now change a bit, and we're going to go for a 54-year-old man with no relevant medical or surgical history that starts with a sudden onset of intermittent right flank pain that radiates to the right inguinal area with vesicular tenesmus. He has a totally normal analysis. He's quite affected because of the pain. So I think that in this case, we would all be thinking about renal colic, maybe secondary to urolethiasis. So all the guidelines suggest that all patients presented with renal colic should undergo at least a blood test and also imaging test. Not necessarily urgently, but probably an imaging test should be needed. So according to the systematic revision of 2019, it ended up concluding that for suspected and complicated kidney stones, CT can be avoided in younger patients and also in middle age patients that have a prior history of kidney stones. However, they strongly recommend to perform a CT scan in older patients as the complications are more frequent and they usually don't have these clinical manifestations that may suggest them. So for the urolethiasis detection, obviously the CT scan is better. U.S. will help trying to detect the heteronephrosis, but the CT scan is better for evaluating the heteronephrosis, demonstrating the possible complications. And I wouldn't recommend just administering intravenous contrast since it could just hide the stone. Nowadays, also with the new technologies and the dual energy of photon content CT scan, we can also try to assess the composition of the stone, which can sometimes determine the treatment. I'm not going to get in the imaging findings since we all know them. I just want you to remember that even they are not frequent, there are some radiolysis in the stones due to medication, the protease inhibitor stones, and to try to assess the composition. This is a companion case. And just try to be aware of the possible complication. It was a 46-year-old man with suspected left-side renal colic secondary to urolethiasis. He had previous history of renal colics. So according to the guy on the app previously presented, we started with an ultrasound. And the ultrasound, which I'm not showing, there was a lot of retroperitoneal free fluid, mainly at the level of the urethral pelvic junction. So we went for a CT. This image shows the stone here. And we can see that it is surrounded by a lot of free fluid with some inflammatory changes. So we decided to perform an excretory phase. And the excretory phase, we can see that there is contrast material outside the excretory system. So these findings are compatible with a urinoma due to a Rho2 of the renal pelvis. I would also like to try to assess, if possible, what the rupture is so that our urologist colleagues will appreciate the information. This is kind of, we could try to say that it is the same, although it's not. This is a 16-year-old girl with intermittent left flank pain. She had no other symptom at all. So an ultrasound was done. And this is what we found. We found a very significant pelvical isolation of the left kidney. So whenever there's such a dilatation, try to assess the urethra. Because it would probably also be dilated and will be accessible and visible on the ultrasound. Though we usually say that the mid-third, it's not accessible. In these cases, it should be. So I was surprised in this case was that the proximal urethra was totally collapsed. We already had something in mind. So we completed the study with an arterial and portal venous phase CT. This is a little video of the arterial phase. And I see that you all managed to see that there was a lower pole aberrant artery arising from the outer. And that was causing this dilatation. This was compatible with a urethral pelvic. It's stuck in there. Let's see. OK, so this was compatible with that urethral pelvic junction stenosis. This entity is congenital or acquired. It can be diagnosed in both pediatric and adult population. And it's bilateral in approximately 30% of the cases. In some cases, renal tract abnormalities are recognized. The ultrasound will just show some dilated renal pelvis with a collapsed proximal urethra. And the CT may show evidence of hydronephrosis, calectasis with collapsed urethras. And it will also be useful to assess crossing vessels at the pelvic urethra junction. So in approximately 40% of the cases, an aberrant accessory or early branching lower pole segment vessel is found and observed to compress the urethra. And also recommended to try to assess vascular area on ultrasound whenever you find this huge pelvic allele system with a collapsed proximal urethra. Sometimes you can see a little branch that is crossing just at the point of the stricture. We're going to now go for our last case. This is a 64-year-old woman with acute onset of left flank pain. She had no other symptoms, no relevant medical or surgical history. So our emergency department physicians asked for an ultrasound. They suspected a renal colic. But she was not responding to the morphic. So an ultrasound was performed. And to our surprise, we found a really affected middle-aged woman. As shown in the images, she had a more politically normal kidney. There was no hydronephrosis, no pre-renal fluid, no nothing. So we do always routinely assess and color-double-mode both kidneys. And although we know it's not the Alexian technique or indicator for assessing possible vascular injuries, but it was a bit surprising to us that no matter how we get this left kidney, the upper and lower pole of the left kidney seemed to have diminished vascularization. So mainly secondary to the absence of clinical radiological correlation, we agreed with our colleagues from the emergency department to complete our study with a CT scan. And this was the result. We could confirm that there was some hyperensities with both cortical and medullary involvement affecting to the upper and lower pole of the left kidney that are compatible with renal impacts. So whenever you see a renal impact, try to assess the renal artery. And in this case, we found an intimal flap, suggesting a left renal artery dissection. This could be traumatic, diatrogenic, or could also be secondary to a fibromuscular displacement. We should rule out a fibromuscular displacement. So renal impacts, the most common cause of renal impact is thrombobolic. A small impact may be asymptomatic. And if symptomatic, they usually manifest as acute flank pain, hematuria, and proteinuria may also be seen. And that's why we could confuse them with a renal colic. The ultrasound is not indicated, but we could see some absence of perfusion and color-double examination. And we should definitely go for a CT scan where it's going to be obvious which shape or intimal defect that involves both the cortex and the medulla and extends to the capsular surface. We have some very characteristic imaging signs that are the cortical rim sign, as shown here, and this flip-flop enhancement after contrast administration. So I tried to classify these non-traumatic renal emergencies in infectious, vascular, obstructive, and older. I obviously don't have time to go over all of them. But in the infectious part, I would say that CT is more sensible and specific than US. US mainly is to rule out abstraction and try to modify the width and the length of the window for a better assessment of the parenchyma. In acute pyelonephritis, imaging tests are not usually needed, and to be done if severe infection, suspected blockage, or absence of improvement after treatment. And the emphysematous pyelonephritis, be aware of potential non-infection sources of gas within the collecting system. It's also important to differentiate emphysematous pyelitis and pyelonephritis and remember the classification with the prognostic implications between type 1 without collections, worse prognosis, and type 2 with collections, better prognosis. In the obstructive, just remember that for younger patients and for those mid-age patients with unknown history of urolithiasis, we could possibly avoid the CT scan. In older patients, go for the CT. CT allows to determine the composition of the stone, dual-energy CT, and remember the radiolysis stones due to medications, and be aware of the complications. So if there's a lot of free fluid when performing the ultrasound, maybe a CT should be done. And remember, as in the utero pelvic junction stenosis case, that it's not always a stone. And in the vascular, I said that in older patients with acute flank pain and cardiovascular risk factors, just have it in mind that there are some vascular complications also. And in patients with suspected renal colic, the years and the non-contrast CTs, so no stone or hydronephrosis, just remember that the vascular complications are maybe an arterial or portal venous phase. CT scans should be done to rule out vascular complications. The renal infarction, remember those two signs that are very characteristic, though not pathognomonic. And thank you all for your attention.

gynecological emergencies

renal emergencies

imaging modalities

ultrasound

CT scan

MRI

acute pelvic pain

ovarian torsion

pyelonephritis