Calculi 1

28/1/2019 Imaging of Calculi of the Urinary System | Clinician's Brief
Imaging of Calculi of the Urinary

System
Daniel VanderHart, DVM, DACVR
IMAGING | FEBRUARY 2017 | PEER REVIEWED | WEB-EXCLUSIVE
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Urinary tract calculi are well documented in companion animals, and diagnostic imaging is
important for detection. Radiography has long been the mainstay for detection of mineral
opaque urinary calculi, but ultrasonography has gained in usefulness for both detection and
better tissue characterization of the disease.1,2
Positive and negative contrast studies can provide additional, often valuable, information to
aid in diagnostic evaluation of the urinary tract.
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Nephrolithiasis and Ureterolithiasis
Identi cation of the normal appearance of the kidney on radiography and ultrasonography is
critical prior to evaluation for abnormalities (Figure 1). In addition, several potential artifacts
—or “pitfalls”—must be taken into account when radiographically or ultrasonographically
evaluating the upper urinary system in dogs and cats (Figure 2).
Calculi within the kidney or ureter present diagnostic and management challenges. It is
important to recognize renal calculi and di erentiate them from dystrophic mineralization of
the renal diverticula. While both dystrophic mineralization and calculi can be incidental
ndings, the presence of calculi can result in further complications. Calculi can obstruct the
renal pelvis or ureter, predispose to pyelonephritis, or result in compressive injury of the
renal parenchyma leading to progressive chronic kidney disease.3
Renal calculi can vary markedly in size, number, shape, and opacity (Figure 3). Dystrophic
mineralization of the renal parenchyma, often associated with the collecting system, is
another di erential for mineralization localized to the kidney (Figure 4). A combination of
radiography, positive contrast radiography (excretory urography), and ultrasonography has
been shown to have an increased sensitivity for the diagnosis of ureteral calculi when
compared with ultrasonography alone (Figure 5).4
Ureteral calculi are a common cause of ureteral obstruction; localization of ureteral calculi is
imperative prior to choosing appropriate management. While ureteral calculi have been
reported as the most common cause of ureteral obstructions, other causes such as iatrogenic
ligation, blood clots, tumor, strictures (congenital and acquired), solidi ed blood stones, and
a circumcaval ureter have been reported.4-7
e obstruction can be located at any point of the ureter and can vary in severity. Normal
ureters are typically not seen on ultrasonography due to their small size. e easiest way to
locate a dilated ureter is to trace the ureter from the renal pelvis. In most cases, the ureter is
dilated proximal to the site of an obstruction and tapers to a more normal appearance distal
to the site of obstruction. Imaging can also reveal retroperitoneal e usion which can result
from ureteritis and possible urine leakage.
Potential indications for removal of renal calculi in dogs include obstruction, recurrent
infection, progressive calculi enlargement, presence of clinical signs (renal pain), and
patients with calculi in a solitary functional kidney.8 e most common indication for
removal of calculi in cats is obstruction caused by ureteral calculi.9
Nonobstructive renal calculi in cats is not typically treated unless the obstruction moves into
the ureter and causes ureteral obstruction. Nonobstructive renal calculi usually have
minimal impact on progression of chronic renal disease in cats, so the presence of calculi
alone is not justi cation for treatment in cats.10
Clinical signs associated with ureteral calculi may range from chronic non-speci c signs to
acute or chronic renal failure. e presence of hydronephrosis can be highly suggestive of a
ureteral obstruction (Figure 6).
Di erentiation between a complete vs partial ureteral obstruction can be di cult with survey
radiography and ultrasonography alone. Antegrade pyelography (nephropyelocentesis with
renal pelvic injection of iodinated positive contrast medium using ultrasound guidance) may
be useful for documenting a complete vs partial obstruction (Figure 7).11
Antegrade pyelography is bene cial when compared with standard IV urography, as it lowers
the risk of potential contrast-induced renal damage and provides excellent lling of the renal
collecting system, regardless of renal function.11
FIGURE 1A Ventrodorsal radiograph of a normal cat for

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evaluation of the Imaging
kidneys (arrows). Note the bean-shaped
of Calculi of the Urinary System | Clinician's Brief
appearance, smooth capsular margin, normal size

(approximately 2.2× the length of L2) and location. Both
kidneys are more readily seen in this cat due to the amount of
retroperitoneal fat. In the dog, the le kidney is easier to
identify and evaluate routinely than the right, as the cranial
pole of the right kidney border e aces with the renal fossa of
the caudate lobe of the liver.
FIGURE 1B Dorsal plane ultrasonographic image of a normal

le kidney in a dog. Note the outer hyperechoic renal cortex
(C) and outer renal medulla (OM) (the two cannot be
di erentiated), as well as the inner, uniformly hypoechoic
renal medulla (M). The renal pelvis forms a right-angled
parenthesis along the deep or medial portion of the kidney
(arrowheads).
FIGURE 1C Sagittal plane ultrasonographic image of a normal

right kidney in a dog. Relative to Figure 1B, this image is
oriented in long axis as before, but the slice is orthogonal to
the dorsal plane. The cortex and the medulla appear the
same; however, the renal pelvis is missing (out-of-plane) from
the deep portion of the image.
FIGURE 1C Transverse image of a normal le kidney in a dog

taken from the midsection of the kidney. The renal hilum (RH)
and vasculature are noted along the medial (le side of the
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image) aspect of the kidney. Note the large amount of
Imaging of Calculi of the Urinary System | Clinician's Brief
hyperechoic fat surrounding the anechoic vessels. This image

is in “short axis” to the body and the le kidney and is
perpendicular to both Figures 1B and 1C.
FIGURE 2A A right lateral radiograph of a normal dog. Notice

several circular so tissue opacities superimposed over the
retroperitoneal space. These represent end-on vessels with
renal veins seen cranially (arrow) and deep circumflex iliac
vessels seen caudally (arrowheads).
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FIGURE 2B A transverse ultrasonographic image of a normal
kidney in a cat. In obese cats, fat can be present in the renal

sinus and extend to the level of the renal diverticula (arrows).
This should not be mistaken for renal diverticular
mineralization, which creates an acoustic shadow artifact (see
Figures 3D and 4B).
FIGURE 3A Close-up radiograph of the le kidney with a large,

smoothly margined renal calculus in a clinically normal
canine patient.
FIGURE 3B Ultrasonographic image of the same le kidney as

Figure 3A. Notice the smooth hyperechoic surface of the
calculus and the marked distal acoustic shadowing artifact (S)
caused by the mineralized calculus.
FIGURE 3C In a di erent clinically normal dog, a similar close-
up radiograph of the le kidney documents an irregularly
margined calculus and areas of dystrophic mineralization of
the renal diverticula (paired mineral opaque thick lines of the
renal diverticula).
FIGURE 3D Ultrasonographic image of the same le kidney as

Figure 3C. Notice the irregular margin and the areas of linear
dystrophic mineralization associated with the renal
diverticula resulting in marked distal acoustic shadowing. Do
to the shadowing artifact (S) on this image it would be di icult
to appreciate the same anatomic information that was readily
seen on the radiograph. Compare this image to the normal
kidney in Figure 1B.
FIGURE 3E Close-up radiograph of the le kidney in a

di erent dog with a small renal calculus located within the
region of the renal pelvis (arrow).
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FIGURE 3F Ultrasonographic image of the same le kidney as
Figure 3E. Only minimal distal acoustic shadowing artifact

(arrowheads) is noted compared to Figures 3B and 3D due to
the small size of the calculus (arrow) in this dog.
FIGURE 4A Close-up radiograph of the le kidney in a dog

with well-defined, linear regions of mineralization localized to
renal diverticula.
FIGURE 4B Ultrasonographic image of the same le kidney as

Figure 4A with hyperechoic regions within the diverticula
representing the mineralization noted on the radiograph
(arrowheads). The regions of mineral vary in echogenicity
due to their size and angle of incidence to the ultrasound
beam.
FIGURE 5A Lateral abdominal radiograph of a dog with 2 well-

defined, oval mineral opacities superimposed over the
retroperitoneal space caudal and dorsal to the kidneys
(arrows). Based on the ventrodorsal projection (not shown),
these calculi were likely to be associated with the right ureter.
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FIGURE 5B Ultrasonographic image of the dog in Figure 5A
confirming the location of the mineralized structures within

the right ureter. Notice the marked dilation of the ureter
(between arrowheads) and the distal acoustic shadowing
artifact (S) caused by the two calculi within the ureteral
lumen.
FIGURE 6A Mild to moderate right hydronephrosis and

proximal ureteral dilation in a Dalmatian.
FIGURE 6B This is an ultrasound image of a right sided

ureteral calculus (between
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obstruction and hydronephrosis in the dog shown in Figure
6A. Notice the ureteral dilation (between the arrowheads)

proximal to the ureteral calculus.
FIGURE 7A Lateral abdominal radiograph of a cat with

multiple, small, oval mineral opacities superimposed over the
ventral aspect of the retroperitoneal space (arrows). These
mineral opacities are arranged linearly extending from the
caudal aspect of the kidneys to the level of the urinary
bladder.
FIGURE 7B Ultrasonographic image of the same cat as Figure

7A, documenting that the calculi (arrows) present on the
radiographs are all localized to within the le ureter (between
arrowheads).
FIGURE 7C Antegrade ultrasound-guided pyelography of the

same cat showing moderate hydronephrosis (H) and multiple
filling defects (calculi) (arrows) within the ureter. Despite the
severe number of ureteral calculi, this patient had only partial
ureteral obstruction, as the positive contrast is distal to the
calculi (arrowheads).
Calculi of the Urinary Bladder and Urethra

Calculi formation within the urinary bladder occurs from a variety of inherited and
environmental conditions, and management is often imperative.7 Radiographic detection of
urinary bladder calculi has up to 87% sensitivity with improvement to 95% when used in
combination with positive-, negative-, or double-contrast cystography.15
e lower detection rates for survey radiography are largely due to the variations in the
chemical composition of di erent calculi. e most common types of calculi in small animal
practice are struvite and calcium oxalate; both are mineral opaque (Figure 8).13,14,16,17
Cystine and urate calculi are less common overall, but more common in bulldog and
dalmatian breeds, respectively. ese are often non-mineral opaque and are unable to be
visualized with survey radiography alone.18 One helpful mnemonic for remembering the
non-mineral opaque calculi is “I can’t C U.” Cysteine and urate calculi cannot be visualized as
they often do not mineralize. For non-mineral opaque calculi, contrast cystography or
ultrasonography will aid in detection (Figure 9).
Urinary bladder calculi can also descend into the urethra, which can potentially lead to
urethral obstruction. In male dogs, it is imperative that the entire urethra is included within
an additional radiographic image using the appropriate collimation (Figure 10).
28/1/2019A Imaging of Calculi
separate center of ossi cation associated with of the
theUrinary Systemmay
os penis | Clinician's
mimic Briefa urethral calculus
(Figure 11 A and B). A separate center of ossi cation can be seen at either end of the os penis
and will be in line with the os penis. A calculus within the penile urethra would be seen
ventral to the os penis in the location of the urethra. Contrast urethrography can be a helpful
way to di erentiate between a separate center of ossi cation and urethral calculus (Figure
11C).
FIGURE 8A Lateral radiograph of the urinary bladder in a dog

with a confirmed calcium oxalate calculus. This calculus has a
very irregular margin o en seen with calcium oxalate calculus
formation.
FIGURE 8B Ultrasonographic image of the same dog as

Figure 8A. Notice the irregular margins of the calculus and the
marked distal acoustic shadowing artifact (S) caused by the
calculus.
FIGURE 8C Lateral radiograph of the urinary bladder in a dog

with confirmed struvite calculi. This calculus has a very
smooth margin o en seen with struvite calculus formation.
FIGURE 8D Ultrasonographic image of the same dog as

Figure 8C. Notice the smooth margins of the calculi compared
with Figure 8B.
FIGURE 9A Lateral radiograph of a bulldog presented for

recurrent hematuria and stranguria. The study was negative
for mineral opaque urinary bladder calculi.
FIGURE 9B Double contrast cystography performed on the

same dog as in Figure 9A. Note the well-defined, smoothly
margined filling defect within the central aspect of the urinary
bladder consistent with a calculus (arrow). This was a
confirmed as a urate calculus via analysis.
FIGURE 10 Lateral radiograph of a male dog centered on the

perineum with the pelvic limbs pulled ventrally (flexion of the
pelvis at the coxofemoral joints). This radiograph documents
multiple well-defined, mineral opaque calculi within the
penile urethra (arrows).
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FIGURE 11A Lateral radiograph of a male dog collimated to
include the urinary bladder and os penis. Note the well-

defined mineral opacity just proximal to and at the same level
as the base of the os penis—a separate center of ossification
(arrow). Also note the two so tissue opaque nodules
summating with the prepuce, presumed to be small nipples
(arrowheads).
FIGURE 11B Lateral radiograph of a male dog collimated to

include the os penis showing a small separate center of
ossification just distal to the tip of the os penis (arrow).
FIGURE 11C Positive contrast urethrography utilizing

fluoroscopy performed on the same dog as in figure 11A.
Note the urethra (U) is filled with iodinated contrast medium
ventral to the mineral opacity noted on the survey images
confirming a separate center of ossification (arrow) of the os
penis and should not be mistaken as a urethral calculus.
Conclusion
Radiography and ultrasonography can provide information related to anatomic changes that
are present within the kidneys. is includes changes in renal size, shape, and margination.
Ultrasonography can help identify and di erentiate between the presence of renal dystrophic
mineralization and renal calculi. Contrast radiography can also supplement these imaging
modalities for visualization of obstructions of the ureters or urethra or the presence of non-
radiopaque (non-mineralized) urocystoliths.
REFERENCES
1. Penninck D, d’Anjou M, eds. Atlas of Small Animal Ultrasonography. 2nd ed.
Ames, IA: John Wiley & Sons; 2015.
2. Mattoon JS, Nyland TG, eds. Small Animal Diagnostic Ultrasound. 3rd ed. St.
Louis, MO: Elsevier Saunders; 2015.
3. Adams LG. Nephroliths and ureteroliths: a new stone age. N Z Vet J.

2013;61(4):212-216.
4. Kyles AE, Hardie EM, Wooden BG, et al. Clinical, clinicopathologic, radiographic,
and ultrasonographic abnormalities in cats with ureteral calculi: 163 cases (1984-
2002). J Am Vet Med Assoc. 2005;226(6):932-936.
5. Westropp JL, Ruby AL, Baili NL, Kyles AE, Ling GV. Dried solidi ed blood calculi
in the urinary tract of cats. J Vet Intern Med. 2006;20(4):828-834.
6. Lee N, Choi M, Keh S, et al. Bilateral congenital ureteral strictures in a young cat.
Can Vet J. 2014;55(9):841-844.
7. Zaid M, Berent AC, Weisse C, Caceres A. Feline ureteral strictures: 10 cases (2007-
2009). J Vet Intern Med. 2011;25(2):222-229.
8. Adams LG, Goldman CK. Extracorporeal shock wave lithotripsy. In: Bartges J,
Polzin DJ, eds. Nephrology and Urology of Small Animals. West Sussex, UK: Wiley-
Blackwell; 2011.
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9. Berent AC. Ureteral obstructions Calculi
dogs of the
and Urinary
cats:System | Clinician's
a review Brief
of traditional and new
interventional diagnostic and therapeutic options. J Vet Emerg Crit Care (San
Antonio). 2011;21(2):86-103.
10. Ross SJ, Osborne CA, Lekcharoensuk C, Koehler LA, Polzin DJ. A case-control
study of the e ects of nephrolithiasis in cats with chronic kidney disease. J Am Vet
Med Assoc. 2007;230(12):1854-1859.
11. Adin CA, Herrgesell EJ, Nyland TG, et al. Antegrade pyelography for suspected
ureteral obstruction in cats: 11 cases (1995-2001). J Am Vet Med Assoc.
2003;222(11):1576-1581.
12. Bannasch DL, Ling GV, Bea J, Famula TR. Inheritance of urinary calculi in the
Dalmatian. J Vet Intern Med. 2004;18(4):483-487.
13. Low WW, Uhl JM, Kass PH, Ruby AL, Westropp JL. Evaluation of trends in urolith
composition and characteristics of dogs with urolithiasis: 25,499 cases (1985-
2006). J Am Vet Med Assoc. 2010;236(2):193-200.
14. Lekcharoensuk C, Osborne CA, Lulich JP, et al. Trends in the frequency of
calcium oxalate uroliths in the upper urinary tract of cats. J Am Anim Hosp Assoc.
2005;41(1):39-46.
15. Weichselbaum RC, Feeney DA, Jessen CR, Osborne CA, Dreytser V, Holte J.
Urocystolith detection: comparison of survey, contrast radiographic and
ultrasonographic techniques in an in vitro bladder phantom. Vet Radiol
Ultrasound. 1999;40(4):386-400.
16. Osborne CA, Lulich JP, Kruger JM, Ulrich LK, Koehler LA. Analysis of 451,891
canine uroliths, feline uroliths, and feline urethral plugs from 1981 to 2007:
perspectives from the Minnesota Urolith Center. Vet Clin North Am Small Anim
Pract. 2009;39(1):183-197.
17. Lulich JP, Osborne CA, Albasan H, Koehler LA, Ulrich LM, Lekcharoensuk C.
Recent shifts in the global proportions of canine uroliths. Vet Rec.
2013;172(14):363.
18. Bartges JW, Osborne CA, Lulich JP, et al. Prevalence of cystine and urate uroliths
in bulldogs and urate uroliths in dalmatians. J Am Vet Med Assoc.
1994;204(12):1914-1918.
AUTHOR
Daniel VanderHart
DVM, DACVR
Daniel VanderHart, DVM, DACVR, is a practicing radiologist in Cleveland, Ohio. He

earned his DVM from the Michigan State University and completed his residency in
28/1/2019
diagnostic imaging at the University of Florida. His interests include advanced imaging
and ultrasound of small animals as well as imaging of exotic and marine animals.
Material from Clinician's Brief may not be reproduced, distributed, or used in whole or in part without prior
permission of Educational Concepts, LLC. For questions or inquiries please contact us.

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28/1/2019 Imaging of Calculi of the Urinary System | Clinician's Brief

Imaging of Calculi of the Urinary

IMAGING | FEBRUARY 2017 | PEER REVIEWED | WEB-EXCLUSIVE

FIGURE 1A Ventrodorsal radiograph of a normal cat for

appearance, smooth capsular margin, normal size

FIGURE 1B Dorsal plane ultrasonographic image of a normal

FIGURE 1C Sagittal plane ultrasonographic image of a normal

FIGURE 1C Transverse image of a normal le kidney in a dog

hyperechoic fat surrounding the anechoic vessels. This image

FIGURE 2A A right lateral radiograph of a normal dog. Notice

kidney in a cat. In obese cats, fat can be present in the renal

FIGURE 3A Close-up radiograph of the le kidney with a large,

FIGURE 3B Ultrasonographic image of the same le kidney as

FIGURE 3D Ultrasonographic image of the same le kidney as

FIGURE 3E Close-up radiograph of the le kidney in a

Figure 3E. Only minimal distal acoustic shadowing artifact

FIGURE 4A Close-up radiograph of the le kidney in a dog

FIGURE 4B Ultrasonographic image of the same le kidney as

FIGURE 5A Lateral abdominal radiograph of a dog with 2 well-

confirming the location of the mineralized structures within

FIGURE 6A Mild to moderate right hydronephrosis and

FIGURE 6B This is an ultrasound image of a right sided

6A. Notice the ureteral dilation (between the arrowheads)

FIGURE 7A Lateral abdominal radiograph of a cat with

FIGURE 7B Ultrasonographic image of the same cat as Figure

FIGURE 7C Antegrade ultrasound-guided pyelography of the

Calculi of the Urinary Bladder and Urethra

FIGURE 8A Lateral radiograph of the urinary bladder in a dog

FIGURE 8B Ultrasonographic image of the same dog as

FIGURE 8C Lateral radiograph of the urinary bladder in a dog

FIGURE 8D Ultrasonographic image of the same dog as

FIGURE 9A Lateral radiograph of a bulldog presented for

FIGURE 9B Double contrast cystography performed on the

FIGURE 10 Lateral radiograph of a male dog centered on the

include the urinary bladder and os penis. Note the well-

FIGURE 11B Lateral radiograph of a male dog collimated to

FIGURE 11C Positive contrast urethrography utilizing

3. Adams LG. Nephroliths and ureteroliths: a new stone age. N Z Vet J.

Daniel VanderHart, DVM, DACVR, is a practicing radiologist in Cleveland, Ohio. He

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