Ultrasound of the bladder: indications, preparation and technique of the procedure. How ultrasound of the kidneys and bladder is done: features of the study Types of ultrasound

Ultrasound scanning of the urinary system is a highly informative diagnostic method. It allows you to identify structural changes in the kidneys and bladder that occur in various diseases. However, scanning is used not only for diagnostic purposes. Ultrasound of the kidneys and bladder plays an important role in assessing the changes that occur in the organs as a result of conservative and surgical treatment.

What is studied with ultrasound of the urinary system

If patients are suspected of developing any diseases of the urinary system, specialists do an ultrasound scan. During it, the kidneys are examined first. This is a paired organ, the main function of which is to remove waste products (creatine, urea) from the human body.

Also, during an ultrasound examination, the bladder is examined. This organ stores urine that comes from the upper urinary tract. Then it is excreted from it through the urethra.

Special preparation for ultrasound of the kidneys is not required. It is necessary when scanning the bladder. Ultrasound examination in children and adults is done with a filled organ. This nuance of ultrasound is very important, because with a too small or large volume of the organ, it is difficult to make a correct diagnosis. Visualization of the walls in such cases is difficult.

Indications for the study

Ultrasound of the kidneys and bladder is performed if adults and children have the following indications:

urinary incontinence;
dysuric disorders;
pain sensations;
suspicious urine tests;
diseases of the endocrine system;
arterial hypertension, not amenable to treatment;
pathological volumetric formations;
injuries;
anomalies in the development of the organs of the urinary system;
acute and chronic inflammatory processes.

There are no contraindications for ultrasound. Any person, regardless of their diseases and injuries, can be examined. Other than that, scanning is harmless. In this regard, ultrasound of the kidneys and bladder occupies a leading position in the detection of various pathologies.

How is an ultrasound of the urinary system performed?

Kidney anatomy

The kidneys of the patient are examined on the back or in a position with a half-turn on the right and left sides. If necessary, a scan is done on the abdomen. During the ultrasound examination, the contours, shape, position of the organs, the state of the parenchyma are evaluated. The perirenal spaces are also examined, and the following measurements are taken:

length and thickness of the kidneys;
thickness of pelvicalyceal structures;
parenchymal thickness.

Bladder Anatomy

To examine the bladder, the specialist places the sensor on the patient's body in the suprapubic region. Oblique, transverse and longitudinal scanning is carried out. During it:

the volume of the organ is determined;
the thickness of its wall is measured;
content is evaluated;
echo signs of additional formations are revealed.

After ultrasound of the kidneys and bladder, the patient is emptied. Then the specialist performs a second scan to determine the amount of residual urine.

The results of the study of the kidneys

During ultrasound, each kidney is found in the form of an oval-shaped organ. The lateral margin is convex, while the medial margin is concave. The most echogenic part of the organ is the central echo complex. It includes the pelvis, calyces, vessels, adipose tissue, nerves located in the renal sinus (in the cavity of the kidney).

Less echogenicity in adults and children is characteristic of the parenchyma. Its thickness is about 1.2-1.8 cm. The parenchyma includes medullary and cortical sections. The first of them consists of 10-18 original pyramids. Their tops are directed towards the renal sinus, and the bases are turned towards the surface of the organ. Along the bases of the pyramids, a conditional line can be drawn dividing the sections of the parenchyma.

During the scan, anomalies in the number of kidneys and their position can be detected. Anomalies of quantity include agenesis. This term refers to the development of the urinary system, in which one of the kidneys is not formed. Both organs may be absent, but this pathology is extremely rare. Children born without kidneys die in the first hours of life.

Anomalies in the position of the kidneys (dystopias) are violations of the movement of the organs of the urinary system during embryonic development. These pathologies can be of the following types:

Pelvic. Ultrasound shows that the kidneys are located in the pelvis. In women, they are behind the uterus, and in men, behind the bladder. The shape of the organs of the urinary system is often correct.
Iliac. With such dystopias, the kidneys are located at the level of the wings of the ilium. Organs have an anomalous appearance.
Lumbar. The kidneys are located in the lumbar region. They are located a little lower than usual. The organs have an unusual flattened and elongated shape.
Thoracic. The kidneys are located in the pleural cavity or above the diaphragm. Such an anomaly in the position of the organs of the urinary system is extremely rare.

Ultrasound examination allows you to determine the size of the kidneys. Normally, in adults and children, they should be as follows:

in adults - length from 10 to 12 cm, thickness from 4 to 5 cm, width from 5 to 6 cm;
at 10 years old - length from 8.5 to 10 cm;
at 5 years - length from 7.5 to 8.5 cm;
at 1 year - length from 5.5 to 6.2 cm;
in a newborn - a length of 4 to 4.5 cm.

A change in the size of organs (their volume) indicates the development of serious diseases. A symmetrical increase may indicate acute renal failure, glomerulonephritis, which occurs in an acute form. An asymmetric increase is a sign of acute pyelonephritis, renal vein thrombosis. A symmetrical decrease in the kidneys is observed in old age. In young people, this can occur with hypertensive nephropathy, chronic glomerulonephritis. Asymmetric reduction of organs occurs in chronic pyelonephritis, kidney infarction, chronic ischemia.

Acute pyelonephritis

One of the diseases detected during a kidney scan is acute pyelonephritis. Ultrasound shows the following signs:

changes in perirenal tissues;
an increase in the size of organs;
change in the structure of the walls of the pelvis;
diffuse or focal changes in the parenchyma;
changes in the central echo complex;
inflammatory thickening of the walls of the pelvis (in adults - more than 1.5 mm, and in children - more than 0.8 mm).

Tuberculosis of the kidney is a disease that occurs due to the hematogenous spread of microorganisms from primary foci. Detecting an ailment through a scan is quite difficult. The affected kidney may have a normal appearance, be reduced in size due to the ongoing cicatricial process, or be sharply enlarged.

Paranephritis is a disease in which inflammation covers the perirenal fatty tissue. The disease develops due to the ingress of pus from the place in the kidneys in which the inflammatory process occurs. Ultrasound diagnostics around the organ or near it reveals a focus that has a heterogeneous structure without clear boundaries.

Bladder: scan norms

This organ, when filled during ultrasound examination in children and adults, is detected in the form of a square formation, which is characterized by low echogenicity. Inside it you can see the vesical triangle. Its anatomical landmarks are the internal opening of the urethra and the mouth of the ureters.

In healthy people, the walls of the organ are even, symmetrical. They appear as a contour with highly echoic mucosa. In people with a filled organ, the wall thickness is no more than 3 mm, with an emptied one, it does not exceed 5 mm. The value of this indicator, determined by ultrasound, is not affected by the gender and age of the patient.

A change in the thickness of the walls of the organ is observed in various diseases. The causes of local thickening can be a tumor (transitional cell carcinoma, adenocarcinoma), acute inflammation, hematoma. Diffuse thickening is inherent in chronic inflammation, amyloidosis.

Necessarily with ultrasound of the kidneys and bladder, the volume of residual urine is determined. Normally, after emptying the body should be almost empty. The residual volume of urine in adults should not be more than 20 ml (or 10% of the initial organ volume). In healthy children, this figure does not exceed 10 ml.

The main pathologies and their signs

Very often, during an ultrasound examination, specialists detect stones in the bladder in patients. They are hyperechoic formations localized in the cavity of the organ and having a rounded or ovoid shape. Stones of small size move when the position of the body changes. Large stones in most cases are motionless.

papillary tumors

Thanks to ultrasound, neoplasms of the organ of the urinary system can be detected. Most often, papillary tumors are found. Benign tumors are polyp-like villous neoplasms. Their height is no more than 1 cm. Tumors are localized in the bladder mainly on the side walls. Malignant tumors are similar in appearance to benign ones, but their size is larger.

Sometimes injuries are detected - ruptures of the organ of the urinary system. They can be:

Extraperitoneal. With such injuries, during the scan, a liquid formation is detected, limited by the wall of the organ and the peritoneum covering it.
Intraperitoneal. Scanning reveals free acoustically transparent fluid (urine) in the abdominal cavity.

Acute cystitis

A fairly common disease is cystitis. With him, the ultrasonographic picture is similar to normal. You can only detect the following suspicious signs that occur with cystitis:

thickening of the walls of the body;
the presence of a finely dispersed echogenic suspension in the bladder;
the occurrence of urge to urinate with a small volume of the organ.

Harmlessness, speed of obtaining the results of the study, no need for special training - the main advantages of ultrasound of the kidneys and bladder. Thanks to the diagnosis, it is possible to identify serious diseases of the urinary system.

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With the help of ultrasound on modern devices, it is possible to visualize the size, shape, position of the organ, inclusions and the intensity of blood flow in it. To exclude artifacts and obtain reliable data, proper preparation for ultrasound is necessary, which depends on which organ is planned to be examined.

Indications for ultrasound of the bladder

An ultrasound examination of the bladder is performed when a number of diseases are suspected and there are corresponding symptoms, such as:

Frequent painful urination and pain in the lower abdomen. They can be a manifestation of inflammation of the bladder (cystitis), urolithiasis with the release of a stone, tumor diseases.
Blood in the urine (hematuria). When urinating, urine becomes red, may be accompanied by a burning sensation in the bladder and urethra (urethra). These symptoms accompany urolithiasis, a tumor process, or trauma to the organs of the genitourinary system. In this case, in addition to ultrasound of the kidneys and bladder, a clinical analysis of urine is mandatory.
Feeling of incomplete emptying of the bladder. It happens with an adenoma (benign tumor) of the prostate in men, foreign bodies or tumors of the bladder or other pelvic organs.
Any abnormalities in the clinical analysis of urine, such as the appearance of protein and bacteria in the urine, an increase in the content of leukocytes and casts (protein casts of the renal tubules).

The examination can be carried out without indications, simply at the request of the patient. Diseases that can be detected by ultrasound of the bladder:

acute and chronic cystitis;
diverticulum - a condition in which a protrusion forms in the wall of the bladder, over time it can become inflamed;
stones in the bladder with urolithiasis;
anomalies in the structure of the bladder - a change in the shape and location of the organ, is a congenital condition as a result of a violation of its development;
foreign body;
Tumors are growths that can be benign (polyps) or malignant (cancer).

What does an ultrasound of the bladder show?

With the help of ultrasound, the doctor can see such deviations:

thickening of the walls of the bladder (hypertrophy) - observed with cystitis and impaired urine outflow;
diverticula and the presence of inflammation in them;
stones and foreign bodies;
volumetric formations that protrude into the cavity of the bladder (tumor);
change in the shape and localization of the organ with its anomalies;
increase in residual urine.

How is an ultrasound of the bladder done?

Ultrasound is performed on a full bladder, as this makes it easier to visualize it with ultrasound. The completeness of the survey is determined by such characteristics as:

the size and shape of the bladder;
localization (location);
the condition of the walls of the bladder (normally 0.3-0.5 cm);
the presence of stones or other foreign bodies;
imaging of the tumor.

The results obtained are analyzed and documented. The doctor of ultrasound diagnostics makes a conclusion. The diagnosis is made by the attending physician based on all the results of the examination and the clinical picture, so the conclusion of the ultrasound and the final diagnosis may not coincide.

There are three ways to carry out the procedure:

non-invasive method - the nozzle is applied to the anterior wall of the abdomen in its lower sections;
ranrectal method - a special nozzle is inserted into the rectum, allows you to well examine the neck of the bladder and its lower sections;
transvesical method - the nozzle is inserted into the cavity of the bladder, used for direct examination of formations and tumors.

If the patient has impaired urine outflow, then an ultrasound is performed to determine the residual urine. The essence of this technique lies in the fact that an ultrasound examination is performed twice - before and after emptying the bladder. At the first ultrasound, all indicators are examined. After urination, ultrasound determines the amount of remaining urine, the normal volume of which is no more than 50 ml.

Preparing for an ultrasound of the bladder

The patient does not require any special preparation for the examination. The only thing that needs to be done is to drink 1-1.5 liters of liquid (water, tea, compote) an hour before the examination. Then you have to be patient and not urinate until the end of the ultrasound. If there is an unbearable urge to urinate, then the bladder can be partially emptied, but not completely.

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Without any restrictions, ultrasound of the bladder can be performed in children and pregnant women, since ultrasound does not damage body tissues and does not cause long-term consequences. This research method is harmless, painless and has no contraindications.

How to prepare for an ultrasound examination of the bladder?

Ultrasound of the bladder is prescribed for the diagnosis of diseases of the urinary system. It is always examined as part of a comprehensive ultrasound examination of the pelvic organs in women and men.

The peculiarity of the bladder is that it is a hollow organ. If it is not filled with liquid, it "crumples" and does not let sound waves through. It is not visible on the monitor and cannot be measured, so the interpretation of the results will be inaccurate. Examination with an empty bladder does not show stones and sediment in its cavity; does not allow to take into account such an important diagnostic factor as residual urine. With complex ultrasound, not only empty, but also insufficiently filled urinary reduces the accuracy of visualization of the uterus, ovaries, and prostate. Therefore, you need to prepare in advance for an ultrasound of the bladder.

How an ultrasound is performed

The procedure is carried out in two ways: externally, through the anterior wall of the peritoneum, and internally, through the vagina in women and through the rectum in men. The interpretation of the results of the study in both cases is the same.

External, transabdominal ultrasound of the bladder can be done already at the initial appointment with a urologist or gynecologist. If the attending physician, after deciphering the ultrasound report, finds a pathology in the bladder or other organs of the small pelvis, he recommends an in-depth study.
Ultrasound with the introduction of a sensor through the rectum is called transrectal, and through the vagina - intravaginal. It is carried out in the diagnosis of gynecological diseases in women and prostate diseases in men, at the same time examining the bladder and ureters. It shows not only problems with the bladder, but also their relationship with other pathologies of the pelvic organs.

For children, ultrasound of the bladder (for cystitis and other urination disorders) is done only transabdominally. For a small child who cannot be explained how to prepare for the procedure, the doctor will prescribe a different examination method. However, in some cases, ultrasound is done to children without preparation in order to determine residual urine: if there is a lot of it, this indicates serious health problems for the baby.

Getting ready for the survey

Preparation for an ultrasound of the bladder partly coincides with the preparation for an ultrasound examination of the abdominal cavity and small pelvis. It is not done after gastro- and colonoscopy - ultrasound after these procedures will not harm you, but its results will be inaccurate. If you are constantly taking any medications, tell your doctor about it.

If the purpose of the study is only the diagnosis of diseases of the urinary system, it is not necessary to follow the rules. But if the doctor warns that during an ultrasound of the bladder, an examination of all the organs of the small pelvis is expected, you will have to prepare for it in a few days. The purpose of preparation is to reduce flatulence, since gases make it difficult to see. Therefore, 1-2 days before the ultrasound, stop eating foods that cause fermentation in the intestines:

raw vegetables and fruits and juices from them;
cakes, muffins;
milk and dairy products;
legumes;
black bread;
carbonated drinks.

Ultrasound of the bladder is best done in the morning on an empty stomach. If it is scheduled for the afternoon, a light breakfast is allowed in the morning (in addition to the above foods, you should not eat fatty foods and eggs). In order for the ultrasound to show accurate results, you can have breakfast no later than six hours before the visit to the doctor.

Special rules

Whether or not you need specific preparation for the procedure depends on how a bladder ultrasound is done at your facility. For example, transvaginal ultrasound is performed with an empty bladder, but it is usually done during a comprehensive study of the abdominal or pelvic organs, so you need to reduce flatulence.

Special preparation is needed only for transabdominal and transrectal ultrasound examination. It is carried out once or twice: with a full bladder and after urination (with determination of the amount of residual urine).

Drink several glasses of any liquid one or two hours before visiting the doctor: tea, compote, still water. If after an hour you do not feel that the bubble is full, you need to drink a few more glasses of liquid. It’s hard to endure, but is it not time to go for an ultrasound yet? Urinate and drink tea or still water again.
When an ultrasound of the bladder is scheduled for the early morning (for example, in a hospital), you can prepare for it in a "natural way", that is, do not urinate at night. This method is ideal for people who rarely wake up at night to go to the toilet.
Sometimes in a hospital or at a doctor's appointment, there is a need for an urgent diagnosis of the bladder and kidneys (with renal colic or suspected blockage by a stone). The patient does not have time to prepare for the procedure, and the doctor prescribes a single dose of a diuretic. Diuretic drugs are not used by people with cardiovascular disease.
If an ultrasound of the bladder is to be performed on a person suffering from urinary incontinence, the bladder is catheterized and filled with saline before the procedure. But the introduction of a catheter is quite traumatic, so it is used only as a last resort.

Before a transrectal ultrasound, so that the feces do not interfere with the procedure, a microclyster is made from 200 ml of ordinary boiled water. The large intestine should be cleansed an hour and a half before the procedure and then empty the rectum.

Bladder ultrasound

In the definition of diseases of the bladder, not the last place is occupied by ultrasound examination. This diagnostic method is prescribed in the presence of symptoms indicating a pathology of the genitourinary system. To obtain reliable results, ultrasound of the bladder should be taken seriously and prepared. All instructions regarding the preparation for the examination are given by the doctor and it is very important to follow them. This method has no contraindications, it is allowed for even a child.

Indications for the appointment of an ultrasound examination

This method of examination is distinguished by its simplicity, the absence of contraindications, complications, and the speed of obtaining results. A study is prescribed for the following symptoms:

frequent or difficult urination;
incontinence;
suspicion of kidney stones;
with cystitis;
urine output with an admixture of blood;
suspicion of vesicoureteral reflux.

Additionally, the study is prescribed to assess the work of the kidneys, the diagnosis of cystitis (both chronic and acute), pyelonephritis. If adenoma or inflammation is suspected in men, prostate examinations are carried out at the same time. Women for a complete assessment of the state of the genitourinary system may be prescribed additional examinations of the uterus and appendages.

How to prepare for a bladder ultrasound

Preparation for ultrasound of the bladder plays a very important role. By the time of the procedure, the organ must be filled - this will help determine the thickness of the walls, the shape of the organ and its contour. To do this, about 1.5 - 2 hours before the ultrasound, you need to drink about 2 liters of liquid in the form of teas, compotes, still water. There is another way - do not empty the bladder for 5 - 6 hours before the procedure.

If the ultrasound will be performed transrectally, it is necessary to make a cleansing enema on the eve of the procedure and a few hours before it. After such preparation, patients do not have questions about whether it is possible to eat before ultrasound of the bladder. After all, it is already clear that it is better to conduct an examination after an enema on an empty stomach or on a diet (with other types of examination: external and transvaginal or transurethral).

Many patients find it difficult to refrain from urinating before the procedure and the question arises how to prepare then. In this case, it is recommended to empty partially, but in this case, you will need to drink 1.5 - 2 liters of liquid, so that by the time of the ultrasound the organ is refilled. The accuracy of the results after the examination depends on the correct preparation of the patient, because only a full bladder can determine the state of the organ.

How is the procedure carried out

Ultrasound of the bladder is carried out in 3 ways:

Abdominally - with it, the examination is carried out from the side of the anterior abdominal cavity. This is an external type of research.
Transurethral - diagnosis occurs through the urination canal.
Transrectal - the organ is examined through the rectum.

The most used is the first method of examination. The other two are needed to confirm or refute the problems that were identified during the external survey. Ultimately, the ultrasound method is determined by the attending physician, who prescribes this procedure. The position of the patient is determined during the diagnosis, you will be asked to lie on your back or side, in some cases you are asked to stand up so that you can examine the organ for the presence of formations inside it .

How is an ultrasound of the bladder done in women

Diagnosis sometimes differs depending on the gender of the patient. Women additionally examine the uterus and ovaries. The procedure provides an opportunity to measure these organs, determine their structure, location, shape. In some cases, women do ultrasound transvaginally. This helps to clearly see the picture of the state of the organs inside and accurately diagnose the existence of certain diseases. Pregnancy and menstruation are not a hindrance to diagnosis, it is only important to warn the doctor so that he correctly chooses the method of conducting the examination.

Ultrasound of the genitourinary system in men

Examination of male patients has some of its own characteristics, for example, during ultrasound of the bladder, sometimes there is a need for a diagnosis of the prostate gland. If you suspect a disease associated with the prostate, ultrasound of the bladder with the determination of residual urine. To do this, the man is asked to go to the toilet, and then the amount of fluid that is stored in the organ is measured. Otherwise, the diagnosis of a bladder in men and women is no different.

What can an ultrasound scan show?

Organ diagnostics helps to see:

Permeability through the urethra.
The presence of foreign formations, tumors, stones.
The sediment in the bladder on ultrasound is seen in the form of salts, crystalline formations, epithelium, erythrocytes and leukocytes.
Inflammation (acute or chronic).
Increased tone.
Atony.
wall diverticulosis.
Omission of an organ.
The existence of problems with the prostate (in men).
Diseases of the ovaries, appendages, uterus (in women).

Primary diagnosis of cystitis is carried out by passing a urine and blood test. After the doctor receives the results, he can refer the patient to an ultrasound examination of the urinary system. Ultrasound of the bladder with cystitis is a necessary measure.

If the doctor has difficulty making a diagnosis, this diagnostic method helps to get an accurate picture of the development of the disease, since ultrasound visually shows the structure of the bladder, in which characteristic signs of inflammation are visible when cystitis occurs.

Cystitis is an inflammation of the walls of the bladder that most often occurs as a result of penetration into the urinary organ of a bacterial infection. Today, this disease is quite common, especially among women. The fact is that in the representatives of the weaker sex, the concomitant anatomical structure of the urinary organs is a wide and short urethra, through which pathogenic microflora can quickly enter the body, thereby causing inflammation.

Is it possible to determine the presence of a problem at an early stage? Often, cystitis appears in a person as a result of the development of an ascending infection in the body, which complicates diagnosis and treatment of the disease.

When are they assigned?

The main indications for ultrasound in case of suspected cystitis are:

rare or, conversely, too frequent urination;
the presence of pus or blood clots in the urine;
the appearance of large white flakes in the urine;
false urge to the toilet, when only a couple of drops of urine are released from the bladder, containing impurities of pus or blood (often this phenomenon is observed with cystitis, which was caused by a specific flora);
change in the shade of urine;
decrease in the total amount of urine produced per day;
pain or discomfort when going to the toilet “in a small way”;
discomfort in the pubic area;
an increase in subfebrile temperature to 38 degrees or more.

It is important to note that these symptoms can characterize not only cystitis, but also other pathologies of the bladder or the entire excretory system (pelvic organs). Therefore, the patient is assigned an ultrasound scan, with the help of which the diagnosis will be established accurately. The question “do I need to do an ultrasound” in such a situation is not worth it.

What does it show?

Is the disease visible in the study? When conducting an ultrasound scan, doctors can detect diverticula - these are peculiar sac-like neoplasms located on the walls of the bladder or growing into its cavity. Also in the organ it is possible to detect sand or oxalate (salt) stones, which significantly violate the integrity of the mucous membrane, and are also considered the main factor in the development of cystitis.

Video 1. Cystitis on ultrasound.

With the course of certain forms of the disease, such a study will be endowed with specific manifestations.

Ulcerative and herpetic forms

For these forms of cystitis, a characteristic symptom of the development of the disease will be the appearance of erosions and small ulcers in the inner part of the urea. At first, they will develop on the mucous membrane, and then they will spread to the deeper layers of the organ. This form is accompanied by severe pain Therefore, the treatment of the patient should be carried out immediately after the signs of cystitis are detected.

Candidal form

With the development of cystitis of the candidal type, ultrasound will show the formations that have appeared in the cavity of the urea. They can have different shapes and sizes. The growth rate of neoplasms depends on the state of the patient's immunity and the time of the course of cystitis.

acute form

A significant thickening of the walls of the ureter becomes noticeable only with the onset of an acute form of pathology. At the beginning of its development, ultrasound will show an even contour of the organ, on which deformations will be completely absent. However with the progression of inflammation, the walls of the bladder will gradually thicken, the contour will become more crooked, and the shape uneven - with the help of ultrasound, such negative changes in the organ can be noticed without problems.

Chronic form

With the development of this form, a thickening of the walls of the organ also occurs. Ultrasound shows the presence of flakes in the bladder, which indicates the neglect of the disease.

If the inflammation is too advanced, hypo and hyperechoic areas can be found in the inflamed organ. Imi may have blood clots. They also cause a violation of the contour of the urinary organ, being in the liquefaction phase, as a result of which it looks asymmetrical.

Healthy bladder

In a normal and healthy state, the organ is even, symmetrical, without protruding walls and uneven contours. On the mucous membrane there should be no deformations, ulcers, spots and thickening. A healthy organ has a wall thickness of 5 mm.

Training

Preparation for the study depends on the method of its conduct.

Known 4 options Urinary ultrasound. It:

transvaginal;
transurethral;
transabdominal;
transrectal.

Ultrasound is accompanied, if necessary, by other types of studies.

Also, for the diagnosis of cystitis, a method is often used that helps to identify all the obstacles that urine overcomes when it enters the bladder or when it leaves it.

The effectiveness of this method lies in the study of residual urine of the patient.

Deciphering the results and the norm

Diagnosis of cystitis, performed in the acute phase, reveals the following picture: inside the bladder, the smallest particles endowed with high echogenicity are clearly visible. They are usually combined into foci. Usually, these particles are an accumulation of a large number of cells- leukocyte, epithelial or erythrocyte. Salt crystals (oxalates) can also be found in them.

The outflow of urine when it reaches its maximum peak should be less than 15 cm / s- otherwise, we can talk about the development of cystitis or other diseases of the urinary organs.

Complications

Cystitis most often develops as a result of finding a valid infection in the body. Therefore, the causative agent of the disease can easily get into the kidneys through the ureters, which will worsen the patient's condition, causing pyelonephritis and other diseases of the paired organ.

Pros and cons of organ ultrasound

This study is absolutely safe for the health of the patient, and also painless. The safety of this diagnostic method is used in the case of a study of pregnant women, children and the elderly.

Conclusion

Ultrasound performed on the bladder is considered one of the most informative examination methods, which is prescribed for the development of acute cystitis. Using this diagnostic method, it is possible to see changes in the urinary organ, the negative effect of pathology on the bladder, and also to understand how many layers are involved in the inflammation process.

The advantage of ultrasound is that today there are several options for the procedure., so it can be selected individually for each patient.

A doctor can diagnose cystitis based on the results of urine and blood tests. But often the specialist has difficulty in accurately determining the pathology, so he directs the patient for an ultrasound examination of the urinary organs.

Indications for the procedure

A number of symptoms from the urinary system are indications for ultrasound in cystitis. Among them:

the appearance in the urine of bloody impurities or pus;
frequent urge to urinate or acute urinary retention;
a small amount of urine;
pain in the suprapubic region, which appear periodically.

Training

The person who received the referral for the procedure must prepare for its implementation. An ultrasound examination is performed with a filled urea, so 1.5-2 hours before the ultrasound, you need to drink about 2 liters of still water or other liquid. If this fails, then it is recommended not to defecate for 5-6 hours.

The procedure may interfere with the intestines filled with gases. Those who suffer from flatulence should follow a diet for 2-3 days before the ultrasound. From the diet, it is necessary to exclude products that promote gas formation - vegetables, fruits, legumes, carbonated and alcohol-containing drinks.

If the study will be carried out by the transrectal method, then a cleansing enema should be done a few hours before the procedure.

Types of ultrasound

The study of the bladder using ultrasound is carried out in several ways:

Transabdominal. The most common method of instrumental diagnostics and less invasive for the patient. It is carried out through the anterior abdominal wall with a filled urinary organ. With urinary incontinence and obesity, transabdominal ultrasound is not prescribed.
Transrectal. It is carried out through the rectum in patients of both sexes.
Transurethral is a rare diagnostic method that requires mandatory anesthesia. It is carried out through the urethra using a special tip. The procedure causes discomfort to a person, possibly injuring the urination canal.
Transvaginal. Women are examined using this method. The urinary organ must be completely emptied. Transvaginal examination allows for a detailed analysis, but gives the patient some inconvenience.

Pathogenic microorganisms that caused cystitis are able to rise through the urogenital canals to the kidneys, provoking pyelonephritis. If the patient complains of back pain, then with ultrasound for cystitis, a kidney test is performed.

Differences in men and women

Depending on the gender of the patient, the examination is carried out in different ways. If a woman came to the appointment, then the ultrasound doctor additionally analyzes the condition of the uterus and ovaries: the organs are measured, their location, shape and structure are determined. Ultrasound can be performed during menstruation and during pregnancy, but the doctor should be warned so that he selects the correct procedure for the procedure.

During the examination of a man, the doctor can analyze the condition of the prostate gland. If a pathology of the prostate is suspected, then the remainder of the urine is determined. The patient is asked to go to the toilet to empty the bladder, and then the amount of urine remaining in the organ is measured.

https://youtube.com/watch?v=Li6xPQ-j7lk

results

The results of an ultrasound examination of the bladder indicate several parameters that help make the final diagnosis:

bubble shape;
its volume;
amount of residual urine;
bubble structure;
Wall thickness;
bladder emptying rate.

Ultrasound allows you to determine whether an inflammatory process develops in the urinary organ.

On the echo picture of a patient with acute cystitis, clusters of cells are visible - epithelium, erythrocytes and leukocytes, which are described by the term "sediment" in the results of the study. If the patient lies during the ultrasound, then the sediment is localized near the posterior wall of the bladder. When the patient gets up, the sediment will move to the anterior wall.

In the chronic form of the pathology or with the progression of acute cystitis, the results of the study will show that the organ has an uneven contour and the walls are thickened. The presence of blood clots in the cavity of the bladder is shown on the echo picture.

The results of the study conducted using ultrasound should be deciphered by the urologist who referred the patient for the procedure. If necessary, the doctor selects a treatment course.

The results of the study of the bladder are normal:

The form. In the transverse projection, the bubble should be round, in the longitudinal projection - ovoid. The shape of the female organ is affected by the number of pregnancies and childbirth.
Structure. Normally, it is echo-negative, but the parameter depends on the age of the person: the older, the higher the echogenicity should be.
Volume. The average indicators for women are 250-550 ml, for men - 350-750 ml.
Walls. The same thickness over the entire surface - 2-4 mm. If thickening or thinning is shown in any area, then this indicates the presence of pathology in the organ.
Residual urine. Its amount should not exceed 50 ml. When conducting a study, it is measured without fail.

What is the price

Ultrasound prices depend on various factors: the city of the study, the clinic (in a commercial medical center, the cost of the service can be 2-3 times higher than in a specialized hospital in a municipal hospital), the level of qualification of the specialist performing the procedure.

In Moscow and St. Petersburg, the average cost of an ultrasound of the urinary tract is from 600 to 2,500 rubles.

Cystitis is a fairly common disease. More common in women. This is due to the anatomical structure - a short and wide urethra. Most often, cystitis occurs due to an ascending infection. About 60 percent of cystitis is due to the ascending pathway of E. coli. E. coli (E. coli) is an opportunistic flora living in the rectum and vagina (in small quantities). Also, cystitis can be caused by staphylococcus aureus (occurs with a febrile temperature), such specific pathogens as chlamydia, mycoplasmas, ureaplasmas. Extremely rarely, cystitis can occur by the hematogenous or lymphogenous route (risk of interstitial cystitis).

Symptoms

The main manifestations of cystitis are:

Pain in the suprapubic region;

Cystitis can occur for the following reasons:

Irregular or improper hygiene (in girls);

Diagnostics

What studies will the doctor need to make a diagnosis:

Collection of anamnesis and complaints;

Ultrasound of the bladder with cystitis carried out after special preparation of the patient. The patient should drink 1-1.5 liters of still water or other drink (not milk) 1-1.5 hours before the scheduled procedure. In chronic cystitis, ultrasound shows thickened walls, as well as sediment at the bottom of the bladder.

In contact with

This is one of the most common pathologies of the urogenital area. It refers to inflammatory diseases of the bladder. It is characterized by damage to the mucous membrane by pathogenic bacteria. The disease affects people of any gender. But women especially often suffer from this disease because of the special anatomical structure, which contributes to the easy penetration of pathogenic microflora (saprophytic bacillus, intestinal staphylococcus and other microorganisms) into the urinary cavity. The disease can be acute or chronic.

For complex diagnostics of the urinary tract, not only such routine methods as a general analysis of urine and blood are used, but also methods of functional diagnostics. The main one is the ultrasound of the bladder. Ultrasound examination (ultrasound, sonography) - an examination of internal organs, performed using ultrasonic waves, with cystitis allows you to get information about the state of the organ itself and the tissues surrounding it.

Diagnosis of cystitis is not particularly difficult. The patient comes to the doctor with typical complaints.

The presence of a characteristic history helps the doctor to suspect cystitis in the patient. Additional research methods are used to confirm the diagnosis.

They include

general urine analysis;
general blood analysis;
urine culture to detect the growth of pathogenic flora;
a smear from the vagina for the presence of pathogenic flora in women;
cystoscopy;
research on sexually transmitted diseases;
Ultrasound of the organs of the urinary system (kidneys, ureters, bladder);
mucosal biopsy.

All these studies will help the doctor differentiate cystitis from other diseases of the genitourinary system with similar symptoms.

Indications for ultrasound

It is important in the process of complex diagnostics to prescribe an ultrasound scan to a patient with suspected cystitis. Carrying out this diagnostic procedure will allow the specialist to determine the size of the affected organ, its shape and wall thickness.

An indication for an ultrasound of the urinary system is the presence of the following signs:

feeling of pain, tingling in the lower abdomen;
frequent or infrequent episodes of urination;
changes in the color of urine;
the presence of inclusions of a different nature in the urine (pus, blood clots, white flakes and other types of sediment);
decrease in the total daily amount of urine;
pain and;
pulling and other discomfort in the pubic region;
pain in the lower abdomen with irradiation to the lower back or perineum;
increased body temperature (up to 38 degrees and above);
feeling of not completely empty urinary.

The organs of the urinary system are closely interconnected, and the infection can quickly spread upward. It is not clear how much inflammation is localized in the urinary tract or whether it has already gone further. Often after cystitis, pyelonephritis quickly occurs.

How and where is the procedure

Urinary ultrasound is performed in many private and public multidisciplinary medical centers, clinics and hospitals. Usually in all large medical institutions there is a department of functional diagnostics with an equipped ultrasound diagnostics room, where ultrasound is done. The study is performed by a doctor of functional diagnostics. He specializes in this type of diagnostic procedures.

The tasks of conducting an ultrasound examination of the bladder for cystitis:

find an inflammatory focus in the wall of the organ;
determine the amount of residual urine;
evaluate the wall thickness, contours and dimensions of the organ;
identify the causes that contribute to the development of inflammation (foreign bodies, calculi (stones), neoplasms, pathologies of organ development).

Training

Before this diagnostic procedure, some preparation is required. Without it, it is impossible to achieve clear and reliable results.

Preparation for this type of diagnostics includes the following recommendations:

three days before the examination is necessary. Exclude food that causes increased gas formation in the intestines (legumes, cabbage, confectionery, fried and fatty foods);
the last meal should be eight hours before the study;
an hour after the last meal, it is recommended to drink activated charcoal tablets (one tablet per 10 kg of the patient's weight) to reduce gas formation in the intestines;
with transrectal ultrasound, an enema is performed an hour before the study;
with vaginal and transurethral access, a thorough treatment of the genital organs is carried out;
an hour before the study, you must drink non-carbonated water at least one and a half liters;
you can drink a diuretic before the examination, if recommended by a doctor, in the case when it is necessary to urgently diagnose;
try not to urinate before the examination.

The course of the procedure

It may differ depending on the access.

There are several ways to examine the condition of the bladder:

transabdominal (classical) method - the examination is carried out with a sensor through the front wall of the abdomen, it is carried out only when the bladder is full;
transvaginal examination is performed for women - the results are more reliable, a vaginal sensor is used, the bladder must be empty;
transrectal access - the sensor is inserted into the rectum, more often done to men in order, in addition to the bladder, to assess the condition of the prostate gland (it is also used if the patient is overweight);
transurethral access is carried out through the urethra, performed under local anesthesia, allows you to explore the urethra.

Most often, ultrasound is performed transabdominally. This is a completely painless procedure.

The procedure is as follows;

the patient lies on the couch on his back;
it is necessary to unbutton the clothes and provide the doctor with access to the lower abdomen;
the doctor applies a special gel to the skin, which ensures movement and a snug fit of the sensor to the skin;
the doctor scans the organ using a sensor;
an image (2D or 3D) of the bladder tissue is sent to the screen;
the doctor evaluates the resulting image.

The duration of the study is approximately twenty minutes. If the doctor needs to examine the walls of the organ in detail, he will ask the patient to visit the toilet and empty the bladder. After that, the study will continue, and the doctor will determine the amount of residual urine.

Deciphering the results

Only a specialist should deal with the interpretation of the results of a study of the pelvic organs. He correlates the results obtained with the established norms and clinical manifestations in the patient, and after that he already makes the final diagnosis.

The parameters that the doctor evaluates according to the study:

the size of the bladder;
the presence of various formations;
content composition;
the possibility of filling and emptying;
volume of residual urine;
organ shape;
its structure (walls and cavity).

When evaluating the parameters, there is a search for signs of inflammation and its provoking factors. The assessment of these parameters influences the diagnosis.

echogenicity

In the normal state, the bubble is echo-negative, its echogenic structure is even. Echogenicity increases with the development of inflammation and as the human body ages.

With inflammation in the bladder, multiple particles appear that have increased echogenicity. These are specific foci, consisting of a complex of many cells (leukocytes, epithelial cells, erythrocytes) with salt crystals (oxalates and phosphates). When examined, they are visible as light spots on a dark background. They are characterized by movement when the position of the patient's body changes. With advanced inflammation, hyper- and hypoechoic areas may appear on the bladder wall.

Dimensions

Normally, the volume of the bladder in men is from 350 to 750 milliliters, and in women - from 250 to 550 milliliters. The volume of residual urine in representatives of both sexes is normally no more than 50 milliliters. An increase in the size of the bladder is almost always accompanied by an increase in the volume of residual urine.

The outflow of urine can be difficult for the following reasons:

the formation of valves in the urinary tract (more often in children);
stones in the cavity of the bladder that violate the outflow;
violation of innervation;
the formation of a diverticulum (pathological protrusion of the organ wall);
prostate hyperplasia (in men).

An increase in the size of the organ and the amount of residual urine is usually caused by urolithiasis, or the formation of a tumor that interferes with the outflow of urine.

Reducing the size of the organ is also pathological. It can be a consequence of tissue wrinkling in non-specific inflammatory processes and some congenital anomalies.

The size of the organ decreases due to the following diseases:

schistostomy invasion in the terminal (final) stage;
consequences of surgical intervention;
consequences of chemotherapy;
urinary tuberculosis.

Most often, a decrease in the size of an organ can be observed at the final stage of the inflammatory process.

Walls and cavity

Normally, a filled bladder in transverse sections has a rounded shape, in a longitudinal section - an elongated ovoid, saucer-shaped - after urination. The wall of a healthy bladder is even and smooth. The normal thickness of the bladder walls does not exceed five millimeters. There should be no defects and any processes.

If the thickness is greater, then this is interpreted as a thickening of the wall, which is typical for. Thickening is local and diffuse. A significant thickening of the walls is typical for the acute form of pathology. The contour of the walls with it is usually curved, and the shape of the bubble is uneven. The organ cavity can take an asymmetric shape.

Thinning of the walls of the organ (less than 2 mm) is also considered a serious pathology in cystitis. This may be with a long-term chronic inflammatory process. Thinning threatens with the occurrence of perforation of the wall, which is a severe complication.

Education

On ultrasound of the bladder with cystitis, pathological formations are detected. They can be mobile and immobile. The degree of their echogenicity and density is important. The denser the formation, the lighter it looks on ultrasound. The lightest of the pathological formations are stones, the darkest are cysts.

Volumetric pathological formations include:

stones;
tumors (malignant and benign);
polyps;
blood parietal clots;
foreign bodies;
cysts;
large flakes.

Until the pathology has reached advanced stages, the ultrasound will not show drastic changes. Therefore, all the results obtained during this examination require further differential diagnosis.

Video

From this video you can find out what an ultrasound of the bladder is, how this examination is carried out, what are the ECHO signs of cystitis.

Watch this video to learn how to prepare for an ultrasound.

Cystitis is a fairly common disease. More common in women. This is due to the anatomical structure - a short and wide urethra. Most often, cystitis occurs due to an ascending infection. About 60 percent of cystitis is due to the ascending pathway of E. coli. E. coli (E. coli) is an opportunistic flora living in the rectum and vagina (in small quantities). Also cystitis can cause staphylococcus aureus (occurs with a febrile temperature), such specific pathogens as chlamydia, mycoplasmas, ureaplasmas. Extremely rarely, cystitis can occur by the hematogenous or lymphogenous route (risk of interstitial cystitis).

On the mucous membrane of the bladder there are special receptors to which Escherichia coli is tropic. The number of these receptors varies from person to person. No genetic predisposition to inheriting the amount of these receptors has been identified. It is due to the amount of these receptors that some people often suffer from cystitis, some do not know about this problem at all. However, timely diagnosis and treatment of acute cystitis prevents the occurrence of a chronic process.

Symptoms

The main manifestations of cystitis are:

Pain in the suprapubic region;
Discomfort or pain when urinating;
Possible subfebrile temperature (up to 38 degrees);
change in color or amount of urine;
Frequent or infrequent urination;
Imperative urge (urge to urinate without excretion of urine) with a drop of blood or pus (mainly with cystitis caused by a specific flora).

Cystitis can occur for the following reasons:

Irregular or improper hygiene (in girls);
Hypothermia and wearing synthetic underwear;
Inflammatory diseases of the vagina (in women), urethritis and prostatitis (in men), defloration (frequent sexual intercourse);
Anatomical anomalies and neoplasms in the bladder (diverticula, polyps, tumors, adhesions);
Metabolic nephropathy (stones and sand in the kidneys and bladder);
Narrowing or inflammation of the urethra;
During pregnancy and after childbirth;
Surgical interventions (transurethral);
Wrong food (spicy, spicy, smoked, salty).

Diagnostics

What studies will the doctor need to make a diagnosis:

Collection of anamnesis and complaints;
Inspection;
General blood analysis. Will show a slight leukocytosis and a slight increase in ESR (except for cystitis caused by staphylococcus aureus);
General urine analysis. It will show an increased number of leukocytes, epithelium, protein, there may be a small amount of erythrocytes, as well as a precipitate in the form of salts;
Urine analysis according to Nechiporenko will show an increase in the number of leukocytes;
Urine bacterial culture and sensitivity to antibiotics (results will be ready in a week, therefore it is rarely prescribed);
(the most informative method);
Perhaps the appointment of voiding cystography (for vesicoureteral reflux);
Cystoscopy.

Ultrasound of the bladder is a modern diagnostic method that allows you to determine the exact size, structure of the organ and violations in its work.

Based on these data, it is much easier for the doctor to make a diagnosis. This study is suitable for people of any gender and age.

What is an ultrasound of the bladder, how is it done and in what cases is it prescribed - the article will tell about this.

An ultrasound doctor is appointed for various reasons. Usually, the doctor sends a patient for such an examination, who complained of a urinary disorder.

For example, blood clots are present in urine, appeared. The method allows you to determine the pathology of the urethra and kidneys.

Men are referred for ultrasound if there are suspicions of diseases of the prostate gland and seminal vesicles. Women are recommended examination for ovarian pathologies. If there are signs of an inflammatory process in the genitourinary system, the doctor without fail writes out a referral for an ultrasound scan.

Ultrasound diagnostics is done in such cases:

air in urine
decrease in the portion of urine;
change in the shade of urine;
the presence of flakes and sediment in the urine, which are visible to the naked eye;
pain in the suprapubic area;
a constant feeling of fullness of the bladder, its incomplete emptying.

An ultrasound is prescribed for women and men with either. These studies make it possible to identify neoplasms in the bladder, foreign bodies in the organ, an inflammatory process, diverticula of the bladder walls,.

Ultrasound is an absolutely safe diagnostic method. It is allowed to be done even by pregnant women and babies. Therefore, you should not refuse such a procedure. In some cases, without it, it is difficult to make an accurate diagnosis.

What do you need to know to conduct research?

The result depends on the correct preparation for the diagnosis. Therefore, you need to know some rules that will help in conducting an ultrasound.

To achieve maximum visibility of the organ, it should be filled. Moreover, the volume should be at least 250 milliliters.

To do this, one hour before the procedure, you need to drink about two liters of liquid. Any drinks are allowed, except for carbonated, alcoholic and sweet.

Suitable tea, mineral water without gases, compote. If fullness cannot be achieved, the specialist will not be able to clearly see and analyze the structure and parameters of the organ. In this case, it is recommended to drink an additional 0.5-1 liter of water and wait a while.

Also, a few hours before the ultrasound, you can try not to go to the toilet. In this case, filling will occur in a physiological way. If it is necessary to carry out diagnostics urgently, there is no time to prepare in advance, then diuretics are indicated.

Sometimes it happens that the patient has already filled the bubble, and there is still some time before the examination. In this case, you can get out of the situation in one of two ways:

empty the organ partially, leaving a sufficient amount of urine for research. But not everyone is able to stop in time. Therefore, this method is not suitable for anyone;
After urinating, drink at least two liters of fluid. This will allow the volume of the urine reservoir to be completely filled by the appointed time.

Preparation for the procedure also includes following a certain diet. Before the diagnosis, it is recommended not to eat anything.

For a day, you need to stop taking foods that provoke gas formation. These are beans, cabbage, peas, corn and milk. On the day of the ultrasound, you should stop taking alcoholic beverages and cigarettes. Nicotine, which is contained in tobacco, can greatly distort the results of the survey.

It is important to follow all the recommendations and follow all the rules regarding preparation. The accuracy of the diagnosis and the effectiveness of the selection of a treatment regimen depend on how clearly the bubble is visible.

How is the procedure carried out?

So, how is an ultrasound of the bladder done in women and men? The procedure lasts no more than 15 minutes. The patient receives the results of ultrasound immediately after the diagnosis. Usually the examination is carried out in a transabdominal way.

The procedure looks like this:

the patient exposes the stomach (lifts clothes or undresses to the waist);
lies down on the couch;
the specialist applies a special contact gel to the abdomen. It is cool, so it may feel uncomfortable at first;
the sonologist begins to move the sensor over the body. The monitor displays an image of the bladder and nearby organs.

Sometimes a transrectal examination is also indicated. In this case, a special probe is inserted into the anus. The device scans the organ through the walls of the intestine. For women, ultrasound is also done through the vagina. All diagnostic options are absolutely safe for the patient's health. In addition, the procedure is painless. The only thing a person can complain about is the discomfort associated with an overflowing bladder.

In some situations, the doctor prescribes an ultrasound with the determination of residual urine. Then the study is carried out twice: the first time on a full bubble, the second - after it is emptied.

Transvaginal and transrectal methods have advantages over transabdominal examination. They allow you to display on the monitor a high-quality picture not only of the urinary tract, but also of the ovaries, uterus and other organs of the small pelvis.

How to understand the results of the study?

Only a doctor can understand the results of an ultrasound scan. The doctor studies and analyzes the shape and size of the organ, the thickness of the walls, the structure of the bladder. The location of the bladder relative to other organs is taken into account.

Ultrasound results

The study also allows you to determine the presence of neoplasms, stones. Ultrasound shows the inflammatory process, any changes in the functions and structure of the genitourinary system. Deciphering the survey data is carried out by the attending urologist by comparing the data obtained with the standard values. This takes into account symptoms and age.

Norm according to ultrasound

A healthy organ, according to the study, should have an echo-negative structure.

The normal bladder shape is ovoid on longitudinal images and rounded on transverse scans.

The bladder is symmetrical with clear and even contours. There should be nothing inside the body. Throughout the wall thickness is an average of 0.4 cm.

In a healthy state, the maximum speed of urine flow is 14.5 cm / s. If during the procedure the rest of the urine is assessed, this parameter normally does not exceed 50 milliliters. A larger number indicates the development of the inflammatory process, the presence of stones and neoplasms.

Ultrasound signs of organ inflammation

Cystitis is an inflammation of the bladder. Pathology can be acute or chronic.

In the acute form of inflammation at an early stage, the following echo pattern is observed:

there are small echogenic particles in different quantities. These inclusions are accumulations of epithelium and erythrocytes, salt crystals. The sonologist describes this picture with the words "sediment in the bubble." If the patient is in a supine position, the sediment will be localized near the back wall of the organ, and if in a standing position, closer to the front;
wall thickening. It is observed only at an advanced stage of the disease. With the progression of pathology, the contour of the wall becomes uneven.

Chronic cystitis on ultrasound is manifested by thickening of the walls of the bladder and the presence of sediment. In this case, specialists in the results of the examination write "flakes in the bladder." Blood clots during diagnosis are defined as hypo- or hyperechoic formations adhered to the mucosa of the organ. After some time, the clot liquefies, and anechoic areas with fuzzy edges appear.

Ultrasound is an accurate method to determine the presence of an inflammatory process. But in addition to this, this study is able to identify other pathologies.

Other pathology on ultrasound

In addition to the inflammatory process, ultrasound shows other diseases. For example:

too thickened wall of the bladder, ureterohydronephrosis indicate
thickening of the entire wall of the bladder and its trabecularity in children indicate obstruction of the urethra by its valve;
echogenic formations that are mobile can be caused by the presence of stones, a foreign body.
an enlarged organ is often found in injuries of the urethra, urolithiasis, prostate hyperplasia.

Ultrasound can detect any abnormalities in the functioning of the bladder. But much here depends on the qualifications of the sonologist. Therefore, you should contact experienced and competent professionals.