563

Sonographic Measurements
of the Normal Bladder Wall
Downloaded from www.ajronline.org by 109.99.92.189 on 05/19/18 from IP address 109.99.92.189. Copyright ARRS. For personal use only; all rights reserved

in Children
‘.

Signd Jequier1 The thickness of the bladder wall was measured sonographically in 410 children (1
Odette Rousseau day to 19 years old) and in 10 adults. None had complaints related to the urinary tract.
The bladder wall thickness varied mostly with the state of bladder filling and only
minimally with age and gender. The normal bladder wall had a mean thickness of 2.76
mm when the bladder is almost empty and 1.55 mm when ft is distended.
There is a linear relationship between bladder fullness and bladder wall thickness;
the upper limits are 3 and 5 mm for a full or empty bladder respectively.

The normal bladder wall is difficult to assess radiographicaily. A smooth bladder

contour on positive contrast studies and absence of elevation of its base during
voiding tend to indicate a normal bladder. A thickened bladder wall can often be
seen on IV urogram as a rim of soft tissue between the contrast material in the
bladder and the penvesical fat. CT also allows demonstration of a thickened bladder
wall [1J. However the normal bladder wall thickness is not well seen on radiographs,
and we were unable to find any radiographic data on normal bladder wall thickness
in children and its possible relation to age, sex, and state of bladder filling. On
sonography with appropriate gain setting, the bladder wall can be seen clearly in
most cases. The more echogenic mucosa can often be distinguished from the
more echolucent detrusor muscle. Having noted a “thick” bladder wall in some
children on chemotherapy or with urinary tract infection, neurogenic bladder,
posterior urethral valves, or hematuria, we recognized a need for normal values of
bladder wall thickness in order to delineate clearly abnormal vs normal measure-
ments.

Materials and Methods

The study included 41 0 children (age range, 1 day to i 9 years) and 10 adults (age range,
19 to 42 years). There were 33 neonates (19 males [M] and 14 females [F]); 57 children i
month to 1 year old (28 M, 29 F); 134 patients 1 to 6 years old (69 M, 65 F); 135 6 to 12
years old (69 M, 66 F); and 61 patients over 12 years of age (33 M, 28 F). A total of 218
males and 202 females. All came for a sonographic examination for reasons unrelated to the
urinary tract (e.g., abdominal pain, questionable mass, questionable congenital anomaly,
remote tumor, family screening) or for follow-up of a remote urinary tract problem (e.g., check
Received November 3, 1986; accepted after re- on renal growth 1 year after a urinary tract infection, remote reimplantation). Patients with
vision May 4, 1987.
urinary tract symptoms were exduded. All sonographic examinations were done with a real
Presented at the meeting of The Society for time ATL machine (Bothel, WA), with 7.5- or 5-MHz probes for children under 5 years of age.
Pediatric Radiology, Washington, DC, April 1986.
A Diasonics machine (Sunnyvale, CA) with a 5-MHz probe was used for older children and
I Both authors: Department of RadiOlOgy, The adults. The bladder wall thickness was measured on transverse and sagittal cuts, usually in
Montreal Children’s Hospital, 2300 Tupper St.,
Montreal, Quebec H3H 1P3, Canada. Address re-
an area of the bladder floor posterolateral to the trigone. Care was taken not to include the
print requests to S. Jequier. vagina, rectum, or peritoneal reflection of the bladder dome into the measurements. The
volume of the bladder was measured, assuming the bladder to be a sphere and calculating
MR 149563-566, September 1987
0361 -803X/87/1 493-0563 the radius (r) by adding sagittal, transverse, and anteroposterior diameter divided by 8 and
C American Roentgen Ray Society using the formula: V =4/3 r The calculated
. volume was compared with the normal bladder
 564 JEQUIER AND ROUSSEAU AJR:149, September 1987

capacity of the patient’s age group

as indicated by Koff [2]. The tionship between age and gender (p < .1 6), age and state of
bladder was considered empty it contained
when less than 10% of filling (p < .83), or gender and state of filling (p < .45).
its normal capacity, ±full with iO-25% of its capacity, full with 26-
The mean values of bladder wall thickness with normal
90%, and full++ when it was filled close to its capacity (Fig. 1).
variants according to age and state of bladder filling are
All recorded data on bladder wall thickness were analyzed statis-
indicated in Table 1.
tically as to their relation to the patient’s age, gender, and filling state
Downloaded from www.ajronline.org by 109.99.92.189 on 05/19/18 from IP address 109.99.92.189. Copyright ARRS. For personal use only; all rights reserved

of the bladder. A factorial analysis of variance [3] was done and a

graphic curve of the findings was obtained (Figs. 2-4).
Discussion

Only a few reports in the literature discuss the sonographic

Results
appearance of the normal bladder wall [4, 5]. A thickness of
The mean bladder wall thickness of all patients combined 5 mm was mentioned for normal adult bladder walls, but it
was 2.13 mm with a standard deviation of 0.59 mm. Calcu- appeared that the perivesical fat was included in these meas-
lating the mean bladder wall thickness of children of different urements.
age groups, we found a minimal increase of the thickness When structures as thin as the bladder wall are being
occurring with age. The mean bladder wall thickness was measured, several factors have to be considered. The axial
2.21 mm (SD, 0.54 mm) in 33 neonates; 1 .96 mm (SD, 0.6 or lateral resolution of the transducer becomes increasingly
mm) in 57 children, ages 1 month to 1 year; 2.09 mm (SD, important. As the axial resolution is better than the lateral
0.61 mm) in 1 34 children, ages 1 to 6 years; 2.23 mm (SD, resolution, measurements of the wall should be made at the
0.56 mm) in 1 35 children, ages 6 to 1 2 years; and 2.20 mm bladder floor using the correct transducer. We found the 7.5-
(SD, 0.62 mm) in 61 patients who were older than 1 2 years. or 5-MHz sufficient for all cases. Using a 3.5-MHz probe for
This difference is barely significant (p < .04) (Fig. 2). transrectal sonography, Perkash and Friedland [6] could not
Grouping the patients according to gender, we found that evaluate the bladder wall. It is best to measure within the
boys tended to have a minimally thicker bladder wall (mean, focal zone of the transducer, which may be difficult in a
2.1 9 mm) than girls (mean, 2.08 mm). This difference was not distended bladder. The bladder wall may not be seen at all
statistically significant (p .07) (Fig. 3).
< without careful gain setting, and the measurements are op-
Measuring and comparing the bladder wall thickness of erator dependent.
empty, ±fuIl, full, and distended (full++) bladders, we found The site of measurement is important. At the dome of the
a highly significant relation between the degree of bladder bladder the pentoneal reflection will add 1 mm to the apparent
distension and wall thickness (p < .0001). Indeed the mean wall thickness. The wall of the vagina or rectum can be
bladder wall thickness of an empty bladder was 2.76 mm (SD, included mistakenly within the measurement when one is
0.58 mm; maximum, 4.5 mm; minimum, 2 mm) and decreased measuring at the bladder floor. The posterior inferior wall of
to a mean of 1 .55 mm (SD, 0.56 mm; maximum, 3 mm; the bladder on sagittal views and the bladder floor lateral to
minimum, 1 mm) in a distended bladder. Nomogram with the trigone on transverse views are optimal sites for meas-
estimated percentiles is shown in Fig. 4. urements.
Assessing group interaction, we found no significant rela- It is difficult to see the anterior bladder wall because of the

Fig. 1.-Transverse bladder sonograms: arrows outline bladder wall.

A, “Empty” bladder in a 1-month-old boy with hydroceles. Wall is 3 mm thick.
B, Bladder ±full in a 7-year-old boy with remote renal contusion. Wall is 2.9 mm thick.
C, Bladder full. Close-up view in a 9-year-old boy with lactose intolerance. Wall is 1.4 mm thick.
 AJR:149, September 1987 BLADDER SONOGRAPHY 565

WALL ThICKNESS WALL THICKNESS

fly”
Downloaded from www.ajronline.org by 109.99.92.189 on 05/19/18 from IP address 109.99.92.189. Copyright ARRS. For personal use only; all rights reserved

3 3

2 2

0 NEWBORN

1 0 IM-IY
1

V 6Y-12Y 95 % C.l.= 0.16 Ii

S > 12Y 95 % C.I.= 0.13

0’ I I I I
I I I
+
Empty + ++

+
Empty + ++
BLADDER FILLING
BLADDER FILLING
Fig. 2.-Nomogram of bladder wall thickness according to Fig. 3.-Nomogram of bladder wall thickness according to
age. See Table I for definitions of bladder fullness. c. i. = gender. See Table 1 for definitions of bladder fullness. c. I. =
confidence interval. confidence interval.

WALL degrees of filling leads to errors in the calculation of the

THICKNESS
bladder volume. The normal bladder gets indented by the
surrounding organs (bowel, uterus). It adapts to the bladder
mm
floor. When the bladder is empty, the transverse diameter is
5 n= 105 120 167 28
usually larger than the anteroposterior or sagittal diameter.
With progressive filling, it becomes more spherical. Any pro-
posed method of volume measurement is therefore inaccurate
4 0
as none applies for both full and empty bladders. The method
n of Hakenberg et al. [7], for instance, has an error factor of ±
, 25% and is recommended for small volumes only. Orgaz et
al. [8] advocate an empirical formula for sonographic bladder
:
50 volume calculations: vol. = 12.56 x radius x height. They
0-_0 also stress the impossibility of an accurate measurement of
I 00
an organ that changes its shape with filling. Their maximum
5 error of a calculated volume compared with a known volume
0 I I I - by retrograde filling was 31.8%.
Empty ± + ++ We compared our data on bladder volume with those of
Hakenberg et al. [7], who calculated the volume as the
BLADDER FILLING product of sagittal maximum diameter H X transverse diam-
Fig. 4.-Nomogram of bladder wall thickness according to
state of filling. n = number of patients in each group. 5, 50, 95 eter W x [(anteroposterior diameter on transverse cut +
= estimated percentiles. See Table I for definitions of bladder anteroposterior diameter on sagittal cut) #{247}2]x 0.6. In general,
fullness.
our method of volume measurement tends to underestimate
slightly the amount of fluid in the bladder.
ring-down artifact of the anterior abdominal wall; therefore, Recognizing the limitations of this study, we conclude that
one cannot obtain a true anteroposterior diameter and must the bladder wall thickness in children is independent of age
estimate bladder volume. Another source of inaccuracy of and gender but varies significantly with the state of bladder
this study is the electronic calipers of the ATL machine filling. Regardless of the patient’s age and gender, the wall of
indicating full millimeters only. A bladder wall measured to be a normal empty bladder should measure less than 5 mm and
2 mm thick could therefore range from 1 .6 to 2.4 mm. that of a well distended bladder should measure less than
In addition, the variable shape of the bladder with different 3mm.
 566 JEQUIER AND ROUSSEAU AJR:149, September1987

TABLE 1: Mean Bladder Wall Thickness in mm (±SD) According to Age and State of
Bladder Filling

Age Empty ±Full Full Full++

<1 mo. 2.62 ± 0.51 (8) 2.10 ± 0.31 (10) 1.92 ± 0.51 (12) 1.67 ± 0.57(3)
1 mo.-1 yr. 2.61 ± 0.62 (14) 1 .93 ± 0.27 (1 4) 1 .65 ± 0.47 (27) 2 (2)
1-6 yr. 2.76 0.73 (29) 2.06 ± 0.35 (39) 1 .87 0.37 (57) 1.44 0.52(9)
Downloaded from www.ajronline.org by 109.99.92.189 on 05/19/18 from IP address 109.99.92.189. Copyright ARRS. For personal use only; all rights reserved

± ± ±

6-12 yr. 2.82 ± 0.46 (36) 2.17 ± 0.32 (43) 1 .97 ± 0.42 (49) 1.43 ± 0.53(7)
>12 yr. 2.83 ± 0.51 (18) 2.18 ± 0.32 (14) 1.89 ± 0.39 (22) 1.64 ± 0.74(7)

Note-Numbers in parentheses indicate numbers of patients in each group. mo. = month; yr. = year. Empty =

of its normal capacity; ±full

bladder contained <10#{176}k = bladdercontained 10-25% of capacity; full = bladder contained
26-90% of capacity; full++ = bladder contained >90% of capacity.

ACKNOWLEDGMENTS sity of California Press, 1985

4. singer D, ltzchak V. Fischelovitch V. LJtrasonographic assessment of
We thank Thierry Petitjean-Roget for statistical analysis, Isabell bladder tumors. II. Iinical staging. J
Urol 1981;126:34-36
Webb for secretarial assistance, Denis Gigu#{232}refor the graphics, and 5. Abu-Vousef MM, Narayana AS, Brown RC, Franken EA Jr. Lhinary bladder
Michel Leblanc for the illustrations. tumors studied by cystosonography. Radiology 1984;153:227-231
6. Perkash I. Friedland GW. Transrectal sonographic urodynarnics. In: Hricak
H, ad. Clinics in diagnostic ultrasound, vol. 18. Genito-urinary ultrasound.
REFERENCES New York: Churchill LMngstone, 1986:181-193
7. Hakenberg OW, RyaN RL, Langlois L, Marshall yR. The estimation of
1 . Korobkin M, CaIIen PW, Fish AE. CT of the pelvic region. Advances in bladder volume by sonocystography. J Urol 1983;130:249-251
uroradiology. RadiOI Clin North Am 1979;xll(2):313-319 8. Orgaz RE, Gomez AZ. Ramirez CT, Torres JLM. Applications of bladder
2. Koff SA. Estimating bladder capacity in children. Urology 1983;21 :248 ultrasonography. I. Bladder content and residue. J Urol 1981;125:
3. BMDP Statistical Package 1985. Program BMDP4F. Los Angeles: Univer- 174-176