Bladder multilithiasis across different clinical scenarios: Multimodality imaging findings, differential diagnosis, and complication assessment in 4 patients.

Bladder calculi are an uncommon form of urolithiasis in developed countries and are usually associated with urinary stasis, bladder outlet obstruction, chronic catheterization, recurrent urinary tract infections, and neurogenic bladder dysfunction. Although their diagnosis is often straightforward, bladder multilithiasis may present across heterogeneous clinical scenarios, ranging from uncomplicated intravesical stones to advanced neglected disease with obstructive complications. Imaging may also be relevant for differential diagnosis when intravesical calcified lesions or bladder wall calcifications are considered. We present a retrospective multimodality imaging case series of 4 male patients (68-80 years) with bladder multilithiasis evaluated with ultrasound, radiography, computed tomography (CT), and magnetic resonance imaging (MRI). Three patients underwent ultrasound as the first-line examination, demonstrating multiple dependent echogenic intravesical foci with posterior acoustic shadowing. CT was particularly valuable in the most advanced case, where massive bladder multilithiasis was associated with severe bilateral hydronephrosis, hydroureter, delayed urinary excretion, renal cortical thinning, and perivesical inflammatory changes. MRI, although not routinely used for stone detection, provided useful incidental anatomical correlation by showing persistent intravesical signal voids across multiple sequences. This case series highlights that the radiologic relevance of bladder multilithiasis extends beyond simple stone detection. Ultrasound remains a first-line modality, whereas CT is essential for evaluating stone obstructive complications. MRI has no primary role in routine stone work-up but may provide complementary information in selected pelvic examinations. Familiarity with imaging patterns, complication signs, and differential diagnoses may improve diagnostic confidence and support appropriate management, particularly in elderly or vulnerable patients with delayed presentation.