GENITOURINARY IMAGING 5 Flashcards

Question

What are the 3 types of Urethral injury?

Answer 1

* Types * Complex trauma with pelvic fractures * Type 1: * urethra intact but narrowed, stretched by periurethral hematoma * Type 2: * rupture above urogenital diaphragm; * extraperitoneal contrast, none in perineum; * partial rupture: contrast seen in bladder; * complete rupture: no contrast seen in bladder. * Type 3: * rupture below urogenital diaphragm; * contrast in extraperitoneal space and perineum * Soft tissue injury * Straddle injury: * injuries to penile or bulbous urethra

Answer 2

* Urethral Strictures and Filling Defects * Infection * **Gonococcal** * most common, 40% of all strictures in United States) * most common in bulbopenile urethra. * Imaging features: * beaded appearance * retrograde filling glands of Littré * **TB** * fistulas result in “watering can” perineum. * **Condylomata acuminata**: * human papilloma virus (HPV) infection * resulting in papillary filling defects on urethrogram * Trauma * **Instrumentation** * Transurethral resection of prostate [TURP]): * short, well-defined stricture in bulbomembranous urethra or penoscrotal junction * **Catheters**: * long, irregular, penoscrotal junction * **Injuries** * straddle injury: bulbous urethra; * pelvic fracture: prostatomembranous urethra * Tumor (Rare) * **Polyps**: * inflammatory, * transitional cell papilloma * **Malignant primaries**: * TCC, 15%; * SCC, 80%; often associated with history of stricture

Answer 3

Watering can perineum. Primary tuberculosis of urethra presenting as stricture urethra and watering can perineum: A rarity A young man presented with irritative lower urinary tract symptoms and multiple fistulae (watering can) in the perineum since 6 months. Micturating cystourethrogram and retrograde urethrogram was performed after 12 weeks following suprapubic cystostomy which showed bulbar urethral stricture with multiple urethrocutaneous fistulae. He underwent anastomotic urethroplasty and excision of the urethrocutaneous fistulae. Histopathology of the excised fistulous tract showed granulomatous pathology suggestive of tuberculosis. Antitubercular treatment was given for 9 months. The patient is voiding well at 12 months follow-up. https://www.urologyannals.com/article.asp?issn=0974-7796;year=2016;volume=8;issue=4;spage=493;epage=495;aulast=Prakash

Answer 4

A retrograde urethrogram opacifies multiple urethroperineal fistulas in a patient with a “watering can perineum” A watering can (Fig. 1) metaphorically describes the fluoroscopic demonstration of contrast opacifying multiple fistulas from the urethra to the perineum, as seen on voiding or retrograde urethrography (Fig. 2) [1]. In patients with this condition, urine exits through multiple perineal openings, hence the descriptive “watering can” [2]. The urethroperineal fistulas are sequelae of traumatic or chronic **inflammatory urethral strictures** [2]. Classically, this sign is associated with advanced **infection of the urethra and adjacent tissues, most commonly gonorrhea.** Associated paraurethral abscesses are frequent [1]. Other etiologies include **schistosomiasis, tuberculosis, and Crohn’s disease** [1, 2]. https://link.springer.com/article/10.1007/s00261-016-0710-2/figures/2

Answer 5

Condyloma acuminata. Retrograde urethrogram demonstrates multiple small filling defects in the anterior urethra. https://www.researchgate.net/figure/Condyloma-acuminata-Retrograde-urethrogram-demonstrates-multiple-small-filling-defects\_fig12\_8230962

Answer 6

Retrograde urethrogram (a, b) in a case of urethritis demonstrates long segment irregular urethral narrowing (long arrow) associated with Littre gland dilatation (short arrow) Urethral inflammatory diseases * **Gonococcal urethritis** is a sexually transmitted disease caused by Neisseria gonorrhoeae. It commonly presents with purulent discharge. It often leads to complications like **strictures** which can be severe. Non-gonococcal urethritis is most commonly caused by Chlamydia Trachomatis, and unlike gonococcal urethritis, is associated with only scanty non-purulent discharge. Complications are less severe as compared to gonococcal infections. **Chronic inflammatory urethritis may result in strictures (15%).** Other reported complications include periurethral abscess, pseudodiverticulum, fasciitis, and Fournier gangrene. **Urethro-perineal fistulas are more common with tuberculosis and schistosomiasis, although severe non-tuberculous infections may also result in fistulae.** **RUG in a case of urethritis typically demonstrates multifocal segmental or long segment irregular urethral narrowing.** **There may be opacification of the glands of Littre;** **visualization of the glands of Littre is quite specific for inflammatory urethritis.** There may be retrograde opacification of the Cowper’s duct, which is usually related to high voiding pressures due to the obstruction caused by the strictures, with resultant reflux into the Cowper’s ducts [2, 3] (Fig. 9). https://link.springer.com/article/10.1007/s00261-019-02356-x

Answer 7

Retrograde urethrogram in an adult male with genitourinary tuberculosis demonstrates a thimble bladder (asterisk), ureteric strictures (long arrow), and vesico-ureteric reflux (short arrow) Tuberculosis rarely involves the urethra and is usually a descending infection from the kidneys. The acute inflammatory phase is characterized by urethral discharge, and associated with prostatitis and epididymitis. The chronic stricturing stage presents with periurethral abscesses, perineal and scrotal fistulas, and a ‘watering can’ perineum. RUG may demonstrate prostato-cutaneous and urethro-cutaneous fistulas, in addition to a small-volume contracted bladder (“thimble bladder”), vesico-ureteric reflux, and ureteric strictures [22] (Fig. 10). https://link.springer.com/article/10.1007/s00261-019-02356-x

Answer 8

Retrograde urethrogram in a case of poor urinary stream. There is a high-grade stricture in the bulbar urethra (long arrow) with retrograde opacification of the Cowper’s duct (short arrow) https://link.springer.com/article/10.1007/s00261-019-02356-x

Answer 9

## Footnote Sphincter seen on US as a hypoechoic structure 1.0–1.3 cm in diameter Urethral sphincter (US) manifested as an omega shape on reconstructed axial planes. Its volume was calculated automatically after drawing along the outline of the urethral sphincter on serial axial planes. A, Cranial portion of the urethral sphincter. B and C, Middle portions of the urethral sphincter. D, Caudal portion of the urethral sphincter. IC indicates inner core. https://www.researchgate.net/figure/Urethral-sphincter-US-manifested-as-an-omega-shape-on-reconstructed-axial-planes-Its\_fig1\_321459511

Answer 10

Condyloma acuminata. Retrograde urethrogram demonstrates multiple small filling defects in the anterior urethra. https://www.researchgate.net/figure/Condyloma-acuminata-Retrograde-urethrogram-demonstrates-multiple-small-filling-defects\_fig12\_8230962

Answer 11

Female uretral diverticulum. In the proximal vagina exists oval hyperintense formation with regular margins that surrounding the urethra. During urination is appreciable filling of a diverticulum located on the back urethra, about 15 mm to external urethral orifice. Normal bladder and the opening of the bladder neck. Case courtesy of Dr Domenico Nicoletti, Radiopaedia.org, rID: 46630

Answer 12

Figure 23. Urethral diverticulum **(female prostate sign).** Sagittal fast spin-echo T2-weighted MR image demonstrates a **large diverticulum surrounding the urethra** (arrow), with a septum that results in an impression at the bladder base. B = bladder, S = pubic symphysis. https://pubs.rsna.org/doi/10.1148/rg.24si045504

Answer 13

Figure 25. Squamous cell carcinoma of the male urethra. Retrograde urethrogram reveals a segment of irregular stricture of the bulbous urethra. Figure 26a. Squamous cell carcinoma of the male urethra. (a) Sagittal fast spin-echo T2-weighted MR image demonstrates a focal mass (M) with low signal intensity in the corpus spongiosum (cs) at the penoscrotal junction. (b) Coronal MR image shows that the mass (large arrow) occupies the corpus spongiosum but has not invaded the corpora cavernosa (small arrows), which are intact. The patient underwent perineal partial urethrectomy. https://pubs.rsna.org/doi/10.1148/rg.24si045504

Answer 14

Figure 29. Urethral metastasis from prostate carcinoma. Retrograde urethrogram shows a segment of smooth extrinsic narrowing of the bulbous urethra. Note the skeletal metastases. https://pubs.rsna.org/doi/10.1148/rg.24si045504

Answer 15

Figure 53. Pie-in-the-sky bladder. Scout image of the pelvis, obtained after administration of contrast material for CT, demonstrates bilateral pubic rami fractures. The associated pelvic hematoma elevates the bladder, giving it the pie-in-the-sky appearance. There was an associated posterior urethral injury https://www.semanticscholar.org/paper/URORADIOLOGIC-SIGNS-S-247-Classic-Signs-in-1-CME-Dyer-Chen/62a3b8a1440bed14d6f2c581d2ed3b46e9fe1ff2/figure/34

Answer 16

Carcinoma * Incidence in females five times that in males * 90% in distal two-thirds; 70% are SCC * TCC is usually posterior

Answer 17

Female urethral diverticula usually acquired after infection, followed by obstruction of Skene glands. https://www.researchgate.net/figure/Urethral-diverticulum-arrow\_fig1\_43341879

Answer 18

* If nonobstructed, * 75% will be seen on postvoid IVP radiograph (intravenous Pyelogram) * 90% on voiding cystourethrogram, * remainder require double-balloon catheter positive-pressure urethrography A voiding cystourethrogram (VCUG) is an exam that takes images of the urinary system. The patient's bladder is filled with a liquid called contrast material. Then, images of the bladder and kidneys are taken as the bladder fills and also while the patient urinates (pees). Image = DBU The preoperative work-up of female urethral diverticula should provide the surgeon with maximum data regarding the anatomy and structure of the diverticulum. Preoperatively, the number of diverticula, as well as the location, size, configuration, and communication to the urethra need to be clearly depicted. The objective of this study was to compare the information gained by voiding cystourethrography (VCUG) and positive-pressure double-balloon urethrography (DBU), and to verify which imaging modality can better delineate the features of the diverticula. Twelve women with a presumptive clinical diagnosis of a urethral diverticulum underwent VCUG followed by DBU, and the radiological data from each modality were compared. In 4 of 12 patients (33.3%) VCUG completely failed in demonstrating the diverticulum, whereas DBU showed a large complex diverticulum in 2 patients and a distinct mid-urethral diverticulum in 2 patients. In the remaining 8 women (66.7%) VCUG delineated only the lower part of the diverticulum, whereas DBU depicted a large diverticulum extending beneath the bladder neck in 3 patients and multiple diverticula in 5 patients. The sensitivity of DBU and VCUG, in our series, was therefore 100 and 66.7%, respectively. The DBU supplied excellent documentation regarding the location, size, configuration, and communication of the diverticula to the urethra in every case, which markedly facilitated surgical excision of the diverticula in 9 of 12 patients. Three patients refused surgery and elected conservative treatment. In our experience, VCUG had a low sensitivity as a screening test for the diagnosis of female urethral diverticula, and failed to demonstrate properly the major structural characteristics of the diverticula, whereas DBU was highly sensitive as a diagnostic tool and supplied excellent anatomical delineation of the diverticula. https: //link.springer.com/article/10.1007%2Fs00330-002-1539-3 https: //www.ajronline.org/doi/pdf/10.2214/ajr.136.2.259

Answer 19

• ## Footnote Most common tumor is adenocarcinoma

Answer 20

Re female urethral diverticulae, how often do calculi occur? **Calculi, 5%–10%** **Fig. 2. Four smooth stones inside the urethral diverticulum.** https://www.sciencedirect.com/science/article/pii/S1879522614000578 UD was first reported 2 centuries ago by Hey,1 but until the invention of positive-pressure urethrography in 1952 by Davis and Cian,2 only a few cases were discovered. Up to 20% of patients may be asymptomatic; therefore, the true incidence is unclear because of missed diagnoses, although the accepted prevalence is about 0.5–6%.3 UD patients present with diverse symptoms, but the classical symptoms of “3Ds” are dysuria, dyspareunia, and postvoiding dribbling. Other symptoms associated with UD are frequency, urgency, hematuria, SUI, and persistent pyuria. The most important findings on physical examination are palpable vaginal mass and discharge after stripping. However, in a series with 46 female patients with urethral diverticula, the mean time from occurrence of symptoms to diagnosis is 5.2 years, despite the fact that 52% of those patients had palpable vaginal masses3—as in the case of our patient, who did not notice the vaginal mass but sought medical advice because of symptoms of SUI. Double balloon positive pressure urethrography is a good diagnostic tool but is not widely available. Compared to voiding cystourethrography and ultrasonography, high-resolution MRI has higher sensitivity and specificity, especially when differential diagnoses of urethral masses other than UD are present.4, 5 **UD presenting with urolithiasis is uncommon, with an incidence of 1–10%. The etiology may be deposition, stasis of infected urine, or stone migration. To our knowledge, studies seldom compare the diagnosis and management between UD with or without stones. Almost all UD with stone present with palpable hard vaginal masses, and patients tend to receive surgical excision rather than conservative treatment.**

GENITOURINARY IMAGING 5 Flashcards

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