DOI: 10.1148/rg.24si045504
Imaging of Urethral Disease: A Pictorial Review1
Akira Kawashima, MD,
Carl M. Sandler, MD2,
Neil F. Wasserman, MD,
Andrew J. LeRoy, MD,
Bernard F. King, Jr, MD and
Stanford M. Goldman, MD
1 From the Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 (A.K., A.J.L., B.F.K.); the Department of Radiology, University of Texas-Houston Medical School, Houston, Tex (C.M.S., S.M.G.); and the Department of Radiology, Veterans Affairs Medical Center, University of Minnesota, Minneapolis (N.F.W.). Presented as an education exhibit at the 2003 RSNA scientific assembly. Received February 4, 2004; revision requested March 9 and received May 5; accepted May 11. All authors have no financial relationships to disclose. Address correspondence to A.K. (e-mail: kawashima.akira@mayo.edu).
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Figure 1. Retrograde urethrogram shows a focal smooth indentation (arrow) on the anterior aspect of the proximal bulbous urethra by the compressor nudae muscle. (Reprinted, with permission, from reference 3.)
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Figure 2a. Affect of patient positioning on the appearance of the urethra during retrograde urethrography. (a) Retrograde urethrogram obtained with the patient supine shows the bulbous urethra as a diverticulum-like outpouching. (b) On a retrograde urethrogram obtained after the patient was placed in a steep oblique position with the penis stretched, the penoscrotal junction and bulbous urethra have a normal appearance.
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Figure 2b. Affect of patient positioning on the appearance of the urethra during retrograde urethrography. (a) Retrograde urethrogram obtained with the patient supine shows the bulbous urethra as a diverticulum-like outpouching. (b) On a retrograde urethrogram obtained after the patient was placed in a steep oblique position with the penis stretched, the penoscrotal junction and bulbous urethra have a normal appearance.
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Figure 3. Cowper gland and duct. Urethrogram obtained with the patient in a steep oblique position shows the left Cowper gland (straight arrow) and duct (curved arrow).
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Figure 4a. Intact but stretched posterior urethra following blunt trauma (type I urethral injury). (a) Retrograde urethrogram reveals stretching of the posterior urethra. Diastasis of the pubic symphysis was diagnosed. (b) Drawing illustrates type I urethral injury.
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Figure 4b. Intact but stretched posterior urethra following blunt trauma (type I urethral injury). (a) Retrograde urethrogram reveals stretching of the posterior urethra. Diastasis of the pubic symphysis was diagnosed. (b) Drawing illustrates type I urethral injury.
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Figure 5a. Posterior urethral rupture above the intact urogenital diaphragm following blunt trauma (type II urethral injury). (a) Partial type II urethral injury. Retrograde urethrogram demonstrates contrast material extravasation confined to the area above the normal cone-shaped proximal portion of the bulbous urethra. However, contrast material flows through the prostatic urethral lumen into the bladder. Fracture of the left pubic ramus was diagnosed. (b) Complete type II urethral injury. Retrograde urethrogram shows a large amount of contrast material extravasation without flow into the prostatic urethra or bladder. Fracture of the right pubic ramus was diagnosed. (c) Drawing illustrates type II urethral injury.
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Figure 5b. Posterior urethral rupture above the intact urogenital diaphragm following blunt trauma (type II urethral injury). (a) Partial type II urethral injury. Retrograde urethrogram demonstrates contrast material extravasation confined to the area above the normal cone-shaped proximal portion of the bulbous urethra. However, contrast material flows through the prostatic urethral lumen into the bladder. Fracture of the left pubic ramus was diagnosed. (b) Complete type II urethral injury. Retrograde urethrogram shows a large amount of contrast material extravasation without flow into the prostatic urethra or bladder. Fracture of the right pubic ramus was diagnosed. (c) Drawing illustrates type II urethral injury.
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Figure 5c. Posterior urethral rupture above the intact urogenital diaphragm following blunt trauma (type II urethral injury). (a) Partial type II urethral injury. Retrograde urethrogram demonstrates contrast material extravasation confined to the area above the normal cone-shaped proximal portion of the bulbous urethra. However, contrast material flows through the prostatic urethral lumen into the bladder. Fracture of the left pubic ramus was diagnosed. (b) Complete type II urethral injury. Retrograde urethrogram shows a large amount of contrast material extravasation without flow into the prostatic urethra or bladder. Fracture of the right pubic ramus was diagnosed. (c) Drawing illustrates type II urethral injury.
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Figure 6a. Posterior urethral rupture extending through the urogenital diaphragm to involve the bulbous urethra following blunt trauma (type III urethral injury). (a) Retrograde urethrogram reveals contrast material extravasation at the membranous urethra (arrow). The contrast material extends below the urogenital diaphragm and surrounds the proximal bulbous urethra. (b) Drawing illustrates type III urethral injury.
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Figure 6b. Posterior urethral rupture extending through the urogenital diaphragm to involve the bulbous urethra following blunt trauma (type III urethral injury). (a) Retrograde urethrogram reveals contrast material extravasation at the membranous urethra (arrow). The contrast material extends below the urogenital diaphragm and surrounds the proximal bulbous urethra. (b) Drawing illustrates type III urethral injury.
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Figure 7a. Type IV urethral injury from blunt trauma. (a) Retrograde urethrogram reveals extraperitoneal periurethral contrast material extravasation at the bladder neck (arrow). The bladder is pear shaped, indicative of perivesical hematoma. Diastasis of the pubic symphysis was diagnosed. (b) Drawing illustrates type IV urethral injury.
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Figure 7b. Type IV urethral injury from blunt trauma. (a) Retrograde urethrogram reveals extraperitoneal periurethral contrast material extravasation at the bladder neck (arrow). The bladder is pear shaped, indicative of perivesical hematoma. Diastasis of the pubic symphysis was diagnosed. (b) Drawing illustrates type IV urethral injury.
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Figure 8a. (a) Retrograde urethrogram obtained in a 32-year-old man with bladder base injury following blunt trauma (type IVa urethral injury) shows extraperitoneal contrast material extravasation that extends from the elevated bladder base and surrounds the proximal urethra. Fracture of the superior and inferior pubic rami bilaterally was diagnosed. (b) Drawing illustrates type IVa urethral injury.
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Figure 8b. (a) Retrograde urethrogram obtained in a 32-year-old man with bladder base injury following blunt trauma (type IVa urethral injury) shows extraperitoneal contrast material extravasation that extends from the elevated bladder base and surrounds the proximal urethra. Fracture of the superior and inferior pubic rami bilaterally was diagnosed. (b) Drawing illustrates type IVa urethral injury.
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Figure 9a. Bladder neck urethral injury (type IV) in a 23-year-old woman. (a) Cystogram shows extraperitoneal contrast material extravasation (arrow) that extends from the bladder neck to the left underneath the balloon of a Foley catheter. (b) Cystogram obtained 2 minutes later shows progressive extraperitoneal contrast material extravasation. (c) Delayed contrast material-enhanced CT scan shows a laceration of the anterior wall of the urethra near the bladder neck (arrowhead), with extraperitoneal contrast material extravasation that extends to the diastatic pubic symphysis. Diastasis of the pubic symphysis and fracture of the left pubic ramus were diagnosed.
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Figure 9b. Bladder neck urethral injury (type IV) in a 23-year-old woman. (a) Cystogram shows extraperitoneal contrast material extravasation (arrow) that extends from the bladder neck to the left underneath the balloon of a Foley catheter. (b) Cystogram obtained 2 minutes later shows progressive extraperitoneal contrast material extravasation. (c) Delayed contrast material-enhanced CT scan shows a laceration of the anterior wall of the urethra near the bladder neck (arrowhead), with extraperitoneal contrast material extravasation that extends to the diastatic pubic symphysis. Diastasis of the pubic symphysis and fracture of the left pubic ramus were diagnosed.
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Figure 9c. Bladder neck urethral injury (type IV) in a 23-year-old woman. (a) Cystogram shows extraperitoneal contrast material extravasation (arrow) that extends from the bladder neck to the left underneath the balloon of a Foley catheter. (b) Cystogram obtained 2 minutes later shows progressive extraperitoneal contrast material extravasation. (c) Delayed contrast material-enhanced CT scan shows a laceration of the anterior wall of the urethra near the bladder neck (arrowhead), with extraperitoneal contrast material extravasation that extends to the diastatic pubic symphysis. Diastasis of the pubic symphysis and fracture of the left pubic ramus were diagnosed.
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Figure 10a. Anterior urethral injury following blunt trauma (type V urethral injury). (a) Retrograde urethrogram demonstrates complete disruption of the proximal bulbous urethra with extensive venous intravasation. (b) Drawing illustrates type V urethral injury.
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Figure 10b. Anterior urethral injury following blunt trauma (type V urethral injury). (a) Retrograde urethrogram demonstrates complete disruption of the proximal bulbous urethra with extensive venous intravasation. (b) Drawing illustrates type V urethral injury.
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Figure 11. Stricture following traumatic bulbomembranous urethral distraction injury. Combined voiding cystourethrogram-retrograde urethrogram depicts both the proximal and distal ends of the stricture (straight arrows), which allowed measurement of the length of the stricture. Some continuing extravasation is also present (curved arrow).
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Figure 12. Prostatic urethrorectal fistula in a patient who sustained both a urethral disruption and a rectal injury in an automobile accident. Voiding cystourethrogram demonstrates a distal prostatic urethrorectal fistula (white arrow); the urethral stricture (black arrow) is just distal to the fistula. R = rectum.
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Figure 13. Penetrating urethral injury from a gunshot wound. Retrograde urethrogram demonstrates contrast material extravasation from the penile urethra.
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Figure 14a. Urethral injury caused by insertion of a foreign body into the external meatus. (a) Conventional radiograph demonstrates a metallic pin (arrow) projected over the pubic bone. (b) Retrograde urethrogram obtained with use of a Brodny urethral clamp (b) demonstrates that the pin (arrow) lies in the posterior urethra and proximal bulbous urethra, with its distal end extending through the deformed bulbous urethral wall toward the perineum.
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Figure 14b. Urethral injury caused by insertion of a foreign body into the external meatus. (a) Conventional radiograph demonstrates a metallic pin (arrow) projected over the pubic bone. (b) Retrograde urethrogram obtained with use of a Brodny urethral clamp (b) demonstrates that the pin (arrow) lies in the posterior urethra and proximal bulbous urethra, with its distal end extending through the deformed bulbous urethral wall toward the perineum.
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Figure 15. Urethral injury in penile fracture. Retrograde urethrogram reveals contrast material extravasation in the penile urethra adjacent to the site of a corpus cavernosal injury.
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Figure 16a. Prostatic urethrorectal fistula following anterior low resection of the rectum and external beam radiation therapy for rectal carcinoma. Axial oblique (a) and sagittal (b) reformatted images generated from CT, performed with 2.5-mm-thick sections after the administration of contrast material into the bladder via a transurethral Foley catheter, demonstrate a prostatic urethrorectal fistula.
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Figure 16b. Prostatic urethrorectal fistula following anterior low resection of the rectum and external beam radiation therapy for rectal carcinoma. Axial oblique (a) and sagittal (b) reformatted images generated from CT, performed with 2.5-mm-thick sections after the administration of contrast material into the bladder via a transurethral Foley catheter, demonstrate a prostatic urethrorectal fistula.
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Figure 17. Urethral disruption after pancreas transplantation. Retrograde urethrogram demonstrates contrast material extravasation from urethral disruption at the bulbomembranous junction. The contrast material surrounds the proximal bulbous urethra.
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Figure 18. Gonococcal urethral stricture. Retrograde urethrogram reveals a segment of irregular, beaded narrowing in the distal bulbous urethra with opacification of the left Cowper duct (arrow).
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Figure 19. Gonococcal urethral stricture with periurethral abscess. Retrograde urethrogram shows a long segment of irregular, beaded narrowing in the bulbous urethra with opacification of the Littré glands (arrow). Note the irregular periurethral cavity originating from the ventral aspect of the bulbous urethra.
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Figure 20a. Stricture of the bulbous urethra with urethrocutaneous fistulas (watering can perineum). (a) Conventional radiograph reveals gas projected over the penile shaft. (b) Retrograde urethrogram reveals a long segment of irregular stricture involving the anterior urethra and membranous urethra with extensive fistulous tracts. Note the opacification of multiple Littré glands and the prostatic glands.
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Figure 20b. Stricture of the bulbous urethra with urethrocutaneous fistulas (watering can perineum). (a) Conventional radiograph reveals gas projected over the penile shaft. (b) Retrograde urethrogram reveals a long segment of irregular stricture involving the anterior urethra and membranous urethra with extensive fistulous tracts. Note the opacification of multiple Littré glands and the prostatic glands.
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Figure 21. Condyloma acuminata. Retrograde urethrogram demonstrates multiple small filling defects in the anterior urethra.
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Figure 22. Female urethral diverticulum. Postvoiding image obtained during excretory urography demonstrates a contrast material-filled urethral diverticulum (arrow).
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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.
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Figure 24a. Calculi associated with urethral stricture. (a) Conventional radiograph reveals faintly opaque stones projected over the penis (arrows). (b) Retrograde urethrogram demonstrates the stones (arrowhead) lying in a segment of anterior urethral stricture.
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Figure 24b. Calculi associated with urethral stricture. (a) Conventional radiograph reveals faintly opaque stones projected over the penis (arrows). (b) Retrograde urethrogram demonstrates the stones (arrowhead) lying in a segment of anterior urethral stricture.
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Figure 25. Squamous cell carcinoma of the male urethra. Retrograde urethrogram reveals a segment of irregular stricture of the bulbous urethra.
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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.
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Figure 26b. 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.
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Figure 27. Squamous cell carcinoma of the female urethra. Voiding cystourethrogram reveals irregular narrowing in the urethra with irregular sinus tracts.
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Figure 28a. High-grade adenocarcinoma of the female urethra in a patient whose uterus had been surgically removed previously. Contrast-enhanced CT scan (a) and sagittal reformatted image from CT data (b) reveal an inhomogeneous soft-tissue mass of the urethra (m). The immunophenotype was characteristic of lesions of müllerian origin.
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Figure 28b. High-grade adenocarcinoma of the female urethra in a patient whose uterus had been surgically removed previously. Contrast-enhanced CT scan (a) and sagittal reformatted image from CT data (b) reveal an inhomogeneous soft-tissue mass of the urethra (m). The immunophenotype was characteristic of lesions of müllerian origin.
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Figure 29. Urethral metastasis from prostate carcinoma. Retrograde urethrogram shows a segment of smooth extrinsic narrowing of the bulbous urethra. Note the skeletal metastases.
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Copyright © 2004 by the Radiological Society of North America.
