DOI: 10.1148/rg.253045067
RadioGraphics 2005;25:749-761
© RSNA, 2005
Cross-sectional Imaging of the Female Urethra: Technique and Results1
Srinivasa R. Prasad, MD,
Christine O. Menias, MD,
Vamsi R. Narra, MD,
William D. Middleton, MD,
Govind Mukundan, MD,
Nayer Samadi, RMDS,
Jay P. Heiken, MD and
Cary L. Siegel, MD
1 From the Department of Radiology, University of Texas Health Science Center, 7703 Floyd Curl Dr, San Antonio, TX 78229 (S.R.P.); and the Department of Radiology, Mallinckrodt Institute of Radiology, St Louis, Mo (C.O.M., V.R.N., W.D.M., G.M., N.S., J.P.H., C.L.S.). Recipient of a Certificate of Merit award and an Excellence in Design award at the 2002 RSNA Scientific Assembly. Received April 12, 2004; revision requested July 27 and received October 19; accepted October 20. All authors have no financial relationships to disclose.
Address correspondence to S.R.P. (e-mail: prasads{at}uthscsa.edu).
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Abstract
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Clinical assessment of women with urethral symptoms is difficult, necessitating further evaluation with imaging. Urethrography provides limited information on luminal abnormalities of the urethra. Recent advances in ultrasound (US) and magnetic resonance (MR) imaging have dramatically improved evaluation of the female urethra, clarifying findings at physical examination and providing accurate road maps for surgeons. High-resolution transvaginal US, transperineal US, and transurethral US are reliable techniques for diagnosis and characterization of urethral abnormalities. High-resolution multiplanar MR imaging with phased-array pelvic and endovaginal coils demonstrates the urethral anatomy in greater detail. In women with urethral diverticula, US and MR imaging demonstrate the number of diverticula and the location, size, configuration, and possible contents of the sac. Most important, the position of the neck of the diverticulum may be identified for the surgeon. Imaging features do not allow differentiation between histologic subtypes of urethral carcinoma; the diagnosis is established with histopathologic examination. Periurethral cysts do not communicate with the urethra and therefore can often be differentiated from urethral diverticula at endocavitary MR imaging. High-resolution multiplanar US and MR imaging allow comprehensive evaluation of abnormalities of the female urethra.
© RSNA, 2005
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LEARNING OBJECTIVES FOR TEST 5
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After reading this article and taking the test, the reader will be able to:
- Discuss the cross-sectional imaging techniques for evaluating women with urethral symptoms.
- Describe the findings of a variety of urethral abnormalities at high-resolution transvaginal, transperineal, or urethral sonography and endocavitary MR imaging.
- Identify various urethral and periurethral abnormalities at cross-sectional imaging.
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Introduction
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Clinical evaluation of women presenting with urethral symptoms is often difficult (1,2). Imaging is frequently performed in patients with urethral symptoms and signs such as dysuria, dyspareunia, dribbling, recurrent urinary tract infections, a urethral mass, or urethral obstruction (1,2). A wide variety of diagnostic tests are available for evaluating the female urethra. Voiding cystourethrography (VCUG) and double-balloon urethrography often serve as the initial imaging test. However, these tests allow evaluation of only abnormalities that are connected to the urethral lumen.
Recent advances in ultrasound (US) and magnetic resonance (MR) imaging have dramatically improved evaluation of the female urethra, clarifying findings at physical examination and providing an accurate road map to surgeons. Several US techniques have been employed in the evaluation of the female urethra. High-resolution transvaginal sonography, transperineal sonography, and transurethral sonography are all reliable diagnostic tests in the evaluation of urethral abnormalities (3–5). High-resolution, multiplanar MR imaging with phased-array pelvic and endovaginal coils depicts the urethral anatomy in greater detail (6–8). Some centers prefer transrectal sonography and MR imaging to evaluate the female urethra (9,10).
In this article, we discuss and illustrate use of high-resolution sonography and MR imaging to demonstrate abnormalities of the female urethra and periurethral tissues. Such abnormalities include urethral diverticula, urethral neoplasms, postoperative changes, and periurethral cysts and cystic lesions.
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Normal Anatomy and Histologic Features
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The female urethra is a 4-cm-long tubular conduit that courses obliquely anteroinferiorly from the internal urethral meatus through the urogenital diaphragm to the external urethral meatus (Fig 1). Multiple paraurethral glands of Skene (derivatives of the urogenital sinus and homologous to the prostate in males) secrete mucus material that provides urethral lubrication during sexual intercourse. There are approximately six to 30 paraurethral ducts that drain into the distal urethral lumen (Fig 2). The proximal one-third of the urethra is lined by transitional epithelium, and the distal two-thirds are lined by stratified squamous epithelium (11). A striated muscle sphincter at the orifice reinforces the two concentric layers of smooth muscle. Urethropelvic ligaments provide structural support to the urethra (Fig 1).
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Figure 1. Normal cross-sectional anatomy of the urethra. Coronal cross-sectional diagram shows the relationship of the urethra to the vagina and rectum. The urethropelvic ligaments provide structural support to the urethra.
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Imaging Techniques
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Sonography is usually performed by using a broadband 5–10-MHz linear array for transperineal scanning and a broadband 5–9-MHz curved array for transvaginal scanning. For transperineal sonography, the transducer is placed on the perineum directly between the labia. Transvaginal sonography is performed with the transvaginal probe placed approximately 1–2 cm in the vaginal introitus. Gray-scale images are obtained in both sagittal and coronal planes, and color Doppler imaging is employed with both techniques (Fig 3a, 3b). Some centers prefer transrectal sonography to evaluate the urethra on the premise that a transducer in the rectum will not compress or distort the urethra (10). Endourethral sonography is performed with a 12.5-MHz, 6.2-F, catheter-based transducer on an intravascular US machine. Serial axial images are obtained as the urethral catheter is slowly withdrawn from the bladder neck to the urethral orifice (Fig 3c). Disadvantages of this technique include the need for a dedicated expensive intravascular US machine, a single-use urethral catheter, and limited field of view.
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Figure 3a. Urethral anatomy at sonography. (a, b) Sagittal transvaginal (a) and transperineal (b) sonograms show normal urethral anatomy. Straight arrow = urethra, curved arrow = bladder. (c) Transurethral sonogram obtained by using a catheter-based high-frequency transducer shows a urethral diverticulum (arrow). Note the neck of the diverticulum (arrowhead). (Fig 3c reprinted, with permission, from reference 4.)
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Figure 3b. Urethral anatomy at sonography. (a, b) Sagittal transvaginal (a) and transperineal (b) sonograms show normal urethral anatomy. Straight arrow = urethra, curved arrow = bladder. (c) Transurethral sonogram obtained by using a catheter-based high-frequency transducer shows a urethral diverticulum (arrow). Note the neck of the diverticulum (arrowhead). (Fig 3c reprinted, with permission, from reference 4.)
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Figure 3c. Urethral anatomy at sonography. (a, b) Sagittal transvaginal (a) and transperineal (b) sonograms show normal urethral anatomy. Straight arrow = urethra, curved arrow = bladder. (c) Transurethral sonogram obtained by using a catheter-based high-frequency transducer shows a urethral diverticulum (arrow). Note the neck of the diverticulum (arrowhead). (Fig 3c reprinted, with permission, from reference 4.)
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Transvaginal MR imaging is performed after intramuscular injection of 1 mg of glucagon and placement of a disposable endovaginal coil. Glucagon is used to prevent rectal contractions. Our technique includes axial and sagittal fast spin-echo T2-weighted imaging (repetition time msec/ echo time msec = 3,000/85, echo train length of eight, three signals acquired, bandwidth = 15.63 kHz, matrix = 256 x 192) and unenhanced and gadolinium-enhanced axial spin-echo T1-weighted imaging (450/21, two signals acquired, matrix = 256 x 192). Images are obtained by using a small field of view of 10–12 cm, extended dynamic range, variable bandwidth, flow compensation, and no phase wrap. Postgadolinium images permit superior tissue contrast and are considered most useful in evaluating the urethra and periurethral tissues (Fig 4). Certain centers perform transrectal MR imaging for urethral assessment. At our institution, transvaginal imaging is preferred over transrectal imaging because of increased patient acceptance.
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Figure 4. Normal urethral anatomy at endovaginal MR imaging. Axial gadolinium-enhanced T1-weighted three-dimensional gradient-echo image shows a normal urethra (arrow). Note the endovaginal coil (C) and pubourethral ligaments (arrowhead).
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The role of computed tomography (CT) in the evaluation of the female urethra is limited. CT can reliably demonstrate urethral calculi. Certain urethral abnormalities may be incidentally discovered at CT performed for other abdominopelvic indications. However, CT has limited utility in the characterization of female urethral abnormalities. Some centers use CT for locoregional staging of urethral carcinomas. At our institution, abdominopelvic staging of urethral malignancies is performed with MR imaging concurrently with the transvaginal MR imaging examination.
The advantages and disadvantages of different imaging modalities in the evaluation of urethral and periurethral disorders are summarized in Tables 1 and 2.
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Urethral Diverticula
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Urethral diverticula occur in up to 6% of women (2). The classic presentation includes postvoiding dribbling, urethral pain, and dyspareunia. At physical examination, a tender periurethral mass with expression of fluid or pus from the urethra may be seen (2). Many patients do not demonstrate the classic presentation and may present with nonspecific, refractory lower urinary tract symptoms (2). Diverticula are hypothesized to result from glandular dilatation secondary to inflammation of the paraurethral glands and subsequent rupture into the urethra (12,13). Escherichia coli, gonococcus, and Chlamydia are the common implicated organisms. Histologically, diverticula consist predominantly of fibrous tissue without an epithelial lining. Transitional or squamous lining epithelium may occasionally be present.
Urethral diverticula occur most frequently on the posterolateral wall of the midurethra (13). Multiplanar US and MR imaging allow comprehensive evaluation of the number of diverticula and the location, size, configuration, and possible content of the sac (Figs 5, 6). Most important, the position of the neck of the diverticulum may be identified for the surgeon (Fig 7). All of these features are necessary for an accurate surgical road map but are difficult or impossible to assess at conventional urethrography. Resection of the neck is important to prevent recurrence. According to Porpiglia et al (14), the most important risk factors for postoperative complications are delayed diagnosis, diverticular size more than 4 cm, and horseshoe configuration of the diverticulum.
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Figure 5. Complex urethral diverticulum in a 48-year-old woman with urethral syndrome. Coronal transvaginal sonogram shows a complex multicompartment diverticulum (arrows). (Reprinted, with permission, from reference 4.)
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Figure 7. Complex circumferential urethral diverticulum. Axial gadolinium-enhanced fat-saturated T1-weighted MR image shows a circumferential diverticulum (arrows) with two necks at the 5- and 9-o’clock positions (arrowheads). This type of diverticulum is difficult to completely excise and prone to recurrence.
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Transvaginal or endoscopic diverticulectomy is the treatment of choice for urethral diverticula; complete enucleation requires accurate identification of the diverticular configuration and the neck.
Complications of a urethral diverticulum are infection, calculus formation, and development of a neoplasm (15,16) (Figs 8, 9). Chronic urinary stasis and superimposed infection in a diverticulum predispose to calculus formation, which occurs in approximately 5% of urethral diverticula (16,17). At US, calculi appear as echogenic foci with distinct acoustic shadowing (Fig 9a). At MR imaging, they appear hypointense on both T1-and T2-weighted images (Fig 9b).
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Figure 9a. (a) Coronal transvaginal sonogram of a 47-year-old woman with a urethral mass shows calculi (arrowhead) within a diverticulum (arrow). (b) Axial endovaginal T2-weighted MR image of a 52-year-old woman with dysuria shows calculi (arrowhead) within a complex diverticulum (arrow).
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Figure 9b. (a) Coronal transvaginal sonogram of a 47-year-old woman with a urethral mass shows calculi (arrowhead) within a diverticulum (arrow). (b) Axial endovaginal T2-weighted MR image of a 52-year-old woman with dysuria shows calculi (arrowhead) within a complex diverticulum (arrow).
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Both benign and malignant tumors may develop in a urethral diverticulum (18–20). Fewer than 100 cases of malignant tumors developing in a female urethral diverticulum have been reported (21). Adenocarcinoma is the most common malignancy, occurring in 60% of cases (21) (Fig 10). Squamous cell carcinoma accounts for 12% of tumors. Because the presentation is insidious, diagnosis is often delayed. Carcinoma arising in a urethral diverticulum is usually of high stage and is often treated aggressively (19).
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Figure 10. Malignancy within a urethral diverticulum. Axial gadolinium-enhanced endovaginal fat-saturated T1-weighted gradient-echo MR image shows a large polypoid adenocarcinoma (straight arrow) within a urethral diverticulum (curved arrow).
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Urethral Neoplasms
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Urethral neoplasms are uncommon. Patients may present with a mass, dyspareunia, dysuria, hematuria, or partial obstruction. A hard palpable mass and urethral bleeding should raise the index of suspicion for malignancy. Leiomyoma and nephrogenic adenoma represent examples of benign tumors. Malignant neoplasms include squamous cell carcinoma, transitional cell carcinoma, and adenocarcinoma.
Urethral tumors are primarily treated with surgical excision. Treatment of urethral malignancies is dependent on the tumor stage; a multimodality approach involving surgery, radiation oncology, and chemotherapy is being increasingly favored.
Leiomyoma
Leiomyoma is an uncommon benign urethral neoplasm that arises from the smooth muscle. Approximately 50 cases have been reported. US and MR imaging are valuable in defining the site and extent of the tumor. At US, leiomyoma appears as a well-defined, homogeneous tumor with increased vascularity (Fig 11). At MR imaging, leiomyoma appears iso- to hypointense (relative to muscle) on T1-weighted images, is hyperintense (to muscle) on T2-weighted images, and shows uniform contrast enhancement (22) (Fig 12).
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Figure 11a. Urethral leiomyoma. (a) Sagittal transvaginal sonogram shows a large urethral mass with uniform echotexture. U = urethra. (b) Coronal transvaginal sonogram shows that the mass has marked vascularity.
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Figure 11b. Urethral leiomyoma. (a) Sagittal transvaginal sonogram shows a large urethral mass with uniform echotexture. U = urethra. (b) Coronal transvaginal sonogram shows that the mass has marked vascularity.
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Urethral Carcinomas
Urethral carcinomas are rare, representing less than 0.02% of all malignancies in women. They typically occur in postmenopausal women. Common risk factors include human papilloma virus infection and urethral diverticula (11,23). They may manifest as exophytic, papillary, and fungating tumors or as infiltrative tumors. Squamous cell carcinoma is the most common histologic subtype of female urethral malignancy. However, adenocarcinoma is the commonest malignancy complicating a urethral diverticulum. Imaging features cannot allow distinction between histologic subtypes of urethral carcinomas; the diagnosis is established with histopathologic examination. Also, markedly inflamed diverticula can be mistaken for a neoplasm at imaging. The prognosis is relatively poor, with up to 50% of women presenting with metastatic disease. The prognosis is more dependent on the tumor location and stage of the disease than the histologic subtype and grade of differentiation (11). Tumors limited to the distal third of the urethra (also called anterior tumors) have a better prognosis than tumors of the proximal urethra. Surgical resection is the treatment of choice, with overall survival rates of approximately 50% for distal urethral tumors and 6% for proximal tumors (11).
Squamous Cell Carcinoma.—
Squamous cell carcinoma is the commonest malignant neoplasm of the female urethra, accounting for 70% of cases (11). It commonly involves the distal urethra and the meatus. Most tumors are moderately differentiated and focally keratinizing. They may appear as either lobulated, exophytic lesions or deeply infiltrating lesions. At US, tumors appear as hypo- to isoechoic, irregularly marginated lesions (Fig 13). At MR imaging, they are hypointense on T2-weighted images and show heterogeneous contrast enhancement.
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Figure 13a. Biopsy-proved squamous cell carcinoma in a patient with a urethral mass. (a) Sagittal transvaginal sonogram shows a large, lobulated, isoechoic urethral mass. Arrow = bladder. (b) Transperineal sonogram shows that the mass has increased vascularity.
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Figure 13b. Biopsy-proved squamous cell carcinoma in a patient with a urethral mass. (a) Sagittal transvaginal sonogram shows a large, lobulated, isoechoic urethral mass. Arrow = bladder. (b) Transperineal sonogram shows that the mass has increased vascularity.
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Transitional Cell Carcinoma.—
Transitional cell carcinoma is the second most common urethral carcinoma, accounting for 20% of cases (11). It commonly involves the proximal urethra. Tumors may be associated with human papilloma virus infection (23). At MR imaging, they appear as lobulated masses that are iso- to hypointense on both T1- and T2-weighted images and demonstrate heterogeneous contrast enhancement (Fig 14).
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Figure 14. Transitional cell carcinoma within a urethral diverticulum. Axial gadolinium-enhanced fat-saturated T1-weighted gradient-echo MR image shows a serpiginous, heterogeneously enhancing mass (curved arrow) within a complex urethral diverticulum (straight arrow).
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Adenocarcinoma.—
Urethral adenocarcinoma is an uncommon malignancy, representing 10% of urethral carcinomas, but accounts for 60% of cancers that develop in a diverticulum (21). In contradistinction to squamous and transitional cell carcinomas, adenocarcinomas are not associated with human papilloma virus infection (11,23). Adenocarcinomas at the urethrovulvar junction have their origin in the Skene glands. Clear cell adenocarcinoma is a distinctive subtype that frequently arises in a diverticulum (11,19). This tumor demonstrates characteristic histologic features such as similarity to nephrogenic adenoma and immunostaining for prostate-specific antigen and prostatic acid phosphatase (11). This tumor resembles müllerian-type carcinoma of the female genital tract and is postulated to have a mesonephric origin (11).
At imaging, adenocarcinoma appears as a heterogeneously enhancing, exophytic tumor commonly located in a diverticulum (Fig 10). At MR imaging, it shows high signal intensity on T2-weighted images with a low-intensity peripheral rim and variable contrast enhancement (24) (Fig 15).
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Figure 15. Urethral adenocarcinoma. Coronal high-resolution endovaginal T2-weighted MR image shows a large, concentric urethral mass with significant peri-urethral extension (arrow).
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Secondary Tumors of the Urethra
Secondary tumors of the urethra are rare; contiguous extension of malignancy from adjacent organs such as the bladder, cervix, vagina, and anus may involve the urethra (13,25) (Fig 16). Hematogenous spread of genitourinary tumors to the urethra occurs rarely.
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Figure 16. Urethral spread of an anal adenocarcinoma. Axial gadolinium-enhanced fat-saturated T1-weighted gradient-echo MR image shows an ill-defined lesion (arrow) contiguous to the urethra.
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Postoperative Urethra
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It is important to recognize postoperative changes in the urethra and periurethral tissues and to differentiate these changes from primary urethral disease. Periurethral injection of collagen for urinary stress incontinence can give rise to an echogenic lesion that may be mistaken for a neoplasm (26) (Fig 17). Periurethral calcification can be seen in patients with suture granulomas and in patients who have undergone Durasphere injection (Fig 18). Durasphere (Carbon Medical Technologies, St Paul, Minn) is an injectable agent for stress urinary incontinence that consists of carbon-coated beads suspended in a water-based carrier gel containing ß-glucan (27). Suture granulomas that develop as a hypersensitivity reaction by the host to suture material may appear as discrete, echogenic foci (Fig 19).
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Figure 17. Changes due to collagen injection. Coronal transvaginal sonogram shows paraurethral echogenic lesions from injected collagen (cursors). Collagen is injected into the periurethral tissues in patients with stress urinary incontinence.
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Figure 18. Changes due to injection of carbon-coated beads. Sagittal transvaginal sonogram shows periurethral calcifications (arrow), which were due to injection of carbon-coated beads for treatment of stress urinary incontinence.
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Periurethral Cysts and Cystic Lesions
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Ectopic ureters and ureteroceles that insert in or adjacent to the urethra may be mistaken for urethral diverticula or periurethral cysts. They can insert anywhere between the bladder neck and the external urethral orifice (28,29) (Fig 20). Patients with ectopic ureters or ureteroceles may present with recurrent urinary tract infections or longstanding urinary incontinence (28).
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Figure 20. Ectopic ureter in a woman with duplication of the collecting system and ureter who presented with urinary incontinence. Sagittal transvaginal color Doppler sonogram shows an ectopic ureter (straight arrow) emptying into the urinary bladder (curved arrow).
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Periurethral cysts include vaginal cysts (müllerian cyst, Gartner duct cyst, epidermal inclusion cyst), Skene duct cysts, Bartholin gland cysts, and perineal/vulvovaginal endometriomas. They frequently occur near the distal urethra (Fig 21). Periurethral cysts do not communicate with the urethra and therefore can often be differentiated from urethral diverticula at endocavitary MR imaging. Complications of periurethral cysts include infection, hemorrhage, and rupture. The features of various periurethral cysts are summarized in Table 3.
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Figure 21. Gartner cyst. Sagittal transperineal sonogram shows a cyst with uniform internal echoes in the region of the distal urethra. Note that most diverticula occur in the midurethra. Arrow = urethra.
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Vaginal cysts may be congenital (embryologic) or acquired. Embryologic cysts include müllerian cysts (the commonest type) and Gartner duct cysts. Distinction between the two embryologic cysts is not clinically significant as both cysts are managed in a similar fashion.
Müllerian cysts, being embryologic remnants of müllerian (paramesonephric) ducts, are commonly located in the anterolateral vaginal wall (30). They are typically lined by mucinous, columnar epithelium. The majority of müllerian cysts are small and asymptomatic. Large, symptomatic cysts require excision.
The Gartner duct is a residual wolffian (mesonephric) duct remnant that typically occurs in the anterolateral vagina (31) (Figs 1, 21, 22). A Gartner duct cyst is a secretory retention cyst (containing proteinaceous fluid) that derives from the Gartner duct and is lined by nonmucinous, low columnar cells (30). These cysts may be associated with metanephric abnormalities such as unilateral renal agenesis, renal hypoplasia, or ectopic ureteral insertion (32). They are usually asymptomatic; large cysts may cause urethral obstruction. Small cysts may be treated conservatively with cyst aspiration; large, symptomatic cysts are surgically excised.
Vaginal inclusion cysts (epidermal inclusion cysts) are the commonest acquired cystic lesions of the vagina, being commonly located within the lower posterior or lateral vaginal wall at sites of previous trauma or surgery (30,33). They are lined by a stratified squamous epithelium and contain keratinous material. Asymptomatic cysts are usually observed; symptomatic cases are treated with marsupialization (33).
Skene duct cysts are retention cysts that form secondary to inflammatory obstruction of the paraurethral ducts (30) (Fig 23). They are lined by stratified squamous epithelium because of their origin from the urogenital sinus. Large, symptomatic cysts warrant excision or marsupialization.
The Bartholin glands are small, bilateral glands located at the posterolateral introitus and are derived from the urogenital sinus. They are homologous to the bulbourethral glands in males. Chronic inflammation leading to ductal obstruction from pus or thick mucus results in retained secretions within the Bartholin glands (30). Bartholin gland cysts (retention cysts) are typically located in the posterolateral introitus medial to the labia minora. Variable signal intensity is seen on MR images, depending on the protein content and superimposed infection (34). Most patients are asymptomatic; infected or symptomatic cysts may require marsupialization.
Endometriosis is defined as the presence of extrauterine endometrial tissue. It occurs most commonly in the ovaries and pelvic peritoneum. Vulvovaginal or perineal endometriosis is extremely rare; direct implantation of endometrial tissues during procedures such as episiotomy is postulated to be the etiologic mechanism (35). When present, endometriosis may be mistaken for a urethral diverticulum; accurate diagnosis is essential to facilitate optimal management (36). Complete surgical excision or lesion destruction by electrocautery or laser is the treatment of choice (30). Danazol treatment is also considered in some cases (35).
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Conclusions
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There is a wide spectrum of abnormalities of the female urethra that have characteristic cross-sectional imaging findings. Conventional urethrography provides limited information on abnormalities that communicate with the urethral lumen. High-resolution, endocavitary sonography and MR imaging allow excellent depiction of urethral and periurethral abnormalities and permit comprehensive evaluation of the female urethra (3–10).
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K. Hosseinzadeh, A. Furlan, and M. Torabi
Pre- and Postoperative Evaluation of Urethral Diverticulum
Am. J. Roentgenol.,
January 1, 2008;
190(1):
165 - 172.
[Abstract]
[Full Text]
[PDF]
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Abstract
LEARNING OBJECTIVES FOR TEST...
