Diagnostic Radiology
Criteria for Examination of the Urethra During Excretory Urography 1 Frederick B. Fitts, Jr., M.D.,2 Steven G. Herbert, M.D., and Harry Z. Mellins, M.D. Of 2,234 patients, 97 (4.3 %) had symptoms suggestive of urethral disease, and underwent excretory voiding urethrography (EVU) as part of their excretory urographic examination. Successful EVU examinations were obtained in 84 (87 %); 43 (51%) had abnormal findings; 29 (34 % ) were normal; and 12 (12 %) were considered probably normal, with no further study required. The additional portion of the study can be accomplished without a significant increase in examination time and without excessive additional imaging; it avoids the risks of catheterization. Urethra, abnormalities. Urethrography. technique. 8[4-5].1239 • Urography, indications • Urography, technique
INDEX TERMS:
Radiology 125:47-52, October 1977
to improve and simplify the radiological diagnosis of urethral disease, we used a population of patients who might have urethral disease, and attempted to determine whether a single radiological examination, the excretion urogram (including upper and lower tracts), could give the information needed prior to treatment. Examination of the urethra has evolved through several stages during the first part of this century. Edling (10), in his excellent monograph, thoroughly outlined the early attempts and subsequent improvements made in the development of radiographic technique. Opacification of the urethra by intravenous injection was first described by Ortmann and Christiansen in 1934 (16) in their studies of the closing mechanism of the urethra. They found that one hour after the intravenous injection of contrast material (Uroselectan or Perabrodil), sufficient contrast material
I
N
AN
ATTEMPT
TABLE
I:
EVU
INDICATIONS FOR
Hesitancy, urgency or dysuria Feeling of incomplete voiding Follow-up transurethral prostatic resection or other urethral procedure History of catheterization or cystoscopy with subsequent voiding difficulties Evidence of bladder outlet obstruction on excretory urography (bladder tics or heavy trabeculation) Hematuria unexplained by excretory urography Recurrent infection Other
was still in the bladder for urethrography.They then placed the patient in the posterior oblique position and asked the patient to void. In 1945, Draper and Siceluff (8) initially performed voiding urethrography after excretion urography, but abandoned the technique because of inability to obtain sufficient bladder contrast. They did, however, introduce another technique to the urethral examination, by area of suspensory ligament
open interna sphincter
\
-------------__ PEN I LE
,
verumontanum _ _........,
\URETHRA
I
PROSTA T IC,::/ URETHRA """" ,»:
I I I I I
, ..., ...
M~~~~~~~Us?--
I I I I I
___________________6\ STAL
\
BU LBOU 5
URETHRA
, ,PROXIMAL BUlBOU( URETHRA
B
Fig. 1. A Normal noncompressed excretion voiding urethrogram (EVU) of 32·year-old man presenting with sterile penile discharge and hematuria. B. Anatomic areas of urethra-internal sphincter, prostatic urethra with verumontanum, membranous urethra, and bulbous and penile urethra.
1 From the Department of Radiology, Harvard Medical School and Peter Bent Brigham Hospital, Boston, Mass. Accepted for publication in November, 1976. Supported in part by NIH Grant GM 18674-07. 2 Current address: Department of Radiology, Univ. Mass. Medical Ctr., 55 Lake Ave. N., Worcester, Mass., 01605. ss
47
48
FREDERICK
B.
FITTS, JR. AND OTHERS
October 1977
CONGENITAL MALFORMATIONS OF RECTUM, ANUS AND GENITO-URINARY TRACTS
B
A
c
D
Levels and zones of occlusion of the urethral lumen by the sphincters.
B
A, Urethra expanded during voiding and B, unexpanded when not voiding. C, Shows internal sphincter zone expanded to the second level when the external sphincter is voluntarily contracted during voiding and D shows the internal and external sphincter zones expanded but the lumen is constricted by the voluntary action of the bulbocavernosus muscle.
Fig. 2. EVU of 25-year-old man presenting with hesitancy and frequency shows abrupt cutoff of the stream just distal to the membranous urethra (A). The area of narrowing represents normal contraction of the bulbocavernosus muscle (8, with permission from Stephens, FD: Congenital Malformations of the Rectum, Anus, and Genito-urinary Tracts. Edinburgh, Livingstone, 1963, p 214).
obtaining radiographs of patients during free voiding and voiding against compression of a clamp. In 1963, Pearman and Miller (17) used this technique to evaluate patients as part of excretion urography. One year later, Schenker (21) also discussed the use of voiding cystourethrography after drip infusion pyelography. Most recently, Fumerton and MacEwan (11) successfully used the technique after excretion urography in all their adult patients. Burrows and Allen (3), in their examinations of children, have taken the opposite approach, and have stated that "The micturition cystourethrogram can never form part of an IVP. It must
always be a separate procedure." This statement reflected their inability to evaluate reflux after excretion urography. In 1965, however, Nogrady and Dunbar (15) successfully examined children after excretion urography, and formulated criteria for evaluating reflux. MATERIALS AND METHODS
We compiled a list of symptoms which suggested the possibility of urethral disease (TABLE I). Any patient referred to our department for excretion urography was screened for these symptoms, and those meeting the criteria were first asked to empty the bladder. We then followed guidelines originally suggested by Pearman and Miller (17). Renografin 60, 1 ml per pound of body weight to a maximum of 150 ml, was injected. An oral hydration regimen was started as soon as the compression release radiograph was obtained. The patient was then moved from the radiographic room to the patient waiting area, was provided free access to water, and was instructed to drink as much as necessary to produce an urgent desire to void. The length of time necessary to reach this goal and the amount of water consumed were tabulated for each patient (TABLE II).
Fig. 3. Gonorrheal bulbar stricture with sequelae in 54-year-old man with recent history of epididymitis and past history of gonococcal urethritis. The EVU shows a complex stricture involving the proximal bulbous urethra (open arrows). The posterior urethra (prostatic and membranous) is dilated by urethral resistance from the stricture. A tract of contrast medium in the ventral wall of this same area of the urethra immediately proximal to the stricture (closed arrow) represents the reflux of contrast medium into Cowper's duct. Reflux from the prostatic urethra into an ejaculatory duct is also present (arrowhead).
When the patient was ready to void and was back in the radiographic room, a scout image was obtained in the supine posterior oblique position. The patient was then requested to void in this position, and radiographs in both posterior oblique positions were obtained. Upright images were obtained whenever a patient could not void in the supine position. In general, however, radiographs obtained in the upright position were inferior to those obtained in the TABLE
II:
ADDITIONAL REQUIREMENTS FOR
Average total time (including urogram) Average water consumption Average number of images added to urogram (includes wasted images due to faulty technique) EVU/urogram ratio
EVU 90 min. 1,500 ml
4 97/2.234
Vol. 125
URETHRAL EXAMINATION DURING EXCRETORY UROGRAPHY
49
Diagnostic Radiology
Fig. 4. A. EVU showing gonorrheal bulbar stricture in 59-year-old man treated previously for gonorrhea and for a subsequent perineal abscess with urethral stricture which was successfully treated by dilation. This patient presented with hesitancy, frequency, and nocturia. The open arrow indicates a stricture in the proximal bulbous urethra, the closed arrow a tract of contrast material ventral and proximal to the stricture representing reflux into Cowper's duct, and the arrowhead indicates the contrast medium refluxing into an ejaculatory duct. B. The complementary role of the retrograde urethrogram with the EVU is shown.
supine position. All images obtained of the area were tabulated; this was done to record semiquantitatively the amount of radiation patients would be subjected to when a procedure such as this was incorporated into the routine urographic examination (TABLE II). RESULTS
By using the criteria outlined, we employed our technique in 1 of every 23 patients referred for excretion urography (TABLE III).
Eleven cases (Figs. 1-11) illustrate some of the material collected during this survey. Figure 1 demonstrates the excretion voiding urethrogram of a normal urethra and its anatomy. Figure 2 shows contraction of the normal bulbocavernosus muscle. These findings have been described previously by both Currarino (5) and Stephens (22). Urethral disease was not evident. Figures 3-5 demonstrate gonorrheal stricture. Figure 3 shows reflux of contrast material into Cowper's duct (6). Figure 4 shows the complementary roles of excretion voiding urethrography (EVU) and retrograde urethrography recently emphasized by DeLacey et
Fig. 5. EVU of a 53-year-old-man with a past history of gonococcal stricture treated with dilatation. He presented with persistent urethral discharge and hesitancy. Gonorrheal stricture in the proximal bulbous urethra (open arrows) is evident (A). The high resistance to flow through the area is demonstrated by the thin stream of contrast material seen distal to the stricture. Note the significant dilatation of the posterior urethra and reflux into the prostate gland (closed arrow), demonstrated vividly in the postvoiding examination with contrast medium in the prostate (B).
50
FREDERICK B. FITTS,
JR.
AND OTHERS
TABLE III:
October 1977
RESULTS OF URETHRAL EXAMINATION
Adequate for diagnosis Normal Probable enlarged prostate Probable normal Stricture Enlarged prostate Probable stricture Urethral diverticulum Neurogenic urethral sphincter Cowper's duct cyst Meatal stenosis Phimosis ? Ureteral reflux Not adequate for diagnosis 13) Total (84
+
Fig. 6. Left posterior oblique projection of 30-year-old man presenting with decreased caliber of urinary stream, occasional dysuria, and feeble ejaculation. He had sustained a straddle injury to the perineum at age 7, which was treated with an indwelling catheter. He underwent perineal urethrotomy with excision of the stricture at age 12, and a two-stage Johanson repair of a recurrent urethral stricture at age 17. The EVU demonstrates stricture of the proximal bulbous urethra (open arrow), a large acquired diverticulum (closed arrow), a short fistulous tract arising from the area of the stricture (arrowhead), and marked dilatation of the posterior urethra.
al. (7). Figure 5 shows stricture, dilatation, and reflux into the prostate (13). The patient shown in Figure 6 had a stricture resulting from a straddle injury of the perineum. Several patients were examined to diagnose recurrent
84
29 12 12
9 8 7 2 1 1 1 1 1 13
97
voiding difficulties occurring several years after transurethral prostatectomy; Figure 7 shows a representative case. Figure 8 demonstrates one type of problem seen in patients examined because of voiding difficulties after a Miles abdominoperineal resection. This patient was diagnosed as having a neuropathic urethra (1). In this condition, inefficient bladder emptying is usually the result of excessive urethral resistance, and may be coupled with a flaccid pelvic floor; detrusor contraction is absent or diminished. Voiding is performed by manual or abdominal pressure. The bladder neck will descend and open (Fig. 8), although the urethra remains closed at the membranous level. These findings have been attributed to abnormal resistance produced by the elasticity of tissue surrounding the triangular ligament (1). Several authors have described the urologic complications which may result from the Miles type of resection (2, 10, 12, 19,23). Cases 9 and 10 represent unusual findings. Figure 9 demonstrates a lesion of the urethra representing a retention cyst of Cowper's duct (14). The Cowper's duct cyst is an unusual entity which has recently been investigated
Fig. 7. EVU in left (A) and right (B) posterior oblique projections of a 77-year-old man with urinary frequency and hesitancy who had undergone transurethral prostatectomy several years earlier. Note the recurrent nodular hypertrophy of the lateral prostatic lobes (open arrows), which has spared a portion of the defect, producing a pseudodiverticulum. These findings were confirmed at cystoscopy.
Vol. 125
URETHRAL EXAMINATION DURING EXCRETORY UROGRAPHY
Fig. 8. EVU of 67-year-old man presenting with feeling of hesitancy and incomplete voiding after recovery from a Miles abdominoperineal resection for rectal carcinoma. The cystoscopic examination gave normal results, but the EVU showed an open bladder neck (arrow) with a narrow membranous urethra and a spasm of the external sphincter (arrow), indicating neuropathic urethra.
by Moskowitz et al. (14). A single papilloma of the urethra (Fig. 10) is also an unusual lesion. At least 90% of these lesions accompany other papillary lesions in the bladder (4). This patient was found to have only a solitary lesion. The last case (Fig. 11) demonstrates one of the many advantages of this technique-demonstration of meatal stenosis when retrograde catheterization is not possible.
Fig. 9. EVU of 25-year-old man presenting with hematuria. The excretion urogram was normal, but the right posterior oblique EVU demonstrated a filling defect in the distal bulbous urethra, indicating a radiolucent mass (arrow). The base of the lesion was fixed to the ventral surface of the urethra, and at cystoscopy was demonstrated to be a cystic structure which released serous fluid when cauterized-a retention cyst of Cowper's duct.
51
Diagnostic Radiology
Fig. 10. EVU of a 32-year-old man who experienced two episodes of urinary tract infection associated with dysuria and frequency. The findings on excretion urography were normal, but the EVU demonstrated a lucent filling defect in the wall of the bulbous urethra (arrow). Contrast seen above and below the lesion indicates attachment to the lateral wall. The cystoscopic examination and biopsy revealed a papilloma involving the right lateral wall of the urethra.
DISCUSSION
The technique we have used has been described previously by several authors (8, 11, 15-17, 21). We intended to evaluate the efficacy and utility of this technique by
Fig. 11. EVU of an 18-year-old man referred because of dysuria. for whom retrograde catheterization was not possible. There is a markedly dilated urethra from the bladder to the meatus, consistent with the diagnosis of a meatal stenosis. No other urethral abnormalities were present, and images of the upper tract showed no back pressure effects or other abnormalities.
52
FREDERICK
B. FITTS, JR. AND OTHERS
selecting, on the basis of history, patients who needed the examination. Although Sane and Worsing (20) have described the advantage of fluoroscopy in recording this examination, we wished to evaluate a technique that could be accomplished without dependence on fluoroscopy, since the necessary equipment is not always accessible. We found that by selecting those patients with symptoms suggestive of urethral disease, we were examining only 1 of every 23 patients referred to us for routine excretory urography. Our success rate in this group of patients was 87 %. Of those patients successfully examined, the results in 34 % were distinctly normal, with another 12% considered probably normal and not requiring further examination. The remaining 51 % had findings which either confirmed a suspected clinical diagnosis or changed the clinical diagnosis completely. The statement of Burrows and Allen (3) that in some instances "adequate micturition cystourethrography may give more information than any cystoscopic examination" is certainly true for several of the disease processes identified in our study. In the patient who has normal renal function, the bladder is able to be filled with contrast material of excellent density. There are several advantages to examining the urethra at the time of the excretion urogram: it spares the patient a second examination, it makes catheterization unnecessary, it provides a diagnostic examination as good as (or better than) standard voiding cystourethrography, and it enables the radiologist to examine those patients who might otherwise be difficult to catheterize (those with stricture, phimosis, or meatal stenosis). Despite the observations of Poznanski and Poznanski (18) that voiding studies performed after catheterization of the bladder are generally more successful than voiding studies after excretion urography, we have had considerable success with the technique described. It is a technique which can be taught to any competent technician, and it can be performed without overloading the capacity of a department. We believe that enough diagnostic information is obtained from this examination, without additional risk to the patient, to warrant its use in those patients fulfilling the criteria outlined. For examination of the urethra, we believe it to be the diagnostic equivalent of voiding cystourethrography, with the added advantage that catheterization is not required. Department of Radiology University of Mass. Medical Ctr. 55 Lake Ave. N. Worcester, Mass. 01605
October 1977
REFERENCES 1. Abel BJ, Gibbon NO, Jameson RM, et al: The neuropathic urethra. Lancet 2: 1,229-1,230, 23 Nov 1974 2. Baumrucker GO, Shaw JW: Urological complications following abdominoperineal resection of rectum. AMA Arch Surg 67:502-513, Oct 1953 3. Burrows EH, Allen RP: Urethral lesions in infancy and childhood studied by micturition cysto-urethrography. Br J Radiol 37: 187-199, Mar 1964 4. Campbell MF, Harrison JH: Urology. Philadelphia, Saunders, 1970, 3d ed, pp 1,203-1,204 5. Currarino G: Narrowings of the male urethra caused by contractions or spasm of the bulbocavernosus muscle: cystourethrographic observations. Am J Roentgenol108:641-647, Mar 1970 6. Currarino G, Fuqua F: Cowper's glands in the urethrogram. Am J RoentgenoI116:838-842, Dec 1972 7. DeLacey GJ, Wilkins RA, Small MP, et al: Urethral stricture and urethral rupture. Am J RoentgenoI119:822-831, Dec 1973 8. Draper JW, Siceluff JG: Excretory cystourethrograms. J Urol 53:539-544, Apr 1945 9. Edling NPG: Urethrocystography in the male with special regard to micturition. Acta Radiol (Suppl) 58:1-144, 1945 10. Eickenberg H-U, Amin M, Klompus W, et al: Urologic complications following abdominoperineal resection. J Urol115:180-182, Feb 1976 11. Fumerton WR, MacEwan OW: Excretory micturition cystourethrography (EMCU)in the adult age group. J Canad Assoc Radiol 21:90-97, Jun 1970 12. Kontturi M, Larmi TK, Tuononen S: Bladder dysfunction and its manifestations following abdominoperineal extirpation of the rectum. Ann Surg 179:179-182, Feb 1974 13. Mitty HA: Roentgen features of reflux into the prostate, seminal vesicles and vasa deferentia. Am J RoentgenoI112:603-606, Jul 1971 14. Moskowitz PS, Newton NA, Lebowitz RL: Retention cysts of Cowper's duct. Radiology 120:377-380, Aug 1976 15. Nogrady MB, Dunbar JS: The value of excretory micturition cysto-urethrography (EMCU) in the pediatric age group. J Canad Assoc Radiol16:181-189, Sep 1965 16. Ortmann KK, Christiansen H: Roentgenologic studies of the male urethra, closing mechanism of bladder, and micturition under normal and pathologic conditions. Acta Radiol 15:258-283, 1934 17. Pearman RO, Miller JB: Choke voiding cystourethrography. J Urol 90:481-488, Oct 1963 18. Poznanski E, Poznanski AK: Psychogenic influences on voiding: observations from voiding cystourethrography. Psychosomatics 10:339-342, Nov 1969 19. Sakkas JL, Mandrekas A, Androulakis J, et al: Urologic complications in malignant disease of the rectosigmoid colon. South Med J 67:287-291, Mar 1974 20. Sane SM, Worsing RA Jr: Voiding cystourethrography. Recent advances. Minn Med 58: 148-153, Feb 1975 21. Schencker B: Drip infusion pyelography. Indications and applications in urologic roentgen diagnosis. Radiology 83: 12-21, Jul 1964 22. Stephens FD: Congenital Malformations of the Rectum, Anus and Genito-urinary Tracts. Edinburgh, Livingstone, 1963, pp 213215 23. Tank ES, Ernst CB, Woolson ST, et al: Urinary tract complications of anorectal surgery. Am J Surg 123:118-122, Jan 1972 ACKNOWLEDGMENT: We wish to thank R. W. McCallum, M.D., Ch.B., F.R.C.P., for reviewing some of the material.
Criteria for Examination of the Urethra During Excretory Urography 1 Frederick B. Fitts, Jr., M.D.,2 Steven G. Herbert, M.D., and Harry Z. Mellins, M.D. Of 2,234 patients, 97 (4.3 %) had symptoms suggestive of urethral disease, and underwent excretory voiding urethrography (EVU) as part of their excretory urographic examination. Successful EVU examinations were obtained in 84 (87 %); 43 (51%) had abnormal findings; 29 (34 % ) were normal; and 12 (12 %) were considered probably normal, with no further study required. The additional portion of the study can be accomplished without a significant increase in examination time and without excessive additional imaging; it avoids the risks of catheterization. Urethra, abnormalities. Urethrography. technique. 8[4-5].1239 • Urography, indications • Urography, technique
INDEX TERMS:
Radiology 125:47-52, October 1977
to improve and simplify the radiological diagnosis of urethral disease, we used a population of patients who might have urethral disease, and attempted to determine whether a single radiological examination, the excretion urogram (including upper and lower tracts), could give the information needed prior to treatment. Examination of the urethra has evolved through several stages during the first part of this century. Edling (10), in his excellent monograph, thoroughly outlined the early attempts and subsequent improvements made in the development of radiographic technique. Opacification of the urethra by intravenous injection was first described by Ortmann and Christiansen in 1934 (16) in their studies of the closing mechanism of the urethra. They found that one hour after the intravenous injection of contrast material (Uroselectan or Perabrodil), sufficient contrast material
I
N
AN
ATTEMPT
TABLE
I:
EVU
INDICATIONS FOR
Hesitancy, urgency or dysuria Feeling of incomplete voiding Follow-up transurethral prostatic resection or other urethral procedure History of catheterization or cystoscopy with subsequent voiding difficulties Evidence of bladder outlet obstruction on excretory urography (bladder tics or heavy trabeculation) Hematuria unexplained by excretory urography Recurrent infection Other
was still in the bladder for urethrography.They then placed the patient in the posterior oblique position and asked the patient to void. In 1945, Draper and Siceluff (8) initially performed voiding urethrography after excretion urography, but abandoned the technique because of inability to obtain sufficient bladder contrast. They did, however, introduce another technique to the urethral examination, by area of suspensory ligament
open interna sphincter
\
-------------__ PEN I LE
,
verumontanum _ _........,
\URETHRA
I
PROSTA T IC,::/ URETHRA """" ,»:
I I I I I
, ..., ...
M~~~~~~~Us?--
I I I I I
___________________6\ STAL
\
BU LBOU 5
URETHRA
, ,PROXIMAL BUlBOU( URETHRA
B
Fig. 1. A Normal noncompressed excretion voiding urethrogram (EVU) of 32·year-old man presenting with sterile penile discharge and hematuria. B. Anatomic areas of urethra-internal sphincter, prostatic urethra with verumontanum, membranous urethra, and bulbous and penile urethra.
1 From the Department of Radiology, Harvard Medical School and Peter Bent Brigham Hospital, Boston, Mass. Accepted for publication in November, 1976. Supported in part by NIH Grant GM 18674-07. 2 Current address: Department of Radiology, Univ. Mass. Medical Ctr., 55 Lake Ave. N., Worcester, Mass., 01605. ss
47
48
FREDERICK
B.
FITTS, JR. AND OTHERS
October 1977
CONGENITAL MALFORMATIONS OF RECTUM, ANUS AND GENITO-URINARY TRACTS
B
A
c
D
Levels and zones of occlusion of the urethral lumen by the sphincters.
B
A, Urethra expanded during voiding and B, unexpanded when not voiding. C, Shows internal sphincter zone expanded to the second level when the external sphincter is voluntarily contracted during voiding and D shows the internal and external sphincter zones expanded but the lumen is constricted by the voluntary action of the bulbocavernosus muscle.
Fig. 2. EVU of 25-year-old man presenting with hesitancy and frequency shows abrupt cutoff of the stream just distal to the membranous urethra (A). The area of narrowing represents normal contraction of the bulbocavernosus muscle (8, with permission from Stephens, FD: Congenital Malformations of the Rectum, Anus, and Genito-urinary Tracts. Edinburgh, Livingstone, 1963, p 214).
obtaining radiographs of patients during free voiding and voiding against compression of a clamp. In 1963, Pearman and Miller (17) used this technique to evaluate patients as part of excretion urography. One year later, Schenker (21) also discussed the use of voiding cystourethrography after drip infusion pyelography. Most recently, Fumerton and MacEwan (11) successfully used the technique after excretion urography in all their adult patients. Burrows and Allen (3), in their examinations of children, have taken the opposite approach, and have stated that "The micturition cystourethrogram can never form part of an IVP. It must
always be a separate procedure." This statement reflected their inability to evaluate reflux after excretion urography. In 1965, however, Nogrady and Dunbar (15) successfully examined children after excretion urography, and formulated criteria for evaluating reflux. MATERIALS AND METHODS
We compiled a list of symptoms which suggested the possibility of urethral disease (TABLE I). Any patient referred to our department for excretion urography was screened for these symptoms, and those meeting the criteria were first asked to empty the bladder. We then followed guidelines originally suggested by Pearman and Miller (17). Renografin 60, 1 ml per pound of body weight to a maximum of 150 ml, was injected. An oral hydration regimen was started as soon as the compression release radiograph was obtained. The patient was then moved from the radiographic room to the patient waiting area, was provided free access to water, and was instructed to drink as much as necessary to produce an urgent desire to void. The length of time necessary to reach this goal and the amount of water consumed were tabulated for each patient (TABLE II).
Fig. 3. Gonorrheal bulbar stricture with sequelae in 54-year-old man with recent history of epididymitis and past history of gonococcal urethritis. The EVU shows a complex stricture involving the proximal bulbous urethra (open arrows). The posterior urethra (prostatic and membranous) is dilated by urethral resistance from the stricture. A tract of contrast medium in the ventral wall of this same area of the urethra immediately proximal to the stricture (closed arrow) represents the reflux of contrast medium into Cowper's duct. Reflux from the prostatic urethra into an ejaculatory duct is also present (arrowhead).
When the patient was ready to void and was back in the radiographic room, a scout image was obtained in the supine posterior oblique position. The patient was then requested to void in this position, and radiographs in both posterior oblique positions were obtained. Upright images were obtained whenever a patient could not void in the supine position. In general, however, radiographs obtained in the upright position were inferior to those obtained in the TABLE
II:
ADDITIONAL REQUIREMENTS FOR
Average total time (including urogram) Average water consumption Average number of images added to urogram (includes wasted images due to faulty technique) EVU/urogram ratio
EVU 90 min. 1,500 ml
4 97/2.234
Vol. 125
URETHRAL EXAMINATION DURING EXCRETORY UROGRAPHY
49
Diagnostic Radiology
Fig. 4. A. EVU showing gonorrheal bulbar stricture in 59-year-old man treated previously for gonorrhea and for a subsequent perineal abscess with urethral stricture which was successfully treated by dilation. This patient presented with hesitancy, frequency, and nocturia. The open arrow indicates a stricture in the proximal bulbous urethra, the closed arrow a tract of contrast material ventral and proximal to the stricture representing reflux into Cowper's duct, and the arrowhead indicates the contrast medium refluxing into an ejaculatory duct. B. The complementary role of the retrograde urethrogram with the EVU is shown.
supine position. All images obtained of the area were tabulated; this was done to record semiquantitatively the amount of radiation patients would be subjected to when a procedure such as this was incorporated into the routine urographic examination (TABLE II). RESULTS
By using the criteria outlined, we employed our technique in 1 of every 23 patients referred for excretion urography (TABLE III).
Eleven cases (Figs. 1-11) illustrate some of the material collected during this survey. Figure 1 demonstrates the excretion voiding urethrogram of a normal urethra and its anatomy. Figure 2 shows contraction of the normal bulbocavernosus muscle. These findings have been described previously by both Currarino (5) and Stephens (22). Urethral disease was not evident. Figures 3-5 demonstrate gonorrheal stricture. Figure 3 shows reflux of contrast material into Cowper's duct (6). Figure 4 shows the complementary roles of excretion voiding urethrography (EVU) and retrograde urethrography recently emphasized by DeLacey et
Fig. 5. EVU of a 53-year-old-man with a past history of gonococcal stricture treated with dilatation. He presented with persistent urethral discharge and hesitancy. Gonorrheal stricture in the proximal bulbous urethra (open arrows) is evident (A). The high resistance to flow through the area is demonstrated by the thin stream of contrast material seen distal to the stricture. Note the significant dilatation of the posterior urethra and reflux into the prostate gland (closed arrow), demonstrated vividly in the postvoiding examination with contrast medium in the prostate (B).
50
FREDERICK B. FITTS,
JR.
AND OTHERS
TABLE III:
October 1977
RESULTS OF URETHRAL EXAMINATION
Adequate for diagnosis Normal Probable enlarged prostate Probable normal Stricture Enlarged prostate Probable stricture Urethral diverticulum Neurogenic urethral sphincter Cowper's duct cyst Meatal stenosis Phimosis ? Ureteral reflux Not adequate for diagnosis 13) Total (84
+
Fig. 6. Left posterior oblique projection of 30-year-old man presenting with decreased caliber of urinary stream, occasional dysuria, and feeble ejaculation. He had sustained a straddle injury to the perineum at age 7, which was treated with an indwelling catheter. He underwent perineal urethrotomy with excision of the stricture at age 12, and a two-stage Johanson repair of a recurrent urethral stricture at age 17. The EVU demonstrates stricture of the proximal bulbous urethra (open arrow), a large acquired diverticulum (closed arrow), a short fistulous tract arising from the area of the stricture (arrowhead), and marked dilatation of the posterior urethra.
al. (7). Figure 5 shows stricture, dilatation, and reflux into the prostate (13). The patient shown in Figure 6 had a stricture resulting from a straddle injury of the perineum. Several patients were examined to diagnose recurrent
84
29 12 12
9 8 7 2 1 1 1 1 1 13
97
voiding difficulties occurring several years after transurethral prostatectomy; Figure 7 shows a representative case. Figure 8 demonstrates one type of problem seen in patients examined because of voiding difficulties after a Miles abdominoperineal resection. This patient was diagnosed as having a neuropathic urethra (1). In this condition, inefficient bladder emptying is usually the result of excessive urethral resistance, and may be coupled with a flaccid pelvic floor; detrusor contraction is absent or diminished. Voiding is performed by manual or abdominal pressure. The bladder neck will descend and open (Fig. 8), although the urethra remains closed at the membranous level. These findings have been attributed to abnormal resistance produced by the elasticity of tissue surrounding the triangular ligament (1). Several authors have described the urologic complications which may result from the Miles type of resection (2, 10, 12, 19,23). Cases 9 and 10 represent unusual findings. Figure 9 demonstrates a lesion of the urethra representing a retention cyst of Cowper's duct (14). The Cowper's duct cyst is an unusual entity which has recently been investigated
Fig. 7. EVU in left (A) and right (B) posterior oblique projections of a 77-year-old man with urinary frequency and hesitancy who had undergone transurethral prostatectomy several years earlier. Note the recurrent nodular hypertrophy of the lateral prostatic lobes (open arrows), which has spared a portion of the defect, producing a pseudodiverticulum. These findings were confirmed at cystoscopy.
Vol. 125
URETHRAL EXAMINATION DURING EXCRETORY UROGRAPHY
Fig. 8. EVU of 67-year-old man presenting with feeling of hesitancy and incomplete voiding after recovery from a Miles abdominoperineal resection for rectal carcinoma. The cystoscopic examination gave normal results, but the EVU showed an open bladder neck (arrow) with a narrow membranous urethra and a spasm of the external sphincter (arrow), indicating neuropathic urethra.
by Moskowitz et al. (14). A single papilloma of the urethra (Fig. 10) is also an unusual lesion. At least 90% of these lesions accompany other papillary lesions in the bladder (4). This patient was found to have only a solitary lesion. The last case (Fig. 11) demonstrates one of the many advantages of this technique-demonstration of meatal stenosis when retrograde catheterization is not possible.
Fig. 9. EVU of 25-year-old man presenting with hematuria. The excretion urogram was normal, but the right posterior oblique EVU demonstrated a filling defect in the distal bulbous urethra, indicating a radiolucent mass (arrow). The base of the lesion was fixed to the ventral surface of the urethra, and at cystoscopy was demonstrated to be a cystic structure which released serous fluid when cauterized-a retention cyst of Cowper's duct.
51
Diagnostic Radiology
Fig. 10. EVU of a 32-year-old man who experienced two episodes of urinary tract infection associated with dysuria and frequency. The findings on excretion urography were normal, but the EVU demonstrated a lucent filling defect in the wall of the bulbous urethra (arrow). Contrast seen above and below the lesion indicates attachment to the lateral wall. The cystoscopic examination and biopsy revealed a papilloma involving the right lateral wall of the urethra.
DISCUSSION
The technique we have used has been described previously by several authors (8, 11, 15-17, 21). We intended to evaluate the efficacy and utility of this technique by
Fig. 11. EVU of an 18-year-old man referred because of dysuria. for whom retrograde catheterization was not possible. There is a markedly dilated urethra from the bladder to the meatus, consistent with the diagnosis of a meatal stenosis. No other urethral abnormalities were present, and images of the upper tract showed no back pressure effects or other abnormalities.
52
FREDERICK
B. FITTS, JR. AND OTHERS
selecting, on the basis of history, patients who needed the examination. Although Sane and Worsing (20) have described the advantage of fluoroscopy in recording this examination, we wished to evaluate a technique that could be accomplished without dependence on fluoroscopy, since the necessary equipment is not always accessible. We found that by selecting those patients with symptoms suggestive of urethral disease, we were examining only 1 of every 23 patients referred to us for routine excretory urography. Our success rate in this group of patients was 87 %. Of those patients successfully examined, the results in 34 % were distinctly normal, with another 12% considered probably normal and not requiring further examination. The remaining 51 % had findings which either confirmed a suspected clinical diagnosis or changed the clinical diagnosis completely. The statement of Burrows and Allen (3) that in some instances "adequate micturition cystourethrography may give more information than any cystoscopic examination" is certainly true for several of the disease processes identified in our study. In the patient who has normal renal function, the bladder is able to be filled with contrast material of excellent density. There are several advantages to examining the urethra at the time of the excretion urogram: it spares the patient a second examination, it makes catheterization unnecessary, it provides a diagnostic examination as good as (or better than) standard voiding cystourethrography, and it enables the radiologist to examine those patients who might otherwise be difficult to catheterize (those with stricture, phimosis, or meatal stenosis). Despite the observations of Poznanski and Poznanski (18) that voiding studies performed after catheterization of the bladder are generally more successful than voiding studies after excretion urography, we have had considerable success with the technique described. It is a technique which can be taught to any competent technician, and it can be performed without overloading the capacity of a department. We believe that enough diagnostic information is obtained from this examination, without additional risk to the patient, to warrant its use in those patients fulfilling the criteria outlined. For examination of the urethra, we believe it to be the diagnostic equivalent of voiding cystourethrography, with the added advantage that catheterization is not required. Department of Radiology University of Mass. Medical Ctr. 55 Lake Ave. N. Worcester, Mass. 01605
October 1977
REFERENCES 1. Abel BJ, Gibbon NO, Jameson RM, et al: The neuropathic urethra. Lancet 2: 1,229-1,230, 23 Nov 1974 2. Baumrucker GO, Shaw JW: Urological complications following abdominoperineal resection of rectum. AMA Arch Surg 67:502-513, Oct 1953 3. Burrows EH, Allen RP: Urethral lesions in infancy and childhood studied by micturition cysto-urethrography. Br J Radiol 37: 187-199, Mar 1964 4. Campbell MF, Harrison JH: Urology. Philadelphia, Saunders, 1970, 3d ed, pp 1,203-1,204 5. Currarino G: Narrowings of the male urethra caused by contractions or spasm of the bulbocavernosus muscle: cystourethrographic observations. Am J Roentgenol108:641-647, Mar 1970 6. Currarino G, Fuqua F: Cowper's glands in the urethrogram. Am J RoentgenoI116:838-842, Dec 1972 7. DeLacey GJ, Wilkins RA, Small MP, et al: Urethral stricture and urethral rupture. Am J RoentgenoI119:822-831, Dec 1973 8. Draper JW, Siceluff JG: Excretory cystourethrograms. J Urol 53:539-544, Apr 1945 9. Edling NPG: Urethrocystography in the male with special regard to micturition. Acta Radiol (Suppl) 58:1-144, 1945 10. Eickenberg H-U, Amin M, Klompus W, et al: Urologic complications following abdominoperineal resection. J Urol115:180-182, Feb 1976 11. Fumerton WR, MacEwan OW: Excretory micturition cystourethrography (EMCU)in the adult age group. J Canad Assoc Radiol 21:90-97, Jun 1970 12. Kontturi M, Larmi TK, Tuononen S: Bladder dysfunction and its manifestations following abdominoperineal extirpation of the rectum. Ann Surg 179:179-182, Feb 1974 13. Mitty HA: Roentgen features of reflux into the prostate, seminal vesicles and vasa deferentia. Am J RoentgenoI112:603-606, Jul 1971 14. Moskowitz PS, Newton NA, Lebowitz RL: Retention cysts of Cowper's duct. Radiology 120:377-380, Aug 1976 15. Nogrady MB, Dunbar JS: The value of excretory micturition cysto-urethrography (EMCU) in the pediatric age group. J Canad Assoc Radiol16:181-189, Sep 1965 16. Ortmann KK, Christiansen H: Roentgenologic studies of the male urethra, closing mechanism of bladder, and micturition under normal and pathologic conditions. Acta Radiol 15:258-283, 1934 17. Pearman RO, Miller JB: Choke voiding cystourethrography. J Urol 90:481-488, Oct 1963 18. Poznanski E, Poznanski AK: Psychogenic influences on voiding: observations from voiding cystourethrography. Psychosomatics 10:339-342, Nov 1969 19. Sakkas JL, Mandrekas A, Androulakis J, et al: Urologic complications in malignant disease of the rectosigmoid colon. South Med J 67:287-291, Mar 1974 20. Sane SM, Worsing RA Jr: Voiding cystourethrography. Recent advances. Minn Med 58: 148-153, Feb 1975 21. Schencker B: Drip infusion pyelography. Indications and applications in urologic roentgen diagnosis. Radiology 83: 12-21, Jul 1964 22. Stephens FD: Congenital Malformations of the Rectum, Anus and Genito-urinary Tracts. Edinburgh, Livingstone, 1963, pp 213215 23. Tank ES, Ernst CB, Woolson ST, et al: Urinary tract complications of anorectal surgery. Am J Surg 123:118-122, Jan 1972 ACKNOWLEDGMENT: We wish to thank R. W. McCallum, M.D., Ch.B., F.R.C.P., for reviewing some of the material.
