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Cross-Sectional Imaging of the Female Urethra

  • Laura Elizabeth TraubeEmail author
  • Vinika Chaudhari
  • Maitraya K. Patel
  • Steven S. Raman
Chapter

Abstract

Diagnosis of female urethral and periurethral pathology is challenging for clinicians because patients present with nonspecific symptoms. In many cases, these symptoms can be attributed to diagnoses such as urethritis, which have no imaging findings. However, these symptoms may be caused by a variety of lesions, which may be diagnosed by imaging.

Conventional imaging studies such as voiding cystourethrography (VCUG) and retrograde double-balloon positive-pressure urethrography have played a limited role in diagnosis. The development of endovaginal sonography and small high-frequency phased-array US transducers has enabled a more comprehensive evaluation of the static and dynamic relationships between urethral and periurethral tissues. MRI has further advanced the imaging of the female urethra, vagina, perineum, and pelvic floor by enabling high contrast, multiplanar static and dynamic imaging of the entire pelvis. The utility of CT is limited predominantly to the assessment of urethral calculi.

This chapter first reviews the normal anatomic appearance of the urethra and adjacent structures. Next, the use of sonography and MRI in the evaluation of urethral pathology is discussed. Algorithms for a pattern-recognition approach to organizing and diagnosing urethral and periurethral pathologic entities based on imaging are presented. Urethral pathologic entities are reviewed in regards to pathogenesis, clinical presentation, diagnosis, imaging features, treatment, and prognosis. Both benign and malignant urethral and periurethral pathology are discussed. Pelvic floor dysfunction is briefly reviewed.

Keywords

Urethra Urethral diverticulum Urethral caruncle Urethral leiomyoma Urethral fistula Ectopic ureterocele Urethral carcinoma Gartner duct cyst Müllerian cyst Epidermal inclusion cyst Bartholin gland cyst Skene duct cyst Periurethral endometrioma Pelvic floor dysfunction 

References

  1. 1.
    Handel LN, Leach GE. Current evaluation and management of female urethral diverticula. Curr Urol Rep. 2008;9(5):383–8.PubMedCrossRefGoogle Scholar
  2. 2.
    Norton PA. Pelvic floor disorders: the role of fascia and ligaments. Clin Obstet Gynecol. 1993;36(4):926–38.PubMedCrossRefGoogle Scholar
  3. 3.
    Strohbehn K. Normal pelvic floor anatomy. Obstet Gynecol Clin North Am. 1998;25(4):683–705.PubMedCrossRefGoogle Scholar
  4. 4.
    Kawashima A, Sandler CM, Wasserman NF, LeRoy AJ, King Jr BF, Goldman SM. Imaging of urethral disease: a pictorial review. RadioGraphics. 2004;24(S1):S195–216.PubMedCrossRefGoogle Scholar
  5. 5.
    Prasad SR, Menias CO, Narra VR, Middleton WD, Mukundan G, Samadi N, Heiken JP, Siegel CL. Cross-sectional imaging of the female urethra: technique and results. RadioGraphics. 2005;25(3):749–61.PubMedCrossRefGoogle Scholar
  6. 6.
    Ryu J, Kim B. MR imaging of the male and female urethra. RadioGraphics. 2001;21(5):1169–85.PubMedCrossRefGoogle Scholar
  7. 7.
    Siegel CL, Middleton WD, Teefey SA, Wainstein MA, McDougall EM, Klutke CG. Sonography of the female urethra. Am J Roentgenol. 1998;170(5):1269–74.CrossRefGoogle Scholar
  8. 8.
    Keefe B, Warshauer DM, Tucker MS, Mittelstaedt CA. Diverticula of the female urethra: diagnosis by endovaginal and transperineal sonography. Am J Roentgenol. 1991;156(6):1195–7.CrossRefGoogle Scholar
  9. 9.
    Kim B, Hricak H, Tanagho EA. Diagnosis of urethral diverticula in women: value of MR imaging. Am J Roentgenol. 1993;161(4):809–15.CrossRefGoogle Scholar
  10. 10.
    Blander DS, Rovner ES, Schnall MD, Ramchandani P, Banner MP, Broderick GA, Wein AJ. Endoluminal magnetic resonance imaging in the evaluation of urethral diverticula in women. Urology. 2001;57(4):660–5.PubMedCrossRefGoogle Scholar
  11. 11.
    Neitlich JD, Foster Jr HE, Glickman MG, Smith RC. Detection of urethral diverticula in women: comparison of a high resolution fast spin echo technique with double balloon urethrography. J Urol. 1998;159(2):408–10.PubMedCrossRefGoogle Scholar
  12. 12.
    Han DH, Jeong YS, Choo M, Lee KS. Outcomes of surgery of female urethral diverticula classified using magnetic resonance imaging. Eur Urol. 2007;51(6):1664–70.PubMedCrossRefGoogle Scholar
  13. 13.
    Aronson MP, Bates SM, Jacoby AF, Chelmow D, Sant GR. Periurethral and paravaginal anatomy: an endovaginal magnetic resonance imaging study. Am J Obstet Gynecol. 1995;173(6):1702–10.PubMedCrossRefGoogle Scholar
  14. 14.
    Hricak H, Secaf E, Buckley DW, Brown JJ, Tanagho EA, McAninch JW. Female urethra: MR imaging. Radiology. 1991;178(2):527–35.PubMedCrossRefGoogle Scholar
  15. 15.
    Lee JW, Fynes MM. Female urethral diverticula. Best Pract Res Clin Obstet Gynaecol. 2005;19(6):875–93.PubMedCrossRefGoogle Scholar
  16. 16.
    Siegelman ES, Banner MP, Ramchandani P, Schnall MD. Multicoil MR imaging of symptomatic female urethral and periurethral disease. RadioGraphics. 1997;17(2):349–65.PubMedCrossRefGoogle Scholar
  17. 17.
    Khati NJ, Javitt MC, Schwartz AM, Berger BM. MR imaging diagnosis of a urethral diverticulum. RadioGraphics. 1998;18(2):517–22.PubMedCrossRefGoogle Scholar
  18. 18.
    Daneshgari F, Zimmern PE, Jacomides L. Magnetic resonance imaging detection of symptomatic noncommunicating intraurethral wall diverticula in women. J Urol. 1999;161(4):1259–62.PubMedCrossRefGoogle Scholar
  19. 19.
    Martensson O, Duchek M. Translabial ultrasonography with pulsed colour-Doppler in the diagnosis of female urethral diverticula. Scand J Urol Nephrol. 1994;28(1):101–4.PubMedCrossRefGoogle Scholar
  20. 20.
    Porpiglia F, Destefanis P, Fiori C, Fontana D. Preoperative risk factors for surgery of female urethral diverticula. Our experience. Urol Int. 2002;69(1):7–11.PubMedCrossRefGoogle Scholar
  21. 21.
    Saroha V, Dhingra KK, Gupta P, Khurana N. Urethral leiomyoma mimicking a caruncle. Obstet Gynecol. 2010;49(4):523–4.Google Scholar
  22. 22.
    Marshall FC, Uson AC, Melicow MM. Neoplasma and caruncles of the female urethra. Surg Gynecol Obstet. 1960;110:723–33.PubMedGoogle Scholar
  23. 23.
    Kara C, Caglar M, Bozkurt OF, Unsal A. Surgical excision of strangulated urethral prolapse mimicking urethral carcinoma under local anesthesia in a post-menopausal woman. J Lower Genit Tract Disord. 2009;13(2):107–9.CrossRefGoogle Scholar
  24. 24.
    Yang JM, Huang WC. Transperineal sonographic findings in a woman with urethral mucosa prolapse. J Clin Ultrasound. 2004;32(5):261–3.PubMedCrossRefGoogle Scholar
  25. 25.
    Khatib RA, Khalil AM, Tawil AN, Shamseddine AI, Kaspar HG, Suidan FJ. Non-Hodgkin’s lymphoma presenting as a urethral caruncle. Gynecol Oncol. 1993;50(3):389–93.PubMedCrossRefGoogle Scholar
  26. 26.
    Tatemichi Y, Oikawa H, Maesawa C, Ambo J, Sato M, Koike H, Sata T, Fujioka T, Masuda T. Detection of human papillomavirus in a urothelial carcinoma mimicking urethral caruncle. Int J Urol. 2010;17(2):189–91.PubMedCrossRefGoogle Scholar
  27. 27.
    Ozel B, Ballard C. Urethral and paraurethral leiomyomas in the female patient. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17(1):93–5.PubMedCrossRefGoogle Scholar
  28. 28.
    Goldman HB, McAchran SE, MacLennan GT. Leiomyoma of the urethra and bladder. J Urol. 2007;177(5):1890.PubMedCrossRefGoogle Scholar
  29. 29.
    Lee MC, Lee SD, Kuo HT, Huang TW. Obstructive leiomyoma of the female urethra: report of a case. J Urol. 1995;153(2):420–1.PubMedCrossRefGoogle Scholar
  30. 30.
    Fasih N, Prasad Shanbhogue AK, Macdonald DB, Fraser-Hill MA, Papadatos D, Kielar AZ, Doherty GP, Walsh C, McInnes M, Atri M. Leiomyomas beyond the uterus: unusual locations, rare manifestations. RadioGraphics. 2008;28(7):1931–48.PubMedCrossRefGoogle Scholar
  31. 31.
    Cornella JL, Larson TR, Lee RA, Magrina JF, Kammerer-Doak D. Leiomyoma of the female urethra and bladder: report of twenty-three patients and review of the literature. Am J Obstet Gynecol. 1997;176(6):1278–85.PubMedCrossRefGoogle Scholar
  32. 32.
    Ikeda R, Suga K, Suzuki K. MRI appearance of a leiomyoma of the female urethra. Clin Radiol. 2001;56(1):76–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Berrocal T, Lopez-Pereira P, Arjonilla A, Gutierrez J. Anomalies of the distal ureter, bladder and urethra in children: embryologic, radiologic, and pathologic features. RadioGraphics. 2002;22:1139–64.PubMedCrossRefGoogle Scholar
  34. 34.
    Prasad N, Vivekanandhan KG, Ilangovan G, Prabakaran S. Duplication of the urethra. Pediatr Surg Int. 1999;15:419–21.PubMedCrossRefGoogle Scholar
  35. 35.
    Sarnelli G, D’Urso L, Muto G. Intermittent bladder urinary retentionin a young woman. An unusual presentation of partial urethral duplication. Int Braz J Urol. 2005;31(3):259–61.PubMedCrossRefGoogle Scholar
  36. 36.
    Elmore JM, Wilson TS, Zimmern PE. Adult presentation of complete female urethral duplication. Br J Urol Int. 2003;92(S3):e13.Google Scholar
  37. 37.
    Yu NC, Raman SS, Patel M, Barbaric Z. Fistulas of the genitourinary tract: a radiologic review. RadioGraphics. 2004;24(5):1331–52.PubMedCrossRefGoogle Scholar
  38. 38.
    Lee RA, Symmonds RE, Williams TJ. Current status of genitourinary fistula. Obstet Gynecol. 1988;72(3):313–9.PubMedGoogle Scholar
  39. 39.
    Takamatsu H, Noguchi H, Tahara H, Kajija H, Kaji T, Ikee T, Yoshioka T, Akiyama H. Ano-Urethral fistula, a special type of anomaly: report of two cases. Surg Today. 1993;23(12):1116–8.PubMedCrossRefGoogle Scholar
  40. 40.
    Thompson IM, Marx AC. Conservative therapy of rectourethral fistula: 5 year follow-up. Urology. 1990;35:533–6.PubMedCrossRefGoogle Scholar
  41. 41.
    Culkin DJ, Ramsey CE. Urethrorectal fistula: transanal, transsphincteric approach with locally based pedicle interposition flaps. J Urol. 2003;169(6):2181–3.PubMedCrossRefGoogle Scholar
  42. 42.
    Jafri SZ, Roberts JL, Berger BD. Fistulas of the genitourinary tract. In: Pollack HM, McClennan BL, editors. Clinical urography. Philadelphia: Saunders; 2000. p. 2992–3011.Google Scholar
  43. 43.
    Ghadimi-Mahani M, Dillman JR, Pai D, Park J, DiPietro M. MRI of congenital urethroperineal fistula. Pediatr Radiol. 2010;40(S1):S1–5.PubMedCrossRefGoogle Scholar
  44. 44.
    Avritscher R, Madoff DC, Ramirez PT, Wallace MJ, Ahrar K, Morello Jr FA, Gupta S, Murthy R, Wright KC, Hicks ME. Fistulas of the lower urinary tract: percutaneous approaches for the management of a difficult clinical entity. RadioGraphics. 2004;24:S217–36.PubMedCrossRefGoogle Scholar
  45. 45.
    Fernbach SK, Feinstein KA, Spencer K, Lindstrom CA. Ureteral duplication and its complications. RadioGraphics. 1997;17:109–27.PubMedCrossRefGoogle Scholar
  46. 46.
    Takeuchi M, Matsuzaki K, Nishitani H. Clear cell adenocarcinoma of the female urethra: magnetic resonance imaging. J Comput Assist Tomogr. 2009;33(1):142–4.PubMedCrossRefGoogle Scholar
  47. 47.
    Dodson MK, Cliby WA, Keeney GL, Peterson MF, Podratz KC. Skene’s gland adenocarcinoma with increased serum level of prostate-specific antigen. Gynecol Oncol. 1994;55(2):304–7.PubMedCrossRefGoogle Scholar
  48. 48.
    Reis LO, Billis A, Ferreira FT, Ikari LY, Stellini RF, Ferreira U. Female urethral carcinoma: evidences to origin from Skene’s glands. Urol Oncol. 2011;29(2):218–23.PubMedCrossRefGoogle Scholar
  49. 49.
    Kier R. Nonovarian gynecologic cysts: MR imaging findings. Am J Roentgenol. 1992;158(6):1265–9.CrossRefGoogle Scholar
  50. 50.
    Eilber KS, Raz S. Benign cystic lesions of the vagina: a literature review. J Urol. 2003;170(3):717–22.PubMedCrossRefGoogle Scholar
  51. 51.
    Moulopoulos LA, Varma DG, Charnsangavej C, Wallace S. Magnetic resonance imaging and computed tomography appearance of asymptomatic paravaginal cysts. Clin Imaging. 1993;17(2):126–32.PubMedCrossRefGoogle Scholar
  52. 52.
    Hahn WY, Israel GM, Lee VS. MRI of female urethral and periurethral disorders. Am J Roentgenol. 2004;182(3):677–82.CrossRefGoogle Scholar
  53. 53.
    Liang CC, Tsai CC, Chen TC, Soong YK. Management of perineal endometriosis. Int J Gynecol Obstet. 1996;53:261–5.CrossRefGoogle Scholar
  54. 54.
    Kuligowska E, Deeds 3rd L, Lu 3rd K. Pelvic pain: overlooked and underdiagnosed gynecologic conditions. RadioGraphics. 2005;25(1):3–20.PubMedCrossRefGoogle Scholar
  55. 55.
    Coutinho Jr A, Bittencourt LK, Pires CE, Junqueira F, Lima CM, Coutinho E, Domingues MA, Domingues RC, Marchiori E. MR imaging in deep pelvic endometriosis: a pictorial essay. RadioGraphics. 2011;31(2):549–67.PubMedCrossRefGoogle Scholar
  56. 56.
    Umaria N, Olliff JF. Imaging features of pelvic endometriosis. Br J Radiol. 2001;74(882):556–62.PubMedCrossRefGoogle Scholar
  57. 57.
    Carr LK, Herschorn S, Leonhardt C. Magnetic resonance imaging after intraurethral collagen injected for stress urinary incontinence. J Urol. 1996;155(4):1253–5.PubMedCrossRefGoogle Scholar
  58. 58.
    Olsen AL, Smith VJ, Bergstrom JO, Collins JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997;89(4):501–6.PubMedCrossRefGoogle Scholar
  59. 59.
    Pannu HK, Kaufman HS, Cundiff GW, Genadry R, Bluemke DA, Fishman EK. Dynamic MR imaging of pelvic organ prolapse: spectrum of abnormalities. RadioGraphics. 2000;20(6):1567–82.PubMedCrossRefGoogle Scholar
  60. 60.
    Goh V, Halligan S, Kaplan G, Healy JC, Bartram CI. Dynamic MR imaging of the pelvic floor in asymptomatic subjects. AJR Am J Roentgenol. 2000;174:661–6.PubMedCrossRefGoogle Scholar
  61. 61.
    Barbaric ZL, Marumoto AK, Raz S. Magnetic resonance imaging of the perineum and pelvic floor. Top Magn Reson Imaging. 2001;12:83–92.PubMedCrossRefGoogle Scholar
  62. 62.
    Yang A, Mostwin JL, Rosenshein NB, Zerhouni EA. Pelvic floor descent in women: dynamic evaluation with fast MR imaging and cinematic display. Radiology. 1991;179:25–33.PubMedCrossRefGoogle Scholar
  63. 63.
    Healy JC, Halligan S, Reznek RH, Watson S, Phillips RKS, Armstrong P. Patterns of prolapse in women with symptoms of pelvic floor weakness: assessment with MR imaging. Radiology. 1997;203:77–81.PubMedCrossRefGoogle Scholar
  64. 64.
    Lienemann A, Anthuber C, Baron A, Kohz P, Reiser M. Dynamic MR colposcytorectography assessing pelvic floor descent. Eur Radiol. 1997;7:1309–17.PubMedCrossRefGoogle Scholar
  65. 65.
    Kelvin FM, Hale DS, Maglinte DDT, Patten BJ, Benson JT. Female pelvic organ prolapse: diagnostic contribution of dynamic cystoproctography and comparison with physical examination. AJR Am J Roentgenol. 1999;173:31–7.PubMedCrossRefGoogle Scholar
  66. 66.
    Boyadzhyan L, Raman SS, Raz SR. Role of static and dynamic MR imaging in surgical pelvic floor dysfunction. RadioGraphics. 2008;28(4):949–67.PubMedCrossRefGoogle Scholar
  67. 67.
    Comiter CV, Vasavada SP, Barbaric ZL, Gousse AE, Raz S. Grading pelvic prolapse and pelvic floor relaxation using dynamic magnetic resonance imaging. Urology. 1999;3:454–7.CrossRefGoogle Scholar
  68. 68.
    Weber AM, Abrams P, Brubaker L, et al. The standardization of terminology for researchers in female pelvic floor disorders. Int Urogynecol J. 2001;12:178–86.CrossRefGoogle Scholar
  69. 69.
    Baessler K, Maher CF. Mesh augmentation during pelvic-floor reconstructive surgery: risks and benefits. Curr Opin Obstet Gynecol. 2006;18(5):560–6.PubMedCrossRefGoogle Scholar
  70. 70.
    Elsayes KM, Mukundan G, Nara VR, Abou El Abbass HA, Prasad SR, Brown JJ. Endovaginal magnetic resonance imaging of the female urethra. J Comput Assist Tomogr. 2006;30(1):1–6.Google Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Laura Elizabeth Traube
    • 1
    Email author
  • Vinika Chaudhari
    • 2
  • Maitraya K. Patel
    • 3
  • Steven S. Raman
    • 4
  1. 1.Department of RadiologyRonald Reagan UCLA Medical CenterLos AngelesUSA
  2. 2.Department of Radiological SciencesRonald Reagan UCLA Medical CenterLos AngelesUSA
  3. 3.Department of RadiologyOlive View – UCLA Medical CenterSylmarUSA
  4. 4.Department of RadiologyRonald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLALos AngelesUSA

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