ascending urethrogram

aug

1. PG: Dr. Nasin Usman Moderator: Dr. Balaji J. ASCENDING URETHROGRAM

2. AUG/RGU AKA Retrograde urethrography (RGU): Iodinated Contrast media are retrogradely injected with urethral orifice occluded to prevent reflux of contrast. Static images are obtained, preferably assessed dynamically using flouriscopy Male urethra best seen in oblique position Female urethra best seen in lateral or anteroposterior position (MCU )

3. ANATOMY Male urethra is 17.5 to 20 cm in length and divided into: The anterior urethra extends from the external meatus to the inferior edge of the urogenital diaphragm - divided into the penile (or pendulous) and bulbous parts at the penoscrotal junction. The posterior urethra is divided into the prostatic and membranous urethrae . Periurethral glands of Littr lie in the anterior urethra. Cowper's glands are two pea-sized glands, which lie within the urogenital diaphragm on each side of the membranous portion of the posterior urethra. Verumontanum (a longitudinal ridge of smooth muscle, urethral crest) on the posterior wall of the posterior urethra, where the paired ejaculatory ducts open.

4. ANATOMY To identify the bulbo -membranous junction : 1 to 1.5cm distal to the inferior margin of the verumontanum when the verumontanum is visible. When the posterior urethra is suboptimally opacified , the bulbomembranous Junction can be arbitrarily localized where an imaginary line connecting with each inferior margin of the obturator foramina intersects the urethra Cowper’s gland and duct Filling of Cowper's duct (figure 5) and/or prostatic ducts should not be misinterpreted as extravasation

5. INDICATIONS Stricture Eg : stricture in the bulbar urethra Urethral trauma 1) Partial urethra injury -- partial disruption of the bulbous urethra demonstrating venous intravasation 2) Complete urethral injury - contrast extravasation from the bulbar urethra throughout the perineum, with no filling of the proximal urethra and bladder.

6. INDICATIONS Fistulae Eg : irregular scarring in the bulbous urethra with a fistula (arrow) extending from the bulbous urethra to the perineum Congenital anomalies Distal bulbar urethral stricture Dilated penile urethra Utricle cyst opening into prostatic urethra

7. INDICATIONS Periurethral / prostatic abscess long segment of irregular, beaded narrowing in the bulbous urethra irregular periurethral cavity originating from the ventral aspect of the bulbous urethra  Abnormal cone of proximal bulbous urethra – indicates scarring extends into the membranous urethra Marked reflux of contrast medium into the dilated open prostatic ducts indicating previous prostatitis and outlet obstruction

8. CONTRAINDICATIONS Recent instrumentation Urethritis UTI (acute)

9. TECHNIQUE 20 ml of HOCM or LOCM (ionic or non-ionic) – warming before procedure reduces onset of spasm of external sphincter Instructed to void prior to procedure Under asp, penile clamp is applied. Eg , Knutssons clamp Foleys / any other catheter is inserted into the meatus Patient positioned in supine RAO 30 with right leg abducted and knee flexed Contrast diluted with 20 ml sterile water Injected continuously and exposure done while last 3-4 ml If the spasm of the external sphincter is so severe as to preclude filling of the posterior urethra, the chance of significant urethral injury is small.

10. C omplications Allergic reactions to contrast (very rare) Acute UTI Urethral trauma/ bleed Intravasation of contrast

11. Urethral injuries - blunt Type I Rupture of the puboprostatic ligaments stretched  post urethra Type II tear of membranous urethra above the urogenital diaphragm No contrast extravasation in perineum Type III combined anterior and posterior urethral injury with disruption of the urogenital diaphragm extravasation into the pelvic extraperitoneal space and the perineum Type IV Bladder neck injury with extension into the urethra where the primary continence sphincter lies Type V Straddle pure anterior urethral injury MC

12. AUG Penile fracture contrast extravasation in the penile urethra 

13. AUG Condyloma acuminata Retrograde urethrogram demonstrates multiple small filling defects in the anterior urethra

14. MALIGNANT TUMORS OF THE URETHRA Location: Bulbomembranous urethra (60%), penile urethra (30%) and prostatic urethra (10%) (10) Histology: squamous cell carcinoma (80%), transitional cell carcinoma (15%), and adenocarcinoma or undifferentiated carcinoma (5%). SCC : Irregularity and narrowing of the bulbous urethra with multiple sinus tracts.

15. AUG Urethral diverticula   Acquired diverticula in males may be found anywhere along the urethra. peno -scrotal junction is the MC site for anterior urethral diverticula . They can occur in patients who have a spinal cord injury as a result of repeated urethral trauma  due to catheterisation

16. THANK YOU