MR of the Urethra 20 th Annual Summer Practicum SCBT-MR Jackson Hole August 11, Evan S. Siegelman MD University of Pennsylvania Medical Center

Transcription

1 MR of the Urethra 20 th Annual Summer Practicum SCBT-MR Jackson Hole August 11, 2010 Evan S. Siegelman MD University of Pennsylvania Medical Center

2 MR of the urethra Normal Anatomy Urethral Diverticula Skene Gland Cysts Urethral Neoplasms Urethral Descent

3 Periurethral Diseases Periurethral Collagen Gartner Duct Cyst

4 Urethral Anatomy Length: cm Bladder neck external urethral meatus at vaginal opening Lined by periurethral glands Mid to Distal urethra Drain via ducts that empty posterior and lateral

5 Urethral Anatomy on T2-WI From Inside Out High SI Center: mucin/fluid Inner Low SI :smooth muscle High SI vascularized submucosa Outer Low SI Striated muscle

6 Female Urethral Diverticula Etiology Infection and obstruction of periurethral glands Form suburethral cysts or abscesses Communication with urethral lumen Pooling of urine diverticulum Prevalance: : 0.5 5% overview

7 Female Urethral Diverticula The 3D s s of urethral diverticula: Dysuria recurrent UTI (30-50%) Dyspareunia (10%) Dribbling (25%) (post-void) 50-60% have urinary incontinence Rovner, E. S. (2007). "Urethral diverticula: a review and an update." Neurourol Urodyn 26(7):

8 Complication: Urethral Diverticula Infection abscess Stones: 1-10% 1 10% Bladder outlet obstruction Malignancy Adenocarcinoma

9 Female Urethral Diverticula Diagnostic Delays 46 Consecutive Women Mean time between onset of symptoms and diagnosis: 5 years Mean # physicians consulted: 9 Cornell. Urethral diverticulum in women: diverse presentations resulting in diagnostic delay and mismanagement. J Urol 2000; 164:

10 Urethral Diverticula: : Surgery Transurethral Saucerization: : Convert narrow neck to wide (distal tics ) Marsupialize diverticulum into vagina (distal tics ) Transvaginal excision Martius Flap if extensive, recurrent or stress incontinence A tertiary experience of urethral diverticulectomy: diagnosis, imaging and surgical outcomes. BJU Int 2009; 103:

11 Urethral Diverticula: : MR appearance Uncomplicated: T1 SI, T2 SI Infected: Variable T1 and T2 SI, fluid fluid levels Calculi: T1 SI, T2 SI Location: Posterior mid urethra Give location, including location relative to bladder base Identify diverticular neck

12 Skene Glands Paired Glands that empty at the level of the urethral orifice Originate from the urogential sinus Prostate Gland in Men Skene AJC. The anatomy and the pathology of two important glands of the female urethra. Am J Obstet 1880; 13 : 265.

13 Skene Gland

14 Skene Gland Cysts Similar to urethral diverticula Distal in location Complication: Infection Skene AJC. The anatomy and the pathology of two important glands of the female urethra. Am J Obstet 1880; 13 : 265.

15 Urethral Malignancy National Cancer Institute Surveillance, Epidemiology, and End Results database (SEER): Annual age adjusted incidence rate Men: 4.3/million; women: 1.5/million TCC (55%), SCC (21%) Adeno (16%), Incidence of primary urethral carcinoma in the United States. Urology 2006; 68:

16 Urethral Descent MR technique: Dynamic Scan with and without Valsalva Single Shot FSE Steady State Free Precession Reference: Pubococcygeal Line Inferior symphysis pubis to last joint space of the coccyx MRI of the urethra in women with lower urinary tract symptoms: spectrum of findings at static and dynamic imaging. AJR Am J Roentgenol 2009; 193:

17 Urethrocele Urethral Descent Descent below pubococcygeal line < 2 cm descent mild < 4 cm moderate, > 4 cm: severe Urethral Hypermobility Horizontal translation away from normal vertical axis > 30 mild, > 45 severe AJR Am J Roentgenol 2009; 193:

18 Periurethral Bulking Agents Treatment for incontinence Collagen ( Contigen Bard Inc) Graphite coated beads Periurethral soft tissue masses Don t t misdiagnose as cancer Collagen injection for female urinary incontinence after urethral or periurethral surgery. J Urol 2009; 181: Urethral bulking agents: imaging review. AJR Am J Roentgenol 2005; 185:

19 Gartner Duct Cyst Remnant of the Wolffian Duct (mesonephric duct) Location: Anterior lateral aspect of proximal vagina Most asymptomatic Association with ipsilateral Mullerian agenesis (e.g. ectopic ureterocole communicaton)

20 Wolffian Ducts In men, think Gardener s s Seed Seminal Vesicles Epididymis Ejaculatory Ducts Ductus deferens Women: proximal duct: Epoophoron origin of parovarian cyst

21 Gartner s s Duct Cyst Anterior Lateral Proximal Vagina Most Low T1, High T2 No communication with urethra

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23 Samuel Clemens: Mark Twain Born: 175 years ago Died: 100 years ago: 1910 Huck Finn: Published 125 years ago: 1885

24 Samuel Clemens: Mark Twain I I was gratified to be able to answer promptly and I did I I said I didn t t know

25 2009 ACR Inservice GU Question 63 SCBT-MR 2010 CME Question Regarding female urethral diverticula,, which of the following statements is true 1. 20% of patients have urinary incontinence 2. Most cases are congenital in origin 3. They often have a saddle-bag configuration 4. The most sensitive test is a voiding cystourethrography

26 CME Answer: C 60% have urinary incontinence 30-50% have repeated UTIs