URETHRA

Imaging Methods
The urethra is studied by retrograde and voiding urethrography (Fig. 34.29) (17). The retrograde
urethrogram is a simple study of the anterior male urethra. Contrast medium is injected into the
anterior urethra by means of a syringe or catheter that occludes the meatal orifice. Films are
exposed in the right posterior oblique projection. The anterior urethra normally distends fully
because of resistance of the external sphincter at the level of the urogenital diaphragm. Complete
filling of the posterior urethra is not possible because contrast runs freely into the bladder.
Voiding cystourethrography is performed by filling the bladder with contrast via a catheter. The
catheter is removed, and films are obtained while the patient urinates into a basin on the
fluoroscopy table. The voiding urethrogram demonstrates distension of both the posterior and
anterior urethra. Radiographic study of the female urethra may be conducted by voiding
cystourethrogram or by retrograde urethrogram with a specially designed double-balloon
catheter. The female urethra is also well studied by transrectal or perineal US and by CT and MR
(18,19).

FIGURE 34.29. Normal Male Urethra. A. Retrograde urethrogram (RUG). B. Voiding

cystourethrogram (VCUG). The anterior urethra consists of the penile and bulbous urethra. The
penile urethra (PU) extends from the urethral meatus to the suspensory ligament of the penis
(straight arrows) at the penoscrotal junction. The bulbous urethra (BU) extends from the
penoscrotal junction to the urogenital diaphragm (curved arrows), marked by the tip of the cone
on the RUG and the slight narrowing of urethral caliber on the VCUG. The posterior urethra
consists of the membranous urethra and the prostatic urethra. The membranous urethra (curved
arrows) is only 1 cm in length and is entirely within the muscle of the urogenital diaphragm. On
a RUG, the membranous urethra extends between the tip of the cone and the verumontanum. The
verumontanum (arrowheads) is a nodular structure that produces a filling defect on the
urethrograms by bulging into the prostatic urethra. The prostatic urethra extends from the inferior
aspect of the verumontanum to the base of the bladder (B).
Anatomy
The male urethra is divided into posterior and anterior portions by the inferior aspect of the
urogenital diaphragm (Fig. 34.29). The posterior urethra consists of the prostatic urethra within
the prostate gland, from the bladder neck to urogenital diaphragm, and the short membranous
urethra, which is totally contained within the 1-cm thick urogenital diaphragm. The anterior
urethra extends from the urogenital diaphragm to the external urethral meatus. It consists of the
bulbous urethra, which extends from the urogenital diaphragm to the penoscrotal junction, and
the penile urethra, which extends to the urethral meatus. The anterior urethra is entirely
contained within the corpus spongiosum penis, except for the proximal 2 cm of the bulbous
urethra, called the pars nuda. The prostatic urethra runs vertically through the prostate over a
length of 3 to 4 cm. An oval filling defect in the midportion of the posterior wall is the
verumontanum. The ejaculatory ducts open into the urethra on either side of the verumontanum,
and the prostatic glands empty into the urethra by multiple small openings that surround the
verumontanum. The utricle, a mllerian remnant, is a small, saccular depression in the middle
of the verumontanum. The distal end of the verumontanum marks the beginning of the
membranous urethra, which extends to the apex of the cone of the bulbous urethra. The voluntary
external urethral sphincter within the urogenital diaphragm entirely surrounds the membranous
urethra. The Cowper glands are pea-sized accessory sex glands within the urogenital diaphragm
on either side of the membranous urethra. Their ducts empty into the bulbous urethra 2 cm
distally (Fig. 34.30).
On retrograde urethrography, the bulbous urethra tapers to a cone shape as the urethra enters the
external sphincter. The apex of the cone marks the division between the membranous and
bulbous urethra. The penoscrotal junction, which divides the bulbous and penile
P.906

urethra, is marked by the suspensory ligament of the penis, which causes a normal bend in the
urethra. The entire anterior urethra is lined by the glands of Littre (see Fig. 34.32), whose
secretions lubricate the urethra. Cowper ducts and the utricle occasionally fill with contrast
during urethrography in a normal patient; however, the filling of these structures with contrast
occurs much more commonly in the presence of urethral strictures. Visualization of the glands of
Littre is always abnormal and is associated with chronic inflammation and urethral stricture.
Reflux of contrast into the prostatic ducts is also abnormal and is associated with prostatitis and
distal urethral stricture.
FIGURE 34.30. Cowper Glands. Radiograph from a voiding cystourethrogram shows filling of
the ducts to Cowper glands. The glands (thin arrow) are in the urogenital diaphragm, and their
ducts (wide arrow) drain into the bulbous urethra (BU). The verumontanum (arrowhead)
produces its usual filling defect in the contrast column.
The female urethra varies in length from 2.5 to 4 cm. The urethra is embedded in the anterior
wall of the vagina and is lined throughout by periurethral glands. On MR, the urethra is
isointense with the vaginal muscle on T1WIs. On T2WIs, the normal urethra demonstrates a
characteristic target appearance (Fig. 34.31), with dark inner and outer rings and a middle zone
of high signal intensity. The middle zone corresponds to highly vascular submucosa and
enhances markedly with gadopentetate administration. The dark inner zone is mucosa, and the
dark outer zone is urethral smooth muscle.
Pathology
Urethral strictures are abnormal narrowings of the urethra caused by fibrous scar tissue. They
may involve the entire urethra or only a small portion. Abrupt, short-segment strictures are
usually traumatic. Long-segment strictures may be either traumatic or inflammatory (Fig. 34.32).
Causes of traumatic urethral strictures include instrumentation, indwelling catheters,
prostatectomy procedures, chemical injury (podophyllin), straddle injuries (usually of the
bulbous urethra), and pelvic fractures. Most inflammatory strictures are attributable to gonorrhea.
Bacteria become sequestered in the glands of Littre and incite the formation of granulation tissue
and fibrosis. Additional etiologies include chlamydia, mycoplasma, tuberculosis, and
schistosomiasis. Complications of urethral strictures include the following:
FIGURE 34.31. Normal Female Urethra. T2WI demonstrates the zonal anatomy of the female
urethra (arrow) in the anterior wall of the vagina (arrowhead). The outer smooth layer is low
signal (dark), the submucosal layer is moderately bright, and the central mucosa is dark. The
rectum (R) is seen posteriorly.

FIGURE 34.32. Urethral Strictures, Glands of Littre. Retrograde urethrogram demonstrates

multiple strictures in the penile and bulbous urethra. Filling of the glands of Littre (arrow) is
evidence of urethritis. This patient had a history of multiple episodes of gonorrhea.
FIGURE 34.33. Carcinoma of the Penile Urethra. Sagittal MR image shows recurrent squamous
cell carcinoma as abnormal low signal (arrow) filling and distending the penile urethra within the
corpus spongiosum. This patient has already experienced partial resection of the tip of his penis
for carcinoma. One of the corpora cavernosa (cc) is seen anteriorly. A normal testis (T) is also
shown.
P.907

Periurethral abscess usually develops on the ventral surface and may drain into the lumen
or onto the skin, creating a periurethral fistula.

False passage is the most common complication of urethral stricture. It is usually

iatrogenic because of attempted passage of catheters or instruments past the obstruction.

Stasis and infection may cause disease of the more proximal urinary tracts, including
hydronephrosis, bladder hypertrophy, calculi, and chronic inflammation.

Carcinoma of the urethra occurs as a complication of chronic urethritis and stricture.

Carcinomas may appear as filling defects in the urethra or as changes in appearance of
the stricture. Most are squamous cell carcinomas and most involve the anterior urethra.
MR is the imaging method of choice for showing extent of tumor (Fig. 34.33). Rare
tumors of the posterior urethra are usually TCCs that occur as part of multiple
uroepithelial neoplasia.