Non-contrast-enhanced CT
Uroradiology & genital male imaging
Case TypeClinical Case
Authors
Muhammad Ismail Randeree 1, Simon Liu 2, Ahmad Khayam Saleem 2, Ignatious Menyatsoe 1, Sadeg Bashir Elsadeg Jermy 2
Patient60 years, female
A 60-year-old female presents with a 6-month history of dysuria and difficulty voiding urine. On clinical examination, a hard mass was palpated on the anterior vaginal wall, along the urethra. She was scheduled for a cystoscopy.
Non-contrast enhanced computed tomography of kidneys, ureters, and bladder revealed a large stone with a smooth border, measuring 3 x 3 x 4 cm, a Hounsfield unit density of 1447 within the middle third of the urethra at the level of the vagina (Figures 1a, 1b and 1c, red arrows). There is also an incidental left ovarian cyst measuring 7 x 7 x 6 cm seen on the sagittal image with a Hounsfield unit density of 25 (Figure 1b, red asterisk).
Background
Urethral diverticulum is a local outpouching of the urethral epithelium into the peri-urethral tissue [1]. It is an uncommon condition in females which can occur at any age [2]. Urethral diverticula are generally thought to be an acquired condition rather than congenital, arising from repeated infections and obstruction of the peri-urethral glands, which leads to enlargement of the gland and subsequent abscess formation. The abscess may then burst into the urethral lumen, forming an epithelised cavity with a narrow neck in the urethra [1–3]. Other causes can include traumatic vaginal delivery and iatrogenic injury [2]. It is considered a benign condition, which can be complicated by recurrent urinary tract infections (UTIs), stone formation and malignant transformation [1,2].
Clinical Perspective
Urethral Diverticulum is a difficult diagnosis to make as the symptomatology is varied and non-specific, which often leads to misdiagnosis, such as urinary incontinence and recurrent urinary tract infections, which delay treatment [2]. The classical triad of dysuria, dyspareunia and post-void dribbling are seldom present. Patients most commonly present with recurrent UTIs, urgency, frequency in urination, pelvic pain and a vaginal mass. On clinical examination, an anterior vaginal mass may be felt, which, if compressed, may expel urine from the urethra; however, if a hard mass is felt, it could indicate a stone in the urethral diverticulum or malignancy [1,3].
Imaging Perspective
MRI is considered the gold standard for diagnosing urethral diverticula due to excellent soft tissue contrast that outlines urethral anatomy and related structures. It has demonstrated superior sensitivity and specificity in showing the relationship between the diverticulum and urethra [7]. There are several ways in which MRI can be performed, which include a surface phased array coil or endoluminal coils such as endorectal, endourethral or endovaginal [7].
MRI findings suggestive of urethral diverticula include a hyperintense cystic lesion contiguous to the urethra on T2-weighted imaging, enhancing diverticular walls and septa on contrast-enhanced T1-weighted imaging [7]. When the lesion and the urethral lumen can be visualised communicating, a definite diagnosis can be established.
Outcome
Primary treatment involves surgical removal of both the diverticulum and the calculus, which generally has a good prognosis. Imaging is crucial in planning the surgery as it helps to show the exact size and location of the diverticulum and calculus, allowing for more accurate surgical intervention [6,8]. Detailed imaging improves surgical outcomes and reduces the risk of complications by ensuring the procedure is well-planned [7]. Accurate management of a urethral diverticulum depends on detailed imaging and understanding clinical symptoms. In our case, the diverticulum was demonstrated on cystoscopy (Figure 2a), with the urolithiasis in situ (Figure 2b), and was successfully removed (Figure 2c).
Take Home Message
Urethral diverticulum is an uncommon condition that requires a high index of suspicion to diagnose.
Written informed patient consent for publication has been obtained.
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URL: | https://eurorad.org/case/18702 |
DOI: | 10.35100/eurorad/case.18702 |
ISSN: | 1563-4086 |
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