J Clin Ultrasound 20:221-223, MarcWApril 1992 0 1992 by John Wiley & Sons, Inc. CCC 0091-2751/92/030221-03$04.00
Case Report
Transperineal Sonography in the Assessment of a Urethral Diverticulum Karen L. Reuter, MD,*,t Stephen B. Young, MD,t and Jay Colby, MD*
Transperineal sonography has been described for the evaluation of vaginal atresia in young women because transvesical sonography has not provided adequate evaluation of the entire length of the vagina. 1,2 Transperineal sonography has also been used to visualize the cervix during the third trimester of pregnancy when the cervix is sometimes obscured by fetal parts or a large maternal body habitus-or the cervix is artificially elongated by a distended bladder.3 To our knowledge, transperineal sonography has not been described as an imaging technique for periurethral evaluation, such as for urethral diverticula. We performed this technique after the diverticulogram to further evaluate the origin of the sac, to characterize it, to determine if there are loculations, and to try t o image any other smaller sac in the periurethral area.
opercula between 5 o’clock and 7 o’clock, with 3 tiny openings in a vertical linear pattern at 6 o’clock, separated from the 5 and 7 o’clock operculae by 2 vertical ridges. Digital pressure on the right parauretheral cyst resulted in the expression of purulent material from the 7 o’clock opening, suggesting the diagnosis of an infected urethral diverticulum. A diverticulogram via high pressure urethrography with the Davis catheter and Urethral Pressure Profilometry were performed. The urethrogram demonstrated contrast filling of a spherical, 30-mm structure immediately adjacent and to the right of the proximal urethra
CASE REPORT
RT a 33-year-old G2, P2, who was 2 months postpartum, presented with minimal symptoms of pressure and a sensation of something pushing to one side in the urethral area. She denied urinary incontinence, urgency, frequency, nocturia, and coital discomfort. A vaginal cystic mass had first been noted at an 8 month prenatal pelvic examination 3 months earlier. It had been drained at delivery but recurred 3 months later. Pelvic physical examination revealed a 3-cm spherical cystic mass arising to the right of the midline. The cyst felt well circumscribed, mobile, and nontender. Urethroscopic evaluation was performed. This procedure revealed 5 posterior, midurethral From the Department of ”Radiology and tobstetrics and Gynecology, University of Massachusetts Medical Center, Worcester, Massachusetts. For reprints contact Karen L. Reuter, MD, Department of Radiology, University of Massachusetts Medical Center, 55 Lake Avenue North, Worcester, MA 01655.
FIGURE 1. The double balloon catheter is seen within the urethra (curved arrow). The diverticulum (straight arrow)fills to the right.
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CASE REPORT: REUTER ET AL.
FIGURE 2. (A) Sagittal transperineal ultrasound image just to the right of the midline through the right labium majorurn shows the fluid-filled urethral diverticulum (straight arrows) with echoes of particulate material (curved arrow) layering toward the left and slightly posteriorly. ( 8 ) Transverse transperineal ultrasound image with the transducer angled inferiorly through the right labium majorum shows the dependent debris in the fluid-filled urethral diverticulum (straight arrows); urethra: open arrow.
(Figure 1).No definite communication with the urethra could be identified on numerous projections. Urethral Pressure Profilometry indicated that marsupializing the diverticulum would be
unsatisfactory; a vaginal excision would have to be performed. Transvesical sonography showed the known urethral diverticulum only with very posterior JOURNAL OF CLINICAL ULTRASOUND
URETHRAL DIVERTICULUM
angulation of the transducer because of the inferior location of the diverticulum. A 16 mm x 18 mm, very echo-poor structure with indistinct borders was seen in a larger oval echogenic mass measuring 26 mm x 30 mm just to the right of the midline. The uterus, ovaries, and bladder appeared normal. Transvaginal ultrasonography was not helpful. However, transperineal ultrasonography (Figure 2) visualized the lesion superbly. A 5-MHz annular array transducer (ATL Mark IV) applied to the right labium majorum demonstrated a 25 mm x 21 mm cystic structure without loculations just to the right of the midline. This cystic structure was clearly irregular in shape and contained echogenic material with a clear level in the left dependent area. No other “cysts” were identified. Three weeks prior to surgery, during a physical examination, pressure was put on the anterior vaginal wall to milk fluid from the known urethral diverticulum. During this maneuver, observation of the operculum through the urethroscope revealed particulate matter with pus flowing through the opening into the urethra. On the day of surgery, the patient reported that the diverticular sac had decreased in size over the previous several days. Examination under anesthesia revealed a 2 cm x 2 cm right, suburethral, partially decompressed cystic structure consistent with the previously confirmed diverticulum. Via an anterior vaginal U-shaped incision, the diverticulum was sharply dissected. Ninety percent of the sac wall was excised, leaving the base for multilayered closure. During surgery, no particulate matter was seen in the diverticulum. DISCUSSION
Transvesical ultrasonography has been used extensively for evaluation of the pelvis because it
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223
provides superb organ detail through the fluidfilled bladder and of the bladder detail itself. In the female the uterus and ovaries, and in the male the prostate, can be well visualized without the use of ionizing radiation. Linear array transrectal scanning has also been used to image the urethra, especially for cases of urinary incontin e n ~ eIn . ~the case presented, the fluid-filled urethral diverticulum was not adequately imaged through a full bladder because of the location of the diverticulum. Transvaginal sonography was not helpful. Transperineal sonography did not disclose the connection between the diverticulum and the urethra. Thus, this modality cannot replace urethroscopy or urethrography. However, transperineal sonography provided precise detail of the diverticulum with its irregular wall and layered contents of particulate debris in the dependent aspect, confirmed through the urethroscope as particulate matter in the pus prior to surgery. This “new” ultrasound modality also confirmed the absence of additional diverticula along the urethra. REFERENCES 1. Scanlon K, Pozniak MA, Fogerholm M, Shapiro S: Value of transperineal sonography in the assessment of vaginal atresia. AJR 154545-548, 1990. 2. Graham D, Nelson MW: Combined perinealabdominal sonography in the evaluation of vaginal atresia. J Clin Ultrasound 14:735-738, 1986. 3. Mahony BS, Nyberg DA, Luthy DA, Hirsch JH, Hickok DE, Petty CN: Translabial ultrasound of the third-trimester uterine cervix. Correlation with digital examination. J Ultrasound Med 9:717-723, 1990. 4. Richmond DH, Sutherst JR, Brown MC: Screening of the bladder base and urethra using linear array transrectal ultrasound scanning. J Clin Ultrasound 14~647-651,1986.
Case Report
Transperineal Sonography in the Assessment of a Urethral Diverticulum Karen L. Reuter, MD,*,t Stephen B. Young, MD,t and Jay Colby, MD*
Transperineal sonography has been described for the evaluation of vaginal atresia in young women because transvesical sonography has not provided adequate evaluation of the entire length of the vagina. 1,2 Transperineal sonography has also been used to visualize the cervix during the third trimester of pregnancy when the cervix is sometimes obscured by fetal parts or a large maternal body habitus-or the cervix is artificially elongated by a distended bladder.3 To our knowledge, transperineal sonography has not been described as an imaging technique for periurethral evaluation, such as for urethral diverticula. We performed this technique after the diverticulogram to further evaluate the origin of the sac, to characterize it, to determine if there are loculations, and to try t o image any other smaller sac in the periurethral area.
opercula between 5 o’clock and 7 o’clock, with 3 tiny openings in a vertical linear pattern at 6 o’clock, separated from the 5 and 7 o’clock operculae by 2 vertical ridges. Digital pressure on the right parauretheral cyst resulted in the expression of purulent material from the 7 o’clock opening, suggesting the diagnosis of an infected urethral diverticulum. A diverticulogram via high pressure urethrography with the Davis catheter and Urethral Pressure Profilometry were performed. The urethrogram demonstrated contrast filling of a spherical, 30-mm structure immediately adjacent and to the right of the proximal urethra
CASE REPORT
RT a 33-year-old G2, P2, who was 2 months postpartum, presented with minimal symptoms of pressure and a sensation of something pushing to one side in the urethral area. She denied urinary incontinence, urgency, frequency, nocturia, and coital discomfort. A vaginal cystic mass had first been noted at an 8 month prenatal pelvic examination 3 months earlier. It had been drained at delivery but recurred 3 months later. Pelvic physical examination revealed a 3-cm spherical cystic mass arising to the right of the midline. The cyst felt well circumscribed, mobile, and nontender. Urethroscopic evaluation was performed. This procedure revealed 5 posterior, midurethral From the Department of ”Radiology and tobstetrics and Gynecology, University of Massachusetts Medical Center, Worcester, Massachusetts. For reprints contact Karen L. Reuter, MD, Department of Radiology, University of Massachusetts Medical Center, 55 Lake Avenue North, Worcester, MA 01655.
FIGURE 1. The double balloon catheter is seen within the urethra (curved arrow). The diverticulum (straight arrow)fills to the right.
22 1
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CASE REPORT: REUTER ET AL.
FIGURE 2. (A) Sagittal transperineal ultrasound image just to the right of the midline through the right labium majorurn shows the fluid-filled urethral diverticulum (straight arrows) with echoes of particulate material (curved arrow) layering toward the left and slightly posteriorly. ( 8 ) Transverse transperineal ultrasound image with the transducer angled inferiorly through the right labium majorum shows the dependent debris in the fluid-filled urethral diverticulum (straight arrows); urethra: open arrow.
(Figure 1).No definite communication with the urethra could be identified on numerous projections. Urethral Pressure Profilometry indicated that marsupializing the diverticulum would be
unsatisfactory; a vaginal excision would have to be performed. Transvesical sonography showed the known urethral diverticulum only with very posterior JOURNAL OF CLINICAL ULTRASOUND
URETHRAL DIVERTICULUM
angulation of the transducer because of the inferior location of the diverticulum. A 16 mm x 18 mm, very echo-poor structure with indistinct borders was seen in a larger oval echogenic mass measuring 26 mm x 30 mm just to the right of the midline. The uterus, ovaries, and bladder appeared normal. Transvaginal ultrasonography was not helpful. However, transperineal ultrasonography (Figure 2) visualized the lesion superbly. A 5-MHz annular array transducer (ATL Mark IV) applied to the right labium majorum demonstrated a 25 mm x 21 mm cystic structure without loculations just to the right of the midline. This cystic structure was clearly irregular in shape and contained echogenic material with a clear level in the left dependent area. No other “cysts” were identified. Three weeks prior to surgery, during a physical examination, pressure was put on the anterior vaginal wall to milk fluid from the known urethral diverticulum. During this maneuver, observation of the operculum through the urethroscope revealed particulate matter with pus flowing through the opening into the urethra. On the day of surgery, the patient reported that the diverticular sac had decreased in size over the previous several days. Examination under anesthesia revealed a 2 cm x 2 cm right, suburethral, partially decompressed cystic structure consistent with the previously confirmed diverticulum. Via an anterior vaginal U-shaped incision, the diverticulum was sharply dissected. Ninety percent of the sac wall was excised, leaving the base for multilayered closure. During surgery, no particulate matter was seen in the diverticulum. DISCUSSION
Transvesical ultrasonography has been used extensively for evaluation of the pelvis because it
VOL. 20, NO. 3, MARCHIAPRIL 1992
223
provides superb organ detail through the fluidfilled bladder and of the bladder detail itself. In the female the uterus and ovaries, and in the male the prostate, can be well visualized without the use of ionizing radiation. Linear array transrectal scanning has also been used to image the urethra, especially for cases of urinary incontin e n ~ eIn . ~the case presented, the fluid-filled urethral diverticulum was not adequately imaged through a full bladder because of the location of the diverticulum. Transvaginal sonography was not helpful. Transperineal sonography did not disclose the connection between the diverticulum and the urethra. Thus, this modality cannot replace urethroscopy or urethrography. However, transperineal sonography provided precise detail of the diverticulum with its irregular wall and layered contents of particulate debris in the dependent aspect, confirmed through the urethroscope as particulate matter in the pus prior to surgery. This “new” ultrasound modality also confirmed the absence of additional diverticula along the urethra. REFERENCES 1. Scanlon K, Pozniak MA, Fogerholm M, Shapiro S: Value of transperineal sonography in the assessment of vaginal atresia. AJR 154545-548, 1990. 2. Graham D, Nelson MW: Combined perinealabdominal sonography in the evaluation of vaginal atresia. J Clin Ultrasound 14:735-738, 1986. 3. Mahony BS, Nyberg DA, Luthy DA, Hirsch JH, Hickok DE, Petty CN: Translabial ultrasound of the third-trimester uterine cervix. Correlation with digital examination. J Ultrasound Med 9:717-723, 1990. 4. Richmond DH, Sutherst JR, Brown MC: Screening of the bladder base and urethra using linear array transrectal ultrasound scanning. J Clin Ultrasound 14~647-651,1986.
