Bennett et al. Their inflammation and disturbance of drainage into the urethra may also promote formation of diverticula in the distal part of the urethra. From a study group of 60 patients (mean age, 44 years), 20 patients (33%) had urethral diverticula and 28 (47%) had an alternative diagnosis, of which 13 (46%) were visualized with MRI. The disadvantages of this modality are that most diverticular necks were identified using the transurethral approach, which is not as convenient for the patient and is not as readily available as transvaginal and transperineal sonography [10]. MRI of Rectal Cancer: An Overview and Update on Recent Advances, Review. Two urethral diverticula showed partly sharp and partly ill-defined margins. Institutional review board approval was obtained for this retrospective study, and informed consent was waived. Other studies reported urethral diverticula in 10% of patients examined with endorectal coil MRI or 74% of patients examined with a combination of transvaginal, transperineal, and urethral sonography (using a catheter-based transducer) [9, 10]. The phased-array coil is a commercially available four-channel coil (Synergy, Philips Healthcare) placed around the pelvis. On the basis of MRI; clinical evaluation, including video urodynamics; and clinical data, 80% of patients were diagnosed with an abnormality that was responsible for their complaints. UD most often occurs in women; symptoms can include pain, frequent urinary tract infections, blood in urine and incontinence. Twenty patients had a total of 27 diverticula; these were mostly locally round (n = 12) with sharp margins (n = 25) and high (n = 19) homogeneous (n = 16) signal intensity on T2-weighted sequences. Image quality of the urethra and periurethral region performed with the endoluminal coil was compared with the pelvic phased-array coil. Urethroscopy and/or magnetic resonance imaging are/is widely used for its identification. Resident’s teaching files: MR imaging diagnosis of a urethral diverticulum. Twenty-three identified ostia of urethral diverticula by both observers were imaged with the endoluminal coil placed in the vagina (17 of 18 diverticula), or anal canal (2 of 2 diverticula), or with the pelvic phased-array coil (4 of 7 diverticula). She did not report any dysuria, vaginal discharge, fever, or abdominal pain. 1, 5 Orthogonal planes aid in finding the neck, which makes the diagnosis definitive. Surgery was performed in the majority of patients (80%), with urethral diverticula proved. Location of the seminal hillock varies from the middle to the most distal part of the rear urethra. Urinalysis was within normal limits. Imaging is essential before surgery is planned. The agreement was 93% (25/27) with κ = 0.72. At endoluminal MRI, image volume encompassed the entire sensitive region of coil. Dedicated MRI is an excellent imaging modality for urethral diverticula; furthermore, MRI will show the alternative diagnosis in almost one half of the remaining patients. Coronal and sagittal T2-weighted fast spin-echo MRI was performed without fat saturation (TR/TE, 2454/100; matrix, 186 × 256; flip angle, 90°; FOV, 120 mm; section thickness, 4 mm with a 0.4-mm gap; and four signals acquired). 2013 Apr 3. . In the remaining patients, MRI findings of urethral diverticula were confirmed with a second imaging modality (video urodynamic studies and voiding cystourethrography) and considered proved by clinical examination and evaluation by the urologist. CONCLUSION: MR imaging is accurate for showing urethral diverticula, but owing to its high cost, it should be considered only when urethroscopic or urethrographic findings are equivocal or when patients are unable to undergo these procedures and clinical findings strongly suggest a urethral diverticulum. The reference standard was surgery or, in case no surgery was performed, confirmation of MRI findings with a second imaging modality, including video urodynamic studies and voiding cystourethrography and clinical examination. More acceptable are explanations stating that recurrent infections and obstruction of paraurethral glands cause development of suburethral cysts. A kappa value ≤ 0.20 was interpreted as slight agreement; 0.21–0.40, fair agreement; 0.41–0.60, moderate agreement; 0.61–0.80, substantial agreement; and ≥ 0.81, almost perfect agreement. To our knowledge, this type of urethral diverticula with its elongated nature has not been described before. An MRI is the imaging test of choice to further evaluate the details, location and complexity of urethral diverticula. The rear urethra forms a right or a little greater angle with the front urethra and extends as far as the bladder bottom. Of 25 MRI examinations with findings of urethral diverticula, 19 were performed with the endoluminal coil placed in the vagina (n = 17) or anal canal (n = 2), and 6 examinations were performed with the pelvic phased-array coil (Table 1). 27 urethral diverticula on 25 different MRI Fig. The only study we found to clearly identify the ostium of urethral diverticula in the majority of cases used a combination of transvaginal, transperineal, and urethral sonography (using a catheter-based transducer) in 19 women with urethral symptoms [10]. We believe that functional aspects of the pelvic floor and supporting ligaments of the bladder base and urethra may be a cause for the complaints in these patients. Periurethral scarring, urethrovaginal fistula, infected cyst of Skene, cystocele, and endometriosis of the vaginal vault were confirmed by surgery. Transverse T2-weighted fast spinecho MRI was performed with and without fat saturation (TR/TE, 5086/100; matrix, 186 × 256; flip angle, 90°; FOV, 120 mm; section thickness, 4 mm with a 0.4-mm gap; and three signals acquired). Diverticulum wall consists of the same layers as the ureter. For the pelvic phased-array coils, parameters were transverse, coronal, and sagittal T2-weighted fast spin-echo sequences without fat suppression (TR/TE, 2500/70; matrix, 512 × 256; flip angle, 60°; FOV, 300 mm; section thickness and gap, 3 mm and 0.3 mm, respectively; and two signals acquired) and transverse T2-weighted fast spin-echo with fat suppression (TR/TE, 4000/85; matrix, 512 × 256; flip angle, 60°; FOV, 300 mm; section thickness and gap, 3 mm and 0.3 mm, respectively; and two signals acquired). Their course and diagnostics depend on anatomic peculiarities of the male and female urethra (Figs. Asterisk indicates endoluminal coil, A = anus. Although a limited number of patients in our study was examined with the endoluminal coil placed in the anal canal or with the pelvic phased-array coil, a qualitative comparison suggests better image quality of the urethra and periurethral region with the endoluminal coil placed in the vagina (Table 1 and Figs. MRI and Other Tests for Urethral Diverticulum. Previous MRI studies of symptomatic female urethral and periurethral diseases were based on the use of the pelvic phased-array coil or the inflatable endoluminal coil placed in the vagina or in the rectum. The differentiation between a communicating or noncommunicating cystic lesion with the urethra is important because the surgical approach for the two entities differs. With the development of new technology and sophisticated imaging techniques, it has become much easier to correctly diagnose urethral diverticulum. In conclusion, there is an expanding role for dedicated MRI in women with suspicion of urethral diverticula. Notice there is no density in the region of the urethra, thus excluding a calcified stone in the urethra. The upper and the lower poles of the seminal hillock pass into the urethral crest which is several millimeters wide and gradually flattens in the distal and proximal directions. Female urinary bladder and urethra (a schematic drawing). Once a doctor reviews your health history, symptoms, and does a physical exam, an MRI is typically performed to confirm a urethral diverticulum diagnosis. In the remaining nine surgical cases, identification and excision of urethral diverticula, including the diverticular neck, was documented. The top of the tapered end of the front urethra passes into the rear urethra which upon retrograde XRCM introduction expands to a width of several millimeters and has a slight bent with incurvity in the front. Inhomogeneous signal intensity was found in diverticula containing debris (n = 9) (Fig. These patients had a total of 19 surgical procedures for urethral diverticula, including three patients with recurrent or residual urethral diverticula. 4A and 4B). A, Axial T2-weighted image shows subtle linear structure (arrow) with high signal intensity within submucosal layer of urethra posteriorly, indicating location of ostium of urethral diverticulum. Kim et al. There are reasons to believe that paraurethral glands get infected by the normal vaginal flora. 11.2 Diagram of urethral diverticulum. Twenty-eight of 60 patients (47%) had an alternative diagnosis. The endoluminal coil is commercially available and consists of a fixed, rectangular, 60-mm-long rigid receiver coil with a width of 16 mm. With intraanal placement of the endoluminal coil, the urethra falls slightly outside the sensitive region of the coil, whereas the perianal region is displayed in great detail (Fig. CORONAL in and out of phase (Large FOV entire pelvis) 3. Finally, there was no uniform reference standard. Urethral diverticulum is often an incidental finding. From the pathogenetic point of view, it was explained as follows: The layer of the inner urethral muscles was ruptured under the pressure created by the fetus head or obstetric forceps which resulted in the formation of a hernia or a diverticulum. Their course and diagnostics depend on anatomic peculiarities of the male and female urethra (Figs. At the same time there are judgments supporting the acquired UTHD genesis. To identify and to assess imaging and clinical features of Posterior urethral diverticula (PUD) in a single-centre series and include a brief review of literature. Complications of urethral diverticulum may also be evident on MRI. A 26-year-old nulliparous woman presented to her gynecologist with a nontender lump in the lateral aspect of the vagina. Diverticula result from inflammatory obstruction of or trauma to the periurethral glands that subsequently ruptures into the urethral lumen. The ostium of urethral diverticula was identified in 23 diverticula (85%) by both readers. Malignancy arising from a diverticulum can be visualized as enhancing soft tissue within the diverticulum [14]. No physical abnormalities were found on MRI and in the clinical follow-up. In the clinical workup, which included palpation and massage of the urethra through the vagina, the diagnosis of urethral diverticula was considered confirmed and proved by the urologist as was documented in patients' records. If UTHD are congenital, can they result from infections, childbearing, or even from iatrogeny? This opening may vary in size and location; it may be located in any area between the external and internal urethral orifices; however, its most common location is the front part of the urethral duct (Figs. At the beginning of the previous century, a birth trauma was considered to be the cause of their formation. Risk factors for a urethral diverticulum include female gender, pelvic trauma, and periurethral procedures, but there are no data to quantify these risks . Nevertheless, we believe that adequate imaging and clinical follow-up information was available for all patients, and therefore we consider our conclusions valid. The seminal hillock at the back wall of the prostatic urethra forms a spindle-shaped bulging. BJU Int. Urethral diverticula are thought to result most commonly from rupture of chronically infected and obstructed periurethral glands into the urethral lumen. If the urethra is unchanged, the prostatic and other paraurethral passages can be seen in retrograde urethrograms only under excessively strong pressure during XRCM introduction or through artificial blockade of the urinary bladder neck. Appropriate investigations play an important role in the diagnosis of urethral diverticula and ideally should provide the surgeon with information regarding location, number, size, configuration, and communication of the urethral diverticula [8]. During urination the rear urethra lowers due to lowering of the pelvic floor. We identified 60 patients (all women; mean age, 44 years; age range, 18–80 years) who fulfilled the criteria for inclusion in the study population. Both observers were of opinion that contrast-enhanced studies had no additional value for the diagnosis of urethral diverticula (Figs. MATERIALS AND METHODS. The sides of the crest are supracollicularly formed by two shallow grooves which reach the neck of the bladder. All patients had two or more lower urinary tract symptoms, including pain, urinary incontinence, dyspareunia, and frequency or urgency. MRI showed the final diagnosis (urethral diverticula or alternative diagnosis) in 33 of 60 patients (55%).