Positive Pressure Urethrography: A Roentgenographic Diagnostic Method for Urethral Diverticula in the Female

The diagnosis of suburethral diverticula in the female has long presented vexing problems to the gynecologist, urologist, and radiologist. Indeed, although the urethra is the most accessible portion of the female genitourinary system, it is the area most infrequently subjected to roentgenographic examination. For the past three years, a new technic of urethrography has been utilized in our clinic, with a marked increase in the diagnosis of this neglected lesion (5, 6). Previous methods for female urethrography have relied either upon the simple injection of a contrast medium with a syringe inserted in the external meatus, or upon voiding urethrograms after instillation of the medium into the bladder (1, 2, 11, 13, 14). In the first instance, there is a rapid reflux of the contrast material past the relatively weak internal sphincter into the bladder; in the second instance, there is rarely adequate filling of known diverticula unless their communication with the urethral lumen be unusually large. The fallacy of the assumption that normal micturition pressure may suffice to fill the diverticulum becomes apparent when one studies numerous pathologic specimens showing the usually extremely narrow openings communicating with the urethra. Still a third method relies upon direct injection of the diverticular orifice at cystoscopy, a difficult and often unfruitful maneuver (7). A wide range of contrast media, from thin barium to viscous iodized oils, have been used for injection (9, 13). This report summarizes experience with 108 examinations by the method of positive pressure urethrography. A special urethrography catheter has been devised, utilizing balloons to obstruct the vesical neck and the external meatus, so that the urethra becomes a closed tube which can be filled with a contrast medium under moderate pressure (5). One or more diverticula have been demonstrated by positive pressure urethrography in 62 examinations, and in only 2 instances was there failure to outline a proved lesion on the initial attempt. A repeat examination was obtained one week later in one of these cases and it is our opinion that the narrow urethral orifice of this diverticulum was occluded when the earlier films were taken. This experience with urethrography as a diagnostic instrument contrasts sharply with reliance on cystoscopic findings alone. Davis and TeLinde (6) reported that in 74 cases of urethral diverticula subjected to cystoscopy, the lesion was never visualized in 12, while in 16 patients four or more unproductive cystoscopies were carried out prior to the discovery of the condition. Diverticula may occur either as simple saccular structures or they may present as complex branching sinus tracts. Some of them may be in intimate association with the internal sphincter. Urethrography is an invaluable tool to the surgeon because it provides a three-dimensional appreciation of such lesions.