AJR 2004; 182:677-682
© American Roentgen Ray Society
MRI of Female Urethral and Periurethral Disorders
Winnie Y. Hahn1,
Gary M. Israel and
Vivian S. Lee
1 All authors: MRI Department, New York University Medical Center, 530 First
Ave., Basement Schwartz Bldg., New York, NY 10016.
Received May 16, 2003;
accepted after revision July 10, 2003.
Address correspondence to V. S. Lee.
Introduction
MRI is emerging as an important imaging technique in the evaluation of the
female urethra and periurethral soft tissues in women who present with dysuria
or palpable masses. Periurethral and perineal cystic lesions are common,
causing often indistinguishable symptoms, and therefore accurate diagnosis is
crucial because it can significantly alter clinical management. Traditional
imaging techniques such as cystoscopy, voiding cystourethrography, and
double-balloon catheter urethrography evaluate only the urothelium and so are
limited in diagnosing lesions that are contiguous with the urethral lumen. The
superb soft-tissue contrast and multiplanar imaging capability of MRI not only
allow characterization of disorders affecting the female urethra but also
permit visualization of lesions outside the urethra, including the perineum,
that may present with clinical symptoms similar to those of urethral disorders
[1–3].
The purposes of this article are to illustrate the MRI findings of perineal
cystic lesions and to show the features that differentiate them.
Technique
MRI was performed on a 1.5-T system (Vision or Symphony, Siemens Medical
Systems, Erlangen, Germany) using a torso phased array coil. Axial, coronal,
and sagittal multishot turbo spin-echo sequences (TR range/TE range,
2,768–9,999/99–138; refocusing flip angle, 180°), typically
with 4- to 6-mm slice thickness and a 200–350 x 512 matrix, and
coronal HASTE sequences (TR/TE range, infinite/60–120; refocusing flip
angle, 120–160°; matrix, 96–218 x 256; and slice
thickness, 4- to 6-mm) were routinely performed through the female pelvis,
including the kidneys, and the urethra. Additionally, as part of our routine
protocol, all patients underwent 2D dual-echo gradient-echo (TR
range/first-echo TE, second-echo TE, 160–200/2.4, 5.2; flip angle,
90°) in-phase and opposed-phase T1-weighted imaging. A T1-weighted
fat-suppressed sequence was also performed; typically a 3D interpolated
sequence is used [4]. If
contrast material was indicated, the 3D gradient-echo sequence was repeated
after administration of a single dose of gadolinium contrast material
(Magnevist, Berlex Laboratories, Wayne, NJ).
Normal Urethra
The normal female urethra has a bull's eye or concentric ringed appearance
on axial and sagittal T2-weighted and axial fat-suppressed gadolinium-enhanced
T1-weighted images [1] (Figs.
1A,
1B and
2).
Urethral Diverticula
Urethral diverticula are the sequelae of periurethral gland infection that
result in glandular dilatation and then progress to fistulization with the
urethra. Diverticula tend to be located in the mid urethra at the level of the
pubic symphysis and typically involve the posterolateral wall (Figs.
3A,
3B and
4). They can best be seen on
T2-weighted sequences as hyperintense lesions adjacent to or surrounding the
urethra. When large enough, diverticula can wrap around the urethra in a
horseshoe configuration (Fig.
4). A periurethral cystic mass may represent a urethral
diverticulum, submucosal cyst, or abscess of a Skene's gland. Showing a
communication between the lesion and the urethra is diagnostic of a urethral
diverticulum (Figs. 3A and
5); however, such a finding is
not reliably seen in all cases
[2]. If a communication is not
identified, the lesion may represent a diverticulum or a submucosal urethral
cyst (a dilated submucosal gland lacking communication with the urethral
lumen) [5]. The differentiation
between diverticulum and submucosal cyst can be challenging, but the
distinction is important because surgical intervention for the two entities
differs. Both lesions are resected; however, a diverticulum requires urethral
reconstruction.
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Fig. 3A. —48-year-old woman with dribbling after voiding. Axial
T2-weighted turbo spin-echo image shows portion of urethral diverticulum
(solid straight arrows) posterior to urethral lumen (open
arrow). Note neck of diverticulum (curved arrow).
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Fig. 4. —68-year-old woman with dysuria. Axial T2-weighted turbo
spin-echo image shows complex urethral diverticulum surrounding urethra
(straight black arrow). Note displacement of urethral–pelvic
ligaments (white arrows) and septation in diverticulum (curved
black arrow).
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Fig. 5. —47-year-old woman with recurrent urinary tract infections.
Axial T2-weighted turbo spin-echo image shows two calculi (solid white
arrows) in urethral diverticulum. Note diffuse urethral wall thickening
(black arrow) that was proven to be squamous cell carcinoma. Neck
(open arrow) of diverticulum is well seen. (Reprinted with permission
from [5])
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In patients with a urethral diverticulum, it is important to evaluate for
complications, including recurrent infection, stones, and carcinoma. Stones
can easily be detected as well-circumscribed low-signal structures in the
diverticular sac on T2-weighted sequences
(Fig. 5). Coexistent carcinoma
is best depicted on contrast-enhanced fat-suppressed T1-weighted images and
usually appears as a focal enhancing soft-tissue mass in the diverticulum
(Fig. 6A,
6B). Urethral diverticula are
associated with transitional cell carcinoma, adenocarcinoma, and squamous cell
carcinoma.
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Fig. 6A. —60-year-old woman with urethral pain. (Courtesy of Veniero
JC, Cleveland, OH) Sagittal T2-weighted turbo spin-echo image shows urinary
catheter (long arrow) in urethra. Urethral diverticulum (short
solid arrow) contains mass (open arrow) of intermediate signal
intensity.
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Fig. 6B. —60-year-old woman with urethral pain. (Courtesy of Veniero
JC, Cleveland, OH) Enhanced axial T1-weighted fat-suppressed gradient-echo
image shows enhancing soft-tissue mass (white arrows) in urethral
diverticulum surrounding urinary catheter (black arrow). Pathology
revealed adenocarcinoma.
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Cysts or Abscesses of Skene's Gland
Periurethral cystic masses located near the external urethral meatus are
likely to represent cysts or abscesses of Skene's gland (Fig.
7A,
7B). The paired Skene's glands
lie laterally to the external urethral meatus, opening their ducts directly
into the urethral lumen. The literature on Skene's gland pathology on MRI is
limited [6,
7]. In our experience, Skene's
gland lesions typically appear as round or oval masses that show hyperintense
signal on T2-weighted imaging and that are located just laterally to the
external urethral meatus. When infected, these Skene's glands present
clinically as tender fluctuant masses and must be surgically excised. However,
they are often incidental findings and asymptomatic.
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Fig. 7A. —45-year-old woman with painful periurethral mass. Sagittal
T2-weighted turbo spin-echo image shows small cystic lesion (arrow)
at urethral meatus that was proven to be abscess of Skene's gland.
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Fig. 7B. —45-year-old woman with painful periurethral mass. Axial
T2-weighted turbo spin-echo image shows abscess (arrow) to be located
to right of external urethral meatus in expected location of Skene's
glands.
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Collagen Injections
Gynecologists and urologists use periurethral collagen injections to treat
female stress urinary incontinence. To our knowledge, the MRI appearance of
female periurethral collagen has been reported only by Carr et al.
[8], who described periurethral
collagen on T1-weighted images as hyperintense nodules in the wall of the
urethra. In our experience, periurethral collagen can sometimes mimic a cystic
periurethral mass (Fig. 8A,
8B). Periurethral collagen may
appear similar to urethral diverticula and can be a pitfall in the diagnosis
of diverticula.
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Fig. 8A. —65-year-old woman with history of stress incontinence and
periurethral collagen injection. Sagittal (A) and axial (B)
T2-weighted turbo spin-echo images show periurethral mass (arrow) at
right aspect of bladder base (B in B). Although mass could be urethral
diverticulum, its location and signal intensity are atypical, so knowledge of
history of prior procedure is critical to correct diagnosis.
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Fig. 8B. —65-year-old woman with history of stress incontinence and
periurethral collagen injection. Sagittal (A) and axial (B)
T2-weighted turbo spin-echo images show periurethral mass (arrow) at
right aspect of bladder base (B in B). Although mass could be urethral
diverticulum, its location and signal intensity are atypical, so knowledge of
history of prior procedure is critical to correct diagnosis.
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Cysts of Gartner's Duct
Cysts of Gartner's duct develop from embryologic remnants of the
mesonephric (wolffian) duct and arise from the anterolateral wall of the
vagina [3] (Fig.
9A,
9B). These lesions are
typically located above the level of the inferiormost aspect of the pubic
symphysis [5]. When they are
located in the lower vagina at the level of the urethra, they can cause mass
effect on the urethra and give rise to urinary tract symptoms. On imaging,
differentiation between cysts of Gartner's duct and urethral diverticula
should not be difficult because diverticula form around the urethra, and cysts
of Gartner's duct are located posteriorly in the vagina.
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Fig. 9A. —42-year-old woman with mass palpated on routine physical
examination that was proven to be cyst of Gartner's duct. (Reprinted with
permission from [5]) Sagittal
T2-weighted turbo spin-echo image shows ovoid cystic mass (arrow)
posterior to urinary bladder and in region of vagina.
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Fig. 9B. —42-year-old woman with mass palpated on routine physical
examination that was proven to be cyst of Gartner's duct. (Reprinted with
permission from [5]) Axial
T2-weighted turbo spin-echo image confirms location of mass (arrow)
in vagina.
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Cysts of Bartholin's Gland
In contrast to cysts of Gartner's duct, cysts of Bartholin's gland are
located in the posterolateral inferior third of the vagina associated with the
labia majora [3] (Fig.
10A,
10B). Their location at or
below the level of the pubic symphysis helps to differentiate them from cysts
of Gartner's duct [5]. Cysts of
Bartholin's gland typically show uniform hyperintensity on T2-weighted imaging
but may be heterogeneous when infected. Contrast administration may be helpful
in cases of infection, because pericystic enhancement may be shown.
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Fig. 10A. —51-year-old woman with dyspareunia and pathologically proven
cyst of Bartholin's gland. Sagittal T2-weighted turbo spin-echo image shows
cystic mass (arrow) inferior to pubic symphysis.
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Fig. 10B. —51-year-old woman with dyspareunia and pathologically proven
cyst of Bartholin's gland. Axial T2-weighted turbo spin-echo image shows mass
(arrow) to be associated with left labia majora, which is consistent
with cyst of Bartholin's gland.
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Summary
In conclusion, localizing female periurethral and perineal lesions is the
key in differentiating pathologic entities. Because therapeutic management can
vary, preoperative diagnosis is crucial. As a noninvasive technique that does
not require exposure to ionizing radiation, MRI is helpful in evaluating such
lesions.
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