MRI of the Urethra in Women with Lower Urinary Tract Symptoms: Spectrum of Findings at Static and Dynamic Imaging

Genevieve L. Bennett; Elizabeth M. Hecht; Teerath Peter Tanpitukpongse; James S. Babb; Bachir Taouli; Samson Wong; Nirit Rosenblum; Jamie A. Kanofsky; Vivian S. Lee

Disclosures

Am J Roentgenol. 2009;193(6):1708-1715. 

In This Article

Results

Ten (11.9%) of the 84 study patients were found to have an abnormality of the urethra. These included urethral diverticulum (n = 2), Skene's gland cyst or abscess (n = 5), and periurethral or suburethral cyst (n = 3). The two patients with urethral diverticula and the five patients with Skene's gland cyst or abscess underwent surgery with pathologic proof of the findings. For the other patients, there was no surgical correlation.

Thirty-three of the 84 patients (39.3%) were found to have pelvic organ prolapse. In four of these patients (12.1%), prolapse was detected on the static, "at rest" images; however, in 29 patients (87.9%), prolapse was identified exclusively on the dynamic "during straining" sequence (Figs.1–5). The dynamic sequence showed an increase in the severity of prolapse in all four patients with prolapse detected at rest. The presence and severity of prolapse in each pelvic compartment are summarized in Table 1 .

Figure 1.

61-year-old woman undergoing MRI evaluation of possible urethral diverticulum. Patient had previously undergone hysterectomy.
A, Axial T2-weighted turbo spin-echo (TSE) image (TR/effective TE, 6,080/116; flip angle, 180°) shows typical appearance of urethral diverticulum (black arrow) containing several calculi (white arrow). Findings were confirmed at pathology. Curved arrow indicates urethra.
B, Midline sagittal T2-weighted TSE image (6,000/116; flip angle, 180°) obtained at rest shows no significant prolapse. Solid line represents pubococcygeal line, above which all pelvic organs are located. B = bladder, dotted line = urethra, R = rectum.
C, Midline sagittal true fast imaging with steady-state free precession image (3.9/1.9; flip angle, 70°) acquired at maximal strain shows mild prolapse with mild descent of urethra (dotted line) and anorectal junction (arrow) below pubococcygeal line (solid line). Urinary bladder (B) remains superior in relation to pubococcygeal line.

Figure 2.

27–year-old woman undergoing MRI evaluation of urethral pain.
A,Axial T2-weighted turbo spin-echo (TSE) image (TR/effective TE, 6,080/116; flip angle, 180°) shows normal urethra (white arrow) and vaginal wall cyst located posterior to urethra (black arrow).
B, Midline sagittal T2-weighted TSE image (6,000/116; flip angle, 180°) obtained at rest shows vaginal wall cyst (arrow) and no prolapse. B = bladder, dotted line = urethra, U = uterus, solid line = pubococcygeal line.
C, Midline sagittal true fast imaging with steady-state free precession image (3.9/1.9; flip angle, 70°) obtained at maximal strain shows tricompartment prolapse below pubococcygeal line (solid line). Note hypermobility of urethra (dotted line), which is tilted from normal vertical axis. B = bladder, V = vagina, C = cervix; arrow indicates rectum. (See also Fig. S2C, cine loop, in supplemental data at www.ajronline.org.)

Figure 3.

42-year-old woman undergoing MRI evaluation of possible urethral diverticulum.
A, Axial T2-weighted turbo spin-echo (TSE) image (TR/effective TE, 6,080/116; flip angle, 180°) obtained at rest shows Skene's gland cyst (arrow).
B, Midline sagittal T2-weighted TSE image (6,000/116; flip angle, 180°) obtained at rest again shows Skene's gland cyst (arrow). No significant prolapse is seen. B = bladder, dotted line = urethra.
C, Midline sagittal true fast imaging with steady-state free precession image (3.9/1.9; flip angle, 70°) obtained at maximal strain shows tricompartment prolapse below pubococcygeal line (solid line) and urethral hypermobility. Dotted line denotes urethra, which descends below pubococcygeal line and is tilted from normal vertical axis. B = bladder, C = cervix, R = rectum.

Figure 4.

48-year-old woman undergoing MRI evaluation of possible urethral diverticulum.
A, Midline sagittal T2-weighted turbo spin-echo (TSE) image (TR/effective TE, 6,080/116; flip angle, 180°) obtained at rest. Urethra is normal. Note mild descent of urethra (dotted line), vagina (V), and anorectal junction (arrow) below pubococcygeal line (solid line). Urinary bladder (B) is located above pubococcygeal line.
B, Midline true fast imaging with steady-state free precession image (3.9/1.9; flip angle, 70°) obtained at maximal strain shows increase in severity of tricompartmental prolapse with descent of bladder (B), urethra (arrow), cervix (C), and rectum (R) below pubococcygeal line (solid line). Severe urethral hypermobility and funneling of proximal urethra are also noted. (See also Fig. S4B, cine loop, in supplemental data at www.ajronline.org.)

Figure 5.

26-year-old woman undergoing MRI evaluation of possible urethral diverticulum.
A, Midline sagittal T2-weighted turbo spin-echo image (TR/effective TE, 6,000/116; flip angle, 180°) obtained at rest shows normal urethra and no evidence of prolapse. Solid line = pubococcygeal line, B = bladder, dotted line = urethra, U = uterus, V = vagina, R = rectum.
B, Midline sagittal true fast imaging with steady-state free precession image (3.9/1.9; flip angle, 70°) obtained at maximal strain shows tricompartment prolapse, marked urethral hypermobility, and moderate cystocele. Solid line = pubococcygeal line, B = bladder, dotted line = urethra, C = cervix, arrow = anorectal junction. (See also Fig. S5B, cine loop, in supplemental data at www.ajronline.org.)

Lower Urinary Tract Symptoms and MRI Findings

The number of patients with each clinical symptom was as follows: dysuria, n = 48 (57.1%); urinary frequency, n = 50 (59.5%); nocturia, n = 19 (22.6%); recurrent urinary tract infection, n = 31 (36.9%); stress incontinence, n = 9 (10.7%); urge incontinence, n = 6 (7.1%); urgency, n = 34 (40.5%); and voiding difficulty, n = 19 (22.6%). Two patients had both stress and urge urinary incontinence; therefore, there were 13 total patients (15.5%) with any type of incontinence (either stress or urge). The number of patients with MRI-detected cystoceles, urethroceles, and urethral hypermobility when each clinical symptom was present or absent is indicated in Table 2 . Values for p from Fisher's exact test to evaluate the association of MRI findings with each urinary tract symptom are indicated in Table 3 . Patients with stress urinary incontinence were significantly more likely to have cystoceles (p = 0.0316) than those without stress urinary incontinence. A trend was seen toward more urethroceles (p = 0.0781) and urethral hypermobility (p = 0.0633) in these patients. Patients with urinary frequency were statistically more likely to have cystoceles (p = 0.0389) than those without frequency. There was a trend for patients with any type of urinary incontinence to have cystoceles (p = 0.0705) and urethroceles (p = 0.0700), and a trend for patients with voiding difficulty to have urethral hypermobility (p = 0.0560). The other clinical symptoms did not correlate with MRI findings, as shown in Table 3 .

Clinical symptoms were also correlated with severity of MRI findings. Women with stress urinary incontinence were statistically more likely to have more severe cysto celes (p = 0.0093), urethroceles (p = 0.0357), and urethral hypermobility (p = 0.0408) than women without stress incontinence. Women with urinary frequency were also statistically more likely to have more severe cystoceles (p = 0.0230) than women without frequency. Women with voiding difficulty were statistically more likely to have more severe urethral hypermobility (p = 0.0149), and there was a trend for more severe urethroceles (p = 0.0537) compared with women without voiding difficulty.

Pregnancy History and MRI Findings

Cystoceles were found in eight (16.7%) of 48 women with no prior pregnancy, one (10%) of 10 women with one pregnancy, four (44.4%) of nine women with two pregnancies, and five (50%) of 10 women with three or more pregnancies. When stratified by number of pregnancies (0, 1, 2, or ≥ 3), only cystoceles were significantly more likely to occur with increasing number of pregnancies (p = 0.034). However, women with at least two or more pregnancies were significantly more likely than women with fewer than two pregnancies to have cystoceles (p = 0.01) and urethroceles (p = 0.031). There was also a trend for these women to be more likely to have urethral hypermobility (p = 0.062) and rectal descent (p = 0.055). Therefore, the association between pregnancy and MRI findings of prolapse was more significant for women with two or more pregnancies.

The number of women with each MRI finding stratified by the number of vaginal deliveries is indicated in Table 4 . As the number of vaginal deliveries increased, there was a statically significant increase in the number of cystoceles (p = 0.0059), urethral hypermobility (p = 0.0255), and rectal descent (p = 0.0353), with a trend for the numbers of urethroceles (p = 0.0537) and vaginal prolapse (0.0537) to increase. If patients were stratified as having at least two vaginal deliveries, there were significantly more cystoceles (p = 0.0014), urethroceles (p = 0.0092), urethral hypermobility (p = 0.0038), vaginal prolapse (p = 0.0092), and rectal descent (p = 0.0076) than in patients with less than two vaginal deliveries. No correlation was seen between MRI findings and the number of cesarean sections.

Patient Age and MRI Findings

A statistically significant association was seen between patient age and the presence of cystoceles, urethral hypermobility, and urethroceles. The mean age of patients with an MRI-detected cystocele was 46.9 years (n = 20), versus 37.9 years (n = 64) for patients without a cystocele (p = 0.0244). The mean age of patients with urethral hypermobility was 46.4 years (n = 30) versus 36.56 years (n = 54) for patients without urethral hypermobility (p = 0.0095). The mean age of patients with a urethrocele was 47.56 years (n = 32) versus 35.46 years (n = 52) for patients without a urethrocele (p = 0.0009). This was also true for rectal descent (p = 0.0002) and vaginal prolapse (p = 0.0009).

Physical Examination and MRI Findings

MRI and physical examination both detected cystoceles in six patients and were both negative for cystocele in 61 patients. In 13 patients, a cystocele was detected on MRI only (nine mild and four moderate), and in two patients, a cystocele was detected only on physical examination (one mild and one moderate). In 10 patients, MRI and physical examination both detected urethral hypermobility, and in 45 patients, both MRI and physical examination were negative for this finding. In 19 patients, urethral hypermobility was detected only on MRI (12 mild and seven severe), and in seven patients, hypermobility was detected only on physical examination (all mild). Ten patients had both a cystocele and urethral hypermobility detected only on MRI.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....