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|Year : 1991 | Volume
| Issue : 2 | Page : 102-4,104A
Urethro-venous intravasation during retrograde urethrography (report of 5 cases).
Gupta SK, Kaur B, Shulka RC
Department of Diagnostic Radiology, Banaras Hindu University, Varanasi.
Department of Diagnostic Radiology, Banaras Hindu University, Varanasi.
Five instances of urethro-venous intravasation during retrograde urethrography are reported. Four cases were of urethral strictures and one case was of urethral hemangioma. All patients had post procedural bleeding while one patient got allergic reactions, another showed chills and rigors. Anatomy of the drainage veins is described. Factors responsible for this complication and its clinical implications are discussed. It is suggested that urethro-venous intravasation should be considered a diagnostic sign of urethral inflammation.
|How to cite this article:|
Gupta S K, Kaur B, Shulka R C. Urethro-venous intravasation during retrograde urethrography (report of 5 cases). J Postgrad Med 1991;37:102-4,104A
|How to cite this URL:|
Gupta S K, Kaur B, Shulka R C. Urethro-venous intravasation during retrograde urethrography (report of 5 cases). J Postgrad Med [serial online] 1991 [cited 2020 Jun 6];37:102-4,104A. Available from: http://www.jpgmonline.com/text.asp?1991/37/2/102/795
Urethro-venous intravasation is a rare phenomenon encountered at times during retrograde urethrography. Also termed urethro-vascular reflux or urethro-cavernous reflux was seen in five cases over a period of 10 years when about 500 retrograde urethrographic procedures were performed in the Department of Diagnostic Radiology, Institute of Medical Sciences. Factors responsible for this complication and its clinical implications are discussed.
After ascertaining that no instrumentation was done during the preceding week and there was no clinical evidence of urethral infection or bleeding, retrograde utethrogram (R.G.U.) was performed. For injection of the contrast medium either a Foley's catheter with inflatable bulb or Knuttson penile clamp was employed. The contrast media used were water soluble (Conray or Urographin). Two oblique pictures (Right and Left) were obtained while the injection was being given. It was followed by another set of two oblique pictures when the injection of about 15-20 ml. of the contrast was completed. In a few cases onligue pictures were supplemented by frontal pictures. The examination was conducted under fluorscopic control. Urethro-vascular reflux was observed in 5 cases. Their record, were scrutinised and the relevant points are prejented here.
Four patients of urethral strictures were between 20-30 years of age. All were on repeated dilatation treatment. While three had history of gonococcal infection in the past, the fourth one had history of perineal trauma. Immediately after the procedure of R. G. U. all these patient had variable degree of urethral bleeding. While one patient had allergic reactions which were managed immediately, another patient had chills and rigors after the procedure. All patients were put on antibiotics for a period of five days. Contrast medium outlined the corpora spongiosa either in its entire length or in small areas leading to visualisation of pariurethral veins, communication veins, dorsal vein of the penis, pudendal venous plexus and internal pudendal veins (See Fig. 1-3). The fifth case of hemangioma of the glans penis in a 20-year old patient was associated with extensive hemangionia of anterior urethra. This patient used to get intermittant urethral bleeding unrelated to micturition since childhood. For the last four yours, erection of the penis was also accompanied by oozing of fresh blood per urethra. Initial urethrogram revealed irregular narrowing of anterior urethra while in the subsequent films there was direct visualization of diffuse hemangiomatous masses along with gross urethro-venous intravasation. After removal of the Foley's cathether there was profuse bleeding per urethra which gradually disappeared in 24 hrs. (See Fig. 4 and 5). Urethroscopy done as few days later, revealed bluish red hemangiomatous masses involving almost the whole of the anterior urethra. Wide surgical excision followed by urethro-plasty was contemplated but the patient refused surgery and was lost to follow up.
Retrograde urethrography is a valuable diagnostic aid but it involves certain hazards. Knowledge of urethral anatomy and the histopathology of urethral stricture will help in understanding this phenomenon. The urethra is composed of a mucous membrane supported by submucosal stroma of connective tissue rich in elastic fibres. This thin walled tube is lying within the highly vascular corpus spongiosum. The tributaries emerging from the corpus spongiosum empty into a series of small veins between the corpus spongiosum and the corpus cavernosa. These vessels drain into the deep dorsal vein of the penis, which communicates with the pudendal venous plexus and empties into the internal pudendal veins. A superficial group of veins drains the integuments of the penis through the superficial dorsal and superficial external pudendal vein and then empties into the saphenous veins. Venous filling seen in our cases of urethral strictures during R. G. U. demonstrated the aforesaid anatomy. Urethro-venous intravasation is due to a breach in the urethral mucosa and is enhanced by inflammation found to accompany most urethral strictures. Inflammation promotes the development of increased local vascularity. Urethrovenous intravasation exposes the patient to hazards like allergic reactions and pulmonary embolism. Additionally the refluxed contrast medium may be accompanied by pathogenic bacteria often found in the male urethra. This bacterial shower in the blood stream usually manifests as fever with chills and rigors and results in septicemia. Medico-legally it is important to ascertain history of allergy prior to R. G. U. The standard interval recommended between intrumentation and the procedure of R. G. U. is 48-72 hours.
We, however, observed an interval of one week. Whatever, the interval between instrumentation and R. G. U. there is always a possibility of entry of urethral pathogens into the systemic circulation and hence prophylactic antibiotic coverage is recommended to protect the patient against the possible gram negative septecemia. In this setting it will be correct to infer that visualisation of contrast in the venous system is a diagnostic sign of urethral inflammation. Embolism of foreign material gaining entry through the same route is also possible. It is, therefore, of utmost importance to use as low a pressure head as possible in introducing contrast material into the urethra and to be very gently in urethral instrumentation. Use of an oil based material presents the hazards of lipiod embolism in the event of venous intravasation.
Urethro-venous intravasation in our cases of urethral hemangioma appears to be unreported in the available literature. Urethral hemangiomas are cavernous in nature and are composed of intercommunicating sinus like blood filled spaces lined by single layer of flattened mature appearing endothelial cells and there are interspersed fibrous septa. These cavities communicate with capillaries and drainage veins. The pooled contrast medium in the hemangioma due to traumatic erosion of fragile surface endothalium lead to urethro-venous intravasation in our case.
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