Case 16589

Anterior urethra mucosal

dissection and contrast medium
urethro-venous intravasation
Published on 05.12.2019

DOI: 10.35100/eurorad/case.16589
ISSN: 1563-4086
Section: Uroradiology & genital male imaging
Area of Interest: Pelvis Urinary Tract / Bladder Veins /
Vena cava
Procedure: Complications
Procedure: Cystography / Uretrography
Procedure: Diagnostic procedure
Imaging Technique: CT
Imaging Technique: Fluoroscopy
Case Type: Clinical Cases
Authors: Vaccher, F; Ambrosini, R; Di Meo, N; Grazioli,
L.
Patient: 87 years, male

Clinical History:

An 87-year-old man with a history of benign prostatic hyperplasia (BPH), nephrolithiasis and bladder lithiasis was
diagnosed with lower limb acute ischaemia. After several failed attempts of pre-operative catheterisation, a
suprapubic cystostomy was performed. The urethral obstruction was evaluated with retrograde urethrography
(RUG). The patient complained chronic weak stream micturition and urinary sediment.

Imaging Findings:

During retrograde urethrography - using diluted iodinated contrast medium and penile clamp device - the anterior
urethra was regularly opacified, without opacification of posterior tract (Fig. 1). Trying to delineate the obstruction,
some tortuous periurethral and pelvic structures were transiently opacified (Fig. 2). In consideration of the patient’s
history and to rule out a urethral injury, a CT evaluation was also performed. In basal scans, opacified urine was
present in the renal pelvis on both sides (Fig. 3) and, in a small amount, in the bladder.
The presence of bladder stones was confirmed, with some of them apparently incuneated in the bladder neck and
prostatic urethra, with a markedly enlarged prostate. Dynamic CT was performed during and immediately after
urethral opacification and contrast medium extravasation was confirmed between the dissected mucosal and
submucosal planes (Fig. 4). Its drainage in the local venous system caused opacification of the tortuous periurethral
submucosal veins and the inferior hypogastric plexus bilaterally (Fig. 5).

Discussion:

Urethro-venous intravasation (UVI) or urethro-vascular reflux (UVR) consists of the outflow of contrast medium from
the urethra into the highly vascular, elastic-rich, submucosal stroma and its drainage into local vascular structures,
thus delineating a “venogram” of the penile plexus and pelvic-ascending venous-vascular pathways. The
phenomenon is probably due to inflammatory micro-lesions or macroscopic iatrogenic breaches of the mucosal
integrity. UVI rarely occurs while performing retrograde urethrography (its incidence is reported approximately
around 1% [1,2,3]) and may lead to some complications, which should be considered [1,2].
In our case, the pathophysiology of the radiological findings is probably due to prior urethral instrumentation with
mucosal damage. Obstruction of the posterior urethra, caused by combined BPH and presence of incuneated
urinary stones, led to a rise in the pressure of the injected contrast medium, which could then infiltrate the pre-
existing mucosal lesions. The contrast would, therefore, gather under the dissected mucosa, with no extravasation
into the corpus spongiosum (Fig. 4). Being drained by the local venous plexus, the contrast medium would then be
rapidly cleared from the local extravasation site and enter the systemic circle, delineating an ascending venous
pathway (Fig. 5). This could explain the only rapidly transient presence of extravasation in the radiographic images
acquired. As shown by our basal CT scans, however, the contrast medium was filtered and excreted by the kidneys,
leading to opacification of the urinary tract, with a descending gradient (Fig. 3) which could not be explained by
vescico-ureteral reflux (VUR). These findings were clearly demonstrated at the dynamic CT scans, showing the
dissection of the mucosal and submucosal layer.

The unlikely event of UVI should be, therefore, kept in mind as it may even result in possible relevant complications,
the major one being allergic contrast medium reactions (both minor or systemic, from urticarial rash to respiratory
difficulty and hypotension) [1,2,4,5]. Other hazards could be pulmonary embolism [4], septicaemia or sepsis [1,2]
and renal failure or acute kidney injury (AKI) in nephropathic patients [1,2]. While performing the exam, it is therefore
mandatory to enquire for a history of allergic reactions, to check the patient’s renal function, to avoid use of oily
contrast medium [9] and to rule out recent ongoing urinary tract infections (the usage of prophylactic antibiotic
coverage is debated and not always employed, even if generally advised [7,8]). In addition, a 72-hours gap between
urethral instrumentation or trauma and retrograde urethrography is advisable [2], even if it may be insufficient for
complete mucosal healing and UVR avoidance (as in our case).

Written informed patient consent for publication has been obtained.

Differential Diagnosis List: Urethro-venous intravasation (UVI) or urethro-vascular reflux (U.V.R.) with urethral
mucosal dissection and pelvic “venogram” after mucosal damage (likely iatrogenic), Cowper’s glands (bulbourethral
glands) opacification, Urethral leakage with intra-spongiosum extravasation, Vescico-uretheral reflux (VUR)

Final Diagnosis: Urethro-venous intravasation (UVI) or urethro-vascular reflux (U.V.R.) with urethral mucosal
dissection and pelvic “venogram” after mucosal damage (likely iatrogenic)

References:

1: Bansal A, Kumar M, Goel S, Aeron R. Urethro-venous intravasation: a rare complication of retrograde

urethrogram. BMJ Case Rep. 2016 Apr 4;2016.
2: Gupta SK, Kaur B, Shulka RC. Urethro-venous intravasation during retrograde urethrography (report of 5 cases).
J Postgrad Med. 1991 Apr;37(2):102-4, 104A-104B. (PMID: 1802991)
3: Lytton B, Brooks MB, Spencer RP. Absorption of contrast material from the urinary tract during retrograde
pyelography. J Urol. 1968 Dec;100(6):779-82. (PMID: 5696672)
4: ULM AH, WAGSHUL EC. Pulmonary embolization following urethrography with an oily medium. N Engl J Med.
1960 Jul 21;263:137-9. (PMID: 13840309)
5: Redman JF, Robinson CM. Allergic reaction secondary to voiding cystourethrography. Urology. 1977
May;9(5):560-1. (PMID: 860348)
6: Katzberg RW. "Acute reactions to urographic contrast medium: incidence, clinical characteristics, and relationship
to history of hypersensitivity states"--a commentary. AJR Am J Roentgenol. 2008 Jun;190(6):1431-2. (PMID:
18492886)
7: Moorthy I, Crook D, Bale M, Cubbon M, Kenney I. Is antibiotic prophylaxis necessary for voiding
cystourethrography? Arch Dis Child. 2010 Apr;95(4):313-4. (PMID: 20335243)
8: Hajibagheri K, Priesemann M, Morrison I, Parikh A, Lessof N, Price E. NICE guidance on urinary tract infection in
children abandons routine antibiotic prophylaxis. Arch Dis Child. 2008 Apr;93(4):356. (PMID: 18356396)
9: McClennan BL, Becker JA, Robinson T. Venous extravasation at retrograde urethrography: precautions. J Urol.
1971 Sep;106(3):412-3. (PMID: 5107053)
Figure 1
a

Description: Apparent contrast medium extravasation during retrograde urethrography, with transient
opacification of some tortuous periurethral structures. Origin: ©Department of Radiology, Spedali Civili
di Brescia, P.le Spedali Civili, 1, 25123, Brescia, Italy
Figure 2
a

Description: Apparent contrast medium extravasation during retrograde urethrography, with transient
opacification of some tortuous periurethral structures. Origin: ©Department of Radiology, Spedali Civili
di Brescia, P.le Spedali Civili, 1, 25123, Brescia, Italy
Figure 3
a

Description: Presence of opacified urine at CT, 20 minutes after the first injection for ascending
urethrography with opacification of the renal pelvis and the urethers on both sides (with a small amount
of contrast medium in the bladder and a visible descending gradient). Origin: ©Department of
Radiology, Spedali Civili di Brescia, P.le Spedali Civili, 1, 25123, Brescia, Italy
Figure 4
a

Description: Dynamic CT scan acquisition showing dissection-wedge between mucosal and

submucosal planes, with evidence of contrast medium in the submucosal space (which should be
virtual). No extravasation into the corpus spongiosum was elicited, while some of the local mucosal
venous vessels are promptly opacified by the contrast medium drained locally. Origin: ©Department of
Radiology, Spedali Civili di Brescia, P.le Spedali Civili, 1, 25123, Brescia, Italy
Figure 5
a

Description: MIP images in different projections of the dynamic CT scans showing the presence of
contrast medium in the systemic circle through the opacification of the ascending venous structures.
Thus delineating a “venogram”, which extends from the mucosal local venous plexus and the pudendal
veins up to the hypogastric veins bilaterally and the distal portion of the common iliac veins. A,C: axial
inferior view; B: sagittal view; C: coronal view. Origin: ©Department of Radiology, Spedali Civili di
Brescia, P.le Spedali Civili, 1, 25123, Brescia, Italy
b

Description: MIP images in different projections of the dynamic CT scans showing the presence of
contrast medium in the systemic circle through the opacification of the ascending venous structures.
Thus delineating a “venogram”, which extends from the mucosal local venous plexus and the pudendal
veins up to the hypogastric veins bilaterally and the distal portion of the common iliac veins. A,C: axial
inferior view; B: sagittal view; C: coronal view. Origin: ©Department of Radiology, Spedali Civili di
Brescia, P.le Spedali Civili, 1, 25123, Brescia, Italy
c

Description: MIP images in different projections of the dynamic CT scans showing the presence of
contrast medium in the systemic circle through the opacification of the ascending venous structures.
Thus delineating a “venogram”, which extends from the mucosal local venous plexus and the pudendal
veins up to the hypogastric veins bilaterally and the distal portion of the common iliac veins. A,C: axial
inferior view; B: sagittal view; C: coronal view. Origin: ©Department of Radiology, Spedali Civili di
Brescia, P.le Spedali Civili, 1, 25123, Brescia, Italy
d

Description: 5:a: MIP images in different projections of the dynamic CT scans showing the presence of
contrast medium in the systemic circle through the opacification of the ascending venous structures.
Thus delineating a “venogram”, which extends from the mucosal local venous plexus and the pudendal
veins up to the hypogastric veins bilaterally and the distal portion of the common iliac veins. A,C: axial
inferior view; B: sagittal view; C: coronal view. Origin: ©Department of Radiology, Spedali Civili di
Brescia, P.le Spedali Civili, 1, 25123, Brescia, Italy