Acta Radiologica

ISSN: 0001-6926 (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/iaro20

On the Technique of Urethrography

Folke Knutsson

To cite this article: Folke Knutsson (1929) On the Technique of Urethrography, Acta
Radiologica, 10:5, 437-441, DOI: 10.3109/00016922909133867
To link to this article: https://doi.org/10.3109/00016922909133867

Published online: 14 Dec 2010.

Submit your article to this journal

Article views: 162

View related articles

Citing articles: 1 View citing articles

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=iaro20
 FROM THE ROENTGENOLOOICAL DEPARTMENT, MARIA HOSPITAL, STOCKHOLM
PHYSICIAX-IN-CIIIEB: AKE AKERLGND, M. D.

ON THE TECHNIQUE OF URETHROGRAPHY

P o l k e Knutsson
(Tabulae XXIIS-XXV)

The male urethra has been subjected to roentgenological examina-

tion for the last 20 years. It has been filled with some opaque fluid
and radiograms taken in different projections. Although as a rule such
an examination gives very full information about the condition of
the urethra, often far better than other methods of examination, such
as by sounds and urethroscopy, it has not come to be employed to any
extent worth mentioning, at any rate not in routine surgical practice.
This has undoubtedly partly been due to the fact that a simple exam-
ination by sound has yielded sufficient information; to some extent
it is probably explaned by the roentgenological technique being found
too cumbersome, difficulties have been encountered in getting the
urethra completely filled, leakage has occured and so on.
This communication is mainly aimed at indicating an improved tech-
nique, whereby the roentgen examination of the urethra is rendered
easy and reliable and can thus without further drawbacks be included
in routine roentgen work. As a preliminary, however, a review will be
submitted of the modes of procedure as described by different authors.

The Catheterization Method

Opaque fluid can be introduced into the bladder by a catheter and
the patient asked to void it during the exposure. By such a procedure
a satisfactory view is obtained of the posterior part of the urethra and
information gained as t o its shape and expansion during micturition
which may be of interest in cases of peripheral obstruction. Fistulous
tracks from this part can also be seen well filled up with opaque fluid.
On examining the posterior urethra in the way just mentioned - when
similar conditions certainly prevail as under natural micturition - an
impression can thus be formed of the functional capacity of the urethra
(elasticity, sclerotization).
M-,290690. Acta Radiologica. Val. X . 1929.
438 FOLKE KNUTSSON

Difficulties, however, are often encountered in the course of such

an examination. Catheterization may take a long time, may be diffi-
cult or even impossible t o carry out or has to be preceded by dilatation.
The patient often finds himself incapable to urinate by order, parti-
cularly when lying down. A SCHMIDT has employed this method in exa-
mining the sequences following upon strictures of the posterior urethra
and then been using a suspension of barium as the opaque fluid.
A similar method by the use of different opaque fluids has been
described by LANGER and WITKOWSKI, who employ 15 per cent umbre-
nal, and BRONNER who has tried a number of different opaque fluids.
The latter author warmly recommends the method and emphasizes the
important information it yields about the width and elasticity of the
posterior urethra. WIDEROEinjects 50-100 c. c. of a 30 per cent solu-
tion of NaBr. MIYATAand KAJIKAWA, the Japanese workers, have also.
used this method but they prefer the instillation method.

The Iiistillation Method

By this more usual method the opaque fluid is instilled from the
urethral orifice by means of a syringe or tube connected with a can as in
the Janet treatment. By this mode of procedure the urethra becomes
well filled up only as far as the membranous sphincter, while the posterior
part of the urethra remains empty. It is true that during the instillation
the opaque fluid passes through this part of the urethra and collects
to some extent in the bladder because of the fact that the posterior
urethra becomes dilated by the pressure set up by the instillation pro-
cess, but as soon as this is over, a reflex contraction of this part of the
urethra takes place via the unstriated musculature, causing the opaque
fluid to become forced up into the bladder. For roentgen examination
of the posterior part of the urethra it is necessary, therefore, to carry out.
the injection during the exposure.
This method has been described by a great many different authors.
So have all the above mentioned authors except SCHMIDT described it.
The first one was CUNNINGHAM,1910, who used argyrol as the opaque
fluid, and then URAY,1912, who employed a suspension of bismuth. The
method has further been referred t o by PFISTER, B~CLBRE and HENRY,
BURDEN,ELFVING,CAVE and KOHNSTAM. A great number of different
fluids has been tried but lately one has generally adopted lipiodol, iodo-
pin or similar oily fluids which possess a marked contrasting effect. The
injection has been done by means of a syringe with a conical tip, a clamp
or band being applied round the glans penis to retain the fluid during
the exposure.
 ON THE TECHNIQUE OF URETHROGRAPHT 439

At)Maria Hospital the instillation method has generally been employed.

With the view of making the method more convenient and reliable we
have recently constructed a clamp especially made for the penis. This
consists of two limbs movable round a joint. A catch locks the joint
in different positions. The ends of the limbs are bent on themselves
and covered with rubber tubing and further curved in a manner to
allow them to be suitably applied round the collum glandis. The
axle of the joint is drawn out in the shape of a fork in which a
cawula can be adjusted and secured by means of a set-screw. The
syringe is inserted into one end of the cannula and the other end, on
which a conical rubber cap has been put on, is pushed into the urethral
orifice after the limbs have been tightly applied round the collum.

Fig. 1. The penis clamp with the syringe.

By means of this device, therefore, the syringe can be conveniently

applied to the penis. For radiograms of the posterior urethra it is
easy to carry out the injection with gloved hand during the exposure
itself. The clamp can be left on the glans penis for a good while
without causing the slightest discomfort to the patient. One is thus able
conveniently to take radiograms with the patient in different positions
and one can wait for the first pictures to be developed and then, if
desirable, take further exposures during renewed filling of the urethra.
As an opaque fluid we have employed iodopin, 20 per cent, and
with our method of procedure we have obtained beautiful radiograms
with the whole of the urethra completely filled up. The posterior urethra
comes out as a narrow slightly arc-shaped tube with a spindle-shaped
enlargement within the prostate gland, in the shadow of which colliculus
seminalis can be seen as an elongated rarefaction. Fistulous tracks
passing out from different parts of the urethra as well as strictures
have also come out well.
The Patients have been examined in the dorsal position turned a
little t o the left with the left lower limb bent in the hip-joint and the
right limb stretched out. With the patient in this position great care
must be exercised when attempting to draw conclusions as to the size
of the prostate from the position and outlines of the opaque fluid in
the bladder, because the fluid collects in the lateral and posterior parts
of the bladder and will not therefore show the outlines of the upper
surface of the prostate. We have instead found it advisable, after
removing the clamp, to let the fluid run out from the anterior part of
440 FOLKE KNUTSSON

the urethra and then take radiograms in standing position, antero-

posteriorly as also with the patient turned about 45". The lower outline
of the bladder will then be influenced by the upper boundary of the
prost ate.
I n the May number of Fortschr. A. d. Geb. d. Rontgenstrahlen,
published while this paper was still in manuscript, there is a paper by
Doctor LUDVIGDRESSLER under the title: ))Neuere Untersuchungen zur
rontgenologischen Darstellung der mannlichen Harnrohre, Prostata
und Samenblase)).The paper is illustrated by very beautiful urethrograms.
The author, however, is undoubtedly under a misapprehension when
inferring the size and condition of the prostate from the radiograms,
maintaining that the supra-collicular elongation of the posterior urethra
must be due to some enlargement of the prostate gland, even assuming
that a deviation to either side of this elongated portion is caused by
one of the prostatic lobes being larger than the other.
I n interpreting the radiograms it must be remembered that the
patient a t the examination is lying down and somewhat turned to either
side. With the patient in this position one gets as a rule a considerable
elongation of the supra-collicular part of the urethra and always a devia-
tion to the declivous side, even in patients where by rectal examination
one has been able to rule out any enlargement of the prostata. In
some cases the supra-collicular part is of such a considerable length that
it is quite absurd to refer to it as an enlarged prostate gland. (Fig. 5 . )
The case is probably this, however, that only a length of 1-2 em.
above the colliculus seminalis really belongs to the urethra and that
the remaining portion is occasioned by some of the opaque fluid collec-
ting in a fold of the mucous membrane a t the bottom of the bladder
when this is empty. It is this part of the shadow that deviates toward
the declivous side and often so at a fairly well marked angle. A small
furrow is often seen here probably just corresponding to the internal
orif ice.
The penis clamp described has been made by A. B. Stille-Werner,
Stockholm.

SUMMARY
After having briefly reviewed the method employed in urethrography the
author describes a penis clamp constructed for that particular purpose. This
clamp reqders the examination simpler and more convenient. The author further
discusses the so-called supra-collicular elongation of the posterior urethra. As
against DRESSLER the author maintains that of this only 1-2 cm. above the
colliculus seminalis is occasioned by the urethra and that the remaining part is
occasioned by some of the opaque fluid collecting in a fold of the mucous mem-
ACTA RAD. VOL. S. FASC. V. FOLKE KNUTSSON Tabula X X I I I

Fig. 2. Fig 3.

Fig. 4.
ACTA KAD. VOL. S . FASC. V. FOLKE KNUTSSON l’abuln X X I V

Fig. 5. Fig. 6.
Fig. 2-6. Normal nrethrograms. The patients were 33, 30, 46, 24 and 52 years of age. In cases
2 and 4 the prostate was not examined by rectal palpation because of freedom of symptoms
from that part. I n case 3 the gland mas of normal size and in cases 5 and 6 it was smaller
than normal.

Fig. 7. 54 years of age. Atrophy of

the prostate with total retention. Pro-
statectomy. The gland was very small.
ACTA R A D . VOL. S. FASC. V. FOLKE KNUTSSOK Tubuln XXV

Fig. 8. 48 years of age. Prostatitis. Fig. 9. 54 years of age. Gonorrhoea1 stric-

Prostatectomy. The gland was very ture. No enlargement of the prostate. Pro-
small and the ducts were dilated. static ducts filled up by opaque fluid.

Fig. 10. 48 years of age. A gonorr- Fig. 11. 26 years of age. Tuberculous
hoeal stricture in the membranous part urethritis.
of the urethra. The prostate was found
a little enlarged by rectal examination.
 ON TIIE TECHNIQUE OF UKETUKOGRAPHY 441
brane a t the bottom of the bladder. The elongation of the urethra is thus as
a rule only apparent and no importance can therefore be ascribed to it in the
estimation of the size of the prostate gland.
The paper is illustrated by a few urethrograms.

ZUSAMMENFASSUNG
Nach einem kurzen Referat uber die bei Urethrographie angewendete
Methode beschreibt Verf. eine fur diesen besonderen Zweck konstruierte Penis-
klammer. Diese Klammer gestaltet die Untersuchung einfacher und bequemer.
Verf. erortert ferner die sog. supra-collikulare Verlangerung der hinteren
Urethra. I m Gegensatz zu DRESSLERbehauptet der Verf., dass von dieser
Verlangerung nur 1-2 cm. uber dem Colliculus seminalis durch die Urethra
gebildet ist, und der ubrige Teil durch den kontrahierten Blasenhals. Die Ver-
langerung der Urethra ist also in der Regel nur scheinbar, und es kann ihr
clemnach fur die Schatzung der GrGsse der Prostatadriise keine Bedeutung
beigemessen werden.
Die Arbeit ist durch einige Urethrogramme illustriert.

RESUME
Aprhs avoir brihvement rappel6 la m6thode utilis6e dans l’ur&thrographie,
l’auteur d6crit m e pince phienne specialement construite dans ce but. Cette
-
pince simplifie l’examen et le rend plus facile. L’auteur discute ensuite la question
de Yelongation dite supra-colliculaire de l’urhthre posterieur. Contrairement i
DRESSLER, il maintient que, de cette Blongation, 1 it 2 cm. seulement imm6diate-
ment au-dessus du veru montanum sont fournis par l’urhthre, le reste &ant dii au
. col contract6 de la vessie. L’Blongation de l’urhthre est donc en rBgle generale
simplement apparente, et aucune importance ne peut donc &re accord6e iL cette
Blongation dans l’appr6ciation de la grandeur de la prostate.
Le travail est illustr6 de quelques ur6throgrammes.