Fluoroscopy RGU & MCU.

Retrograde Cysto Urethrogram & Micturating Cystourethrogram

Indication of RGU and MCU:

Stricture.
Urethral tears.
Congenital abnormalities.
Fistula.
Abscess.

Contra - Indication of RGU and MCU:

Acute urinary tract infection.
Recent instrumentation.

Instrument Name:

Foley Catheter
Kidney Tray
Syringe 50 cc
Cotton
Inj, Iopamiro/Omniscan
Gel

Procedure:

এই পরীক্ষাটির Advice নিয়ে রোগী আসলে, উপড়ে ইল্লেখিত উপাদান গুলো রোগীকে নিয়ে আসতে বলতে হবে।
সব উপাদান ঠিকমতো আনলে রোগীকে প্রস্রাব করে আসতে বলতে হবে। প্রস্রাব করে এলে রোগীকে Bucky Tube এ Supine Position এ শুইয়ে দেই।
এই অবস্থায় A/P Position-এ Penis include করে Control X-ray করতে হবে। অবশ্যই ১৫ ডিগ্রী Angle-এ X-ray পরিচালিত হবে।
Control X-ray করার পর Foley catheter, Penis/Vegina এর মধ্যে ১ ইঞ্চি ঢুকিয়ে 2 ml পরিমাণ Distil Water দিয়ে বেলুন ফুলিয়ে নিলে, আর catheter বের হবে না।এবার Foley catheter এর মধ্য দিয়ে Syringe এর মাধ্যমে Contrast 20 ml + Distil water 10 ml Total 30 ml ঢুকিয়ে Right Anterior Oblique অবস্থায় Bladder Include করে ছবি নিতে হবে। লক্ষ রাখতে হবে যে Right Leg এবং Right Hip যেন flexed থাকে। আর বাম পা যেন Abdicated থাকে।
6. Right Anterior Oblique এর ছবি ঠিক মতো এলে রোগীকে আস্তে আস্তে ঘুরিয়ে Left Anterior Oblique Position করি। Syringe এ রক্ষিত বাকি Contrast push করে Left Anterior Oblique Position-এ Bladder Include করে আরেকটি ছবি নিই।
Left Anterior Oblique ছবি নেওয়া শেষ হলে A/P Position-এ আরেকটি ছবি নিই। তারপর Catheter খুলে দিব এবং রোগীকে প্রস্রাব করতে বলি। প্রস্রাব করা অবস্থায় Maturating Cystourethrogram (MCU) এর ছবি নিই।
সবগুলি ছবি ঠিকমতো এলে রেডিওলজিষ্ট কে দেখাই এবং আরও ছবি নেওয়ার প্রয়োজন হলে রেডিওলজিষ্ট এর Advice অনুযায়ী নিতে হবে।

Anatomy urethra

The urethra is the vessel responsible for transporting urine from the bladder to an external opening in the perineum.

It is lined by stratified columnar epithelium, which is protected from the corrosive urine by mucus secreting glands.

In this article, we shall look at the anatomy of the male and female urethra – their anatomical course, neurovascular supply, and any clinical correlations.

Male Urethra

The male urethra is approximately 15-20cm long. In addition to urine, the male urethra transports semen – a fluid containing spermatozoa and sex gland secretions.

Fig 1 – Coronal section of the penis, showing the three parts of the urethra.

According to the latest classification, the male urethra can be divided anatomically into three parts (proximal to distal):

Prostatic urethra:

Begins as a continuation of the bladder neck and passes through the prostate gland.

Receives the ejaculatory ducts (containing spermatozoa from the testes and seminal fluid from the seminal vesicle glands) and the prostatic ducts (containing alkaline fluid).

It is the widest and most dilatable portion of the urethra.

Membranous urethra:

Passes through the pelvic floor and the deep perineal pouch.

Surrounded by the external urethral sphincter – which provides voluntary control of micturition.

It is the narrowest and least dilatable portion of the urethra.

Penile (bulbous) urethra:

Passes through the bulb and corpus spongiosum of the penis, ending at the external urethral orifice (the meatus).

Receives the bulbourethral glands proximally.

In the glans (head) of the penis, the urethra dilates to form the navicular fossa.

Note: The part of the urethra that passes through the bladder neck is considered by some authors as a fourth anatomic part of the urethra.

Fig 2 – Endoscopic view of the prostatic urethra from the entrance of the ejaculatory ducts (A) towards the bladder neck (C).

Neurovascular Supply

The arterial supply to the male urethra is via several arteries:

Prostatic urethra – supplied by the inferior vesical artery (branch of the internal iliac artery which also supplies the lower part of the bladder).

Membranous urethra – supplied by the bulbourethral artery (branch of the internal pudendal artery)

Penile urethra – supplied directly by branches of the internal pudendal artery.

The nerve supply to the male urethra is derived from the prostatic plexus, which contains a mixture of sympathetic, parasympathetic and visceral afferent fibres.

Lymphatic Drainage

Lymphatic drainage also varies according to the region of the urethra. The prostatic and membranous portions drain to the obturator and internal iliac nodes, while the penile urethra drains to the deep and superficial inguinal nodes.

Clinical Relevance: Male Catheterisation

Urinary catheterisation is the process of inserting a tube through the urethra and into the bladder. This is typically performed in situations where urine output needs to be monitored (such as sepsis), or when the patient is unable to pass urine (urinary retention).

Catheterisation is more complex in males, as there are two angles to consider – the infrapubic and prepubic angles. The prepubic angle can be diminished by holding the penis upwards during urinary catheterisation.

It is also important to note the three constrictions in the male urethra – the internal urethral sphincter, external urethral sphincter, and external urethral orifice.

Fig 3 – The infrapubic and prepubic angles of the male urethra. The prepubic angle can be reduced by raising the penis during catheterisation.

Female Urethra

In females, the urethra is relatively short (approximately 4cm). It begins at the neck of the bladder, and passes inferiorly through the perineal membrane and muscular pelvic floor. The urethra opens directly onto the perineum, in an area between the labia minora, known as the vestibule.

Within the vestibule, the urethral orifice is located anteriorly to the vaginal opening, and 2-3cm posteriorly to the clitoris. The distal end of the urethra is marked by the presence of two mucous glands that lie either side of the urethra – Skene’s glands. They are homologous to the male prostate.

Neurovascular Supply

The arterial supply to the female urethra is via the internal pudendal arteries, vaginal arteries and inferior vesical branches of the vaginal arteries. Venous drainage is given by veins of the same names.

The nerve supply to the female urethra arises from the vesical plexus and the pudendal nerve. Visceral afferents from the urethra run in the pelvic splanchnic nerves.

Lymphatic Drainage

Lymphatic drainage of the proximal female urethra is to the internal iliac nodes, while the distal urethra drains to the superficial inguinal lymph nodes.

Fig 4 – Location of the external urethral orifice in the vestibule.

Clinical Relevance: Urinary Tract Infections

Due to the short length of the urethra, women are more susceptible to infections of the urinary tract. This usually manifests as cystitis, an infection of the bladder.

Common symptoms of cystitis are dysuria (pain upon urination), frequency, urgency, and haematuria (blood in the urine). A mid-stream urine sample can be tested for the presence of nitrites and leukocytes (both of which indicate infection).

Simple urinary tract infections are typically treated with a three-day course of antibiotics.

Shape of the Bladder

The appearance of the bladder varies depending on the amount of urine stored. When full, it exhibits an oval shape, and when empty it is flattened by the overlying bowel.

The external features of the bladder are:

Apex – located superiorly, pointing towards the pubic symphysis. It is connected to the umbilicus by the median umbilical ligament (a remnant of the urachus).

Body – main part of the bladder, located between the apex and the fundus

Fundus (or base) – located posteriorly. It is triangular-shaped, with the tip of the triangle pointing backwards.

Neck – formed by the convergence of the fundus and the two inferolateral surfaces. It is continuous with the urethra.

Urine enters the bladder through the left and right ureters, and exits via the urethra. Internally, these orifices are marked by the trigone – a triangular area located within the fundus.

In contrast to the rest of the internal bladder, the trigone has smooth walls (this is explained by the different embryological origin: the trigone is developed by the integration of two mesonephric ducts at the base of the bladder).