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We present a case of heavy intermittent urethral bleeding in a 57-year-old man after traumatic catheterization caused by an urethral pseudoaneurysm. The source of bleeding could be detected by angiography and a superselective embolization was performed.

A female urethral diverticulum (UD) is a rare condition with a prevalence of 0.6 - 4.7 %. Possible aetiologies include chronic infection of the periurethral glands, childbirth trauma, and iatrogenic lesions after urethral manipulation. The main symptoms are recurrent urinary tract infections, post-void dribbling and leakage of urine or purulent discharge by movement, which is caused by the emptying of the diverticular lumen (paradoxical incontinence). As this may imitate stress urinary incontinence, the final diagnosis is a challenge for urologists. We report the case of a female UD containing multiple calculi, which were diagnosed during diagnostic work-up of incontinence. Based on this case report, we want to present and analyse the symptoms as well as the diagnostic evaluation and treatment of UD as reported in the literature. Also we wish to emphasise that the differential diagnosis between a complicated diverticulum and stress urinary incontinence requires a precise knowledge of the symptoms and the diagnostic algorithm for the detection of a DU because the symptoms of these two conditions are similar., Competing Interests: Interessenkonflikt: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Urethral pain syndrome is a symptom complex including dysuria, urinary urgency and frequency, nocturia and persistent or intermittent urethral and/or pelvic pain in the absence of proven infection. These symptoms overlap with several other conditions, such as interstitial cystitis bladder pain syndrome and overactive bladder. Urethral pain syndrome may occur in men but is more frequent in women., Diagnostic: The exact etiology is unknown but infectious and psychogenic factors, urethral spasms, early interstitial cystitis, hypoestrogenism, squamous metaplasia as well as gynecological risk factors are discussed. These aspects should be ruled out or confirmed in the diagnostic approach. Despite the assumption of a multifactorial etiology, pathophysiologically there is a common pathway: dysfunctional epithelium of the urethra becomes leaky which leads to bacterial and abacterial inflammation and ends in fibrosis due to the chronic impairment., Therapy: The therapeutic approach should be multimodal using a trial and error concept: general treatment includes analgesia, antibiotics, alpha receptor blockers and muscle relaxants, antimuscarinic therapy, topical vaginal estrogen, psychological support and physical therapy. In cases of nonresponding patients intravesical and/or surgical therapy should be considered. The aim of this review is to summarize the preliminary findings on urethral pain syndrome and to elucidate the diagnostic and therapeutic options.

Epispadias is the mildest form of the exstrophy-epispadias complex and rarely occurs in an isolated form. The characteristic clinical sign is a mucosal strip on the penile dorsum. Clinically, epispadias presents with urinary incontinence. Primary surgical correction is recommended at the age of 12 months and should only be performed at a specialized center. During follow-up, further bladder neck surgery may be necessary. Despite a functional and cosmetically appealing penis, psychosocial and psychosexual development of the affected individuals can severely be affected. The incidence of urethral duplication remains unclear. Several classifications reflect the anatomical variation. The clinical presentation depends on the continuity of the duplicated urethra and its relationship to the sphincteric mechanism. In addition to clinical examination, a voiding cysturethrography is part of the basic diagnostic workup. After endoscopic examination an individual operative approach can be defined.

Background: Hypospadias is the second most common birth anomaly in male newborns. Most have a distal variant with the urethral opening on or near the glans, which is called distal hypospadia., Methods: Surgical repair is recommended around the first birthday of the child in distal hypospadias mostly due to cosmetic and psychosexual reasons to establish a normal body image., Results: Recently published long-term follow-up studies revealed a complication rate of around 20%, which means that for every fifth child undergoing surgery for distal hyspoapdia, more than one operation is needed in the long term. Parents of patients who have undergone distal hypospadia repair suffer from decisional regret in around 50% of cases, especially when complications occurred., Conclusion: Surgeon's experience and patient's age have a direct impact on complication rates. Thus, urological counseling of parents and patients should take these issues into account.

Condyloma acuminata are the most frequent cause of infections in the anal genital area. They are caused by the human papilloma virus (HPV). Risk factors are early onset of sexual activity, multiple sexual partners, a history of sexually transmitted disease, and immunosuppression. The urethra is afflicted in only 20% of cases; of these, 80% of the warts are at the meatus and 20% in the proximal urethra. This article reports on two cases with condyloma acuminata affection of the total urethra. The current diagnostic, different treatment modalities, and prophylaxis are reviewed.

Hypospadias is the most common congenital abnormality of the lower urinary tract affecting one of 300 male newborns. More than 300 different surgical hypospadias repair techniques have been described. Currently, tubularized incised plate and meatal advancement and glansplasty integrated repair are the preferred techniques for distal hypospadias, whereas two-staged procedures are most frequently used in proximal forms. Success rates are high in the hands of dedicated surgeons, although studies on long-term results are sparse. The most frequent complications of hypospadias repairs include urethrocutaneous fistulas, meatal stenosis, and urethral strictures. Urological follow-up into puberty is warranted, as well as further studies with standardized reporting of long-term results and complications.

Urethral condyloma is a therapeutic challenge. This article reports the case of a patient with spinal cord injury with the incidental finding of a massive spread of urethral condyloma. After removal of the condyloma with biopsy forceps neither recurrence of the condyloma nor a urethral stricture occurred. In patients where intermittent catheterization is performed, condyloma may be dispersed into the bladder, therefore, prompt endoscopic removal is crucial. As condyloma frequently recurs even after complete removal regular controls are mandatory.

We present a 3 day old girl born at term presenting with an interlabial, cystic mass. Pregnancy, delivery and routine antenatal screening were unremarkable. The smooth lesion was located in the anterior half of the vulva, covered with thin vessels. The medially displaced urethra and the medio-posteriorly displaced hymen were identified. Voiding was not impaired. We discuss the differential diagnosis of vulvar masses in the newborn girl. A thorough clinical examination must be the standard of care of pediatric examinations in infants.

We report about a rare case of malakoplakia in a female urethral diverticulum. A 25-year-old patient with a long history of recurrent urinary tract infections and a plum-sized, painful swelling on the vaginal roof presented for operative treatment. In the anamnesis the patient reported about two spontaneous perforations, emptying several millilitres of pus each time. After total operative excision using a vaginal approach the histology showed malakoplakia in a urethral diverticulum. We found the typical intracytoplasmatic "Michaelis-Gutmann bodies" as well as "von Hansemann cells". Postoperatively we excluded an underlying tumour disease or a chronic infection. The further urological diagnostics (cystoscopy and MRI) were without any pathological findings. In patients with atypical cystic tumours of the urogenital tract, especially with an immune deficiency, malakoplakia should be taken in consideration. The preferred therapy is surgical management followed by long-term antibiosis as well as a close follow-up as recurrences are frequent.

A 53-year-old woman suffering for 20 years from chronic genitourinary pain was seen in our urogynecological unit. Quality of life assessment by King's Health Questionnaire showed a highly negative impact on quality of life. Clinical examination revealed a painful and swollen distal urethra, and a small fistula was seen located 12 mm proximal to the meatus externus. Perineal ultrasound and magnetic resonance imaging showed multiple cystic formations bilaterally located in the suburethral and paraurethral regions. A diverticulectomy was performed using the vaginal approach. Twelve months after surgery the woman is completely satisfied and only complaining about slight alguria., ((c) 2008 S. Karger AG, Basel)

Purpose: To evaluate the cause and management of paraurethral abscess developing after injection of a mixture of hyaluronic acid and dextranomer (Zuidex) for treating stress urinary incontinence., Patients and Method: A total of 127 women having undergone midurethral Zuidex injection and 34 women after endoscopically guided Deflux injection into the tissue around the bladder neck were followed up 1 to 24 months after the intervention. At follow-up, the paraurethral tissue was evaluated clinically by gynecologic examination and by introital ultrasound., Results: Thirteen of 127 women (10 %) having undergone midurethral Zuidex injection had a sterile paraurethral abscess that was treated by transvaginal puncture (1 to 3 punctures with removal of 10-60 ml of fluid per patient). No case of postoperative paraurethral abscess formation was demonstrated in the control group treated by Deflux injection into the area around the bladder neck., Conclusions: Paraurethral abscess must be excluded in the postinterventional follow-up of patients after Zuidex injection. Patients in whom an abscess is demonstrated can be treated by transvaginal puncture. Abscess formation can be avoided by injecting dextranomer/hyaluronic acid into the area around the bladder neck.

Epidermolysis bullosa (EB), a hereditary, blistering form of dermatosis, can be divided into the following three main groups: epidermolysis bullosa simplex (EBS), junctional epidermolysis bullosa (JEB) and dystrophic epidermolysis bullosa (DEB). The previously known form of generalized atrophic benign epidermolysis bullosa (GABEB) is classified as junctional epidermolysis bullosa non-Herlitz (JEB-nH) today. An 11-year-old boy with junctional epidermolysis bullosa non-Herlitz with urethal involvement had a complicated course with bladder obstruction and secondary renal insufficiency. According to currently available literature, this is the earliest case known of JEB-nH with involvement of the urinary tract in childhood. Taking into account the complicated course in this young patient, it must be emphasized that in cases of epidermolysis bullosa hereditaria, uncommon affections occurring in infancy should be given careful attention, as such types of associated manifestations are mainly responsible for the lethality in this disease.

Purpose: To detect pathomorphological changes of the pelvic floor, the vagina, and the urethra by MR imaging in patients with stress urinary incontinence in the absence of organ descent compared with findings in 10 healthy controls., Materials and Methods: The study included 10 healthy controls and 38 patients with stage II urinary incontinence showing no urge symptoms but a pathological stress profile on urodynamic testing. The subjects underwent MR imaging with a phased-array coil at 1.5 T in addition to urodynamic testing and gynecological examination. The following sequences were used: axial and coronal PD-weighted TSE sequences with a FOV of 20 cm and a section thickness of 4 mm; axial STIR sequence. Sagittal T2-weighted HASTE sequences were acquired during pelvic floor contraction, relaxation, and straining maneuvers., Results: In 22/38 cases pathomorphological changes were found by MR imaging. The pathomorphological changes were classified as lateral defects (n = 14) if the musculofascial connection between the levator muscle and the lateral vaginal wall or the butterfly shape of the vagina was absent and as central (n = 16) if changes were detected in the urethral wall. Defects of the pelvic floor muscles were detected in 8 cases. No underlying changes were identified in 16/38 cases., Conclusion: In cases of female urinary incontinence, MR imaging of the pelvic floor can detect pathomorphological changes, which are difficult to identify by clinical examination. MR imaging currently does not allow the detection of morphological changes in all forms of female urinary stress incontinence.

Aim: To give recommendations for the standard diagnostic assessment of urethral diverticula and periurethral masses based on an evaluation of our results and a survey of the recent literature., Methods: Group I (1981-1993) included 47 women in whom urethral diverticula (n = 34), periurethral cysts (n = 11), and periurethral leiomyomas (n = 2) were diagnosed and the results compared with the intraoperative findings. Diagnostic work-up comprised history taking, vaginal palpation, introitus ultrasound, double-balloon urethrography (DBU), voiding cystourethroscopy (VCU), excretion urography (EU), and urethrocystoscopy. Group II (1994-1996) included 12 women with urethral diverticula who were examined by DBU, 2D and 3D introitus ultrasound. The diagnostic accuracy of the different methods was assessed., Results: Group I: The diagnostic accuracy in identifying urethral diverticula was 85.3% for palpation, 61.5% for introitus ultrasound, 93.8% for DBU, 37.5% for EU, and 30.0% for urethrocystoscopy. Of all imaging modalities used, only introitus ultrasound depicted periurethral cysts and leiomyomas. Group II: The DBU, 2D and 3D introitus ultrasound had a diagnostic accuracy of 100% in identifying urethral diverticula., Conclusions: Introitus ultrasound should be used as the basic diagnostic tool in clinically suspected urethral diverticula or periurethral masses and additional DBU should be restricted to cases with inconclusive findings.

Involvement of the male genitalia by langerhans cell histiocytosis ist very rare. It has been reported in only three cases yet. We present a patient with recurrent disease of the skin of the penis and by proliferation involvement of the distal urethra and the corpus cavernosum. An overview of the disease and its therapy is given.

Magnetic resonance tomography reliably provides all anatomic information necessary for the differential diagnosis of a urethral diverticulum even when other imaging procedures cannot provide conclusive evidence. In general, the methodological limitations concern only the less important detail findings such as representation of the neck of the diverticulum or the distinction between septated and multiple diverticula. In addition, possible complications and the pelvic anatomy are shown in one examination. Thus magnetic resonance tomography has a key position among the imaging processes and should be used as the imaging procedure of choice for diagnostically doubtful cases.

The history of Cowper Gland is described. Next the clinical, radiological and endoscopical findings in 172 patients (age 18 to 82) are evaluated with regard to the importance of these alterations in clinical practice. There was no tumor. In three cases, only the bulbourethral gland showed inflammation. Out of 169 syringoceles 9 were closed (3 perineal, 6 bulbar). Only one case of the urethral (bulbar) type of closed syringocele showed obstruction. There were 56 patients with various forms of dilatation and opening into the urethra. Only one case showed obstruction. Thirty-one out of 104 patients with so-called simple syringocele had mild dilatation of the duct, mainly normal gland and mild symptoms. Alterations of the urethral wall as well as clinical symptoms were noted in the remaining 73 men with irregular ducts and alterations of the gland; all of them had local urethral signs; in 42 there were extensive urethral strictures.

We report on a complete longitudinal rupture of the urethra in combination with a rupture of the pubic symphysis and pelvic fracture during spontaneous vaginal delivery. Only after stabilisation of the pelvic fracture by external skeletal fixation adaptation of the urethra was possible. Three weeks later after removing of the transurethral catheter a mild stress incontinence could be observed. In the follow up one year later the patient was completely continent. The cosmetic result was satisfactory. There was no cystocele. An unclear haematuria after delivery needs a meticulous urological examination. Early repair of urethral disruption minimize the risk of severe incontinence. Coordinated care between the trauma surgeon and urologist is required for successful treatment of this rare combined injury after birth.

Urethral diverticula have proved to be a common cause of recurrent urinary tract infections in female subjects. Positive-pressure urethrography, mostly performed by means of double-balloon catheters, has hitherto been regarded as the method of choice for their detection. Unfortunately, the few existing commercial catheter devices have certain disadvantages, which have led to a lack of acceptance of this important technique and restricted its use. We therefore present an improved tool for positive-pressure urethrography and a synopsis of diagnostic visualization procedures for urethral diverticula in women.

Diverticula and prestenotic dilatations of the urethra are rare causes of urinary incontinence. By means of two case reports symptoms, diagnose and treatment are discussed. The right interpretation of anamnesis and results of investigations, often misinterpreted because of the rarity of these kind of urinary incontinence, is of special importance.

In 40 women a comparative urethrocystometric study between microtransducer catheters and open-end catheters was performed. Analysis of resting and cough urethrapressure profile concerned clinical and practical value as well as reproducibility. All of these aspects can better be achieved by microtransducer catheters compared to the open-end catheter system. Best results were obtained when measuring with microtransducers in standing position.

In order to demonstrate a urogenital mycoplasmosis, restriction is made frequently also in women - to withdrawal of smear from the urethra. For recognizing whether this procedure is sufficient, 640 female patients of the fluor consulting hours were examined, and 2560 smears were withdrawn from the cervical canals, the surface of the portio, the laterovaginal walls, and from the urethra. The least frequency of mycoplasmas was stated in the urethra. Smears merely withdrawn from the urethra are, therefore, the least appropriate ones for fluor or for identification of a urogenital mycoplasmosis of the female genitals. According to the present results, it is recommended to carry out simultaneously smears from the surface of the portio, from the laterovaginal walls, as well as from the cervical canal and the urethra.

Nine cases of female urethral diverticuli were successfully operated in the years between 1978 and 1980. The anatomic pathophysiology of female urethral diverticuli is discussed according to the currently accepted international and Hungarian terminology. A new modified surgical method is described and the possibilities opened by its adequate application are outlined. No postoperative urethrovaginal fistula has ever been observed. It is emphasized that the new surgical method can only be applied to large diverticuli with a narrow neck. In the interest of the patient co-operation between the urologist and gynaecologist is indispensable.

The clinical course, pathology as well as the operative treatment of the disease are recapitulated and 8 cases with urethral diverticula of are presented. Total divertriculectomies were carried out in 5 cases. No significant complication were observed, except one case of transient incontinence.

Experience with the treatment of 39 cases of urethral diverticula between the years 1954 and 1974 is reported. The patients were 32 women and 7 men. In 7 cases (3 women and 4 men) the condition was congenital in origin. In 30 patients the first symptoms appeared between the 31st and 60th year. In a 12 months old infant a hazelnut sized diverticulum in the posterior urethra caused complete ischuria. In two-third of the patients symptoms of cystitis dominated, dyspareunia in women (8%) and prostatitis in men (16%) had a lower incidence. 80% of the diverticula were infected; they contained stones in 3 cases. In one case the diverticulum recurred and histology revealed in its wall a planocellular carcinoma. Thirty-five patients were subjected to operation. Postoperative fistula developed in 3 cases which had to be re-operated. In cases of recurring urethritis, cystitis and prostatitis, urography is recommended, since the symptoms might be due to the presence of urethral diverticula.

X-ray contrast imaging of the urethra, retrograde as urethrogram (UG) or antegrade as part of the miction cystourethrogram (MCU), has proved successful as a standard examination in urological diagnosis. The article presents a sonography technique enabling three-dimensional morphological and functional imaging the entire male urethra by real-time sonography. Advantages over x-ray film methods are the repeatability at any time, low invasiveness, absence of exposure to x-rays, and lesions of the urethral mucosa by catheters, as well as the avoidance of iodine-induced contrast medium reactions. Miction urethrosonography (MUS) is suitable for screening diagnosis of urethral stricture in miction difficulties, for excluding an iatrogenic of congenital urethral diverticulum, and for control after urethral surgery (internal urethrotomy, urethroplasty).

Diverticulum of the urethra was diagnosed by us in ten women during the past two years. In nine of these, the urethral pressure profile showed a characteristic course: In the region of the diverticulum--confirmed subsequently by radiography--a drop in pressure was recorded as a sign of damage to the wall. The value and importance of the individual steps in the diagnosis of diverticula are discussed. Suspicion of a diverticulum in the urethra can be raised by careful anamnesis and by means of the urethral pressure profile. This suspicion can be safely confirmed or refuted via urethrography using the double-balloon catheter.

With the help of four cases of urethra duplications, a report is presented on the occurrence, symptomatology, diagnostics, and therapy of the clinical picture. The developmental anatomy is dealt with briefly.