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Purpose: Surgical procedures for anorectoplasty for anorectal malformations (ARMs), particularly rectourethral fistula (RUF), depend on the institution. We investigated the diagnosis and treatment of RUF in male patients with ARMs in Japan using a questionnaire survey., Methods: An online survey inquiring about the diagnosis and treatment (diagnostic modalities, surgical approaches, fistula dissection devices, and fistula closure techniques) of each type of ARM in male patients was conducted among institutional members of the Japanese Study Group of Anorectal Anomalies. Fisher's exact test was used to compare surgical methods between posterior sagittal anorectoplasty (PSARP) and laparoscopy-assisted anorectoplasty (LAARP)., Results: Sixty-one institutions (100%) completed the survey. LAARP was the preferred approach for high-type ARM (75.4%). PSARP was preferred for intermediate-type ARM (59.0%). Monopolar devices were most commonly used (72.1%) for RUF dissection. Blunt dissection was more frequent in the PSARP group (PSARP vs. LAARP: 55.6 vs. 20.0%, p < 0.005). Cystoscopy/urethroscopy to confirm the extent of dissection was used more frequently in the LAARP group (70.0% vs. 25.0%, p < 0.005). Clips and staplers were used more frequently in the LAARP group (p < 0.05)., Conclusion: Distinct fistula management strategies for PSARP and LAARP were revealed. Further studies are needed to investigate the postoperative outcomes associated with these practices., (© 2024. The Author(s).)

Examinations of young children for suspicions of sexual abuse are challenging for the involved medical specialists because the consequences of the interpretation of the findings can be severe and dramatic. A broad knowledge of differential diagnoses including rare pathologies like urethral prolapse and failure of the midline fusion of the perineum, known as perineal groove, is essential in order to avoid unnecessary diagnostics and treatment, prejudgment, and to reduce patient family's anxiety. We report two independent cases of girls aged 7 months and 5 years suffering from these rare pathologies, one presenting with painless lower genital tract bleeding, the other showing a lesion of the perineum as random finding during a neuropediatrician's consultation. In both cases, the pathologies were initially misdiagnosed as injuries due to sexual assault, and judicial investigation procedures were initiated. In this paper, the characteristic symptoms and morphology of urethral prolapse and perineal groove are presented to enhance the awareness of these pathologies among forensic experts and help to establish the correct diagnosis., (© 2021. The Author(s).)

Objective: To determine the sensitivity and specificity of 640-Multislice CT (640-MSCT) in diagnosing the female UD., Materials and Methods: We investigated 16 patients with symptomatic UDs preoperatively in our hospital from August 2010 to March 2016. The patients' average age was 38.8 years. All patients were performed 640-MSCT of pelvis; then, 3D and 4D images were reconstructed preoperatively., Results: In 3D and 4D-CT images, out of 16 patients, thirteen patients had one ostium, two had 2 ostia and one had 3 ostia. Out of those thirteen patients, eight patients' ostia were located at 5 o'clock and five patients' at 7 o'clock. Patients with 2 ostia location were at 5 and 6 o'clock and 5 and 7 o'clock, respectively. Patients with 3 ostia location were at 5, 6 and 7 o'clock. The mean distance from the bladder neck to the ostia was 22.5 mm. The shape of UD was out-pouching in 11 patients (68.8%), U-shaped in four patients (25.0%) and circumferential in 1 patient (6.2%). The CT findings were confirmed by surgical findings., Conclusions: 640-MSCT is a useful tool in identifying UD's shape and ostium (including number, location) before operation. Preoperative 640-MSCT should be an adaptable modality for clinically suspected UD patients., Advances in Knowledge: Several imaging methods have been used to diagnose female UD. 640-MSCT may be more suitable to diagnose it for its higher sensitivity and specificity in diagnosis of female UD, especially in identifying UD's shape and number and location of ostium.

Purpose: The purpose of this study is to report the outcomes of an algorithm-based multidisciplinary treatment approach to rectourethral fistula., Methods: This study is a retrospective review of a prospectively collected database at a tertiary center of all consecutive patients treated between 2003 and 2013., Results: Thirty males (mean age 63 years) were reviewed. Prostate cancer treatment was the most common fistula etiology (97%). Urinary drainage consisted of urethral catheter in all patients and suprapubic catheter in 14 (47%). The rate of fecal diversion was 67%. During a mean follow-up of 72 months, healing rate was 90% and recurrence rate 0%. Spontaneous healing was achieved in 14 patients (47%): 8 (27%) without fecal diversion and 6 (20%) following fecal diversion. Thirteen patients (43%) required definitive intervention. The majority of operated patients underwent transanal or transperineal flap (endorectal, dartos, or gracilis) successfully. Only 2 patients (7%) required an abdominal approach (positive oncologic margins or non-functioning bladder). Fifteen out of the 20 patients (75%) who underwent fecal diversion had stoma closure with an overall permanent stoma rate of 17%. Long-term urinary incontinence was noted in 11 patients (37%). Six patients (20%) required permanent urinary diversion or drainage catheters., Conclusions: Algorithm-based treatment approach for rectourethral fistula is useful in the management of this rare condition. Selective fecal diversion is possible, and majority of patients who require definitive intervention can be treated with a transanal or transperineal approach. The rate of permanent stoma is low, but long-term urinary dysfunction is frequent.

Uro-genital bleeding in pre-menarcheal girls always raises concerns regarding child abuse. There are serious social issues involved; however, before labeling it as sexual abuse, all efforts must be made to rule out an organic pathology. We recently encountered two young girls of Afro-Caribbean origin who presented with vaginal bleeding with concerns from referring physicians about child/sexual abuse. On examination both had a rare condition of urethral prolapse. One of them underwent four-quadrant excision and the other was treated conservatively with urethral catherization.

Rectourethral or rectovaginal fistula is a troublesome complication after anorectal surgery. The pelvic and perineal dissection may be difficult because of severe fibrosis adhesion around the fistula. The authors applied a novel technique: a combined laparoscopic assisted abdominal and posterior sagittal approach (PSA) to perform the redo surgery. Three boys and two girls (3-13 years old): case 1 had rectovaginal fistula after rectal dialation and modified Swenson's procedure; case 2 had rectovestibular fistula after twice perineal anorectoplasty; case 3 had rectourethral fistula after twice anorectoplasty; case 4 was imperforate anus with Hirschsprung's disease and rectourethral fistula that had been misdiagnosed; case 5 had rectourethral fistula after abdominoperineoanoplasty and Mollard procedure and posterior sagittal anorectoplasty. Laparoscopic assisted abdominal dissection was done first to mobilize the colon as far as the mid pelvis, and the normal colon was marked with a suture. The lower pelvic dissection was performed through the posterior sagittal route, the proximal rectum was mobilized and servered, the distal rectum was left undisected, endorectal mucosectomy with electric ablation was performed, then the fistula was closed from inside the rectum, and the stump of the colon was pulled through the rectum, the stump and the dentate line were anastomosed extraanally. Colostomy was done in case 2 and case 5. The postoperative follow-up showed no recurrent fistula, and all patients had attained normal voluntary bowel actions, but one child had infrequent minor soiling. Laparoscopic assisted endorectal pull-through of the intact colon can offer precise dissection, minimal abdominal injure, and spare troublesome mobilization of the fistula, and can prevent the recurrent of fistula. Posterior sagittal approach provides a direct repair of the fistula and anastomosis.

We described the clinical presentations, radiological findings, urodynamic patterns and endoscopic management in a series of patients with symptomatic lacuna magna (LM). The medical records of 14 boys diagnosed as LM were reviewed, retrospectively. The presence of LM was first diagnosed based on clinical history, physical exam, and radiological findings; then confirmed by urethroscopy. Urodynamic study was performed in 10 boys before and after the procedure. Transurethral incision and fulguration of the valve was performed in all patients. The mean (range) age of patients was 3.1 years (6 months to 8 years). The boys presented with dysuria (n = 9), postvoid dribbling (n = 4), hematuria (n = 3), bloody spotting (n = 3), enuresis (n = 4), and glanular irritation and pain (n = 6). The post-operative period was uneventful in all patients. The symptoms were relieved and repeat radiological exam showed complete resolution of LM in all children by the 3rd post-surgical month. Before the procedure, main urodynamic abnormalities in children were high P(detmax) and detrusor instability that significantly improved within 3-6 months after treatment. Despite evidence suggesting that a LM is a frequent, normal anatomical variant, the valve may cause symptoms such as intermittent hematuria, dysuria, and bloody spotting of underwear. The lesion may be associated with obstructive urodynamic patterns in some children. Endoscopic treatment of patients effectively relieves the symptoms and corrects the urodynamic abnormalities.

Cowper's syringocele is cystic dilatation of the excretory bulbourethral gland duct. It is an uncommon condition and is usually reported in children. There are only ten previous case reports of late presentation in adulthood to the best of our knowledge. We present the imaging findings of such a case manifesting at 30 years of age.

Currently, laparoscopic-assisted colon pull-through (LACPT) is the treatment of choice for male patients with high-type imperforate anus and rectourethral fistula. Since laparoscopy was introduced for treating this condition, reports concerning post-LACPT complications are rare. Here we discuss the case of a boy, now 3.5 years old, born at 37 weeks' gestation weighing 2,300 g, who was diagnosed with rectobulbar urethral fistula (RUF) at birth. LACPT was performed when the boy was 11 months old and weighed 7.2 kg. No intraoperative complications occurred, and the initial post-LACPT course was uneventful. When he was 2 years old, he developed dysuria requiring urethral catheterization. Diagnostic radiology confirmed a large cystic mass behind the bladder, suggestive of a posterior urethral diverticulum (PUD). Histopathology of the excised mucosa of the cyst showed colonic mucosa, confirming that the cyst was indeed an enlarged residual RUF. We discuss our treatment and our approach to prevention.

We report an unusual case of anorectal agenesis with a rectourethral fistula diagnosed in a 48-year-old man. The patient presented after noticing hematuria, although he had been aware of urinary leakage from his colostomy with occasional fecal urine for about 4 years. He had had a double-barrel colostomy created soon after birth for an imperforate anus, with revision at the age of 4 years to correct a prolapse of the stoma, but his malformation had never been repaired. We performed a physical examination, which did not reveal a perineal fistula, but urethrocystography demonstrated high anorectal agenesis with a rectourethral fistula. Thus, we resected the rectourethral fistula and created an end-colostomy. The patient had an uneventful postoperative course, and was discharged in good health on postoperative day 19. To our knowledge, this is the oldest patient to be diagnosed with anorectal agenesis and undergo resection of a rectourethral fistula.

The male urethral imaging and pathology is not widespread in the radiology literature because this part of the urinary tract is easily studied by urologists with clinical or endoscopic examinations. Ultrasonography and MR imaging are increasingly being used in association with voiding cystourethrography and retrograde urethrography. The posterior urethra is being studied with voiding cystourethrography or voiding sonography which allows the detection of bladder neck pathology, post-surgical stenosis, and neoplasms. The functional aspects of the bladder neck and posterior urethra can be monitored continuously in patients with neuromuscular dysfunction of the bladder. The anterior urethral anatomy and pathology is commonly explored by retrograde urethrography, but recently sonourethrography and MR imaging have been proposed, distending the lumen with simple saline solution instead of iodinated contrast media. They are being used to study the urethral mucosa and the periurethral spongy tissue which can be involved in the urethral pathologies such as strictures, diverticula, trauma, and tumors. Imaging has an important role to play in the study of the diseases of the male urethra since it can detect pathology not visible on urethroscopy. The new imaging techniques in this area, such as sonography and MR, can provide adjunct information that cannot be obtained with other modalities.

Retrograde urethrography is the method commonly employed in the detection of anterior male urethra pathology. Ultrasonography and magnetic resonance imaging have been proposed recently as new methods that can replace conventional radiography. Normal urethral anatomy can be easily studied after saline distention of the urethra, which creates high contrast relative to adjacent structures such as mucosa and corpus spongiosum. Sonourethrography with high-frequency probes has a high spatial resolution and has proved to be sensitive, specific, and accurate in the diagnosis of anterior urethral pathologies such as strictures, syringocele, tumors, and trauma. It has a major role in the selection of therapy in patients with bulbar strictures. Magnetic resonance imaging with a surface coil with a small field of view can detect penile and bulbar stenoses and tumor extension. After contrast administration, the activity of the inflammatory process in the spongiosum can be assessed and used to modify the urethroplasty technique. The clinical use of the new imaging modalities in the male anterior urethra is limited despite their demonstrated accuracy in diagnosis and presurgical staging of different diseases.

Congenital urethral fistula is an extremely rare but easily manageable anomaly that may be confused with hypospadias. This is a case description of a congenital fistula of the anterior urethra. Awareness of the entity will avoid complications.

Anterior urethral injuries, although rare, may be associated with substantial long-term morbidity. Urethral injuries that occur due to penetrating trauma or penile fracture are best treated by meticulous two-layer primary repair. Those that occur due to rapid deceleration injury are usually best treated by suprapubic diversion and delayed reconstruction because of associated injuries and concomitant contusion of the supporting spongiosum.

This article reviews and illustrates bladder and urethral injuries, including their mechanisms of injury, imaging diagnosis, systems for classification, and the accuracy/pitfalls of the diagnostic methods. The bulk of this review will focus on lower urinary tract injuries caused by high speed, wide impact blunt trauma which is the most common mechanism of lower urinary tract injury encountered in civilian practice.

We report an unusual case of primary amyloidosis isolated to the urethra in a patient with tender, periurethral masses and obstructive voiding symptoms. When not secondary to other phenomena, amyloidosis most commonly affects the skin, respiratory, and urinary tracts. Isolated amyloidosis of the urethra should be in the differential diagnosis of a patient with irregular strictures of the penile urethra, a clinical presentation consistent with urethral carcinoma, and no evidence of systemic disease.

A midline cystic structure in the prostate most commonly represents a Mullerian duct cyst or dilated utricle. We describe the sonographic and magnetic resonance imaging (MRI) appearance of a rare diverticulum of the posterior urethra presenting as a midline prostatic cyst.

We report the thirteenth case of a recto-urethral fistula in Crohn's disease. The patient, a 37-year-old white male, had a 20-year history of intestinal Crohn's disease and had undergone numerous bowel resections. His symptoms were fecaluria, urorrhea and passing of urine from an orifice just outside the base of the scrotum. He had urinary infection and severe ileocolitis. He underwent a diagnostic evaluation (cystourethroscopy, proctoscopy, retrograde pyelography, intravenous urography, voiding cystourethrography) that revealed a fistula comprising the membranous urethra, the rectum, the perineum and the scrotum. He was treated with Metronidazole (20 mg/kg/day/12 mo). At 1 year no signs of intestinal disease and urinary sepsis were noted. The external orifice and the perineal fistulous network were closed, and the drainage from the rectum and the urethra had improved. No side effects limited use of the drug. No relapse was observed in the 3 months, after the therapy was discontinued. We present a review of the literature on the management of rectourethral fistulas in Crohn's disease. Surgeons have used successfully several approaches in the repair of this lesion, but no single procedure has proved optimal or even universally applicable. We emphasize, as the literature suggests, that the management must be individualized. Medical therapy with metronidazole has an important role in a patient with rectourethral fistula and concomitant proctitis, ileocolitis, urinary sepsis and multiple previous surgical procedures.

This paper presents two unusual fistulae between the rectum and the lower urinary tract in adults, one a posttraumatic fistula following dilatation of a sigmoid colon stricture and the other a congenital anomaly. In both cases a contrast enema was negative; in one case a voiding cystourethrogram was negative. The fistula was demonstrated in case 1 by repeating the enema and having the patient raise his intraabdominal pressure, and in case 2 by having the patient hold while attempting to pass flatus during a cystogram, which demonstrated gas bubbles entering the bladder.

Magnetic resonance imaging has opened up a new horizon in the evaluation of the male pelvis. Its direct multiplanar imaging and display of the unique tissue contrast allows for the demonstration of prostate anatomy. Prostatic disease, even when confined to the gland, is easily depicted. However, one cannot distinguish benign from malignant processes. In a patient with a known prostatic neoplasm, magnetic resonance is useful as a staging modality. Accuracy in the staging of prostatic malignancies by MRI surpasses that of ultrasound or CT. In the evaluation of the urinary bladder, the greatest advantage of magnetic resonance is its ability to differentiate between a normal bladder, and other pathologic conditions affecting the bladder, including inflammatory, congestive and neoplastic processes. In the evaluation of bladder carcinoma, magnetic resonance is useful as a staging modality. Clinical application of magnetic resonance is just beginning and therefore, the full potential of the modality has yet to be explored.