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The Roentgen Diagnosis of the Diseases of the Prostate
THE JOURNAL OF UROLOGY
Vol. 67, No. 2, February 1952
Printed in U.S.A.
THE ROENTGEN DIAGNOSIS OF THE DISEASES OF THE PROSTATE NILS P. G. EDLING From the Roentgen Diagnostic Department, Karolinska Sjukhuset, Stockholm, Sweden
The radiological studies of the prostate by means of urethrocystography require an examination which must include both the prostatic urethra and the bladder base. This is especially true if one desires to study an enlarged prostate which protrudes into the bladder or to study changes around the internal urethral orifice. In these cases it is of greatest importance to demonstrate the junction of the prostatic urethra with the bladder base during the retrograde filling and during micturition. Only then can details be studied and an accurate diagnosis be made. The principles of roentgen studies of the entire urethra by retrograde filling with contrast medium were established by Baensch and Boeminghaus (1921), Haudek (1921), Kurtzahn (1921-1922), Beclere and Henry (1922), Janssen (1922), and Kohnstam and Cave (1925). The first papers on urethrography during micturition were published by Fasiani (1925), and by Frumkin (1925). More extensive papers in retrograde filling of the urethra were published by Knutson (1935) and by Kerr and Gilles (1944), and on studies during micturition by Puhl (1929), Vincent (1935), and Edling (1945). Cystography, which is much more widely used than urethrography, is discussed at some length in larger textbooks on roentgen diagnosis. Earlier authors have regarded urethrography and .eystography as two separate examinations and used different contrast mediums for each study. For examples, they performed the retrograde filling with one contrast medium, often oil, and the micturition examination with another. Such an examination, however, cannot give a good view of the urethra and bladder as a unit. We perform urethrocystography with a water-soluble contrast medium of the abrodil (skiodan) type, which mixes readily with the urine in the bladder. This enables us to study simultaneously the urethra, prostate and bladder during injection. An examination during micturition follows. The subjective discomforts within the urethra caused by contrast medium can be avoided by local anaesthesia of the urethral mucosa (e.g., with onequarter of 1 per cent of decicain solution). For the injection of the anesthetic and contrast solutions Knutsson's instrument is particularly well suited, especially as modified by Markman (1946) for distant manipulation of the syringe.* After the patient has evacuated his bladder the examination is begun with a scout film. One or two frontal views, as well as right and left obliques views, follow during injection, and one or two oblique views during micturition. According to the writer's experience, urethrocystographic investigations which include both injection and micturition films gives the most satisfactory results. Normal urethrocystograms show the prostatic urethra in the sagittal mid* From A. B. Stille, Stockholm, Sweden. 197
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NILS P. G. EDLING
plane. It is slightly curved, its concavity pointing anteriorly. The contours are smooth. During injection the lumen is contracted and narrow and the collicular relief is always visible (fig. l). During micturition the prostatic urethra dilates,
Fm. 1. Normal case. Both pictures in exactly same oblique view. During injection, A, contracted prostatic urethra with smooth contours. Collicular relief and internal urethral orifice are seen. During micturition, B, widening of lumen of posterior urethra, change of shape of bladder and sinking of pelvic floor.
Fm. 2. Normal case during injection. Contracted prostatic urethra, distinctly marked internal urethral orifice and interureteric ridge.
passing with a broad lumen into the bladder cranially, and into the membranous portion caudally. The colliculus is oval and protrudes into the lumen. The shadow of the moderately filled bladder is more or less oval and its long axis runs transversely to the body in frontal or oblique vie,vs. The base of the bladder is flat. With the patient in the recumbent position the internal urethral orifice
ROJ~XTGEN DIAGKOSIS OF DISEASES OF PROSTATE
19fl
lies approximately at the le,-el of the upper horder of the symphysis. The illterureteric ridge is often ,.'isible (fig. 2). When the bladder contracts during micturition it it1 raised a11d may sometimes show an apparent division, or a drawn-out apex 1Yhich cloes not appear in rest. At the same time, the prostate and bladder are lmrnred due to a relaxation of the pelYic floor. Both duri11g injection and mictmition the contours of the bladder base are smooth, a11d the portion" are either smooth or Hlightly irregular. In normal cases there is no contrnst filling outside the limits of the urethra and bladder proper. Pathological changes of the prostate, such as calcifieati011s, c:,wities or ment of the organ, may be Yisualized by the urethrocystogrnphic method. The size and positio11 of calcificaticms, if prese11t, should be studied at fast on plain radiographs. Oiherwise it may be difficult to determine ·whether a shadow in the prostate has or has not appeared during a contrast examination_ :K nmerous and \Yiclespread c:alcification:o are of importance, as the prostate may appear hard on rectal examination. In addition, according to their distribution, the caleificatious may indicate general or local enlargement of the '\Vhat is the diagnostic significance of these calcifications? According to pathologists, the corpora amylacea may calcify in one prese11ium or senium due to involution. 111 such cac;es the calcifications are sparne and small_ If calcifications are numernus and large, or if they lie unilaterally, they may be due to postinflammatory <'hanges_ These calcifications may be present both in tuberculous and septic cases, often lying within cavities which communicate ,Yith the urethral lumen. HmYeYer, the contrast exami11ation is of the greatest importance in diagnosis of proHtatic cha11ges, giving the radiologist the opportunity to demonstrate typical pictures of various pathological conditions. The well lrnmrn sign of prostatitis consists of filling of prm,tatic duct;; and glandt,; \Yith ccmtra;.;t medium, thus indicating open communication ,Yith the urethral lumen resulting from postinflammatory ,rnll changes (fig. 3). All stages may be seen, from :oingle narro\Y ducts to large cavities_ It it:i of importance to stress that the large cavities may appear both in t:ieptic and tuberculom, infections and that a correct diagnosis is impossible ,vithout bacteriological studies. B'rom the differential diagnostic point of view it is necessary to knm,· the roentgen appearance of the utricle filled with opaque solution. This finding is not infrequent and the appearance is typicaL The utricle is situated in the midplane of the prostate, directed upwards and bacbYards from the collicul11s into ,Yhich it opens "·ith or ,,ithout a duc:t. There are, hmYeYer, many cases ill which one must assume that contrast filling of the utricle during urethrocy:otography is caused by postinflammatory changes. Sometimes the ejaculatory ducts are Yisualizecl, most often in connection ,Yith contrast filling of oue or both seminal ampullae and Yesicles. The course of the ducts and the typical picture and site of the vesicles are easy to recognize_ :False passages and fistulas are very rare in the prostatic area. There is also another sign that indicates postinflammatory changes of the prostate. Due to the shrinkage of the surrounding tissue the prostatic urethra
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NILS P. G. EDLING
may be dilated during injection, ·without showing a deformity or any other changes. In the less advanced cases the pericollicular urethra is widened, while the remaining portion is normally contracted (fig. 3). In chronic cases, on the other hand, the prostatic urethra may be changed into a stiff tube which stands in broad communication ·with the membranous urethra and the bladder, respectively, and the patients are incontinent. In such cases one may find numerous contrast-filled cavities and short dilated ducts close to the urethral lumen, also indicating an atrophy of the prostatic tissue. The bladder is often fibrotic in these severe cases. From the point of vie,v of differential diagnosis, in cases of cystitis a widening of the urethral lumen during injection may sometimes appear if distention of the bladder causes urgency. If the history is not knom1 or is incomplete, a
Fru. 3. Case of prostatitis with atrophy during injection. Fairly pronounced dilatation of pericollicular urethra without deformity. Contrast filling of small glandular cavities in prostate.
widening after electroresection or removal may give rise to an incorrect diagnosis as well. In most cases of prostatitis the prostatic urethra appears of normal length and shape on urethrocystograms. In some, however, the contrast examination may show an elongation of the supracollicular portion, the lumen of which is normally contracted and smooth (fig. 4). In addition, there may be a slight smooth protrusion into the bladder base. The collicular relief is intact, or swollen, and during micturition the dilatability of the prostatic urethra is normal. This urethrocystographic finding can be explained by a diffuse inflammatory enlargement of prostatic tissue in subacute and chronic cases. In a true prostatic enlargement there is no deformity or dislocation of the urethral lumen. Inflammatory changes seem in some cases to mask even the adenomatous signs if hypertrophy of the prostate is complicated by prostatitis. In this way may be explained the absence of a deformity of the prostatic urethra on urethrocysto-
ROENTGEN DIAGNOSIS OF DISEASES OF PROSTATE
201
grams in cases in which the biopsy after electroresection or removal shows both prostatitis and hypertrophy. The other two lesions causing enlargement of the prostate are hypertrophy and cancer. The differential diagnosis will be discussed in the following paragraphs. On a plain radiograph hypertrophy must be assumed if calcifications within the prostate are displaced caudally and show a cup-like arrangement, due to adenomas pressing from above. During urethrocystography contrast filled ducts and cavities may give similar information if they show the same displacement and arrangement as the above mentioned calcifications. However, most important in the roentgenological diagnosis of hypertrophy is the study of the prostatic urethra and the bladder base.
Fm. 4. Case of prostatitis during injection. Elongation of supracollicular urethra with normal shape of collicular relief and no deformity or dislocation of lumen.
It is well known that the changes appearing in prostatic hypertrophy are caused by adenomatous expansion. Because of their close relation to the prostatic urethra, the adenomas influence the appearance of its lumen very early. In early stages they protrude slightly into the supracollicular lumen or into the bladder base at the urethral orifice, causing only moderate indentations. As their growth continues the supracollicular portion lengthens and its lumen will be more deformed. The lumen may become ribbon-like through aplanation from side to side (fig. 5) or is, in a transverse section, cross-shaped due to indentations from different directions. The adenomas are usually situated laterally and posteriorly to the supracollicular urethra which, therefore, is angulated anteriorly or anteriorly and a little laterally. Occasionally the urethra is angulated posteriorly due to an adenomatous expansion in front of the lumen. As the adenomas grow in a typical way, the changes are usually symmetrical or fairly symmetrical on either side. In some cases the growth is unilateral, and the
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NILS P. G. EDLING
differential diagnosis in respect to cancer is difficult. In hypertrophy the unilateral displacement seems to be limited to the supracollicular portion, and a dislocation of the whole prostatic urethra is never seen. This is true even in advanced cases, where the protrusions may be followed into the infracollicular region. Therefore, localization of this feature to the upper part of the prostatic urethra, forming a smoothly outlined flat compression of the lumen from one side, indicates hypertrophy. The collicular relief is most often deformed or not visible. In the bladder base there may be found one or more indentations of different sizes. In some cases the only sign of hypertrophy may be a single adenoma at the internal orifice. The radiographs show a spherical protrusion into the most proximal portion of the urethra and into the bladder base. In addition, the
FIG. 5. Case of prostatic hypertrophy during injection. Typical picture of adenomatous enlargement with elongation and compression of prostatic urethra, angulation, and moderate bulging into bladder base. Contours are smooth.
frontal view during injection may show this portion of the urethra to form a delta due to spreading of the contrast medium at the lower surface of the adenoma. This finding of a spherical adenoma ("third lobe") is very important because of its valve action during micturition. The contours of the urethral lumen and the bladder base in hypertrophy are smooth, with very few exceptions. As opposed to hypertrophy, the growth of cancer is atypical, starting usually in the posterior lobe. The enlargement of the prostate is most often asymmetrical, and causes a deformity of the urethral lumen different from that produced by hypertrophy. On plain radiographs the localization of calcifications may be studied according to rule. If these have a high position in the prostatic area or are situated in separated groups they may have been forced upwards or apart by tumor masses expanding from the posterior lobe (fig. 8). Osteoplastic metastases of the pelvic bones must be kept in mind as an important sign of prostatic cancer.
ROBI\/TGEN DL\GNOSIS OF DISEASES OF PROST.tTE
203
The possibility of an early urethrocystographic diagnosis of cancer of the prostate is unlikely because the point of origin lies in most cases ,Yithin the posterior lobe and is distant from the urethra. Yet, it is necessary to observe carefully those eases -where the collicular relief seems to be larger than normal, and is asymmetrical or is faintly outlined, indicating small expanding foci close to the urethra. The cancer is usually advanced when examined. As in hypertrophy, the enlargement of the prostate due to tumor grmYth causes a lengthening of the prostatic urethra. Thus, this finding per se is of no importance from the viewpoint of differential diagnosis. Owing to the constricting gmwth of cancer mas:,,es the urethra is often narrowed and straightened and, contrary to the normally contracted lnmen, has irregular contours or irregular deformities (figs. 6, 7, 8). In many cases the collicular relief ic; deformed. In :,,ome eases
Fm. 6. Case of prostatic cancer during injection. Elongation of prostatic urethra demonstrating a fairl:v narrow lumen with inegular contours and displacemen1 to left and anteriorly.
there is an abrupt kink in the course of the lumen caused by asymmetncal pressure on any part of the prostatic urethra. Other eases have an angulation of a type seen in hypertrophy, explained by accompanying hypertrophy. However, the cancer i:,, accompanied by a more pronounced deviation, due to its more extensive growth. In addition to this deviation of a part of the lumeu, often supracollicularly, one may find a displacement of the entire prostatic methra (figs. 6, 7) :From the junction of the membranous with the infracollicular urethra to the internal orifice, the urethral lumen is dislocated anteriorly and laterally, often to a Yarying degree in different portions. A deviation of the infracollicular urethra from its normal course is the most prominent feature and, if knmvn, is easy to recognize. This is a very important sign and appears almost exchrnively in malignant expansion. As in hypertrophy, the cancer masses may bulge into the bac:e of the bladder. In a series of hypertrophy and cancer cases, irregular contours, -when present,
204
NILS P. G. EDLING
were caused by cancer only (fig. 8), while every adenomatous protrusion had a smooth outline (fig. 5). The differential diagnosis of hypertrophy and cancer is most difficult when hypertrophy is associated with cancer, which occurs in about 50 per cent of
L
Fm. 7. Case of prostatic cancer. Both injection, A, and micturition, B, pictures. Elongation of prostatic urethra with left posterolateral bulging into lumen and irregular contours.
Fm. 8. Case of prostatic cancer and hypertrophy during injection. Elongated, flattened and angulated prostatic urethra. Flattening is interrupted in midpart and contours are irregular. Irregular bulging into bladder base. To right two groups of calcifications, one forced upwards, other downwards, by expanding masses from posterior part of prostate.
cancer cases. In these instances the signs of hypertrophy may predominate on urethrocystograms, and the cancer be masked. If the cancer, however, has expanded to the prostatic urethra or grown into the adenomas, it may cause a deformity or displacement of quite a different nature or degree from pure hypertrophy and may be recognized.
HOENTGe;N DL-lcG1\'0SIS OF DISKI_SES OF PROSTATE
205
:Fron1 the differential diagnostic -viewpoint, irregularities of the lumen after remontl and electroresec1ion mi.mt he kept in mind as \\-ell. Where a complete operation was performed the Yisualizatiou of the postoperative cavity is an important differential diagum,tic sign. Incomplete intervention may cause a false diagnosis of cancer, in the almeuce of an accnrate anamneRis. "Contracture" of the bladder neck may he caused by each of the above described lesions, as ,rcll as by congenital and neurogenic disorders. Hmvever, the condition is treated in a l'ipecial paragraph, clue to its clinical and roentgenological character. The nature of this lesion is such that urethrocystography clming micturition is ideally suited to demonstrate cases with a po,-,terior bar,
Fm. 9, Two cases of contrncture of bladder neck during micturition. A, clinical s,·mptoms of prostatitis. Circular contracture of internal opening with markedly decreased dilatability. B, prostatic hypertrophy with bar formation. Bulging into internal urethral orifice from behind. In addition, in both cases trnbeculation of bladder wall also indicating an obstacle to the outflmL
or a circular contracture. 1Yith successful technique it is possible to shm,- not only the narrowing of the urethral orifice, but also the dilatability of the prostatic urethra, thus demonstrating the rigidity of the orifice. The typical mictmition picture shmrn pressure upon the methral orifice, posteriorly (fig. 9, B), or in a(i"l'anced cases ,,-ith a common bar, a ma;,sive protrusion into the bladder base and prostatic urethra. In cases with a circular contracture the urethrocystogram shows a concentric constriction of the internal opening (fig. 9, Micturition films shonlcl be taken e,·en if the stream of contrast uriue is scanty or the patient is only able to void in drops. If the bladder ha;, risen and shmrn trabeculation and di,-erticula as a sign of chronic obstruction to the outflow, these findings indicate a rigidity of the urethral orifice. This holds
206
NILS P. G. EDLING
true in spite of the fact that the incomplete contrast filling makes it impossible to study the shape of the orifice and the prostatic urethra. In such cases the radiologist must also bear in mind the possibility of a dysfunction of neurogenic origin. Some of the cases with protrusion of a mass into the internal urethral orifice showed the most proximal portion of the urethra distinctly curved, anteriorly or a little laterally, during the injection of contrast medium. It can be best studied in oblique views. In a frontal view the central ray is tangential to this proximal part of the lumen, giving a foreshortening of typical appearance. As mentioned above, the so-called "contracture of the bladder neck" may be a part of adenomatous or cancerous enlargement of the prostate. The true barrier, without other roentgenological changes, occurs in prostatitic cases. Then it may be confused with a single adenoma of a "third lobe" type. The differential diagnosis is based on the smooth spherical shape of the adenoma. Cavities after removal or electroresection show typical urethrocystograms if the intervention has been performed correctly. After removal they have the appearance of a spindle-shaped widening of the urethral lumen, whereas after eleJtroresection they are funnel-shaped. The contours are often irregular. If surgical intervention has been incomplete, irregular contours may be the sole postoperative sign. This may result in a mistaken diagnosis of cancer, should the history be incomplete. The differential diagnosis also brings into question the condition of sphincter paresis, which may cause dilatation of the prostatic urethra similar to a postoperative cavity. Here, however, the case history is of greatest importance. The paralytic widening is, in addition, always smoothly outlined. Finally, cases of cystitis may show a widened prostatic urethra due to violent urgency and immediate micturition when the bladder distends during injection of the contrast medium. There is a very intimate functional correlation between the sphincter system of the prostatic urethra and the detrusor muscle of the bladder. Therefore, a disturbance of the filling and emptying mechanism of the bladder, if neurogenic in character, should also be studied in both organs. As a detailed study of bladder lesions lies beyond the scope of this paper, the neurogenic disorders are not treated. The writer wishes to emphasize that the watersoluble contrast media in urethrocystography give a good view of the contraction or dilatation of the prostatic urethra, and the size and the wall changes of the bladder. In addition to the local changes previously described, the appearance of the bladder will be of value in the assessment of the functional importance of prostatic diseases. The bladder reacts to a chronic obstruction with dilatation of the lumen and hypertrophy of the detrusor. The longer the obstruction has lasted and the higher it is situated in the prostatic urethra, the more difficult is the emptying and the more pronounced the trabeculation and the diverticula formation of the bladder wall. In using urethrocystography in the previously described manner, it is possible to combine in one examination a study of the changes of the urethra and the bladder base with a study of the bladder changes caused by prostatic disorders.
HOK\TGEN DIAGNOSIS OF DISE.\SES OF PROSTATE
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The information gi,·en by urethrocystography relati,,e to the morphology and functional disorders of the lmnor urinary tract has been of greatest importance in the clinical assessment of the patients and in their treatment. SUMMARY
The author describes the urethrocystographic method and stresses the ntlue of an examination with a ,vatersoluble contrast medium during both injection and micturition, allmving a study both of the prostatic urethra and bladder base and the bladder changes caused by a diseased prostate. In the paper are discussed the roentgen signs of po:ot-inflammatory changes, enlargement of the prnstate due to prostatitis, hypertrophy and cancer; contracture of the bladder neck, and finally the state of affairs after surgical intervention. REFEREXCES B.u:,-;:sct-r, \V. BECLERE, H.
H. · Ztschr. f. urol. Chir., 7: +8, 1\J21. AKD HEXRY, R. · J. d'urol., 13: -±17, 1\J22 EDLIN<,, N. P. G.: Act11 rncliol., Suppl. 58, Stockholm 1945. F.-1.sL-1."11, G. l\I.· Arch. ital. di urol., 1: -±87, 1[)25. FRnIKTK, A. P.· Fortschr. iuL CciJ. d. H.onlgenstrahlen 33: +01, 1925" H.\UlEK, :u. ·Wien.med. Wchnschr., 71: 4\J0, 1921. JA:-;ssBN, P.: l\Hinchen. med. Wchnschr., 11: 394, 1922. 1{BRR, H. D. Ac-TD GILLIES, C. L.: Chicago 1\J44. KNV'l'SSON, F.: Acta rndiol., Suppl. 28, Stockholm 1935. KoHKSTAi-r, G. L. S. AND CAvJc, E. H.P.: London 1\J25. KFRTZAH:'-T, H.: Fortschr. 11.d. Gdi. cl. Riintgenstrnhlcn 29: 2!H, Hl21-1!}22 :\LrnKl\IAN, B. J.: Acta rndiol. 27: 388, l\J46. PPHL, H.: Deutsche Ztschr. f. Chir., 220: 372, 1\J29. V1c\!CBKT, P. G. A.: Paris HJ35. A"ID Bcrn:111\:GHAus.
Vol. 67, No. 2, February 1952
Printed in U.S.A.
THE ROENTGEN DIAGNOSIS OF THE DISEASES OF THE PROSTATE NILS P. G. EDLING From the Roentgen Diagnostic Department, Karolinska Sjukhuset, Stockholm, Sweden
The radiological studies of the prostate by means of urethrocystography require an examination which must include both the prostatic urethra and the bladder base. This is especially true if one desires to study an enlarged prostate which protrudes into the bladder or to study changes around the internal urethral orifice. In these cases it is of greatest importance to demonstrate the junction of the prostatic urethra with the bladder base during the retrograde filling and during micturition. Only then can details be studied and an accurate diagnosis be made. The principles of roentgen studies of the entire urethra by retrograde filling with contrast medium were established by Baensch and Boeminghaus (1921), Haudek (1921), Kurtzahn (1921-1922), Beclere and Henry (1922), Janssen (1922), and Kohnstam and Cave (1925). The first papers on urethrography during micturition were published by Fasiani (1925), and by Frumkin (1925). More extensive papers in retrograde filling of the urethra were published by Knutson (1935) and by Kerr and Gilles (1944), and on studies during micturition by Puhl (1929), Vincent (1935), and Edling (1945). Cystography, which is much more widely used than urethrography, is discussed at some length in larger textbooks on roentgen diagnosis. Earlier authors have regarded urethrography and .eystography as two separate examinations and used different contrast mediums for each study. For examples, they performed the retrograde filling with one contrast medium, often oil, and the micturition examination with another. Such an examination, however, cannot give a good view of the urethra and bladder as a unit. We perform urethrocystography with a water-soluble contrast medium of the abrodil (skiodan) type, which mixes readily with the urine in the bladder. This enables us to study simultaneously the urethra, prostate and bladder during injection. An examination during micturition follows. The subjective discomforts within the urethra caused by contrast medium can be avoided by local anaesthesia of the urethral mucosa (e.g., with onequarter of 1 per cent of decicain solution). For the injection of the anesthetic and contrast solutions Knutsson's instrument is particularly well suited, especially as modified by Markman (1946) for distant manipulation of the syringe.* After the patient has evacuated his bladder the examination is begun with a scout film. One or two frontal views, as well as right and left obliques views, follow during injection, and one or two oblique views during micturition. According to the writer's experience, urethrocystographic investigations which include both injection and micturition films gives the most satisfactory results. Normal urethrocystograms show the prostatic urethra in the sagittal mid* From A. B. Stille, Stockholm, Sweden. 197
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NILS P. G. EDLING
plane. It is slightly curved, its concavity pointing anteriorly. The contours are smooth. During injection the lumen is contracted and narrow and the collicular relief is always visible (fig. l). During micturition the prostatic urethra dilates,
Fm. 1. Normal case. Both pictures in exactly same oblique view. During injection, A, contracted prostatic urethra with smooth contours. Collicular relief and internal urethral orifice are seen. During micturition, B, widening of lumen of posterior urethra, change of shape of bladder and sinking of pelvic floor.
Fm. 2. Normal case during injection. Contracted prostatic urethra, distinctly marked internal urethral orifice and interureteric ridge.
passing with a broad lumen into the bladder cranially, and into the membranous portion caudally. The colliculus is oval and protrudes into the lumen. The shadow of the moderately filled bladder is more or less oval and its long axis runs transversely to the body in frontal or oblique vie,vs. The base of the bladder is flat. With the patient in the recumbent position the internal urethral orifice
ROJ~XTGEN DIAGKOSIS OF DISEASES OF PROSTATE
19fl
lies approximately at the le,-el of the upper horder of the symphysis. The illterureteric ridge is often ,.'isible (fig. 2). When the bladder contracts during micturition it it1 raised a11d may sometimes show an apparent division, or a drawn-out apex 1Yhich cloes not appear in rest. At the same time, the prostate and bladder are lmrnred due to a relaxation of the pelYic floor. Both duri11g injection and mictmition the contours of the bladder base are smooth, a11d the portion" are either smooth or Hlightly irregular. In normal cases there is no contrnst filling outside the limits of the urethra and bladder proper. Pathological changes of the prostate, such as calcifieati011s, c:,wities or ment of the organ, may be Yisualized by the urethrocystogrnphic method. The size and positio11 of calcificaticms, if prese11t, should be studied at fast on plain radiographs. Oiherwise it may be difficult to determine ·whether a shadow in the prostate has or has not appeared during a contrast examination_ :K nmerous and \Yiclespread c:alcification:o are of importance, as the prostate may appear hard on rectal examination. In addition, according to their distribution, the caleificatious may indicate general or local enlargement of the '\Vhat is the diagnostic significance of these calcifications? According to pathologists, the corpora amylacea may calcify in one prese11ium or senium due to involution. 111 such cac;es the calcifications are sparne and small_ If calcifications are numernus and large, or if they lie unilaterally, they may be due to postinflammatory <'hanges_ These calcifications may be present both in tuberculous and septic cases, often lying within cavities which communicate ,Yith the urethral lumen. HmYeYer, the contrast exami11ation is of the greatest importance in diagnosis of proHtatic cha11ges, giving the radiologist the opportunity to demonstrate typical pictures of various pathological conditions. The well lrnmrn sign of prostatitis consists of filling of prm,tatic duct;; and glandt,; \Yith ccmtra;.;t medium, thus indicating open communication ,Yith the urethral lumen resulting from postinflammatory ,rnll changes (fig. 3). All stages may be seen, from :oingle narro\Y ducts to large cavities_ It it:i of importance to stress that the large cavities may appear both in t:ieptic and tuberculom, infections and that a correct diagnosis is impossible ,vithout bacteriological studies. B'rom the differential diagnostic point of view it is necessary to knm,· the roentgen appearance of the utricle filled with opaque solution. This finding is not infrequent and the appearance is typicaL The utricle is situated in the midplane of the prostate, directed upwards and bacbYards from the collicul11s into ,Yhich it opens "·ith or ,,ithout a duc:t. There are, hmYeYer, many cases ill which one must assume that contrast filling of the utricle during urethrocy:otography is caused by postinflammatory changes. Sometimes the ejaculatory ducts are Yisualizecl, most often in connection ,Yith contrast filling of oue or both seminal ampullae and Yesicles. The course of the ducts and the typical picture and site of the vesicles are easy to recognize_ :False passages and fistulas are very rare in the prostatic area. There is also another sign that indicates postinflammatory changes of the prostate. Due to the shrinkage of the surrounding tissue the prostatic urethra
200
NILS P. G. EDLING
may be dilated during injection, ·without showing a deformity or any other changes. In the less advanced cases the pericollicular urethra is widened, while the remaining portion is normally contracted (fig. 3). In chronic cases, on the other hand, the prostatic urethra may be changed into a stiff tube which stands in broad communication ·with the membranous urethra and the bladder, respectively, and the patients are incontinent. In such cases one may find numerous contrast-filled cavities and short dilated ducts close to the urethral lumen, also indicating an atrophy of the prostatic tissue. The bladder is often fibrotic in these severe cases. From the point of vie,v of differential diagnosis, in cases of cystitis a widening of the urethral lumen during injection may sometimes appear if distention of the bladder causes urgency. If the history is not knom1 or is incomplete, a
Fru. 3. Case of prostatitis with atrophy during injection. Fairly pronounced dilatation of pericollicular urethra without deformity. Contrast filling of small glandular cavities in prostate.
widening after electroresection or removal may give rise to an incorrect diagnosis as well. In most cases of prostatitis the prostatic urethra appears of normal length and shape on urethrocystograms. In some, however, the contrast examination may show an elongation of the supracollicular portion, the lumen of which is normally contracted and smooth (fig. 4). In addition, there may be a slight smooth protrusion into the bladder base. The collicular relief is intact, or swollen, and during micturition the dilatability of the prostatic urethra is normal. This urethrocystographic finding can be explained by a diffuse inflammatory enlargement of prostatic tissue in subacute and chronic cases. In a true prostatic enlargement there is no deformity or dislocation of the urethral lumen. Inflammatory changes seem in some cases to mask even the adenomatous signs if hypertrophy of the prostate is complicated by prostatitis. In this way may be explained the absence of a deformity of the prostatic urethra on urethrocysto-
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grams in cases in which the biopsy after electroresection or removal shows both prostatitis and hypertrophy. The other two lesions causing enlargement of the prostate are hypertrophy and cancer. The differential diagnosis will be discussed in the following paragraphs. On a plain radiograph hypertrophy must be assumed if calcifications within the prostate are displaced caudally and show a cup-like arrangement, due to adenomas pressing from above. During urethrocystography contrast filled ducts and cavities may give similar information if they show the same displacement and arrangement as the above mentioned calcifications. However, most important in the roentgenological diagnosis of hypertrophy is the study of the prostatic urethra and the bladder base.
Fm. 4. Case of prostatitis during injection. Elongation of supracollicular urethra with normal shape of collicular relief and no deformity or dislocation of lumen.
It is well known that the changes appearing in prostatic hypertrophy are caused by adenomatous expansion. Because of their close relation to the prostatic urethra, the adenomas influence the appearance of its lumen very early. In early stages they protrude slightly into the supracollicular lumen or into the bladder base at the urethral orifice, causing only moderate indentations. As their growth continues the supracollicular portion lengthens and its lumen will be more deformed. The lumen may become ribbon-like through aplanation from side to side (fig. 5) or is, in a transverse section, cross-shaped due to indentations from different directions. The adenomas are usually situated laterally and posteriorly to the supracollicular urethra which, therefore, is angulated anteriorly or anteriorly and a little laterally. Occasionally the urethra is angulated posteriorly due to an adenomatous expansion in front of the lumen. As the adenomas grow in a typical way, the changes are usually symmetrical or fairly symmetrical on either side. In some cases the growth is unilateral, and the
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differential diagnosis in respect to cancer is difficult. In hypertrophy the unilateral displacement seems to be limited to the supracollicular portion, and a dislocation of the whole prostatic urethra is never seen. This is true even in advanced cases, where the protrusions may be followed into the infracollicular region. Therefore, localization of this feature to the upper part of the prostatic urethra, forming a smoothly outlined flat compression of the lumen from one side, indicates hypertrophy. The collicular relief is most often deformed or not visible. In the bladder base there may be found one or more indentations of different sizes. In some cases the only sign of hypertrophy may be a single adenoma at the internal orifice. The radiographs show a spherical protrusion into the most proximal portion of the urethra and into the bladder base. In addition, the
FIG. 5. Case of prostatic hypertrophy during injection. Typical picture of adenomatous enlargement with elongation and compression of prostatic urethra, angulation, and moderate bulging into bladder base. Contours are smooth.
frontal view during injection may show this portion of the urethra to form a delta due to spreading of the contrast medium at the lower surface of the adenoma. This finding of a spherical adenoma ("third lobe") is very important because of its valve action during micturition. The contours of the urethral lumen and the bladder base in hypertrophy are smooth, with very few exceptions. As opposed to hypertrophy, the growth of cancer is atypical, starting usually in the posterior lobe. The enlargement of the prostate is most often asymmetrical, and causes a deformity of the urethral lumen different from that produced by hypertrophy. On plain radiographs the localization of calcifications may be studied according to rule. If these have a high position in the prostatic area or are situated in separated groups they may have been forced upwards or apart by tumor masses expanding from the posterior lobe (fig. 8). Osteoplastic metastases of the pelvic bones must be kept in mind as an important sign of prostatic cancer.
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The possibility of an early urethrocystographic diagnosis of cancer of the prostate is unlikely because the point of origin lies in most cases ,Yithin the posterior lobe and is distant from the urethra. Yet, it is necessary to observe carefully those eases -where the collicular relief seems to be larger than normal, and is asymmetrical or is faintly outlined, indicating small expanding foci close to the urethra. The cancer is usually advanced when examined. As in hypertrophy, the enlargement of the prostate due to tumor grmYth causes a lengthening of the prostatic urethra. Thus, this finding per se is of no importance from the viewpoint of differential diagnosis. Owing to the constricting gmwth of cancer mas:,,es the urethra is often narrowed and straightened and, contrary to the normally contracted lnmen, has irregular contours or irregular deformities (figs. 6, 7, 8). In many cases the collicular relief ic; deformed. In :,,ome eases
Fm. 6. Case of prostatic cancer during injection. Elongation of prostatic urethra demonstrating a fairl:v narrow lumen with inegular contours and displacemen1 to left and anteriorly.
there is an abrupt kink in the course of the lumen caused by asymmetncal pressure on any part of the prostatic urethra. Other eases have an angulation of a type seen in hypertrophy, explained by accompanying hypertrophy. However, the cancer i:,, accompanied by a more pronounced deviation, due to its more extensive growth. In addition to this deviation of a part of the lumeu, often supracollicularly, one may find a displacement of the entire prostatic methra (figs. 6, 7) :From the junction of the membranous with the infracollicular urethra to the internal orifice, the urethral lumen is dislocated anteriorly and laterally, often to a Yarying degree in different portions. A deviation of the infracollicular urethra from its normal course is the most prominent feature and, if knmvn, is easy to recognize. This is a very important sign and appears almost exchrnively in malignant expansion. As in hypertrophy, the cancer masses may bulge into the bac:e of the bladder. In a series of hypertrophy and cancer cases, irregular contours, -when present,
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were caused by cancer only (fig. 8), while every adenomatous protrusion had a smooth outline (fig. 5). The differential diagnosis of hypertrophy and cancer is most difficult when hypertrophy is associated with cancer, which occurs in about 50 per cent of
L
Fm. 7. Case of prostatic cancer. Both injection, A, and micturition, B, pictures. Elongation of prostatic urethra with left posterolateral bulging into lumen and irregular contours.
Fm. 8. Case of prostatic cancer and hypertrophy during injection. Elongated, flattened and angulated prostatic urethra. Flattening is interrupted in midpart and contours are irregular. Irregular bulging into bladder base. To right two groups of calcifications, one forced upwards, other downwards, by expanding masses from posterior part of prostate.
cancer cases. In these instances the signs of hypertrophy may predominate on urethrocystograms, and the cancer be masked. If the cancer, however, has expanded to the prostatic urethra or grown into the adenomas, it may cause a deformity or displacement of quite a different nature or degree from pure hypertrophy and may be recognized.
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:Fron1 the differential diagnostic -viewpoint, irregularities of the lumen after remontl and electroresec1ion mi.mt he kept in mind as \\-ell. Where a complete operation was performed the Yisualizatiou of the postoperative cavity is an important differential diagum,tic sign. Incomplete intervention may cause a false diagnosis of cancer, in the almeuce of an accnrate anamneRis. "Contracture" of the bladder neck may he caused by each of the above described lesions, as ,rcll as by congenital and neurogenic disorders. Hmvever, the condition is treated in a l'ipecial paragraph, clue to its clinical and roentgenological character. The nature of this lesion is such that urethrocystography clming micturition is ideally suited to demonstrate cases with a po,-,terior bar,
Fm. 9, Two cases of contrncture of bladder neck during micturition. A, clinical s,·mptoms of prostatitis. Circular contracture of internal opening with markedly decreased dilatability. B, prostatic hypertrophy with bar formation. Bulging into internal urethral orifice from behind. In addition, in both cases trnbeculation of bladder wall also indicating an obstacle to the outflmL
or a circular contracture. 1Yith successful technique it is possible to shm,- not only the narrowing of the urethral orifice, but also the dilatability of the prostatic urethra, thus demonstrating the rigidity of the orifice. The typical mictmition picture shmrn pressure upon the methral orifice, posteriorly (fig. 9, B), or in a(i"l'anced cases ,,-ith a common bar, a ma;,sive protrusion into the bladder base and prostatic urethra. In cases with a circular contracture the urethrocystogram shows a concentric constriction of the internal opening (fig. 9, Micturition films shonlcl be taken e,·en if the stream of contrast uriue is scanty or the patient is only able to void in drops. If the bladder ha;, risen and shmrn trabeculation and di,-erticula as a sign of chronic obstruction to the outflow, these findings indicate a rigidity of the urethral orifice. This holds
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true in spite of the fact that the incomplete contrast filling makes it impossible to study the shape of the orifice and the prostatic urethra. In such cases the radiologist must also bear in mind the possibility of a dysfunction of neurogenic origin. Some of the cases with protrusion of a mass into the internal urethral orifice showed the most proximal portion of the urethra distinctly curved, anteriorly or a little laterally, during the injection of contrast medium. It can be best studied in oblique views. In a frontal view the central ray is tangential to this proximal part of the lumen, giving a foreshortening of typical appearance. As mentioned above, the so-called "contracture of the bladder neck" may be a part of adenomatous or cancerous enlargement of the prostate. The true barrier, without other roentgenological changes, occurs in prostatitic cases. Then it may be confused with a single adenoma of a "third lobe" type. The differential diagnosis is based on the smooth spherical shape of the adenoma. Cavities after removal or electroresection show typical urethrocystograms if the intervention has been performed correctly. After removal they have the appearance of a spindle-shaped widening of the urethral lumen, whereas after eleJtroresection they are funnel-shaped. The contours are often irregular. If surgical intervention has been incomplete, irregular contours may be the sole postoperative sign. This may result in a mistaken diagnosis of cancer, should the history be incomplete. The differential diagnosis also brings into question the condition of sphincter paresis, which may cause dilatation of the prostatic urethra similar to a postoperative cavity. Here, however, the case history is of greatest importance. The paralytic widening is, in addition, always smoothly outlined. Finally, cases of cystitis may show a widened prostatic urethra due to violent urgency and immediate micturition when the bladder distends during injection of the contrast medium. There is a very intimate functional correlation between the sphincter system of the prostatic urethra and the detrusor muscle of the bladder. Therefore, a disturbance of the filling and emptying mechanism of the bladder, if neurogenic in character, should also be studied in both organs. As a detailed study of bladder lesions lies beyond the scope of this paper, the neurogenic disorders are not treated. The writer wishes to emphasize that the watersoluble contrast media in urethrocystography give a good view of the contraction or dilatation of the prostatic urethra, and the size and the wall changes of the bladder. In addition to the local changes previously described, the appearance of the bladder will be of value in the assessment of the functional importance of prostatic diseases. The bladder reacts to a chronic obstruction with dilatation of the lumen and hypertrophy of the detrusor. The longer the obstruction has lasted and the higher it is situated in the prostatic urethra, the more difficult is the emptying and the more pronounced the trabeculation and the diverticula formation of the bladder wall. In using urethrocystography in the previously described manner, it is possible to combine in one examination a study of the changes of the urethra and the bladder base with a study of the bladder changes caused by prostatic disorders.
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The information gi,·en by urethrocystography relati,,e to the morphology and functional disorders of the lmnor urinary tract has been of greatest importance in the clinical assessment of the patients and in their treatment. SUMMARY
The author describes the urethrocystographic method and stresses the ntlue of an examination with a ,vatersoluble contrast medium during both injection and micturition, allmving a study both of the prostatic urethra and bladder base and the bladder changes caused by a diseased prostate. In the paper are discussed the roentgen signs of po:ot-inflammatory changes, enlargement of the prnstate due to prostatitis, hypertrophy and cancer; contracture of the bladder neck, and finally the state of affairs after surgical intervention. REFEREXCES B.u:,-;:sct-r, \V. BECLERE, H.
H. · Ztschr. f. urol. Chir., 7: +8, 1\J21. AKD HEXRY, R. · J. d'urol., 13: -±17, 1\J22 EDLIN<,, N. P. G.: Act11 rncliol., Suppl. 58, Stockholm 1945. F.-1.sL-1."11, G. l\I.· Arch. ital. di urol., 1: -±87, 1[)25. FRnIKTK, A. P.· Fortschr. iuL CciJ. d. H.onlgenstrahlen 33: +01, 1925" H.\UlEK, :u. ·Wien.med. Wchnschr., 71: 4\J0, 1921. JA:-;ssBN, P.: l\Hinchen. med. Wchnschr., 11: 394, 1922. 1{BRR, H. D. Ac-TD GILLIES, C. L.: Chicago 1\J44. KNV'l'SSON, F.: Acta rndiol., Suppl. 28, Stockholm 1935. KoHKSTAi-r, G. L. S. AND CAvJc, E. H.P.: London 1\J25. KFRTZAH:'-T, H.: Fortschr. 11.d. Gdi. cl. Riintgenstrnhlcn 29: 2!H, Hl21-1!}22 :\LrnKl\IAN, B. J.: Acta rndiol. 27: 388, l\J46. PPHL, H.: Deutsche Ztschr. f. Chir., 220: 372, 1\J29. V1c\!CBKT, P. G. A.: Paris HJ35. A"ID Bcrn:111\:GHAus.