Genitourinary Imaging

Chou et al.
CT Urethrography and Virtual
Urethroscopy

Original Report
Chen-Pin Chou1
Jer-Shyung Huang1
CT Voiding Urethrography and
Ming-Ting Wu1,2 Virtual Urethroscopy: Preliminary
Huay-Ben Pan1,2
Fong-Dee Huang3
Chia-Cheng Yu3
Study with 16-MDCT
Chien-Fang Yang1,2
Chou C-P, Huang J-S, Wu M-T, Pan H-B, Huang F-D, Yu C-C, Yang C-F
OBJECTIVE. The purpose of this study was to demonstrate CT voiding urethrography and
CT virtual urethroscopy. Fourteen CT voiding urethrography examinations on 13 men (mean
age, 30 years) were prospectively performed with 16-MDCT. The clinical diagnoses of those
patients included urethral injury, urethral stricture, and hypospadia. The CT voiding urethro-
gram was obtained with transverse CT of the voiding, contrast-filled urethra and display of 2D
multiplanar and 3D virtual images.
CONCLUSION. The full urethral structure was clearly shown by CT voiding urethrog-
raphy and virtual urethroscopy in all patients. The results of CT voiding urethrography and con-
ventional methods correlated closely with the urethral diseases being imaged.

ost diagnostic imaging of the The thin-section transverse images and

M urethra continues to be per-

formed using conventional radi-
ography with luminal distention
by iodine contrast media. However, radio-
graphic contrast material–enhanced studies
are invasive and do not provide information
about periurethral tissue. Other, more mod-
ern imaging techniques such as sonography
and MRI can contribute, in some specific
circumstances, to the diagnosis of urethral
diseases. Sonography has a small field of
Received January 18, 2004; accepted after revision view, and the technique is operator-depen-
September 15, 2004. dent. MRI is not widely used to examine the
Supported by Kaohsiung Veterans General Hospital urethra because the technique is somewhat
research program (VGHKS93-82). complex and expensive. CT is used only
1Department of Radiology, Kaohsiung Veterans General rarely to study the urethra. Its usefulness is
Hospital, 386 Da-Chung First Rd., Kaohsiung 813, Taiwan, limited to the evaluation of inflammatory
ROC. Address correspondence to C.-P. Chou fluid collections or the identification of gas
(r2207759@ms19.hinet.net).
formed during necrosis or trauma [1]. Re-
2National Yang-Ming University School of Medicine,
Taipei, Taiwan, ROC.
cent advances in MDCT, rapid image acqui-
3Department
sition, and software have made 2D and 3D
of Urology, Kaohsiung Veterans General
Hospital, Kaohsiung, Taiwan, ROC. reformatted images available for the newer
diagnostic techniques. These techniques
AJR 2005;184:1882–1888
have been applied to many organs, includ-
0361–803X/05/1846–1882 ing the colon, bronchus, stomach, and uri-
© American Roentgen Ray Society nary bladder [2, 3].
high scanning speed of CT have led to the de-
velopment of promising new techniques for
urethral evaluation: CT voiding urethrogra-
phy and virtual urethroscopy. With these
techniques, the voiding, contrast-filled ure-
thra is scanned with 16-MDCT in approxi-
mately 6 sec. Real-time 3D rendering of CT
images is performed to visually simulate ure-
throscopic examination. In this study, we in-
vestigated the technique of 16-MDCT in the
detection of urethral diseases.
Subjects and Methods
Patients
From January 2003 to May 2004, 13 men (age
range, 18–50 years; mean, 30 years) in whom ure-
thral diseases were suspected were referred from the
genitourinary or emergency department for urethral
imaging studies. In total, 14 CT voiding urethrogra-
phy examinations were performed. One man with
hypospadia underwent CT voiding urethrography
before and after surgery. The micturating condition
of patients was checked before examination. If the
patients reported an inability to void before and dur-
ing CT examination, they were not considered for
this study. Our series included suspected urethral in-

1882 AJR:184, June 2005

 CT Urethrography and Virtual Urethroscopy

juries, urethral stricture, and hypospadia. All pa-
tients were alert and oriented and had stable vital
signs when they arrived at the radiology depart-
ment. The patients signed informed consent forms
for CT voiding urethrography.
Patient Preparation
CT voiding urethrography was performed as an
independent CT examination (n = 13) or as part of
serial CT examinations (n = 1). The urinary bladder
was opacified by renal excretion of iodine contrast
medium administered IV (n = 13) or through infu-
sion into a suprapubic tube (n = 1). Sixty milliliters
of IV iopamidol (Iopamiro 300, Bracco) was ad-
ministered 30 min before scanning. We urged the
patients to drink water or increased their IV saline
fluid supplement to distend the urinary bladder rap-
idly. For pelvic trauma patients who might need
emergent surgery, we increased the rate of IV fluid
administration to accelerate urine production and
distend the urinary bladder satisfactorily. If the pa-
tient had suprapubic tubes or Foley urethral cathe-
ters, we directly infused 400 mL of diluted water-
soluble iopamidol via catheters. We performed CT
when the patient expressed a strong desire to void.
No oral contrast medium was used in our series.
Patients wore urinary bags over their penises to
collect urine and avoid wetting the CT machine. CT
was performed with the patient prone (n = 9) or su-
pine (n = 5). Patients with pelvic fractures were su-
pine while scanned because they could not lie
prone. In contrast to CT colonography or CT cys-
tography, for which both supine and prone scan-
ning is necessary, CT urethrography requires
scanning in only one position.
Image Acquisition
After an anteroposterior topogram had been ob-
tained for slice selection, the patients were asked to
press a handheld wireless bell controller when they
began voiding. As soon as technologists heard the
bell, they began scanning. The CT topogram was
used as a pelvic radiogram. We did not perform pre-
voiding CT routinely because we wanted to avoid
exposing the patients to additional radiation.
All serial thin-section images of the lower urinary
tract were obtained using a 16-MDCT scanner (So-
matom Sensation 16, Siemens). Scanning parame-
ters included a 0.5-sec gantry rotation speed, high-
quality scanning mode (0.75-mm collimation × 16-
detector array, 512 × 512 matrix, 120 mA, and 120
kVp), a 1.0-mm reconstructed slice width at inter-
vals of 0.7 mm (0.3-mm overlap), a total scanning
time of 6 sec, and a total scan length of 16–20 cm.
Data acquisition was craniocaudad and resulted in
about 300 transverse images for each scan.
Image Evaluation
The transverse thin sections were transferred to
a workstation (Syngo, Siemens) with manufac-
turer-provided software that allows generation of
2D maximum intensity projection, 2D multiplanar
reconstruction, 3D shaded-surface display, and 3D
volume-rendered technique (Fig. 1). Two experi-
enced abdominal radiologists (who were trained in
interactive navigation and interpretation of 3D vir-
tual-reality CT colonography or CT cystography
and were unaware of the results of other examina-
tions) prospectively and independently interpreted
the CT voiding urethrography. The urethra was
evaluated with 2D transverse images and a soft-tis-
sue window setting (window level, 40 H; window
width, 300 H).
Virtual endoscopy was performed using sur-
face-rendered or volume-rendered techniques. We
adjusted the attenuation coefficient range for voxel
categorization to the contrast material in the urethra
until the normal mucosal surface appeared smooth
and no noise was seen in the lumen. The lower limit
of the attenuation coefficient range for voxel cate-
gorization on virtual urethroscopy was 200–250 H;
the upper limit range was 700–850 H. Because the
attenuation coefficient of the urethral lumen varied
from patient to patient, variable ranges were tried
for each patient to optimize the setting. With CT
endoscopic fly-through navigator software, radiol-
ogists performed interactive intraluminal naviga-
tion from the urinary bladder to the urethra.
Interactive standard axial, sagittal, and coronal ref-
erence images were obtained automatically during
navigation (Fig. 2A).
The new vessel-view tool of the Syngo worksta-
tion is a semiautomatic protocol-driven analysis

A B

Fig. 1.—Imaging of urethra with 2D and 3D techniques in 27-year-old man after vehicle accident.
A, Three-dimensional volume-rendered urogram shows comminuted fractures of left ilium bones extending to left acetabulum with displaced bone fragments, and diastasis of bilateral
sacroiliac joints and symphysis pubis. Urethra (arrows), urinary bladder, and ureters (arrowheads) are shown well. No urethral interruption or contrast medium extravasation is noted.
B, Two-dimensional curve reformatted sagittal image using maximum intensity projection shows normal segmental anatomy of male urethra. M = membranous urethra, P =
prostatic urethra, B = bulbous urethra, Pe = penile urethra.

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 Chou et al.

tool for CT angiography. This tool also works well
for the urethra. The vessel navigator displays a lon-
gitudinal cut along the centerline of the urethra, the
so-called ribbon multiplanar reformation, with
multiplanar reference images along the curve of the
urethra (Fig. 2B). The required longitudinal multi-
planar reformatted section view and cine imaging
are created using the angle slider to rotate the image
plane. We could create urethral boundaries using
semiautomatic segmentation functions. We easily
could find the urethral path distance by clicking ei-
ther the multiplanar reformation or the volume-ren-
dering techniques to place the first seed point and
terminal point. Also, maximum luminal diameter
and luminal area could be measured perpendicu-
larly to the urethral axis (Fig. 2C).
Further Urethral Study
Eleven men were assessed using conventional ret-
rograde urethrography on the same day. Because CT
voiding urethrography obtains antegrade urethral im-
ages similar to voiding cystourethrograms (VCUG)
and we did not wish to expose the patients to addi-
tional radiation, we did not routinely obtain VCUG.
An experienced abdominal radiologist interpreted the
conventional urethral examinations without knowing
the results of CT voiding urethrography.
Cystourethroscopy
Three men were examined with cystourethros-
copy by experienced urologists on the same or next
day. Cystourethroscopy was performed if the pa-
tient sensed a foreign body in the urethra, had a Fo-
ley catheter placed because of urethral injury, or
required optic urethrostomy for urethral stricture.
Results
The time required for the CT procedure
ranged from 4 to 20 min (mean, 9 min), depend-
ing on how soon patients began to void. The
time required for interpretation of the CT ure-
thrographic data ranged from 6 to 20 min
(mean, 10 min). CT voiding urethrography ex-
aminations were completed successfully for all
patients. No significant difference in image
quality was noted between supine and prone po-
sitioning. Images on CT voiding urethrography
were of excellent quality, with adequate contrast
filling of both the anterior and the posterior ure-

A B

Fig. 2.—37-year-old man with straddle injury.

A, Display panel of 3D volume-rendered virtual urethroscopy shows axial, sagittal,
and coronal reference images. Verumontanum is viewed at 6-o’clock position
(arrow). Fly path of virtual urethroscopy is identified on synchronized multidirectional
reference images.
B, Vessel-view display panel shows entire urethra with 2D curve multiplanar refor-
mation technique and measurement tools. Focus pointer (arrows) displays as line in
vessel navigator. When focus pointer is moved, reference imaging segments are syn-
chronized to position of pointer.
C, Maximum transverse diameter and area in axial cross-section of urethra are
determined automatically by clicking required position of urethral path.
C

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 CT Urethrography and Virtual Urethroscopy

thra in all patients. The final diagnosis was
based on retrograde urethrography, cystoure-
throscopy, or surgical findings (Table 1).
For urethral injury, CT voiding urethrogra-
phy and conventional methods were of simi-
lar accuracy. Nine patients with clinically
suspected urethral injury underwent retro-
grade urethrography. Pelvic fractures were
noted in three. A type 5 urethral injury ac-
cording to the classification by Goldman et al.
[4] was diagnosed in two patients. Patients 1
and 10 had a straddle injury, and the retro-
grade urethrograms showed contrast medium
extravasation in the bulbous urethra. CT void-
ing urethrography also revealed extravasa-
tion, an intraluminal blood clot, and mucosal
abnormality (Fig. 3). Patient 12 experienced
bleeding from the urethra after sexual inter-
course; contrast medium extravasation from
the penile urethra was detected with CT void-
ing urethrography but was missed on retro-
grade urethrography (Fig. 4). A blood clot at
the site of injury was found in two of the three
patients with urethral injury.
For three cases of urethral stricture, CT void-
ing urethrography was superior to conventional
examinations for imaging of pathologic anat-
omy and measurement of lesions and created
greater diagnostic confidence. The retrograde
urethrograms did not allow proper evaluation of
the posterior urethral stricture. Patient 9 had a
history of surgical realignment for type 3 ure-
thral injury with disruption of the urogenital
diaphragm. After 3 months, CT voiding ure-
thrography showed a short-segment urethral
stenosis at a bulboprostatic anastomosis. Patient
12 had had a urethral injury and a complicated
urethral stricture 1 year earlier. CT voiding ure-
thrography revealed stricture in the membranous
urethra with proximal urethral dilatation (Fig. 5).
Patient 13 had undergone plastic surgery for
hypospadia 30 years earlier and complained of
postvoid dripping. Retrograde urethrography was
unsuccessful because of a small meatus opening
and pain intolerance. CT voiding urethrography
showed penile hypospadia and a diverticulum
within the penile skin coverage (Fig. 6A). The pa-
tient underwent corrective surgery with flap re-
construction. Five months later, a penile urethral
stricture requiring urethrotomy developed (Fig.
6B). CT voiding urethrography provided useful
information before and after surgery.
Discussion
CT voiding urethrography is a technique
similar to conventional VCUG. The CT void-
ing urethrography protocol in this study in-
volved 0.75-mm collimation and revealed the
entire urethra in 6 sec. The more thinly colli-
mated transverse images and the subsequent
better quality of the reformatted images
should further increase the ability of CT to de-
pict the urinary tract accurately [5].
At a normal urinary flow rate of 15 mL/sec
for men, the time needed to void 400 mL is
longer than 20 sec. High-speed 16-MDCT

TABLE 1 Patient Data and Examination Findings

Patient Age Position and Method of
Clinical History Findings of CT Voiding Urethrography Additional Study
No. (yr) Contrast Administration
1 25 Prone, IV Blunt perineum injury Contrast medium extravasation, Retrograde urethrography: contrast
irregular mucosa surface at injury medium extravasation in bulbous
region, and blood clot in bulbous urethra
urethra
2 27 Supine, IV Vehicle accident, urinary bladder Negative Retrograde urethrography: negative
rupture after primary suture 2 wk
earlier
3 37 Prone, IV Blunt perineum injury Negative Retrograde urethrography: negative
4 32 Prone, IV Blunt perineum injury Negative Retrograde urethrography: negative
5 35 Prone, IV Foreign body sensation when voiding Negative Cystourethroscopy: negative
6 30 Supine, IV Vehicle accident Bladder wall contusion and blood clot Retrograde urethrography and
at right vesicoureteric junction; no cystography: mass effect at right
urethral injury vesicoureteric junction; no urethral
injury
7 24 Prone, IV Blunt perineum injury Negative Retrograde urethrography: negative
8 22 Prone, IV Blunt perineum injury Negative Retrograde urethrography: negative
9 23 Supine, IV Complete transection of urethra after Short segment narrowing at Retrograde urethrography: posterior
surgical realignment bulboprostatic anastomosis region urethra cannot be evaluated well
10 26 Supine, suprapubic Foley Falling injury Contrast medium extravasation in Retrograde urethrography: contrast
catheter bulbous urethra medium extravasation in bulbous
urethra
Cystourethroscopy: mucosa
perforation in bulbous urethra
11 50 Supine, IV Bleeding from the urethra after sexual Contrast medium extravasation in Retrograde urethrography: negative
intercourse penile urethra
12 18 Prone, IV Traumatic urethral stricture Membranous urethra stricture Retrograde urethrography: posterior
urethra cannot be evaluated
13 38 Prone, IV Surgically repaired hypospadia 30 yr Hypospadia at middle shaft of penis Retrograde urethrography: failure to
previously and a diverticulum within penile skin insert a Foley catheter because of
coverage narrow meatus opening and pain
Prone, IV Difficult voiding 5 mo after corrective Stricture in penile urethra Cystourethroscopy: optic urethrotomy
surgery for penile urethral stricture

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 Chou et al.

can scan the entire urethra and urinary blad-
der in 6 sec. In this study, transverse CT im-
ages showed the full extent of the urethra.
Complete evaluation of the entire urinary
tract, kidney to urethra, is easy with the newly
developed 16-MDCT.
Patient compliance is an important deter-
minant of the success of CT voiding urethrog-
raphy. CT voiding urethrography could play a
role in lower urinary tract evaluation for clin-
ically stable patients. The technique should
not be used on patients with acute major
trauma or acute pelvic fracture unless they al-
ready have shown an ability to void. Patients
should be interviewed before the examination
to evaluate their acceptance of it. Radiologists
should know that the patients have no diffi-
culty with voiding. Good communication be-
tween patients and CT technologists during
the examination also is necessary. Patients
need to understand and follow the instruc-
tions of technologists. Radiologists should
participate in the whole procedure and inter-
pret the real-time images on monitors.
Because CT easily depicts the high attenua-
tion produced by contrast material, diluted con-
trast material is better appreciated on CT images
than on conventional urethrograms. Missing of
lesions obscured by bone structures, contrast
media, or instruments can be avoided with use
of axial and multiplanar images.
We preferred to position patients prone
with pillows below their abdomen to in-
crease intraabdominal pressure and enhance
the force of micturation. A supine scanning
position was preferred for patients with mul-
tiple pelvic fractures. The scan processes or
imaging quality in our study were the same
whether patients were prone or supine. Vari-
ations in patient positioning and penile trac-
tion during imaging can greatly alter the
radiographic appearance of the urethra and
strictures. Multiple views, including bilat-
eral oblique, may be required on conven-
tional radiographs [6]. When multiple pelvic
fractures and associated patient discomfort
are present, the oblique position for conven-
tional radiography may not always be possi-
ble. CT voiding urethrography is more
convenient because patients are required to
adopt only one position and the scanning
time is only 6 sec. CT voiding urethrography
is more accurate with computer-aided tools
for urethral measurement. The vessel view is
longitudinal along the curve of the urethra
and accurately measures stricture length,
distance from the urethral meatus, and lumi-
nal area. Exact comparison of the luminal
size and stricture length on clinical follow-
up is possible.
Compared with retrograde urethrography
and conventional cystourethroscopy, urethral
imaging with CT voiding urethrography and
virtual endoscopy can reduce organ injury
and patient suffering. Conventional radiogra-
phy requires positioning of the patient’s ure-
thra and avoidance of overlapping with bone
structures. The patient’s position is not criti-
cal with high-quality 3D images, and patients
with complex pelvic fractures do not need to
change positions. In our experience, CT void-
ing urethrography improved patient compli-
ance. Some patients who could not tolerate
conventional urethral examinations could ac-
cept CT voiding urethrography.
Display of CT data in the form of virtual
urethroscopy images affords a number of ad-
vantages over transverse CT images alone.

A B C

Fig. 3.—25-year-old man who presented with hematuria after blunt perineum contusion.
A, Retrograde urethrogram shows contrast medium extravasation (arrow) in bulbous urethra.
B, Volume-rendered CT voiding urethrogram obtained with contrast infusion from suprapubic tube shows contrast
extravasation and irregular mucosal surface (arrow) in bulbous urethra. Urethrocavernous and urethrovascular
reflux (arrowhead) also were noted.
C, Conventional cystourethroscopy image reveals bleeding and perforation at 5- to 7-o’clock position of bulbous urethra.
D, Virtual urethroscopy image based on surface rendering shows mucosal disruption (arrows) in bulbous urethra.
D

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 CT Urethrography and Virtual Urethroscopy

A B

Fig. 4.—50-year-old man with urethral bleeding after sexual activity.

A, Retrograde urethrogram shows no finding.
B, Contrast medium extravasation (arrow) in penile urethra is identified on CT voiding urethrogram, vessel view.

Virtual urethroscopy allows data from more
than 300 slices of CT images to be com-
pressed into one interactive data set. The data
set can be manipulated easily for multidirec-
tional viewing and can be recorded as cine
files [7]. For urologists who are not familiar
with transverse images, CT voiding urethrog-
raphy and virtual endoscopy provide a global
orientation for focal findings and aid naviga-
tion for endoscopists.
Standard practice dictates that trauma and
stricture of the male urethra be evaluated with
retrograde technique because of the belief that
only it produces sufficient distention. Retro-
grade urethrography is not a physiologic ex-
amination. Contrast material often is injected
under pressure to overcome the resistance of a
stricture. Rapid and forceful injection of the
contrast medium in retrograde urethrography
may lead to rupture of the mucosal barrier and
extravasation of the contrast material into the
systemic circulation, with occasional resultant
systemic complications such as sepsis and
anaphylaxis. Reflex contraction of the pelvic
muscle because of forceful injection of the
contrast material may lead to a false-positive
diagnosis of stricture [8]. Although retrograde
urethrography also can be performed during
CT, such as in CT voiding urethrography,
some technical problems remain. These in-
clude inadequate contrast medium filling and
radiation exposure to the operators. In this
study, we showed in several instances that the
new CT technology can show clear urethral
imaging sufficient for diagnoses.
According to previously published articles,
the disadvantages of CT virtual cystoscopy
versus conventional cystoscopy include ex-
posure to radiation, difficulty in detecting flat

Fig. 5.—18-year-old man with urethral stricture; he sustained urethral injury 1 year
earlier in motor vehicle collision. Multiplanar coronal reformatted image (curved
along urethra) shows posterior urethral stricture (arrow) and prostatic urethral dila-
tation (arrowhead).

AJR:184, June 2005 1887


Fig. 6.—38-year-old man with history of hypospadia after plastic surgery 30 years earlier. He arranged another surgical correction because of dripping after voiding.
A, CT voiding urethrogram, vessel view, shows ectopic urethral orifice (black asterisk) in middle of penile shaft and diverticulum (arrow) within penile skin coverage (arrow-
heads). White asterisk is at expected location of meatus.
B, Urethral stricture (arrow) developed 5 months after surgical correction.
or small mucosal lesions, lack of information
on the color and texture of the mucosa, and
lack of biopsy [9].
The technical limitations are the same for CT
voiding urethrography as for VCUG. Effective
antegrade imaging may be impossible in patients
with complete urethral disruption and severe
posttraumatic urethral stricture [10]. Some pa-
tients are psychologically inhibited from mictur-
ating because of the required investigational
procedures and surroundings. Simple VCUG
cannot provide pressure as great as that provided
by retrograde urethrography or double-balloon-
catheter urethrography, and some urethral ab-
normalities can be missed with CT voiding ure-
thrography. The combination of retrograde
urethrography and CT voiding urethrography
may help radiologists avoid potential pitfalls.
The volume of contrast medium extravasation in
CT voiding urethrography is usually less than
that in retrograde urethrography, and radiolo-
gists might misinterpret extravasation as a nega-
tive finding or, if from the bulbous urethra, as a
reflux into a normal Cowper’s duct. Analysis of
thin-section axial CT images and associated
findings such as intraluminal blood clots and
mucosal irregularity may improve the accuracy
of diagnosis. Currently, experience with CT
voiding urethrography is limited. Thus, conven-
tional urethral examinations should be per-
formed to confirm the diagnosis in doubtful
cases. Because of the excessive time needed to
create virtual images, radiologists need to select
patients carefully.
A data supplement for this article can be viewed in the online version of the article at: www.ajronline.org.
1888
Chou et al.
A B
A theoretic concern with MDCT voiding
urethrography, in comparison with VCUG, is
the possibility that patients will receive more
radiation. The dose from MDCT can be esti-
mated from the dose–length product, a mea-
surement of radiation exposure that takes into
account the volume of irradiation [11]. The ef-
fective dose of radiation from CT voiding ure-
thrography for an average man is
approximately 5 mSv. When VCUG is used
for a child of 5–10 years old, the effective ra-
diation dose is about 1.6 mSv [12]. As experi-
ence with CT voiding urethrography increases,
it may become possible to reduce the radiation
dose by adjusting CT parameters, as is done in
low-dose CT colonography.
The benefits of CT voiding urethrography
and virtual endoscopy over conventional im-
aging include accurate measurement of le-
sions, without magnification or distortion;
production of both transverse and 3D images
of urinary tract abnormalities; depiction of
extraluminal anatomic landmarks; good pa-
tient compliance; and the ability to survey
the whole urinary tract, from the kidney to
the urethra.
To our knowledge, CT voiding urethrogra-
phy has not been reported previously, and
urethral pathology has not been described us-
ing virtual urethroscopy. Conventional ure-
thral imaging is challenged by the new CT
techniques. However, a large study of various
urethral diseases is needed to determine the
clinical value of CT voiding urethrography.
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