Gonococcal and Nongonococcal Urethritis

The diagnoses of acute gonococcal or nongonococcal urethritis are usually made by

means of clinical and laboratory findings. No imaging studies are necessary for
noncomplicated urethritis. Complications associated with gonococcal urethritis are
more common and more serious than those associated with nongonococcal urethritis
and include urethral stricture, periurethral abscess, and periurethral fistula.
The typical urethrographic finding in gonococcal urethral stricture is an irregular
urethral narrowing several centimeters long (Fig 18). An estimated 15% of men with
gonococcal urethritis go on to develop stricture, with an interval of 230 years
between infection and the onset of obstructive symptoms. With adequate
antimicrobial treatment, however, the frequency of stricture associated with
nongonococcal urethritis is believed to be extremely low (16). Hard fibrous scars are
present at the distal portion of the bulbous urethra in 70% of patients. These scars are
due to less effective flushing by urination and the preponderance of Littr glands in
this area. Associated dilatation of Littr glands may be present at urethrography. If the
proximal cone-shaped bulbar urethra appears to be narrowed, elongated, asymmetric,
irregular, or absent, the stricture is seen to extend into the membranous urethra in
more than 90% of cases (17). This radiologic finding is of prime importance to the
urologist because surgical treatment may involve cutting the scar tissue and,
consequently, the distal sphincter, which could result in iatrogenic incontinence.
Urethroscopic or open surgical interventions are usually required to alleviate
obstructive symptoms (eg, straining to void, weak stream, and a feeling of incomplete
emptying of the bladder) secondary to urethral strictures. In selected cases,
intraluminal stent placement may be effective for treating urethral stricture (18). (See
also the section entitled Strictures of the Urethra.)
Periurethral abscess is a life-threatening infection of the male urethra and periurethral
tissue and frequently a sequela of gonococcal infection, urethral stricture disease, or
urethral catheterization. Periurethral abscess arises initially when a Littr gland
becomes obstructed by inspissated pus or fibrosis. The most common infecting
organisms are gram-negative rods, enterococci, and anaerobes. Pseudodiverticulum
formation results from urethral communication with a periurethral abscess. Because
the tunica albuginea of the penis prevents the dorsal spread of infection, the abscess
tends to track ventrally along the corpus spongiosum, where it is confined by the
Buck fascia. However, when the Buck fascia is perforated, there can be extensive
necrosis of the subcutaneous tissue and fascia. Approximately 10% of periurethral
abscesses drain spontaneously. Rapid diagnosis and treatment are essential. Imaging
studies may be indicated if the diagnosis is not established clinically. An abscess that
drains into the urethra may be demonstrated at urethrography (Fig 19).
Ultrasonography (US) can demonstrate the presence of periurethral abscess, and CT
and MR imaging are helpful for assessing the extent of the periurethral abscess and
complications such as fasciitis and Fournier gangrene. Treatment consists of
immediate suprapubic urinary drainage, wide surgical abscess debridement, and
administration of appropriate antibiotics.

Urethroperineal fistulas are most often the consequence of a periurethral abscess. In

general, the initial abscess cavity contracts by means of healing fibrosis, which leaves
only the narrow fistulous tract from the urethra to the perineum. Consequently,
urination usually occurs through the perineal fistulas, which results in the so-called
watering can perineum (Fig 20) (19). Urethroperineal fistulas are usually the result
of tuberculosis and schistosomiasis infections.
Condyloma Acuminata
Condyloma acuminata are caused by viral infection and produce soft, sessile,
squamous papillomas on the penile glans and shaft and the prepuce. Condyloma
acuminata are termed venereal warts. Urethral involvement occurs in 0.5%5% of
male patients. On occasion, condyloma acuminata may extend to the prostatic urethra
and bladder. The use of catheterization, instrumentation, and retrograde
urethrography is not recommended because of the possibility of retrograde seeding.
The diagnostic procedure of choice is voiding cystourethrography. However, the
diagnosis is often not suspected until retrograde urethrography has been performed.
The typical urethrographic findings are multiple papillary filling defects in the
anterior urethra (Fig 21). Urethral lesions are treated with the instillation of
podophyllin, thiotepa, or 5-fluorouracil into the urethra.
Tuberculosis
Tuberculosis of the urethra is very rare. Usually, genital tuberculosis is a descending
infection and renal tuberculosis is evident. The prostate is involved in 70% of patients
with genital tuberculosis. Prostatic abscess may rupture into any surrounding
structure, which results in prostatorectal and prostatoperineal urethral fistulas. In the
acute phase, there is urethral discharge with associated involvement of the
epididymis, prostate, and other parts of the urinary system. The diagnosis is made at
clinical examination, and administration of antituberculous agents should be initiated.
In the chronic phase, diagnosis becomes difficult because patients present with
obstructive symptoms secondary to urethral strictures. Tuberculous urethral strictures
result in periurethral abscesses, which, unless treated, produce numerous perineal and
scrotal fistulas. The end result is watering can perineum. Retrograde urethrography
typically demonstrates an anterior urethral stricture associated with multiple
prostatocutaneous and urethrocutaneous fistulas. Simultaneous fistulography may be
useful for assessing the entire urethra because most contrast material exits the urethra
through the urethroperineal fistulas, which may prevent visualization of the entire
urethra.