Misc. male GU

Question 1

Embryologic development, genital ducts:

• Name 2 duct pairs that male & female embryos have.
• Which develop in males vs. females?
• What does the mesonephric duct become?
• What is the verumontanum?

Answer 1

• Wolffian (mesonephric) & Mullerian (paramesonephric).
• Males: Wolffians develop & Mullerians involute; females opposite.
• Mesonephric duct = vas deferens; distal mesonephric = seminal vesicles.
• Verumontanum: aka seminal colliculus.
  
  • Rounded crest in the posterior wall of the mid-prostatic urethra.
  • The prostatic utricle opens into it in the midline.
    
    • This is the Mullerian duct remnant & projects upward/backward into the prostate.
  • 2 ejaculatory ducts open just distal to the utricle.
  • The prostatic sinuses/ducts drain into it.
  • Urologists use it as a surgical landmark for TURP, to locate the urethral sphincter.

Question 2

Male urethra anatomy

• Name the parts.
• Eponym for the urethral injury classification system.
  
  • Most common injury?

Answer 2

• Male urethral parts:
  
  • Prostatic: ~3.5cm, passes through prostate; includes verumonatum.
  • Membranous: ~1cm, traverses urogenital diaphragm/external urethral sphincter; from distal verumontanum to conical tip of the bulbar urethra.
  • Bulbar: to penoscrotal junction.
  • Penile: ends at external meatus.
• Goldman urethral injury classification: based on anatomic location.
  
  • Goldman III: membranous urethral injury, w/urogenital diaphragm disruption & extension into the bulbous urethra.
  • Ix contrast extrav blow the urogenital diaphragm. Bladder neck intact.

Question 3

RUG & VCUG

Retrograde urethrography: preferred for; main indication.

• Technique.

Voiding cystourethrography: preferred for; main indication.

• Technique.

Answer 3

RUG: anterior urethra; blood at meatus.

• 10F catheter placed in penis tip; penis gently stretched to elongate the urethra; 20-30ml contrast hand injected under fluoro.

VCUG: posterior urethra; stricture on RUG.

• Contrast instilled via an indwelling suprapubic catheter or previously placed transurethral catheter; urethral catheter removed & pt asked to void under fluoro.

Question 4

Male pelvic cysts DDx

• DDx midline vs lateral.

Answer 4

Midline: intraprostatic; behind upper half of the prostatic urethra

• prostatic utricle
• Mullerian duct cyst
• ejaculatory duct cyst (paramedian, really)

Lateral: extraprostatic

• seminal vesicle cyst
• vas deferens diverticulosis
• Cowper duct cyst

Question 5

Lateral: seminal vesicle cyst

Px: name 4 congenital associations, 1 strong; name 2 ways in which they may be acquired.

Ex: commonest age & why?

Ix: classic look; when may they look midline.

Answer 5

Px:

• 4 congenital assns: renal & vas deferens agenesis; ectopic ureter insertion; PCKD.
• 2 acquired: obstruction 2dry to prostatic hypertrophy or chronic infection/scarring.

Ex: 10-40yrs, during years of sexual activity, when seminal secretions peak.

Ix: intraseminal, unilateral cyst, lateral to the prostate, posterior to bladder, <5cm.

Question 6

Midline: prostatic utricle cyst

Px: how formed; 5 associations & 1 most common; cancer type.

Sx: 3

Ex: 2

Ix: RUG, MRI.

Answer 6

Px: focal dilation in the prostatic urethra, specifically the prostatic utricle (Mullerian duct remnant which is in the posterior prostatic urethra); always arise at level of verumontanum. Cancer types: endometrial carcinoma (!!), clear cell or squamous cell (3%).

• Associations: hypospadias most common (makes sense given the relationship w/the urethra) (urethral meatus is proximal & ventral)
• intersex disorders (makes sense re: Mullerian duct still there)
• Cryptorchidism
• Renal agenesis
• Imperforate anus

Sx: since they communicate w/the urethra, they can cause dribbling; superinfection; hematospermia (contain sperm on aspiration).

Ex: males <20yrs; 1-5%.

Ix:

• RUG: since it communicates w/the urethra, opacifies on RUG; focal outpouching from the prostatic urethra.
• MRI: pear-shaped, smaller; will NOT extend above prostate base; communicates w/urethra.
  *

Question 7

Midline: Mullerian duct cyst

Px: 2

Ex: 1

Ix: RUG, MRI

Answer 7

Midline: Mullerian duct cyst

Px: failure of regression of caudal end of the Mullerian duct (male vagina); does not communicate w/urethra.

Ex: 30-40yos.

Ix: tear-drop shaped

• RUG: will not opacify as does not communicate w/urethra.
• MRI: extends above prostate base.

Question 8

This vs. that: utricle vs. Mullerian duct cyst: