Urethrogram

Urethrogram is a diagnostic procedure to examine the urethra. Genital Urethrogram is almost always carried out on male patients with symptoms such as dribbling of urine, sense of incomplete bladder emptying, hesitancy, poor stream, urinary urgency, urinary frequency, poor bladder emptying etc.

In many patients, the most prominent indication is potential urethral stricture disease. Genital Urethrogram is an essential tool for doctors for careful examination of the images followed by best interpretation so as to plan appropriate course of treatment. In males, the urethra is the tube that caries urine and semen through the penis, outside the body. Genital Urethrogram involves taking an X-ray of the tube. Measuring 20 cm in length, there are two divisions:

Anterior ( penile and bulbar)
Posterior ( membranous and prostatic)

What is Genital Urethrogram ?

The diagnostic X-ray procedure, Urethrogram is done to study the urethra. It can be either retrograde Urethrogram or antegrade urethrogram. It may take 30-60 minutes for completion of the procedure. Depending on the need to examine the anterior or posterior urethra, either of the two is done.

Retrograde Urethrogram (RUG): Ascending study to assess the anterior urethra which is composed of the penile and bulbar urethra.

Antegrade Urethrogram: Descending study to assess the posterior urethra which is composed of the membranous and prostatic urethra.

Why do Genital Urethrogram ?

Doctors recommend Genital Urethrogram when patients express problems with poor urinary flow or problems passing urine. In older men, the reason can be attributed to enlargement of the prostate. But in young and middle aged males and male children, it might be a history of injury, infection etc.

The procedure throws light on two major aspects of the urethra. Firstly, the capacity of the bladder and its emptying ability and secondly, examination of the urethra, the narrow tube which connects the bladder to the genitals through which urine passes before leaving the body.

Indications of Genital Urethrogram

Infection: Gonococcal Urethritis, non-gonoccocal urethritis

Inflammatory: Balanitis Xerotica obliterans

Trauma: Straddle injury, pelvic fractures

Iatrogenic: Instrumentation, prolonged catheterization, trans-urethral resection of the prostate, open radical prostatectormy, urethra reconstruction.

On the appointed day, the patient is admitted in the hospital radiology department or radiology practice where the procedure is to be done. The patient will be asked to empty the bladder and put on a hospital gown. He is made to lie on an x-ray table called a fluoroscopy table in a specific position. Sterile drapes are placed over the lower body. The penis and groin will be cleaned with an antiseptic solution. A narrow catheter or a thin plastic, silicone or rubber tube will be placed into the end part of the penis from where the urine exits. A small balloon will be inflated in order to keep the catheter in place and to stop contrast medium (special dye) running out of the end of the penis.

Contrast medium is gently injected into the urethra by placing a catheter at the top of the penis. As the bladder is filled with the contrast, the patient is likely to experience some discomfort. There can be an urgent need to pass urine. At this point, the catheter will be removed. The final images of the bladder will be taken.

The X-ray table will be tilted. The patient is now in a standing position. A bottle will be handed over to pass urine. When the patient is passing urine, x-ray pictures of the bladder and the urethra will be taken to understand how well the bladder empties. The images also pin-point if there is any narrowing in the urethra.

After completion of Genital Urethrogram, it is normal to notice some blood at the tip of the penis. The patient may experience some discomfort or stinging at the end of the penis where the catheter was inserted and the balloon was inflated. This will subside after passing urine few times on the same day or the next day. The urine can be with small amount of blood too.

Are there risks associated with Genital Urethrogram ?

Three potential risks have been identified but all the three are rare instances. Allergic reaction to the dye (contrast medium), urine infection and damage to the urethra are the three possible risks associated with Genital Urethrogram. Of the three, urine infection and allergic reaction are easily manageable.

Prior to the procedure, the patient must inform the medical team if he is allergic to iodine-containing contrast. With regard to urinary infection, if it does not subside even after 36 hours of the procedure, it is best to seek medical attention. Antibiotics will be prescribed. Damage to the urethra is also rare but might occur if Genital Urethrogram is performed as an emergency procedure. In some cases, emergency surgical repair is recommended. The surgery aims at restoring urethral function and near-perfect cosmetic appearance.

DSD

After childbirth, the usual and much awaited announcement from a midwife in the labor ward is - 'it's a boy' or 'it's a girl'. But there are instances when the midwife cannot determine the sex of the baby as the sex organs do not conform to defined norms of a male or a female. The baby is born with sex organs that aren't clearly male or female. There is ambiguity about the gender. The child is born with a disorder of sex development (DSD). In all probability the midwife may relate to the newborn as 'baby'. Here is a child diagnosed with DSD at birth.

An estimated 2,000 babies are born 'intersex' each year, referring to a set of over 60 different conditions that fall under the diagnosis of 'DSD' (Differences/Disorders of Sex Development). DSD occurs more often than Down syndrome or cystic fibrosis. In the last 15 years, there is more openness about DSD which has led to moving beyond the medical/biological realm. There is growing interest in gender studies as well.

From Intersex syndrome to DSD

Other terms in place of disorder of sex development are 'intersex' (between the sexes) or 'hermaphrodite' or 'pseudohermaphroditism'. International experts held a conference (International Consensus Conference on Intersex) in 2006 and have reached a consensus that the term DSD or disorder of sex development should replace all those terms.

Some people prefer to use terms like 'differences in sex development' or 'diversity of sex development'. There are three basic types of DSDs. These manifest in different ways. Understanding X and Y chromosomes can help in sorting out the types of DSDs.

Females have two X chromosomes (XX) in each cell. This is by inheriting one X chromosome from each parent. Two X chromosomes is medically written as Karyotype 46, XX. And males have an X chromosome and a Y chromosome (XY). This is by inheriting an X chromosome from the mother and a Y chromosome from the father. An XY is referred to as Karyotype 46, XY.

The Y chromosome helps make a boy as it contains the genes for the development of male organs like the testes and penis. This happens around the 6th week of fetal development. As the testes make testosterone, the penis, scrotum and urethra form. Between 7th and 8th month of the pregnancy, the testes descend into the scrotum. In the absence of the Y chromosome, the fetal tissue in a female fetus (XX) will form the female sex organs – the ovaries, uterus and the fallopian tubes.

Causes of disorder of Sex development

Through the many stages of sex development, if all is typical the fetus develops into a normal male or a female. But, if at any stage of sex development an atypical development takes place it results in a 'disorder of sex development. Like:

• Influence of chromosome variations result in genetic disorders
  
  
• Congenital issues (that are present at birth)
  
  
• Genetic change that may or may not be inherited from a parent
  
  
• Unknown exposure to certain medications or hormones during pregnancy
  
  
• Problem during the development stage that prevents the production of enough hormones due to lack of blood flow to the ovaries or testes.
  

Types of DSDs

• Sex chromosome DSD
  
  
• 46, XY DSD
  
  
• 46,XX DSD
  

Diagnostic approach to DSD

Diagnosis begins with determining the type of disorder of sex development. Physical examination, medical history of the mother's health during pregnancy and family history of any neo-natal deaths form part of the diagnosis. A biopsy of the reproductive organs is done where necessary.

• Blood tests to check DNA and hormone levels
  
  
• MRI to study internal structures like gonads
  
  
• Ultrasound or direct Cystoscopy or vaginoscopy to take images of internal gonads.
  
  
• MRI or CT, and a retrograde genitogram to assess the Müllerian structures and the kidneys.
  
  
• Genital Urethrogram to look at the urethra and vagina, if present
  
  
• Chromosomal analysis to determine the genetic sex (46 XX or 46 XY)
  
  
• SRY Gene evaluation: An essential protein for sex termination in human males found on the Y chromosome. Also known as sex-determining region on Y, sex determining region protein, SRY_HUMAN, TDF, TDY or testis determining factor.
  
  
• Endoscopy, laparoscopy and gonadal biopsy
  
  
• Electrolyte tests such as sodium, potassium and glucose levels
  
  
• Fertility test
  
  
• Test to determine size and potential for growth of the penis in an undersized male pseudohermaphrodite
  
  
• Test to analyze the ability of an internal reproductive organ to produce sex hormones for the gender chosen
  
  
• Test to check possibility of future health conditions that may develop in the original reproductive organs
  
  
• Test to determine the action of male or female hormones on the fetal brain.
  

Treatment of DSD

Treatment options are based on specific diagnosis and issues involved. Not restricted to medical treatment, it involves psychological support as well. Reconstructing external genitalia or removing internal genitalia are surgical procedures. In some cases, more than one surgery is needed.

• Diagnostic evaluation, including examination, blood tests such as chromosome analysis and other genetic testing, and imaging (X-ray, ultrasound, MRI)
  
  
• Psychosocial support
  
  
• Genetic counseling
  
  
• Medical management, including hormone treatment (hormone replacement and hormone suppression)
  
  
• Surgical procedures when indicated
  

Surgical procedures for DSD

Not every DSD requires surgery. Medications may also be used to treat certain DSDs. Experts recommend waiting till adolescence to understand the individual's preference for identity. In children, surgery is necessary:

• For a child born without an opening for urination and to remove risks of complication, a surgery for opening is essential.
  
  
• A surgery to obtain a sample of the gonad to determine whether ovarian and/or testicular tissue, a biopsy and surgery is required.
  
  
• A surgery to reduce the size of a large clitoris or surgery to remove a gonad that is at risk to develop cancer is important.
  

Feminizing surgery: Going by 'Chicago Consensus', Feminizing surgery should only be considered in cases of severe virilisation. Also, the emphasis should be on functional outcome rather than cosmetic appearance. An ongoing debate on Feminizing Surgery is the timing of the surgery. A section believes in performing early feminizing surgery. Yet another section advocate feminizing surgery in adolescence as the patient is involved in discussions and decision-making.

• Clitoroplasty: Reduce the size of the clitoris
  
  
• Labioplasty: surgical modification of the labia
  
  
• Vaginoplasty: to create a vagina or enlarge an existing one.