An ascending urethrogram (AUG) involves retrograde injection of iodinated contrast into the urethra to visualize its anatomy and identify any abnormalities. The male urethra is best seen in the oblique position while the female urethra is best seen laterally or anteroposteriorly. The AUG can detect urethral strictures, trauma, fistulas, congenital anomalies, periurethral abscesses, and tumors. Complications are rare but can include allergic reactions, urinary tract infection, and urethral injury. The AUG is useful for evaluating the type and extent of blunt urethral injuries as well as conditions like penile

1. PG: Dr. Nasin Usman
Moderator: Dr. Balaji J.
ASCENDING URETHROGRAM

2. AUG/RGU
• AKA Retrograde urethrography (RGU): Iodinated Contrast media are retrogradely
injected with urethral orifice occluded to prevent reflux of contrast.
• Static images are obtained, preferably assessed dynamically using flouriscopy
• Male urethra best seen in oblique position
• Female urethra best seen in lateral or anteroposterior position (MCU)

3. ANATOMY
• Male urethra is 17.5 to 20 cm in length and
divided into:
• The anterior urethra extends from the
external meatus to the inferior edge of the
urogenital diaphragm - divided into the
penile (or pendulous) and bulbous parts at
the penoscrotal junction.
• The posterior urethra is divided into the
prostatic and membranous urethrae.
• Periurethral glands of Littr lie in the anterior
urethra.
• Cowper's glands are two pea-sized glands,
which lie within the urogenital diaphragm on each
side of the membranous portion of the posterior
urethra.
• Verumontanum (a longitudinal ridge of smooth
muscle, urethral crest) on the posterior wall of the
posterior urethra, where the paired ejaculatory
ducts open.

4. ANATOMY
• To identify the bulbo-membranous junction:
• 1 to 1.5cm distal to the inferior margin of the
verumontanum when the verumontanum is
visible.
• When the posterior urethra is suboptimally
opacified, the bulbomembranous Junction
can be arbitrarily localized where an
imaginary line connecting with each inferior
margin of the obturator foramina intersects
the urethra
• Cowper’s gland and duct
• Filling of Cowper's duct (figure 5) and/or
prostatic ducts should not be misinterpreted
as extravasation

5. INDICATIONS
• Stricture
• Eg: stricture in the bulbar
urethra
• Urethral trauma
• 1) Partial urethra injury--
partial disruption of the
bulbous urethra
demonstrating venous
intravasation
• 2) Complete urethral
injury - contrast
extravasation from the
bulbar urethra
throughout the perineum,
with no filling of the
proximal urethra and
bladder.

6. INDICATIONS
• Fistulae
• Eg: irregular scarring in the
bulbous urethra with a fistula
(arrow) extending from the
bulbous urethra to the
perineum
• Congenital anomalies
Distal bulbar urethral
stricture
Dilated penile urethra
Utricle cyst opening
into prostatic
urethra

7. INDICATIONS
• Periurethral/ prostatic abscess
• long segment of irregular, beaded
narrowing in the bulbous urethra
• irregular periurethral cavity originating from
the ventral aspect of the bulbous urethra
• Abnormal cone of proximal bulbous urethra –
indicates scarring extends into the membranous
urethra
• Marked reflux of contrast medium into the dilated
open prostatic ducts indicating previous
prostatitis and outlet obstruction

8. CONTRAINDICATIONS
• Recent instrumentation
• Urethritis
• UTI (acute)

9. TECHNIQUE
• 20 ml of HOCM or LOCM (ionic or non-ionic) – warming
before procedure reduces onset of spasm of external
sphincter
• Instructed to void prior to procedure
• Under asp, penile clamp is applied. Eg, Knutssons
clamp
• Foleys / any other catheter is inserted into the meatus
• Patient positioned in supine RAO 300 with right leg
abducted and knee flexed
• Contrast diluted with 20 ml sterile water
• Injected continuously and exposure done while last 3-4
ml
• If the spasm of the external sphincter is so severe as to
preclude filling of the posterior urethra, the chance of
significant urethral injury is small.

10. COMPLICATIONS
• Allergic reactions to contrast (very rare)
• Acute UTI
• Urethral trauma/ bleed
• Intravasation of contrast

11. URETHRAL INJURIES - BLUNT
Type I
Rupture of the
puboprostatic ligaments
stretched post urethra
Type II
tear of membranous
urethra above the
urogenital diaphragm
No contrast extravasation
in perineum
Type III
combined anterior and
posterior urethral injury
with disruption of the
urogenital diaphragm
extravasation into the
pelvic extraperitoneal
space and the perineum
Type IV
Bladder neck injury with
extension into the urethra
where the primary
continence sphincter lies
Type V
Straddle pure anterior
urethral injury
MC

12. AUG
• Penile fracture
• contrast extravasation in the penile
urethra

13. AUG
• Condyloma acuminata
• Retrograde urethrogram
demonstrates multiple small filling
defects in the anterior urethra

14. MALIGNANT TUMORS OF THE URETHRA
• Location: Bulbomembranous urethra
(60%), penile urethra (30%) and prostatic
urethra (10%) (10)
• Histology: squamous cell carcinoma
(80%), transitional cell carcinoma (15%),
and adenocarcinoma or undifferentiated
carcinoma (5%).
• SCC: Irregularity and narrowing of the
bulbous urethra with multiple sinus tracts.

15. AUG
• Urethral diverticula
• Acquired diverticula in males may be
found anywhere along the urethra.
• peno-scrotal junction is the MC site
for anterior urethral diverticula. They
can occur in patients who have a
spinal cord injury as a result of
repeated urethral trauma due to
catheterisation

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