PMC6195911_01
Pre-operative ultrasound images of the patient. (a) Longitudinal image of the left kidney showing cortical scarring (arrows) and caliectasis (asterisks). (b) Sagittal transperineal image shows an abscess (ab) in the perineum in relation to oedematous root of penis (r); the anal canal (ac) and urinary bladder (u) appear normal. (c) Axial image showing a normal proximal penile urethra (arrow) and normal parts of the corpus spongiosum (cs) and corpora cavernosa (cc). (d) Axial image showing a bulbar urethra (arrow) with an oedematous corpus spongiosum. (e) Sagittal transperineal image showing perineal abscess (ab) extending to the proximal corpus spongiosum (cs).
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Ultrasound revealed an overdistended urinary bladder with a normal-sized prostate and scarring and focal caliectasis in the left kidney (Figure 1a). A perineal ultrasound revealed an abscess in the perineum, which extended to the proximal parts of the corpus spongiosum (Figure 1b-e).
Post-operative clinical photograph (a) of the patient showing external opening of the fistula. Retrograde urethrogram (b) showing periurethral extravasation of the injected contrast with extension to the skin surface (arrow) and a lytic lesion in the left inferior pubic ramus (double arrow). Sagittal transperineal ultrasound image (c) showing the main fistulous tract (arrows) extending from the skin surface to the corpus spongiosum (asterisk).
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The patient subsequently developed a discharging sinus at the operative site (Figure 2a) leaking purulent fluid. A retrograde urography revealed periurethral extravasation of the injected contrast material with a lytic lesion in the left pubic ramus (Figure 2b). A repeat perineal ultrasound revealed a linear hypoechoic tract leading from the skin surface to the corpus spongiosum (Figure 2c).
Post-operative axial (a) and volume-rendered (b) CT images showing a lytic lesion of the left inferior pubic ramus (arrows).
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On the non-contrast CT scan, a lytic lesion was seen involving the left inferior pubic ramus (Figure 3).
Post-operative axial retrograde CT urethrogram images (a and b) show extension of the injected contrast to intersphincteric planes of the anal canal (arrow in a) and a lytic lesion in the left inferior pubic ramus (arrow in b). The sagittal maximum intensity projection (c) and the volume-rendered (d) CT images show a complex periurethral collection communicating with the perineal skin (arrow in c) and spilling into the natal cleft (double arrow in c).
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An extension of the contrast through the external anal sphincter into the intersphincteric plane (Figure 4a) with inflammatory stranding in the ischioanal fossae was seen. The contrast also extended into the lytic lesion present in the left inferior pubic ramus (Figure 4b). The contrast also extravasated through the cutaneous opening in the perineum and the natal cleft (Figure 4c,d).