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Advances in Urogynecology

Urethral Diverticula: A Review of Evaluation and Management

Sandra Culbertson, MD

The traditional presentation of a urethral diverticulum is a palpable anterior vaginal-wall mass with the ñthree Dsî: dysuria, dribbling, and dyspareunia. Although many urethral diverticula have this classic presentation, a significant percentage present with nonspecific symptoms and no palpable masses. While diagnostic techniques are improving, the most important tool in the evaluation of a urethral diverticulum is still a high index of suspicion.1 Surgical management remains the treatment of choice, although expectant observation may be appropriate in some cases.

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PATHOPHYSIOLOGY

As diverticula in children are unusual, it is likely that most diverticula are acquired. The mechanism of formation has been linked to inflammation of the paraurethral glands, which leads to cystic dilation and obstruction of the original communication of the gland to the urethra. The inflamed cystic mass then enlarges and eventually perforates into the urethral lumen to create a urethral diverticulum (Figure 1).4 At times, a diverticulum may not decompress when pressure is applied to it, indicating that there is no obvious communication with the urethra. In these cases, either the communication to the urethra is extremely stenotic, or the dilated gland never perforated into the urethra.

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FIGURE 1. Proposed mechanism of formation of urethral diverticula. (A) Initial inflammatory response occurs in SkeneÍs gland duct or paraurethral ducts. (B) Abscess formation and obstruction of gland neck. (C) Expansion of abscess. (D) Perforation of abscess into the urethra, leading to formation of diverticulum. From: Sogor L. Suburethral diverticula. In: Walters MD, Karram MM, eds. Urogynecology and Reconstructive Pelvic Surgery. 2nd ed. St. Louis, Mo: Mosby; 1999:367-375. Reprinted with permission.

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CLINICAL PRESENTATION

Pain is a common presenting symptom of urethral diverticulum, occurring in 48% of patients in one series.5 The pain may involve burning, ñsticking,î pressure, or aching, and is not limited to dysuria. Recurrent urinary tract infections (UTIs) are another frequent feature. While dyspareunia is considered to be a primary symptom, a summary of case series found an incidence of only 12% to 14%.4 Postvoid dribbling—another traditional primary symptom—is variable in occurrence, ranging from 8% to 17%.5,6 Other than pain, the most consistently reported symptoms are urinary incontinence, urgency, and frequency.

A palpable mass is appreciated on examination in the majority of patients (Figure 2). However, diverticula that originate from the anterior or anterolatral urethra may be nonpalpable. Careful palpation of the anterior vagina in the area of the urethra can reveal areas of discrete tenderness or thickening that may indicate a diverticulum. Expression of purulent material or urine when pressure is applied to an anterior vaginal mass is considered pathognomonic of a urethral diverticulum, but may not be appreciable because of the location of the diverticulum or stenosis of the ostium.

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FIGURE 2. This patient presented with a palpable anterior vaginal wall mass that was found to be a urethral diverticulum at cystoscopy. Courtesy of Sandra Culbertson, MD.

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DIFFERENTIAL DIAGNOSIS

The differential diagnosis of urethral diverticulum depends on whether a palpable mass is present. In the patient with a palpable anterior vaginal-wall mass, the differential diagnosis is limited, and includes fibroma or leiomyoma of the anterior vagina (Figure 3).7 Although usually thought to originate from the lateral vaginal walls, a Gartner duct cyst with a more anterolateral origin may be confused with a urethral diverticulum. Anterior vaginal-wall prolapse—especially when it involves the distal vagina—has also been mistaken for urethral diverticulum.

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FIGURE 3. This anterior wall vaginal mass was solid, and was found to be a fibroma on histologic examination. Courtesy of Sandra Culbertson, MD.

Because a nonpalpable urethral diverticulum poses a diagnostic challenge, the patient is often evaluated and treated for many other conditions before a diverticulum is considered. Incorrect diagnoses often include interstitial cystitis, vulvar vestibulitis, urethral syndrome, and chronic pelvic pain of unclear origin. In one series, there was a mean interval of 5.2 years between onset of symptoms and definitive diagnosis, and subjects consulted an average of nine physicians before the diagnosis of urethral diverticulum was established.5

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EVALUATION

A variety of imaging modalities are potentially useful in the diagnosis of urethral diverticulum, but there is some controversy as to which technique is best. The choice of modality depends on the patientÍs symptoms, findings on initial examination, and index of suspicion of urethral pathology. Common methods of evaluation include cystourethroscopy, voiding cystourethroscopy (VCUG), ultrasonography, and magnetic resonance imaging (MRI).

Positive-pressure urethrography (PPUG) was long considered to be the ñgold standardî for diagnosis. This uses double-balloon Davis or Trattner catheters to create a closed system within the urethra, so that when a contrast medium is injected, there is sufficient pressure to visualize even small communications to the urethra. However, while data show that PPUG has a higher sensitivity than voiding cystourethrography for detecting urethral diverticula,8 the usefulness of PPUG is limited by patient discomfort and infrequent performance by most radiology departments.

Voiding cystourethrography is often used for the diagnosis of urethral diverticula. If, however, there is stenosis of the ostium or loculations of the diverticular sac, it may be impossible to visualize the diverticulum. When compared with MRI, Blander et al9 found that only 85% of diverticula were visualized with VCUG, and VCUG underestimated the size or complexity of the diverticulum in 52% of cases. Although more comfortable than PPUG, VCUG requires catheterization of the patient, and the patient must void while images are captured.

Transvaginal ultrasonography can also be used to investigate urethral diverticulum (Figure 4). In a small series of patients,10 this technique showed greater sensitivity in diagnosing urethral diverticula when compared with cystoscopy and VCUG. Although data on the relative accuracy of ultrasonography in the diagnosis of urethral diverticulum are limited, its low cost, availability, and ease of use make it attractive—especially as a first-line study.

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FIGURE 4. Transvaginal ultrasound image of a urethral diverticulum. bl = bladder; D = diverticulum.

The use of MRI is increasing in the diagnosis of urethral diverticulum. With the addition of endorectal or endovaginal coils, detailed images of the urethra can be obtained (Figure 5).11 Studies have shown that MRI has a higher sensitivity in iagnosis of urethral diverticulum compared with both PPUG and VCUG.9,12 It should be particularly useful in patients presenting with urethral symptoms and no palpable mass, and in whom other diagnostic studies are negative. However, the cost of MRI limits its use; for example, a patient with an anterior vaginal-wall mass that obviously communicates with the urethra can likely be adequately evaluated with ultrasonography to determine the size and extent of the diverticulum, and cystoscopy to evaluate the communication.

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FIGURE 5. Magnetic resonance image with endorectal coil in place. Both a posterior diverticulum (Up) and an anterior diverticulum (Ua) are visualized in this patient. The communication of the posterior diverticulum to the urethra (Ur) is easily visualized. B = bladder; V = vagina; R = rectum; Ps = pubic symphysis; Ut = uterus. From: Vakili B. Wai C. Nihira M. Anterior urethral diverticulum in the female: diagnosis and surgical approach. Obstet Gynecol. 2003;102(5 Pt 2):1179-1183. Reprinted with permission.

Cystourethroscopy (Figure 6) is valuable for visualizing the location and size of the diverticular ostium, and assessing for multiple points of communication. If there is a large ostium at the level of the proximal urethra, the patient may be at risk for stress incontinence, and may require a sling procedure at the time of surgical excision. Urodynamic testing should be performed in any patient with a diverticulum who reports urinary incontinence.

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FIGURE 6. Urethroscopy demonstrates a large communication between urethra and diverticulum. D = diverticular ostia; U = urethra. Courtesy of Sandra Culbertson, MD.

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TREATMENT

Treatment of urethral diverticula is usually surgical excision or marsupialization of distal diverticula. Asymptomatic or minimally symptomatic diverticula can be managed conservatively with observation, prophylactic antibiotics, and postvoid digital decompression.13 However, there are minimal data on patient outcomes or eventual need for surgical excision in such patients. A pregnant patient may sometimes present with a large diverticulum. If the diverticulum decompresses with pressure, it should not pose a problem during labor. If it does not decompress, the diverticulum can be aspirated transvaginally with a small-gauge needle before the second stage of labor. Prior to surgery for a urethral diverticulum, the patient should be assessed and treated for UTIs, which may be difficult in patients with narrowed diverticular ostia.

Marsupialization

While urethral diverticula are usually addressed via transvaginal excision, marsupialization may be utilized for diverticula in the distal urethra. This can be accomplished using the Spence procedure.14 The floor of the urethra and the underlying vagina are opened from the urethral meatus to the orifice of the diverticular sac. An absorbable suture is used to approximate the edges of the diverticulum and urethra to the vagina, essentially creating a larger urethral meatus. In a series of 16 patients, Roehrborn15 showed no recurrent diverticula, but three patients demonstrated stress incontinence. Marsupialization is easily and rapidly performed, but should be reserved for only the most distal diverticula.

Transvaginal Excision

Transvaginal excision can be performed on an outpatient basis unless extensive dissection is required. The basic technique consists of incision of the anterior vaginal wall, mobilization of the diverticular sac, excision of the sac from the urethra, closure of the urethra without tension, and closure of the periurethral tissue and vagina. Overlapping of suture lines from consecutive tissue layers should be avoided. The vaginal incision can be an inverted U, or a vertical or an inverted T,6,16 each of which has advantages and disadvantages. The author utilizes an inverted T incision, making the horizontal cut just proximal to the diverticulum (Figure 7). The incision then proceeds vertically by undermining with dissecting scissors, separating the vagina in the midline. The periurethral fascia is dissected from the vaginal mucosa before mobilizing the diverticulum to provide sufficient material to cover the repaired urethra.

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FIGURE 7. Surgical repair of urethral diverticulum. (A) Vaginal incision. (B) Incision is made over the diverticulum to begin mobilization of the diverticular sac. (C) After the diverticular sac is completely mobilized, it is opened. The catheter in the urethral lumen then becomes visible. (D) The sac is excised, and the urethral defect is closed with a series of interrupted absorbable sutures. (E) The periurethral fascia is imbricated over the urethral closure. If adequate tissue is available, a ñvest-over-pantsî technique is employed. (F) The vaginal incision is reapproximated. Courtesy of Samir Hajj, MD.

The diverticular sac is dissected free in its entirety and excised, and the urethral defect is closed with interrupted, delayed absorbable sutures. If inflammation prevents complete excision of the sac, Tancer et al17 described leaving a portion of the base of the diverticulum and then closing this tissue in an imbricating fashion. The periurethral fascia is then closed in a ñvest-over-pantsî fashion to provide two layers of intervening fascia and prevent overlapping suture lines (Figure 8). Finally, the vaginal mucosa is reapproximated.

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FIGURE 8. ñVest-over-pantsî closure. This method of closure avoids overlapping of suture lines and creates an additional layer of closure over the urethra. From: Rock J, Horowitz I, Dominguez C. Surgical conditions of the vagina and urethra. In: TeLinde R, Rock J, Jones H, eds. TeLindeÍs Operative Gynecology. 9th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003:918. Reprinted with permission.

If the quality of the periurethral fascia is poor due to excessive scarring or inflammation, a Martius flap may be utilized to provide an intervening layer of vascularized tissue. In this instance, a portion of the adjacent bulbocavernosus muscle is mobilized with its blood supply and tunneled over the plicated periurethral fascia. This vascular flap prevents overlapping of suture lines, lessening the incidence of urethrovaginal fistula formation.

Concomitant Sling Procedure

A pubovaginal sling procedure using autologous material can be performed safely at the time of diverticulum excision.18 Not only is a sling procedure indicated in the patient with stress incontinence, but it may also be useful in the patient with a large diverticular ostia at the proximal urethra. In the latter situation, there is a substantial risk to the urethral sphincter mechanism with extensive dissection. While there are no data regarding the use of mesh slings at diverticular excision, the risk of complications such as urethral erosion of the mesh would seem to make this inadvisable.

Postoperative Considerations

The excised diverticular sac should be sent for pathologic evaluation. Although rare, malignancies have been described in urethral diverticula (eg, adenocarcinoma, squamous cell/transitional cell carcinomas).19,20 Nephrogenic adenomas have also been reported. Stone formation occurs in 1.5% to 10% of diverticula due to stasis and deposition of minerals within the diverticulum (Figure 9).21 Patients with such stones generally have a firm, palpable mass in the anterior vagina.

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FIGURE 9. This patient presented with a firm suburethral mass. When the diverticulum sac (A) was opened, it was found to contain three stones (B). Courtesy of Sandra Culbertson, MD.

Postoperatively, patients are discharged with a transurethral catheter for bladder drainage. Concomitant use of suprapubic drainage tubes has been described,6 but there are no data regarding the preferred route of bladder drainage. Recommendations for postoperative bladder drainage range from 5 to 14 days, depending on the difficulty of the excision and size of the ostium.16 In some centers, VCUG is performed postoperatively to evaluate for adequate closure of the urethral defect,6 but this is probably not necessary in uncomplicated repairs.

Complications

The most commonly reported complications after surgery for urethral diverticula include recurrence (1% to 29%), urethrovaginal fistula (0.9% to 8.3%), stress urinary incontinence (1.7% to 16%), and urethral stricture formation (1% to 2%).3 It is unclear whether subsequent diverticula are true recurrences, or persistence of additional diverticula that were not diagnosed or treated initially.

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CONCLUSION

Urethral diverticula are not an uncommon finding in women. In patients with classic symptoms and findings, the diagnosis is not difficult. However, many patients present with nonspecific lower urinary tract symptoms, and may see several physicians over an extended period before they are diagnosed correctly. For such patients, clinicians should remain alert to the possibility of a urethral diverticulum, especially if they do not respond to conventional therapies. Advances in MRI and ultrasonography provide less invasive and more detailed information regarding the presence and size of urethral diverticula. Although some patients may be candidates for observation or marsupialization, surgical excision remains the treatment of choice.

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Sandra Culbertson, MD, is associate professor and vice-chairman for clinical affairs, Department of Obstetrics and Gynecology, Pritzker School of Medicine, The University of Chicago, Ill.

References

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