AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Urethral diverticula are a relatively common finding among women with chronic genitourinary conditions, such as recurrent infections, postvoid dribbling, and dyspareunia. The level of awareness of the disorder and the practitioner's desire to make the diagnosis are reported to have the most direct influence on the incidence of urethral diverticulum. This statement reflects both the difficulty of the diagnosis and the varying levels of awareness of the disorder throughout the medical community. Recently, increased awareness and discussion of urethral diverticula have allowed the diagnosis to be made more frequently and with less delay than in the past.

History of the Procedure

In 1805, William Hey first described a female with suburethral diverticulum in the medical literature; however, he claimed to have first observed and treated this lesion about 20 years earlier. In the first half of the 20th century, only 17 cases were reported, and, as a result, the condition was assumed to be quite rare. Reports of cases, including a large series from Johns Hopkins Hospital, dating from 1950-1970 have revealed that suburethral diverticula in fact are not rare. Increased awareness of the diagnosis and increased interest in female urology and urogynecology have led to the publication of many reports and review articles in recent years.

In 1875, Lawson Tait was the first to suggest surgical excision as treatment for these lesions. In 1938, Johnson reported on 5 patients treated with complete excision of the diverticular sac. In 1962, Tancer and Hyman described surgical treatment by partial ablation in a small series of 11 patients. Subsequently, the lead author has reported successful treatment of many additional patients with no occurrences of postoperative urethrovaginal fistulas. In 1970, Spence and Duckett pioneered a marsupialization procedure for distally occurring diverticula. These 3 operations continue to be the mainstays of surgical therapy today.

In 1956, Davis and Cian introduced positive-pressure urethrography, which was a major advance in the diagnostic tools and preoperative evaluation of urethral diverticula. In 1973, Jack Robertson published a landmark article on gynecologic urethroscopy using carbon dioxide gas as a distension media. He described visualization of the diverticular orifice using this technique. Subsequently, ultrasound and magnetic resonance imaging (MRI) have been added to the diagnostic armamentarium.

Problem

The definition of a diverticulum according to Dorland's Medical Dictionary is "a pouch or sac occurring normally or created by herniation of the lining mucous membrane through a defect in the muscular coat of a tubular organ." Because the etiology of suburethral diverticula is uncertain, whether or not this disorder is the result of a true herniation of urethral mucosa or some other pathologic process is equally unclear. In fact, the favored theory describing the genesis of urethral diverticula, ie, rupture of an obstructed infected paraurethral gland back into the urethra, does not fit the definition of a true diverticulum.

A urethral diverticulum can be described as an outpouching of tissue from the urethra into the urethrovaginal potential space. The lining of the diverticulum most commonly is identical to the urethral mucosa. Most urethral diverticula are believed to be derived from dilated paraurethral ducts or glands.

Frequency

The frequency with which this disorder occurs is difficult to estimate due to the high probability of a substantial number of missed or misdiagnosed cases in any given population. In addition, research has demonstrated a sizable pool of asymptomatic women with demonstrable diverticula. In one study, asymptomatic women with cervical cancer were studied with positive-pressure urethrography. A prevalence of urethral diverticula of 3% was reported in this group. Many of these diverticula were small, ranging in size from 2-16 millimeters in diameter. Based on these findings, the smallest of these diverticula conceivably may have represented filling of large, but otherwise normal, paraurethral glands.

Another series identified diverticula in 4.7% of 129 asymptomatic women. Other sources reveal an incidence of 2-5% in a referral population of women with genitourinary ailments. Finally, prevalence rates of 16% and 40% have been reported in female patients with recurrent urinary tract infections (UTIs).

In a recent publication, a referral practice in urology and urogynecology reviewed a database consisting of almost 2000 patients seen over an 8-year period. Seventy-nine patients (4%) were identified with a periurethral mass. Most patients (91%) were referred due to persistent irritative lower urinary tract symptoms or incontinence with the mass discovered during the subsequent evaluation. Only 7 patients (9%) were referred specifically for a mass. The diagnosis of urethral diverticulum was made in 84% of the cases. Notably 4 patients (6%) were diagnosed with an associated malignancy. Other diagnoses included fibromuscular tissue mass (7%), leiomyomata (5%), ectopic ureterocele (2.5%), vaginal squamous cell carcinoma (2.5%), and 1 patient had an infected granuloma.

Urethral diverticula are much more common in females than in males. The rare cases reported in males generally have been associated with lower urinary tract congenital anomalies or surgical trauma. In a series of 108 female patients from the Mayo Clinic, the age range was reported as 10-76 years, with the disorder observed most commonly in women aged 30-50 years.

Very rarely, periurethral cystic masses have been reported in newborns. Whether these masses represent a congenital form of urethral diverticulum or some type of genitourinary congenital remnant remains uncertain.

Etiology

The etiology of urethral diverticulum is uncertain, although several theories exist. In 1890, in England, Routh first proposed the most widely quoted theory. He postulated that obstruction of one or more paraurethral ducts may result in formation of a retention cyst within the paraurethral gland. Later, infection supervenes and results in abscess formation and rupture back into the urethral lumen. Epithelialization of the rupture tract results in formation of the neck of the diverticulum.

Over the years, several findings have lent support to this theory. First, the anatomic location of most urethral diverticula corresponds to the location of the highest density of paraurethral glands. The predominant location of both the paraurethral glands and urethral diverticula is along the dorsolateral aspect of the distal two thirds of the urethra. One review found that 85% of diverticula occurred in the distal two thirds of the urethra. In another more recent series, about 60% of diverticula were located along the middle or distal one third of the urethra, with about 15% in multiple locations. In 4% of cases, the location was unknown. In addition, small dilations of the paraurethral duct and gland system have been observed in females without diverticula.

Another etiologic theory is that of urethral trauma from childbirth, catheterization, urethral dilation, or other surgical injury. Although this mechanism may account for a small number of urethral diverticula, causation is difficult to prove. Also, 15% or more of all urethral diverticula occur in nulliparous females with no known history of urethral trauma.

Some suburethral cysts may be congenital, as evidenced by the fact that they have been reported in newborns. Many of these cysts have epithelial linings, which indicate that they arise from structures that are not the paraurethral glands or ducts. Examples include cloacogenic rests lined with colonic epithelium, Gartner duct cysts, and Müllerian remnants. In the opinion of this author, these cysts should not be classified as urethral diverticula.

Rarely, a diverticulum may be associated with an anomalous accessory urethra. Such diverticula are generally recognized at birth, presenting as a large fluid-filled mass occupying space between the main urethra and the clitoris. The external meatus of the accessory urethra is stenotic and drains poorly, resulting in the accumulation of urine in the diverticular sac. Associated genitourinary anomalies, such as absence of the perineum, absence of the labia minora, a multicystic kidney, and hydronephrosis can be encountered. The enlarged accessory urethra and diverticulum can have phallic appearance and, as such, this congenital abnormality is considered by many experts to be a form of pseudohermaphroditism.

A recently published case report describes the use of urography and genitography to aid in defining the anatomy. At 2 days of age, the stenotic meatus was incised to promote drainage. Definitive surgery was undertaken at 5 months of age including excision of the accessory urethra and diverticulum, and indicated genital reconstruction with attention paid to preserving the clitoris and associated structures.

Pathophysiology

The pathophysiology of most cases of urethral diverticula appears to revolve around obstruction of and infection within the paraurethral glands. The glands are thought to become enlarged and inflamed, eventually forming a retention cyst and then an abscess, which ruptures back into the urethra. In 1890, Routh first described this pathophysiologic mechanism.

In 1953, Telinde suggested that gonococcal infection in the paraurethral glands was an important initiating factor in the pathogenesis of urethral diverticula. In a subsequent small series in 1975, 10 of 31 patients had proven gonorrhea and another 7 had histories suggestive of gonococcal infection. Bacteruria is a common finding in individuals with urethral diverticula. Typical urinary tract pathogens predominate. Bacteruria and recurrent UTIs are thought to result from bacterial growth in the stagnant urine within the diverticulum and reflux of infected material into the bladder. Little else apparently is known regarding the bacteriology of this disorder.

Urethral diverticula may be associated with variable degrees of peridiverticulitis. Tancer and Ravski (1982) state that this may result from recurring infection within the diverticulum. They argue that signs and symptoms, such as urethral tenderness and dyspareunia, appear or become more severe upon development of peridiverticulitis.

On occasion, severe, recurrent infection in and around the diverticulum may result in rupture through the periurethral connective tissue and into the space between this tissue and the vaginal wall. Leng and McGuire (1998) proposed this phenomenon in their description of urethral diverticulum subtypes. The author has observed this phenomenon on 2 occasions, including 1 case in which the rupture may have occurred at the time of double balloon positive-pressure urethrography.

In as many as 10% of cases, stones may form within the diverticular sac. Stones may be singular or multiple. Most are calcium oxalate or calcium phosphate stones. Stagnation of urine with crystal formation in the presence of chronic infection probably is the main etiologic factor. In rare instances, giant calculi have been reported to occur in urethral diverticula.

Due to the presence of chronic inflammation, mucosal changes within the diverticulum often resemble chronic cystitis. Cystitis glandularis, glandular metaplasia, and focal hyperplasia have been reported. Chronic mucosal injury may cause hyperplastic and neoplastic changes within the diverticulum. Rarely, carcinoma develops within a diverticulum. These cases represent 5% of all urethral carcinomas. For unknown reasons, carcinomas appear to be more common in blacks with urethral diverticula. Among diverticulum-associated cancers, about 60% are adenocarcinomas, 30% are transitional cell carcinomas, and 10% are squamous cell cancers. Traditionally, the squamous cell variety was thought to have worse prognosis. More recent information suggests that tumor grade may be more important than cell type as an indicator of prognosis.

In 1998, Leng and McGuire proposed a simple classification system of urethral diverticula partly based on pathophysiologic findings and proposed etiologies. In their series of patients, they observed some cases in which the mucosal lining of the urethra was observed to be extruding through a defect in the periurethral connective tissue. This finding was at variance with the more typical intraoperative finding of intact periurethral connective tissue surrounding the diverticular sac. They found this subtype to be associated more commonly with previous periurethral surgery. They called this subtype a pseudodiverticulum, although the described lesion closely approximates the medical definition of a true diverticulum.

In the series reported by Leng and McGuire, the pseudodiverticulum often was observed following suture bladder neck suspension procedures. They hypothesized that traction on these sutures during increases in intra-abdominal pressure may have torn the connective tissue, leaving a gaping defect. Most often, this type of lesion had a broad-based ostium, which was easily identifiable on urethroscopy. Also, these patients tended to have fewer chronic lower urinary tract symptoms, with the exception of stress incontinence, which was more common. In this series of 18 patients, 12 had true diverticula, 5 had pseudodiverticula, and 1 patient had both subtypes.

Clinical

The clinical presentation of urethral diverticula varies considerably from patient to patient and also may vary depending on when during the natural history of the disorder the diagnosis is made. Early in the natural history, when the periurethral gland initially becomes infected, the predominant symptoms may be related to urination. At this stage, dysuria, frequency, and postmicturition dribbling may bring the patient to clinical attention. Later, as chronic and recurrent inflammation develops around the diverticulum, low pelvic pain and dyspareunia may be reported as well. Clinical signs such as pyuria, a palpable suburethral mass, suburethral induration, and tenderness may be present. A recent review reported the most common symptoms as follows:

• Urinary frequency and urgency (40-100%)
• Dysuria (30-70%)
• Recurrent UTI (30-50%)
• Postmicturition urinary dribbling (10-30%)
• Dyspareunia (10-25%)
• Hematuria (10-25%)

Less commonly reported symptoms included stress or urge incontinence, pelvic or suprapubic pain, perineal pain, pelvic pressure, urinary hesitancy, purulent urethral discharge, feeling of incomplete emptying, urinary retention, and isolated terminal dysuria. A recent review of malignancies within urethral diverticula reported a higher incidence of hematuria (49%) and a lower incidence of dyspareunia (5%) in these women.

In a recent series of 120 patients conducted in Taiwan, 100% of the patients presented with the classic triad of postmicturition dribbling, dyspareunia, and dysuria. The next most common presenting symptoms were incomplete voiding, urgency, and frequency, reported in 38%, 21%, and 18% of the patients, respectively.

Physical examination findings in cases of urethral diverticulum may be striking, subtle, or completely absent. The appreciated findings may be dictated by the natural history of the disorder and the presence or absence of acute infection. Classic findings include a palpable anterior vaginal wall mass (see Image 1) and expression of purulent material from the urethra upon compression. Early series commonly (78%) reported these findings. In more recent series, much lower rates, 2-6%, of this finding have been reported. One factor that may explain these vast differences in physical examination findings is the use of antibiotics early in the disease course and subsequent prevention of abscess formation.

Additionally, changes in reporting habits and increased use of imaging modalities in cases suspected on history alone may be important factors. Still, in a very recent series of 46 consecutive patients, 52% had a palpable mass; however, only 13% had purulent material expressed from the urethra. Of note, 8% of the palpable diverticula contained malignancies, and another 8% contained stones or endometriosis. Hardness or grittiness within the mass can be appreciated in some cases of diverticula with stones. A palpable anterior vaginal wall mass in the clinical setting of a possible urethral diverticulum raises the index of suspicion for malignancy.

At times, suburethral tenderness may be the only physical examination finding of note in suspected cases of urethral diverticulum. The differential diagnosis in these instances includes urethral syndrome, acute or chronic urethritis, and interstitial cystitis. In one recent series, suburethral tenderness was present in about 50% of cases, with or without the presence of a palpable mass.

The inability to easily palpate a urethroscope or a similar caliber rigid catheter vaginally along the full length of the urethra has been suggested as an indication of urethral diverticulum. This finding was present in 2 cases of urethral diverticulum and absent in all cases of patients undergoing urethroscopy for other reasons.

The differential diagnosis of an anterior vaginal wall mass includes urethral diverticulum; urethral carcinoma; endometrioma; leiomyomata; Skene gland abscess; Gartner duct cyst; ectopic ureter with ureterocele; and other embryonic remnants, rests, or cysts. Essentially any tissue type can, in rare instances, form a suburethral mass. For example, urethral diverticula with colonic epithelium and Paneth cell metaplasia have been reported. Also, tumors of neuroendocrine origin have been observed in the suburethral region. Rarely, combinations of 2 or more of the above problems may be present. An example of this is carcinoma within a urethral diverticulum. A case of ectopic ureter terminating within a urethral diverticulum also has been reported.

Include urethral diverticulum in the differential diagnosis in patients reporting recurrent UTIs, stress incontinence or postvoid dribbling, urinary urgency and frequency, dysuria, urethral pain, urinary retention, dyspareunia, hematuria, or purulent urethral discharge.

INDICATIONS

Section 3 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Treatment of urethral diverticulum is indicated if patients are symptomatic. Small asymptomatic diverticula can be noted in patients' charts and monitored. Indications for future treatment could include the onset of symptoms, hematuria not attributable to another cause, and an increase in size. Following the cases of patients with minimal symptoms may be acceptable because the potential complications from surgical intervention may outweigh the benefits of symptom relief. No studies of expectant management in this setting exist, however. Filling defects within the diverticulum identified on imaging studies may be an indication for surgical treatment, even in the absence of symptoms, because this finding may indicate a malignancy or a stone within the sac.

RELEVANT ANATOMY

Section 4 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The female urethra is approximately 4 cm in length. It is embedded in the connective tissue supporting the anterior vagina. The epithelium is stratified squamous in type, which variably becomes transitional as the bladder is approached. The epithelium is arranged into longitudinal folds. At the base of the folds are scattered gland openings along the entire urethral length. These are the openings of the paraurethral glands. Although Regeneri de Graaf first described the openings of the paraurethral glands in 1672, these structures remained poorly characterized until the 20th century. In 1880, Skene detailed the 2 main distal-most ducts and glands, which now commonly are referred to as Skene glands.

In 1948, Huffman published his classic detailed anatomic description of the paraurethral glands. He performed serial sections in cadaveric specimens and observed the glands to be mostly in relation to the distal two thirds of the urethra. The gland openings primarily were found along the posterior and posterolateral mucosal surfaces. The epithelial lining of these glands was noted to be columnar, and he found that associated inflammation was common.

Many anatomists now regard the paraurethral glands as the homologue to the male prostate gland. In the 1980s, positive histochemical staining of tissue specimens from the paraurethral glands for prostate-specific antigen (PSA) lent support to this concept.

The intrinsic smooth muscle of the urethra is arranged longitudinally and obliquely, with a few circularly arranged fibers. The oblique and circular fibers, in particular, contribute to urethral closure at rest. The striated urethral sphincter is complex, and the configuration of this group of muscles is not universally agreed upon. The bulk of this muscle group is located in the proximal two thirds of the urethra and is composed predominantly of slow-twitch fibers. The pubovisceral portion of the levator ani muscle group, the posterior pubourethral ligaments, and the endopelvic connective tissue that lies between the urethra and the vagina contribute to urethral support and urethral closure during times of increased intra-abdominal pressure. A complete description of extrinsic urethral support and the continence mechanism is beyond the scope of this article.

CONTRAINDICATIONS

Section 5 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Contraindications for surgical treatment of urethral diverticula are few and generally involve medical disorders that render surgery of any kind unsafe. In cases of active abscess, definitive surgical treatment probably should be postponed. Temporizing measures include treatment with broad-spectrum, tissue-penetrating antibiotics and drainage either by vaginal incision or by urethral dilation and massage.

WORKUP

Section 6 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Lab Studies

• Urinalysis and culture
• • A urethral diverticulum is as an excellent reservoir in which urine can stagnate. As such, recurrent UTIs are common in patients with this disorder.
  • Preoperatively, determine the presence of bacteria in the urine and treat if found.
  • The presence of hematuria without other findings consistent with bacterial infection or colonization could indicate a stone or malignancy within the diverticulum.
• Urine cytology
• • Although not a routine test in all patients with a known or suspected diverticulum, obtain urine cytology if findings suggest an associated malignancy. Such findings include a mass within the diverticulum, filling defects on imaging studies, or unexplained hematuria.
  • Consider a positive result significant and investigate further. However, a negative result does not rule out the presence of coexisting malignancy.

Imaging Studies

• Voiding cystourethrography
• • Voiding cystourethrography (VCUG) is one of the most commonly used imaging studies in the workup of suspected urethral diverticula. The range of diagnostic accuracy reported in the literature is 44-95.2%, with an overall accuracy of approximately 65%.
  • The procedure generally is performed in the upright position. Obtain filling, voiding, and postvoid films. Sometimes, the diverticulum fills during the voiding phase, and the diverticulum is best visualized on postvoid films.
  • Because the test is simple, relatively noninvasive, and painless, many experts recommend performing this imaging study first, reserving positive-pressure urethrography for cases in which findings on VCUG are negative and urethral diverticulum still is strongly suspected.
  • In one small study using this approach, physicians diagnosed 90% of diverticula using VCUG. One additional diverticulum was found using positive-pressure urethrography as a backup test. Others argue that the 90% or greater diagnostic accuracy of positive-pressure urethrography makes it the imaging study of choice in all suspected cases.
• Positive-pressure urethrography
• • Double balloon positive-pressure urethrography has been a mainstay in the diagnosis of urethral diverticula since the 1950s. In a recent study of 32 women, positive-pressure urethrography was 100% sensitive in the diagnosis of urethral diverticulum, versus 44% for VCUG.
  • The technical steps of performing positive-pressure urethrography are relatively simple. With an empty bladder, a triple-channel double balloon catheter of the Trattner or Davis variety is placed. Both balloons are inflated with air or diluted liquid contrast. The intravesical balloon is filled first and then pulled snugly against the urethrovesical junction. The balloon at the external urethral meatus is inflated next. Dye then is injected through the middle port of the catheter in order to fill the isolated urethral lumen. This is performed under fluoroscopic control with permanent films obtained as indicated (see Image 2).
  • In a recent study, the possibility of performing this procedure with minimal discomfort was demonstrated when viscous lidocaine jelly was used as a urethral anesthetic and lubricant. In addition, the cost of positive-pressure urethrography was found to be the same as VCUG.
  • Several studies have demonstrated that small and very small (several mm in diameter) diverticula can be visualized using this method. Many patients with small diverticula in these studies were minimally symptomatic or asymptomatic. Supposed small diverticula possibly may represent artificially distended, but otherwise normal, paraurethral glands. Overdiagnosis and overtreatment could result in these instances. Another potential shortcoming of positive-pressure urethrography is missing diverticula that have not yet developed ostia.
  • In 1980, Greenberg et al undertook a study of 51 women with lower urinary tract symptoms. They performed double balloon catheter studies on all patients and described 6 distinct patterns.
    • Patients with type I findings had normal appearing urethras with essentially the same caliber throughout.
    • Patients with type II findings had distal urethral ballooning. One patient in this group had findings consistent with urethritis, but all others had negative findings on urethroscopy and physical examinations.
    • Patients with type III findings had proximal ballooning or funneling at the urethrovesical junction, but workup findings were negative otherwise.
    • Type IV findings included filling of the distal periurethral glands, with 2 of 4 patients showing physical signs of Skene gland tenderness.
    • Patients with type V findings had localized, broad-based outpouchings of the urethra, which were of unclear clinical significance. This finding appears possibly to be similar to what Leng and McGuire later described as a pseudodiverticulum.
    • Patients with type VI findings had urethral diverticula, most of which had identifiable ostia on urethroscopy.
  • This diagnostic modality is not perfect; interpret any positive or negative results in light of other clinical or radiographic findings. In the author's opinion, the test should not be ordered unless a suburethral mass can be appreciated on physical examination or urethral diverticulum is strongly suspected based on the findings of other tests or studies. One of the greatest strengths of positive-pressure urethrography may be in further characterizing the anatomy of a known diverticulum as part of good preoperative planning.
• Ultrasonography
• • Ultrasonography (US) imaging of urethral diverticula can be performed using transabdominal, endovaginal, transperineal and/or translabial, and transrectal techniques. Recently, catheter-based endourethral imaging has been added to the list of possible techniques. US can provide precise measurements of the size of the lesion, the number of loculations, and the orientation and location with respect to the urethra. In some cases, US can be used to visualize the connection between the diverticulum and urethra. Also, US can be used to help differentiate solid from cystic suburethral masses, identify stones within diverticula, and visualize intraluminal masses. The relative noninvasiveness and low cost of this imaging method are potential advantages.
  • The best route for examining potential diverticula has not been established. Transabdominal US generally is agreed to be suboptimal, especially with small (<2 cm) lesions. Transvaginal US has been useful for some, but not all, investigators. Direct compression of the urethra and diverticulum may be a problem. The transrectal approach has many strong advocates. Improved visualization of the periurethral area has been cited as one substantial advantage. Transperineal or translabial US is performed by placing the imaging probe between the labia minora and directly on the external urethral meatus. This may be the route of choice with distal diverticula, although the transrectal approach actually may allow probe placement closer to the lesion in cases of proximal urethral diverticula.
  • In small case series, US appears to compare favorably with more traditional imaging techniques such as positive-pressure urethrography and VCUG. In an early series, 5 of 5 diverticula originally visualized with urethrography techniques could be visualized by endovaginal or transperineal US. More recently, in a series of 19 women, use of both VCUG and US allowed identification of 13 of 15 patients with urethral diverticula. In addition, US was used to identify 2 Skene gland cysts, a periurethral leiomyomata, and a case of diffuse urethritis. In this study, transvaginal and transperineal scanning was used. Also, a catheter-based endourethral probe was employed in some cases. Importantly, with US, the neck of the diverticulum was identified in 13 of the 15 cases, and it was identified using VCUG in only 2 instances.
  • Techniques have been described to enhance US visualization of urethral diverticula. Imaging can be performed before, during, and after voiding. Filling and expansion of the sac can be observed in this way. Also, US can be performed after injecting the sac with fluid, with or without contrast material. Color Doppler US of urethral diverticula recently has been reported. Identification of abnormal blood vessels and blood flow patterns may increase the preoperative index of suspicion for malignancy. Also, identification of diverticular ostia may be enhanced during retrograde urethral filling using color Doppler techniques.
  • US appears to be a promising diagnostic modality in cases of suspected urethral diverticulum. It also may be useful in better defining diverticular and peridiverticular anatomy prior to surgery. Some investigators argue that US should be the initial imaging method of choice. More research is needed to define the role of US in diagnosis and treatment of urethral diverticulum precisely.
• Magnetic resonance imaging
• • MRI is an excellent method of securing a diagnosis when traditional workup of an anterior vaginal wall mass has yielded inconclusive results. In many of these instances, no ostia are evident on urethroscopy and findings on both VCUG and positive-pressure urethrography are negative. In these cases, consider other types of vaginal wall cysts or masses in addition to the diagnosis of urethral diverticulum. Multiplanar imaging capabilities and superb tissue contrast are properties of MRI that can aid in differentiating soft tissue masses from cysts. T1-weighted images may demonstrate urethral diverticula, but they are represented only as a urethral enlargement with a homogeneous, low signal density. Administration of gadolinium-based contrast material enhances the urethral tissues and allows better definition of the internal architecture of the lesion. T2-weighted images may be more effective when detecting urethral diverticula because the lumen appears hyperdense and the wall projects a low signal density.

    Occasionally, diverticular ostia are discernible, but not reliably so. Other anterior vaginal wall masses, such as leiomyomata, endometriomas, and urethral tumors, can display characteristic MRI appearances as well.

  • In one small study of 13 patients, findings on double balloon urethrography were compared to findings on MRI using a high-resolution fast spin echo technique as a primary diagnostic modality for suspected urethral diverticulum. Of the 4 surgically confirmed diverticula, all were detected using the MRI technique, whereas only 1 was observed on double balloon urethrography. The authors state that the major disadvantage of the MRI is cost. Technical difficulties and patient pain are cited as drawbacks to double balloon studies.
  • A case series of 3 symptomatic women with small diverticula (1-5 mm) detected using MRI was published recently. In this series, no apparent communication with the urethra could be found on urethroscopy or urethrography. All lesions responded to surgery, and specimens revealed transitional cell–lined cysts. The authors surmised that perhaps they had made the diagnosis early in the disease process and prior to rupture of the retention cysts back into the urethra.
  • Much larger comparative studies are needed to define the role of MRI in the primary workup of suspected urethral diverticula. For now, MRI is best reserved for research situations and confusing cases that cannot be resolved by other means.
• Intravenous pyelography (IVP) can be useful in cases in which a urethral diverticulum must be differentiated from an ectopic ureter with ureterocele. If the findings on IVP are negative for an ectopic ureter, postvoiding images may reveal a urethral diverticulum if present.

Other Tests

• Urethral pressure profilometry
• • A characteristic double camel hump configuration can be observed in approximately 30-100% of cases of urethral diverticulum (see Image 3). This finding is due to a fall in intraurethral pressure, which is recorded as the transducer passes through the location within the urethra that contains the diverticular ostium. This sign may not be present if the ostium is occluded and is less likely if the transducer is oriented away from the ostium. Occasionally, unsuspected diverticula are discovered due to this finding. Also, urethral pressure profilometry (UPP) findings can aid in mapping the anatomical location of the ostium along the anatomic and functional length of the urethra.

    In particular, UPP tracings can be useful in determining whether the intraurethral opening into the diverticulum is distal to the peak in urethral closure pressure and thus distal to the bulk of the urethral rhabdosphincter. In such cases, the patient may be a candidate for simple marsupialization of the diverticulum.

  • One study demonstrated similar findings between this technique and urethroscopy in determining which third of the urethra contained the ostium. However, the authors reported that this technique cannot be used to determine the precise location of the ostium along the urethra. They argue that at least part of the pressure depression observed on UPP was due to the larger muscular defect in the urethral wall that accompanies the smaller mucosal defect represented by the ostium. Also, they found that 2 of 3 patients that ultimately were proven not to have urethral diverticula had suspicious pressure depressions. They concluded that UPP is not useful in the diagnosis of urethral diverticula because of an unacceptably high false-positive rate and a relatively low specificity (80%) for the disorder. They also argue that the UPP has no benefit over urethroscopy as an aid to surgical planning.
• Other urodynamic studies: The presence of stress or urge incontinence symptoms or voiding dysfunction should prompt performance of additional urodynamic tests. Such tests include cystometry, leak point pressures, uroflowmetry, and stress testing. Individualize tests to each case.

Diagnostic Procedures

• Urethroscopy
• • Urethroscopy can be useful in diagnosing a suspected diverticulum; on occasion, its use may reveal the presence of an unsuspected lesion. Characteristically, a defect in the urethra, ie, the diverticular ostia, is observed (see Image 4). Most commonly, the ostia are located in the posterior or posterolateral wall of the urethra. Simultaneous massage of the posterior urethra sometimes results in expulsion of purulent material into the urethral lumen, thereby enhancing localization of the ostia. In addition, positive-pressure urethroscopy can enhance visualization by causing the ostia to balloon open. This technique is performed by occluding the urethra proximal to the urethroscope while filling the urethra with sodium chloride solution or carbon dioxide gas. The instrument is withdrawn slowly while carefully checking the urethra for defects.
  • In addition to diagnosing urethral diverticula, urethroscopy can be important in further characterizing known lesions. For example, the location, size, and number of ostia sometimes can be ascertained on urethroscopy. A technique of grasping the shaft of the urethroscope outside the external meatus at the point where the ostium is just visualized during withdrawal of the instrument has been used to estimate the distance from the meatus to the ostium. However, in some instances, diverticular ostia may not be appreciated on urethroscopy. The ostia may be too small or, if early in the natural history of the disorder, may have yet to develop. Also, visualization may be obscured by inflammatory debris or blood.
• Milking of the urethra
• • This simple maneuver is performed on physical examination and requires no special equipment. The urethra is massaged, or milked, with the examiner's gloved index finger beginning at the bladder neck and proceeding from proximal to distal. Simultaneously, the urethral meatus is examined visually for expulsion of purulent material or cloudy urine.
  • In one small series of 15 cases of proven urethral diverticula, this maneuver produced positive results in 80% of patients.
• Urethral or diverticular biopsy
• • Strongly consider obtaining a biopsy of a urethral diverticulum prior to excision procedures if an associated solid component that is not a stone can be identified.
  • If the diverticular ostium is wide, visualizing an intraluminal mass urethroscopically and obtaining a biopsy with flexible forceps sometimes is possible. Transvaginal biopsy is another option.
  • If a diverticulectomy specimen reveals cancer, performing urethroscopy with biopsies is recommended prior to planning subsequent therapy. At times, bladder or vaginal biopsies may be indicated also.

Histologic Findings

Histologic findings in excised urethral diverticula may be fairly nonspecific. Usually, varying degrees of inflammatory infiltration of the deeper tissue layers, such as the urethral submucosa and muscularis, are present. The epithelial lining, when identifiable, most often is transitional but may be focally cuboidal. Columnar and squamous epithelium also has been reported. Some authorities believe that the type of epithelium found in the paraurethral ducts should reflect the type of epithelium found in the adjacent urethral segment. Using this conceptual framework, squamous epithelium should be more common in distal urethral diverticula and transitional epithelium should be more common in proximal lesions. In the author's experience, this idea has never been tested formally in pathologic specimens from urethral diverticula. Due to destruction by acute and chronic inflammation, lack of identifiable epithelial lining on pathology specimens from urethral diverticula is not uncommon.

About one third of nephrogenic adenomas found in the female urethra are located within a urethral diverticulum. Microscopic examination reveals the typical tubular, cystic, and papillary patterns. These are believed to be metaplastic changes due to chronic infection and inflammation. At times, differentiating nephrogenic adenoma from clear cell adenocarcinoma may be difficult when found within a diverticulum.

A single case of Wegener granulomatosis diagnosed, in part, by the histologic findings in a urethral diverticulum has been reported. In this case, microscopic examination of the excised lesion revealed geographic necrosis with neutrophilic debris and vasculitis. Urethral diverticula with histologic findings consistent with endometriosis and colonic epithelium have been described as well.

TREATMENT

Section 7 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Medical therapy

Urethral diverticulum is, for all intensive purposes, a surgical disorder. Treatment of recurrent UTIs with appropriate antibiotic therapy can be utilized preoperatively as a temporizing measure or in patients who are unable or unwilling to undergo surgery. Urethral dilation sometimes can be used in this capacity as well. Antibiotic therapy and urethral dilation, however, does not result in cure of the problem.

Expectant management is appropriate for small, asymptomatic diverticula. In several surgical series of patients with urethral diverticulum, small numbers of minimally symptomatic patients have declined surgical management. Unfortunately, the ongoing management and progress of these patients has not been well documented.

Finally, ultrasonic lithotripsy has been used in a few cases to break up large stones within diverticula, followed by urethroscopic extraction of the fragments. Definitive surgical treatment of the diverticula was accomplished several months later.

Surgical therapy

Surgery is the mainstay of therapy for urethral diverticulum. The choice of surgical procedure depends largely on the location of the diverticulum along the urethra. Simple marsupialization may be appropriate for diverticula with ostia emptying into the distal one third of the urethra, although not all authorities advocate this approach. If the ostium of the diverticulum lies distal to the urethral rhabdosphincter, then incision into the posterior urethral wall to achieve exteriorization of the diverticular sac is thought to have no adverse effect on continence.

Diverticula involving the middle or proximal one third of the urethra are treated most effectively with either total excision or partial ablation. Each procedure has advocates; however, partial ablation generally is considered simpler and less likely to result in urethrovaginal fistula. This especially may be true if significant peridiverticular inflammation is present, if the sac is adherent to the posterior urethra, or if tissue planes are obscured. A third, more conservative approach has been described for use under these adverse surgical conditions. This technique involves a small transvaginal incision into the sac of the diverticulum followed by copious irrigation with an antiseptic solution and packing of the diverticular lumen with Oxycel. The resultant extensive fibrosis is thought to close the diverticulum from within.

With either total excision or partial ablation, the diverticulum is approached surgically through a vaginal incision. Transverse or midline vertical vaginal incisions both have been used with good results. Some surgeons have advocated an inverted horseshoe-shaped incision, with the line of the incision away from the anticipated underlying suture lines that will close the urethra and periurethral connective tissue. Avoiding superimposed suture lines is thought to lower the incidence of postoperative fistula formation; however, this concept never has been proven. Probably more important than the choice of vaginal incision are the basic principles of tension-free meticulous layered closure and good hemostasis. Finally, a semilunar submeatal incision has been described. With this technique, the diverticular neck and sac are approached by way of dissection beneath and parallel to the urethra. Experience with this incision is limited, but reported results have been favorable.

Optimal surgical treatment of patients with diverticula associated with malignancy has yet to be determined. In patients with the diagnosis made prior to surgery, treatment can be wide local excision (urethrectomy) followed by local radiation. Anterior exenteration is reserved for local recurrences. Some patients have been treated primarily with anterior exenteration and diversion. Cure rates at 0.5-2 years of follow-up have been high (87%) but at the cost of high morbidity. If the diagnosis is made after diverticulectomy, postoperative radiation therapy is an option versus anterior exenteration and urinary diversion.

Difficulties with surgical excision can arise in a variety of circumstances. Surgical planes can be obliterated by the sequelae of chronic and acute infection. Bleeding may obscure visualization. Rupture of the diverticular sac or inability to keep the sac distended can be a significant impediment to complete dissection and excision. Friability of the diverticular wall may impair dissection further. Unexpected intraoperative findings, such as multiple or complex diverticula, can prolong and complicate any procedure. The surgeon must be patient, meticulous, and resourceful in order to achieve the best possible outcomes.

Preoperative details

Preoperative planning for surgical correction of urethral diverticula revolves around meticulous characterization of the lesions themselves. Knowledge of the size, location, adjacent anatomy, and other pertinent characteristics are important factors in choosing and executing a successful procedure. In 1993, Leach et al devised a classification system, in part, to aid surgeons in preoperative planning. The system was derived from their experience with evaluation and surgical treatment of 61 patients over 10 years. A secondary purpose of the classification system was to provide a standard means of describing urethral diverticula for the purpose of comparative research. Known as L/N/S/C3, the classification system is as follows:

• L refers to location (distal, mid, or proximal urethra, with or without extension beneath the bladder neck).
• N refers to number of diverticula (single or multiple).
• S refers to size in centimeters.
• C3 refers to configuration (C1 is single, multiloculated, or saddle shaped), communication (C2 is site of communication with the urethral lumen described as distal, mid, or proximal), and continence (C3 is the presence or absence of genuine stress incontinence).

The location of diverticula along the urethra can be ascertained on physical examination in conjunction with imaging studies, such as VCUG or positive-pressure urethrography. The number, size, and configuration usually can be determined via radiographic techniques. Recently, newer modalities, such as US and MRI, have been used. Communication with the urethra often can be determined on urethroscopy. Positive-pressure urethroscopy by way of digital occlusion at the level of the bladder neck can help dilate ostia that are difficult to locate. Additionally, transvaginal injection of dye into the diverticulum can help identify the site of communication with the urethra during urethroscopy.

In patients who report urinary incontinence, urodynamics are indicated prior to surgery. Identifying patients with genuine stress incontinence due to urethral hypermobility is especially important. Genuine stress incontinence can be difficult to differentiate from paradoxical incontinence due to stress-induced emptying of the diverticulum. If genuine stress incontinence is diagnosed, surgical repair of the diverticulum can be combined with a procedure to limit bladder neck mobility. Reports of successfully combining diverticulum excision and needle urethropexy or suburethral sling procedures can be found in the literature. Urethral pressure profilometry may be helpful in identifying the location of the diverticular ostium along the functional length of the urethra.

Finally, in order to ensure the highest possible chance of safe, successful surgery, the surgical field should be free of acute infection. Treat UTIs on the basis of culture and sensitivities. In cases of abscess formation, initiate broad-spectrum antibiotic coverage, and, in most instances, perform a drainage procedure of some kind. Postpone definitive surgery until after the infection is cleared. Marsupialization procedures may be the only exception to this rule because drainage and definitive treatment are accomplished simultaneously.

A realistic preoperative discussion between surgeon and patient should take place. In addition to discussing the usual risks and complications of surgery in general, mention the following procedure-specific complications:

• Recurrent or persistent diverticula
• Urethrovaginal fistula (especially with complete diverticulectomy)
• Postoperative stress incontinence
• Urethral pain syndrome

Intraoperative details

Simple marsupialization (the Spence procedure)

Spence and Duckett first described surgical treatment of female urethral diverticula by marsupialization in 1970. Their intent was to devise a simple procedure with less morbidity and fewer complications than diverticulectomy. They reported on 9 cases, achieving a 100% success rate. In 1975, Lichtman and Robertson subsequently reported on 8 additional cases. They, too, experienced a 100% cure rate at 6-12 months of follow-up, with no new cases of urinary incontinence. They did not treat any cases of urethral diverticula with ostia at or near the bladder neck. They recommended marsupialization only for patients with diverticular ostia in the middle or distal one third of the urethra. Since that report, others have recommended using this procedure only for diverticula limited to the distal one third of the urethra due to concern over damaging the striated urethral sphincter complex.

The Spence procedure is carried out with the patient in the dorsal lithotomy position. The bladder is emptied with a catheter, and the vagina and vulva are prepared for surgery. A straight Mayo scissors is used for the initial incision. One blade is placed in the urethra and the second blade rests along the anterior vagina beneath the posterior wall of the urethra in the midline. The initial incision is made with the intent of entering the diverticular sac. The length of the incision is individualized in order to achieve this goal. Once entry into the sac is accomplished, the remainder of the diverticular sac can be opened by extending the original incision using Mayo scissors or a scalpel. Next, the urethral and diverticular epithelium is sewn to the edges of the incised vaginal epithelium using a continuous running stitch of 3 or 4 absorbable suture.

The urinary tract epithelium is exteriorized by what has been called a large posterior meatotomy. No catheter is placed postoperatively, and the patient is encouraged to resume spontaneous voiding as soon as she recovers from anesthesia. Most patients can be discharged in 24 hours or less.

Partial ablation or partial diverticulectomy

Partial ablation, as described by Leon Tancer, MD, involves a midline vertical incision of the vaginal mucosa over the diverticulum. The peridiverticular connective tissue over the diverticulum itself is exposed (see Image 5). Next, the periurethral connective tissue over the sac is incised and mobilized as flaps. This tissue is widely mobilized on all sides of the diverticulum. The diverticular sac then is dissected free and entered (see Image 6). The body of the sac is excised.

A small metallic probe can be used to locate the ostia. A cuff of tissue is left around the probe as the bulk of the diverticular epithelium is excised (see Image 7). No attempt is made to excise the diverticulum flush with the urethra or to dissect close to the junction with the urethra. Tissue is closed over theneckinseveral layers if possible. The periurethral connective tissue flaps are closed in an overlapping, vest-over-pants fashion (see Image 8). Finally, the mucosa is reapproximated (see Image 9). Fine absorbable suture is used throughout. An indwelling urinary catheter, either urethral or suprapubic, is left in place for 5-7 days.

Urethral diverticulectomy

Urethral diverticulectomy is a more extensive procedure in terms of the dissection of the diverticular sac. Some surgeons inflate the diverticulum using a double balloon catheter in order to facilitate identification and dissection and to avoid entry in the sac. The vaginal incision is made. Surgeons advocate longitudinal, transverse, and inverted U-shaped incisions. Periurethral connective tissue is incised and mobilized into flaps completely around the diverticulum.

Next, the diverticulum itself is completely dissected, including the neck, but it is not entered if possible. The sac is excised flush with the urethra. The urethra is closed longitudinally over a catheter with fine absorbable suture. Some surgeons recommend transverse closure of the urethra in order to minimize the chance of urethral stricture. The validity of this recommendation has never been tested. Next, the connective tissue flaps are closed in overlapping fashion to avoid superimposed suture lines. A vest-over-pants closure often is used.

The vaginal mucosa is sutured to complete the procedure.

Transurethral techniques

Transurethral surgical therapy for urethral diverticula has been reported sporadically in the literature since 1970, largely in the form of case reports and small case series. In 1970, Davis and Robinson described a technique of transurethral resection of the roof of the diverticulum with fulguration of the lining of the sac. In 1979, Lapides reported on a simplified urethroscopically guided transurethral procedure in which the diverticular ostium was enlarged via a linear incision using a specially designed knife electrode. No tissue was removed with this technique, and the epithelial lining of the diverticulum was not excised or fulgurated. More recently, a similar technique was developed in which an incision to widen the ostia was performed using a cold-knife urethrotome urethroscopically. Finally, a nonendoscopic method of widening of the ostia with small vascular scissors under direct visualization has been described.

This procedure, which seems most applicable to distal diverticula, relies on direct visualization of the ostia with the aid of expression of pus, insertion of small metallic probes, and, if needed, a small posterior meatotomy.

Transurethral procedures appear to work by decompression of the diverticulum and drainage of purulent material. Decompression also may improve local blood flow and, as a result, improve local defenses against infection. After such procedures, urine flows freely across the floor of the diverticulum due to the enlarged opening. Symptomatic relief is nearly immediate, and complications have been few. The possible advantages of transurethral procedures may include the following:

• Low morbidity and complication rates
• Shorter operation
• Shorter hospital stay
• Technical ease
• Adaptability of the technique to different locations along the urethra and multiple diverticula

Despite these proposed advantages and the excellent record reported in the few available studies, widespread acceptance of this approach is lacking. Continued research and experience with these techniques will help define their role in the armamentarium of the genitourinary tract surgeon.

Adjunctive procedures and techniques

Excision or partial ablation of urethral diverticula can be challenging surgical endeavors. Difficult surgical conditions can lead to suboptimal results and excessive complications. Incomplete dissection of complicated or inflamed diverticula can lead to incomplete excision of the epithelium-lined sac, resulting in recurrence. Thin and poorly vascularized tissue at the repair site can predispose to development of urethrovaginal fistula. Several ingenious techniques have been devised in order to minimize these problems.

Intraoperative distention of the diverticulum can enhance surgical dissection. The double balloon catheter can be used intraoperatively for this purpose. Injection of dye, coagulum, or other materials transvaginally into the diverticulum has been described as well. Finally, traction on a Foley catheter with a balloon located at the bladder neck can be used to close the ostium of a proximally located diverticulum. This maneuver can enhance the ability to distend the diverticula with injected materials by preventing leakage through the ostia.

Use of intraoperative endoluminal US as an aid to surgical dissection was reported on in a series of 8 patients with urethral diverticula. Catheter-based transducers of 6.2F or 9F at 12.5 or 20 MHz, respectively, were utilized. Potential intraoperative information gained from this technique includes improved identification of the size, configuration, and orientation of the diverticulum. Also, an estimate of the degree of peridiverticular inflammation, thickness of the sac wall, and intraluminal distances can be obtained. The role of this imaging modality in the intraoperative management of urethral diverticula has yet to be determined; however, it may be of some benefit in difficult cases.

Transurethral catheterization of diverticular ostia with a fine pigtail catheter over a guide wire has been described. The catheter, in this case report, was used to irrigate and drain an acutely infected complex diverticulum with a poorly draining loculation. After a series of treatments and resolution of the acute infection, the catheter was left in place as a dissection guide during surgical excision of this multiloculated lesion. The same group also reported the use of a small pediatric Foley catheter to guide dissection after inadvertent intraoperative rupture of a thin-walled diverticulum. The catheter was introduced through the defect in the diverticular wall after cutting off the tip. The balloon then was inflated in order to distend the collapsed cavity.

A bulbocavernosus fat pad interposition, the Martius operation, can be used to enhance blood supply, increase tissue thickness, and buffer dead space following excision procedures. The technique involves making a full-length incision over the labia majus longitudinally. The fat pad is gathered up in a series of Babcock clamps and isolated by sharp dissection. The superior pole of the fat pad is freed after the anterior branches of the internal pudendal artery are suture ligated. The suture around the freed superior end of the graft is left long.

A tunnel is created connecting the vulvar and suburethral vaginal incisions using a clamp. The graft pedicle is pulled through the tunnel by grasping the long suture end at the superior pole. The fat pad then is fixed by suture to the area overlying the repaired urethra. The vagina is closed over the graft. The donor site is closed with deep stitches to eliminate dead space and gain hemostasis. The vulvar skin is closed with simple interrupted sutures or a running subcuticular stitch.

Recently, posterior pole disarticulation and mobilization of the graft has been used in cases where anterior vaginal tissue support is needed. In this manner, the graft can be sutured in place under less tension. The chance of vascular compromise to the graft may be less significant with this approach. Another method of increasing tissue vascularity and thickness is through the use of a bipedicled vaginal flap. A transverse vaginal incision is used to perform the diverticulectomy. The flap is created and then fixed to the repair site. The flap is buried beneath the transverse vaginal closure. In a small case series, no cases of vaginal retention cysts were reported.

Postoperative details

Postoperative care of patients surgically treated for urethral diverticula may differ from case to case depending on the specifics of the procedure(s) performed. Generally, vaginal packing is avoided or limited to one day. Stool softeners may be prescribed in order to avoid straining.

With simple marsupialization procedures, urinary catheterization usually is not needed, and most patients resume voiding promptly. Tancer recommends urinary drainage for 5-7 days by either the transurethral or suprapubic route following partial ablation. Similarly, many surgeons drain the bladder for 5-7 days following diverticulectomy; however, some authors have recommended drainage for as long as 5 weeks via a transurethral catheter. No definitive reports exist in the literature to guide catheter management. One author suggested that longer periods of drainage should be considered if more than one diverticulum was excised or the diverticulum was located at the bladder neck. Also, concomitant surgery for stress incontinence may affect catheter management decisions.

Most patients with uncomplicated repairs are ready for discharge in 24-48 hours. Patients with more complicated surgeries or who require additional procedures may have more prolonged hospital stays.

Follow-up

Short-term postoperative follow-up revolves around close surveillance for complications, such as infection, hematoma, urethrovaginal fistula formation, stress incontinence, urethral stricture, and urethral pain syndromes. Submit excised tissue for pathologic examination. Unexpected early carcinomas have been diagnosed solely on the basis of examination of the pathologic specimen.

Long-term follow-up of patients surgically treated for urethral diverticulum involves surveillance for recurrence. Recurrences, even several years after surgery, have been reported.

For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see eMedicine's patient education article Bladder Control Problems.

COMPLICATIONS

Section 8 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The types of complications observed following surgery for urethral diverticulum are partly related to the type of lesion treated and the particular operation utilized. For example, postoperative stress incontinence appears to be more common after surgery for proximal and bladder neck diverticula. Urethrovaginal fistula occurs more commonly after complete diverticulectomy than after partial ablation. Overall complication rates for surgical treatment of urethral diverticula have been reported to range from 5-46%. Common complications reported following surgery for urethral diverticulum include the following:

• Recurrence or persistence of diverticula
• Urethrovaginal fistula
• Vesicovaginal fistula
• Urethral stricture
• Urethral pain syndrome
• New-onset or persistent stress incontinence
• Missed carcinoma
• UTI
• Hemorrhage or hematoma formation

In one series of 70 patients undergoing mostly diverticulectomy from 1955-1979, the cases were divided into 3 groups based on the location of the lesion along the urethra. With diverticula of the proximal one third of the urethra, the main complication was recurrence (33%), indicating difficulty with complete sac excision. Mid urethral diverticula excision resulted in fistula formation in 4 of 26 cases (15.4%). Recurrence was observed in 31% and stricture in 3.8% of cases. Distal urethral diverticula had the lowest postoperative complication rates, with no fistulas and 2 out of 17 cases recurring 1-6 years after surgery.

One hundred and eight patients at the Mayo Clinic were treated over 15 years with complete diverticulectomy. Low complication rates in this series can be attributed to meticulous surgical technique. Reported complications included urethrovaginal fistula (0.9%), urethral pain syndrome (1.8%), recurrent UTIs (0.9%), immediate postoperative urinary incontinence (1.8%), delayed (>2 y) urinary incontinence (13%), recurrent diverticulum in less than 1 year (3.7%), and recurrent diverticulum after longer than 1 year (5.6%). Of note, the author found that most recurrences were at the same location as the original diverticulum. This finding suggests that most recurrences are the result of incomplete excision of the sac or remaining local weakness in the urethral wall rather than the formation of entirely new lesions.

In 1994, in series of 63 patients over 10 years, complication rates for complete diverticulectomy were less than those previously reported. Urethrovaginal fistulas and recurrences were observed in 1.6% and 3.2% of the cases, respectively. No cases of vesicovaginal fistula were reported. UTIs occurred postoperatively in 9.5% of cases. Twenty-two percent of women who had genuine stress incontinence and urethral diverticulum had persistent stress incontinence despite treatment with bladder neck suspension at the same surgery. The degree of incontinence was reported as requiring less than 2 pads per day. About 10% of patients undergoing diverticulectomy alone developed mild de novo stress incontinence in this series.

Tancer et al (1983) reported no cases of recurrence, fistula formation, or stress incontinence in their series of 34 patients treated with partial ablation. Follow-up was from 4 months to 10 years. This group attributed most of the serious complications from excision procedures to overzealous attempts to completely remove the diverticular sac and neck.

Marsupialization procedures, if limited to treatment of distal diverticula only, should have low complication rates. In a review of 17 cases treated in this manner, no cases of fistula formation, recurrence, stricture, or recurrent UTIs occurred. One case of mild, new-onset stress incontinence was noted.

OUTCOME AND PROGNOSIS

Section 9 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Surgical outcomes with regard to urethral diverticula generally have been good; however, surgical outcomes have been reported in an inconsistent manner in the literature. Several issues create the inconsistency. First, outcome can be considered in terms of resolution of individual symptoms or in terms of recurrence of the diverticulum itself. Additionally, that recurrences can be found years after primary excision is well documented. Some recurrences may have not yet occurred at the time of case series publication. Whether or not these recurrences are due to incomplete initial treatment or the formation of completely new diverticula by reinfection and obstruction of paraurethral glands is uncertain. Finally, publication bias may be a problem. Occasionally, some urethral surgeons may have lower cure rates and might be less likely to publish results.

Given these uncertainties, an overall cure rate of 70% for symptomatic patients was cited in a recent review article. Successful excision by diverticulectomy can be expected in 80-90% of cases as evidenced by recurrence rates of 10-20%.

Marsupialization in properly selected patients has yielded symptomatic cure in essentially 100% of patients; however, published numbers are small. In general, treatment of distal diverticula is highly successful in terms of high cure rates and minimal complications regardless of surgical approach.

Tancer et al (1983) reported symptomatic relief and no recurrences in all of 34 patients treated with partial ablation. Follow-up was from 4 months to 10 years.

FUTURE AND CONTROVERSIES

Section 10 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Future research in the area of urethral diverticulum should help optimize diagnostic strategies and improve therapeutic options. Questions to be answered include the following:

• What should be the first-line imaging study in the diagnostic workup of suspected urethral diverticulum?
• Which imaging modality provides the most valuable anatomic information as a guide to surgical management? Will outcomes be improved with this information?
• Are minimally invasive surgical approaches, such as transurethral unroofing, as effective and less morbid than the traditional vaginal approaches?
• Which adjunctive surgical techniques are of value in maximizing effective treatment and minimizing complications?
• What is the role of expectant management in treating minimally symptomatic diverticula?
• What is the optimal treatment for diverticulum-associated carcinomas?

The main impediment to productive research is low numbers of patients in any given center. Pooling of resources and multicenter research may be the long-term answer to this dilemma.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Media file 1:  A suburethral, anterior vaginal wall mass that proved to be a suburethral diverticulum.
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Media file 2:  A mid-to-proximal urethral diverticulum demonstrated on a positive-pressure urethrogram.
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Media file 3:  A urethral pressure profile in a patient with a urethral diverticulum that displays a mid peak decrease in pressure.
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Media file 4:  Urethral diverticulum. A wide-mouthed ostium with visible stones demonstrated on positive-pressure urethroscopy.
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Media file 5:  Urethral diverticulum. After opening and retraction of the vaginal mucosal flaps, the glistening white peridiverticular connective tissue is apparent.
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Media file 6:  The urethral diverticular sac is grasped with an Allis clamp as dissection nears completion.
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Media file 7:  Clamps hold a peridiverticular connective tissue flap. The forceps point to the neck of the urethral diverticulum.
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Media file 8:  Urethral diverticulum. The peridiverticular connective tissue is sutured closed in an overlapping fashion.
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Media file 9:  Closure of the vaginal epithelium concludes the partial ablation procedure for urethral diverticulum.
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Media file 10:  In the presence of a known urethral diverticulum, this tracing would suggest that the ostium is located just distal to the point of peak urethral pressure. However, the tracing itself is not diagnostic of a urethral diverticulum. Falsely positive findings, such as this small dip in pressure, are not rare. For this reason, urethral pressure tracings are not considered effective diagnostic tests for urethral diverticula.
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Media type:  Illustration

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

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• Bass JS, Leach GE. Surgical treatment of concomitant urethral diverticulum and stress incontinence. Urol Clin North Am. May 1991;18(2):365-73. [Medline].
• Bennett SJ. Urethral diverticula. Eur J Obstet Gynecol Reprod Biol. Apr 2000;89(2):135-9. [Medline].
• Blaivas JG, Flisser AJ, Bleustein CB, Panagopoulos G. Periurethral masses: etiology and diagnosis in a large series of women. Obstet Gynecol. May 2004;103(5 Pt 1):842-7. [Medline].
• Blander DS, Broderick GA, Rovner ES. Images in clinical urology. Magnetic resonance imaging of a "saddle bag" urethral diverticulum. Urology. Apr 1999;53(4):818-9. [Medline].
• Boyd SD, Raz S. Ectopic ureter presenting in midline urethral diverticulum. Urology. Jun 1993;41(6):571-4. [Medline].
• Brandes BM, Mesrobian HG. Giant accessory female phallic urethral diverticulum. Urology. May 2006;67(5):1084.e19-21.
• Catalano S, Jones I. Transitional cell carcinoma in a urethral diverticulum. Aust N Z J Obstet Gynaecol. Feb 1992;32(1):85-6. [Medline].
• Cea PC, Ward JN, Lavengood RW. Mesonephric adenocarcinomas in urethral diverticula. Urology. Jul 1977;10(1):58-61. [Medline].
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