INCIDENCE

The true incidence of urethral diverticula is unknown, and the reported incidence varies. The incidence of urethral diverticula was examined in 1967. Andersen showed that of 300 women examined for cervical cancer, 9 patients were diagnosed with urethral diverticula, an incidence of 3%. The estimated incidence in the literature shows that urethral diverticula have been identified in 0.6% to 6% of women.

ETIOLOGY

The female urethra is a short tubular structure that is surrounded by multiple periurethral ducts and glands, the largest being the Skene’s glands; these are adjacent to the distal urethra and drain into the meatus. Congenital anomalies of the female urethra are quite rare. Infrequently, obstructing urethral valves have been identified; more often an ectopic ureter is identified within the urethra, which may masquerade as a urethral diverticular communication site. Boyd and Raz (1993) reported a patient with an ectopic ureter that drained into a urethral diverticulum.

Identifying congenital urethral diverticula is exceptionally rare, although suburethral cysts have been identified in the newborn. Even in those few instances, the urethral diverticula have been shown, ultimately, to be remnants of Gartner’s duct cyst. These diverticula are linked histologically to cloacal rests and even confused as a possible urethral duplication. Nevertheless, the incidence of childhood female urethral diverticula is exceedingly low and, as such, urethral diverticula are rarely diagnosed before age 20.

Female urethral diverticula are diagnosed most frequently in the third to fifth decades. Most diverticula are acquired, and a favored hypothesis regarding the etiology of female urethral diverticula begins in the paraurethral glands. Most diverticula of the female urethra are located dorsally or laterally and distally. Physicians believe that repeated infections and subsequent destruction of the paraurethral glands lead to abscess formation within the periurethral and urethral glands. These obstructed glands then rupture into the urethral lumen and remain as outpouchings off the urethra, which eventually epithelialize, becoming a true urethral diverticulum as opposed to a urethrocele or pseudodiverticulum.

Other possible etiologies of female urethral diverticula include the formation of urethral diverticula resulting from obstetric trauma, trauma from urethral instrumentation, and after urethral and vaginal surgery. Another rare, iatrogenic cause for a urethral diverticulum has been described after collagen injection therapy for treatment of stress urinary incontinence, resulting in a noncommunicating diverticulum, with obstruction of a periurethral gland and persistent accumulation of secretions. A noncommunicating urethral diverticulum results when the communication site from the urethra to the diverticulum closes off and creates a de novo obstruction.

Urethral diverticula are urothelial mucosa-lined sacs that lie outside the urethra within the periurethral fascia and lack surrounding muscle. They are prone to urine stasis and repeated infections. Inflammation and chronic irritation due to the presence of urine and debris may lead to malignant degeneration into adenocarcinoma, transitional cell carcinoma, or squamous cell carcinoma. More commonly, the stasis of urine causes repeated urinary tract infections and possible calculus formation. Recurrent urinary tract infections are a frequent complaint of women with urethral diverticula; positive urine cultures (>100,000 CFU/mL) will often grow strains of Escherichia coli, or other gram-negative bacilli, as well as gram-positive species, such as Streptococcus faecalis.

Prolonged urinary stasis may result in the formation of calculi. Calculi in diverticula are uncommon with stone formation occurring in only 1.5% to 10%. Stones are usually due to salt deposition, stagnant urine, and mucus from the epithelial lining of the diverticula.

The location, number, and extent of urethral diverticula have an impact on the choice of treatment. A classification system for female urethral diverticula—location, number, size, configuration, communication, and continence (LNSC3)—has been described by Leach et al. (1993). Providing an accurate description of the diverticula under evaluation will, in turn, facilitate therapy.

PRESENTATION

Women present to their physicians with a host of symptoms, and, unfortunately, the patient’s description of each complaint is not always textbook clear. Therefore, the task is left up to the physician to identify, evaluate, and treat the pathology. A history of recurrent urinary tract infections, stress urinary incontinence, and incomplete voiding are some of the most common presenting symptoms in women with urethral diverticula (Table 36-1). According to Hoffman and Adams (1965), the single most important complaint is postmicturition-dribbling. The addition of dysuria and dyspareunia complete the classic triad “3 D’s.” These are all nonspecific complaints, however. If the symptoms are also accompanied by urgency, urge incontinence, frequency, and/or even a protruding vaginal mass, they are more highly suggestive of a urethral diverticulum. If pus can be expressed from the meatus with manual compression of the anterior vaginal wall, this strongly indicates the presence of a urethral diverticulum. Romanzi et al. (2000) reviewed their experience with diverse presentations of urethral diverticula and decided that when symptoms mimic other disorders, and especially when they do not improve and respond with standard therapy, entertaining the possibility that the source of the pathology is a urethral diverticulum is important.

Table 36-1 Most Common Initial Complaints in Women Who Present for Evaluation and Are Ultimately Found to Have Urethral Diverticula From 1964 to 2000

Patients who have hematuria, difficulty voiding, and frank urinary retention may have urethral diverticula as the cause of the voiding disorder.

Many patients receive various treatments that include antibiotics, anticholinergic and antidepressant medications, bladder hydrodistention, and urethral dilations for suspected pelvic disorders. Some of the more common presumed diagnoses are listed in Table 36-2. In summary, in any case of persistent lower urinary tract symptoms unresponsive to therapy, one should exclude a urethral diverticulum.

Table 36-2 Initial Diagnoses First Given to Patients and Their Subsequent Treatments Before the Diagnosis of Female Urethral Diverticulum

DIAGNOSIS

To establish the correct diagnosis in women with a myriad of symptoms, performing a thorough history and physical examination is critical. Included in a standard history are questions related to urinary control for stress urinary incontinence, urgency and urge incontinence, and pad usage. Irritative voiding symptoms, such as frequency, nocturia, urgency, dysuria, urinary tract infections, pyelonephritis, and hematuria, should be noted. Obstructive voiding symptoms, such as poor urine stream, difficulty voiding, hesitancy, and double-voiding, should also be noted. A complete obstetric history should be taken, noting the number of pregnancies, live births, and method of delivery. A neurologic history and bowel patterns should be included in the questions. A complete medication list with allergies and past medical and surgical histories are also important.

A focused genitourinary examination is performed with the patient in lithotomy position. A half-speculum is placed into the vagina to expose the anterior vaginal wall. The urethra and bladder are then well visualized, and the patient is asked to perform a Valsalva maneuver and cough to evaluate for urethral hypermobility and stress urinary incontinence, as well as the presence of a cystocele. Careful attention is given to palpation of the urethra, with attempts to express purulent material via the meatus and to evaluate for suburethral masses or tenderness. Postvoid residual volume measurement can be accomplished with an office ultrasound or with a red rubber catheter. The catheterized urine specimen should be sent for urine culture. If the patient had complaints of hematuria and irritative voiding symptoms, a urine cytology should be obtained.

Not all patients will present with a suburethral mass, and not all suburethral masses are urethral diverticula. The differential diagnosis of periurethral or suburethral masses is extensive and include urethral diverticulum, urethrocele, Skene’s gland abscess, Gartner’s duct cyst, ectopic ureterocele, vaginal wall inclusion cyst, and other less frequent diagnoses (Box 36-1). The urethra may be tender, and, on occasion, a large diverticulum is evident as an anterior wall mass that may express pus and debris from the urethral meatus when compressed. Suspicions of a urethral carcinoma or calculi arise if a firm mass is palpated along the vaginal wall.

Urinary incontinence may be seen in patients suspected of having a urethral diverticulum. Examination for urethral hypermobility, stress incontinence, and pelvic organ prolapse are documented during the physical examination. Evidence of stress urinary incontinence may require urodynamic testing to assess the abdominal leak point pressure and to determine a need for a simultaneous sling with the excision of the diverticulum and reconstruction of the urethra.

One must clinically suspect a urethral diverticulum to select the most appropriate procedures and imaging studies. Many patients with urethral diverticula undergo urodynamic testing to evaluate their complaints of voiding dysfunction. Urodynamics provide information on bladder function, during both the storage and voiding phases. Certainly, not all patients will require urodynamic testing; however, it should be used in patients who have had previous pelvic surgery, recurrent stress urinary incontinence after bladder surgery, and urinary retention without any other known reason.

Urethroscopy may help establish the diagnosis of urethral diverticula; it is easily performed, has minimal morbidity, and produces a high yield of the correct diagnosis in experienced hands. Urethroscopy should be focused on the posterior wall in the 3 o’clock and 9 o’clock positions to try to identify the suspected communication sites.

RADIOLOGIC IMAGING

To supplement the pertinent history, thorough physical examination, urodynamic testing, and cystourethroscopy, radiologic imaging has clearly enhanced the detection rate of urethral diverticula. With suspicion of a female urethral diverticulum, the judicious selection of imaging techniques should correctly establish the diagnosis and provide details that aid in surgical excision. Traditionally, the evaluation to confirm the diagnosis of female urethral diverticula was performed with positive-pressure urethrography (PPUG) and voiding cystourethrography (VCUG). However, multiple modalities are currently available to identify and characterize female urethral diverticula: PPUG, VCUG, ultrasonography, and magnetic resonance imaging (MRI). Ongoing controversy continues as to which modality is the most accurate, while considering parameters, such as cost, time, and patient comfort.

Positive-Pressure Urethrography

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