Female Urethral Diverticulum: Current Diagnosis and Management

Abstract

While urethral diverticulum (UD) affects less than 20 per 1,000,000 women overall, it is thought to represent 1.4% of women with incontinence presenting to urology practices. It is hypothesized to evolve from periurethral glands that become obstructed, infected, and dilated over time, and patients typically present with dyspareunia, bothersome lower urinary tract symptoms (LUTS), and/or recurrent UTIs. In many patients, a periurethral mass can be appreciated on exam. In recent years, magnetic resonance imaging (MRI) has become the imaging test of choice for diagnosis of UD, but ultrasound (US) is a readily available alternative and provides good specificity at a lower cost. Surgical excision of the diverticulum with tension-free, water-tight, three-layer closure continues to be the mainstay of treatment of UD with most studies reporting cure rates of >90%. Concomitant treatment of preexisting stress incontinence with autologous fascial pubovaginal sling can be used at the time of diverticulectomy to avoid a secondary procedure. However, since secondary anti-incontinence procedures are needed in only a small number of patients, up-front stress incontinence treatment may result in significant overtreatment, and staged anti-incontinence procedures continue to be a reasonable option for patients with persistent bothersome stress urinary incontinence (SUI) after diverticulectomy.

Translabial ultrasound imaging of urethral diverticula

“…However, good agreement was noticed between major urethral abnormalities on TLUS and the diagnosis of UD on urethroscopy, with a sensitivity of 100% and a specificity of 99.8% for the diagnosis of UD on ultrasound when using urethroscopy as the gold standard. The latter is highly specific for diagnosing UD, nevertheless, it has variable reported sensitivities, as the test is largely operator-dependent, and small diverticular ostia can easily be overlooked 3,5,17 . We believe that a high degree of suspicion following TLUS might increase the sensitivity and accuracy of urethroscopy.…”

Outcomes of treatment of stress urinary incontinence associated with female urethral diverticula: A selective approach

“…Ninety‐six percent of women who underwent concomitant SUI and TVUD reported pre‐operative bothersome SUI compared to 43% of those who underwent TVUD alone ( P < 0.00006) with an average reported pad per day use of 3.18 versus 0.59, respectively. Offering concomitant surgery is not in agreement with several authors . For example, Crescenze et al posit that concomitant SUI treatment may result in significant overtreatment and favor a staged anti‐incontinence procedure.…”

Female Urethral Diverticulum: Diagnosis, Treatment and Outcome

“…As stated by Fortunato et al, a full history and thorough physical examination are the first steps in the patient screening process [7]. In over 80% of patients periurethral masses are present [8]. It should be noted that 2 to 11% of UDs may be totally asymptomatic.…”