Periurethral and Anterior Vaginal Wall Masses: Etiology, Presentation, and Treatment Outcomes

Abstract

The increasing proportion of elderly Americans has brought about an anticipation of 50% rise in prolapse surgeries by 2050. It is anticipated that 25% to 40% of patients undergoing surgeries will develop de novo stress urinary incontinence (SUI) after prolapse repair. The Outcomes Following Vaginal Prolapse Repair with Midurethral Sling (OPUS) found a 36% reduction in the risk for de novo SUI, but also demonstrated increased risk of bladder perforations, urinary tract infections, and incomplete bladder emptying symptoms (N Engl J Med. 2012;366:2358-2367. As a result, pelvic reconstructive surgeons often vary their approach toward prophylactic MUS at the time of vaginal prolapse repair (VPR). Although a cost-effectiveness analysis found universal MUS placement to be the most cost-effective strategy over both selective and staged strategies (J Urol. 2013;190:1306-1312, this analysis did not include an arm for the less-costly option of using a selective approach via a prolapse-reduced cough stress test (CST). In addition, Richardson analysis of patients undergoing sacral colpopexy lacks generalizability for VPR surgeries (which account for two thirds of all prolapse surgeries). The manuscript described here therefore tested the cost-effectiveness of 3 generalizable MUS utilization strategies for preventing de novo SUI within 1 year post-VPR.Three approaches were compared: (1) staged strategy performing VPR with later MUS placement only for de novo SUI;(2) universal sling placement at the time of VPR; and (3) selective sling placement with MUS at the time of VPR when occult SUI was observed at the time of preoperative prolapse-reduced CST. A representative population of women with symptomatic pelvic organ prolapse (at least stage II) was modeled. Included in the VPR model was colpocleisis, apical suspension, or anterior colporrhaphy, with or without hysterectomy. The base assumption was that all VPRs were uncomplicated and anatomically successful. Subsequent treatment pathways were formed based on the 3 aforementioned options if de novo SUI was to occur.A 2017 systematic review by van der Ploeg was used for obtaining literature to gain point estimates concerning the risk for postoperative SUI (Int Urogynecol J. 2016;27:1029-1038). The search was performed via PubMed through January 2017, and exclusionary criteria were as follows: studies examining urodynamics preoperatively, abdominal prolapse repairs, duplicate studies, and studies lacking clear definitions for VPR, MUS, or SUI. Using data from 3 previous studies, for a selective MUS, the authors estimated the rate of de novo SUI after VPR with a negative preoperative CST to be 33.6%. The authors determined the existence of 4 possible adverse outcomes following MUS: (1) persistent SUI, (2) sling lysis required for voiding dysfunction, (3) mesh exposure requiring excision, and (4) anticholinergic medications required for de novo overactive bladder. Information on costs was gathered Physician Fee Schedules from the 2020 Centers for Medicare and Medicaid Services. Incr...

Evaluation and management of urethral and periurethral masses in women

“…Urethral and periurethral masses are first identified using patient history and physical examination. The most common presenting symptom is that of a palpable mass, but half of women may also present with dyspareunia and/or vaginal discharge [1 ▪▪ ]. Urinary symptoms such as frequency and urgency, dysuria, or stress urinary incontinence may occur in 15–40.5% of patients [1 ▪▪ ,4].…”

“…The most common presenting symptom is that of a palpable mass, but half of women may also present with dyspareunia and/or vaginal discharge [1 ▪▪ ]. Urinary symptoms such as frequency and urgency, dysuria, or stress urinary incontinence may occur in 15–40.5% of patients [1 ▪▪ ,4]. Similarly, 11.1–36.7% of women may present with pelvic or urethral pain, especially in the setting of an infection [1 ▪▪ ,5].…”

“…Urinary symptoms such as frequency and urgency, dysuria, or stress urinary incontinence may occur in 15–40.5% of patients [1 ▪▪ ,4]. Similarly, 11.1–36.7% of women may present with pelvic or urethral pain, especially in the setting of an infection [1 ▪▪ ,5]. Women presenting with pain are more likely to require surgical management [6].…”

“…These masses can become infected and evolve into abscesses. In general, imaging is not required in patients who present with a periurethral cystic mass, but is recommended to be performed if there is any concern for potential urethral diverticulum [1 ▪▪ ]. We will discuss in more detail the two most common periurethral masses: Skene's gland and Gartner's duct cysts.…”

“…1). In a case series of 126 women, the most common etiologies of periurethral masses were urethral diverticula (39.7%) and Skene's gland cysts or abscesses (30.2%), followed by Gartner cysts (7.1%), Mullerian cysts (4.0%), and epidermal inclusion cysts and abscesses (3.2%) [1 ▪▪ ]. The most common lesion of the female urethra is a urethral caruncle, which is typically found in postmenopausal women.…”