You are in: eMedicine Specialties > Urology > Common Problems of the Urethra Urethral DiverticulaArticle Last Updated: May 25, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Sandip P Vasavada, MD, Co-Head, Section of Female Urology, Joint Appointment, Urological Institute and Department of Gynecology, Co-Director, Center for Pelvic Neuromodulation, Cleveland Clinic Foundation Sandip P Vasavada is a member of the following medical societies: American Urogynecologic Society, American Urological Association, and International Continence Society Coauthor(s): Raymond Rackley, MD, Professor of Surgery, Cleveland Clinic Lerner College of Medicine at CWRU; Co-Section Head, Section of Voiding Dysfunction and Female Urology, Glickman Urological Institute, Cleveland Clinic Foundation Editors: Allen Donald Seftel, MD, Department of Urology, Associate Professor, Case Western Reserve University; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Mark Jeffrey Noble, MD, Consulting Staff, Urologic Institute, Cleveland Clinic Foundation; J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center; Stephen W Leslie, MD, FACS, Founder and Medical Director of the Lorain Kidney Stone Research Center, Clinical Assistant Professor, Department of Urology, Medical College of Ohio Author and Editor Disclosure Synonyms and related keywords: incontinence, urinary incontinence, stress incontinence, urge incontinence, overflow incontinence, mixed incontinence, reflex incontinence, urethral diverticulum, diverticulum, pelvic pain, dyspareunia, urethral discharge INTRODUCTIONSection 2 of 11
  Female urethral diverticulum is a localized outpouching of the urethra into the anterior vaginal wall. Most often present in the mid or distal urethra, it results from enlargement of obstructed periurethral glands. Although urethral diverticulum is often difficult to diagnose, it has been identified with increasing frequency over the past several decades because of increased physician awareness of the condition. The most common associated symptoms are urinary frequency, urgency, and dysuria. Occasionally, urethral carcinoma and calculi may be present. Surgical excision is the treatment of choice. With appropriate surgical management, cure rates are high, and recurrences are rare. History of the ProcedureHey described the first female urethral diverticulum in 1805. Since this initial report, urethral diverticulum has been diagnosed with increasing frequency. Despite the increased awareness in recent years, this entity continues to be overlooked during routine evaluation of women with voiding problems. Accurate diagnosis and treatment require a high index of suspicion and appropriate radiologic and endoscopic evaluations. ProblemUrethral diverticulum is defined as a localized outpouching of the urethra into the anterior vaginal wall. FrequencyIncidence of female urethral diverticulum ranges from 1.4-5% but may be higher. True incidence is unknown because many urethral diverticula are clinically asymptomatic. Urethral diverticula occur most commonly in people aged 30-60 years. The mean age at diagnosis is 45 years. Occurrence in children is rare. Although reports exist of racial predilection toward black women, this remains controversial. EtiologySeveral theories have been proposed to explain the etiology of female urethral diverticulum. Congenital urethral diverticula are rare. Evidence supporting the congenital origin theory is the presence of children with urethral diverticula. Congenital urethral diverticula have been postulated to arise from the following:
Most authors suggest that most urethral diverticula are acquired. Potential theorized causes of acquired urethral diverticula include vaginal birth trauma, urethroscopy, urethrotomy, and various open surgical procedures. However, these theories have largely been abandoned. The most widely accepted theory implicates repeated infections of the periurethral glands with subsequent obstruction eventually evolving into urethral diverticula. PathophysiologyTubuloalveolar mucous glands, known as periurethral glands, line the urethral wall. They are located posterolaterally in the mid and distal third of the urethra. The majority of periurethral glands drain into the distal urethra. When periurethral glands become infected, they may become obstructed. Repeated infections lead to increasing obstruction of the gland and result in periurethral gland enlargement into a suburethral cyst or an abscess cavity. Eventually, the cavity ruptures into the urethral lumen, creating a communication between the urethral lumen and the suburethral cyst. Repeated pooling of urine into the suburethral cyst during urination leads to the formation of a urethral diverticulum. Urethral diverticula commonly occur in the distal third of the urethra. Although uncommon, distal urethral diverticula may also originate from an obstructed Skene gland. Rarely, urethral diverticula occur in the anterior urethra or its proximal third. Pathologically, the diverticulum is a urethral evagination consisting of mostly fibrous tissue. Often, an epithelial lining is absent. The chronic inflammation within the diverticulum results in marked fibrosis and adherence of the diverticular wall to the neighboring structures. Surrounding periurethral fascia often remains intact. However, a severely infected urethral diverticulum may result in spontaneous erosion into the vagina. Urethral diverticula vary in size, shape, and communication with the urethra (see Image 1). They may be unilocular or multilocular. Some are spherical, and others are horseshoe shaped. The diverticular opening into the urethral lumen may be very narrow or extremely wide. Although different types of pathogens have been cultured from the diverticulum, the most commonly identified pathogens are Escherichia coli, Chlamydia species, and gonococci. ClinicalHistory Presenting symptoms are classically described as the triad of postvoid dribbling, dysuria, and dyspareunia. However, the symptoms of urethral diverticula are quite variable. Irritative voiding symptoms, such as urinary frequency, urgency, and dysuria, are most common. Recurrent urinary tract infections occur in approximately 40% of patients, whereas approximately 25% report postvoid dribbling, and approximately 10% report dyspareunia. Other less frequent symptoms include hematuria and an anterior vaginal wall mass. Symptoms of urethral diverticulum can often be confused with other disorders such as interstitial cystitis, overactive bladder, or carcinoma in situ. Patients who have irritative voiding symptoms that do not respond to medical therapy should trigger a high index of suspicion for urethral diverticulum. Interestingly, many urethral diverticula are completely asymptomatic and are discovered incidentally. Approximately one third of patients present with recurrent urinary tract infections. Chronically infected diverticula may demonstrate no other associated symptoms except for recurrent urinary tract infections. At times, the infected diverticulum may progress to an abscess, requiring transvaginal aspiration. Physical examination A careful pelvic examination frequently reveals the suburethral mass on the anterior vaginal wall. The differential diagnosis of an anterior vaginal wall mass should include urethral diverticulum, Skene gland abscess, ectopic ureterocele, Gartner duct cyst, müllerian remnant cyst, and vaginal inclusion cyst. Palpation of the anterior vaginal wall may reveal a soft spherical mass, which often is exquisitely tender. Compression of the mass may express urine or purulent material from the external meatus. Distinct firmness or hardness may reflect the presence of a stone or neoplasm within the diverticulum. Stress urinary incontinence may coexist with urethral diverticula. The pelvic examination should also include careful assessment of urethral hypermobility as well as vaginal prolapse. The presence of stress incontinence or vaginal prolapse should be noted prior to surgery because either may require simultaneous repair at the time of diverticulectomy. Once a diagnosis is suspected based on history and physical examination findings, endoscopic and radiologic studies help to localize the diverticulum. Female urethral diverticula may be complicated by infection, stones, bladder outlet obstruction, and malignancy. Infection may be acute or chronic and may result in abscess formation. Stone formation within urethral diverticula is reported to occur in 1-10% of patients. When proximal urethral diverticula become very large, they can obstruct the bladder outlet causing acute urinary retention. Urethral carcinoma is a rare complication of urethral diverticula. Although squamous cell carcinoma is the most common histologic type of female urethral malignancy, adenocarcinoma is by far the most common cancer associated with urethral diverticula. Nephrogenic adenoma and endometriosis have also been reported in female urethral diverticula. INDICATIONSSection 3 of 11
Surgery is indicated in patients with significant symptoms, including recurrent urinary tract infections, severe pain, dyspareunia, frequency, urgency, and postvoid dribbling. Additional indications for surgery include urethral calculi, urinary retention, and carcinoma. RELEVANT ANATOMYSection 4 of 11
The adult female urethra is approximately 4 cm long and traverses the bladder neck to the external meatus. The mucosa of the female urethra is lined by transitional cell epithelium that gradually changes to nonkeratinizing squamous epithelium from the bladder neck to the external urethral meatus. Small periurethral secretory glands interdigitate the wall of the urethra to produce lubrication for the inner mucosa. These periurethral glands converge at the distal urethra as Skene glands and empty through 2 small ducts on either side of the external meatus. Repeated bouts of infection and occlusion of the periurethral glands lead to formation of suburethral cysts (see Image 2). These suburethral cysts enlarge and eventually rupture into the urethral lumen. During urination, constant pooling of urine within these cysts gives rise to urethral diverticula. The submucosa of the female urethra is a rich vascular network of spongy tissue. The submucosal layer nourishes the urethral epithelium and the underlying mucous glands. Both the mucosa and the submucosa are responsible for providing a part of the continence mechanism—the mucosal seal. The mucosal epithelium and the submucosal vascular plexus are highly responsive to estrogen. Loss of estrogen at menopause may result in atrophy or loss of the mucosal seal, causing intrinsic sphincteric deficiency. Intrinsic sphincter deficiency is a complex form of stress urinary incontinence. The urethra contains 2 layers of smooth muscle: the inner longitudinal layer and an outer circular-oblique layer. The inner longitudinal smooth muscle layer is the thicker of the 2 and continues from the bladder neck to the external meatus. The outer circular-oblique smooth muscle layer encases the longitudinal fibers throughout the length of the urethra. Normally, the inner and the outer smooth muscle layers are adherent via strong connective tissue fibers. The separation of these layers leads to complete urethral prolapse. The female bladder neck is an internal sphincter but possesses little adrenergic innervation and has limited sphincteric action. The striated urethral sphincter is composed of delicate type I (slow-twitch) and type II (fast-twitch) skeletal muscle fibers surrounded by abundant collagen. It forms a complete ring around the proximal urethra to provide the zone of highest urethral closure pressure. The striated urethral sphincter receives dual somatic innervation from the pudendal and pelvic somatic nerves. Little sympathetic innervation is found in the female urethra, but parasympathetic cholinergic fibers are found throughout the smooth muscle fibers. Activation of the parasympathetic fibers causes the inner longitudinal smooth muscle of the urethra to contract in synchrony with the detrusor. Contraction of the longitudinal fibers shortens and widens the urethra to allow normal urination. CONTRAINDICATIONSSection 5 of 11
Active infection of the urinary tract or the diverticulum precludes surgical intervention until the infection is eradicated. The presence of a urethral abscess may require transvaginal aspiration under ultrasonographic guidance prior to definitive therapy. WORKUPSection 6 of 11
Lab Studies
Imaging Studies
Diagnostic Procedures
TREATMENTSection 7 of 11
Medical therapySurgery is the current treatment of choice for urethral diverticula. To date, no known medical therapy exists for successful treatment of urethral diverticulum. Long-term low-dose antibiotic therapy may allow resolution of localized symptoms, but the anatomic abnormality remains. Treat infected urethral diverticula with appropriate antibiotics prior to surgery. Surgical therapyMultiple open surgical and endoscopic approaches have been described for the treatment of urethral diverticula. They include transurethral saucerization of the diverticulum, marsupialization of the diverticular sac into the vagina, and excision of the diverticulum. Transurethral saucerization of the urethral diverticulum involves incising the opening of the diverticulum to convert a narrow neck into a wide neck. In general, reserve this for distal diverticula because more proximal incision of the urethral wall may compromise continence. The marsupialization of a diverticulum is performed by incising the urethrovaginal septum. It is essentially a generous meatotomy, which may result in vaginal voiding. As with endoscopic saucerization, overzealous incision or treatment of mid or proximal diverticula with this technique may result in urinary incontinence. Numerous techniques are available for transvaginal excision. A popular transvaginal technique uses a vaginal flap (see Images 3-5). This technique allows complete excision of the diverticulum, closure of the urethral communication, reinforced coverage with periurethral fascia, and closure of the anterior vaginal wall. It allows a secure 3-layer closure without overlapping suture lines. For correction of coexisting stress urinary incontinence, a simultaneous pubovaginal sling or bladder neck suspension may be performed. Preoperative detailsPrior to surgery, proper antibiotic therapy is mandatory. Reconstructive surgery in a patient with active urinary and diverticular infection may lead to urethrovaginal fistula formation or recurrent diverticula. Preoperative counseling should include discussion of possible complications such as infection, bleeding, recurrent diverticulum, urethrovaginal fistula, and urinary incontinence. Intraoperative detailsAfter general anesthesia is induced, place the patient in the lithotomy position. Sterilely prepare and drape the lower abdomen and genitalia. A percutaneous suprapubic catheter is often placed; many surgeons forego the suprapubic tube. After infiltrating the anterior vaginal wall with sodium chloride solution, make a U-shaped incision. Mobilize the anterior vaginal wall flap to expose the diverticulum. Take care to prevent premature violation of the periurethral fascia or the diverticulum. Transversely incise the periurethral fascia. Develop proximal and distal flaps of periurethral fascia and reflect them off the underlying diverticulum. Dissect the diverticulum circumferentially down to its urethral communication and excise it completely. In the case of a very large diverticulum, the proximal portion may be left and the inner surface electrocauterized to destroy any epithelial elements. Close the urethral defect vertically without tension using a running 4-0 absorbable suture incorporating both mucosal and muscular layers of the urethral wall. Transversely reapproximate the periurethral fascia with a 3-0 absorbable suture constituting the second layer of closure. The third layer of closure is the vaginal wall, which is closed with a running 2-0 absorbable suture. Place an antibiotic-soaked vaginal pack and place both the suprapubic and urethral catheters to sterile drainage. Important factors in operative success include precise anatomic dissection, a watertight closure, and closure in multiple layers. Avoid overlapping suture lines. Postoperative detailsContinue intravenous antibiotics for 24 hours postoperatively, followed by oral antibiotics until the catheters are removed. Belladonna and opium (B&O) suppositories or oral anticholinergics prevent bladder spasms. The morning after the operation, remove the vaginal packing. The patient is usually discharged home the following day with both catheters still indwelling. Follow-upPerform voiding cystourethrography 10-14 days postoperatively. Discontinue anticholinergics 24 hours before the voiding study. Remove the urethral catheter and instill the contrast into the bladder via the suprapubic catheter. If the surgeon elected not to place a suprapubic catheter, then place the contrast via the urethral catheter. Carefully observe the urethra fluoroscopically during voiding. If no extravasation is observed and the patient empties the bladder to completion, remove the suprapubic tube. If the postvoid residual is more than 100 mL, leave the suprapubic catheter in place, intermittently unclamping it to drain the residual urine. Approximately 50% of patients may manifest extravasation during the first voiding study. If extravasation is observed, the suprapubic catheter is placed to gravity drainage. Do not replace the urethral catheter. Perform repeat voiding cystourethrography in 7-10 days. For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see eMedicine's patient education article Bladder Control Problems. COMPLICATIONSSection 8 of 11
Patients with active diverticular infection may experience profuse bleeding during vaginal dissection. A large defect created during excision of a large diverticulum may result in urethral strictures. A large proximal diverticulum that extends under the trigone and bladder neck may result in the risk of ureteric injury. Operating on patients with active infection may lead to fistula formation. Urethrovaginal fistula formation is the most difficult complication of diverticular surgery. If it occurs, repair the fistula after an adequate period of healing. Anterior vaginal infection is unusual but responds well to antibiotics. If a suburethral abscess forms, surgical drainage is required. If urethral diverticulum recurs, perform secondary surgery after a prudent period of observation. Secondary stress incontinence not present prior to surgical therapy is rare; however, this may occur in patients after extensive dissection of the urethral wall or its lateral attachments. OUTCOME AND PROGNOSISSection 9 of 11
The success rate of urethral diverticulectomy has a range of 86-100%. Complications reported in the literature include the following:
MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Article Last Updated: May 25, 2006 | |||||||||||||||||||||||||||||||||||
