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Female Urethral Diverticula—An Update

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Female Urethral Diverticula—An Update Urol Sci 2010;21(1):23−29 CME Credits MINI REVIEW Female Urethral Diverticula—An Update Yu-Lung Chang1,2, Alex T.L. Lin1,3* 1Department of Urology, National Yang-Ming University, School of Medicine, Taipei, Taiwan 2Division of Urology, Department of Surgery, Chutung Veterans Hospital, Taipei, Taiwan 3Division of Urology, Department of Surgery, Taipei Veterans General Hospital, Taipei. Taiwan Female urethral diverticula can arise from repeated infections with abscess formation Accepted: May 5, 2009 within the periurethral and urethral glands. Symptoms or signs of female urethral diver- ticula are usually not typical, thereby resulting in a delayed or incorrect diagnosis. New KEY WORDS: radiographic imaging modalities, such as magnetic resonance imaging and a new method female urethral diverticulum; of virtual computed tomography urethroscopy, can also help to diagnose female urethral stress urinary incontinence diverticula. An accurate preoperative understanding of the anatomic conditions with a female urethral diverticulum and complete evaluation of associated voiding dysfunction such as urinary incontinence can help to accurately and properly treat this disease. *Corresponding author. Division of Urology, Department of Surgery, Taipei Veterans General Hospital, 201, Shih-Pai Road, Section 2, Taipei 11217, Taiwan. E-mail: [email protected] There are 2 CME questions based on this article 1. Introduction They may arise from repeated infections with abscess formation within the periurethral and urethral glands.3 Female urethral diverticula present some of the most Most urethral glands lie in the mid to distal portion of challenging diagnostic and therapeutic problems in female the urethra. When the obstructed glands rupture into urology. The presentations of female urethral diverticula the urethral lumen, an outpouching is formed. Once the are very diverse and can range from completely asymp- outpouching is epithelialized, it becomes a true urethral tomatic or incidental findings on a physical examination diverticulum.3,4 Urethral diverticula may also form after or radiologic images, to painful vaginal masses associated obstetric trauma, urethral instrumentation, and urethral or with post-micturition incontinence, frequent urinary tract vaginal surgery.5 In recent years, collagen injections were infections (UTIs), dyspareunia, stones, and tumors.1 With also described as a rare cause of urethral diverticula, which the development of imaging techniques such as double result in a non-communicating diverticulum with obstruc- balloon urethrography and magnetic resonance imaging tion of the periurethral gland and persistent accumula- (MRI), we have more-advanced understanding of female tion of secretions.6 Moreover, urethral diverticula are also urethral diverticula. In addition, a video urodynamic study reported after tension-free vaginal tape procedures for can also help to evaluate concomitant stress urinary in- SUI.7 Congenital formation of urethral diverticula was also continence (SUI). When a diagnosis of female urethral suggested, particularly in pediatric patients.8 diverticulum is confirmed, excision and reconstructive Inflammation and chronic irritation from the presence surgery can be performed.2 of urine and debris can induce malignant changes into an adenocarcinoma, transitional cell carcinoma or squa- mous cell carcinoma.9–11 Among malignant tumors of 2. Pathophysiology and Etiology of Female urethral diverticula, 54% tend to be adenocarcinomas, Urethral Diverticula 43% transitional cell carcinomas, and 22% squamous cell carcinomas.11 Female urethral diverticula are considered a localized out- Stasis of the urine in urethral diverticula can cause pouching of the urethra into the anterior vaginal wall. recurrent UTIs and stone formation in the diverticulum ©2010 Taiwan Urological Association. Published by Elsevier Taiwan LLC. 23 Y.L. Chang, A.T.L. Lin itself. Martinez-Maestre et al.12 reported an elderly woman with a firm vaginal mass, which was discovered to be a 5 × 6 cm stone in a urethral diverticulum. Stones in diver- ticula are rare, with the occurrence rate of stone forma- tion in urethral diverticula being approximately 1.5–10%, and the stone formation results from stagnant urine, salt deposition, and mucus from the urothelial lining.12 3. Prevalence In 1952, Moore13 stated that urethral diverticulum as an entity was “found in direct proportion to the avidity with which it is sought”. After development of a series of imaging techniques including positive pressure ure- thrography in the 1950s, the diagnoses of female ure- thral diverticula increased. Female urethral diverticula Figure 1 Preoperative urethral diverticulum of a female patient. are identified in 0.6–6% of women and are diagnosed The arrow indicates the bulging mass in the anterior vaginal wall. most frequently in the third to fifth decade of life.14 In 1967, Andersen15 reported the results of positive pressure 5. Diagnosis and Evaluation urethrography on 300 women with cervical cancer but without lower urinary tract symptoms, and the incidence Diagnosis and comprehensive evaluation of the female of urethral diverticula was 3%. Lorenzo et al.16 reported urethral diverticula are best made with a combination of the results of endorectal coil MRI on 140 consecutive fe- detailed history taking, physical examination, urine analysis male patients with lower urinary tract symptoms, and and culture, endoscopic examination of the bladder and the incidence of urethral diverticula was approximately urethra, and radiologic imaging.2 Romanzi et al.1 reported 10%. This percentage might not be reflective of the gen- their experience with diverse presentations of urethral di- eral population because of a selection bias at tertiary verticula in women and concluded that the symptoms of referral centers. urethral diverticula may mimic other disorders. When fe- male patients with pelvic pain, urinary incontinence and ir- ritative voiding symptoms do not respond to therapy, the 4. Signs and Symptoms of Female possibility of a urethral diverticulum should be considered.1 Urethral Diverticula A physical examination may show a tender urethra or a bulging mass in the anterior vaginal wall (Figure 1). Historically the classic presentation of a urethral diver- Pus or turbid urine may be pressed from the urethral mea- ticulum was described as the “3 D’s”: dribbling, dysuria, tus when the suburethral bulging mass is compressed. and dyspareunia.2 However, these symptoms are neither However, if a firm mass is palpated over the anterior vag- sensitive nor specific for urethral diverticula. The presen- inal wall, stones or a carcinoma in the urethral diverticu- tation is very diverse, and the most common symptoms lum should be considered.5 are recurrent UTI (9–61%), urinary incontinence (35–39%), SUI may coexist with urethral diverticula, and urody- and dysuria (9–55%). Post-void dribbling was noted by namic studies are important to evaluate the continence sta- 4–31% of patients. Moreover, dyspareunia was noted by tus. Even in the absence of a complaint of SUI, a urodynamic 6–24% of patients.5 evaluation is wise. The need for extensive surgical dissection There should be a palpable urethral mass with an during a diverticulectomy may convert asymptomatic or emergence of purulent discharge out of the meatus on occult stress incontinence into gross postoperative SUI.18 milking the mass. However, in our series, we found that the presenting symptoms or signs of female urethral di- verticulum were so diverse that a diagnosis of a female 6. Imaging urethral diverticulum could easily be missed.17 They are usually misdiagnosed as chronic pelvic pain, voiding dys- Appropriate evaluations play an important role in diagnos- function, and uncomplicated recurrent UTI. Other symp- ing female urethral diverticula and can provide maximum toms and signs of female urethral diverticula may include data about the number, location, size, configuration, and urethral pain, urinary frequency, urinary urgency, urge communication of a female urethral diverticulum.19 Ra- incontinence, stress incontinence, nocturia, vaginal ten- diologic imaging can provide the anatomic relationship derness, and pyuria.17 If a female urethral diverticulum is between the urethral diverticulum and surrounding tis- not included in the differential diagnosis, diagnosis and sues. Some radiographic images, e.g., ultrasound, voiding management are usually delayed.1 cystourethrography (VCUG), double balloon urethrography 24 Vol. 21, 23–29, March 2010 Female urethral diverticula urethrography, because the contrast medium cannot enter the diverticulum.4 VCUG may also provide excellent imaging of female urethral diverticula. It is commonly used for diagnosing and evaluating patients with a known or suspected ure- thral diverticulum. The overall accuracy is about 65%.19 But it has several limitations including being invasive, pos- sible urethral catheterization-related UTIs, and the poten- tial for underfilling or non-visualization of the urethral diverticulum due to a poor voiding effect by the patient.19 When the ostia or neck of the urethral diverticulum is ob- structed because of acute inflammation of urethral di- verticulum or non-communicating between urethra and diverticulum, VCUG cannot show the lesions.22 Ultrasonography can also help to evaluate urethral di- verticula with transvaginal, transperineal and transurethral Figure 2 Double balloon urethrography of a female patient with techniques.24 Transvaginal ultrasonography
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