Female Urethral Diverticula—An Update

Urol Sci 2010;21(1):23−29

CME Credits

MINI REVIEW

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 diverticula 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 squamous 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 diverticula are rare, with the occurrence rate of stone formation 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 urethrography in the 1950s, the diagnoses of female urethral 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 female 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 diverticulum 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 urethral diverticulum. The overall accuracy is about 65%.19 But it has several limitations including being invasive, possible urethral catheterization-related UTIs, and the potential 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 obstructed because of acute inflammation of urethral diverticulum or non-communicating between urethra and diverticulum, VCUG cannot show the lesions.22 Ultrasonography can also help to evaluate urethral diverticula with transvaginal, transperineal and transurethral Figure 2 Double balloon urethrography of a female patient with techniques.24 Transvaginal ultrasonography can show the urethral diverticulum. The arrow indicates a near-circumferential number, size, configuration, location, and possible con- urethral diverticulum. tents of urethral diverticula.24 However, ultrasonography cannot produce high-resolution images of the urethral diverticula and the surrounding anatomy. Increased resolution was noted with transurethral ultrasonography. But like double balloon urethrography and VCUG, transurethral ultrasonography is also an invasive procedure.2 MRI may be considered the gold standard imaging technique for evaluating female urethral diverticula.2 Urethral diverticula appear as areas of decreased signal intensity on T1 images compared with the surrounding soft tissues and have a high signal intensity on T2 images.25 Compared with double balloon urethrography and VCUG, MRI is inde- pendent of voiding and free from ionizing radiation while still able to successfully image female urethral diverticula.2 In addition, MRI is relatively noninvasive, and produces high-resolution, multiplanar images of female urethral 24 Figure 3 T2-weighted magnetic resonance image of a female diverticula. Two kinds of MRI of surface coil and endo- patient with a urethral diverticulum. The arrow indicates a cir- luminal techniques were developed.26–28 Endoluminal cumferential urethral diverticulum. MRI for urethral diverticula places the magnetic coil into a body cavity near the urethra, such as the vagina or rectum.25 (Figure 2), MRI (Figure 3) and the new method of virtual This produces an improved signal-to-noise ratio and a computed tomography (CT) urethroscopy, can also help in high-resolution image of the urethra, urethral diverticulum, diagnosing a female urethral diverticulum.16,20–22 However, and surrounding tissues.26,27 Both surface coil and endo- the modality that is most accurate remains controversial. luminal MRI appear to be superior to VCUG and double Double balloon urethrography is known as a positive balloon urethrography for evaluating urethral diverticula, pressure urethrogram; it is performed by inserting a dou- but the technology is expensive and not widely available.25 ble balloon catheter into the urethra, and the contrast With advances in imaging technology, virtual CT ure- medium is injected with high pressure into the isolated throscopy was developed as a new diagnostic technique urethra. Then, the contrast can be filled into the urethral for female urethral diverticula.20 CT urethrography con- diverticulum from the ostia.23 Double balloon urethrog- sists of thin-section transverse images of VCUG on a high- raphy is considered to be a good choice for diagnosis and speed CT scan. These reformatted images are transferred evaluation of a female urethral diverticulum.22 However, to a workstation. Then, virtual CT urethroscopy can be per- double balloon urethrography is not performed so widely formed under the aid of manufacturer-provided software.20 for several reasons: first, this method requires a specially Virtual CT urethroscopy is less invasive than conventional designed urethral catheter and an experienced radiologist; cystourethroscopy. Virtual CT urethroscopy can better second, it is an invasive procedure for the patient with show the extraluminal anatomy and pathology than a urethral diverticulum;19 third, diverticular loculations conventional cystourethroscopy.20 Chou et al.20 reported cannot be well defined; and fourth, non-communicating a female patient with a horseshoe-shape urethral diver- urethral diverticula cannot be seen with double balloon ticulum detected by virtual CT urethroscopy; it clearly

Vol. 21, 23–29, March 2010 25 Y.L. Chang, A.T.L. Lin identified the neck and orifice of the diverticulum in these lesions do not communicate with the urethral lu- the mid-urethra. VCUG and cystourethroscopy showed men.25 Skene’s duct cysts can be differentiated from ure- negative findings for a diverticulum in the same female thral diverticula on physical examination, as these lesions patient.20 Kim et al.29 reported another two patients with are located relatively distal on the urethra, often distorting urethral diverticula. In their series, virtual CT urethroscopy the urethral meatus, in contrast to urethral diverticula, was better able to identify the ostia of the diverticula than which most commonly occur over the mid and proximal VCUG, transvaginal sonography and MRI. Identification urethra.25 of the ostium of a urethral diverticulum is important for surgical management. Virtual CT urethroscopy can provide 7.3. Gartner’s duct cysts good identification of the ostium and neck of a urethral diverticulum and can help urologists in surgical planning.29 Gartner’s duct cysts are mesonephric remnants and However, some limitations can also be noted for virtual are found on the anterolateral vaginal wall.35 Because CT urethroscopy. First, it is still experimental and time- Gartner’s duct cysts are mesonephric remnants, they may consuming. Second, if the patient cannot void on the CT have the function of draining ectopic ureters from poorly table, voiding images cannot be obtained. Third, there functioning or nonfunctioning upper pole moieties in is significant radiation exposure to female patients of duplicated systems. Other metanephric abnormalities. reproductive age.29 such as unilateral renal agenesis and renal hypoplasia, are associated with Gartner’s duct cysts.25,36 Treatment depends on symptoms and the association with ectopic 7. Differential Diagnosis: Periurethral Cystic ureters. Lesions and Masses Other than Urethral Diverticula 7.4. Bartholin gland cysts

Periurethral cystic lesions include vaginal cysts (müllerian Bartholin gland cysts are typically located in the postero- cysts, Gartner’s duct cysts, and epidermal inclusion cysts), lateral introitus medial to the labia minora.24,37 Most pa- Skene’s duct cysts, Bartholin gland cysts, and perineal/ tients are asymptomatic. Infected or symptomatic cysts vulvovaginal endometriomas.24,30 Such lesions are fre- may require marsupialization.24 quently noted near the distal urethra. Periurethral cysts do not communicate with the urethra and can be dif- 7.5. Vaginal wall cysts ferentiated from urethral diverticula with endoluminal MRI.24 In addition, periurethral masses, such as vaginal Vaginal wall cysts are usually presented as small asymp- leiomyomas,31 and solid urethral masses, such as carcino- tomatic masses on the anterior vaginal wall.25 They may mas, nephrogenic adenomas, mesonephric adenocarcino- arise from multiple cell types. A specific diagnosis can- mas and embryonal cell rhabdomyomas, may be mistaken not reliably be made until the specimen is excised and ex- for urethral diverticula.32 Ectopic ureters and ureteroceles amined by a pathologist. Treatment is usually by a simple that insert in or adjacent to the urethra may be mistaken excision in symptomatic patients. for urethral diverticula or periurethral cysts.24 Ectopic Other periurethral masses, such as a urethral muco- ureteral orifices can be noted from the bladder neck to sal prolapse and urethral carbuncle,25 can be differenti- the external urethral orifice.33,34 ated from urethral diverticula by a physical examination because of their special appearance.25 7.1. Vaginal leiomyomas

Vaginal leiomyomas are benign mesenchymal tumors of 8. Nonsurgical Treatment of Female the vaginal wall that arise from smooth muscle elements. Urethral Diverticula They commonly present as a smooth, firm, round mass on the anterior vaginal wall. These masses are apparent Many patients do not have significant symptoms from on a physical examination as freely mobile, firm, non- urethral diverticula. Such asymptomatic patients can be tender masses on the anterior vaginal wall.25 They can be treated with conservative methods including antibiotics, misdiagnosed as urethral diverticula.31 Excision or enu- anticholinergics, simple observation, post-void digital cleation through a vaginal approach is often curative and decompression,5 and obliteration with oxidized cellulose38 is recommended to confirm the diagnosis, to exclude a or polytetrafluoroethylene.39 If an acute infection is noted malignant histology, and to alleviate symptoms.25 in the urethral diverticulum, treatment with antibiotics should be performed before surgical intervention can be 7.2. Skene’s duct cysts considered.19 Moran et al.40 reported four pregnant patients with urethral diverticula. Those patients were suc- Skene’s duct cysts are lateral or inferolateral to the urethral cessfully treated with adequate antibiotic therapy and meatus. Classically, compared with urethral diverticula, judicious aspiration.

26 Vol. 21, 23–29, March 2010 Female urethral diverticula

9. Surgical Treatment of Female (0–31.3%), and recurrent urethral diverticula (1–25%).23 Urethral Diverticula Porpiglia et al.44 reported their experience with preoperative risk factors with surgery for female urethral divertic- Generally, there are three surgical options for female ure- ula and showed that a delayed diagnosis (> 12 months), thral diverticula: (1) transurethral incision of the divertic- a large size (> 4 cm), and a lateral or horseshoe-shaped ular communication by transforming a narrow-mouthed diverticulum are the most important preoperative risk diverticulum to a wide-mouthed one; (2) marsupializa- factors for complications with a female urethral diverti- tion of the diverticular sac into the vagina by incision of culectomy. A brief flow chart of the diagnosis, treatment, the urethrovaginal septum; and (3) excision with recon- and potential surgical complications of female urethral struction.5 Excision and reconstruction are probably the diverticula is given in Figure 4. most common surgical approach to urethral diverticula in the modern era.2 Principles of a urethral diverticulectomy have been 10. Special Considerations for Concomitant well described2 and include: (1) mobilization of one or Female Urethral Diverticula and SUI more well-vascularized anterior vaginal wall flaps; (2) preservation of the periurethral fascia; (3) identification The unique symptom of post-micturition incontinence can and excision of the neck of the urethral diverticula or be used to differentiate urethral diverticula from genuine ostia; (4) removal of the entire urethral diverticular wall incontinence. In our previous study,17 14 female patients or sac (mucosa); (5) watertight urethral closure; (6) multi- with urethral diverticula were enrolled. Seven patients layered, non-overlapping closure with absorbable sutures; had minor SUI occurring immediately after voiding, while (7) closure of the dead space; and (8) preservation or classic SUI patients typically do not have SUI immediately creation of continence. following bladder emptying. SUI was so dominant in two The most common surgical techniques for female patients with large urethral diverticula that they were urethral diverticula were described by Leach et al.40 falsely treated with anti-incontinence surgery. Further When the diverticulum is a saddlebag or circumferential, inquiry showed that their stress incontinence only occurred meticulous dissection with complete excision anterior to immediately, but not 1 or 2 hours after voiding when the the urethra and behind the pubic bone is used.5 When a bladder contained more urine and stress incontinence circumferential urethral diverticulum is noted, it may be should have more easily occurred. Nevertheless, patients necessary to completely divide and excise the involved with both genuine stress incontinence and a urethral di- segment of the urethra to expose the dorsal wall of the verticulum may have stress incontinence all the time, both diverticulum.5 To reconstruct the continuity of the ure- immediately after voiding and when the bladder is fuller. thra, end-to-end urethroplasty or tubularization of the Bass and Leach45 reported 61% abnormal urodynamic dorsal wall of the urethral diverticulum to construct a studies in 41 female patients with urethral diverticula. neourethra can be performed.42 Twenty patients had genuine SUI (49%), eight had SUI Adequate drainage of the urinary bladder is important. with detrusor instability (19.5%), two had detrusor in- Whether suprapubic catheter drainage or transurethral stability alone (5%), and one had myogenic decompen- drainage is preferred is controversial. Some authors use sation (2%). Bhatia et al.46 found that the urethral pressure both a suprapubic tube and transurethral Foley tube for profile decreases at the level of the diverticular ostium perioperative bladder drainage. If only an indwelling trans- (biphasic pattern), but it may be difficult to show the bi- urethral Foley tube is used and unfortunately the trans- phasic pattern of the urethral pressure profile when the urethral Foley tube is obstructed postoperatively, then ostium is only a pinhole. Some patients may have evidence bladder spasms and a blowing out of the urethral diver- of bladder outlet obstruction on the urodynamic evalua- ticular repair may occur.5,43 After 10–14 days postopera- tion due to the obstructive or mass effects of the urethral tively, the transurethral Foley tube is removed, and VCUG diverticula on the urethra. Furthermore, SUI can coexist is performed to evaluate the extravasation. If no extrava- with an obstruction.47 There is also the potential that the sation is noted, the suprapubic tube is removed. How- urethral diverticulectomy may unmask occult SUI by re- ever, if extravasation is noted, the suprapubic tube is moving an obstructive diverticulum.48 Therefore, it is kept in place for bladder drainage, and VCUG is repeated important to determine the continence status before 1 week later.5,43 In our opinion, before removing the cath- the operation for a urethral diverticulum. However, the eters, VCUG is a necessary examination, because VCUG urethral reconstruction may itself predispose a patient has an important role in detecting the healing condition to an increased risk of SUI.18 Vaginal and periurethral of the repaired urethra and surrounding tissues. surgical dissection performed during the diverticulec- Complication rates of a transvaginal urethral diver- tomy may alter the patient’s continence status by com- ticulectomy range 5–46%.19 The most common compli- promising urethral support or altering the neurovascular cations of transvaginal urethral diverticulectomy include supply to the sphincter muscle. Alternatively, the patho- urinary incontinence (1.7–16.1%), urethrovaginal fistula physiologic inflammatory pathway involved in urethral (0.9–8.3%), urethral stricture (0–5.2%), recurrent UTI diverticula may alter the tissue integrity of the urethra

Vol. 21, 23–29, March 2010 27 Y.L. Chang, A.T.L. Lin

Paents with suspected UD

1. Detailed history: including associated symptoms 1. Laboratory examinaons: urinalysis, (recurrent UTI, UI, dysuria, LUTS, post-void urine culture dribbling, dyspareunia, etc.) 2. Radiology: VCUG, DBU, MRI 2. Physical examinaon: tender urethra, bulging 3. Cystourethroscopy mass in the anterior vaginal wall, pus or turbid urine may be pressed from urethral meatus when the suburethral bulging mass was compressed, etc.

Diﬀerenal diagnosis: vaginal leiomyoma, Skene’s duct cysts, Gartner’s duct cysts, Bartholin gland cysts, vaginal wall cysts, etc.

Anbiocs, simple Asymptomac and/or observaon, post-void unsuitable condions UD conﬁrmed digital decompression, etc. for surgery

Symptomac and/or other complicang factors requiring surgical repair

Transvaginal urethral Transvaginal urethral diverculectomy with an- SUI conﬁrmed VUDS No SUI diverculectomy inconnence surgery

Potenal surgical complicaons

Urinary inconnence, urethrovaginal ﬁstula, urethral stricture, recurrent UTI, recurrent urethral divercula, etc.

Figure 4 Brief flow chart for the diagnosis, treatment, and potential surgical complications with a female urethral diverticulum. DBU = double balloon urethrography; LUTS = lower urinary tract symptoms; MRI = magnetic resonance imaging; SUI = stress urinary incontinence; UD = urethral diverticulum; UI = urinary incontinence; UTI = urinary tract infection; VCUG = voiding cystourethrography; VUDS = videourodynamic study. and/or the sphincteric mechanism. For patients with ure- reconstruction of the periurethral fascia might enhance thral diverticula and SUI, concomitant anti-incontinence urethral resistance and thus overcome the problem of surgery can be performed. Several authors described SUI. For patients with a proximal or distal urethral diver- successful concomitant repair of urethral diverticula and ticulum and symptoms of SUI, adding anti-incontinence stress incontinence with needle suspension or autologous surgery to the urethral diverticulectomy may be justified. fascial pubovaginal slings, without increasing the risk of postoperative infection.3,45,49 However, the safety and efficacy of midurethral polypropylene tape procedures 11. Conclusion in patients with SUI and urethral diverticula have not been well studied.2 Symptoms or signs of a female urethral diverticulum are Alternatively, the procedures can be staged. In 2006, usually not typical, thereby resulting in delayed or wrong Juang et al.50 reported two female patients with middle diagnoses. A high suspicion of this disorder, a detailed his- urethral diverticula and SUI. They treated those two pa- tory taking, and a physical examination are important for tients with only a diverticulectomy without concomitant detecting urethral diverticula in females. New radiographic anti-incontinence surgery. Those two patients received imaging technologies especially MRI may be considered postoperative follow-up for 6 months and 2 years, and the gold standard for diagnosing female urethral diver- showed complete resolution of the SUI. They concluded ticula. It can provide surgeons with an accurate preop- that according to their experience, it is not mandatory to erative understanding of the anatomic condition of the perform a combined vaginal diverticulectomy and anti- female urethral diverticulum. In addition, complete eval- incontinence surgery for all patients with a urethral di- uation of the associated voiding dysfunction such as uri- verticulum presenting with SUI. Meticulous suturing of nary incontinence can help to accurately and properly the urethral defect left by the diverticulectomy with treat this disease.

28 Vol. 21, 23–29, March 2010 Female urethral diverticula References 26. Blander DS, Broderick GA, Rovner ES. Images in clinical urology: magnetic resonance imaging of a “saddle bag” urethral diverticulum. Urology 1999;53:818–9. 1. Romanzi LJ, Groutz A, Blaivas JG. Urethral diverticulum in women: 27. Siegelman ES, Banner MP, Ramchandani P, Schnall MD. Multicoil diverse presentations resulting in diagnostic delay and misman- MR imaging of symptomatic female urethral and periurethral agement. J Urol 2000;164:428–33. disease. Radiographics 1997;17:349–65. 2. Rovner ES. Urethral diverticula: a review and an update. Neurourol 28. Kim B, Hricak H, Tanagho EA. Diagnosis of urethral diverticula Urodyn 2007;26:972–7. in women: value of MR imaging. AJR Am J Roentgenol 1993;161: 3. Leng WW, McGuire EJ. Management of female urethral diverticula: 809–15. a new classification. J Urol 1998;160:1297–300. 29. Kim SH, Kim SH, Park BK, et al. CT voiding cystourethrography 4. Daneshgari F, Zimmern PE, Jacomides L. Magnetic resonance imag- using 16-MDCT for the evaluation of female urethral diverticula: ing detection of symptomatic noncommunicating intraurethral initial experience. AJR Am J Roentgenol 2005;184:1594–6. wall diverticula in women. J Urol 1999;161:1259–61. 30. Chowdhry AA, Miller FH, Hammer RA. Endometriosis presenting 5. Aspera AM, Rackley RR, Vasavada SP. Contemporary evaluation as a urethral diverticulum: a case report. J Reprod Med 2004;49: and management of the female urethral diverticulum. Urol Clin 321–3. North Am 2002;29:617–24. 31. Shirvani AR, Winters JC. Vaginal leiomyoma presenting as a urethral 6. Clemens JQ, Bushman W. Urethral diverticulum following trans- diverticulum. J Urol 2000;163:1869. urethral collagen injection. J Urol 2001;166:626. 32. Hosseinzadeh K, Furlan A, Torabi M. Pre- and postoperative evalu- 7. Athanasopoulos A, McGuire EJ. Urethral diverticulum: a new com- ation of urethral diverticulum. AJR Am J Roentgenol 2008;190: plication associated with tension-free vaginal tape. Urol Int 2008; 165–72. 81:480–2. 33. Berrocal T, Lopez-Pereira P, Arjonilla A, Gutierrez J. Anomalies of 8. Marshall S. Urethral diverticula in young girls. Urology 1981;17: the distal ureter, bladder, and urethra in children: embryologic, 243–5. radiologic, and pathologic features. Radiographics 2002;22:1139–64. 9. Hickey N, Murphy J, Herschorn S. Carcinoma in a urethral divertic- 34. Vijayaraghavan SB. Perineal sonography in diagnosis of an ectopic ulum: magnetic resonance imaging and sonographic appearance. ureteric opening into the urethra. J Ultrasound Med 2002;21: Urology 2000;55:588–9. 1041–6. 10. Lang EK, Sethi E, Ordonez A, Colon I, Macchia R. Adenocarcinoma 35. Hagspiel KD. Giant Gartner duct cyst: magnetic resonance imaging of suburethral diverticulum. J Urol 2008;179:728. findings. Abdom Imaging 1995;20:566–8. 11. Shalev M, Mistry S, Kernen K, Miles BJ. Squamous cell carcinoma 36. Currarino G. Single vaginal ectopic ureter and Gartner’s duct cyst in a female urethral diverticulum. Urology 2002;59:773. with ipsilateral renal hypoplasia and dysplasia (or agenesis). J Urol 12. Martinez-Maestre A, Gonzalez-Cejudo C, Canada-Pulido E, Garcia- 1982;128:988–93. Macias JM. Giant calculus in a female urethral diverticulum. Int 37. Eilber KS, Raz S. Benign cystic lesions of the vagina: a literature Urogynecol J Pelvic Floor Dysfunct 2000;11:45–7. review. J Urol 2003;170:717–22. 13. Moore TD. Diverticulum of female urethra; an improved technique 38. Ellik M. Diverticulum of the female urethra: a new method of of surgical excision. J Urol 1952;68:611–6. ablation. J Urol 1957;77:243–6. 14. Young GPH, Wahle GR, Raz S. Female urethral diverticulum. In: 39. Mizrahi S, Bitterman W. Transvaginal, periurethral injection of Raz S, ed. Female Urology, 2nd ed. Philadelphia: WB Saunders, polytetrafluoroethylene (polytef) in the treatment of urethral diver- 1996:478–9. ticula. Br J Urol 1988;62:280. 15. Andersen MJ. The incidence of diverticula in the female urethra. 40. Moran PA, Carey MP, Dwyer PL. Urethral diverticula in pregnancy. J Urol 1967;98:96–8. Aust N Z J Obstet Gynaecol 1998;38:102–6. 16. Lorenzo AJ, Zimmern P, Lemack GE, Nurenberg P. Endorectal coil 41. Leach GE, Schmidbauer CP, Hadley HR, Staskin DR, Zimmern P, magnetic resonance imaging for diagnosis of urethral and peri- Raz S. Surgical treatment of female urethral diverticulum. Semin urethral pathologic findings in women. Urology 2003;61:1129–33. Urol 1986;4:33–42. 17. Chang YL, Lin AT, Chen KK. Presentation of female urethral diver- 42. Rovner ES, Wein AJ. Diagnosis and reconstruction of the dorsal or ticulum is usually not typical. Urol Int 2008;80:41–5. circumferential urethral diverticulum. J Urol 2003;170:82–6. 18. Lee UJ, Goldman H, Moore C, Daneshgari F, Rackley RR, Vasavada 43. Foote J, Leach FE. Urethral diverticula in the female. In: Kursh DD, SP. Rate of de novo stress urinary incontinence after urethal diver- McGuire E, eds. Female Urology. Philadelphia: JB Lippincott, 1994: ticulum repair. Urology 2008;71:849–53. 449–474. 19. Lee JW, Fynes MM. Female urethral diverticula. Best Pract Res 44. Porpiglia F, Destefanis P, Fiori C, Fontana D. Preoperative risk Clin Obstet Gynaecol 2005;19:875–93. factors for surgery female urethral diverticula: our experience. 20. Chou CP, Huang JS, Yu CC, Pan HB, Huang FD. Urethral diverticulum: Urol Int 2002;69:7–11. diagnosis with virtual CT urethroscopy. AJR Am J Roentgenol 2005; 45. Bass JS, Leach GE. Surgical treatment of concomitant urethral 184:1889–90. diverticulum and stress incontinence. Urol Clin North Am 1991;18: 21. Gerrard ER Jr, Lloyd LK, Kubricht WS, Kolettis PN. Transvaginal 365–73. ultrasound for the diagnosis of urethral diverticulum. J Urol 2003; 46. Bhatia NN, McCarthy TA, Ostergard DR. Urethral pressure profiles 169:1395–7. of women with urethral diverticula. Obstet Gynecol 1981;58:375–8. 22. Golomb J, Leibovitch I, Mor Y, Morag B, Ramon J. Comparison of 47. Bradley CS, Rovner ES. Urodynamically defined stress urinary voiding cystourethrography and double-balloon urethrography in incontinence and bladder outlet obstruction coexist in women. the diagnosis of complex female urethral diverticula. Eur Radiol J Urol 2004;171:757–60. 2003;13:536–42. 48. Huffman JW. The detailed anatomy of the para-urethral ducts in 23. Patel AK, Chapple CR. Female urethral diverticula. Curr Opin Urol the adult human female. Am J Obstet Gynecol 1948;55:86–101. 2006;16:248–54. 49. Faerber GJ. Urethral diverticulectomy and pubovaginal sling for 24. Prasad SR, Menias CO, Narra VR, et al. Cross-sectional imaging of simultaneous treatment of urethral diverticulum and intrinsic the female urethra: technique and results. Radiographics 2005; sphincter deficiency. Tech Urol 1998;4:192–7. 25:749–61. 50. Juang CM, Horng HC, Yu HC et al. Combined diverticulectomy and 25. Rovner ES. Bladder and urethral diverticula. In: Wein AJ, Kavoussi anti-incontinence surgery for patients with urethral diverticulum LR, Novick AC, Partin AW, Peters CA, eds. Campbell-Walsh Urology, and stress urinary incontinence: is anti-incontinence surgery really 9th ed. Philadelphia: WB Saunders, 2007:2361–90. necessary? Taiwan J Obstet Gynecol 2006;45:67–9.

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