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Managing Troublesome Urethral Diverticula

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Managing Troublesome Urethral Diverticula VIEW AN Accompanying Video To watch a demonstration of various surgical techniques for managing urethral diverticula, visit www.obgmanagement.com Pelvic surgery controversies Mickey M. Karram, MD Director of Urogynecology, Good Samaritan Hospital, and Managing troublesome Professor of Obstetrics and Gynecology, University of Cincinnati, urethral diverticula Cincinnati, Ohio Jerry G. Blaivas, MD Clinical Professor of Urology, Which test is best? Does medical therapy work? Weill Medical College of When should you consider surgery? Cornell University, New York, NY Drs. Karram and Blaivas co-chair the 6th Annual International Symposium rethral diverticula are often over- Which test is best? on Female Urology & Urogynecology, to be held April 26–28, 2007, looked as a source of recurrent Imaging has been used in different ways, in Las Vegas (www.urogyn-cme.org). Uurinary tract infection, voiding with variable success. dysfunction, dyspareunia, and chronic • Most diverticula are well visualized pelvic pain. Here, in brief, is how ®to Dowdenby voiding Health cystourethrography Media or diagnose and manage this condition, in- magnetic resonance imaging (MRI); cluding a look at surgical options. we view these as complementary CopyrightFor personaltechniques, use in fact, only because some diverticula are visualized only by What are the one modality or the other. MRI pro- common complaints? vides a superior examination for Urethral diverticula present in myriad surgical planning because it defi nes FAST TRACK ways—most often, as recurrent uri- urethral and diverticular anatomy Massage the nary tract infection, overactive bladder, most clearly stress urinary incontinence, and pelvic • Ultrasonography has been used with anterior vaginal pain. Other common presenting symp- some success wall underneath toms include voiding dysfunction, a • Positive-pressure urethrography, using the urethra; painful or palpable mass, and postvoid a Tratner or double balloon catheter, discharge or dribbling. is diffi cult to perform and uncomfort- excretion of fl uid from able for the patient. the external urethral What can be done meatus is routinely during a pelvic What is the role pathognomonic exam to make the Dx? of urethroscopy? Become accustomed to massaging the We fi nd urethroscopy very helpful. One anterior vaginal wall underneath the caveat: Inability to visualize a diverticu- urethra. Any discharge or excretion of lum or its opening does not, by any means, fl uid that you observe from the exter- exclude a urethral diverticulum. nal urethral meatus as you massage is pathognomonic for urethral diverticu- lum. In addition, palpate the anterior How should you manage vaginal wall for paraurethral masses. a urethral diverticulum? Sometimes, a diverticulum is ballotable • Urinary tract infection should be treated but not palpable. with a culture-specifi c antibiotic; in www.obgmanagement.com OB G MANAGEMENT • February 2007 25 For mass reproduction, content licensing and permissions contact Dowden Health Media. Pelvic surgery controversies some cases, the patient will become INSTANT POLL asymptomatic afterwards RESULTS • Overactive bladder symptoms can be treated with an anticholinergic Here’s how you • In most cases, surgery proves necessary and your peers voted • When you identify a urethral diver- ticulum during pregnancy, manage the patient conservatively during the What is your crash C-section time? antenatal period A woman at term presents to your triage unit • A patient who has an asymptom- atic urethral diverticulum can be with persistent fetal bradycardia confirmed by managed expectantly, but perform a ultrasonography. pelvic exam periodically. From the time you call for a crash cesarean section, approximately how long does it take When is surgery appropriate? your team to deliver? By what method? Several observations are useful: • Hardness or induration of the diver- 30 to 45 minutes 5 to 10 minutes ticular mass is extremely rare; such 15% 19% a fi nding should prompt surgical ex- cision because it may signal cancer • Marsupialization has been demon- strated to be successful for very dis- tal and small urethral diverticula 20 to 30 minutes • Most diverticula at the level of the 32% 10 to 20 minutes midurethra and proximal urethra 34% require some form of excision, FAST TRACK broadly classifi ed as partial ablation A urethral or complete excision • Placement of a suburethral sling is diverticulum controversial, but some experts be- identifi ed during lieve that, to prevent stress incon- Metabolic syndrome pregnancy calls tinence, this intervention should be for conservative undertaken simultaneously with any Diagnosis requires that we measure waist management other surgical treatment for divertic- circumference and blood pressure, and obtain antenatally ula of the proximal urethra measurements of fasting glucose, triglycerides, • Sometimes a Martius fat pad must and HDL-C. Are you collecting this information be brought into the fi eld to avoid from your patients? devascularization and breakdown of the repair. When a suburethral sling is necessary, we routinely place a Martius fl ap between the urethra and the sling. ■ Yes 30% VIEW AN Accompanying Video No 70% To watch a demonstration of various surgical techniques for managing urethral diverticula, visit www.obgmanagement.com 26 OBG MANAGEMENT.
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