Alana M. Murphy, MD
BASICS
DESCRIPTION
• A urethral diverticula is an out-pocketing off the urethra between the submucosal layer and the periurethral fascia
• Often contains a collection of urine and/or pus
• Usually connects to the urethra through a neck or ostium
• Classic symptoms are dysuria, dyspareunia, and post-void dribbling
EPIDEMIOLOGY
Incidence (1)
• Depends on avidity with which it is sought
• Mean age at surgery ∼48 yr
Prevalence
• Difficult to determine true prevalence
• 1–3% asymptomatic women
RISK FACTORS
Some series have demonstrated a higher prevalence in African American women compared to Caucasian women
Genetics
No known genetic risk factors
PATHOPHYSIOLOGY
• Congenital female urethral diverticula are uncommon
• Most common theory regarding adult female diverticula (2)
– Infection or obstruction of periurethral glands
– Obstruction or abscess formation leads to cyst-like cavity
– Diverticulum is contained within periurethral fascia
ASSOCIATED CONDITIONS
• Urinary incontinence
• Dyspareunia
• Dysuria
• Storage or voiding symptoms
– Occasional urinary retention
GENERAL PREVENTION
No known method of prevention
DIAGNOSIS
HISTORY
• Classic 3 Ds (rare for all 3 to be present):
– Dysuria: Pain during voiding
– Dribbling (incontinence): Typically due to urine leaking from the diverticulum, patient may also have concomitant stress and/or urgency incontinence
– Dyspareunia: Pain with intercourse
• Nonspecific complaints are common:
– Frequency/urgency
– Hematuria
– Palpable or visible vaginal lump/bulge
– Periurethral pain
– Recurrent UTIs
– Voiding symptoms or urinary retention
• May be an incidental finding
PHYSICAL EXAM
• Inspect the anterior vaginal wall:
– Some diverticula are visible as a suburethral mass
– Assess bladder neck mobility
– Observe for stress incontinence
– Assess for point tenderness suburethrally, which may be the only sign of a urethral diverticulum.
• If a suburethral mass is noted:
– Classic sign: Compressing the mass expresses urine or pus from urethral meatus.
– If the mass does not compress, consider:
Vaginal wall cyst
Obstructed (noncommunicating) diverticulum
– Induration suggests stone or cancer
• Evaluate for other pelvic pathology
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urine analysis, urine culture
• Preoperative tests appropriate to patient’s age and medical condition
Imaging
• Magnetic resonance imaging (MRI) (3)
– Diverticulum has high signal intensity on T2-weighted imaging
– Most accurate diagnostic test
– Does not require the patient to void
– Shows noncommunicating diverticula
– Helps surgical planning
– Shows size, extent, location, and presence of filling defects
• Voiding cystourethrogram (VCUG):
– Advantage: Less costly than MRI, allows assessment of other causes of voiding symptoms (ie, closed bladder neck)
– Disadvantages compared to MRI:
More invasive
Patient must be able to void
Less sensitive for diagnosis
Less anatomic detail
• Positive-pressure double-balloon urethrogram:
– Less sensitive than MRI
– More sensitive than VCUG
– Requires special radiology expertise
• Ultrasound (US): Highly operator-dependent
– Intraurethral or transvaginal
Diagnostic Procedures/Surgery
• Cystoscopy:
– Much less sensitive than VCUG or MRI
– Ostium usually in mid-urethra at 5–7 o’clock
– Main value: Rule out other pathology
• Urodynamics (UDS):
– Not mandatory in straightforward cases
– Useful if the patient has incontinence or voiding difficulty
– Fluoroscopic UDS: Combines VCUG with lower-tract functional evaluation
Pathologic Findings
• Histology of epithelium may be:
– Transitional
– Stratified squamous
– Columnar
– Cuboidal
– Absent (wall just fibrous tissue)
• May have carcinoma (4)
– Adenocarcinoma more common than transitional or squamous cell
• Diverticulum may contain stones
DIFFERENTIAL DIAGNOSIS
• Benign neoplasms
– Leiomyomas:
Increased prevalence in females aged 30–50 yr
– Skene gland cyst or abscess
Associated with meatal deviation
– Gartner duct cyst
– Ectopic ureterocele
– Urethral prolapse or caruncle
– Vaginal wall cyst
• Malignant neoplasms:
– Primary urethral carcinoma; more common in females:
Squamous cell (80%)
Transitional cell (15%)
Adenocarcinoma (4%)
Melanoma (1%)
– Rarely and adenocarcinoma can arise in a urethral diverticulum or in Skene gland
TREATMENT
GENERAL MEASURES
• No treatment is necessary if the patient is asymptomatic
– Patient must understand the small risk that the diverticulum may harbor neoplastic cells
• Little is known about the natural history of untreated diverticula
• Antibiotics and analgesics may control symptoms
• With significant symptomatology, surgical excision is best
MEDICATION
First Line
• Antibiotics (eg, trimethoprim/sulfamethoxazole)
• Analgesics (eg, phenazopyridine), and antispasmodics (eg, oxybutynin) may control mild symptoms
• Surgical excision should be considered if medications are required for symptoms
Second Line
If first-line medications do not alleviate symptoms, then surgical excision is appropriate
SURGERY/OTHER PROCEDURES
• Transvaginal excision and reconstruction is the most common operation.
• Key principles of excision include:
– Well-vascularized anterior vaginal wall flap
– Preserve periurethral fascia
– Excise diverticulum completely
– Watertight, tension-free urethral closure
– Avoid overlapping suture lines
– Close dead space
– Multiple layer closure (consider Martius flap)
– Adequate bladder drainage with a urethral catheter ± suprapubic catheter
– Antimuscarinics can be used to prevent bladder spasms
• Perform simultaneous anti-incontinence procedure (fascial sling) for stress urinary incontinence (SUI) if:
– Stress incontinence is present before surgery
– Patient desires concomitant treatment
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
N/A
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• If untreated, natural history is not well known
• Reported surgical success rates 70–99%
COMPLICATIONS
• Related to the diverticulum:
– Stones
– Carcinoma: Adenocarcinoma, transitional cell, squamous cell
– Recurrent UTIs
– Dysuria
– Dyspareunia
– Urinary incontinence
– Storage or voiding symptoms
• Related to the surgery:
– Infection
– Bleeding
– Urinary incontinence
– Recurrent diverticulum
– Urethrovaginal fistula
– Urethral stricture or necrosis
– Bladder or ureteral injury
– Vaginal scarring or narrowing
FOLLOW-UP
Patient Monitoring
• VCUG after surgery at the time of catheter removal
• History and genitourinary exam on follow-up visits
• Additional studies if indicated based on history and exam findings
Patient Resources
http://www.urologyhealth.org/urology/index.cfm?article=110
REFERENCES
1. El-Nashar SA, Bacon MM, Kim-Fine S, et al. Incidence of female urethral diverticulum: A population based analysis and literature review. Int Urogynecol J. 2013;25(1):73–79.
2. Scarpero HM, Dmochowski RR, Leu PB. Female urethral diverticula. Urol Clin North Am. 2011;38(1):65–71.
3. Singla P, Long SS, Long CM, et al. Imaging of the female urethral diverticulum. Clin Radiol. 2013;68(7):428–425.
4. Thomas AA, Rackley RR, Lee U, et al. Urethral diverticula in 90 patients: A study with emphasis on neoplastic alterations. J Urol. 2008;180(6):2463–2467.
ADDITIONAL READING
Rovner ES. Urethral diverticula: A review and an update. Neurourol Urodyn. 2007;26:972–977.
See Also (Topic, Algorithm, Media)
• Dribbling, Post-Void
• Dyspareunia
• Martius Flap
• Müllerian Duct Remnants and Syndrome
• Skene (paraurethral) gland, adenocarcinoma
• Skene (paraurethral) gland, inflammation/adenitis
• Urethra, Abscess (Periurethral Abscess)
• Urethra, Carcinoma
• Urethra, Caruncle
• Urethra, Diverticular Carcinoma
• Urethra, Leiomyoma
• Urethra, Mass
• Urethra, Nephrogenic Metaplasia (Adenoma)
• Urethra, Prolapse (Female)
• Urethral Diverticula Image 
• Urinary Tract Infection (UTI), Adult Female
• Vaginal Discharge, Urologic Considerations
CODES
ICD9
• 599.2 Urethral diverticulum
• 625.0 Dyspareunia
• 788.1 Dysuria
ICD10
• N36.1 Urethral diverticulum
• N94.1 Dyspareunia
• R30.0 Dysuria
CLINICAL/SURGICAL PEARLS
• Classic symptoms include dysuria, dyspareunia, and post-void dribbling.
• Definitive management requires transvaginal excision with a multilayer closure.