Skip to main content

Advertisement

SpringerLink
Log in

Female Urethral Diverticulum: Current Diagnosis and Management

  • Lower Urinary Tract Symptoms & Voiding Dysfunction (H Goldman and G Badlani, Section Editors)
  • Published:
Current Urology Reports Aims and scope Submit manuscript

Abstract

While urethral diverticulum (UD) affects less than 20 per 1,000,000 women overall, it is thought to represent 1.4 % of women with incontinence presenting to urology practices. It is hypothesized to evolve from periurethral glands that become obstructed, infected, and dilated over time, and patients typically present with dyspareunia, bothersome lower urinary tract symptoms (LUTS), and/or recurrent UTIs. In many patients, a periurethral mass can be appreciated on exam. In recent years, magnetic resonance imaging (MRI) has become the imaging test of choice for diagnosis of UD, but ultrasound (US) is a readily available alternative and provides good specificity at a lower cost. Surgical excision of the diverticulum with tension-free, water-tight, three-layer closure continues to be the mainstay of treatment of UD with most studies reporting cure rates of >90 %. Concomitant treatment of preexisting stress incontinence with autologous fascial pubovaginal sling can be used at the time of diverticulectomy to avoid a secondary procedure. However, since secondary anti-incontinence procedures are needed in only a small number of patients, up-front stress incontinence treatment may result in significant overtreatment, and staged anti-incontinence procedures continue to be a reasonable option for patients with persistent bothersome stress urinary incontinence (SUI) after diverticulectomy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. El-Nashar SA, Bacon MM, Kim-Fine S, Weaver AL, Gebhart JB, Klingele CJ. Incidence of female urethral diverticulum: a population-based analysis and literature review. Int Urogynecol J. 2014;25:73–9.

    Article  PubMed Central  PubMed  Google Scholar 

  2. Burrows LJ, Howden NL, Meyn L, Weber AM. Surgical procedures for urethral diverticula in women in the United States, 1979–1997. Int Urogynecol J Pelvic Floor Dysfunct. 2005;16:158–61.

    Article  PubMed  Google Scholar 

  3. Aldridge Jr CW, Beaton JH, Nanzig RP. A review of office urethroscopy and cystometry. Am J Obstet Gynecol. 1978;131:432–7.

    PubMed  Google Scholar 

  4. Blaivas JG, Flisser AJ, Bleustein CB, Panagopoulos G. Periurethral masses: etiology and diagnosis in a large series of women. Obstet Gynecol. 2004;103:842–7.

    Article  PubMed  Google Scholar 

  5. Reeves FA, Inman RD, Chapple CR. Management of symptomatic urethral diverticula in women: a single-centre experience. Eur Urol. 2014;66:164–72. This study is one of the largest recent series describing single center experience in management of UD. It provides an excellent overview of the symptoms and diagnosis of UD, compares use of MRI vs. US, and describes surgical techniques and outcomes. It is especially valuable because none of the patients in this series had concomitant anti-incontinence procedure; however, 20 of the 32 patients with pre-operative SUI had resolution of SUI post operatively. Additionally, of the 25 patients with post-operative SUI (12 patients with persistent SUI and 13 de novo SUI), only 13 (52%) desired treatment. This indicates that placement of concomitant sling may result in a significant rate of overtreatment of SUI.

    Article  PubMed  Google Scholar 

  6. Davis BL, Robinson DG. Diverticula of the female urethra: assay of 120 cases. J Urol. 1970;104:850–3.

    CAS  PubMed  Google Scholar 

  7. Huffman JW. The detailed anatomy of the para-urethral ducts in the adult human female. Am J Obstet Gynecol. 1948;55:86–101.

    CAS  PubMed  Google Scholar 

  8. Leach GE, Bavendam TG. Female urethral diverticula. J Urol. 1987;30:407–15.

    Article  CAS  Google Scholar 

  9. Gera PK, Matthews K, Smith G. Urethral diverticulum in a female child. J Pediatr Urol. 2007;3:148–50.

    Article  PubMed  Google Scholar 

  10. Marshall S. Urethral diverticula in young girls. J Urol. 1981;17:243–5.

    Article  CAS  Google Scholar 

  11. Williams DI, Woodard JR. Problems in the management of ectopic ureteroceles. J Urol. 1964;92:635–52.

    CAS  PubMed  Google Scholar 

  12. Silk MR, Lebowitz JM. Anterior urethral diverticulum. J Urol. 1969;101:66–7.

    CAS  PubMed  Google Scholar 

  13. Stav K, Dwyer PL, Rosamilia A, Chao F. Urinary symptoms before and after female urethral diverticulectomy—can we predict de novo stress urinary incontinence? J Urol. 2008;180:2088–90.

    Article  PubMed  Google Scholar 

  14. Romanzi LJ, Groutz A, Blaivas JG. Urethral diverticulum in women: diverse presentations resulting in diagnostic delay and mismanagement. J Urol. 2000;164:428–33.

    Article  CAS  PubMed  Google Scholar 

  15. Thomas AA, Rackley RR, Lee U, Goldman HB, Vasavada SP, Hansel DE. Urethral diverticula in 90 female patients: a study with emphasis on neoplastic alterations. J Urol. 2008;180:2463–7.

    Article  PubMed  Google Scholar 

  16. Ljungqvist L, Peeker R, Fall M. Female urethral diverticulum: 26-year followup of a large series. J Urol. 2007;177:219–24. discussion 224.

    Article  PubMed  Google Scholar 

  17. Shalev M, Mistry S, Kernen K, Miles BJ. Squamous cell carcinoma in a female urethral diverticulum. J Urol. 2002;59:773.

    Article  Google Scholar 

  18. Kim B, Hricak H, Tanagho EA. Diagnosis of urethral diverticula in women: value of mr imaging. AJR Am J Roentgenol. 1993;161:809–15.

    Article  CAS  PubMed  Google Scholar 

  19. Ganabathi K, Leach GE, Zimmern PE, Dmochowski R. Experience with the management of urethral diverticulum in 63 women. J Urol. 1994;152:1445–52.

    CAS  PubMed  Google Scholar 

  20. Golomb J, Leibovitch I, Mor Y, Morag B, Ramon J. Comparison of voiding cystourethrography and double-balloon urethrography in the diagnosis of complex female urethral diverticula. Eur Radiol. 2003;13:536–42.

    PubMed  Google Scholar 

  21. Ockrim JL, Allen DJ, Shah PJ, Greenwell TJ. A tertiary experience of urethral diverticulectomy: diagnosis, imaging and surgical outcomes. BJU Int. 2009;103:1550–4.

    Article  PubMed  Google Scholar 

  22. Gugliotta G, Calagna G, Adile G, Polito S, Speciale P, Perino A, et al. Use of trans-labial ultrasound in the diagnosis of female urethral diverticula: a diagnostic option to be strongly considered. J Obstet Gynaecol Res. 2015;41(7):1108–14. In this series, the authors describe their experience with the use of trans-labial US for diagnosis and follow-up of UD. They have done an excellent job at describing the details of trans-labial US technique and outlined US characteristics of UD and other lesions on differential diagnosis for anterior vaginal wall mass. They provide evidence for US use in follow-up of patients with UD and demonstrate great results. This article is very useful for readers looking to implement the use of US in their UD management algorithm.

    Article  PubMed  Google Scholar 

  23. El-Zein C, Khoury N, El-Zein Y, Bulbul M, Birjawi G. Intraoperative translabial ultrasound for urethral diverticula: a road map for surgeons. Eur J Radiol. 2009;70:133–7.

    Article  CAS  PubMed  Google Scholar 

  24. Foster RT, Amundsen CL, Webster GD. The utility of magnetic resonance imaging for diagnosis and surgical planning before transvaginal periurethral diverticulectomy in women. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18:315–9.

    Article  PubMed  Google Scholar 

  25. Blander DS, Rovner ES, Schnall MD, Ramchandani P, Banner MP, Broderick GA, et al. Endoluminal magnetic resonance imaging in the evaluation of urethral diverticula in women. J Urol. 2001;57:660–5.

    Article  CAS  Google Scholar 

  26. Chung DE, Purohit RS, Girshman J, Blaivas JG. Urethral diverticula in women: discrepancies between magnetic resonance imaging and surgical findings. J Urol. 2010;183:2265–9.

    Article  PubMed  Google Scholar 

  27. Ingber MS, Firoozi F, Vasavada SP, Ching CB, Goldman HB, Moore CK, et al. Surgically corrected urethral diverticula: long-term voiding dysfunction and reoperation rates. J Urol. 2011;77:65–9.

    Article  Google Scholar 

  28. Spence HM, Duckett Jr JW. Diverticulum of the female urethra: clinical aspects and presentation of a simple operative technique for cure. J Urol. 1970;104:432–7.

    CAS  PubMed  Google Scholar 

  29. Lapides J. Transurethral treatment of urethral diverticula in women. Trans Am Assoc Genitourin Surg. 1978;70:135–7.

    CAS  PubMed  Google Scholar 

  30. Saito S. Usefulness of diagnosis by the urethroscopy under anesthesia and effect of transurethral electrocoagulation in symptomatic female urethral diverticula. Eur J Endocrinol / Endod Soc. 2000;14:455–7.

    CAS  Google Scholar 

  31. Vergunst H, Blom JH, De Spiegeleer AH, Miranda SI. Management of female urethral diverticula by transurethral incision. Br J Urol. 1996;77:745–6.

    Article  CAS  PubMed  Google Scholar 

  32. Busch FM, Carter FH. Vaginal flap incision for urethral diverticulectomy. J Urol. 1974;111:773.

    CAS  PubMed  Google Scholar 

  33. Leach GE, Schmidbauer CP, Hadley HR, Staskin DR, Zimmern P, Raz S. Surgical treatment of female urethral diverticulum. Semin Urol. 1986;4:33–42.

    CAS  PubMed  Google Scholar 

  34. Han DH, Jeong YS, Choo MS, Lee KS. Outcomes of surgery of female urethral diverticula classified using magnetic resonance imaging. Eur Urol. 2007;51:1664–70.

    Article  PubMed  Google Scholar 

  35. Faerber GJ. Urethral diverticulectomy and pubovaginal sling for simultaneous treatment of urethral diverticulum and intrinsic sphincter deficiency. Tech Urol. 1998;4:192–7.

    CAS  PubMed  Google Scholar 

  36. Scarpero HM, Dmochowski RR, Leu PB. Female urethral diverticula. Urol Clin North Am. 2011;38:65–71. vi.

    Article  PubMed  Google Scholar 

  37. Nickles SW, Ikwuezunma G, MacLachlan L, El-Zawahry A, Rames R, Rovner E. Simple vs complex urethral diverticulum: presentation and outcomes. Urology. 2014;84:1516–9. This article examines differences between complex and simple diverticula. Specifically, the authors found that patients with complex diverticula were more likely to present with stress urinary incontinence and more likely to have post-operative UTI. Additionally, this study describes complete transection of the urethral and end-to-end anastomosis for management of complex diverticula, which allows for complete resection of otherwise unresectable UD, and demonstrates the feasibility and safety of this technique.

    Article  PubMed  Google Scholar 

  38. Porpiglia F, Destefanis P, Fiori C, Fontana D. Preoperative risk factors for surgery female urethral diverticula. Our experience Urol Int. 2002;69:7–11.

    Article  PubMed  Google Scholar 

  39. Swierzewski 3rd SJ, McGuire EJ. Pubovaginal sling for treatment of female stress urinary incontinence complicated by urethral diverticulum. J Urol. 1993;149:1012–4.

    PubMed  Google Scholar 

  40. Enemchukwu E, Lai C, Reynolds WS, Kaufman M, Dmochowski R. Autologous pubovaginal sling for the treatment of concomitant female urethral diverticula and stress urinary incontinence. J Urol. 2015;85:1300–3. This is the largest series published to date of outcomes after concomitant anti-incontinence procedure at the time of UD repair. While retrospective, the study describes the safety of an anti-incontinence procedure at the time of diverticulectomy and demonstrates that good outcomes can be achieved with minimal complications. Additionally, the authors provide an excellent summary and discussion of prior studies examining outcomes after concomitant anti-incontinence procedures at the time of diverticulectomy.

    Article  Google Scholar 

  41. Dmochowski RR, Blaivas JM, Gormley EA, Juma S, Karram MM, Lightner DJ, et al. Update of aua guideline on the surgical management of female stress urinary incontinence. J Urol. 2010;183:1906–14.

    Article  PubMed  Google Scholar 

  42. Lee UJ, Goldman H, Moore C, Daneshgari F, Rackley RR, Vasavada SP. Rate of de novo stress urinary incontinence after urethal diverticulum repair. J Urol. 2008;71:849–53.

    Article  Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

Iryna M. Crescenze declares no potential conflicts of interest.

Howard B Goldman is a section editor for Current Urology Reports.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information

Authors and Affiliations

  1. Glickman Kidney and Urological Institute Cleveland Clinic, Lerner College of Medicine, 9500 Euclid Ave, Q10-1, Cleveland, OH, 44195, USA

    Iryna M. Crescenze & Howard B. Goldman

Authors
  1. Iryna M. Crescenze
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Howard B. Goldman
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Howard B. Goldman.

Additional information

This article is part of the Topical Collection on Lower Urinary Tract Symptoms & Voiding Dysfunction

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Crescenze, I.M., Goldman, H.B. Female Urethral Diverticulum: Current Diagnosis and Management. Curr Urol Rep 16, 71 (2015). https://doi.org/10.1007/s11934-015-0540-8

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11934-015-0540-8

Keywords

Search

Navigation