Female urethral diverticulum

1. FEMALE URETHRAL DIVERTICULA
Dr Nawaz Ali

2. Definition
Urethral diverticula(UD) in female patients are variably
sized, urine-filled periurethral cystic structures adjacent to
the urethra within the confines of the pelvic fascia,
connected to the urethra via an ostium.
Completely asymptomatic, incidentally noted lesions on
physical examination or imaging, to very debilitating
conditions like painful vaginal masses associated with
incontinence, stones, severe dyspareunia, and/or tumors.

3. Anatomy of the Female Urethra
A musculofascial tube approximately 3 to 4 cm in
length,
extending from the bladder neck to the external urethral
meatus,
suspended from the pelvic sidewall and pelvic fascia
(tendinous arc of the obturator muscle) by a sheet of
connective tissue known as the urethropelvic ligament.

4. Urethropelvic ligament
An abdominal side (the endopelvic fascia)
A vaginal side (the periurethral fascia).
Within and between these two leaves of fascia lie the
urethra and the location of most UD.

5.  Within the thick, vascular lamina propria/ submucosal layer
are the periurethral glands.
 These tubuloalveolar glands exist over the entire length of
the urethra posterolaterally; however, they are most
prominent over the distal two-thirds.
 It is from pathological processes
involving the periurethral glands
that most acquired female UD are
thought to originate.

6. The urethra has several muscular layers: an internal
longitudinal smooth muscle layer, an outer circular smooth
muscle layer, and a skeletal muscle layer.
The skeletal muscle component
spans much of the length of the
urethra but is more prominent in
the middle third.
It has a U-shaped configuration,
deficient dorsally.
The location and competence of the urethral sphincters have
important implications when considering surgical repair of
UD because of the anatomic overlap of these two entities.

7. Pathophysiology and Etiology
As conceptualized by Young and Wahle (1996), UD
represent a cavity dissecting within the confines of the
fascia of the urethropelvic ligament.
This defect is often an isolated cyst like appendage with
a single discrete connection to the urethral lumen known
as the neck or ostium.
However complicated anatomic patterns may exist,
o Saddlebag UD
o Circumferential UD

8. Multiple different morphologies of urethral
diverticulum (UD)

9. The exact origin of UD is still unproven, whether UD were
congenital or acquired lesions??
The vast majority of UD, however, are classified as
acquired and are diagnosed in adult females.
There are multiple theories regarding the formation of
acquired UD.
The result of trauma from vaginal childbirth (McNally,
1935) ── an old concept
Pathophysiology and Etiology

10. The periurethral glands are thought to be the probable site of
origin of acquired UD (Young and Wahle, 1996).
What are these periurethral glands ??
As located primarily dorsolateral
to the urethra, arborizing proximally
along the urethra and draining into
ducts located in the distal one-third
of the urethra
Pathophysiology and Etiology

11. Infection of the periurethral glands seems to the most
generally accepted common etiologic factor in most cases.
Recurrent infection of the periurethral glands, with
obstruction, suburethral abscess formation, and subsequent
rupture of these infected glands into the urethral lumen.
Reinfection, inflammation, and recurrent obstruction of the
neck of the cavity are theorized to result in patient symptoms
and enlargement of the diverticulum.
Pathophysiology and Etiology

12. This expansion occurs most commonly ventrally, resulting
in the classic anterior vaginal wall mass palpated on physical
examination in some patients with UD.
Eventually, the abscess cavity ruptures into the urethral
lumen, resulting in the communication between the UD and
the urethral lumen.
Pathophysiology and Etiology

13. Prevalence
The true prevalence of female UD, however, is not
known; it is reported to occur in up to 1% to 6% of adult
females in some series.

14. Diverticular Anatomy and Histology
The interior surface of UD may be urothelial, squamous,
columnar, or cuboidal epithelium, or mixed
Most UD demonstrate benign histopathology, but
premalignant and malignant changes can be seen.
Approximately 10% of urethral diverticulectomy specimens
may demonstrate significant histopathologic abnormalities,
including metaplasia, dysplasia, or frank carcinoma, which
require long-term follow-up or additional therapy

15. The most common malignant pathology in UD is
adenocarcinoma, followed by urothelial cell and squamous
cell carcinomas.
Calculi within UD are not uncommon and may be
diagnosed in 4% to 10% of cases.

17. Presentation
The majority of patients with UD are seen initially
between the third and seventh decades of life.
The classic presentation of UD has been described
historically as the “three Ds”—dysuria, dyspareunia and
dribbling (postvoid) ── 5% only
Now variable presentation with the most
common symptoms are irritative lower LUTS(e.g.,
frequency, urgency), pain, and infection.

18. Presentation
 Dyspareunia in 12% to 24% of patients
 Postvoid dribbling in 5 to 32%
 Recurrent cystitis or UTI 30% to 46%
Other complaints include
o pain,
o a vaginal mass, hematuria, vaginal discharge,
obstructive symptoms,
o or urinary retention.
 Notably, up to 10% to 20% of patients diagnosed
with UD may be completely asymptomatic, having the
lesions diagnosed incidentally on imaging or physical
examination

19. Evaluation and Diagnosis
The diagnosis of UD can be made with a combination of a
thorough
 History and physical examination,
 Appropriate urine studies (including urine culture and
analysis),
 Endoscopic examination of the bladder and urethra, and
 Selected radiologic imaging.
 A urodynamic study may also be helpful in completing
the evaluation in selected cases

20. History and physical examination
 Lower urinary tract symptoms, hematuria
 Prior diagnostic studies,
 Prior pelvic surgery, esp. incontinence procedures;
(bulking agents, use of sling procedures etc)
 Urinary incontinence and type ?
 Sexual function and
 Dyspareunia

21. Exammination
 The anterior vaginal wall should be carefully palpated
for masses and tenderness.
 The location, size and consistency of any suspected
UD should be recorded.
 Gently “stripped” or “milked” urethra distally
 The vaginal walls are assessed for atrophy, rugation,
and elasticity.
 The distal vagina and vaginal introitus are also
assessed for capacity.
 Provocative measures to elicit incontinence and
presence or absence of prolapse

22. Urine Studies
Urine analysis and culture should be performed.
E. Coli most common
Urine cytology ── suspect malignancy
Cystourethroscopy :
o CPE is performed in an attempt to visualize the UD
ostium as well as to evaluate for other causes for the
patient’s lower urinary tract symptoms.
o The UD ostium is most often located posterolaterally at
the 4 and 8 o’clock positions at level of the mid-urethra

23. Urodynamics:
Approximately one-third of women with UD are seen
initially with symptoms of urinary incontinence, and up to
50% of women with UD demonstrate SUI on urodynamic
evaluation

24. Imaging
Currently available techniques for the evaluation of UD
include :
 Double-balloon PPU,
 VCUG,
 Intravenous urography ,
 Ultrasonography and
 MRI with or without an endoluminal coil.

25. Double-balloon PPU
 A highly specialized catheter (Trattner catheter) with
two balloons separated by several centimeters .
 No need for patient
voiding
 Not widely
used clinically

26. VCUG
 Widely available and is a familiar diagnostic technique
to most radiologists.
Limitations:
Invasive,
Painful
Must void to image
UD ostia must be patent to
image
Poor stream will underestimate
size, loculations(?)

27. Intravenous Urography or CT urogram
 Intravenous urography or CT urogram may be
considered in patients in whom it is necessary to delineate
the upper urinary tract
or
 To evaluate for the possibility of a congenital ectopic
ureteral anomaly as the cause of an anterior vaginal wall
mass

28. Ultrasonography
Abdominal, transvaginal, translabial and transurethral
techniques have been described.
Transvaginal imaging often provides information
regarding the size and location of UD.
The UD appears as an anechoic or hypoechoic area with
enhanced through-transmission.
However the limitations are operator dependent and
images lack precise “surgical anatomy”

29. Magnetic Resonance Imaging
 UD appear as areas of decreased signal intensity on T1
images compared with the surrounding soft tissues and
have high signal intensity on T2 images.
 Surface coil MRI and eMRI appear to be superior to
VCUG and/or PPU in the evaluation of UD

30. Differential Diagnosis: Periurethral Masses
Vaginal Leiomyoma.
freely mobile, firm, nontender
masses on the anterior vaginal
wall.
fourth to fifth decade.
Excision or enucleation

31. Skene Gland Abnormalities.
Skene gland cysts and Abscesses
 Small, cystic masses
 Just lateral or inferolateral
to the urethral meatus
 Extremely tender and
inflamed
 No communication
 Young to middle-age
female patients

32. Gartner Duct Abnormalities.
 Mesonephric remnants and are found on
the anterolateral vaginal wall from the cervix to
the introitus.
 They may drain ectopic ureters
from poorly functioning or
nonfunctioning upper pole
moieties
 Upper tract evaluation
is recommended

33. Vaginal Wall Cysts.
 The derivation of the cyst was mullerian in 44%,
epidermoid in 23%, and mesonephric in 11%.
 Multiple cell types:
o Mesonephric (Gartner duct cysts),
o Paramesonephric (mullerian),
o Endometriotic,
o Urothelial, or
o Epidermoid (inclusion cyst).
 Postmenopausal women and
prepubertal girls

34. Urethral Caruncle
 An inflammatory lesion of the distal urethra
 Postmenopausal women
 Reddish exophytic mass at
the urethral meatus
 Etiologically, they are
related to mucosal prolapse
 Consevative Mx and in rare
case need excision

35. Periurethral Bulking Agents.
 The transurethral or periurethral injection of bulking
agents for the treatment of stress incontinence may result
in an anterior vaginal wall mass that appears cystic on
imaging, consistent with a UD.

37. Urethral Diverticula and Stress Urinary
Incontinence
 7% and 16%
 Risk factors for de novo SUI may include
o The size of the diverticulum (>30 mm),
o More proximal location and
o Circumferential configuration
 A concomitant anti-incontinence surgery can be offered
 Synthetic materials (e.g., mid-urethral polypropylene mesh)
should not be used
 Autologous pubovaginal fascial slings provide satisfactory
outcomes

38. Surgical Repair of Female Urethral
Diverticula
Indications for Repair
Symptomatic patients, including those with dysuria,
refractory bothersome postvoid dribbling, recurrent UTIs,
dyspareunia, and pelvic pain, may be offered surgical
excision.

39. Techniques for Repair
Approaches include
 Transurethral marsupialization (Davis et al., 1970) and
open marsupialization ( Spence and Duckett, 1970)
 Endoscopic unroofing (Spencer and Streem, 1987),
 Fulguration (Saito, 2000),
 Incision and obliteration with oxidized cellulose
(Ellick,1957)
 Excision of UD with reconstruction

40. Excision and Reconstruction
Excision and reconstruction is probably the most common
surgical approach to UD in the modern
era.

41. Preoperative Preparation.
 Prophylactic antibiotics
 Application of topical estrogen creams for several weeks
before surgery may be beneficial in postmenopausal atrophic
vaginitis.
 Video-urodynamics can often accurately differentiate and
characterize true SUI from postvoid dribbling, vaginal
voiding, and false incontinence resulting from urine
discharge from a urine-filled UD.

43. Postoperative Care.
 Antibiotics are continued for 24 hours postoperatively.
 The vaginal packing is removed and the patient
discharged home with closed urinary drainage.
 Antispasmodics are used liberally to reduce bladder
spasms.
 A pericatheter VCUG is obtained at 14 to 21 days
postoperatively.
 If there is no extravasation, the catheters are removed.

44. Complications
 Overall, common complications include recurrent UTIs,
urinary incontinence, or recurrent UD
 Urethrovaginal fistula is an uncommon but distressing
complication.

45. Thank you