This document discusses female urethral diverticula (UD). It defines UD as urine-filled cysts connected to the urethra. UD can cause a range of symptoms from asymptomatic to severe pain. The document discusses the anatomy of the female urethra and theories on the pathophysiology and etiology of UD. It describes the variability in presentation of UD and evaluations used for diagnosis including physical exam, imaging like VCUG, and cystoscopy. The document also covers differential diagnosis, indications for surgical repair, techniques for repair like excision and reconstruction, and potential postoperative complications.

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