Urethral Diverticulum

Suffering from recurrent urinary tract infections or experiencing urinary problems? Then perhaps small, bulging pouches along the urethra are the cause. Read on to learn more about what problems they can cause.

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What is urethral diverticulum?
Urethral diverticulum (UD) is a condition in which a variably sized "pocket" or outpouching forms next to the urethra. Because it most often connects to the urethra, this outpouching repeatedly gets filled with urine during the act of urination thus causing symptoms.

Who usually gets urethral diverticulum?
It is much more common in females then in males and usually appears between the ages of 40 and 70. Occurrence in children is extremely rare in the absence of prior urethral surgery.

How common is urethral diverticulum?
With the development of sophisticated imaging techniques, the diagnosis of UD has become increasingly common. However, the true prevalence in any given population is still not known since many cases are missed or misdiagnosed simply because no one suspected it.

What causes urethral diverticulum?
The origin of acquired UD has recently been attributed to repeated infections and/or obstruction of the periurethral glands with subsequent obstruction eventually evolving into UD. Although some earlier studies have suggested congenital causes or trauma experienced during childbirth.

What are the symptoms of urethral diverticulum?
Although symptoms are highly variable, the most common symptoms are irritative (i.e., frequency, urgency and dysuria) lower urinary tract symptoms (LUTS). Dyspareunia will be noted by 12 to 24 percent of patients and approximately five to 32 percent of patients will complain of post-void dribbling. Recurrent cystitis or urinary tract infection is also a frequent symptom in one-third of patients. Other complaints include pain, hematuria, vaginal discharge, obstructive symptoms or urinary retention and incontinence (stress or urge). Up to 20 percent of patients diagnosed with UD may not have noticeable symptoms. Some patients may also have a tender anterior vaginal wall mass, which upon gentle compression may reveal retained urine or pus discharge through the urethral opening.

It is important to note that the size of the UD does not correlate with symptoms. In some cases, very large UD may result in minimal symptoms, and conversely, some UD that are non-palpable may result in considerable discomfort and distress.

Finally, symptoms may come and go and may even disappear for long periods of time.

What is urethral diverticulum diagnosed?
Since many of the symptoms associated with UD are non-specific, patients may often be misdiagnosed and treated for years for a number of unrelated conditions before the diagnosis of UD is made. This may include therapies for interstitial cystitis, recurrent cystitis, vulvodynia, endometriosis, vulvovestibulitis and other conditions.

The diagnosis and complete evaluation of UD can be made through a combination of thorough history, physical examination, appropriate urine studies, endoscopic examination of the bladder and urethra and selected radiologic imaging.

A number of imaging techniques have been applied to the study of UD and no single study can be considered the gold standard or optimal imaging study for the evaluation of UD. Each technique has relative advantages and disadvantages, and the ultimate choice of diagnostic study in many centers often depends on several factors including local availability, cost and the experience and expertise of the radiologist. Currently available techniques for the evaluation of UD include double-balloon positive-pressure urethrography (PPU), voiding cystourethrography (VCUG), ultrasound (US) and magnetic resonance imaging (MRI) with or without an endoluminal coil (eMRI).

A urodynamic study may also be used in selected cases and may document the presence or absence of stress urinary incontinence prior to repair. A videourodynamic study may also be used as a diagnostic tool. The type of study combines both a voiding cystourethrogram and a urodynamic study thus consolidating the diagnostic evaluation and decreasing the number of required urethral catheterizations during a patient's clinical work-up. In addition, videourodynamic evaluation may be able to differentiate true stress incontinence from pseudo-incontinence related to emptying of a UD with physical activity.

During physical examination, the urethra may be "milked" distally in an attempt to express pus or urine from the UD cavity. For females, during physical examination, the anterior vaginal wall may be carefully felt for masses and tenderness.

How is urethral diverticulum treated?
Although often highly symptomatic, not all urethral diverticula require surgical excision (removal). Some patients may not have noticeable symptoms and the UD was incidentally diagnosed on imaging for another condition or during a routine physical examination. While other patients may be unwilling or medically unable to undergo surgical removal.

Very little is known regarding the natural history of untreated UD-whether they will grow in size, complexity or if symptoms will increase over time is unknown. For these reasons, and due to the lack of symptoms in selected cases, some patients may not desire surgical treatment. However, there have been recent reports of carcinomas arising in UD thus patient counseling and ongoing monitoring is recommended in patients who elect not to undergo surgical treatment.

Surgical options include transurethral incision of the diverticular neck, marsupialization (creation of permanent opening) of the diverticular sac into the vagina [often referred to as a Spence procedure], and surgical excision.

Surgical excision is the treatment of choice but it should be performed with caution. The diverticular sac may be quite attached to the adjacent urethral lumen and careless removal of the sac may result in a large urethral defect requiring construction of a new urethra. Other important considerations during surgery include identification and closure of the diverticular neck (connection to the urethral lumen), complete removal of the mucosal lining of the diverticular sac to prevent recurrence, and a multiple layered closure to prevent postoperative urethrovaginal fistula formation (formation of an abnormal opening between the urethra and vagina).

What can be expected after treatment for urethral diverticulum?
For those patients who elect not to undergo surgical treatment, it is recommended that they continue to be monitored by their urologist.

Patients who are treated surgically can expect to be on antibiotics for 24 hours postoperatively and discharged home with both urethral and suprapubic catheters. Antispasmodics are used liberally to reduce bladder spasms. A VCUG is obtained at 14 to 21 days postoperatively. If there is no extravasation, the catheters are removed. If extravasation is seen, then the urethral catheter is reinserted and repeat VCUGs are performed weekly until resolution is noted. In the vast majority of cases, extravasation will resolve in several weeks with this type of conservative management. Common implications may arise from surgical treatment and may include recurrent UTIs, urinary incontinence or recurrent UD. In females, urethrovaginal fistula is a devastating complication of urethral diverticulectomy and deserves special mention.

Some patients will have persistence or recurrence of their preoperative symptoms postoperatively. The finding of a UD following a presumably successful urethral diverticulectomy may occur as a result of a new UD, or alternatively, as a result of recurrence. Recurrence of UD may be due to incomplete removal of the UD, inadequate closure of the urethra or residual dead space or other technical factors. Repeat urethral diverticulectomy surgery can be challenging, as anatomic planes may be difficult to identify.

Reviewed April 2010

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Glossary Terms

anterior:
	At or near the front.
antibiotic:
	Drug that kills bacteria or prevents them from multiplying.
bladder:
	The bladder is a thick muscular balloon-shaped pouch in which urine is stored before being discharged through the urethra.
carcinoma:
	Cancer that begins in the skin or in tissues that line or cover body organs.
catheter:
	A thin tube that is inserted through the urethra into the bladder to allow urine to drain or for performance of a procedure or test, such as insertion of a substance during a bladder X-ray.
catheterization:
	Insertion of a narrow tube through the urethra or through the front of the abdominal wall into the bladder to allow urine drainage.
congenital:
	Present at birth.
continence:
	The ability to control the timing of urination or a bowel movement.
cyst:
	An abnormal sac containing gas, fluid or a semisolid material. Cysts may form in kidneys or other parts of the body.
cystitis:
	Also known as bladder infection. Urinary tract infection involving the bladder, which causes inflammation of the bladder and results in pain and a burning feeling in the pelvis or urethra.
cystourethrogram:
	Also called a voiding cystogram. A specific X-ray that examines the urinary tract. A catheter (hollows tube) is placed in the urethra (tube that drains urine from the bladder to the outside of the body)and the bladder is filled with a liquid dye. X-ray images are taken as the bladder fills and empties. The X-rays will show if there is any reverse flow of urine into the ureters and kidneys.
distal:
	Location of urethral opening between the middle or the penile shaft and the head of the penis (glans).
distally:
	Far from the center; remote.
diverticula:
	Plural of diverticulum. A pouch or sac in the lining of the mucous membrane of an organ.
diverticulum:
	A pouch or sac in the lining of the mucous membrane of an organ.
dysuria:
	Painful or difficult urination, most frequently caused by infection or inflammation but it can also be caused by certain drugs.
endoluminal coil:
	Coil that is placed near the tissue of interest.
endometriosis:
	Cells that normally grow inside the uterus grow outside the uterus instead.
endoscopic:
	A procedure performed in order to examine the bladder.
excision:
	Surgical cut.
extravasation:
	Process of passing urine.
fistula:
	An abnormal opening between two organs (between the bladder and vagina in women or the bladder and the rectum in men).
frequency:
	The need to urinate more often than is normal.
gland:
	A mass of cells or an organ that removes substances from the bloodstream and excretes them or secretes them back into the blood with a specific physiological purpose.
hematuria:
	Blood in the urine, which can be a sign of a kidney stone or other urinary problem. Gross hematuria is blood that is visible to the naked eye. Microscopic hematuria cannot be seen but is detected on a urine test.
incision:
	Surgical cut for entering the body to perform an operation.
incontinence:
	Loss of bladder or bowel control; the accidental loss of urine or feces.
infection:
	A condition resulting from the presence of bacteria or other microorganisms.
interstitial cystitis:
	Also referred to as IC and painful bladder syndrome. A disorder that causes the bladder wall to become swollen and irritated, leading to scarring and stiffening of the bladder, decreased bladder capacity, and, in rare cases, ulcers in the bladder lining.
ions:
	Electrically charged atoms.
magnetic resonance imaging:
	Also referred to a MRI. A diagnostic procedure that uses a combination of large magnets, radiofrequencies and a computer to produce detailed images of organs and structures within the body.
MRI:
	Also referred to a magnetic resonance imaging. A diagnostic procedure that uses a combination of large magnets, radiofrequencies and a computer to produce detailed images of organs and structures within the body.
palpable:
	Able to be felt by the hands especially during medical examination.
periurethral:
	Lining of the urethra.
pus:
	The yellowish or greenish fluid that forms at sites of infection.
radiologic:
	X-ray.
radiologist:
	Doctor specializing in the interpretation of X-rays and other scanning techniques for the diagnosis of disorders.
retention:
	In ability to empty urine from the bladder, which can be caused by atonic bladder or obstruction of the urethra.
stress incontinence:
	Also referred to as stress urinary incontinence. The most common type of incontinence that involves the leakage of urine caused by actions--such as coughing, laughing, sneezing, runnig or lifting--that put pressure on the bladder from inside the body. Can result from either a fallen bladder or weak sphincter muscles.
stress urinary incontinence:
	Also referred to as stress incontinence. The most common type of incontinence that involves the leakage of urine caused by actions--such as coughing, laughing, sneezing, runnig or lifting--that put pressure on the bladder from inside the body. Can result from either a fallen bladder or weak sphincter muscles.
suprapubic:
	An area of the central lower abdomen above the bony pelvis and overlying the bladder.
transurethral:
	Through the urethra. Several transurethral procedures are used for treatment of BPH. (See TUIP, TUMT, TUNA or TURP.)
ultrasound:
	Also referred to as a sonogram. A technique that bounces painless sound waves off organs to create an image of their structure to detect abnormalities.
urethra:
	A tube that carries urine from the bladder to the outside of the body. In males, the urethra serves as the channel through which semen is ejaculated and it extends from the bladder to the tip of the penis. In females, the urethra is much shorter than in males.
urethral:
	Relating to the urethra, the tube tha carries urine from the bladder to outside the body.
urethral diverticulum:
	A sac-like or tubular growth caused by a weakened area in the urethra.
urethral lumen:
	Urethral opening.
urethrography:
	X-ray examination of the urethra involving radiopaque fluid used to detect any narrowing or other abnormalities.
urethrovaginal:
	Between the urethra and vagina.
urge:
	Strong desire to urinate.
urgency:
	Strong desire to urinate.
urinary:
	Relating to urine.
urinary incontinence:
	Inability to control urination.
urinary incontinence:
	Inability to control urination.
urinary problems:
	Abnormal urination patterns or bladder habits, including wetting, dribbling and other urination control problems.
urinary retention:
	Failure to empty the bladder totally.
urinary tract:
	The system that takes wastes from the blood and carries them out of the body in the form of urine. Passageway from the kidneys to the ureters, bladder and urethra.
urinary tract infection:
	Also referred to as UTI. An illness caused by harmful bacteria, viruses or yeast growing in the urinary tract.
urination:
	The passing of urine.
urine:
	Liquid waste product filtered from the blood by the kidneys, stored in the bladder and expelled from the body through the urethra by the act of urinating (voiding). About 96 percent of which is water and the rest waste products.
urologist:
	A doctor who specializes in diseases of the male and female urinary systems and the male reproductive system. Click here to learn more about urologists. (Download the free Acrobat reader.)
UTI:
	Also referred to as urinary tract infection. An illness caused by harmful bacteria growing in the urinary tract.
vagina:
	The tube in a woman's body that runs beside the urethra and connects the uterus (womb)to the outside of the body. Sometimes called the birth canal. Sexual intercourse, the outflow of blood during menstruation and the birth of a baby all take place through the vagina.
vas:
	Also referred to as vas deferens. The cordlike structure that carries sperm from the testicle to the urethra.
VCUG:
	Also referred to as voiding cystourethrogram or voiding cystogram. A catheter is placed in the urethra and the bladder is filled with a contrast dye. X-ray images are taken as the bladder fills and empties to show any blockage or reverse urine flow.
void:
	To urinate, empty the bladder.
voiding:
	Urinating.
voiding cystourethrogram:
	Also referred to as VCUG or voiding cystogram. A specific X-ray that examines the urinary tract. A catheter (hollows tube) is placed in the urethra (tube that drains urine from the bladder to the outside of the body)and the bladder is filled with a liquid dye. X-ray images are taken as the bladder fills and empties. The X-rays will show if there is any reverse flow of urine into the ureters and kidneys.
voiding cystourethrography:
	Also referred to as voiding cystourethrogram or voiding cystogram. A catheter is placed in the urethra and the bladder is filled with a contrast dye. X-ray images are taken as the bladder fills and empties to show any blockage or reverse urine flow.
vulvodynia:
	Chronic vulvar pain usually accompanied by complaints of burning and irritation.

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