What is Urethral Diverticulum?

Male Urinary Tract
Male urinary tract
Medical Illustration Copyright © 2015 Nucleus Medical Media, All rights reserved

Female Urinary Tract
Female urinary tract
Medical Illustration Copyright © 2015 Nucleus Medical Media, All rights reserved

Urethral diverticulum (UD) is a pocket or pouch that forms along the urethra. Because of its location, it can be filled with urine and lead to infections. It is can cause:

  • A painful vaginal mass
  • Ongoing pelvic pain
  • Many urinary tract infections (UTI)

It is rare, but more common in women between age 40 and 70. Children are not usually affected, unless they've had urethral surgery.

With better imaging, more UDs have been found and treated. Still, many cases are missed or misdiagnosed simply because no one considered it.



What Causes UD?

The cause of a UD is not clear. It is often linked to repeat infections causing weakness in the urethra wall. A block in the glands near the urethra may also cause it. Or, earlier studies point to a birth defect or trauma during childbirth.



What are the Symptoms of UD?

Up to 20% of patients with UD may not have clear signs. Symptoms are different for everyone, but the most common are:

  • Bladder or UTIs that return
  • Pelvic pain
  • Lower urinary tract symptoms (similar to an overactive bladder)
  • Nocturia (feeling the need to urinate several times at night)
  • Pain with sex
  • Dribbling
  • Blood in the urine
  • Vaginal discharge
  • Urinary blockage
  • Trouble emptying the bladder
  • Accidental loss of urine (incontinence)

Some women have a tender area or mass at the front vaginal wall. With a gentle press, urine or pus may show through the urethral opening.

It is important to note that the size of the UD doesn’t matter. In some cases, a very large UD may cause only minor symptoms. Or a small UD may still cause pain. Symptoms can also go away and come back.



How is UD Diagnosed?

Because UDs do not have clear signs, they can be found during an exam or imaging test. In some people, it can be years before the correct diagnosis is made. Patients are often misdiagnosed and treated for other things first.

A proper diagnosis can be made with:

  • An in-depth health history
  • Physical exam
  • Urine studies
  • Direct exam of the bladder and urethra (with an endoscope, or tube-like test with a light)
  • Imaging tests, such as an MRI or Ultrasound

Physical Exam

When a UD is found, the urologist may “milk” the sac to try to remove pus or urine. In women, the front vaginal wall may be felt for masses and soreness.

Imaging

Many imaging tests can be used to find UD. No single test is best. Each has pros and cons. The final choice often depends on:

  • Whether the test is available
  • How much it costs
  • The skill of the radiologist

Magnetic Resonance Imaging (MRI)

This type of test uses radio waves and a magnetic field to look closely at the urinary tract. It has the best record of finding a UD. For more information on MRI please visit our UH.org article.

Ultrasound

Using sound waves, this test may show a UD, but would need a follow-up MRI to be sure. For more information on ultrasounds please visit our UH.org article.

Urodynamic Studies

These tests measure lower urinary tract function. They may find stress urinary incontinence (SUI) (accidental loss of urine caused by pressure on the bladder) from a UD. For more information on urodynamics please visit our UH.org article.

Videourodynamic studies (that add imaging) may be able to tell why SUI is happening.



How is UD Treated?

Counseling and Monitoring

Surgery is the main way to treat UD. Still, not all cases call for surgery. Some patients may not want it, or be able to have surgery.

Not much is known about untreated UD. It is not known if the pockets will become larger or if symptoms will get worse. Some people prefer to wait until symptoms get worse before doing anything. In rare cases there have been reports of cancers growing in people with UD.

If you prefer not to have surgery, counseling and follow-up visits with your doctor is important.

Surgery

Surgical excision is the treatment of choice. It should be performed with care with an experienced urologist. The UD sac may be attached to the urethral opening. If the sac is not removed carefully, it could damage the urethra. This would lead to a major surgical repair.

Surgical options are:

  • Cutting into the sac neck
  • Creating a permanent opening of the sac into the vagina
  • Removing the sac

Other Key Issues in Surgery

  • The diverticular neck (the connection to the urethral opening) should be closed.
  • The lining of the diverticular sac should be fully removed to prevent the UD from coming back.
  • A closure with many layers is needed so a new opening doesn’t form between the urethra and vagina.
  • If you have stress urinary incontinence (SUI), a procedure to fix the leaking may be done at the same time as fixing the diverticulum.


What Can Be Expected After Treatment?

If you choose not to have surgery, you should still see your urologist for follow-up care.

If you have surgery:

  • You will have antibiotics for at least 24 hours.
  • You will be sent home with a catheter in place for 2-3 weeks.
  • You may have bladder spasms, which can be managed with drugs.

Two to 3 weeks after surgery, a voiding cystourethrogram (VCUG, an x-ray using dye) will be done.

  • If there is no fluid leaking, the catheter will be removed.
  • If fluid is seen, repeat VCUG will be done weekly until leaking ends.
  • In most cases the leaking will end in a few weeks.

Common issues after surgery are:

If UD returns, it may be due to a few things. For example: the pouching is not completely removed, the opening is not completely sealed, remaining dead space, or other technical issues. Repeat surgery can be difficult. This surgery requires a high level of technical skill.



Questions to Ask Your Doctor

What other tests will I need to confirm this diagnosis?

If I choose surgery, which do you recommend? Why?

Can you give me the name of an experienced urologist for a second opinion?

If I don’t choose surgery, is there anything I can do to prevent infections?