eMedicine Specialties > Obstetrics and Gynecology > Prolapse and Incontinence

Urethral Diverticulum: Workup

Author: Michael O'Shaughnessy, MD, FACOG, Assistant Chief, Director of Urogynecology, Assistant Clinical Professor, Department of Obstetrics and Gynecology, University of California at San Francisco, UCSF Fresno University Medical Center
Contributor Information and Disclosures

Updated: Mar 19, 2009

Workup

Laboratory Studies

  • Urinalysis and culture
    • A urethral diverticulum acts as an excellent reservoir in which urine can stagnate. As such, recurrent UTIs are common in patients with this disorder.
    • Preoperatively, determine the presence of bacteria in the urine and treat if found.
    • The presence of hematuria without other findings consistent with bacterial infection or colonization could indicate a stone or malignancy within the diverticulum.
  • Urine cytology
    • Although not a routine test in all patients with a known or suspected diverticulum, obtain urine cytology if findings suggest an associated malignancy. Such findings include a mass within the diverticulum, filling defects on imaging studies, or unexplained hematuria.
    • Consider a positive result significant and investigate further. However, a negative result does not rule out the presence of coexisting malignancy.

Imaging Studies

  • Voiding cystourethrography
    • Voiding cystourethrography (VCUG) is one of the most commonly used imaging studies in the workup of suspected urethral diverticula. The range of diagnostic accuracy reported in the literature is 44-95.2%, with an overall accuracy of approximately 65%.
    • The procedure generally is performed in the upright position. Obtain filling, voiding, and postvoid films. Sometimes, the diverticulum fills during the voiding phase, and the diverticulum is best visualized on postvoid films.
    • Because the test is simple, relatively noninvasive, and painless, many experts recommend performing this imaging study first, reserving positive-pressure urethrography for cases in which findings on VCUG are negative and urethral diverticulum still is strongly suspected.
    • In one small study using this approach, physicians diagnosed 90% of diverticula using VCUG. One additional diverticulum was found using positive-pressure urethrography as a backup test. Others argue that the 90% or greater diagnostic accuracy of positive-pressure urethrography makes it the imaging study of choice in all suspected cases.
  • Positive-pressure urethrography
    • Double balloon positive-pressure urethrography has been a mainstay in the diagnosis of urethral diverticula since the 1950s. In a recent study of 32 women, positive-pressure urethrography was 100% sensitive in the diagnosis of urethral diverticulum, versus 44% for VCUG.13
    • The technical steps of performing positive-pressure urethrography are relatively simple. With an empty bladder, a triple-channel double balloon catheter of the Trattner or Davis variety is placed. Both balloons are inflated with air or diluted liquid contrast. The intravesical balloon is filled first and then pulled snugly against the urethrovesical junction. The balloon at the external urethral meatus is inflated next. Dye then is injected through the middle port of the catheter in order to fill the isolated urethral lumen. This is performed under fluoroscopic control with permanent films obtained as indicated (see Media file 2).

      A mid-to-proximal urethral diverticulum demonstra...

      A mid-to-proximal urethral diverticulum demonstrated on a positive-pressure urethrogram.

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      A mid-to-proximal urethral diverticulum demonstra...

      A mid-to-proximal urethral diverticulum demonstrated on a positive-pressure urethrogram.

    • In a recent study, the possibility of performing this procedure with minimal discomfort was demonstrated when viscous lidocaine jelly was used as a urethral anesthetic and lubricant. In addition, the cost of positive-pressure urethrography was found to be the same as VCUG.
    • Several studies have demonstrated that small and very small (several mm in diameter) diverticula can be visualized using this method. Many patients with small diverticula in these studies were minimally symptomatic or asymptomatic. Supposed small diverticula possibly may represent artificially distended, but otherwise normal, paraurethral glands. Overdiagnosis and overtreatment could result in these instances. Another potential shortcoming of positive-pressure urethrography is missing diverticula that have not yet developed ostia.
    • In 1980, Greenberg et al undertook a study of 51 women with lower urinary tract symptoms. They performed double balloon catheter studies on all patients and described 6 distinct patterns.14
      • Patients with type I findings had normal appearing urethras with essentially the same caliber throughout.
      • Patients with type II findings had distal urethral ballooning. One patient in this group had findings consistent with urethritis, but all others had negative findings on urethroscopy and physical examinations.
      • Patients with type III findings had proximal ballooning or funneling at the urethrovesical junction, but workup findings were negative otherwise.
      • Type IV findings included filling of the distal periurethral glands, with 2 of 4 patients showing physical signs of Skene gland tenderness.
      • Patients with type V findings had localized, broad-based outpouchings of the urethra, which were of unclear clinical significance. This finding appears possibly to be similar to what Leng and McGuire later described as a pseudodiverticulum.
      • Patients with type VI findings had urethral diverticula, most of which had identifiable ostia on urethroscopy.
    • This diagnostic modality is not perfect; interpret any positive or negative results in light of other clinical or radiographic findings. In the author's opinion, the test should not be ordered unless a suburethral mass can be appreciated on physical examination or urethral diverticulum is strongly suspected based on the findings of other tests or studies. One of the greatest strengths of positive-pressure urethrography may be in further characterizing the anatomy of a known diverticulum as part of good preoperative planning.
  • Ultrasonography
    • Ultrasonography (US) imaging of urethral diverticula can be performed using transabdominal, endovaginal, transperineal and/or translabial, and transrectal techniques. Recently, catheter-based endourethral imaging has been added to the list of possible techniques. US can provide precise measurements of the size of the lesion, the number of loculations, and the orientation and location with respect to the urethra. In some cases, US can be used to visualize the connection between the diverticulum and urethra. Also, US can be used to help differentiate solid from cystic suburethral masses, identify stones within diverticula, and visualize intraluminal masses. The relative noninvasiveness and low cost of this imaging method are potential advantages.
    • The best route for examining potential diverticula has not been established. Transabdominal US generally is agreed to be suboptimal, especially with small (<2 cm) lesions. Transvaginal US has been useful for some, but not all, investigators. Direct compression of the urethra and diverticulum may be a problem. The transrectal approach has many strong advocates. Improved visualization of the periurethral area has been cited as one substantial advantage. Transperineal or translabial US is performed by placing the imaging probe between the labia minora and directly on the external urethral meatus. This may be the route of choice with distal diverticula, although the transrectal approach actually may allow probe placement closer to the lesion in cases of proximal urethral diverticula.
    • In small case series, US appears to compare favorably with more traditional imaging techniques such as positive-pressure urethrography and VCUG. In an early series, 5 of 5 diverticula originally visualized with urethrography techniques could be visualized by endovaginal or transperineal US.15 More recently, in a series of 19 women, use of both VCUG and US allowed identification of 13 of 15 patients with urethral diverticula. In addition, US was used to identify 2 Skene gland cysts, a periurethral leiomyomata, and a case of diffuse urethritis. In this study, transvaginal and transperineal scanning was used. Also, a catheter-based endourethral probe was employed in some cases. Importantly, with US, the neck of the diverticulum was identified in 13 of the 15 cases, and it was identified using VCUG in only 2 instances.16
    • Techniques have been described to enhance US visualization of urethral diverticula. Imaging can be performed before, during, and after voiding. Filling and expansion of the sac can be observed in this way. Also, US can be performed after injecting the sac with fluid, with or without contrast material. Color Doppler US of urethral diverticula recently has been reported. Identification of abnormal blood vessels and blood flow patterns may increase the preoperative index of suspicion for malignancy. Also, identification of diverticular ostia may be enhanced during retrograde urethral filling using color Doppler techniques.
    • US appears to be a promising diagnostic modality in cases of suspected urethral diverticulum. It also may be useful in better defining diverticular and peridiverticular anatomy prior to surgery. Some investigators argue that US should be the initial imaging method of choice. More research is needed to define the role of US in diagnosis and treatment of urethral diverticulum precisely.
  • Magnetic resonance imaging
    • MRI is an excellent method of securing a diagnosis when traditional workup of an anterior vaginal wall mass has yielded inconclusive results. In many of these instances, no ostia are evident on urethroscopy and findings on both VCUG and positive-pressure urethrography are negative. In these cases, consider other types of vaginal wall cysts or masses in addition to the diagnosis of urethral diverticulum. Multiplanar imaging capabilities and superb tissue contrast are properties of MRI that can aid in differentiating soft tissue masses from cysts.

      T1-weighted images may demonstrate urethral diverticula, but they are represented only as a urethral enlargement with a homogeneous, low signal density. Administration of gadolinium-based contrast material enhances the urethral tissues and allows better definition of the internal architecture of the lesion. T2-weighted images may be more effective when detecting urethral diverticula because the lumen appears hyperdense and the wall projects a low signal density. Diffusion-weighted MRI has been reported to demonstrate a urethral diverticulum yielding clear and detailed images. Occasionally, diverticular ostia are discernible, but not reliably so. Other anterior vaginal wall masses, such as leiomyomata, endometriomas, and urethral tumors, can display characteristic MRI appearances as well.
    • Endoluminal magnetic resonance imaging (eMRI) as described in one small case series appeared useful in imaging complex diverticula such as dorsal (anterior) or circumferential lesions. Although these complex diverticula are relatively rare, they may be more common than was once believed, especially in cases of recurrent diverticula. This series identification of a complex diverticulum led to a change in operative approach, which, in the authors opinion, contributed to improved outcomes.17
    • In one small study of 13 patients, findings on double balloon urethrography were compared to findings on MRI using a high-resolution fast spin echo technique as a primary diagnostic modality for suspected urethral diverticulum. Of the 4 surgically confirmed diverticula, all were detected using the MRI technique, whereas only 1 was observed on double balloon urethrography. The authors state that the major disadvantage of the MRI is cost.18 Technical difficulties and patient pain are cited as drawbacks to double balloon studies.
    • A case series of 3 symptomatic women with small diverticula (1-5 mm) detected using MRI was published recently. In this series, no apparent communication with the urethra could be found on urethroscopy or urethrography. All lesions responded to surgery, and specimens revealed transitional cell–lined cysts. The authors surmised that perhaps they had made the diagnosis early in the disease process and prior to rupture of the retention cysts back into the urethra.
    • Much larger comparative studies are needed to define the role of MRI in the primary workup of suspected urethral diverticula. Recent reports show great promise as a noninvasive means of diagnosis.
  • Intravenous pyelography (IVP) can be useful in cases in which a urethral diverticulum must be differentiated from an ectopic ureter with ureterocele. If the findings on IVP are negative for an ectopic ureter, postvoiding images may reveal a urethral diverticulum if present.

Other Tests

  • Urethral pressure profilometry
    • A characteristic double camel hump configuration can be observed in approximately 30-100% of cases of urethral diverticulum (see Media file 3). This finding is due to a fall in intraurethral pressure, which is recorded as the transducer passes through the location within the urethra that contains the diverticular ostium. This sign may not be present if the ostium is occluded and is less likely if the transducer is oriented away from the ostium. Occasionally, unsuspected diverticula are discovered due to this finding. Also, urethral pressure profilometry (UPP) findings can aid in mapping the anatomical location of the ostium along the anatomic and functional length of the urethra. In particular, UPP tracings can be useful in determining whether the intraurethral opening into the diverticulum is distal to the peak in urethral closure pressure and thus distal to the bulk of the urethral rhabdosphincter. In such cases, the patient may be a candidate for simple marsupialization of the diverticulum.

      A urethral pressure profile in a patient with a u...

      A urethral pressure profile in a patient with a urethral diverticulum that displays a mid peak decrease in pressure.

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      A urethral pressure profile in a patient with a u...

      A urethral pressure profile in a patient with a urethral diverticulum that displays a mid peak decrease in pressure.

    • One study demonstrated similar findings between this technique and urethroscopy in determining which third of the urethra contained the ostium. However, the authors reported that this technique cannot be used to determine the precise location of the ostium along the urethra. They argue that at least part of the pressure depression observed on UPP was due to the larger muscular defect in the urethral wall that accompanies the smaller mucosal defect represented by the ostium. Also, they found that 2 of 3 patients that ultimately were proven not to have urethral diverticula had suspicious pressure depressions. They concluded that UPP is not useful in the diagnosis of urethral diverticula because of an unacceptably high false-positive rate and a relatively low specificity (80%) for the disorder. They also argue that the UPP has no benefit over urethroscopy as an aid to surgical planning.
  • Other urodynamic studies: The presence of stress or urge incontinence symptoms or voiding dysfunction should prompt performance of additional urodynamic tests. Such tests include cystometry, leak point pressures, uroflowmetry, and stress testing. Individualize tests to each case.

Diagnostic Procedures

  • Urethroscopy
    • Urethroscopy can be useful in diagnosing a suspected diverticulum; on occasion, its use may reveal the presence of an unsuspected lesion. Characteristically, a defect in the urethra, ie, the diverticular ostia, is observed (see Media file 4). Most commonly, the ostia are located in the posterior or posterolateral wall of the urethra. Simultaneous massage of the posterior urethra sometimes results in expulsion of purulent material into the urethral lumen, thereby enhancing localization of the ostia. In addition, positive-pressure urethroscopy can enhance visualization by causing the ostia to balloon open. This technique is performed by occluding the urethra proximal to the urethroscope while filling the urethra with sodium chloride solution or carbon dioxide gas. The instrument is withdrawn slowly while carefully checking the urethra for defects.

      Urethral diverticulum. A wide-mouthed ostium with...

      Urethral diverticulum. A wide-mouthed ostium with visible stones demonstrated on positive-pressure urethroscopy.

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      Urethral diverticulum. A wide-mouthed ostium with...

      Urethral diverticulum. A wide-mouthed ostium with visible stones demonstrated on positive-pressure urethroscopy.

    • In addition to diagnosing urethral diverticula, urethroscopy can be important in further characterizing known lesions. For example, the location, size, and number of ostia sometimes can be ascertained on urethroscopy. A technique of grasping the shaft of the urethroscope outside the external meatus at the point where the ostium is just visualized during withdrawal of the instrument has been used to estimate the distance from the meatus to the ostium. However, in some instances, diverticular ostia may not be appreciated on urethroscopy. The ostia may be too small or, if early in the natural history of the disorder, may have yet to develop. Also, visualization may be obscured by inflammatory debris or blood.
  • Milking of the urethra
    • This simple maneuver is performed on physical examination and requires no special equipment. The urethra is massaged, or milked, with the examiner's gloved index finger beginning at the bladder neck and proceeding from proximal to distal. Simultaneously, the urethral meatus is examined visually for expulsion of purulent material or cloudy urine.
    • In one small series of 15 cases of proven urethral diverticula, this maneuver produced positive results in 80% of patients.
  • Urethral or diverticular biopsy
    • Strongly consider obtaining a biopsy of a urethral diverticulum prior to excision procedures if an associated solid component that is not a stone can be identified.
    • If the diverticular ostium is wide, visualizing an intraluminal mass urethroscopically and obtaining a biopsy with flexible forceps sometimes is possible. Transvaginal biopsy is another option.
    • If a diverticulectomy specimen reveals cancer, performing urethroscopy with biopsies is recommended prior to planning subsequent therapy. At times, bladder or vaginal biopsies may be indicated also.

Histologic Findings

Histologic findings in excised urethral diverticula may be fairly nonspecific. Usually, varying degrees of inflammatory infiltration of the deeper tissue layers, such as the urethral submucosa and muscularis, are present. The epithelial lining, when identifiable, most often is transitional but may be focally cuboidal. Columnar and squamous epithelium also has been reported. Some authorities believe that the type of epithelium found in the paraurethral ducts should reflect the type of epithelium found in the adjacent urethral segment. Using this conceptual framework, squamous epithelium should be more common in distal urethral diverticula and transitional epithelium should be more common in proximal lesions. In the author's experience, this idea has never been tested formally in pathologic specimens from urethral diverticula. Due to destruction by acute and chronic inflammation, lack of identifiable epithelial lining on pathology specimens from urethral diverticula is not uncommon.

About one third of nephrogenic adenomas found in the female urethra are located within a urethral diverticulum. Microscopic examination reveals the typical tubular, cystic, and papillary patterns. These are believed to be metaplastic changes due to chronic infection and inflammation. At times, differentiating nephrogenic adenoma from clear cell adenocarcinoma may be difficult when found within a diverticulum.

A single case of Wegener granulomatosis diagnosed, in part, by the histologic findings in a urethral diverticulum has been reported. In this case, microscopic examination of the excised lesion revealed geographic necrosis with neutrophilic debris and vasculitis. Urethral diverticula with histologic findings consistent with endometriosis and colonic epithelium have been described as well.

More on Urethral Diverticulum

Overview: Urethral Diverticulum
Workup: Urethral Diverticulum
Treatment: Urethral Diverticulum
Follow-up: Urethral Diverticulum
Multimedia: Urethral Diverticulum
References
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Further Reading

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Keywords

urethral diverticulum, suburethral diverticulum, urethral diverticula, chronic cystitis, cystitis glandularis, glandular metaplasia, focal hyperplasia, pseudodiverticulum, paraurethral glands, obstruction of paraurethral ducts, suburethral cysts

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Contributor Information and Disclosures

Author

Michael O'Shaughnessy, MD, FACOG, Assistant Chief, Director of Urogynecology, Assistant Clinical Professor, Department of Obstetrics and Gynecology, University of California at San Francisco, UCSF Fresno University Medical Center
Michael O'Shaughnessy, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Urological Association, Association of Professors of Gynecology and Obstetrics, California Medical Association, and Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey B Garris, MD, Chief, Assistant Professor, Department of Obstetrics and Gynecology, Division of Urogynecology and Reconstructive Pelvic Surgery, Tulane University School of Medicine
Jeffrey B Garris, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, American Urological Association, Association of Professors of Gynecology and Obstetrics, Louisiana State Medical Society, Royal Society of Medicine, and Sigma Xi
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gail F Whitman-Elia, MD, Professor, Department of Obstetrics and Gynecology, University of South Carolina School of Medicine
Gail F Whitman-Elia, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Clinical Endocrinologists, American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, American Medical Women's Association, American Public Health Association, American Society for Reproductive Medicine, Endocrine Society, and South Carolina Medical Association
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

 
 
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