eMedicine Specialties > Obstetrics and Gynecology > Prolapse and Incontinence

Urethral Diverticulum: Follow-up

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

Outcome and Prognosis

Surgical outcomes with regard to urethral diverticula generally have been good; however, surgical outcomes have been reported in an inconsistent manner in the literature. Several issues create the inconsistency. First, outcome can be considered in terms of resolution of individual symptoms or in terms of recurrence of the diverticulum itself. Additionally, that recurrences can be found years after primary excision is well documented. Some recurrences may have not yet occurred at the time of case series publication. Whether or not these recurrences are due to incomplete initial treatment or the formation of completely new diverticula by reinfection and obstruction of paraurethral glands is uncertain. Finally, publication bias may be a problem. Occasionally, some urethral surgeons may have lower cure rates and might be less likely to publish results.

Given these uncertainties, an overall cure rate of 70% for symptomatic patients was cited in a recent review article.27 Successful excision by diverticulectomy can be expected in 80-90% of cases as evidenced by recurrence rates of 10-20%.

Marsupialization in properly selected patients has yielded symptomatic cure in essentially 100% of patients; however, published numbers are small. In general, treatment of distal diverticula is highly successful in terms of high cure rates and minimal complications regardless of surgical approach.

Tancer et al reported symptomatic relief and no recurrences in all of 34 patients treated with partial ablation. Follow-up was from 4 months to 10 years.26

Future and Controversies

Future research in the area of urethral diverticulum should help optimize diagnostic strategies and improve therapeutic options. Questions to be answered include the following:

  • What should be the first-line imaging study in the diagnostic workup of suspected urethral diverticulum?
  • Which imaging modality provides the most valuable anatomic information as a guide to surgical management? Will outcomes be improved with this information?
  • Are minimally invasive surgical approaches, such as transurethral unroofing, as effective and less morbid than the traditional vaginal approaches?
  • Which adjunctive surgical techniques are of value in maximizing effective treatment and minimizing complications?
  • What is the role of expectant management in treating minimally symptomatic diverticula?
  • What is the optimal treatment for diverticulum-associated carcinomas?

The main impediment to productive research is low numbers of patients in any given center. Pooling of resources and multicenter research may be the long-term answer to this dilemma.

 


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Multimedia: Urethral Diverticulum
References
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References

  1. Spence HM, Duckett JW. Diverticulum of the female urethra: clinical aspects and presentation of a simple operative technique for cure. J Urol. Sep 1970;104(3):432-7. [Medline].

  2. Davis HJ, Cian LG. Positive pressure urethrography: a new diagnostic method. J Urol. Apr 1956;75(4):753-7.

  3. Robertson JR. Gynecologic urethroscopy. Am J Obstet Gynecol. Apr 1 1973;115(7):986-90. [Medline].

  4. Blaivas JG, Flisser AJ, Bleustein CB, Panagopoulos G. Periurethral masses: etiology and diagnosis in a large series of women. Obstet Gynecol. May 2004;103(5 Pt 1):842-7. [Medline].

  5. Tancer ML, Ravski NA. Suburethral diverticulum. Clin Obstet Gynecol. Dec 1982;25(4):831-7. [Medline].

  6. Leng WW, McGuire EJ. Management of female urethral diverticula: a new classification. J Urol. Oct 1998;160(4):1297-300. [Medline].

  7. Mahdy A, Elmissiry M, Ghoniem GM. Urethral diverticulum after tension-free vaginal tape procedure: case report. Urology. Aug 2008;72(2):461.e5-6. [Medline].

  8. Hammad FT. TVT can also cause urethral diverticulum. Int Urogynecol J Pelvic Floor Dysfunct. Apr 2007;18(4):467-9. [Medline].

  9. Wang AC, Wang CR. Radiologic diagnosis and surgical treatment of urethral diverticulum in women. A reappraisal of voiding cystourethrography and positive pressure urethrography. J Reprod Med. May 2000;45(5):377-82. [Medline].

  10. Romanzi LJ, Groutz A, Blaivas JG. Urethral diverticulum in women: diverse presentations resulting in diagnostic delay and mismanagement. J Urol. Aug 2000;164(2):428-33. [Medline].

  11. Boyd SD, Raz S. Ectopic ureter presenting in midline urethral diverticulum. Urology. Jun 1993;41(6):571-4. [Medline].

  12. Huffman JW. The detailed anatomy of the paraurethral ducts in the adult human female. Am J of Obstet and Gynec. 1948;55:86-100.

  13. Jacoby K, Rowbotham RK. Double balloon positive pressure urethrography is a more sensitive test than voiding cystourethrography for diagnosing urethral diverticulum in women. J Urol. Dec 1999;162(6):2066-9. [Medline].

  14. Greenberg M, Stone D, Cochran ST. Female urethral diverticula: double-balloon catheter study. AJR Am J Roentgenol. Feb 1981;136(2):259-64. [Medline].

  15. Keefe B, Warshauer DM, Tucker MS. Diverticula of the female urethra: diagnosis by endovaginal and transperineal sonography. AJR Am J Roentgenol. Jun 1991;156(6):1195-7. [Medline].

  16. Siegel CL, Middleton WD, Teefey SA. Sonography of the female urethra. AJR Am J Roentgenol. May 1998;170(5):1269-74. [Medline].

  17. Rovner ES, Wein AJ. Diagnosis and reconstruction of the dorsal or circumferential urethral diverticulum. J Urol. Jul 2003;170(1):82-6; discussion 86. [Medline].

  18. Neitlich JD, Foster HE, Glickman MG. Detection of urethral diverticula in women: comparison of a high-resolution fast spin echo technique with double balloon urethrography. J Urol. Feb 1998;159(2):408-10. [Medline].

  19. Leach GE, Sirls LT, Ganabathi K. L N S C3: a proposed classification system for female urethral diverticula. Neurourol Urodyn. 1993;12(6):523-31. [Medline].

  20. Lichtman AS, Robertson JR. Suburethral diverticula treated by marsupialization. Obstet Gynecol. Feb 1976;47(2):203-6. [Medline].

  21. Lapides J. Transurethral treatment of urethral diverticula in women. J Urol. Jun 1979;121(6):736-8. [Medline].

  22. Chancellor MB, Liu JB, Rivas DA. Intraoperative endo-luminal ultrasound evaluation of urethral diverticula. J Urol. Jan 1995;153(1):72-5. [Medline].

  23. Ginsburg D, Genadry R. Suburethral diverticulum: classification and therapeutic considerations. Obstet Gynecol. Jun 1983;61(6):685-8. [Medline].

  24. Ganabathi K, Leach GE, Zimmern PE. Experience with the management of urethral diverticulum in 63 women. J Urol. Nov 1994;152(5 Pt 1):1445-52. [Medline].

  25. Stav K, Dwyer PL, Rosamilia A, Chao F. Urinary symptoms before and after female urethral diverticulectomy--can we predict de novo stress urinary incontinence?. J Urol. Nov 2008;180(5):2088-90. [Medline].

  26. Tancer ML, Mooppan MM, Pierre-Louis C. Suburethral diverticulum treatment by partial ablation. Obstet Gynecol. Oct 1983;62(4):511-3. [Medline].

  27. Bennett SJ. Urethral diverticula. Eur J Obstet Gynecol Reprod Biol. Apr 2000;89(2):135-9. [Medline].

  28. Baert L, Willemen P, Oyen R. Endovaginal sonography: new diagnostic approach for urethral diverticula. J Urol. Feb 1992;147(2):464-6. [Medline].

  29. Bass JS, Leach GE. Surgical treatment of concomitant urethral diverticulum and stress incontinence. Urol Clin North Am. May 1991;18(2):365-73. [Medline].

  30. Blander DS, Broderick GA, Rovner ES. Images in clinical urology. Magnetic resonance imaging of a "saddle bag" urethral diverticulum. Urology. Apr 1999;53(4):818-9. [Medline].

  31. Brandes BM, Mesrobian HG. Giant accessory female phallic urethral diverticulum. Urology. May 2006;67(5):1084.e19-21. [Medline].

  32. Catalano S, Jones I. Transitional cell carcinoma in a urethral diverticulum. Aust N Z J Obstet Gynaecol. Feb 1992;32(1):85-6. [Medline].

  33. Cea PC, Ward JN, Lavengood RW. Mesonephric adenocarcinomas in urethral diverticula. Urology. Jul 1977;10(1):58-61. [Medline].

  34. Clayton M, Siami P, Guinan P. Urethral diverticular carcinoma. Cancer. Aug 1 1992;70(3):665-70. [Medline].

  35. Daneshgari F, Zimmern PE, Jacomides L. Magnetic resonance imaging detection of symptomatic noncommunicating intraurethral wall diverticula in women. J Urol. Apr 1999;161(4):1259-61; discussion 1261-2. [Medline].

  36. Davis HJ, Telinde RW. Urethral diverticula: an assay of 121 cases. J Urol. Jul 1958;80(1):34-9.

  37. Dias P, Hillard P, Rauh J. Skene's gland abscess with suburethral diverticulum in an adolescent. J Adolesc Health Care. Jul 1987;8(4):372-5. [Medline].

  38. Drutz HP. Urethral diverticula. Obstet Gynecol Clin North Am. Dec 1989;16(4):923-9. [Medline].

  39. Ellik M. Diverticulum of the female urethra: a new method of ablation. J Urol. Feb 1957;77(2):243-6.

  40. Evans KJ, McCarthy MP, Sands JP. Adenocarcinoma of a female urethral diverticulum: case report and review of the literature. J Urol. Jul 1981;126(1):124-6. [Medline].

  41. Faerber GJ. Urethral diverticulectomy and pubovaginal sling for simultaneous treatment of urethral diverticulum and intrinsic sphincter deficiency. Tech Urol. Dec 1998;4(4):192-7. [Medline].

  42. Fall M. Vaginal wall bipedicled flap and other techniques in complicated urethral diverticulum and urethrovaginal fistula. J Am Coll Surg. Feb 1995;180(2):150-6. [Medline].

  43. Fortunato P, Schettini M, Gallucci M. Diverticula of the female urethra. Br J Urol. Oct 1997;80(4):628-32. [Medline].

  44. Fujikawa K, Matsui Y, Fukuzawa S. A case of female large urethral diverticulum treated by electrofulguration. Int J Urol. Dec 1999;6(12):620-2. [Medline].

  45. Geisler E, Basu A, Abughaida A. Mesonephric carcinoma arising from a female urethral diverticulum. Br J Urol. Apr 1998;81(4):637-8. [Medline].

  46. Ginsburg DS, Genadry R. Suburethral diverticulum in the female. Obstet Gynecol Surv. Jan 1984;39(1):1-7. [Medline].

  47. Gittes RF, Nakamura RM. Female urethral syndrome. A female prostatitis?. West J Med. May 1996;164(5):435-8. [Medline].

  48. Goldman HB, Mandell BF, Volk EE, Rackley RR, Appell RA. Urethral diverticulum: an unusual presentation of Wegener's granulomatosis. J Urol. Mar 1999;161(3):917-8. [Medline].

  49. Guidi HG, Montelatto NI, Ribeiro RM. The treatment of female urethral diverticulum with calculus through ultrasonic lithotripsy. Int J Gynaecol Obstet. Jun 1993;41(3):277-81. [Medline].

  50. Hickey N, Murphy J, Herschorn S. Carcinoma in a urethral diverticulum: magnetic resonance imaging and sonographic appearance. Urology. Apr 2000;55(4):588-9. [Medline].

  51. Hricak H, Secaf E, Buckley DW. Female urethra: MR imaging. Radiology. Feb 1991;178(2):527-35. [Medline].

  52. Huffman JW. Clinical significance of the paraurethral ducts and glands. Archives of Surgery. 1951;62:615-626.

  53. Iula G, Stefano ML, Castaldi L. Postirradiation female urethral diverticula: diagnosis by voiding endovaginal sonography. J Clin Ultrasound. Jan 1995;23(1):63-5. [Medline].

  54. Jensen LM, Aabech J, Lundvall F. Female urethral diverticulum. Clinical aspects and a presentation of 15 cases. Acta Obstet Gynecol Scand. Sep 1996;75(8):748-52. [Medline].

  55. Julian TM. Simple examination techniques to aid in the diagnosis of urethral diverticulum. Obstet Gynecol. Nov 1990;76(5 Pt 2):910-2. [Medline].

  56. Kato H, Ogihara S, Kobayashi Y. Carcinoembryonic antigen positive adenocarcinoma of a female urethral diverticulum: case report and review of the literature. Int J Urol. May 1998;5(3):291-3. [Medline].

  57. Kim B, Hricak H, Tanagho EA. Diagnosis of urethral diverticula in women: value of MR imaging. AJR Am J Roentgenol. Oct 1993;161(4):809-15. [Medline].

  58. Klutke CG, Akdman EI, Brown JJ. Nephrogenic adenoma arising from a urethral diverticulum: magnetic resonance features. Urology. Feb 1995;45(2):323-5. [Medline].

  59. Kohorn EI, Glickman MG. Technical aids in investigation and management of urethral diverticula in the female. Urology. Oct 1992;40(4):322-5. [Medline].

  60. Lee RA. Diverticulum of the urethra: clinical presentation, diagnosis, and management. Clin Obstet Gynecol. Jun 1984;27(2):490-8. [Medline].

  61. Lopez Rasines G, Rico Gutierrez M, Abascal Abascal F. Female urethra diverticula: value of transrectal sonography. J Clin Ultrasound. Feb 1996;24(2):90-2. [Medline].

  62. Martensson O, Duchek M. Translabial ultrasonography with pulsed colour-Doppler in the diagnosis of female urethral diverticula. Scand J Urol Nephrol. Mar 1994;28(1):101-4. [Medline].

  63. Martinez-Maestre A, Gonzalez-Cejudo C, Canada-Pulido E. Giant calculus in a female urethral diverticulum. Int Urogynecol J Pelvic Floor Dysfunct. 2000;11(1):45-7. [Medline].

  64. Medeiros LJ, Young RH. Nephrogenic adenoma arising in urethral diverticula. A report of five cases. Arch Pathol Lab Med. Feb 1989;113(2):125-8. [Medline].

  65. Miskowiak J, Honnens de Lichtenberg M. Transurethral incision of urethral diverticulum in the female. Scand J Urol Nephrol. 1989;23(3):235-7. [Medline].

  66. Mizrahi S, Bitterman W. Transvaginal, periurethral injection of polytetrafluoroethylene (polytef) in the treatment of urethral diverticula. Br J Urol. Sep 1988;62(3):280. [Medline].

  67. Mouritsen L, Bernstein I. Vaginal ultrasonography: a diagnostic tool for urethral diverticulum. Acta Obstet Gynecol Scand. Feb 1996;75(2):188-90. [Medline].

  68. Mueller EJ, Drake GL. A new surgical procedure for the removal of the wide mouthed urethral diverticulum in females. Surg Gynecol Obstet. Mar 1989;168(3):269-70. [Medline].

  69. Nakamura Y, Takahashi M, Suga A. A case of adenocarcinoma arising within a urethral diverticulum diagnosed only by the surgical specimen. Gynecol Obstet Invest. 1995;40(1):69-70. [Medline].

  70. Niemiec TR, Mercer LJ, Stephens JK. Unusual urethral diverticulum lined by colonic epithelium with Paneth cell metaplasia. Am J Obstet Gynecol. Jan 1989;160(1):186-8. [Medline].

  71. Nurenberg P, Zimmern PE. Role of MR imaging with transrectal coil in the evaluation of complex urethral abnormalities. AJR Am J Roentgenol. Nov 1997;169(5):1335-8. [Medline].

  72. Ogihara S, Kato H. Endocrine cell distribution and expression of tissue-associated antigens in human female paraurethral duct: possible clue to the origin of urethral diverticular cancer. Int J Urol. Jan 2000;7(1):10-5. [Medline].

  73. Paik SS, Lee JD. Nephrogenic adenoma arising in an urethral diverticulum. Br J Urol. Jul 1997;80(1):150. [Medline].

  74. Patanaphan V, Prempree T, Sewchand W. Adenocarcinoma arising in female urethral diverticulum. Urology. Sep 1983;22(3):259-64. [Medline].

  75. Pauwels M, Wyndaele JJ. Female urethral diverticula: a report of 5 cases. Acta Urol Belg. Sep 1996;64(3):27-31. [Medline].

  76. Perlmutter S, Huang AB, Hon M. Sonographic demonstration of calculi within a urethral diverticulum. Urology. Dec 1993;42(6):735-7. [Medline].

  77. Peters W, Vaughan ED. Urethral Diverticulum in the Female. Etiologic Factors and Postoperative Results. Obstet Gynecol. May 1976;47(5):549-52. [Medline].

  78. Rajan N, Tucci P, Mallouh C. Carcinoma in female urethral diverticulum: case reports and review of management. J Urol. Dec 1993;150(6):1911-4. [Medline].

  79. Ramahi AJ, Richardson DA, Ataya KM. Urethral stones in women. A case report. J Reprod Med. Sep 1993;38(9):743-6. [Medline].

  80. Reuter KL, Young SB, Colby J. Transperineal sonography in the assessment of a urethral diverticulum. J Clin Ultrasound. Mar-Apr 1992;20(3):221-3. [Medline].

  81. Reuter KL, Young SB, Davidoff A. Magnetic resonance imaging of an infected urethral diverticulum: a case report. Magn Reson Imaging. 1991;9(6):955-7. [Medline].

  82. Seballos RM, Rich RR. Clear cell adenocarcinoma arising from a urethral diverticulum. J Urol. Jun 1995;153(6):1914-5. [Medline].

  83. Sholem SL, Wechsler M, Roberts M. Management of the urethral diverticulum in women: a modified operative technique. J Urol. Oct 1974;112(4):485-6. [Medline].

  84. Siegelman ES, Banner MP, Ramchandani P. Multicoil MR imaging of symptomatic female urethral and periurethral disease. Radiographics. Mar-Apr 1997;17(2):349-65. [Medline].

  85. Steinberg JB, Remis RE, Roy JB. Urethral diverticula in women: an update with a case presentation. Mil Med. Aug 1988;153(8):424-6. [Medline].

  86. Stewart M, Bretland PM, Stidolph NE. Urethral diverticula in the adult female. Br J Urol. Aug 1981;53(4):353-9. [Medline].

  87. Summitt RL, Stovall TG. Urethral diverticula: evaluation by urethral pressure profilometry, cystourethroscopy, and the voiding cystourethrogram. Obstet Gynecol. Oct 1992;80(4):695-9. [Medline].

  88. Swierzewski SJ, McGuire EJ. Pubovaginal sling for treatment of female stress urinary incontinence complicated by urethral diverticulum. J Urol. May 1993;149(5):1012-4. [Medline].

  89. Tancer ML. Bulbocavernosus fat pad interposition: The Martius operation. J Pelvic Surg. 1996;4:205-207.

  90. Tancer ML. Suburethral diverticulum treatment by partial ablation. J Pelvic Sug. 1996;2:32-35.

  91. Thomas RB, Maguire B. Adenocarcinoma in a female urethral diverticulum. Aust N Z J Surg. Nov 1991;61(11):869-71. [Medline].

  92. Tines SC, Bigongiari LR, Weigel JW. Carcinoma in diverticulum of the female urethra. AJR Am J Roentgenol. Mar 1982;138(3):582-5. [Medline].

  93. Townsend RR, Meacham RB, Drose JA. Color Doppler evaluation of urethral diverticulum. J Ultrasound Med. Apr 1994;13(4):309-11. [Medline].

  94. Vargas-Serrano B, Cortina-Moreno B, Rodriguez-Romero R. Transrectal ultrasonography in the diagnosis of urethral diverticula in women. J Clin Ultrasound. Jan 1997;25(1):21-8. [Medline].

  95. Vargas-Serrano B, Rodriguez-Romero R, Burgos F. Nephrogenic adenoma in urethral diverticulum in a woman. J Clin Ultrasound. May 1994;22(4):268-70. [Medline].

  96. Vergunst H, Blom JH, De Spiegeleer AH. Management of female urethral diverticula by transurethral incision. Br J Urol. May 1996;77(5):745-6. [Medline].

  97. Ward JN. Technique to visualize urethral diverticula in female patients. Surg Gynecol Obstet. Mar 1989;168(3):278-9. [Medline].

  98. Ward JN, Draper JW, Tovell HM. Diagnosis and treatment of urethral diverticula in the female. Surg Gynecol Obstet. Dec 1967;125(6):1293-300. [Medline].

  99. Wexler JS, McGovern TP. Ultrasonography of female urethral diverticula. AJR Am J Roentgenol. Apr 1980;134(4):737-40. [Medline].

  100. Wittich AC. Excision of urethral diverticulum calculi in a pregnant patient on an outpatient basis. J Am Osteopath Assoc. Aug 1997;97(8):461-2. [Medline].

  101. Young RH. Pseudoneoplastic lesions of the urinary bladder and urethra: a selective review with emphasis on recent information. Semin Diagn Pathol. May 1997;14(2):133-46. [Medline].

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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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