Urethral Diverticula Workup

  • Author: Sandip P Vasavada, MD; Chief Editor: Edward David Kim, MD, FACS   more...
 
Updated: Sep 19, 2011
 

Laboratory Studies

  • Urine culture: Obtain urine culture to exclude coexisting urinary tract infection.
  • Fluid culture: When possible, obtain culture of the expressed fluid from the diverticulum so that appropriate antibiotics may be used.
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Imaging Studies

  • Voiding cystourethrography
    • The most helpful plain film radiologic study is a properly performed voiding cystourethrography (VCUG).
    • The study should be performed under fluoroscopic control with the patient sitting or standing in an oblique position.
    • This study aids in defining the location, size, and number of diverticula present.
    • The presence of filling defects within the diverticulum may suggest the possibility of urethral calculi or a tumor.
  • Retrograde urethrography using a double-balloon catheter
    • Retrograde urethrography using a double-balloon catheter may be useful if a suspected diverticulum cannot be observed on a VCUG.
    • This technique has been popular in the past but has fallen out favor because retrograde positive-pressure urethrography is technically difficult to perform and is usually painful. However, this procedure may be performed under general anesthesia, if desired. This procedure has largely been replaced by MRI.
  • MRI: This imaging study has emerged as the criterion standard in diagnostic imaging for urethral diverticula, as it reveals the extent and location of the diverticula. In patients with strongly suspect symptoms, MRI seems to demonstrate the diverticulum with the highest sensitivity and specificity of any of the imaging modalities. Furthermore, planar technology allows the exact ostium to be identified prospectively in many cases and can give the operating surgeon a “roadmap” from which to guide the operative intervention.[3]
  • Intravenous pyelography and CT urography
    • Urethral diverticula have been noted incidentally on intravenous pyelography (IVP) relatively infrequently.
    • Postvoid radiography from an IVP may reveal a collection of contrast below the urinary bladder consistent with urethral diverticulum.
    • While IVP is not recommended as a routine imaging study to document urethral diverticulum, it is useful when ectopic ureterocele is suspected.
    • CT urography may be better since it offers more planes of view; however, no studies to date have confirmed it should be used routinely in the evaluation of suspect diverticula.
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Diagnostic Procedures

  • Urodynamics
    • Consider urodynamic studies in patients with symptoms of stress urinary incontinence or overactive bladder.
    • Patients with overactive bladder may require anticholinergic therapy to control irritative voiding symptoms.
  • Cystoscopy
    • Cystourethroscopy is often performed using a short beaked female urethroscope with a 0° lens. Alternatively, flexible cystoscopy or a urethrotome sheath may be used. Constant water flow and bladder neck occlusion during urethroscopy allows the entire urethra to be distended to enhance visualization.
    • Simultaneous digital compression of the urethral diverticulum may cause active drainage of pus into the urethral lumen, allowing identification of the communication site.
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Contributor Information and Disclosures
Author

Sandip P Vasavada, MD  Physician, Associate Professor of Surgery, Cleveland Clinic Lerner College of Medicine, Center for Female Urology and Genitourinary Reconstructive Surgery, The Glickman Urological and Kidney Institute; Joint Appointment with Women's Institute, Cleveland Clinic

Sandip P Vasavada, MD is a member of the following medical societies: American Urogynecologic Society, American Urological Association, International Continence Society, Society for Urology and Engineering, and Society of Urodynamics and Female Urology

Disclosure: Pfizer Consulting fee Speaking and teaching; NDI Medical, LLC Ownership interest Review panel membership; AMS Consulting fee Consulting

Coauthor(s)

Raymond Rackley, MD  Professor of Surgery, Cleveland Clinic Lerner College of Medicine; Staff Physician, Center for Pelvic Medicine and Pelvic Reconstruction, Glickman Urological Institute, Joint Appointment with Women's Institute Cleveland Clinic Foundation

Raymond Rackley, MD is a member of the following medical societies: American Urological Association

Disclosure: Pfizer, Novartis, Proctor & Gamble, Allergan Honoraria None; Pfizer, Novartis, Proctor & Gamble, Allergan Consulting fee Other

Specialty Editor Board

Allen Donald Seftel  MD, Professor of Urology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School; Head, Division of Urology, Director, Urology Residency Training Program, Cooper University Hospital

Allen Donald Seftel is a member of the following medical societies: American Urological Association

Disclosure: lilly Consulting fee Consulting; sanofi-aventis Consulting fee Consulting; auxilium Consulting fee Consulting; solvay Consulting fee Consulting; plethora Grant/research funds clinical trial; endo Consulting fee Consulting; nature publishing journal editor

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark Jeffrey Noble, MD  Consulting Staff, Urologic Institute, Cleveland Clinic Foundation

Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, and Southwest Oncology Group

Disclosure: Nothing to disclose.

J Stuart Wolf Jr, MD, FACS  The David A Bloom Professor of Urology, Director, Division of Endourology and Stone Disease, Department of Urology, University of Michigan Medical School

J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS  Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Sexual Medicine Society of North America, and Tennessee Medical Association

Disclosure: Lilly Consulting fee Advisor; Astellas Consulting fee Speaking and teaching; Watson Consulting fee Speaking and teaching; Allergan Consulting fee Speaking and teaching

References

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  3. Dwarkasing RS, Dinkelaar W, Hop WC, et al. MRI evaluation of urethral diverticula and differential diagnosis in symptomatic women. AJR Am J Roentgenol. Sep 2011;197(3):676-82. [Medline].

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The urethral diverticulum is shown as spherical mass at the distal urethra.
Voiding cystourethrogram reveals contrast pooling in a urethral diverticulum. The urethral diverticulum is located well away from the bladder neck at the distal urethra.
The anterior vaginal wall and the periurethral fascia have been dissected off, exposing the urethral diverticulum.
The urethral diverticulum has been excised sharply. Foley catheter is visible through the neck of the diverticulum.
The urethral diverticulum is closed in 3 layers with nonoverlapping suture lines. The vaginal wall is closed.
 
 
 
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