History
Presenting symptoms of urethral diverticula are classically described as the triad of postvoid dribbling, dysuria, and dyspareunia (known as the 3Ds). However, the symptoms of urethral diverticula vary significantly. The most common presentations of urethral diverticula are as follows [13] :
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Recurrent urinary tract infections (70%)
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Stress urinary incontinence (60%)
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Dyspareunia (60%)
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Vaginal mass (52%)
Irritative voiding symptoms that do not respond to medical therapy should trigger a high index of suspicion for urethral diverticulum. However, many urethral diverticula produce no symptoms and are discovered incidentally.
Patients with chronically infected diverticula may demonstrate no other associated symptoms except for recurrent urinary tract infections. At times, the diverticular infection may progress to an abscess, requiring transvaginal aspiration.
Owing to the variety of presenting symptoms, diagnosis of urethral diverticula is often delayed. A high index of suspicion for this entity is required.
Physical Examination
A careful pelvic examination frequently reveals the suburethral mass on the anterior vaginal wall. Palpation of the anterior vaginal wall may reveal a soft spherical mass, which is often exquisitely tender. Compression of the mass may express urine or purulent material from the external meatus. Distinct firmness or hardness may reflect the presence of a stone or neoplasm within the diverticulum.
Stress urinary incontinence may coexist with urethral diverticula. The pelvic examination should also include careful assessment of urethral hypermobility and vaginal prolapse. The presence of stress incontinence or vaginal prolapse should be noted prior to surgery because either may require simultaneous repair at the time of diverticulectomy.
Female urethral diverticula may be complicated by infection, stones, bladder outlet obstruction, and malignancy. Infection may be acute or chronic and may result in abscess formation. Stone formation within urethral diverticula is reported to occur in 1-10% of patients. When proximal urethral diverticula become very large, they can obstruct the bladder outlet, causing acute urinary retention. [14]
Urethral carcinoma is a rare complication of urethral diverticula. Although squamous cell carcinoma is the most common histologic type of female urethral malignancy, adenocarcinoma is by far the most common cancer associated with urethral diverticula. [11] This type of cancer found within diverticula likely represents the cell of origin of most diverticula (being glandular). Nephrogenic adenoma and endometriosis have also been reported in association with female urethral diverticula. [15]
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The urethral diverticulum is shown as spherical mass at the distal urethra.
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Voiding cystourethrogram reveals contrast pooling in a urethral diverticulum. The urethral diverticulum is located well away from the bladder neck at the distal urethra.
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The anterior vaginal wall and the periurethral fascia have been dissected off, exposing the urethral diverticulum.
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The urethral diverticulum has been excised sharply. Foley catheter is visible through the neck of the diverticulum.
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The urethral diverticulum is closed in 3 layers with nonoverlapping suture lines. The vaginal wall is closed.
