Urethral Diverticula Workup

Updated: Jun 13, 2018
  • Author: Sandip P Vasavada, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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Workup

Approach Considerations

Once a diagnosis is suspected based on history and physical examination findings, endoscopic and radiologic studies help to localize the diverticulum. Urine culture should be performed to exclude coexisting urinary tract infection.  When possible, obtain culture of the expressed fluid from the diverticulum, as this aids in appropriate antibiotic selection.

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Imaging Studies

The principal imaging studies used in the workup of urethral diverticula are voiding cystourethrography (VCUG) and magnetic resonance imaging (MRI). Infrequently used techniques that may have utility in selected cases include intravenous pyelography (IVP), computed tomography (CT) urography, and retrograde urethrography using a double-balloon catheter. 

Voiding cystourethrography

The most helpful plain film radiologic study is properly performed VCUG. This study aids in defining the location, size, and number of diverticula present. The study should be performed under fluoroscopic control with the patient sitting or standing in an oblique position.  The presence of filling defects within the diverticulum may suggest the possibility of urethral calculi or a tumor.

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. [5] In patients with strongly suspect symptoms, MRI demonstrates 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. [11, 12]

Intravenous pyelography and CT urography

Urethral diverticula have been noted incidentally on 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 a better modality 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.

Retrograde urethrography using a double-balloon catheter

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. Retrograde urethrography using a double-balloon catheter may be useful if a suspected diverticulum cannot be observed on a VCUG.

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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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