Definition of female urethral diverticulum: a variably sized urine-filled periurethral cystic structure adjacent to the urethra within the confines of the pelvic fascia, connected to the urethra via an ostium
Ostium of the urethral diverticulum is located postero/ventrolaterally at the 4 and 8 o’clock positions in the mid- or distal urethra in >90%, corresponding to the location of the periurethral glands
The interior surface of the UD may be urothelial, squamous, columnar, or cuboidal epithelium, or mixed. In some cases, the epithelium is absent and the wall of the UD consists of only fibrous tissue.
2/3 of resected UD demonstrate inflammatory changes. Most UD demonstrate benign histopathology but premalignant and malignant changes can be seen.
Most common malignant histology in urethral diverticulum is adenocarcinoma
Recall, most common malignant histology in females urethral carcinoma is squamous cell carcinoma while in male urethral cancers most common histology is urothelial; see Urethral Tumours Chapter Notes)
Notable for a range of clinical presentations ranging from completely asymptomatic (up to 20% of patients), incidentally noted lesions on physical examination or imaging, to very debilitating, painful vaginal masses associated with incontinence, stones, severe dyspareunia, and/or tumors
Most common symptoms (3):
Storage LUTS
Pain
Infection
Multiple bouts of recurrent cystitis should alert the possibility of a urethral diverticulum
Reinfection, inflammation, and recurrent obstruction of the neck of the cavity are theorized to result in patient symptoms and enlargement of the diverticulum. This expansion occurs most commonly ventrally, resulting in the classic anterior vaginal wall mass palpated on physical examination in some patients with UD. However, it is important to note that these may also expand laterally, or even dorsally, about the urethra. Eventually, the abscess cavity ruptures into the urethral lumen, resulting in the communication between the UD and the urethral lumen.
Other symptoms (8):
Dysuria
Hematuria
Post-void dribbling
Urinary retention
Incontinence (stress or urge)
Dyspareunia
Vaginal mass
Patients may present with complaints of a tender or nontender anterior vaginal wall mass, which upon gentle compression may reveal retained urine or purulent discharge per the urethral meatus.
Vaginal discharge
Vaginal pruritis is not a symptom associated with urethral diverticulum
Very little is known regarding the natural history of untreated UD. For these reasons, and because of the lack of symptoms in selected cases, some patients may not desire surgical therapy.
There are reports of malignancy arising in UD. Therefore,patients should be counselled on the risk of malignancy with nonoperative management
Patients electing nonoperative management can be treated with low-dose antibacterial suppressants and digital stripping of the anterior vaginal wall following micturition to prevent postvoid dribbling and reduce the risk of UTI resulting from stasis in the UD.
Whether long-term surveillance is required in these patients, with periodic physical examinations, radiographic imaging, or endoscopic examination, is unknown.
Symptomatic patients, including those with dysuria, dyspareunia, refractory bothersome postvoid dribbling, recurrent UTIs, and pelvic pain, may be offered surgical excision.
Mobilization of a well-vascularized anterior vaginal wall flap(s)
Preservation of the periurethral fascia
Identification and excision of the neck, or ostium, of the UD
Removal of entire UD wall or sac (mucosa)
Watertight urethral closure
Multilayered, nonoverlapping closure with absorbable suture
Closure of dead space
Preservation or creation of continence
The location and competence of the urethral sphincters have important implications when considering surgical repair of urethral diverticulectomy because of the anatomic overlap of these two entities.
Varying degrees of sphincteric compromise may exist prior to intervention because of the location of diverticulum relative to the proximal and distal urinary sphincter mechanisms, or sphincteric compromise may coexist with UD as a result of other factors.
Technique
Successful excision of a urethral diverticulum involves removal of the ostium that connects with the urethral lumen. This often results in direct visualization of the urethral catheter within the urethral lumen during surgery. The urethral defect is closed primarily with absorbable suture in a watertight fashion following completion of the removal of the sac.
Additional procedures such as buccal mucosal urethroplasty, Martius flap, or vaginal flaps are not necessary to close the urethra.
Synthetic materials (e.g., mid-urethral polypropylene mesh) should not be used in an anti-incontinence procedure synchronously with urethral diverticulum surgery because of the potentially increased risk of urethral erosion and infection
Adverse Events
Recurrent UTIs
Urinary incontinence
Recurrent urethral diverticulum
Urethrovaginal fistula (uncommon)
Size of diverticulum does correlated with risk of recurrence following surgical repair
Postoperatively, some patients will have persistence or recurrence of their preoperative symptoms.
