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Evaluation and Management of Urethral Diverticula
Howard B. Goldman, MDSection of Female Pelvic Medicine and Reconstructive Surgery
Glickman Urologic and Kidney Institute
The Cleveland Clinic
Lerner College of Medicine
Case Western Reserve University
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• 32 yo woman referred for cystocele
• No pain
• No voiding complaints
• Has noticed a vaginal bulge for 6 months
• G1P1 - vaginal
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urethra
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Urethral Diverticulum
• Defect in the periurethral fascia with an outpouching of mucosa– Infection within periurethral glands– Obstruction and abscess formation– Rupture into urethral lumen
outpouchings
• Typically located dorsally and laterally
• Most common in 3rd to 5th decades of life
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Presentation
• “Dysuria, Dyspareunia and Dribbling”• Recurrent UTIs• Urethral pain, pelvic pain, vag wall tenderness• Purulent drainage per urethra• Overactive bladder complaints: urgency,
frequency, incontinence
• Romanzi et al. (J Urol, 2000): diverse presentations, mimics other disorders
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Evaluation
• History and physical exam• Careful palpation of distal anterior vaginal wall
– Milk the urethra and observe meatus
• Cystoscopy• Radiographic evaluation
– Voiding cystourethrography (VCUG)– Ultrasonography (transvaginal, endourethral)– MRI
• ? Urodynamics - fluoro– Evaluate for stress urinary incontinence
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VCUG• Radiographic study of choice for years• Voiding and post-void views important
– Many patients cannot void on the table
• Blander et al. (Urology 2001): MRI and VCUG– VCUG missed 7% of diverticula and underestimated size and
complexity
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VCUG
tic
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Ultrasonography
• Transvaginal, endoluminal
• Relatively inexpensive, good visualization
• Operator dependant
• Siegel et al.: VCUG vs ultrasound. 13/15 diverticula detected with both modalities, but US showed extent and location better
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Urethral diverticulum - UStransurethral
tic
neck
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CT vs MRI
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Urethral diverticulumaxial MRI
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Urethral Diverticuli• Management:
– Conservative treatment measures: antibiotics, anticholinergics, anesthetics, etc..
• Acutely or for very small tics
– Operative• Spence procedure
– Very distal diverticulum
• Excision
• SUI considerations
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Prepare Vaginal Wall Flap
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Inicise Periurethral Fascial
Tic
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Prepare Periurethral Fascial Flaps
Periurethral fascia flaps
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Dissect Out and Excise Tic
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Identify Ostium
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Close Ostium
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Closure of Dead Space
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Periurethral Fascial Defect Closure
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Close with Vaginal Wall Flap
*Avoid overlapping suture lines
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• 32 yo woman referred for cystocele
• No pain
• No voiding complaints
• Has noticed a vaginal bulge for 6 months
• G1P1 - vaginal
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urethra
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Urethral diverticulumaxial MRI -saggital
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Urethral diverticulumaxial MRI - saggital
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ostium
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Martius flap
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Management of Stress Incontinence
• Faerber et al: simultaneous diverticulectomy and sling, no complications, no erosions, no SUI
• Vasavada et al: 5 diverticulectomies, xenograft tissue for sling, no erosions, no SUI
• Some controversy over whether to place sling at time of diverticulectomy – if place – never use synthetic mesh
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Postoperative management
• Urethral catheter for 14 days• VCUG??• complications:
– stress incontinence (de novo)– urethrovaginal fistula– recurrence
– Evaluate path specimen
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4/5 (80%) with Invasive adenoca had history of urinary retention
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Long Term f/u of Diverticulum Recurrence
• N=122 50 month avg f/u
• 10.7% had surgery for recurrence– Risk factors
• Proximal diverticulum
• Multiple diverticula
• Prior vaginal or urethral surgery
• 26% persistent pain/discomfort with voiding
• 39% UTI in prior yearIngber et al, J Urol, 2011
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Conclusions
• Diagnosis of urethral diverticula may be difficult• High index of suspicion• MRI is the gold standard for evaluation of suspect
diverticula• Surgery is the mainstay of therapy• Careful exposure of all layers allows proper
reconstruction• Majority successfully treated
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