Urethral diverticulum in women
- Lieschen H Quiroz, MD
Lieschen H Quiroz, MD
- Assistant Professor
- Female Pelvic Medicine and Reconstructive Surgery
- Oklahoma University Health Sciences
- Robert E Gutman, MD
Robert E Gutman, MD
- Associate Professor of Obstetrics and Gynecology and Urology
- Georgetown University Medical Center
- Associate Fellowship Director
- Female Pelvic Medicine and Reconstructive Surgery
- Washington Hospital Center
- Section Editors
- Linda Brubaker, MD, FACS, FACOG
Linda Brubaker, MD, FACS, FACOG
- Section Editor — Urogynecology and Pelvic Organ Prolapse
- Dean and Professor of Obstetrics and Gynecology
- Stritch School of Medicine Loyola University, Chicago
- Deborah Levine, MD
Deborah Levine, MD
- Section Editor — Imaging
- Professor of Radiology
- Director of Ob/Gyn Ultrasound
- Department of Radiology
- Beth Israel Deaconess Medical Center
A urethral diverticulum is a localized outpouching of the urethral mucosa into the surrounding non-urothelial tissues . This is an uncommon condition that is found mainly in adult women. The possibility of this diagnosis is often overlooked, even in women with presenting symptoms or findings (eg, urinary incontinence, dysuria, dyspareunia, vaginal mass). Delayed or missed diagnosis of this condition can lead to chronic morbidity including urethral calculus formation, chronic or recurrent urinary tract infections (UTIs) or, rarely, malignant transformation .
The epidemiology, diagnosis, evaluation, and treatment of urethral diverticula in women are reviewed here. Diagnosis and management of other etiologies of urinary incontinence or dyspareunia are discussed separately. (See "Evaluation of women with urinary incontinence" and "Approach to the woman with sexual pain".)
The true prevalence of urethral diverticula is difficult to estimate, given the difficulty of accurate and timely diagnosis. The reported prevalence of urethral diverticula in adult females from studies of autopsy specimens or urethrography series ranges from 1 to 5 percent [3,4]. A population-based study estimated the incidence to be less than 20 per 1,000,000 (<0.02 percent) per year . Urethral diverticula have rarely been reported in men or in children [6,7].
Urethral diverticula typically present between the ages of 20 and 60 years [1,4].
Risk factors for a urethral diverticulum include female gender, pelvic trauma, and periurethral procedures, but there are no data to quantify these risks [8-10]. It appears that black women are three-fold more likely than white women to have a urethral diverticulum, based upon data from hospital admissions and surgical procedures related to this diagnosis .
- Foley CL, Greenwell TJ, Gardiner RA. Urethral diverticula in females. BJU Int 2011; 108 Suppl 2:20.
- Romanzi LJ, Groutz A, Blaivas JG. Urethral diverticulum in women: diverse presentations resulting in diagnostic delay and mismanagement. J Urol 2000; 164:428.
- Mårtensson O, Duchek M. Translabial ultrasonography with pulsed colour-Doppler in the diagnosis of female urethral diverticula. Scand J Urol Nephrol 1994; 28:101.
- Burrows LJ, Howden NL, Meyn L, Weber AM. Surgical procedures for urethral diverticula in women in the United States, 1979-1997. Int Urogynecol J Pelvic Floor Dysfunct 2005; 16:158.
- El-Nashar SA, Bacon MM, Kim-Fine S, et al. Incidence of female urethral diverticulum: a population-based analysis and literature review. Int Urogynecol J 2014; 25:73.
- Kadian YS, Rattan KN, Singh M, Kajal P. Congenital anterior urethral diverticulum in children: a case report and review. ISRN Surg 2011; 2011:120307.
- Alphs HH, Meeks JJ, Casey JT, Gonzalez CM. Surgical reconstruction of the male urethral diverticulum. Urology 2010; 76:471.
- Athanasopoulos A, McGuire EJ. Urethral diverticulum: a new complication associated with tension-free vaginal tape. Urol Int 2008; 81:480.
- Clemens JQ, Bushman W. Urethral diverticulum following transurethral collagen injection. J Urol 2001; 166:626.
- Morton HC, Hilton P. Urethral injury associated with minimally invasive mid-urethral sling procedures for the treatment of stress urinary incontinence: a case series and systematic literature search. BJOG 2009; 116:1120.
- Stepp KJ, Walters MD. Anatomy of the lower urinary tract, rectum, and pelvic floor. In: Urogynecology and Reconstructive Surgery, 3rd, Walters, MD, Karram, MM. (Eds), Mosby Elsevier, Philadelphia 2007. p.17.
- Thomas AA, Rackley RR, Lee U, et al. Urethral diverticula in 90 female patients: a study with emphasis on neoplastic alterations. J Urol 2008; 180:2463.
- Rovner ES, Wein AJ. Diagnosis and reconstruction of the dorsal or circumferential urethral diverticulum. J Urol 2003; 170:82.
- Tsivian M, Tsivian A, Shreiber L, et al. Female urethral diverticulum: a pathological insight. Int Urogynecol J Pelvic Floor Dysfunct 2009; 20:957.
- DAVIS HJ, TELINDE RW. Urethral diverticula: an assay of 121 cases. J Urol 1958; 80:34.
- Aspera AM, Rackley RR, Vasavada SP. Contemporary evaluation and management of the female urethral diverticulum. Urol Clin North Am 2002; 29:617.
- Chou CP, Levenson RB, Elsayes KM, et al. Imaging of female urethral diverticulum: an update. Radiographics 2008; 28:1917.
- Kim B, Hricak H, Tanagho EA. Diagnosis of urethral diverticula in women: value of MR imaging. AJR Am J Roentgenol 1993; 161:809.
- Daneshgari F, Zimmern PE, Jacomides L. Magnetic resonance imaging detection of symptomatic noncommunicating intraurethral wall diverticula in women. J Urol 1999; 161:1259.
- Lorenzo AJ, Zimmern P, Lemack GE, Nurenberg P. Endorectal coil magnetic resonance imaging for diagnosis of urethral and periurethral pathologic findings in women. Urology 2003; 61:1129.
- Neitlich JD, Foster HE Jr, Glickman MG, Smith RC. Detection of urethral diverticula in women: comparison of a high resolution fast spin echo technique with double balloon urethrography. J Urol 1998; 159:408.
- Blander DS, Rovner ES, Schnall MD, et al. Endoluminal magnetic resonance imaging in the evaluation of urethral diverticula in women. Urology 2001; 57:660.
- Foster RT, Amundsen CL, Webster GD. The utility of magnetic resonance imaging for diagnosis and surgical planning before transvaginal periurethral diverticulectomy in women. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18:315.
- Dwarkasing RS, Dinkelaar W, Hop WC, et al. MRI evaluation of urethral diverticula and differential diagnosis in symptomatic women. AJR Am J Roentgenol 2011; 197:676.
- Chung DE, Purohit RS, Girshman J, Blaivas JG. Urethral diverticula in women: discrepancies between magnetic resonance imaging and surgical findings. J Urol 2010; 183:2265.
- Siegel CL, Middleton WD, Teefey SA, et al. Sonography of the female urethra. AJR Am J Roentgenol 1998; 170:1269.
- Gerrard ER Jr, Lloyd LK, Kubricht WS, Kolettis PN. Transvaginal ultrasound for the diagnosis of urethral diverticulum. J Urol 2003; 169:1395.
- Lee JW, Fynes MM. Female urethral diverticula. Best Pract Res Clin Obstet Gynaecol 2005; 19:875.
- Golomb J, Leibovitch I, Mor Y, et al. Comparison of voiding cystourethrography and double-balloon urethrography in the diagnosis of complex female urethral diverticula. Eur Radiol 2003; 13:536.
- Jacoby K, Rowbotham RK. Double balloon positive pressure urethrography is a more sensitive test than voiding cystourethrography for diagnosing urethral diverticulum in women. J Urol 1999; 162:2066.
- Dmochowski RR, Ganabathi K, Zimmern PE, Leach GE. Benign female periurethral masses. J Urol 1994; 152:1943.
- Greco A, Giammò A, Tizzani A. [Nephrogenic adenoma arising from an urethral diverticulum in a female. Report of a case and review of the literature]. Minerva Urol Nefrol 1999; 51:39.
- Fortunato P, Schettini M, Gallucci M. Diagnosis and therapy of the female urethral diverticula. Int Urogynecol J Pelvic Floor Dysfunct 2001; 12:51.
- Delancey, JO. Anatomy of the Female Bladder and Urethra. In: Ostergard's Urogynecology and Pelvic Floor Dysfunction, 5th ed, Bent, AE (Ed), Lippincott Williams & Wilkins, Philadelphia PA 2003. p. 3.
- Ganabathi K, Leach GE, Zimmern PE, Dmochowski R. Experience with the management of urethral diverticulum in 63 women. J Urol 1994; 152:1445.
- Swierzewski SJ 3rd, McGuire EJ. Pubovaginal sling for treatment of female stress urinary incontinence complicated by urethral diverticulum. J Urol 1993; 149:1012.
- Migliari R, Pistolesi D, D'Urso L, Muto G. Recurrent pseudodiverticula of female urethra: five-year experience. Urology 2009; 73:1218.
- Enemchukwu E, Lai C, Reynolds WS, et al. Autologous Pubovaginal Sling for the Treatment of Concomitant Female Urethral Diverticula and Stress Urinary Incontinence. Urology 2015; 85:1300.
- Bennett SJ. Urethral diverticula. Eur J Obstet Gynecol Reprod Biol 2000; 89:135.
- Scarpero HM, Dmochowski RR, Leu PB. Female urethral diverticula. Urol Clin North Am 2011; 38:65.
- Porpiglia F, Destefanis P, Fiori C, Fontana D. Preoperative risk factors for surgery female urethral diverticula. Our experience. Urol Int 2002; 69:7.
- Ljungqvist L, Peeker R, Fall M. Female urethral diverticulum: 26-year followup of a large series. J Urol 2007; 177:219.
- Lapides J. Transurethral treatment of urethral diverticula in women. J Urol 1979; 121:736.
- Spence HM, Duckett JW Jr. Diverticulum of the female urethra: clinical aspects and presentation of a simple operative technique for cure. J Urol 1970; 104:432.
- Moran PA, Carey MP, Dwyer PL. Urethral diverticula in pregnancy. Aust N Z J Obstet Gynaecol 1998; 38:102.
- ANATOMY AND HISTOPATHOLOGY
- CLINICAL PRESENTATION
- Vaginal mass
- EVALUATION OF WOMEN WITH A SUSPECTED URETHRAL DIVERTICULUM
- Medical history
- Physical examination
- Urine tests
- Imaging studies and endoscopy
- - Magnetic resonance imaging
- - Ultrasound
- - Urethroscopy
- - Tests no longer recommended
- Voiding cystourethrography
- Retrograde positive pressure urethrography
- DIFFERENTIAL DIAGNOSIS
- EVALUATION TO EXCLUDE ASSOCIATED CONDITIONS
- Malignant or benign neoplasms
- Patients without bothersome symptoms
- - Conservative management
- Patients with bothersome symptoms or suspected malignancy or calculi
- - Transvaginal diverticulectomy
- Preoperative preparation
- Concomitant incontinence procedures
- Postoperative care
- Outcome and complications
- - Other surgical procedures
- Urethroscopic excision
- Pregnant women
- SUMMARY AND RECOMMENDATIONS