Urethral diverticulum in females

INTRODUCTION — A urethral diverticulum is a localized outpouching of the urethral mucosa into the surrounding non-urothelial tissues [1]. 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 or, rarely, malignant transformation [2].

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 "Female urinary incontinence: Evaluation" and "Female sexual pain: Evaluation".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.

EPIDEMIOLOGY — 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 [5]. 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 sex, pelvic trauma, and periurethral procedures, but there are no data to quantify these risks [8-10]. It appears that Black women are threefold more likely than White women to have a urethral diverticulum, based upon data from hospital admissions and surgical procedures related to this diagnosis [4].

ANATOMY AND HISTOPATHOLOGY — The female urethra is a tubular structure 2.5 to 4 cm in length and approximately 0.6 cm in diameter that runs from the bladder to the urethral meatus in the anterior aspect of the vulvar vestibule (figure 1) [11]. Along its path, it passes from the retropubic space and perforates the perineal membrane.

The periurethral glands are located medially and posterolaterally along the distal two-thirds of the urethra and drain into the distal third of the urethra. The periurethral glands secrete mucin that acts as sealant and contributes to urinary continence [1]. Skene glands are periurethral glands found on either side of the urethra and are the female homologues of the prostate in males, since they arise from the urogenital sinus.

The proximal third of the urethra is lined by transitional epithelium and the distal two-thirds by squamous epithelium. The type of epithelial cells lining a diverticulum is usually identical to the epithelium of the urethra in the area of the diverticulum. Histologic changes commonly found within urethral diverticula include squamous metaplasia, adenomatous metaplasia, cystitis cystica, and cystitis glandularis [1,12].

The morphology of diverticula is heterogeneous. Most urethral diverticula occur in the middle or distal portion of the posterior aspect of the urethra [12]. Diverticula range in size from 0.3 to 5.0 cm in diameter. They may be unilocular or multilocular. More than one diverticulum may be present. The neck that connects the diverticulum to the urethral lumen may be closed, very narrow, or wide.

Diverticula are classified as simple or complex. Complex diverticula include multiple diverticula, those involving the urethral sphincter or bladder neck, horseshoe-shaped and saddle diverticula (diverticular sac that partially or circumferentially surrounds the urethra) [13].

PATHOGENESIS — Urethral diverticula are thought to be acquired rather than congenital in nearly all cases [1,6]; they are rarely found in neonates. The pathogenesis is not clearly understood.

The most widely proposed theory is that a urethral diverticulum develops as a result of repeated infection of the periurethral glands, leading to obstruction and enlargement of the glands/ducts and formation of a suburethral abscess [1]. Eventually, the abscess ruptures into the urethral lumen, creating a communication between the lumen and the abscess cavity. Evidence of chronic inflammation is supported by histopathology studies [14]. Chronic inflammation results in marked fibrosis within and surrounding the diverticulum, often with accompanying adherence to the neighboring structures. Over 90 percent of communicating tracts (ostia) are located posterolaterally in the mid to distal urethra, which corresponds to the location of the periurethral glands, which drain in the distal one-third of the urethra [15].

Other possible etiologies include trauma, which may derive from any type of lower genital tract trauma, including vaginal, bladder, or urethral surgery or vaginal delivery. Diverticula have been reported as a rare complication following a midurethral sling procedure or after transurethral collagen injection [8-10]. Although trauma associated with vaginal delivery has been postulated as an etiology, the disorder often occurs in nulliparous women. As an example, one series reported that 30 percent of 121 urethral diverticula occurred in nulliparous women [16]. It is important to identify and repair if more than one ostia is present in order to minimize the risk of diverticula recurrence [17].

CLINICAL PRESENTATION — Women with a urethral diverticulum may present with postvoid dribbling of urine and an anterior vaginal wall mass, particularly a tender mass. In addition, the presentation may include dysuria or dyspareunia.

A high index of suspicion is essential for making the diagnosis. This is because urethral diverticulum is an uncommon condition and many of the presenting symptoms (urinary incontinence, dysuria, dyspareunia) are more frequently associated with other etiologies. In addition, some women may have both a urethral diverticulum and another more common condition; for example, stress urinary incontinence (SUI) is a common condition in women, and the symptoms of this condition may obscure the concurrent presence of postvoid dribbling. As a result, diagnosis is often delayed. In one series of 46 patients with urethral diverticula, the mean time from onset of symptoms to diagnosis was 5.2 years [2].

Symptoms — The presenting symptoms of a urethral diverticulum are highly variable. Patients may also be asymptomatic.

While the classic presentation is described as a triad of symptoms (urinary dribbling, dysuria, and dyspareunia) [12,18], the classic triad is uncommon in any one patient. One study of 54 women with urethral diverticula reported that only 5 percent of patients had the classic symptom triad while 27 percent had none of the triad symptoms [19]. In two studies, each symptom was present with the following frequencies [12,18]:

●Postvoid dribbling (4 to 31 percent)

●Dysuria (9 to 55 percent)

●Dyspareunia (6 to 24 percent)

Other potential presenting complaints include [2,12,18,20,21]:

●Chronic or recurrent urinary tract infections (UTIs; 9 to 61 percent)

●Urinary frequency and/or urgency (6 to 41 percent)

●Hematuria (2 to 13 percent)

●Bloody urethral discharge (2 percent)

●Urinary incontinence (29 to 39 percent)

●Urinary retention (2 to 19 percent)

●Pelvic or urethral pain (6 to 48 percent)

●Vaginal mass (6 to 50 percent)

In the largest case series of 228 women, the most common presentations were irritative voiding symptoms and recurrent UTIs [21]. A smaller review of 54 women reported recurrent UTIs, stress incontinence, dyspareunia, and vaginal mass as the most common presenting symptoms [19]. Recurrent UTI may be related to urinary stasis in the diverticulum. Urinary incontinence may be secondary to periurethral support defects, compromise of the urethral sphincter, or drainage of urine from the diverticulum. Preoperative stress incontinence presents in up to 57 percent of patients [15,22].

Vaginal mass — A palpable vaginal mass is present in up to half of the patients with a urethral diverticulum [2]. Tenderness is often present with palpation of the mass.

EVALUATION OF WOMEN WITH A SUSPECTED URETHRAL DIVERTICULUM

Medical history — The medical history should include questions regarding symptoms associated with a urethral diverticulum. (See 'Symptoms' above.)

For women with urinary incontinence or postvoid dribbling, a voiding diary is often helpful to characterize the pattern and amount of incontinence (form 1). Bloody urethral discharge must be differentiated from vaginal or anal bleeding. One approach to confirming the source of bleeding is to ask the patient to dab each area with toilet paper after an episode and note if blood is present.

Women who report dyspareunia should be asked whether the pain is localized to the anterior vaginal wall.

Physical examination — Urethral diverticula are usually located at the middle or distal portion on the posterior aspect of the urethra. An anterior vaginal wall mass is found on physical examination in many, but not all, patients [18]. The finding of suburethral mass on examination does not confirm the diagnosis of a urethral diverticulum. Further evaluation is required to exclude other conditions or associated findings. (See 'Differential diagnosis' below.)

To best visualize the anterior vaginal wall during the pelvic examination, the anterior vaginal wall is first visualized by using a half speculum to retract the posterior vaginal wall. The anterior vaginal wall is inspected while the patient rests and then does a Valsalva maneuver.

The anterior wall and the course of the urethra are then palpated to assess for findings that suggest the presence of a diverticulum (a suburethral mass, fullness, or tenderness). An attempt should also be made to express urine or purulent or bloody discharge from the suburethral mass. Palpating the suspicious area with and then without a bladder catheter in the urethral lumen may help to distinguish a true urethral mass from conditions that may give the appearance of a mass, such as redundant vaginal epithelium associated with anterior vaginal wall prolapse. Testing for urethritis is performed if urethral discharge is expressed during physical examination.

Most urethral diverticula are soft. A firm mass may represent malignancy, leiomyoma, or a calculus, and warrants further evaluation. (See 'Evaluation to exclude associated conditions' below.)

Urine tests — For patients with symptoms of dysuria, urinary urgency or frequency, or hematuria, a urinalysis should be performed. If leukocytes are present, a urine culture should be sent to exclude infection. Women with hematuria should be evaluated for other conditions, including urinary tract malignancy, as appropriate. (See "Acute simple cystitis in adult and adolescent females" and "Etiology and evaluation of hematuria in adults".)

Imaging studies and endoscopy

Choice of study or procedure — There are few data to guide the choice of diagnostic study for urethral diverticula. We suggest magnetic resonance imaging (MRI) as the first line imaging study for patients with a suburethral mass and symptoms consistent with a urethral diverticulum. MRI appears to have the best diagnostic performance and can also help to exclude clinically important features of a diverticulum (ie, solid mass suggestive of malignancy, calculi) or other periurethral conditions. (See 'Evaluation to exclude associated conditions' below and 'Differential diagnosis' below.)

It is reasonable to use ultrasound as the first-line study if MRI is not feasible due to expense or lack of available expertise in the interpretation of an MRI regarding this condition. Newer ultrasound techniques include 3D manipulation capabilities and higher resolution with excellent visualization [23]; however, high-resolution ultrasound with multiplanar capabilities may not be readily available and may be predicated upon the skill of the user. Multislice computed tomography (CT) with 3D and 4D reconstruction is another reasonable option when MRI is not feasible [24]. (See "Ultrasound examination of the female pelvic floor".)

Urethroscopy is performed only as an adjunct to MRI or ultrasound to provide information regarding the anatomic relationship of the diverticular ostium to urethra.

Traditionally, contrast-enhanced radiography (eg, voiding cystourethrography, retrograde double-balloon positive pressure urethrography) were used to evaluate women for urethral diverticulum. However, these procedures are invasive and technically difficult and the contrast-dependent studies are only able to visualize diverticula that are patent enough to allow filling with contrast material [25]. Thus, these studies have largely been replaced by MRI or ultrasound.

Magnetic resonance imaging — MRI appears to be effective for the diagnosis of urethral diverticulum, but this is based upon limited data from small observational studies [26-32]. No studies have compared MRI with other imaging modalities for evaluation of this condition.

Case series with 40 to 60 women with a suspected diverticulum who were evaluated with MRI have reported that the sensitivity for the diagnosis of urethral diverticulum was 86 to 100 percent and the specificity was 95 to 100 percent; the reference standard was either surgical findings or a second imaging study [32,33]. The sensitivity of MRI in evaluating urethral masses may also depend upon the expertise of the radiologist reading the study.

Advantages of MRI compared with ultrasound or urethroscopy are that it allows better visualization of diverticula that are small or noncommunicating and provides multiplanar resolution lending superior tissue resolution and allowing for differentiation between normal anatomical variants, soft tissue masses, and urethral pathology (image 1A-C). Although in experienced hands, similar imaging information can also be obtained by ultrasound [34].

In terms of technique, most reports have found that use of an endoluminal coil (endourethral, endovaginal, or endorectal) is a useful technique for evaluating the urethra and periurethral region [27,28,32]. Detection of multiple diverticula is optimally achieved using MRI with slices from just above the bladder neck to the distal urethra.

MRI is potentially better able than ultrasound to detect findings such as a solid mass within the diverticulum (which may signify malignancy) [27]. In addition, malignancy should be suspected if the wall of the diverticulum is focally thickened or irregular. Alternatively, infection and inflammation can lead to a more diffusely thick-walled and hyperemic appearance. Use of contrast will show contrast enhancement in the lesion. (See 'Malignant or benign neoplasms' below.)

However, MRI may miss some diagnoses of malignancy. As an example, in one study with 41 women, 2 patients were found to have malignancy within the wall of a urethral diverticulum at time of surgery, but no findings suggestive of this were detected with preoperative MRI [33].

On MRI, the appearance of calculi is dependent upon the imaging sequence utilized. On T2-weighted imaging, a calculus appears with low signal intensity. If the calculus is surrounded by fluid within a diverticulum, the fluid will be bright on T2 weighted imaging, and the stone will be seen as a filling defect. (See 'Calculi' below.)

Ultrasound — The diagnostic performance of ultrasound for evaluation of urethral diverticulum has been evaluated only in small case series. A study comparing ultrasound (transvaginal, transperineal, or endourethral) with voiding cystourethrography found that both studies were able to diagnose 13 of 15 urethral diverticula, but ultrasound was also able to diagnose periurethral cysts and leiomyomas not detected by voiding cystourethrography [35]. In another study, 10 cases of urethral diverticulum diagnosed with transvaginal ultrasound were confirmed with surgery [36].

When ultrasound is used to assess for a urethral diverticulum, transvaginal ultrasonography is the preferred technique. Transabdominal, transrectal, or transperineal approaches generally provide images of lower quality than transvaginal ultrasound. Both transurethral and biplane transrectal approaches have been reported, but more data are needed [37]. Emerging 3D ultrasound techniques that provide higher resolution are gaining popularity due to lower cost and patient comfort compared with MRI [23,25,38].

In terms of technique for transvaginal ultrasound, the probe is partially inserted into the vagina, and imaging is directed to the expected location and course of the urethra. A high-frequency probe (>7 MHz) is used for real-time visualization of the diverticular wall and its contents and to measure the overall size and circumference of the urethral mass (image 2) [35,39]. When available, a 3D image may be obtained for postprocessing. The patient should have a partially full bladder during the examination for anatomic orientation. Color Doppler may be used if there is a finding of a solid mass suggestive of malignancy [3].

On ultrasound, a finding of a soft tissue mass within a diverticulum with flow on Doppler is suggestive of malignancy. An irregular or thickened diverticular wall may be noted. As discussed above, wall thickening may also result from infection or inflammation. Color Doppler will show flow to the region of suspicion. In a study that evaluated 95 patients with diverticula with ultrasound, carcinomas appeared to have mixed echogenicity and exhibited blood flow signaling on color Doppler [40]. (See 'Malignant or benign neoplasms' below.)

Calculi are seen on ultrasound as strongly echogenic masses with shadowing within the diverticulum. (See 'Calculi' below.)

Computed tomography — While traditional CT imaging has played a limited diagnostic role, the ability of multislice (or multicenter) CT to perform 3D and 4D reconstructions makes this technique potentially useful for the diagnosis and evaluation of urethral diverticulum [41,42]. In one study of 16 patients with symptomatic urethral diverticulum, preoperative evaluation using this technology confirmed the diagnosis and identified the location of the ostia accurately compared with intraoperative findings [24]. This technique was able to detect small amounts of contrast passing through narrow ostia.

Urethroscopy — Urethroscopy may be used as an adjunct to MRI or ultrasound to provide information regarding the anatomic relationship of the diverticular ostium to the urethra. This information can be helpful during surgical treatment. This procedure permits visual examination of the urethral epithelium and urethrovesical junction and may be useful in diverticula with large ostia (picture 1). The limitations of this procedure are that it cannot visualize beyond the ostium of the diverticulum, does not provide information on the size or complexity of the diverticulum, causes patient discomfort, and is expensive if performed in an operating room setting. If urethroscopy is not performed as part of the preoperative evaluation, we recommend urethroscopy be done at the beginning of the surgical procedure.

Tests no longer recommended

Voiding cystourethrography — This test is no longer recommended for routine evaluation of urethral diverticulum since it is uncomfortable for the patient, has limited diagnostic performance, and involves exposure to radiation [39,43]. The sensitivity is low, approximately 65 percent, which may be attributable to inadequate filling of the diverticulum through a stenotic ostium. In addition, this study does not provide images of periurethral lesions that are necessary to exclude other conditions.

Retrograde positive pressure urethrography — This test is no longer recommended for routine evaluation of urethral diverticulum since it is uncomfortable for the patient, has limited diagnostic performance, and involves exposure to radiation [44]. Similar to voiding cystourethrography, retrograde double-balloon positive pressure urethrography is not effective for detecting stenotic diverticula and also does not provide images of periurethral lesions to exclude other conditions. The test is performed by occluding each end of the urethra by a double balloon catheter. Contrast medium is then infused under pressure into an opening in the urethral portion of the catheter in order to distend any urethral communication.

DIAGNOSIS — The diagnosis of urethral diverticulum is made by urethral and periurethral imaging, preferably magnetic resonance imaging (MRI), in women with characteristic symptoms and/or a periurethral mass. For women who undergo surgical treatment, the diagnosis is confirmed at time of surgery. (See 'Imaging studies and endoscopy' above.)

More than a single diverticulum may be present, so after identifying a single diverticulum, it is prudent to search for additional diverticula.

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of a urethral diverticulum depends upon the presenting symptoms and findings. For women with a periurethral mass, other diagnostic possibilities include other urinary or genital tract lesions [45]:

●Vaginal or urethral benign or malignant neoplasm (eg, vaginal leiomyoma, vaginal wall inclusion cyst, Gartner's duct cyst, vaginal cancer, urethral cancer)

●Anterior vaginal wall prolapse

●Periurethral fibrosis

●Ectopic ureterocele

●Skene gland abscess

The evaluation required to exclude these conditions depends upon the patient’s other clinical features. The most common condition in the differential diagnosis is anterior vaginal wall prolapse, which typically involves the entire anterior vaginal wall on examination, while a urethral diverticulum is generally palpable as a discrete mass. If other conditions are suspected, imaging should be performed. Depending upon the imaging findings, biopsy or surgical exploration may be required to differentiate some conditions from a urethral diverticulum. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management" and "Congenital anomalies of the hymen and vagina" and "Ureterocele".)

Women with postvoid dribbling of urine should be evaluated for other etiologies of urinary incontinence. Urinary incontinence in the absence of elevated intraabdominal pressure (suggestive of stress incontinence) or a feeling of urinary urgency (suggestive of urgency incontinence) raises suspicion of ectopic ureters, urinary tract fistula, or a urethral diverticulum. Incomplete bladder emptying (overflow incontinence) or obstructive voiding symptoms should also be excluded. (See "Female urinary incontinence: Evaluation".)

Urinary tract infection should be excluded in women with dysuria and urinary frequency or urgency. If infection is not found, other etiologies of these symptoms should be investigated, including interstitial cystitis/bladder pain syndrome or overactive bladder syndrome. Persistent, sterile pyuria may also raise suspicion for a diverticulum. (See "Acute simple cystitis in adult and adolescent females" and "Interstitial cystitis/bladder pain syndrome: Clinical features and diagnosis".)

Some women with a urethral diverticulum have gross or microscopic hematuria. Women with hematuria should be evaluated for other conditions, including urinary tract malignancy and renal abnormalities, as appropriate. (See "Etiology and evaluation of hematuria in adults".)

Women who present with dyspareunia should be evaluated for other etiologies of sexual pain. (See "Female sexual pain: Evaluation".)

EVALUATION TO EXCLUDE ASSOCIATED CONDITIONS — Once the diagnosis of a urethral diverticulum is made, the patient should be evaluated for associated conditions that impact treatment choices, including: malignancy, benign neoplasms, or a diverticular calculus. In many patients, these conditions are identified during the diagnostic evaluation process.

Malignant or benign neoplasms — Malignancy has been reported in 6 to 9 percent of patients with a urethral diverticulum [1,12]. These are usually adenocarcinomas, but transitional and squamous cell tumors have been reported. In addition, precancerous lesions or findings associated with malignancy have been found (ie, dysplasia, villous adenoma).

There are no specific symptoms associated with malignancy. Malignancy should be suspected if a solid mass in a diverticulum is found on examination and/or imaging. The imaging features are discussed above. (See 'Magnetic resonance imaging' above and 'Ultrasound' above.)

If malignancy is suspected on an imaging study, surgical excision should be performed. Alternatively, in some cases, malignancy is found incidentally following surgical removal of the diverticulum. Women with urethral malignancy should undergo staging and treatment, as appropriate. (See 'Patients with bothersome symptoms or suspected malignancy or calculi' below and "Urethral cancer".)

Benign neoplasms have also been found in urethral diverticula [46]. One study of 90 patients found 10 nephrogenic adenomas [12]. Women with benign diverticular neoplasm are typically diagnosed following surgical treatment, since they present with imaging findings of a solid mass, similar to malignant lesions.

Calculi — Calcium oxalate or calcium phosphate stones have been reported in 2 to 10 percent of urethral diverticula [18]. Stone formation is likely due to urinary stasis within the diverticulum, salt deposition, and periglandular mucus.

Women with a diverticular calculus typically present with the same symptoms as other women with a diverticulum. Calculi of larger sizes can sometimes be palpated as a solid mass on examination, and are nearly always visualized on imaging studies. The imaging features are discussed above. (See 'Magnetic resonance imaging' above and 'Ultrasound' above.)

Diverticulectomy with calculi removal prevents recurrence. (See 'Patients with bothersome symptoms or suspected malignancy or calculi' below.)

MANAGEMENT — Women with a urethral diverticulum who have no bothersome symptoms may be managed with conservative measures. If bothersome symptoms are present or there is a suspicion of malignancy or a diverticular calculus, surgical treatment is required. Transvaginal diverticulectomy is the surgical procedure of choice.

Patients without bothersome symptoms — Conservative management is a reasonable option for women without bothersome symptoms and without signs suggestive of malignancy or a urethral calculus. Conservative measures are intended to minimize postvoid dribbling and prevent urinary tract infection (UTI), however, there are no data regarding their efficacy.

Conservative management — Conservative management includes: digital decompression by applying pressure on the suburethral mass after voiding or periodic needle aspiration [47].

Antibiotic prophylaxis may be used in women with recurrent UTIs, but surgical treatment should also be offered to these patients [15]. (See "Recurrent simple cystitis in women", section on 'Antimicrobial prophylaxis in select cases'.)

These measures may allow resolution of localized symptoms, but the anatomic abnormality remains. The long-term prognosis of patients treated conservatively is not known. There are no guidelines regarding surveillance for patients undergoing conservative management. In our practice, we perform periodic clinical assessments every 6 to 12 months, including an examination. If bothersome symptoms develop, patients should be evaluated with imaging and treated surgically.

Patients with bothersome symptoms or suspected malignancy or calculi — For women with bothersome symptoms or a diverticular calculus, we suggest surgical treatment rather than conservative management. Surgery is indicated if a diverticular malignancy is suspected.

No studies have compared surgical procedures for urethral diverticula. Transvaginal diverticulectomy is the procedure of choice since it is a definitive procedure. For patients with a diverticulum that is distal to the urethral sphincter, a marsupialization procedure is a reasonable option. The choice of a particular procedure is also dependent upon the individual surgeon’s expertise. Procedures for treatment of urethral diverticula should be performed only by surgeons with experience with vaginal and periurethral surgery.

Transvaginal diverticulectomy

Preoperative preparation — All patients should undergo periurethral imaging with magnetic resonance imaging, ultrasound, or computed tomography prior to surgery to define the number, size, and location of diverticula. It is important to identify if more than one ostia is present to facilitate repair of all and thus minimize the risk of diverticula recurrence [17]. (See 'Imaging studies and endoscopy' above.)

Preoperative counseling should include a discussion of possible complications, including the potential for urinary incontinence, as well as details about postoperative care. (See 'Concomitant incontinence procedures' below and 'Outcome and complications' below.)

UTI or periurethral abscess should be treated with antibiotics treatment preoperatively. For acute abscesses, incision and drainage may be required. Failure to completely treat infection may increase the risk of surgical complications.

Antibiotics for prevention of surgical site infection are typically administered for this procedure. The infectious risk is similar to other procedures that involve a vaginal wall or lower urinary tract incision. Antibiotics for prevention of endocarditis are not required. (See "Pelvic organ prolapse in women: Surgical repair of anterior vaginal wall prolapse", section on 'Antibiotic prophylaxis'.)

These procedures are typically brief and thromboprophylaxis is not required if the patient has no risk factors for venous thromboembolism. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients", section on 'Assess risk for thrombosis'.)

Procedure — The goal of this procedure is complete excision of the diverticular sac and closure of the communication with the urethral lumen (picture 2).

The procedure is as follows (figure 2):

●The patient is placed in the dorsal lithotomy position and sterile preparation is performed. Urethroscopy is often undertaken prior to surgical incision in an attempt to visualize the exact location of the ostium of the diverticulum to help guide surgical dissection. (See 'Urethroscopy' above.)

●A size 14 or 16 French bladder catheter is inserted into the urethra and an incision is made on the anterior vaginal wall under the urethra and urethrovesical junction. Several different types of vaginal incisions have been employed, including vertical midline, U-shaped, inverted U-shaped, semilunar, and transverse. Choice of incision should be made based on the best access to the diverticulum. The inverted U-shaped incision avoids overlapping suture lines.

●The vaginal epithelium is dissected off the periurethral pubocervical fibromuscularis with Metzenbaum scissors. This dissection should be superficial.

●An incision is made in the pubocervical fibromuscularis, typically a transverse incision, which is then mobilized to expose the diverticulum. This can be difficult, as the fibromuscularis is often attenuated or adherent to the wall of the diverticulum.

●An attempt is made to isolate and mobilize the diverticulum intact; however, often the diverticulum ruptures during this process. If the diverticulum is intact, it is excised after proper identification of its communication with the bladder neck. If the diverticulum ruptures, placing a finger into the lumen of the diverticulum sac facilitates dissection of the residual sac toward the urethral communication.

●The diverticulum is excised flush to its communication with the urethral lumen. Similar to the vaginal repair of vesicovaginal or urethrovaginal fistulae, the entire communication at the junction with the urethra need not be excised. Such excision of the entire communication may result in a larger urethral defect that may predispose to further complications without increasing the overall cure rate. It is important to identify if multiple ostia are present to avoid an incomplete excision and chance of diverticulum recurrence [17].

●The urethral wall is reapproximated with 3-0 or 4-0 polyglactin suture over a Foley catheter in a continuous or interrupted fashion. Most urethral closures are performed longitudinally, but this may increase the risk of urethral stenosis in cases of large ostia.

●The periurethral fibromuscularis is closed transversely or in an overlapping fashion depending on the degree of attenuation using 2-0 or 3-0 polyglactin suture. The goal is to avoid an overlapping suture line with the urethral closure.

In cases where there is poor quality devascularized tissue, inadequate pubocervical fibromuscularis to perform a layered closure, or a large urethral defect, a bulbocavernosus fat pad interposition (Martius flap) may be used to increase vascularity in hopes of decreasing the risk of urethrovaginal fistula formation [34].

●The anterior vaginal wall incision is closed with 2-0 or 3-0 polyglactin suture. A vaginal pack with estrogen cream may be applied for additional hemostasis.

Complex diverticuli — An alternative approach may sometimes be needed when dealing with a dorsal or circumferential urethral diverticulum. This requires a complete dissection of the diverticulum with our without urethral transection, sometimes requiring a Martius flap for appropriate reconstruction [13].

In repairs of large dorsal and/or proximal diverticula, a modified jack-knife position or robotic-assisted transabdominal repair have been reported [48,49].

Concomitant incontinence procedures — Diverticulectomy may involve disruption of the "continent zone" of the urethra. This portion is located in the middle portion of the urethra and is surrounded by the striated urogenital sphincter.

●Risk of postoperative urinary incontinence – Patients without preexisting stress urinary incontinence (SUI) should be counseled about the possible development of incontinence if the continence zone is disturbed during the procedure [50]. A literature review reported that postoperative SUI develops in 1.7 to 16 percent of women following surgical treatment of a diverticulum [47].

●Surgery for urinary incontinence – The role of additional surgery to treat or prevent SUI is a point of debate.

•Concomitant procedure – While some surgeons advocate performing a concomitant SUI procedure [51-53], other surgeons disagree since many patients will not develop urinary incontinence or will experience resolution of their stress incontinence even without an anti-incontinence procedure [22,47,54]. In a study to assess the incidence and outcomes of urinary incontinence after surgery for urethra diverticulum, up to 60 percent had resolution of their urinary symptoms after 12 months of conservative management. In addition, many patients with a diverticulum are young and anti-incontinence procedures are not typically performed in women who have not completed childbearing. For patients with persistent bothersome urinary incontinence symptoms, nonsurgical management such as pelvic floor physical therapy can be offered as a nonsurgical alternative. The choice of a concomitant continence surgery at the time of surgical treatment of a urethral diverticulum needs to be individualized after a discussion of the risks and benefits of the procedure. (See "Female stress urinary incontinence: Choosing a primary surgical procedure", section on 'Women finished with childbearing'.)

•Staged procedure – An alternative to a concomitant incontinence procedure would be to perform a staged procedure, with either an autologous pubovaginal sling or a synthetic midurethral sling if SUI develops or persists. The quality of the reconstructed urethral tissue (eg, amount of tissue involved) should be carefully considered prior to inserting synthetic mesh in order to avoid a potential future mesh erosion. (See "Female stress urinary incontinence: Choosing a primary surgical procedure", section on 'Comparison of efficacy'.)

●Choice of pubovaginal or synthetic sling – While synthetic mesh midurethral slings are generally the procedure of choice for SUI, the choice of anti-incontinence procedure may differ for patients with a urethral diverticulum. For patients with a urethral diverticulum, an important concern is that placement of synthetic material near the line of the fresh incision may result in mesh erosion. For this reason, the use of a pubovaginal sling with autologous fascia appears to be a better choice, although there are few data regarding this issue. The few studies evaluating concomitant autologous pubovaginal sling report low risk of diverticulum recurrence and high cure rates for stress incontinence symptoms [55-57]. The largest retrospective multicenter cohort study compared 96 patients undergoing diverticulectomy with concomitant autologous pubovaginal sling to 389 patients undergoing diverticulectomy alone [53]. Concomitant sling resulted in a greater than twofold odds of SUI symptom resolution, with an associated increased risk of urinary retention and recurrent UTIs.

Postoperative care — In our practice, we leave in a 14 to 16 French urethral catheter (with or without a suprapubic catheter) for 7 to 14 days after diverticulectomy. If there is extensive dissection and it is felt there may be voiding dysfunction even after 7 to 14 days, a suprapubic catheter may be preferable. The duration of catheterization depends upon the size of the urethral defect.

We perform a voiding cystourethrogram (VCUG) 14 days after surgery to evaluate the integrity of the repair. If a small amount of extravasation is seen, we continue bladder drainage and repeat the VCUG the following week. Once no extravasation is seen, we begin voiding trials, making sure that the patient is able to empty her bladder adequately (eg, postvoid residual <100 mL). However, there are no data to support the routine use of VCUG postoperatively. An alternative approach is to perform a retrograde bladder instillation of saline colored with indigo carmine, methylene blue, or sterile infant formula into the urethra and bladder and examine the vaginal incision lines for evidence of a fistula.

Outcome and complications — Observational studies have reported that transvaginal diverticulectomy is associated with cure of diverticulum-related symptoms in approximately 70 to 86 percent of patients [58,59]. The reported rate of recurrent diverticula ranges from 1 to 25 percent [51]. Potential risk factors for recurrence include multiple diverticula, proximal location, prior urethral surgery, and circumferential configuration [60,61].

Complications are common, however, likely due to the extensive dissection required to surgically excise the diverticulum. The most common postoperative complications are urethrovaginal fistula (1 to 8 percent), SUI (1 to 16 percent), urethral strictures (0 to 5 percent), and recurrent UTIs (7 to 31 percent) [51]. Profuse hemorrhage may occur intraoperatively, especially during bladder neck diverticulectomy. Although less common, excision of a large proximal diverticulum may result in ureteric injury.

Risk factors for developing postoperative complications include delayed diagnosis of the diverticulum (>12 months after the onset of symptoms), large size (>4 cm), lateral or horseshoe shape diverticulum, or repeat diverticulectomy [62].

Patients who undergo repeat surgery for a urethral diverticulum are at increased risk for postoperative complications such as recurrent diverticula, urethral stricture, and urethrovaginal fistulas [63]. In cases of recurrent urethral diverticulum repair, additional reconstruction with dorsal on-lay buccal mucosal graft or Martius graft interposition may improve outcomes and prevent urethral stricture for large urethral defects. The addition of an autologous fascial sling has also been suggested to improve success by providing posterior urethral support in patients with and without stress incontinence symptoms [55].

A 2015 systematic review found no comparative studies on the different types of surgery for women with urethral diverticula. Thus, there are insufficient outcome data for comparing the surgical techniques [64]. Future use of a registry to help track success and complication rates by surgical approach may be a helpful way to systematically document outcomes.

Other surgical procedures

Urethroscopic excision — Urethroscopic excision of the ostium using a cold urethrotome proximally and distally to open the roof of the diverticulum, thereby promoting drainage of contents into the urethral lumen [65]. This endoscopic is not considered a definitive surgical procedure.

Marsupialization — In 1976, Spence and Duckett described a procedure for the management of distal urethral diverticula [66]. The surgical approach involved making an incision along the floor of the distal urethra from the external urethral meatus to the orifice of the diverticulum, followed by trimming vaginal mucosa and saucerizing the sac into the vagina. The end-product of the surgery was the appearance of a "generous meatotomy."

This technique involves marsupialization of the distal urethral diverticulum resulting in decreased urethral length and a more patulous urethral meatus. Proper patient selection of only distal urethral diverticula is critical so as to avoid further proximal extension of the urethral incision that will compromise the urethral sphincter and overall continence mechanism. Other potential complications include UTI and dyspareunia.

Pregnant women — Urethral diverticula diagnosed during pregnancy should be managed conservatively during the antenatal period to relieve symptoms and because a large diverticulum may obstruct fetal descent during labor. A pregnant patient with a diverticulum may present with a variety of vague urinary symptoms including suprapubic pain, urinary infections, and voiding dysfunction [67]. Excision should not be performed during pregnancy. One study including four cases of urethral diverticula managed conservatively during pregnancy reported that three women underwent urethral decompression by aspiration for symptom relief, and one patient was treated with antibiotic therapy only [68]. Postpartum, three of four women underwent urethral diverticulectomy.

SUMMARY AND RECOMMENDATIONS

●Description and anatomy – A urethral diverticulum is a localized outpouching of the urethral mucosa into the surrounding non-urothelial tissues. Most urethral diverticula occur in the middle portion or distal urethra. More than a single diverticulum may be present. (See 'Introduction' above and 'Anatomy and histopathology' above.)

●Prevalence and clinical implications – The reported prevalence of urethral diverticula ranges from 1 to 5 percent of women. However, the true prevalence may be higher, given the difficulty of accurate and timely diagnosis. Delayed or missed diagnosis of this condition can lead to chronic morbidities including calculus formation, chronic infections, or malignant transformation. (See 'Epidemiology' above.)

●Clinical presentation – Urethral diverticulum should be suspected in women with postvoid dribbling of urine and a mass, particularly a tender mass, along the anterior vaginal wall. This condition should also be excluded in women who present with dysuria or dyspareunia. (See 'Clinical presentation' above.)

●Diagnostic evaluation – We suggest magnetic resonance imaging (MRI) rather than other imaging studies or urethroscopy as the first line imaging study for patients with a suburethral mass and symptoms consistent with a urethral diverticulum (image 1A-C). MRI appears to have the best diagnostic performance and can also help to exclude associated conditions (ie, solid mass suggestive of malignancy, calculi) or other conditions in the differential diagnosis. Ultrasound and multislice computed tomography with 3D and 4D reconstructions are reasonable alternatives if MRI is not feasible due to expense or lack of available expertise in MRI diagnosis of this condition. (See 'Imaging studies and endoscopy' above.)

●Diagnosis – The diagnosis of urethral diverticulum is made by urethral and periurethral imaging in women with characteristic symptoms and/or a suburethral mass. For women who undergo surgical treatment, the diagnosis is confirmed at time of surgery. (See 'Diagnosis' above.)

●Differential diagnosis – The differential diagnosis of a periurethral mass includes vaginal wall inclusion cyst, Skene gland abscess, Gartner's duct cyst, ectopic ureterocele, periurethral fibrosis, urethrocele, vaginal leiomyoma, and urethral or vaginal neoplasm. (See 'Differential diagnosis' above.)

●Symptom-based treatment options

•Asymptomatic – Conservative management of a urethral diverticulum is a reasonable option for women who have no bothersome symptoms and in whom there is no suspicion of malignancy or a diverticular calculus. (See 'Patients without bothersome symptoms' above.)

•Symptomatic – For patients with bothersome symptoms or a diverticular calculus, we suggest surgical treatment rather than conservative management (Grade 2B). Surgery is indicated if a diverticular malignancy is suspected.

●Surgical treatment

•Diverticulectomy – We suggest transvaginal diverticulectomy rather than other surgical procedures (Grade 2C). For patients with a diverticulum that is distal to the urethral sphincter, a marsupialization procedure is a reasonable option. (See 'Patients with bothersome symptoms or suspected malignancy or calculi' above.)

•Role of concomitant continence surgery – Surgical treatment of a diverticulum may disrupt the continence zone of the urethra. The decision of whether to perform a concomitant continence procedure at the time of surgical treatment should be individualized. When performing a concomitant incontinence procedure, we use an autologous pubovaginal sling to avoid the risk of erosion associated with synthetic mesh slings. (See 'Concomitant incontinence procedures' above.)

•Outcomes and complications – Surgical cure rates after diverticular excision are approximately 70 to 86 percent. The most common postoperative complications are recurrent diverticulum, urethrovaginal fistula, stress incontinence, urethral strictures, and recurrent urinary tract infections. (See 'Outcome and complications' above.)