Female urethral diverticula: from pathogenesis to management. An update

Abstract

Urethral diverticulum, a sac-like protrusion communicating with the urethral lumen, is a relatively uncommon occurrence. It represents either an infected paraurethral gland that has ruptured in the urethra or a prolapse of the urethral wall through a defect in the periurethral fascia. The classic clinical presentation is a soft, slightly tender vaginal lesion causing dysuria, dyspareunia and dribbling incontinence. Unfortunately, this classic presentation is only seldom seen. The condition may be either asymptomatic or manifest nonspecific symptoms of any lower genitourinary tract pathology. In the majority of cases, diagnosis relies on imaging, with MRI becoming the technique of choice, as it is accurate and provides detailed anatomical information. Complete excision of the diverticular sac with meticulous urethral and periurethral reconstruction is the ‘gold standard’ treatment. Success rates of 70–100% have been reported, with a few complications occurring, particularly in cases of large and complex diverticula.

Keywords::

• diverticulectomy
• imaging
• symptom
• treatment
• urethral diverticulum

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Learning objectives

Upon completion of this activity, participants should be able to:

• • Define urethral diverticula and their prevalence

• • Identify the epithelial tissue types involved in urethral diverticula

• • Describe the L/N/S/C3 classification for urethral diverticula

• • Describe the frequency associated with different clinical presentations of urethral diverticula

• • Identify the best diagnostic test for urethral diverticula

Financial & competing interests disclosure

EDITOR

Elisa Manzotti,Editorial Director, Future Science Group, London, UK.

Disclosure:Elisa Manzotti has disclosed no relevant financial relationships.

CME AUTHOR

Désirée Lie,MD, MSEd, Clinical Professor, Department of Family Medicine, University of California, Irvine, CA, USA.

and

Director, Division of Faculty Development, UCI Medical Center, Irvine, CA, USA.

Disclosure:Désirée Lie has disclosed no relevant financial relationships.

AUTHOR

Konstantinos Giannitsas,MD, Patras University Hospital, Urology Department, Building A, 4th floor, Patras, 26500, Greece

Anastasios Athanasopoulos,MD, Patras University Hospital, Urology Department, Building A, 4th floor, Patras, 26500, Greece

Disclosure:The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Urethral diverticula were first described at the beginning of the 19th Century. A urethral diverticulum is a sac-like protrusion that is continuous with the urethral lumen. A number of conditions other than urethral diverticula may fall under this broad definition, such as periurethral or paraurethral cysts, Skene’s duct cyst and periurethral duct abscesses, adding to the confusion in the literature regarding the essence of the diagnosis. A ‘non-communicating diverticulum’ is a common misuse of the term, characterizing periurethral or paraurethral pathology as not freely communicating with the urethra.

Despite the broad use of the term ‘urethral diverticulum’, the condition seems to be relatively uncommon. Nevertheless, its true prevalence is probably underestimated, as many cases remain asymptomatic or are misdiagnosed and treated as other lower genitourinary pathologies.

Increased physician awareness and the availability of highly efficacious imaging modalities will probably lead to an increasing number of cases requiring diverticulectomy, the cornerstone of surgical management for this condition.

Available information on the epidemiology, pathogenesis, clinical presentation and diagnosis of urethral diverticula is reviewed here. Methods of surgical management are also summarized, focusing on their efficacy.

Pathogenesis of urethral diverticula

A urethral diverticulum can be a congenital disorder, but it is most commonly acquired, presenting in adult life. The pathogenesis of urethral diverticula has been debated for over 200 years. The most widely accepted theory suggests that the origin of a urethral diverticulum is an infected paraurethral gland. Infection leads to duct obstruction with retention cyst or abscess formation, which eventually ruptures in the urethra, creating the diverticulum’s neck or ostium. This theory was introduced more than a century ago and was further supported by a detailed anatomical model of the periurethral gland network some 50 years later [1].

The periurethral glands, known as Skene’s glands, provide urethral lubrication with mucus production. The ducts of these glands terminate in the middle to the distal urethra near the 3- and 9-o’clock positions. The finding that most diverticula are located in the posterolateral wall of the middle third of the urethra, corresponding to the location of periurethral ducts [2], supports the aforementioned theory.

Histopathologic features of urethral diverticula match those of a paraurethral cyst and further support their paraurethral origin. In a study of 18 consecutive women diagnosed with urethral diverticula and treated surgically, the epithelial types were squamous (41.9%), columnar (31.8%), mixed squamous and columnar (18.2%), and cuboidal (13.6%). Inflammatory changes were very common but there were no cases of transitional epithelium [3].

It has to be noted, however, that findings of typical transitional urethral epithelium, known to line the proximal female urethra, have also been reported [4], supporting the second most popular theory for the pathogenesis of urethral diverticula: a urethral diverticulum is formed when urethral mucosa and fibromuscular tissue protrude into the periurethral tissue through a periurethral fascia defect [5]. In the original publication that introduced this theory, the authors characterized diverticula forming secondary to defects in periurethral fascia as ‘pseudodiverticula’, while their description approximates the definition of a true diverticulum, as we know it from other hollow organs. The involvement of a paraurethral fascia defect in the pathogenesis of diverticula makes its intraoperative recognition and meticulous repair mandatory in order to prevent recurrence.

Reports of diverticula formation after injury to the periurethral fascia, for example, during anti-incontinence surgery, such as periurethral collagen injection [6] or, more recently, tension-free vaginal tape [7–9], also support the second pathogenetic theory.

Urethral diverticula can be single or multiple. In some cases, they can extend around the urethra partially (‘saddlebag’ or ‘horseshoe’) or completely, varying in size from a few millimeters to 5 cm or more [10].

In 1993, a classification system for urethral diverticula was proposed, called L/N/S/C3 [11]. Each letter of the system represents a different characteristic of urethral diverticula. L describes location (distal, mid or proximal urethra), N the number (single or multiple) and S the size (expressed in cm). C3 describes three Cs: configuration, communication and continence. Configuration (C1) describes whether the diverticulum is single, multiloculated or saddle shaped. Communication (C2) indicates the site of communication with the urethral lumen (distal, mid- or proximal urethra). Continence (C3) is the presence of genuine stress urinary incontinence (SUI). The authors proposing this classification system suggested that this format provides a standard terminology, which, if adhered to, would allow accurate comparison of surgical results from different series.

Epidemiology

Epidemiologic studies screening significant numbers of asymptomatic women for urethral diverticula are lacking. Therefore, the true prevalence of this condition is unknown. The incidence of urethral diverticula has historically been reported to range between 0.6 and 5% [12,13], but rates as high as 40% have been found in a small series of women investigated for lower urinary tract symptoms suggestive of diverticula [14].

Heightened clinical awareness of the condition among urologists and gynecologists and more sensitive imaging techniques may lead to increased detection of urethral diverticula. Still, the condition is rather uncommon. Only 139 cases were recorded in the UK in 2005–2006 [15]. In the USA, approximately 27,000 inpatient procedures were performed for the repair of urethral diverticula in the 19-year period between 1979 and 1997, ranging from an estimated 500 to 3400 cases per year [16]. These figures were presented in 2005, using data from the National Hospital Discharge Survey (NHDS), a federal database that samples inpatient hospitals in the USA, and the National Statistics for Ambulatory Surgery (NSAS) database.

Significant findings from the same analysis were a decrease in the median age-adjusted rate of procedures, from 14.2 per 1 million women, between 1979 and 1988, to 6.4 per 1 million women between 1989 and 1997, an increase in procedures performed in the outpatient setting, averaging 6.7 cases per 1 million women per year between 1994 and 1996, and a threefold-higher age-adjusted rate for black compared with white women [16]. The authors concluded that urethral diverticulectomy is, overall, infrequent and that rates appear to have decreased over time, at least for inpatient procedures. Nevertheless, the analyzed data were relatively old and databases always have data coding and entry inadequacies, which means that the information gathered may not reflect the true epidemiology of the condition.

Clinical presentation

Historically, the classic presentation of urethral diverticula is the ‘three Ds’: dysuria, dyspareunia and postvoid dribbling. Only seven (23%) out of 30 women with urethral diverticula, in a recently reported series, presented with this classic triad [15]. The aforementioned symptoms were individually reported by 60, 53 and 30% of patients, respectively. Recurrent urinary tract infection was the presenting complaint in 17%. Interestingly, 23% of the women were asymptomatic. More or less similar findings were reported in a series of 22 cases [5]. The most common symptoms were dysuria (72.2%), dyspareunia (50%), perineal pain (45.5%), recurrent urinary tract infections (40.9%), purulent discharge (27.3%) and incontinence (18.2%). The classic postvoid dribbling was reported by only one patient (4.5%). Urgency and frequency are also very common, with rates as high as 60% [17].

From the previous symptomatology, it is obvious that clinical presentation is nonspecific. Many patients are initially diagnosed and treated with other conditions, such as cystitis, overactive bladder, SUI or urge urinary incontinence and pelvic pain syndromes, until the correct diagnosis is made. This usually results in significant delays in treatment. The mean interval between onset of symptoms and diagnosis was 5.2 years in some cases [18], but a shorter interval of approximately 9.5 months has been reported by others [19]. Differential diagnosis should include other periurethral masses, such as cystocele, vaginal leiomyoma, Skene’s gland and Gartner’s duct abnormalities, vaginal wall cysts, urethral mucosal prolapse and urethral caruncle.

On physical examination, a cystic lesion, often tender, is palpated in the anterior vaginal wall. In some series, the diverticulum was palpable in 83% of the patients [15], but this is not always the case, especially for small diverticula. Digital compression of the diverticulum during vaginal examination would result in pus or urine expulsion from the urethra, further supporting clinical suspicion.

Urethral diverticula may infrequently present with complications, including calculi formation [20–23], endometriosis [24] and development of neoplasms [25–29].

As mentioned previously, urinary incontinence can be one of the many clinical presentations of a urethral diverticulum. In particular, dribbling incontinence from intermittent diverticulum emptying in the urethra is part of the classic triad of clinical presentation. Nevertheless, true incontinence may coexist. Urodynamic evaluation is paramount in diagnosing detrusor overactivity and SUI, even though differential diagnosis of the latter from intermittent diverticulum emptying may be extremely difficult without video-urodynamics. Urethral pressure profiles may demonstrate a biphasic pattern or pressure drop at the level of diverticulum [30,31] and should be part of the evaluation when a diverticulum is suspected.

The majority of cohort studies show a high prevalence of urinary incontinence in women with urethral diverticula. In a small series of 14 patients who underwent diverticulectomy [32], urinary incontinence was the chief complaint in ten patients (71%). Eight (57%) of these patients had symptoms of SUI (urodynamically confirmed in seven) and two had postvoid dribbling. In another series of 63 women, incontinence was the only presenting complaint in 31.7% of patients, and genuine SUI was found in 28 (48.3%) out of 58 patients who were urodynamically evaluated [33].

Given the variety of clinical presentation, a high index of suspicion seems to be the most sensitive clinical tool for the diagnosis of urethral diverticula.

Imaging

Apart from history and clinical examination, urethroscopy is, in many cases, the next logical step. Not only are specialists familiar with the technique, but it can check for other urethral and bladder pathology that could explain the symptoms. In typical cases, the ostium of the diverticulum is directly seen in the urethra. Unfortunately, the sensitivity of the technique is low, even in experienced hands. In a series of 68 women, the diverticula orifice was visualized in only 42.6% of patients [34], and in another series, in 23% of patients [15]. Digital compression of the diverticulum during urethroscopy can help visualize the ostium by pus or debris expulsion in the urethra, thus enhancing diagnostic accuracy.

Imaging modalities available for the diagnosis of urethral diverticula have evolved in the past decades and continue to evolve. Their relative advantages and disadvantages have been discussed in relevant reviews [35]. A brief summary of their technical aspects and diagnostic accuracy is given here.

One of the classic methods used for imaging urethral diverticula is voiding cystourethrography (VCUG). It is relatively easy to perform, and most radiologists are familiar with the technique. The aim of this study is visualization of the diverticulum through filling with contrast media. Apart from the need of catheterization and the use of ionizing radiation, a significant limitation of the technique is its inability to define the diverticular ostium.

Double-balloon urethrography (DBU; or positive pressure urethrography) is another technique aiming to fill the diverticulum with contrast media. A specialized, double-balloon catheter, such as the Davis or the Madduri catheter, is inserted into the urethra. One balloon is inflated at the bladder neck, the other at the external urethral meatus, and contrast is injected at high pressure between them, aiming to force it into the diverticulum. The diverticular ostium can be, but is not always, visualized during early filling.

Double-balloon urethrography is infrequently used, as it is technically challenging and uncomfortable for the patient, requiring general anesthesia. Furthermore, the injection of contrast medium under pressure may lead to overdiagnosis of small lesions.

Injection of contrast medium under pressure makes DBU more sensitive than VCUG, to which it is often compared, even though it may lead to overdiagnosis of small lesions. In a small series of patients, DBU diagnosed 100% of complex diverticula, compared with 66.7% with VCUG [36]. In an older series of 32 women with suspected diverticula, diagnosis was confirmed in 30 (94%) patients by DBU [37]; however, VCUG failed to show the diverticulum in 22 out of these 30 cases.

Ultrasonography is increasingly used for the diagnosis of urethral abnormalities. The urethra can be assessed using transabdominal, perineal or endoluminar (transvaginal, endourethral and transrectal) probes. The transabdominal route requires a full bladder as a ‘window’ and has low sensitivity in detecting small diverticula [38]. Transvaginal ultrasonography is more sensitive but has the disadvantage of necessitating direct urethral compression for imaging, which somewhat distorts anatomy [39]. In 25 patients with suspected urethral diverticulum who underwent transvaginal ultrasound as a diagnostic procedure, ten were diagnosed with urethral diverticulum. Transvaginal ultrasound did not miss a urethral diverticulum that was identified by another diagnostic technique [40]. Endourethral ultrasound is known to have the highest sensitivity, but it is expensive and not widely available [41]. Disadvantages of the use of ultrasound in general are poor resolution for soft tissues and operator dependency.

Conventional computed tomography may help in the diagnosis and characterization of urethral diverticula. Newer techniques for evaluation of urethral pathology include computed tomography-voiding urethrography and virtual urethroscopy [42,43]. These techniques provide excellent anatomical information with 2D and 3D images but have the disadvantages of classic voiding urethrography and require time and effort for postacquisition image processing.

Magnetic resonance imaging is rapidly becoming the imaging technique of choice, not only for identifying urethral diverticula but also for providing high-resolution images and anatomical information for preoperative planning. Surface or endoluminar (endorectal, vaginal or endourethral) coils may be used [44–46], increasing the accuracy of the technique.

In a small series, including four patients with urethral diverticula confirmed at surgery, fast-spin echo T2-weighted pulse sequence MRI using a dedicated pelvic multicoil was positive in all patients, while DBU was positive in only one (25%) patient [47]. In another series, 27 consecutive patients underwent endoluminar MRI in the evaluation of suspected urethral diverticula [48]. Endoluminar MRI demonstrated a urethral diverticulum, which was subsequently confirmed at surgery, in two out of the 27 patients, whereas VCUG did not. In 14 out of 27 patients, VCUG underestimated the size and complexity of the urethral diverticulum as compared with endoluminar MRI and operative exploration. In a series of 30 women with already suspected or confirmed urethral diverticulum referred to a tertiary center [15], transvaginal ultrasonography revealed the diverticulum in six out of nine (67%) patients, VCUG in 13 out of 18 (72%) patients and MRI in all 11 (100%) patients assessed.

The aformentioned findings support the increasingly important role of MRI in the diagnosis of urethral diverticula.

Treatment

Surgical excision and reconstruction is the ‘gold-standard’ treatment of urethral diverticula. Nevertheless, mildly symptomatic patients can be treated conservatively. Antibiotics should be administered to treat acute urinary infections and low-dose chemoprophylaxis may be required in patients with recurrent infections. If the classic symptom of postvoid dribbling incontinence is present, manual stripping of the anterior vaginal wall after micturition may be suggested.

In cases where an asymptomatic urethral diverticulum is incidentally found on imaging or during routine physical examination, surgical excision may not be mandated, but patients must be counseled and followed-up, given that the natural history of untreated diverticula is unknown, and complications, such as stone formation or malignancy, do occur. However, recommendations for follow-up in such cases do not currently exist.

Surgical management is indicated in patients with bothersome symptoms attributed to the diverticulum despite conservative treatment and those with complicating factors found during evaluation. A variety of surgical techniques have been described for the management of urethral diverticula during the past two centuries. They include transurethral [13] and open [49] marsupialization, transurethral diverticulotomy using a knife electrode [50], transurethral electrocoagulation [51] and obliteration using materials such as cellulose [52] or Teflon^®[53].

All of the previously mentioned procedures have, at least theoretically, the disadvantage of not removing the diverticular sac and not reconstructing the periurethral tissues, thus leading to recurrence or other complications. Open marsupialization can only be applied to mid- and distal urethral diverticula, and obliteration using cellulose or Teflon has been abandoned owing to the risk of necrosis, abscess formation or foreign body reaction.

Consequently, transvaginal excision and reconstruction has become the standard surgical treatment. A transverse, midline, U-shaped, inverted-U or semi-lunar incision is performed and the diverticular sac meticulously developed and excised. A three-layer closure follows using the urethral wall, periurethral fascia and vaginal wall with nonoverlapping suture lines. The goal of surgery is to completely excise the diverticular wall (which can be very challenging in an area that is anatomically distorted and chronically inflamed), close the ostium and repair the periurethral fascia defect in a tension-free way, thus minimizing the risk of recurrence or fistula formation. The transvaginal approach allows sufficient access for complete excision of the lesion in the majority of cases. Other approaches may also be used in complicated cases [54,55]. The need for complete urethral mobilization with end-to-end reconstruction has also been described in the management of saddlebag or circumferential diverticula [56]. Depending on intraoperative findings, a Martius fat flap [57], dipedicled vaginal flap [58] or synthetic materials [59] have been used to reinforce the reconstruction. In patients with circumferential diverticula, complete excision of the diverticulum may necessitate additional surgery, such as urethroplasty using the diverticular sac or an end-to-end urethroplasty.

The operative time varies according to the size and complexity of the diverticulum and the reconstruction performed, but a mean operative time of 87.8 min has been reported [60]. The postoperative catheter and hospital stay is usually 3–5 days. A suprapubic catheter may be inserted during surgery and removed at first follow-up visit according to physician preference and site protocol.

Results of diverticulectomy

Results for a relatively small number of surgical series of diverticulectomy have been published, giving encouraging results. They are presented in Table 1.

A total of 32 women with recurrent pseudodiverticula who underwent transvaginal diverticulectomy with concomitant pubovaginal sling placement between 2000 and 2007 were followed-up for a mean of 4.3 years [10]. All patients had a MRI preoperatively and at 1 year after surgery. All patients had at least one diverticulectomy in the past and 15 had SUI. Postoperative recurrence of diverticula was clinically detected in two (6.2%) patients and in one more with MRI (no reoperation was required).

A retrospective case note review of 30 consecutive patients treated with diverticulectomy between 1999 and 2007 was recently reported [15]. Overall, 29 (95%) patients were cured of their diverticulum. Patients with simple diverticula were cured at the first attempt, while 17 procedures were performed in 11 patients with complex diverticula.

In a group of 30 women with simple and complex diverticula, 23 (77%) were cured at first attempt [60]. None of the simple diverticula recurred, but 33% of the U-shaped and 60% of the circumferential diverticula did recur. The success rate for circumferential diverticula after initial diverticulectomy was less than that of simple or U-shaped diverticula. In disagreement with other groups, this one claimed that location, size and multiplicity of urethral diverticula did not affect the surgical outcome.

The postoperative results of 68 women who underwent diverticulectomy between 1979 and 2005 were published in 2007 [34]. In this series, ten patients with distal urethra diverticula were treated with transurethral division and marsupialization instead of the classic transvaginal excision and reconstruction. Out of the total patient population, 11 (16%) patients experienced recurrence of the diverticulum and two (3%) experienced fistula formation. All of these patients were previously operated for the same indication. In no case was anti-incontinence surgery performed concomitantly. A total of 13 women developed de novo incontinence. Based on telephone interviews of 64 patients, the authors found that 92% of the patients were satisfied and would recommend surgery to a friend.

In another series of 18 women, there was substantial improvement in symptoms with diverticulectomy and no recurrences [19].

In an older series, out of the 18 patients operated, 16 (89%) were cured [5]. Failure was defined as persisting SUI in patients with pre-existing incontinence. Sling revision in these two patients led to 100% cure rate. There was no retropubic infection or sling erosion in this series.

Low rates of complications, such as recurrence and fistula formation, have been reported. Fistula occurred in three (7.7%) out of the 39 patients of diverticulectomies in one series [61], and de novo SUI developed in four (16%) patients postoperatively in another [17]. In an older publication, there were two cases of diverticulum recurrence and one of urethrovaginal fistula in 68 patients [33]. Delayed diagnosis, large size and complex configuration are associated with a higher rate of complications [62].

Of particular interest in relation to planning the operative technique to be followed is the presence or absence of incontinence. Some authors suggest that surgical treatment of incontinence should be postponed until operative results from diverticulectomy can be assessed. They argue that placement of synthetic materials commonly used in sling procedures for SUI in an already inflamed area increases the risk of infection, erosion of the sling with fistula formation and recurrence of diverticula. On the contrary, others argue that use of synthetic materials can reinforce the reconstruction following excision of diverticulum and cure incontinence, thus obviating the need for further surgery.

So far, reports of results from older, small series of surgical management of diverticula and incontinence in one step do not substantiate the fear for increased complication rates. Among seven women with urodynamically confirmed SUI who underwent diverticulectomy with a concomitant pubovaginal sling [32], there was only one (14%) recurrence of diverticulum.

In a series of diverticulectomy and concomitant sling placement in 16 women preoperatively diagnosed with intrinsic sphincter deficiency, diverticula were cured in 14 (88%) out of 16 women while two had small, stable residual diverticula [63]. All 16 patients reported significant improvement of incontinence, with 14 (88%) cured and two (12%) out of 16 significantly improved. No patient had erosion of the sling at a mean follow-up of 25 months. There was no retropubic infection or sling erosion among four women with SUI at initial urodynamic evaluation (seven with symptoms of urinary incontinence) who underwent diverticulectomy with concurrent placement of a fascial sling [5]. Similar results were reported in another series of 35 patients [18]. None of the patients had postoperative incontinence and no erosion of sling was reported.

In a recently published series, SUI was cured in 80% of the 15 cases of diverticulectomy with concomitant sling placement without complications [10].

Bladder neck suspension has also been performed concomitantly with diverticulectomy in women with incontinence, and results have also been satisfactory [33,64].

Not only is incontinence common in women before diverticulectomy, but it may develop postoperatively. In a group of 50 women who underwent diverticula repair [65], de novo SUI (diagnosed by responses to domain 3 of the urogenital distress inventory short form [UDI-6]) developed in five (33%) out of 15 patients with no preoperative urinary leakage, but they were most often mild.

Expert commentary

Urethral diverticula seem to be uncommon occurrences considering the relatively small size of published surgical series and evidence from various national databases and registries. Despite their rarity, interest in the medical literature is steadily increasing. The most obvious reason for this is that they can cause significant morbidity in affected women and they are a challenge for the physician to diagnose and treat.

The clinical presentation of urethral diverticula is so variable that the classic triad of dysuria, dyspareunia and dribbling incontinence is the exception and not the rule. A diverticulum can manifest with any combination of lower genitourinary tract dysfunction symptoms. Of particular interest is urinary incontinence. Dribbling incontinence due to intermittent emptying is difficult to differentiate from genuine SUI even with full urodynamic evaluation. Despite this, urodynamic evaluation may be necessary to exclude bladder dysfunction, such as detrusor overactivity.

In any woman with longstanding symptoms from the lower genitourinary tract without obvious cause, a urethral diverticulum should be suspected and appropriate imaging requested. VCUG is a classic radiology technique with satisfactory sensitivity that is relatively cheap and readily available to urologists and gynecologists. Therefore, it is still used to a considerable extent despite the need for catheterization and use of ionizing radiation. This is not the case for positive pressure urethrography, which requires special equipment and is considerably more uncomfortable for the patient. MRI has become the imaging modality of choice. It is somewhat more sensitive than classic imaging, but it is noninvasive and provides excellent anatomical information on the female urethra and surrounding tissues, thus differentiating diverticula from other periurethral pathologies, and helps preoperative procedure planning. Unfortunately, it is expensive and time consuming, restricting its use to clinical trials and specialist centers. Given this and the acceptable sensitivity of physical examination and classic imaging, a high index of suspicion remains the most useful diagnostic tool.

In several series reported, a significant proportion of patients, as many as one in five, were asymptomatic. Whether these patients should be offered diverticulectomy or managed expectantly is unknown, given that the natural history of untreated asymptomatic diverticula has not been studied. This issue needs to be clarified as the expanding use of imaging will increase the number of diverticula found incidentally.

The lack of a cheap, accurate and convenient diagnostic tool prevents screening of the general female population. Consequently, the exact prevalence of the condition is unknown. The incidence reported in several series is probably misleadingly high, given that studied populations are selected. Most women had longstanding symptoms, and other diagnoses had been previously excluded.

The challenge in diagnosis of urethral diverticula is followed by a very demanding surgical treatment. Minimally invasive transurethral and transvaginal procedures have been abandoned for fear of higher rates of recurrence and complications resulting from not removing the diverticular sac and reconstructing the defect. This argument is not clearly evidence-based. Transvaginal diverticulectomy with complete removal of the diverticular sac and ligation of the ostium is the gold standard of treatment. This can be very difficult, especially in cases of complex diverticula that extend near the urethral sphincter or the bladder neck. After removal of such diverticula, reconstruction of the urethra and periurethral fascia in a tension-free manner with nonoverlapping suture lines requires particular skill. Various tissue flaps and, more recently, synthetic materials have been used to reinforce the reconstruction, but the safety of the latter needs to be established. The lack of concrete evidence from comparative trials makes recommendations on specific techniques impossible. Surgeons should use the method that they are most familiar with.

The preoperative presence of SUI is an additional challenge in the management of urethral diverticula. Some authors in recent publications are adamant that antistress incontinence surgery, sling procedures in particular, should be avoided concomitantly to diverticulectomy for fear of sling erosion and fistula formation. They suggest that incontinence should be re-evaluated and treated after diverticulectomy. Despite this, there is no evidence of increased complication rates should the issue of SUI be addressed concomitantly. It has to be noted, however, that trials in favor of concomitant treatment are old and underpowered. Adequately powered trials, preferably randomized trials using standardized techniques, are needed to clarify this issue.

In the majority of published series, cure rates ranging between 70 and 100% are reported with only a few cases of recurrence or fistula formation. It has to be emphasized, however, that most series comprised quite a diverse female population, ranging from completely asymptomatic to highly symptomatic with large, complex diverticula. A significant proportion of diverticulectomies were second or third attempts after previous failures. Although such factors are known to influence success and complication rates, results are seldom reported separately. Moreover, definitions of success are not standardized and have included symptom improvement, cure of incontinence and lack of recurrence of diverticulum on imaging. In future publications, results need to be reported in relation to diverticular and patient characteristics and surgical technique. Successful outcomes should be clearly defined. This will allow pooling of results from different centers and increase our evidence-based knowledge on the management of urethral diverticula.

Five-year view

The first description of urethral diverticula dates to at least two centuries ago. After the introduction of classic radiological techniques in the 1950s and the transvaginal approach to complete diverticulectomy, no breakthrough changes have occurred in diagnosis and management. Furthermore, only a few slow changes are expected to occur in the next 5–10 years.

An increased number of publications on the subject of urethral diverticula in the past 3–5 years has already helped, and will continue to help, increase the awareness of the condition. Consequently, fewer women with lower genitourinary symptomatology will be misdiagnosed and unsuccessfully treated for other conditions long before the diverticulum is recognized and treated. This will hopefully reduce the number of sizable and complex diverticula that have been associated with a higher rate of postoperative complications.

The increased use of MRI in the imaging of pelvic pathology may increase the number of asymptomatic cases incidentally detected. This will help in the understanding of the natural history of the untreated condition, which is currently unknown.

An area of interest for further study is the safety of sling procedures for SUI in women with urethral diverticula. If no increase in complication rates is shown, the currently recommended two-step management will be obviated.

Table 1. Published results of diverticulectomy.

Study (year)	Patients (n)	Procedure	Efficacy outcomes	Complications	Ref.
Migliari et al. (2009)	32	Diverticulectomy and sling	6.2% recurrence		[10]
Ockrim et al. (2009)	30	Diverticulectomy	95% cure		[15]
Han et al. (2007)	30	Diverticulectomy	95% overall cure 33% recurrence in U-shape 60% recurrence in circumferential diverticula		[60]
Ljungqvist et al. (2007)	68	Diverticulectomy (58) Marsupialization (10)	16% recurrence	3% fistula formation	[34]
Rufford and Cardozo (2004)	18		No recurrence	No fistula formation	[19]
Wang and Wang (2000)	39			7.7% fistula formation	[61]
Stav et al. (2008)				16% de novo incontinence	[17]
Ganabathi et al. (1994)	68		Two recurrences	One fistula	[33]
Swierzewski and McGuire (1993)	7	Diverticulectomy and pubovaginal sling	16% recurrence		[32]
Faerber (1998)	16	Diverticulectomy and sling	88% cure		[63]

Key issues

• • The true prevalence of urethral diverticula is unknown. Incidence may be rising owing to increased awareness of the condition.

• • Clinical presentation is variable and nonspecific. A substantial percentage of cases remain asymptomatic.

• • Urethral diverticulum should be included in the differential diagnosis of women with lower genitourinary tract symptoms, especially if an etiologic diagnosis is not apparent and response to conservative treatment is poor.

• • Imaging is the cornerstone of diagnosis. Classic radiology techniques are sensitive enough, but MRI provides high-quality anatomical information and helps in the differential diagnosis of paraurethral and periurethral pathology.

• • The natural history of asymptomatic diverticula that are left untreated is unknown, but complications, such as stone formation and carcinogenesis, have been reported.

• • Complete surgical excision of the diverticular sac through a vaginal approach is the treatment of choice for symptomatic diverticula, with success rates ranging between 70 and 100%.

• • Meticulous reconstruction of the periurethral tissues is paramount in preventing recurrence and fistula formation. The technique of reconstruction depends on the anatomy post-diverticulectomy, as well as surgeon preference and familiarity.

• • The safety of concomitant diverticulectomy and sling procedure for stress incontinence is not established. Nevertheless, existing reports do not suggest an increased risk of recurrence of diverticulum of sling erosion with fistula formation.

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Female urethral diverticula: from pathogenesis to management. An update.

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1. Which of the following best describes a urethral diverticulum?

• □ A A periurethral duct abscess

• □ B A noncommunicating diverticulum of the urethra

• □ C A sac-like protrusion continuous with the urethral lumen

• □ D A periurethral or paraurethral cyst

2. Which of the following epithelial tissue types is least likely to be involved in urethral diverticula?

• □ A Transitional epithelium

• □ B Squamous epithelium

• □ C Columnar epithelium

• □ D Cuboidal epithelium

3. In the proposed classification system of L/N/S/C3 for urethral diverticula, the L and S categories are most likely to describe which of the following characteristics?

• □ A Length and size

• □ B Location and spread

• □ C Location and size

• □ D Length and stress incontinence

4. Which of the following clinical symptoms are the top two presentations of urethral diverticula?

• □ A Dysuria and dyspareunia

• □ B Recurrent urinary tract infection and postvoid dribbling

• □ C Purulent discharge and incontinence

• □ D Perineal pain and postvoid dribbling

5. Which one of the following is becoming the imaging test of choice for the diagnosis and localization of urethral diverticula?

• □ A Voiding cystourethrography

• □ B Magnetic resonance imaging

• □ C Computed tomographic scan

• □ D Double-balloon urethrography