A urethral diverticulum (UD) is a pocket or pouch that forms along the urethra. Many are small and not symptomatic. However, because of their location, they can become filled with urine and lead to infections. UDs only occur in approximately 5% of adult females, most commonly between the age 40-70.
Symptoms of UD include:
- Dysuria (painful and burning urination)
- Dribbling (urinary leakage after finishing urinating)
- Dyspareunia (painful sexual intercourse)
Urethral diverticulum commonly causes a mass or lump in the top vaginal wall as well as dribbling urine, burning or pain when urinating, and pain with sexual intercourse. They can also cause urinary infections that don’t respond well to antibiotic treatment. On occasion, a urethral diverticulum may cause obstructive lower urinary tract symptoms (LUTS) and rarely, the inability to urinate.
The underlying cause of urethral diverticula is often an infection and/or obstruction in the para-urethral glands. These glands surround the urethra and when they become obstructed, the glands can become infected and lead to abscess formation which subsequently ruptures into the urethra. During the healing phase, the cells that line the urethra can then grow out into the cavity formed by the ruptured abscess, forming a urethral diverticulum.
A pelvic exam typically reveals a tender, firm, cystic swelling of the top vaginal wall. When the swelling is manipulated, urine or possibly pus may be expressed through the urethra. MRI is the imaging test of choice to further evaluate the details, location and complexity of urethral diverticula. Another important test is urethroscopy, a visual inspection of the urethra using a small, lighted instrument to establish the location of the connection site between the diverticulum and the urethra.
Not all urethral diverticula require treatment, particularly if they are small and not symptomatic. Conservative measures that may relieve symptoms include compressing the diverticulum after urinating to preclude the post-void dribbling, antibiotics and using a needle and syringe to aspirate the contents.
Surgical management of symptomatic urethral diverticula involves excision of the diverticulum (urethral diverticulectomy) with repair of the urethra (urethroplasty). The surgery is performed via vaginal incision and requires the complete removal of the diverticular sac(s) down to the connection with the urethra. In the event of an infected diverticulum, it is important to treat with antibiotics prior to the surgery to eradicate the infection as best as possible. The surgical procedure is generally done on an outpatient basis and requires a urinary catheter (typically for 7–14 days), antibiotics, pain medication, and a bladder relaxant.
Urethral diverticulectomy has a high success rate with respect to relieving the presenting symptoms and resumption of normal urinary function post-surgery. As with any surgical procedure, there is always a small risk of complication. In general, the closer a urethral diverticulum is located to the bladder neck (where the urethra and bladder meet), the greater the risk for complications. Risks include bladder or ureteral injury, urinary incontinence, urethral stricture (scarring resulting in narrowing of the channel), urethral-vaginal or vesico-vaginal fistulas (abnormal connection between the vagina and the urethra or the vagina and bladder) and recurrence of the urethral diverticulum.