Urethral diverticulum: A systematic review

Abstract

Objective: To present a review of the current literature regarding the presentation, diagnosis, and treatment of female urethral diverticula (UD). Methods: A systematic search of the PubMed database was performed to identify studies evaluating female UD. Article titles, abstracts and full-text manuscripts were screened to identify relevant studies, which then underwent data extraction and analysis. Results: In all, 50 studies evaluating the presentation, diagnosis and treatment of female UD were deemed relevant for inclusion. Almost all studies were retrospective single-arm case series. Female UD are outpouchings of the urethral lumen into the surrounding connective tissue. The presentation of female UD is diverse and can range from incidental findings to lower urinary tract symptoms, frequent urinary tract infections, dyspareunia, urinary incontinence (UI), or malignancy. Repair of UD begins with an accurate assessment and diagnosis, which should include adequate radiographic imaging, usually including magnetic resonance imaging. Once the diagnosis is confirmed, the usual treatment is surgical excision and reconstruction, most often through a transvaginal approach. The principles of transvaginal urethral diverticulectomy include: removal of the entire urethral diverticulum wall, watertight closure of the urethra, multi-layered and non-overlapping closure of surrounding tissue with absorbable suture, and preservation or creation of continence. Results of surgical repair are usually excellent, although long-term recurrence of these lesions may occur. Complications of urethral diverticulectomy include urethrovaginal fistula, UI, and rarely urethral stricture. Conclusion: Whilst urethral diverticulectomy excision and reconstruction is a challenging procedure, it is ultimately satisfying for the patient and the surgeon when relief of bothersome symptoms is achieved. Adherence to principles of reconstructive surgery is important to ensure a satisfactory result.

“Sandwich” mesh reconstruction of female giant urethral diverticulum: a case report

“…After surgery for an UD, about 10% of patients have SUI that subsequently requires a sling. Significant risk factors for the development of de novo SUI after diverticulectomy reportedly include a diverticulum larger than 30 mm and location in the proximal urethral [2,7].…”

“…The diagnosis and treatment of female urethral diverticula (UD) present a challenge to the urologist. Female urethral diverticula are considered relatively rare, with a prevalence of 1-6% [1]; however, their incidence is probably underestimated because they can be asymptomatic or misdiagnosed because of the characteristically nonspecific clinical manifestations such as vaginal mass, chronic pelvic pain, refractory lower urinary tract symptoms, and recurrent urinary tract infections [2]. However, increased awareness on physical examination and the use of imaging modalities such as magnetic resonance imaging have improved diagnostic accuracy [3].…”

Female Urethral Disease: A Contemporary Review of Presentation, Diagnosis and Current Management Strategies

“…Secondary to the presentation of urethral caruncle frequently presenting with signs and symptoms related to the more common diagnosis of UTI urine dipstick with or without urine microscopy with or without urine culture are usually the first line laboratory tests ordered. The combination of signs, symptoms and abnormal anatomy often leads the next step of evaluation to either flexible or rigid cystoscopy to evaluate for other causes of irritative or obstructive voiding symptoms [120]. Patients with significant voiding dysfunction or incontinence may benefit from an urodynamic study, as it can identify severity of the dysfunction and set a baseline to compare with after repair [121][122][123].…”

“…While ultrasound, voiding cystourethrogram and MRI are all modalities that may be used to evaluate urethral diverticula MRI is deemed the most optimal and "gold-standard" as it allows clear delineation of the soft tissue anatomy that permits both accurate diagnosis and enhanced surgical planning [120]. The T2 weighted imaging on MRI delineates the ostium in approximately 85% of cases [120].…”

Metaplastic Paneth Cells in Extra-Intestinal Mucosal Niche Indicate a Link to Microbiome and Inflammation

“…PCM was also observed in the lining of urethral diverticulum (Niemiec et al, 1989), a condition in which a variable sized pouch is formed. The E. coli was the most common organism among other enteric gram-negative bacteria isolated from urethral diverticulum patients (Ljungqvist et al, 2007;Greiman et al, 2019). Since urethral diverticulum is connected to the urethra and filled during urination, the metaplastic change in urethral lining could be due to exposure to irritants like bacterial colonization and retained urine.…”