RSS feedUrethral diverticulum
A urethral diverticulum is a pouch-like sac which develops from the female urethra – the tube carrying urine out of the body. The diverticulum does not empty properly during voiding and as a result may cause problems with repeated infections, dribbling and pain during sexual intercourse.
What are the symptoms of urethral diverticulum?
Urethral diverticulae can cause a triad of symptoms: Dysuria (painful voiding), Dyspareunia (painful sexual intercourse) and Dribbling (of urine after voiding). In fact, the classical symptom triad is only seen in a third of cases, and urethral diverticulae may cause a variety of urinary symptoms, most commonly:
- Any of the triad of symptoms above.
- Recurrent urinary tract infections or cystitis.
- Urethral discharge.
- Urinary frequency and urgency.
- A feeling that bladder has failed to empty after going to the toilet.
- Difficulty passing urine.
- Other non-specific lower urinary tract symptoms.
The severity of symptoms is not always related to the size of the urethral diverticulum.
What are the causes of urethral diverticulum?
The development of urethral diverticulae is often linked to repeated infections and the obstruction of the periurethral glands. These glands run over the entire length of the urethra, with the majority draining into the middle third of the urethra. For this reason, urethral divericulae are most likely to develop in the lower part of the urethra. Urethral diverticulae may also be caused by the trauma of childbirth, or in some cases, the symptoms may come to light following childbirth.
Who gets urinary diverticulum?
Urethral diverticulum is an unusual condition found in 1–3% of women generally and 1.5% of women with stress incontinence. In recent years, the reports of this condition have increased with better X-ray techniques to aid diagnosis, and greater awareness amongst (specialist) doctors. Urethral diverticulae are more common in African women and usually occur between the ages of 30 and 60.
How is urethral diverticulum diagnosed?
Many of the symptoms associated with urethral diverticulae are non-specific and mistaken for other conditions. This means that patients are often misdiagnosed and do not receive effective treatment for many years. Most patients had been treated for cystitis, bladder overactivity, incontinence, interstitial cystitis and pelvic pain syndromes before the correct diagnosis is made.
Diagnosis involves taking a thorough history with a high index of awareness, physical examination and specialised imaging. Specialist MRI is considered the best test to look at urethral anatomy and video urodynamics imaging to assess urethral and bladder function. Endoscopic examination of the bladder and urethra may also be required.
How is urethral diverticulum treated?
For patients without problematic symptoms, surgery may not be necessary. It is not clear which urethral diverticulae will grow over time and become increasingly bothersome. Some patients prefer to wait and continue surveillance and defer surgery until such time as symptoms become problematic.
Surgical excision
Surgical excision of urethral diverticulae is the preferred option for symptomatic patients. This can be a complex procedure, and should only be performed by specialists with experience of this type of surgery. The diverticulum can be firmly attached to the urethra and in removing it; there is a risk of damaging the urethra and causing incontinence. It is very important that the whole lining of the urethral diverticulum is excised to prevent reoccurrence and to ensure that the neck of the diverticulum is identified and closed.
What should I expect following surgery for urethral diverticulum?
The urethral diverticulum is excised through a vaginal incision. Fat from one of the labia is often tunnelled into the vaginal incision before closure to bolster and protect the repair, and reduce the risk of leak. Hospital discharge is usually allowed within 24–48 hours. A urethral cathter is left in situ for two weeks to drain the bladder and protect the repair until the urethra has healed. A dye test is performed before the catheter is removed to confirm healing.
Successful urethral divertiulum excision can be achieved in over 90 per cent of patients, although a few may require more than one procedure. The risk of incontinence is less than 5 per cent if the procedure is undertaken by an experienced specialist surgeon. Jeremy Ockrim is one of three subspecialist Urologists performing urethral diverticular surgery at the Institute of Urology, University College Hospital London. He recently published the group’s results of 30 urethral diverticlum procedures, the biggest series reported in the United Kingdom in over 20 years.
