Diagnosis of female urethral diverticulum using transvaginal contrast-enhanced sonourethrography

Urethral diverticular with broadly squamous metaplasia in a patient with urethral diverticular calculi: A case report

RATIONALE

There are already several reports concerning the occurrence of urethral diverticulum (UD) in female patients, but only rarely has a article describing UD combined with UD calculi or squamous carcinoma been published. Moreover, a case with squamous carcinoma and UD calculi at the same time has never been reported, making this the first case report about this condition.

PATIENT CONCERNS

A 43-year-old woman presented to the gynaecology department with a complaint of a hard mass beneath the anterior vaginal wall.

DIAGNOSES

Transvaginal ultrasound (TVU) revealed a UD.

INTERVENTIONS

We performed a standard urethral diverticular excision. Intraoperatively, we identified and removed a stone from the diverticulum. The intraoperative finding of a stone challenged the diagnosis of UD, with subsequent histological examination of biopsy tissue from the mass demonstrating broadly squamous metaplasia.

OUTCOMES

The broadly squamous metaplasia predominantly originated from the stone, and the stone was entirely removed. No complications occurred during the whole follow-up period. Moreover, after the 12-month follow-up, there was no diverticular recurrence or carcinoma metastasis.

LESSONS

UD calculi may be considered a risk factor for female urethra squamous metaplasia, which with the potential of squamous carcinoma, so patients will be advised to treat this condition immediately.

Preoperative Transurethral Contrast-Enhanced Ultrasonography in the Diagnosis of Female Urethral Diverticula

OBJECTIVES

To explore the value of transurethral contrast-enhanced ultrasonography (CEUS) in the diagnosis and evaluation of female urethral diverticula.

METHODS

This study prospectively enrolled 35 women with periurethral cystic lesions, who underwent preoperative transurethral CEUS at our single center between April 2015 and May 2017. The diagnosis of a urethral diverticulum was made by the detection of microbubbles inside the lesion. Data regarding the structure and ostia of the diverticula were collected and then compared with intraoperative findings.

RESULTS

The median (interquartile range) age of the 35 patients was 43 (34-48) years. The most common manifestations were dysuria (43%) and palpable masses (40%). On transurethral CEUS, 20 patients were found to have urethral diverticula. The diverticula involved the proximal, mid, and distal urethra with different sizes. The shapes of the diverticula were simple in 4 patients (20%), U shaped in 8 patients (40%), and circumferential in 8 patients (40%). A total of 23 ostia were identified. Seventeen women (85%) had 1 ostium, and 3 women (15%) had 2 ostia. Twenty-one diverticular ostia (91%) were located from the 3- to 9-o'clock positions. The median (interquartile range) distance from the diverticular ostia to the bladder neck was 20 (9-31) mm. During surgery, all US presentations correlated well with surgical findings, and 21 patients were confirmed to have urethral diverticula. The transurethral CEUS had sensitivity of 95% and specificity of 100%.

CONCLUSIONS

Transurethral CEUS is an effective method for identifying the structure and ostium of female urethral diverticula. It may have a potential role in preoperative planning and surgical management.

Incidental Finding of Urethral Diverticulum in a Woman with History of Recurrent Urinary Tract Infections

We present an incidental finding and management of a urethral diverticulum containing mixed composition of struvite and ammonium urate stones. Status post sleeve gastrectomy, patient presented to our bariatric clinic with epigastric pain associated with nausea and vomiting. A computed tomography scan was performed to rule out any complications of the procedure in which urethral stones were reported contained within a diverticulum. This finding, in retrospect, correlated with patient's past history of recurrent urinary tract infections. Over all, urethral diverticulum with struvite stones is a rare entity with few reported cases in literature thus a high index of suspicion is needed in patients with related symptoms. Here a case presentation and treatment rationale are described along with a brief review of existing literature.

Ultrasonographic Features of Female Urethral Diverticula: A Retrospective Study of 25 Patients

OBJECTIVES

This article summarizes the ultrasonographic features of female urethral diverticula on biplane transrectal ultrasound (B-TRUS).

METHODS

A retrospective study was performed with 25 consecutive women who were diagnosed and treated as having urethral diverticulum (UD) between January 2012 and March 2016. All the patients were preoperatively evaluated using B-TRUS. The number, location, configuration, size, and type of the UD on B-TRUS were assessed.

RESULTS

Twenty-eight diverticula were found on B-TRUS. Twenty-two patients had single diverticulum, whereas the other 3 had double diverticula. The locations included proximal (14%), mid (46%), and distal (40%) urethra. In transverse section, the configuration presented as round or oval (46%), and horseshoe-like or circumferential (54%). The maximal diameter of the 28 diverticula ranged from 3 to 48 mm. The types contained simple UD (36%) and complex UD (64%). Color blood flow signal could be detected in the septa, cystic wall, and solid mass, whereas negative in other areas inside the UD.

CONCLUSIONS

Various sonographic characters of female UD could be observed during the evaluation, including single or multiple diverticula, different sites, diverse shapes, and septa, calculi, or neoplasm inside diverticulum, all of which could be clearly displayed on B-TRUS.

Urethral Diverticulum in Women: Retrospective Case Series

PURPOSE

We present the management of 17 cases of urethral diverticulum in our department. We describe the various clinical presentations of urethral diverticulum, which may mimic other pelvic floor disorders and result in diagnostic delay.

MATERIALS AND METHODS

We reviewed 17 cases of urethral diverticulum presented to the urogynaecology department between January 2006 and February 2011 retrospectively. Patient demographics, history, clinical evaluation, diagnostic modalities, and management plans were reviewed. All of them underwent Magnetic Resonance Imaging (MRI) prior to the procedure.

RESULTS

The mean time from onset of symptoms to diagnosis of a urethral diverticulum was 24 ± 5.6 months. MRI identified the urethral diverticulum in all cases while voiding cystourethrography confirmed the diagnosis in 4 (23.5 %). They have been divided into two groups: Group A, (4-6 mm largest axis range) 5 (29.41 %) cases; Group B, (6-33 mm largest axis range) 12(70.59 %). All in Group A were symptomatic with recurrent Urinary Tract Infection (UTI), whereas only 8 (66.6 %) in Group B were symptomatic. Transvaginal diverticulectomy was done in 12 women who were symptomatic (70.5 %). Postoperative evaluation revealed complete resolution of symptoms, such as recurrent UTI, dysuria, and dyspareunia. One patient was unsure of surgery, while conservative approach was opted for asymptomatic patients 4 (23.5 %). The use of preoperative MRI altered the management in 2 (11.7 %) women.

CONCLUSION

The diagnosis of urethral diverticulum should be considered in women with recurrent UTI, dysuria, dyspareunia, and irritative voiding symptoms not responding to conservative therapy.

Urethral diverticula in women

Female urethral diverticula are rare, benign epithelium-lined outpouchings of the female urethra. Patients can present with a multitude of symptoms, most commonly urinary incontinence, recurrent UTIs and dyspareunia. These presenting symptoms are often confused with other diagnoses leading to delayed diagnosis or misdiagnosis. Diagnosis and preoperative assessment of bladder function is most accurate using a combination of clinical examination, T2-weighted postvoid MRI and videocystometrography. Best treatment is by vaginal excision, a procedure with a very low recurrence rate and high patient acceptability. Excision also results in high cure rates for associated dyspareunia, UTI and voiding dysfunction. Pre-existing urodynamically proven stress urinary incontinence (USUI) resolves in 50% of patients after excision of the diverticulum with Martius labial fat pad interposition without the need for further treatment. Potential adverse effects after surgery are new-onset USUI, urethrovaginal fistula and urethral stricture. The rate of onset of these potential adverse effects is low and related to the preoperative appearance of the diverticulum on an MRI scan and the complexity of the diverticulum.