Female urethral diverticula

Pathophysiology and Management of Long-term Complications After Transvaginal Urethral Diverticulectomy

Female urethral diverticulum (UD) is a rare and benign condition that presents as an epithelium-lined outpouching of the urethra. It has various symptoms, of which incontinence in the form of postmicturition dribble is the most common. The gold standard for the diagnosis of UD is magnetic resonance imaging, and the treatment of choice is transvaginal diverticulectomy. Despite the high success rate of transvaginal diverticulectomy, postoperative complications such as de novo stress urinary incontinence (SUI), recurrence, urethrovaginal fistula, recurrent urinary tract infections, newly-onset urgency, and urethral stricture can occur. De novo SUI is thought to result from weakening of the anatomical support of the urethra and bladder neck or damage to the urethral sphincter mechanism during diverticulectomy. It can be managed conservatively or may require surgical treatment such as a pubovaginal sling, Burch colposuspension, or urethral bulking agent injection. Concomitant SUI can be managed by concurrent or staged anti-incontinence surgery. Recurrent UD may be a newly formed diverticulum or the result of a remnant diverticulum from the previous diverticulectomy. In cases of recurrent UD requiring surgical repair, placing a rectus fascia pubovaginal sling may be an effective method to improve the surgical outcome. Urethrovaginal fistula is a rare, but devastating complication after urethral diverticulectomy; applying a Martius flap during fistula repair may improve the likelihood of a successful result. Malignancies in UD are rarely reported, and anterior pelvic exenteration is the recommended management in such cases.

Urethral diverticulum: A systematic review

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.

Abbreviations: PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; UD: urethral diverticulum/diverticula; UI: urinary incontinence; US: ultrasonography; VCUG: voiding cystourethrogram

The treatment of complex female urethral pathology

Lower urinary tract symptoms (LUTS) in women produce significant bother. Common conditions causing LUTS in women include urinary tract infections, overactive bladder, and stress incontinence. Urethral diverticulae and female urethral strictures are rare pathologies. They can cause symptoms, which can mimic commoner conditions, leading to delay in diagnosis and unnecessary delay in treatment. In this article, we discuss in detail the definition, symptoms, epidemiology, pathogenesis, diagnosis, and treatment option for these two conditions. Further understanding of these conditions will aid in the proper diagnosis and prevent delay in management.

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.

Female Urethral Diverticulum: Current Diagnosis and Management

While urethral diverticulum (UD) affects less than 20 per 1,000,000 women overall, it is thought to represent 1.4% of women with incontinence presenting to urology practices. It is hypothesized to evolve from periurethral glands that become obstructed, infected, and dilated over time, and patients typically present with dyspareunia, bothersome lower urinary tract symptoms (LUTS), and/or recurrent UTIs. In many patients, a periurethral mass can be appreciated on exam. In recent years, magnetic resonance imaging (MRI) has become the imaging test of choice for diagnosis of UD, but ultrasound (US) is a readily available alternative and provides good specificity at a lower cost. Surgical excision of the diverticulum with tension-free, water-tight, three-layer closure continues to be the mainstay of treatment of UD with most studies reporting cure rates of >90%. Concomitant treatment of preexisting stress incontinence with autologous fascial pubovaginal sling can be used at the time of diverticulectomy to avoid a secondary procedure. However, since secondary anti-incontinence procedures are needed in only a small number of patients, up-front stress incontinence treatment may result in significant overtreatment, and staged anti-incontinence procedures continue to be a reasonable option for patients with persistent bothersome stress urinary incontinence (SUI) after diverticulectomy.

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.

Female urethral diverticulum: cases report and literature

Introduction

A female urethral diverticulum is an uncommon pathologic entity. It can manifest with a variety of symptoms involving the lower urinary tract. Our objective is to describe the various aspects of the diverticulum of the female urethra such as etiology, diagnosis and treatment.

Cases presentation

We report five female patients, without prior medical history. They had different symptoms: dysuria in four cases, recurrent urinary tract infection in three cases, stress incontinence in two cases and hematuria in two cases. All patients had dyspareunia. The physical exams found renitent mass located in the endovaginal side of urethra which drained pus in two cases. Urethrocystography found a diverticulum of urethra in all cases. Our five patients underwent diverticulotomy by endovaginal approach. The course after surgical treatment was favorable. The urinary catheter was withdrawn after ten days. Some recurrent symptoms were reported.

Conclusion

Evaluation of recurrent urinary complaints in young women can lead to the finding of a diverticulum of urethra. Urethrocystography can reveal this entity. Diverticulectomy by endovaginal approach is the best choice for treatment.

Incidence of female urethral diverticulum: a population-based analysis and literature review

INTRODUCTION AND HYPOTHESIS

Urethral diverticulum (UD) is a protrusion of the urethra through the periurethral fascia. We aimed to determine the population-based incidence of female UD.

METHODS

Using the records-linkage system of the Rochester Epidemiology Project (REP), we identified women 18 years and older with a new diagnosis of UD in Olmsted County, Minnesota, USA, from 1 January 1980, through 31 December 2011. We also identified cases meeting the same criteria diagnosed at Mayo Clinic, regardless of county of residency. Incidence rates were calculated and trends for changes in incidence over time were tested. We conducted a systematic search of the MEDLINE, EMBASE, Cochrane Systematic Reviews, CENTRAL, Web of Science, and Scopus databases from inception through 30 March 2013, to identify published reports of UD incidence or prevalence.

RESULTS

We identified 164 incidence cases, including 26 women residing in Olmsted County. Age-adjusted annual incidence of UD in Olmsted County was 17.9 per 1,000,000 women (<0.02 %) per year (95 % CI, 10.9-24.9). We observed a trend toward increased incidence during the past 3 decades (P = 0.03). In our literature review, only 7 studies included an estimate of incidence or prevalence of UD; these estimates ranged from 6.4 per 1,000,000 per year (<0.01 %) having surgical intervention related to UD to a 4.7 % rate of UD diagnosed in asymptomatic women admitted for gynecological or obstetric issues.

CONCLUSIONS

In this population-based study, female UD was a rare disease, affecting fewer than 20 per 1,000,000 women (<0.02 %) per year.

Diagnosis and management of female urethral diverticulum

Female urethral diverticulum is a disorder that affects 1% to 6% of women. Women with diverticula may present with a variety of nonspecific genitourinary complaints, making the diagnosis challenging. Diagnosis is made by physical examination and can be confirmed with cystourethroscopy and/or radiographic imaging. Asymptomatic women can be managed conservatively, whereas treatment for symptomatic women usually involves a diverticulectomy. Potential complications from diverticulectomy include diverticulum recurrence, de novo stress incontinence, urethrovaginal fistula, urethral stricture, and recurrent urinary tract infections. This article reviews the etiology, differential diagnoses, evaluation, and management of female urethral diverticula.

Utility of clinical parameters, cystourethroscopy, and magnetic resonance imaging in the preoperative diagnosis of urethral diverticula

INTRODUCTION AND HYPOTHESIS

Our purpose was to assess the accuracy of history and physical, cystourethroscopy, and magnetic resonance imaging (MRI) in preoperative diagnosis of urethral diverticula.

METHODS

This was a retrospective review of all patients who underwent surgical excision of periurethral masses between 1998 and 2009. Presenting symptoms and examination and cystourethroscopic findings were noted. A single pathologist reviewed all cases and provided the reference standard for the diagnosis of a diverticulum. A single radiologist reviewed all preoperative MRI studies. Sensitivities, specificities, and positive and negative predictive values (PPV, NPV) were determined.

RESULTS

Diverticula were diagnosed in 36/60 (60 %) patients. Transurethral fluid expression on palpation and recurrent urinary tract infection (UTI) had high PPV. Sensitivity, specificity, PPV, and NPV, respectively, for cystourethroscopy were 33 %, 100 %, 100 %, and 42 %; for MRI, these were 100 %, 83 %, 92 %, and 100 %.

CONCLUSION

These data reinforce the utility of transurethral fluid expression for preoperative evaluation of urethral diverticula. Additionally, MRI is an excellent adjunctive diagnostic tool and may assist in establishing the diagnosis when there is high clinical suspicion of a urethral diverticulum but nonconfirmatory findings on cystourethroscopy.

Recurrent pseudodiverticula of female urethra: five-year experience

OBJECTIVES

To report our experience of transvaginal diverticulectomy with pubovaginal sling placement in a series of 32 women with recurrent urethral pseudodiverticula.

METHODS

A total of 32 women underwent surgical repair from January 2000 to June 2007. Of the 32 women, 12 had undergone other concomitant previous urethral surgery, predominantly for stress urinary incontinence. Transvaginal excision of the diverticulum and concomitant pubovaginal sling placement were performed routinely. The women were evaluated postoperatively for symptom relief, anatomic result, and postoperative continence status at 1, 6, and 12 months and annually thereafter. Pelvic magnetic resonance imaging was repeated after 1 year.

RESULTS

The mean follow-up was 4.3 years. In all cases, the voiding urethrogram after catheter removal showed a good urethral shape with an absence of urinary leaks. At the postoperative urodynamic investigation, 27 patients had an unobstructed and 5 an equivocal Blaivas-Groutz nomogram. Three patients (20%) reported a persistent degree of stress urinary incontinence, including 2 with grade 1 stress urinary incontinence and 1 with mixed incontinence. Two patients presented with clinically evident diverticulum recurrence, and in 1 patient, an intraurethral diverticulum, was found at the 1-year magnetic resonance imaging examination.

CONCLUSIONS

A pubovaginal sling added routinely to all diverticulectomy procedures offers significant support to the urethral repair and/or prevention of urinary incontinence, including in recurrent cases, and does not increase the risk of erosion into the urethra or fistula formation.

The utility of magnetic resonance imaging for diagnosis and surgical planning before transvaginal periurethral diverticulectomy in women

The objective of this paper is to report the value of magnetic resonance imaging (MRI) in the evaluation of urethral diverticulum in women. Medical records were identified by a query of urethral diverticulectomy billing data from January 1, 2000 through December 31, 2004. Patient demographics, preoperative evaluation data, and surgical outcomes were collected. Twenty-seven women were diagnosed with a urethral diverticulum during the study period. The cohort presented with a variety of symptoms. The mean time from onset of symptoms to diagnosis of a urethral diverticulum was 47 months. Seven (26%) women had a history of one or more prior diverticulectomies, and 8 (30%) had prior incontinence or other urethral surgery. Twenty-one (78%) had undergone a preoperative MRI, which detected the diverticulum in all cases. In three women, multiple other prior imaging studies had failed to identify the diverticulum despite clinical suspicion of its presence. MRI revealed an unsuspected intradiverticular carcinoma in one patient. Twenty-six women were treated with periurethral diverticulectomy, and one patient was treated with cystourethrectomy. Average follow-up was 9 (range 1-60) months. No patients had significant intraoperative complications. One patient was diagnosed (by MRI) with a recurrent diverticulum. The use of preoperative MR imaging altered the management in 15% of our patients. Furthermore, this study cohort had a long duration of complex symptoms with one-third having had prior urethral surgery. The use of MR imaging allows for accurate diagnosis and improved surgical planning.

Female urethral diverticula

Urethral diverticula are frequently under-diagnosed. The pathogenesis of this condition is poorly understood, and these lesions represent a spectrum of disorders ranging from isolated suburethral cysts to herniation of the urethral lining into the vaginal mucosa. Women with this disorder frequently complain of a host of symptoms referable to the lower urinary and genital tracts. Accurate diagnosis is based on history and clinical evaluation. Perineal ultrasound and MRI are often helpful. Repeated courses of antibiotics and urethral dilatation often fail to resolve the problem, and definitive intervention usually requires surgical excision to provide relief. This chapter describes the current management of this condition, and it heralds a re-look at the patho-aetiology in view of recent MRI findings of symptomatic non-communicating microcystic lesions.

Surgical procedures for urethral diverticula in women in the United States, 1979?1997

The objective of this study was to describe national rates of surgery for urethral diverticula in women. Data from the National Hospital Discharge Survey (NHDS), a federal database that samples inpatient hospitals in the United States, were analyzed from 1979 to 1997 for diagnosis and procedure codes using the ICD-9-CM classification system. The difference between the median age-adjusted rates from 1979 to 1988 and 1989 to 1997 were evaluated using the Mann-Whitney U test since the yearly rates fluctuated in a nonlinear fashion. Data from the National Statistics for Ambulatory Surgery (NSAS) database were analyzed from 1994 to 1996 in a similar fashion. The average age of women undergoing surgery for urethral diverticula increased from 41.6+/-15.1 years from 1979 to 1988 to 49.4+/-14.8 years from 1989 to 1997 (p=0.02). The average length of hospital stay decreased from 8.4+/-5.0 days in 1979 to 3.2+/-1.7 days in 1997 (p=0.007). Approximately 27,000 inpatient procedures were performed for the repair of urethral diverticula in the United States over a 19-year period, ranging from an estimated 500 to 3400 cases per year. The median age-adjusted rate of procedures decreased from 14.2 per 1 million women from 1979 to 1988 to 6.4 per 1 million women from 1989 to 1997 (p=0.009). Data from the NSAS indicated that an average of 6.7 surgeries per 1 million women per year were performed in the outpatient setting from 1994 to 1996. Age-adjusted rates of inpatient surgery for urethral diverticula were threefold higher for black compared to white women. Inpatient surgical repair of urethral diverticula is three times as high in black as compared to white women. These procedures are infrequent and rates appear to have decreased over time.

[The female urethral diverticula: apropos of 21 cases]

PURPOSE

Our goal is to study the clinical, radiological and therapeutic particularity of the female urethral diverticula via a retrospective study of 21 cases.

PATIENT AND METHODS

Twenty one females, with a mean age of 37 years (range 15 to 62 years) presenting an urethral diverticula, were treated between 1988 and 2000. Clinical examination made diagnosis in all cases. Cystorethrography shown a direct image of diverticula in 100% of cases and intravenous Pyelography in only 24% of cases. The urethral diverticula was excised via a transvaginal approach in all cases.

RESULTS

Eighteen patients had favourable immediate outcome. Three patients presented an urethrovaginal fistula treated surgically in one case and by bladder drainage in one case. The last patient refused treatment and she was lost to follow-up. After a median follow-up of 54 months (range 18 to 120) only three patients have some urinary urgency that was treated by anticholinergics.

CONCLUSION

Female urethral diverticula is a rare disease, the diagnosis is easy and only surgical excision gives good results.

MRI of Vaginal Leiomyomas

The MR appearances of two cases of vaginal leiomyoma are described. Both patients presented with a periurethral mass; one patient presented during pregnancy. MRI allowed precise anatomic localization of the masses and confident preoperative characterization in both cases.

Pelvic floor imaging

A greater awareness of the therapies now available for pelvic floor dysfunction has increased demand for specialized imaging of this region. Some of the techniques required are available at relatively few centers, and the purpose of this review is to introduce the emerging subspecialty of pelvic floor imaging to a more general readership. Pelvic floor anatomy is complex and is being unraveled by means of magnetic resonance (MR) imaging. This is discussed in detail by using a global, rather than a compartmentalized, anatomic approach. The physiology of normal urinary and anal function and the routine clinical tests applied to them are outlined. The imaging techniques involved include MR imaging, endosonography, and fluoroscopy. The main investigations include video urodynamic imaging, evacuation proctography, dynamic cystoproctography, dynamic MR imaging of the pelvic floor, and endoluminal imaging of the anal sphincters with MR imaging and ultrasonography. These are described in detail, and their role with regard to the main pathologic conditions of the pelvic floor--urinary and anal incontinence, constipation, and prolapse--are discussed.

Usefulness of diagnosis by the urethroscopy under anesthesia and effect of transurethral electrocoagulation in symptomatic female urethral diverticula

OBJECTIVE

We report accurate diagnosis and simple treatment of female urethral diverticula.

PATIENTS AND METHODS

When routine urologic evaluation suggested a urethral diverticulum, urethroscopy was performed with the patient under anesthesia with palpation by an intravaginal finger and transurethral catheterization to seek the orifice of the lesion. When a diverticulum was detected, transurethral electrocoagulation was performed regardless of the lesion size.

RESULTS

Urethral diverticula were detected in 18 of 30 women examined (60%), with the maximum size being that of the tip of the little finger (about 10 mm in diameter). Transurethral electrocoagulation was performed. The postoperative course was uneventful in all patients, who were discharged from the hospital a day after surgery.

CONCLUSIONS

Careful urethroscopy under anesthesia is a useful diagnostic tool, and transurethral electrocoagulation may be one of the best first choices of treatment for female urethral diverticula.

Urethral diverticula

Urethral diverticula are a common cause of chronic genitourinary symptoms in women. They occur in three percent of women overall with higher frequencies in selected populations of symptomatic women. The peak incidence is between the ages of 25-45 but they affect all ages. The classical presentation is with recurrent urinary tract infections and post micturition dribbling but almost any urinary symptom may be a presenting feature. Reported cure rates following surgery approach 70% for recurrent urinary tract infection and almost 100% for local symptoms such as dyspareunia. However, despite this and the availability of effective diagnostic techniques diagnosis is often delayed. This is partly due to a lack of awareness among clinicians and partly because the condition overlaps the traditional territories of gynaecologists and urologists.

Imaging studies of the pelvic floor

A variety of imaging modalities complement the history and physical examination in the investigation of pelvic floor dysfunction in women. Current fluoroscopic techniques, including defocography, can reveal underlying pelvic floor defects by reproducing normal daily activities that cause symptoms. Magnetic resonance imaging provides fine musculoskeletal detail of this region in anatomic plane not well seen via computerized tomography. Ultrasound is used primarily in assessment of the anal sphincter muscles. Cystourethroscopy provides direct visualization of the lower urinary tract. This article describes the clinical applications and technique of each modality.

Urethral diverticula in pregnancy

In 4 cases, the clinical presentation of urethral diverticulum (UD) during pregnancy was a paraurethral mass (3), urinary incontinence (2), irritative symptoms (2), urinary tract infection (1), urethral pain and discharge (1) and voiding difficulty (1). The diagnosis of UD during pregnancy was made by transvaginal ultrasonography (2), cystoscopy (1), and after pregnancy by a voiding cystourethrogram (1). Management during pregnancy involved antibiotics (2), diverticulum aspiration (2) and incision and drainage (1). Delivery was by the vaginal route in 2 women with diverticular aspiration being performed during the second stage to aid delivery in 1 woman. Caesarean section was performed in the other 2 women for reasons unrelated to the presence of the UD. Three women had diverticulectomy performed following pregnancy for persisting symptoms. Although uncommon, it is important to diagnose urethral diverticula given the associated morbidity and the potential for causing complications during pregnancy.

The contribution of urethrocystoscopy to evaluation of lower urinary tract dysfunction in women

The aim of this study was to determine whether the evaluation of lower urinary dysfunction with urodynamics and urethrocystoscopy provides unique information that is missed by urodynamics alone. Eighty-four women underwent multichannel urodynamics and urethrocystoscopy. Retrospective analysis included evaluation of the relationships between lower urinary tract lesions and risk factors using chi2 and Fisher's exact tests. Urethrocystoscopic findings changed the diagnosis and management in 6 patients. New urethrocystoscopic findings included papillary transitional-cell carcinoma, cystitis glandularis, an intravesical suture and a urethral diverticulum. Clinical parameters were not predictive of these findings. Urethrocystoscopic findings also contributed to the final diagnosis in 10 patients with intrinsic sphincter deficiency. Considered alone, maximum urethral closure pressure < or =20 cmH2O had a sensitivity of only 20% and a positive predictive value of 40% for this diagnosis. Urodynamics without urethrocystoscopy would have missed important diagnoses in 19% of women. Urethrocystoscopy and urodynamics complement one another, and both have a role in the evaluation of women with lower urinary tract dysfunction.

Experience with the management of urethral diverticulum in 63 women

The presentation and management are reviewed of 63 women with urethral diverticulum seen at a single institution in 10 years. Of the women 36 (61.9%) had urinary incontinence as a presenting symptom and 20 (31.7%) had incontinence as the only presenting complaint. Diverticula were suspected in 57 cases (90.5%) based on the presence of a periurethral mass during pelvic examination. Investigations included voiding cystourethrogram, excretory urogram, urodynamic studies and recently transvaginal ultrasound. Voiding cystourethrography adequately demonstrated the diverticulum in 60 of the 63 women (95.2%). Urodynamic studies performed in 58 women revealed abnormal findings in 36 (62%), including genuine stress urinary incontinence in 28 (48.3%). The location/number/size/configuration, communication, continence classification was used to define the characteristics of the diverticula. Seven women either refused operation or had small asymptomatic diverticula not requiring treatment. Transvaginal diverticulectomy was performed using a 3-layer closure in 56 women. Concomitant bladder neck suspension was performed in 27 women with documented stress urinary incontinence and/or urethral hypermobility. With a mean followup of 70 months (range 6 to 136) 48 women (85.7%) were completely relieved of the presenting complaint. Complications of diverticulectomy included 2 small distal recurrent diverticula, 1 urethrovaginal fistula and 6 transient early urinary tract infections. None of the women had urethral stricture or recurrent urinary tract infection. Six women (22.2%) who underwent diverticulectomy and bladder neck suspension, and 3 (10.3%) treated with diverticulectomy alone had minimal urinary incontinence requiring less than 2 pads a day.

Sonographic demonstration of calculi within a urethral diverticulum

A case in which sonography demonstrated that calculi may arise in female urethral diverticula is presented. The diagnosis of female urethral diverticula is reviewed.

L N S C3: a proposed classification system for female urethral diverticula

No descriptive criteria for the preoperative classification of female urethral diverticula have been proposed. Consequently, alternative therapies and different treatment series are not easily compared. Since 1982 the authors have evaluated 61 women with urethral diverticula and have identified those preoperative factors critical to an organized surgical approach to urethral diverticula. From this experience, a simple, comprehensive classification system for female urethral diverticula is proposed. The classification system is called L/N/S/C3. Each letter of the system represents a different characteristic of urethral diverticula. L = Location, the site of the diverticulum, i.e., distal, mid, or proximal urethra, with or without extension beneath the bladder neck. N = Number, whether single or multiple diverticula are present. S = Size, expressed in centimeters (cm). C3 = Configuration, Communication, and Continence Configuration (C1) describes whether we diverticulum is single, multiloculated, or saddle shaped. Communication (C2) indicates the site of communication with the urethral lumen, i.e., distal, mid, or proximal urethra. Continence (C3) is the presence of genuine stress urinary incontinence. Adhering to this format provides the surgeon a systematic means of approaching a urethral diverticulum and thus may minimize postoperative complications. Finally, the authors encourage other surgeons reporting series of urethral diverticula to adopt this system so that standard terminology may allow accurate comparison of surgical results.

Technical aids in investigation and management of urethral diverticula in the female

Three aids in the diagnosis and management of urethral diverticula are described. First, the technique of double-balloon urethrography has been modified. Diluted contrast medium is used to inflate the intravesical and external balloons so that improved delineation of the anatomy of the diverticular pouches is obtained with undiluted contrast medium. Second, for identification and irrigation with antibiotic solution of the nondraining pouches of compound diverticula, an angiographic catheter is placed in the most distal pouch using fluoroscopically guided manipulation, and then this catheter is replaced with a pigtail-shaped nephrostomy drainage catheter. Third, a 7 F Foley catheter balloon is placed in thin-walled and friable diverticular pouches to facilitate dissection.

Endovaginal sonography: new diagnostic approach for urethral diverticula

Too often a urethral diverticulum is a long-standing and unrecognized problem. Suprapubic sonography has been proposed for assessment of this pathological condition. We report on endovaginal sonography as a new improved imaging modality for the diagnosis of urethral diverticula. In positive cases additional morphological information can be obtained from positive pressure urethrography or from diverticulography via fine needle puncture under digital guidance or under sonographic control. Direct puncture of the lesion allows the injection of contrast material to facilitate the diverticulectomy.

Stone formation in a female urethral diverticulum. Review of the literature

A case of stone formation within a female urethral diverticulum is presented together with a brief literature review. Clinical diagnosis may be suspected if a stony hard mass is palpable on the floor of the urethra. The definitive diagnosis depends upon a plain X-ray film and a retrograde positive pressure urethrogram. Surgical excision of the diverticulum together with the calculus is best performed by the vaginal route.