Diagnosis of urethral diverticula in women: value of MR imaging

Peri-Urethral and Anterior Vaginal Wall Masses: Does Radiological Imaging Change the Predicted Diagnosis?

INTRODUCTION

This study aims to determine the accuracy of radiological imaging compared with surgical pathology in patients with periurethral (PU) and anterior vaginal wall (AVW) lesions.

METHODS

This study is a retrospective analysis of 126 women who underwent surgical treatment for PU and AVW masses between 2011 and 2020. Clinicopathological data were extracted along with radiological findings from medical records. The primary outcome was the diagnostic accuracy of preoperative imaging compared to the gold standard, pathological diagnosis. The secondary outcome was the rate of imaging correcting the clinical diagnosis.

RESULTS

A total of 126 women with a median age of 42 underwent surgical treatment for PU and AVW masses. The most diagnoses were periurethral cysts (PUC) (52%) and urethral diverticulum (UD) (39%). Clinical diagnosis was accurate in 102 cases (81%) for the group of pathological diagnoses. Magnetic resonance imaging (MRI) and transvaginal ultrasound (TV US) were performed in 82 (65%) and 22 (17%) cases. The accuracy of MRI and TV US for the diagnosis of PU and AVW lesions was 76% and 82%, respectively. MRI and TV US corrected the clinical diagnosis in five (6%) and two (9%) cases, respectively. Voiding cystourethrography (VCUG) and double balloon urethrography (DBU), each performed in six (5%) cases, were accurate in four (67%) and three (50%) cases. No statistical difference was found for any imaging modality compared to clinical diagnosis.

CONCLUSION

Clinical diagnosis based on pelvic and cystoscopy examinations was sufficient for diagnosing PU and AVW masses and was not significantly different from imaging diagnosis. Imaging may be helpful with preoperative surgical planning in selected cases.

Does a tailored magnetic resonance imaging technique affect the surgical planning and outcomes for different cystic urethral and periurethral swellings in females? Seven years tertiary center experience

PURPOSE

To evaluate the use of magnetic resonance imaging (MRI) in preoperative delineation and surgical planning for the management of female urethral and periurethral cystic vaginal swellings, with emphasis on postoperative surgical outcomes.

MATERIALS AND METHODS

This is a retrospective analysis of females complaining of periurethral and urethral cystic swellings referred to our tertiary center, who underwent MRI for preoperative planning in the period from January 2014 till January 2021, with a total number of 57 patients. Data retrieved from the medical records included: patients' demographics, presenting symptoms and signs, preoperative radiological investigations, duration of symptoms, previous surgical intervention, detailed intraoperative data, postoperative complications, and postoperative follow-up.

RESULTS

Urethral diverticulum was the commonest cystic lesion representing (64.9%) followed by Skene gland cysts in 14%, Mullerian cysts in 7%, Gartner cysts in 3.5%, and dermoid inclusion cysts in 10.5%. MRI precisely diagnosed the various pathological entities and anatomical complex lesions prior to surgery. This was confirmed after surgery and pathology analysis. All patients were followed up with a mean duration of 35 months, without any evidence of recurrence.

CONCLUSION

MRI as a standalone imaging technique is mandatory for diagnosis of all urethral and periurethral cystic lesions, as it offers the most accurate diagnostic modality for delineation of these lesions and hence aids in the preoperative surgical planning, aiming to avoid recurrence and improving surgical outcomes.

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.

Transvaginal management of symptomatic complex urethral diverticula by definite closure of diverticula and robust reconstruction of the urethra

Background

Management of complex urethral diverticula (UDs) is challenging not only for the ostia detection and urethral reconstruction in surgery but also for the high risk of postoperative complications. We aimed to present the experience of surgical management for UDs by transvaginal partial diverticulectomy and urethral reconstruction.

Methods

The database of medical record library was retrospectively searched for patients underwent partial diverticulectomy for symptomatic complex UDs. During the surgical procedure, the cystourethroscopy was firstly performed to locate the diverticular ostium. The surgeon exposed and opened the diverticulum along its maximum axis. The surgeon recorded the location of ostia where saline solution flowed out, when one assistant pressed suprapubic region to increase inner-pressure of bladder and urethra. We focused on definite closure of diverticular ostia and robust urethral reconstruction.

Results

The present study included 39 patients with mean age of 45 years. There were 28 patients, 23 patients and 21 patients suffering from recurrent urinary infection, frequency and urgency. Ten patients had stress urinary incontinence. All of the 39 patients had complex UDs because of U-shaped diverticula (24/39) and circumferential diverticula (15/39). Multiloculated UDs were detected in 17 out of 39 patients. During the median follow-up time of 2.0 (1.0-12.0) years, there was no case of de novo urinary incontinence. However, 2 patients still had mild stress urinary incontinence without additional treatment. At postoperative 3 months, five patients had para-urethral cysts with the size ranging from 0.3 to 0.4 cm, which were absorbed in follow-up.

Conclusions

The method of transvaginal partial diverticulectomy, definite closure of diverticular ostium, and layered reconstruction of the urethra is a feasible surgical alternative for UDs.

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

A Case of Urethral Diverticulum with Surgical Repair Using Cadaveric Pericardial Tissue

A urethral diverticulum is a relatively uncommon finding. The estimated prevalence is approximately 1-5% in the general population. While the definitive treatment is surgical correction, there are limited studies guiding the best approach to repair. This is the case of a 48-year-old female who initially presented with vaginal discharge, dysuria, and dyspareunia. MRI revealed the diagnosis of suspected urethral diverticulum. The patient was treated with surgical correction with the aid of needle localization prior to the procedure. After the diverticulum was excised, the resulting defect in the urethra was successfully closed with cadaveric pericardial tissue. A urethral diverticulum should be considered in the differential diagnosis when a patient presents with symptoms such as recurrent urinary tract infections (UTIs) vaginal mass, dysuria, dyspareunia, or vaginal discharge. The use of cadaveric tissue augments the surgical technique for repair.

New frontiers in molecular and imaging research on evaluation and diagnosis of bladder outlet obstruction in women

Purpose

Diagnosis of bladder outlet obstruction (BOO) often presents a challenge in female patients. Traditional diagnostic elements such as symptom history and urodynamic data are rarely clear cut in women. Therefore, we sought to review the current literature on diagnosis of female BOO, focusing on new frontiers in the realm of molecular markers and imaging modalities.

Recent Findings

In addition to fluoroscopy in the setting of videourodynamics, ultrasound and MRI can augment the diagnosis and aid in therapeutic planning in certain etiologies of female BOO. Furthermore, multiple potential biomarkers (i.e. nerve growth factor, prostaglandins, ATP) that have been studied in correlation to BOO in animal models as well as human subjects hold promise for diagnostic applications.

Summary

These novel techniques may augment standard clinical and urodynamic evaluation of BOO in females. Future directions include further studies of each of these biomarkers in female patients with BOO compared to normal controls to test their feasibility as potential screening tools.

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.

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.

Patient Characteristics and Perioperative Outcomes of Female Urethral Diverticulectomy: Analysis of a Multi-Institutional Prospective Database

OBJECTIVE

To assess the patient and perioperative characteristics of urethral diverticulectomy using a large multi-institutional prospectively collected database.

MATERIALS AND METHODS

Female patients were identified using the American College of Surgeons National Surgical Quality Improvement Program participant user files (2007-2012) and current procedural terminology codes for urethral diverticulectomy (53,230). Preoperative variables and 30-day complications were examined.

RESULTS

Urethral diverticulectomies were performed on 122 females during the study period. The cohort was relatively healthy; 80% of patients had an American Society of Anesthesiologists score of 1 or 2. The majority of procedures were performed in an outpatient setting (82%). The median procedure length was 77.5 minutes (interquartile range: 50.5-112.5), and the median length of stay was 0 days (interquartile range: 0-1). The overall 30-day complication rate was 3.3% (n = 4): 3 patients developed urinary tract infections (UTIs) and 1 patient developed both a UTI and a superficial wound infection.

CONCLUSION

To our knowledge, our study represents the largest multi-institutional cohort of patients having undergone urethral diverticulectomy. The patients requiring this intervention were relatively healthy, and the procedure itself was short, allowing most patients to be discharged within 24 hours. The 30-day complication rate was very low, with UTI being the most common complication. Thus, patients can continue to be confidently counseled that urethral diverticulectomy is a safe procedure with very few perioperative complications.

Preoperative CT voiding cystourethrography using 16-multidetector CT in female urethral diverticulum

Purpose

To evaluate the clinical usefulness of preoperative CT voiding cystourethrography (CT-VCUG) using 16-multidetector computed tomography for female urethral diverticula.

Materials and Methods

Preoperative CT-VCUG was performed in 15 consecutive patients who underwent urethral diverticulectomy from May 2004 to December 2012. The result of preoperative cystourethroscopy and surgical findings were recorded by a single surgeon and CT-VCUG findings including the location of osita were retrospectively reviewed by another urologist who was blinded to the surgical finding. The location of the ostium detected on CT-VCUG was compared descriptively with the intraoperative surgical and preoperative cystourethroscopic findings.

Results

A total of 14 consecutive patients who underwent preoperative CT-VCUG and urethral diverticulectomy were included in the analysis. Ostia were detected on CT-VCUG in all cases, whereas ostia were identified in 10 patients (71.4%) by cystourethroscopy. Ostia were located between the 4 and 8 o’clock direction. Mean distance from the bladder neck to the ostium was 24.2 mm. Circumferential and horseshoe shaped diverticula were observed in 6 and 4 patients, respectively. The surgical findings correlated well with the CT findings.

Conclusions

Preoperative CT-VCUG can be useful in identifying the ostia of urethral diverticula in patients scheduled for urethral diverticulectomy and can provide structural information, useful to establish surgical strategy.

Congenital giant male anterior urethral diverticulum with calculi

Urethral diverticulum is a sac-like outpouching of urethral mucosa. It may be anterior or posterior according to anatomical locations. It is less common in men than in women. It can be congenital or acquired. Anterior urethral diverticula are usually congenital as compared to majority of posterior diverticula which are acquired. The most common aetiologies of male acquired diverticula are stricture, abscess, trauma or post-hypospadias repair. We report a case of congenital giant anterior urethral diverticulum with a calculus which has been managed successfully with surgical excision and repair in two layers.

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.

Diagnosis of female urethral diverticulum using transvaginal contrast-enhanced sonourethrography

INTRODUCTION AND HYPOTHESIS

This study investigated the value of transvaginal contrast-enhanced sonourethrography for the diagnosis of female urethral diverticulum (UD) by comparing results of contrast-enhanced ultrasound images and surgical findings.

METHODS

A total of 14 female UD patients underwent preoperative transvaginal contrast-enhanced sonourethrography between July 2010 and June 2012. History and physical examination were initially assessed by the same urologist. Transvaginal contrast-enhanced ultrasound imaging was performed and interpreted by the same ultrasonographer. Definite diagnosis was made by tracking the flow of the microbubbles into the cyst. Additionally, sagittal, cross-sectional, and dynamic images were obtained, and color Doppler ultrasound was applied in all cases. Data on the size, location, configuration, and opening of the UD was documented, and then compared with the surgical findings.

RESULTS

The most common symptoms presenting in the UD patients included urinary incontinence (71.5 %), recurrent urinary tract infection (57.1 %), frequency (50 %), urgency (35.7 %), dysuria (35.7 %), and dyspareunia (21.4 %). On physical examination, 8 out of 14 patients (57.1 %) had a palpable anterior vaginal wall mass, while 6 out of 14 patients (42.9 %) had no palpable mass. Transvaginal contrast-enhanced sonourethrography revealed 17 diverticula orifices in total and correlated well with surgical findings regarding the size, location, configuration, and the opening of the UD.

CONCLUSIONS

In patients with chronic irritative bladder symptoms, but with no response to conventional treatment a high index of suspicion for UD should be maintained. Our study demonstrates that transvaginal contrast-enhanced sonourethrography is a useful tool for defining the size, location, configuration, and opening of the UD before surgery.

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.

Female urethral diverticulum presenting with acute urinary retention: Reporting the largest diverticulum with review of literature

Female urethral diverticulum is a rare entity with diverse spectrum of clinical manifestations. It is a very rare cause of bladder outlet obstruction and should be considered as a differential diagnosis in females presenting with acute urinary retention associated with a vaginal mass. Strong clinical suspicion combined with thorough physical examination and focused radiological investigations are vital for its diagnosis. Herein we report a case of giant urethral diverticulum presenting with acute urinary retention in a young female. It was managed by excision and urethral closure, and is the largest urethral diverticulum reported till date in the literature.

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.

Utility of preoperative examination and magnetic resonance imaging for diagnosis of anterior vaginal wall masses

INTRODUCTION AND HYPOTHESIS

The clinical evaluation of anterior vaginal wall masses can present a dilemma, as there are no well-defined pathways for diagnosis and management. Our objective was to evaluate the role and accuracy of preoperative exam and magnetic resonance imaging (MRI) for these masses.

METHODS

We identified women with a mass using billing codes for 10 years. We compared data from the preoperative evaluation to postoperative pathology if available.

RESULTS

Analysis after chart review on 47 women was performed. Of the 34 women who had surgery, 28 (82.4%) also underwent an MRI. MRI diagnosis was accurate in 22/28 women compared to histology, inconclusive in 4, and inaccurate in 2. Preoperative diagnosis, including exam, MRI, and cystourethroscopy, had a diagnostic accuracy of 94.1% compared to postoperative diagnosis. The positive predictive value of MRI alone was 91.7%.

CONCLUSIONS

Preoperative diagnosis using exam, MRI, and cystourethroscopy have a high diagnostic accuracy for anterior vaginal wall masses.

[Treatment approach to female urethral diverticulum]

Female urethral diverticula are uncommon and are more frequent between the third and fifth decades of life. They are usually diagnosed late. Most urethral diverticula are related to recurrent infections of the periurethral glands or urethral trauma. Cystourethrography and magnetic resonance imaging are the most valuable diagnostic methods. The treatment of choice is thte resection of the diverticulum.

Technical note: Dynamic MRI in a complicated giant posterior urethral diverticulum

Congenital posterior urethral diverticulum is an uncommon anomaly, sometimes complicated by infection or calculi formation. A conventional voiding cystourethrogram (VCUG) is the most commonly used diagnostic modality. Dynamic magnetic resonance imaging (MRI) has not been frequently described in this entity. We describe a case of posterior urethral diverticulum complicated with secondary calculi, where the patient was evaluated using dynamic MRI and conventional VCUG.

An unusual cause of pelvic pain and fever: periurethral abscess from an infected urethral diverticulum

BACKGROUND

The evaluation of patients with pelvic pain is a common task for emergency physicians. Accurate diagnosis of the underlying cause of pelvic pain in women is often difficult given the diversity of pathology that can generate pelvic pain.

OBJECTIVE

To report a rare but clinically significant cause of acute pelvic pain in women.

CASE REPORT

We describe a rare case of a periurethral abscess secondary to an infected urethral diverticulum in a 41-year-old woman. She presented to our Emergency Department with pelvic pain, dysuria, and fever of 4 days duration.

CONCLUSION

Physical examination, imaging studies, and surgery aided in confirming the diagnosis of a periurethral abscess.

Malignant transformation of Gartner cyst

Vaginal cysts are common lesions that include Gartner cysts, which develop from the wolffian duct remnants in the vaginal wall. Malignant transformation of Gartner cysts is exceedingly rare. Our case was diagnosed upon evaluation of vaginal bleeding in a 67-year-old woman. Histologic examination showed a clear cell carcinoma. Treatment consisted of surgical excision and radiation therapy. Treatment quality, stage, and pelvic node status are the main prognostic factors. Regular long-term follow-up is crucial.

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.

Transvaginal sonographic diagnosis of female urethral diverticula

PURPOSE

We report our experience with transvaginal sonography (TVUS) in the diagnosis of female urethral diverticulum (UD).

METHOD

We reviewed the TVUS examinations of 4 patients with a clinical diagnosis of UD and correlated the sonographic findings with the operative findings, especially regarding the UD's size, content, and location.

RESULTS

All UDs were demonstrated on TVUS. The size, content, and location of the UD correlated well with the operative findings.

CONCLUSION

TVUS is accurate in diagnosis and determination of the size, content, and location of female UD.

Diagnosis of female diverticula using magnetic resonance imaging

We investigate the ability of physical exam to diagnose urethral diverticula with or without magnetic resonance imaging (MRI) and exclusive of invasive modalities. A retrospective chart review of all women undergoing urethral diverticulectomy at our institution since 1999 was performed. We identified 28 female patients with a mean age at diagnosis of 42.6 years (range 18-66). Common presenting symptoms included dyspareunia, urgency, and frequency. Physical exam revealed a suspected urethral diverticulum in 26 (92.9%) patients, which was confirmed postoperatively in 17 of the 20 (85%) women who underwent surgical resection. Noninvasive imaging modalities (MRI or CT) were available for review in 20 (71%) cases and made the correct diagnosis of urethral diverticulum (presence or absence) in 19 (95%) patients. In those patients with symptoms of stress or urge incontinence (11, 39%), voiding cystourethrogram (VCUG) was performed. Urethral diverticula are often easily diagnosed on physical exam. MRI can be a useful adjunct for defining diverticular extent in surgical planning, especially for proximal and complex diverticula, and should be the modality of choice if clinical suspicion is high based on patient symptoms and physical exam.

Urethral diverticula: a review and an update

Likely originating from the periurethral glands, female urethral diverticula (UD) are an uncommon but fascinating clinical entity. UD are variable in their presentation and the diagnosis is sometimes difficult and delayed. Modern imaging modalities such as surface coil and endoluminal magnetic resonance imaging (MRI) have added to the diagnostic armamentarium but have also furthered our understanding of UD. Accurate preoperative characterization of the often complex anatomical patterns seen on these imaging studies including saddlebag and circumferential urethral involvement, as well as complete evaluation of associated voiding dysfunction such as complete evaluation of associated voiding dysfunction such as urinary incontinence often impacts contemporary surgical management.

Diagnosis and management of vaginal mullerian cyst in a virgin patient

Benign cystic lesions of the vagina are uncommon and may become symptomatic. We describe two symptomatic anterior vaginal wall cysts in a virgin patient and the usefulness of imaging modalities. A 36-year-old virgin woman presented with a complaint of vaginal bulging and pelvic pressure. Pelvic examination revealed a cystic mass protruding from the vagina surrounded by the intact hymen. The initial abdominopelvic ultrasound showed a hypoechoic cystic mass measuring 42 x 20 mm in the vagina. She then had a pelvic magnetic resonance imaging (MRI) that revealed two anterior vaginal wall cysts with no communication with the urethra or bladder. The cysts were excised and histologic examination with mucicarmine revealed mucin-secreting tall columnar cells consistent with a diagnosis of mullerian cyst. While both ultrasonographic examination and MRI are helpful in localizing vaginal cysts, MRI is superior in showing multiple cystic lesions of the vagina and their communication with the surrounding structures.

Outcomes of Surgery of Female Urethral Diverticula Classified Using Magnetic Resonance Imaging

OBJECTIVES

We evaluated the surgical outcomes of transvaginal diverticulectomies classified using magnetic resonance imaging (MRI).

METHODS

We evaluated 30 women (mean age: 46.4 yr; range: 31-73 yr) who were followed up for at least 12 mo after urethral diverticulectomies (mean follow-up: 29 mo; range: 12-93 mo). Characteristics of urethral diverticula were confirmed before surgery by MRI. Diverticula were classified as simple, U-shaped, or circumferential according to MRI features. Transvaginal excisions of urethral diverticula were performed using vaginal flaps and three-layer closures. Cure was defined as the absence of a diverticulum and symptoms.

RESULTS

Seventeen cases (57%) had simple diverticula, three (10%) had U-shaped diverticula, and 10 (33%) had circumferential diverticula. After the first operation, 23 cases (77%) were cured. None of the simple diverticula recurred, but 33% of the U-shaped and 60% of the circumferential diverticula did recur. Of the seven recurrent cases, three did not require a second operation because their symptoms resolved. Of the four cases that underwent a second operation, three were cured and one was cured after two additional operations. The success rate for circumferential diverticula after initial diverticulectomies was less than that of simple or U-shaped diverticula (p<0.05). Location, size, and multiplicity of urethral diverticula did not affect the surgical outcome (p>0.05).

CONCLUSIONS

Transvaginal diverticulectomy is effective for treatment of female urethral diverticula. For circumferential urethral diverticula, however, surgical procedures should be adapted to achieve complete resections of the diverticulum.

Diagnosis and management of periurethral cysts

BACKGROUND/AIMS

Periurethral cysts are a rare entity that may be confused with urethral diverticula. The protocol for diagnosis and management of these lesions is still unclear. We present our experience with six patients presenting with periurethral cysts.

METHODS

From 2001 to 2005 we evaluated six patients with a paraurethral mass. History, physical examination, laboratory and radiographic findings were analyzed to determine factors helpful in mass diagnosis. Cyst excision was performed via trans-vaginal approach in all patients and outcomes of this approach were assessed.

RESULTS

Six female patients, average age of 29.7 years, presented with the complaint of a paraurethral mass. Transvaginal sonography was performed in two patients to confirm the presence of a periurethral cyst. Cystourethroscopy in all patients revealed no communication between the cyst and the urethra or presence of other lesions. Pathology revealed a benign cyst in all patients. No cyst recurrence has been seen in any patient.

CONCLUSION

Most periurethral cysts can be diagnosed by physical examination. The diagnosis may be confirmed with transvaginal sonography. Cystourethroscopy should be performed to rule out other pathology, but may be done in the same setting as surgical excision. Complete surgical excision is effective and is associated with minimal risk of recurrence during short-term follow-up.

TVT can also cause urethral diverticulum

Since the introduction of tension-free vaginal tape (TVT) procedure by Ulmsten, the majority of reports have concentrated on TVT procedure's success to correct urinary stress incontinence with fewer reports on its complications. In this study, we describe the first case in the English literature, of urethral diverticulum, which occurred after the use of polypropylene synthetic sling in a woman with previous vaginal surgery.

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.

Cross-sectional imaging of the female urethra: technique and results

Clinical assessment of women with urethral symptoms is difficult, necessitating further evaluation with imaging. Urethrography provides limited information on luminal abnormalities of the urethra. Recent advances in ultrasound (US) and magnetic resonance (MR) imaging have dramatically improved evaluation of the female urethra, clarifying findings at physical examination and providing accurate road maps for surgeons. High-resolution transvaginal US, transperineal US, and transurethral US are reliable techniques for diagnosis and characterization of urethral abnormalities. High-resolution multiplanar MR imaging with phased-array pelvic and endovaginal coils demonstrates the urethral anatomy in greater detail. In women with urethral diverticula, US and MR imaging demonstrate the number of diverticula and the location, size, configuration, and possible contents of the sac. Most important, the position of the neck of the diverticulum may be identified for the surgeon. Imaging features do not allow differentiation between histologic subtypes of urethral carcinoma; the diagnosis is established with histopathologic examination. Periurethral cysts do not communicate with the urethra and therefore can often be differentiated from urethral diverticula at endocavitary MR imaging. High-resolution multiplanar US and MR imaging allow comprehensive evaluation of abnormalities of the female urethra.

Endovaginal Magnetic Resonance Imaging of the Female Urethra

Magnetic resonance imaging (MRI) is playing an important role in the clinical evaluation of women presenting with urethral symptoms. Voiding cystourethrography, direct urethrography, and pelvic sonography provide limited information on abnormalities that are in continuity with the urethra. On the other hand, urethra and periurethral tissues can be noninvasively evaluated by high-resolution endocavitary MRI. Because of its multiplanar capability and high tissue contrast, endovaginal MRI is an extremely reliable diagnostic test in the evaluation of urethral abnormalities. In this article, the utility of endovaginal MRI in the detection and characterization of a wide spectrum of urethral pathologic conditions, such as congenital anomalies, diverticula, urethritis, and benign and malignant neoplasms, is discussed.