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

A giant calculus within urethral diverticulum causing urinary retention in an uncommunicative woman

Introduction

There is no prior case report of calculus within a female urethral diverticulum causing urinary retention. We present such a case successfully treated by transurethral lithotripsy.

Case presentation

A 34‐year‐old bedridden and uncommunicative woman with spinocerebellar degeneration presented with fever for 5 days. She was admitted to the hospital for a urinary tract infection with a 3‐cm calculus in the lower urinary tract. At the time of admission, acute urinary retention occurred. A bladder catheter was placed, and antibiotics were administered; both improved the urinary tract infection. Subsequently, transurethral lithotripsy was performed and revealed that the giant calculus was incarcerated within the urethral diverticulum. The bladder catheter was removed postoperatively, and urinary retention did not recur. No calculus reformation or urinary tract infections were observed for 6 months after discharge.

Conclusion

A giant calculus within a urethral diverticulum may cause acute urinary retention in an uncommunicative patient.

Female urethral diverticula: An elusive pathology that can cause significant problems

Female urethral diverticula are a rare pathology, although thought to be under-diagnosed. They can present with a large variety of symptoms, and can be complicated by stones or malignancy. Magnetic resonance imaging is widely accepted to be the best form of imaging for this condition, although voiding cystourethrogram studies are helpful in providing information on bladder function. Symptomatic patients should be treated surgically through urethral diverticulectomy.

Level of evidence: Not applicable for this multicentre audit.

Female urethral diverticulum containing large calculi

Urinary stones in female urethral diverticulum are rarely seen. We report a 79-year-old woman who presented with irritative lower urinary tract symptoms and vaginal cystocele with incontinence. The urethral stones in the diverticulum were successfully extracted through the trans-urethral route and anterior tension-free vaginal mesh was applied one month later. The patient has been well, with no lower urinary symptoms or incontinence for 4 months.

Preoperative 3D and 4D-CT imaging using 640-Multislice CT (640-MSCT) in diagnosis of female urethral diverticulum

Objective

To determine the sensitivity and specificity of 640-Multislice CT (640-MSCT) in diagnosing the female UD.

Materials and methods

We investigated 16 patients with symptomatic UDs preoperatively in our hospital from August 2010 to March 2016. The patients’ average age was 38.8 years. All patients were performed 640-MSCT of pelvis; then, 3D and 4D images were reconstructed preoperatively.

Results

In 3D and 4D-CT images, out of 16 patients, thirteen patients had one ostium, two had 2 ostia and one had 3 ostia. Out of those thirteen patients, eight patients’ ostia were located at 5 o’clock and five patients’ at 7 o’clock. Patients with 2 ostia location were at 5 and 6 o’clock and 5 and 7 o’clock, respectively. Patients with 3 ostia location were at 5, 6 and 7 o’clock. The mean distance from the bladder neck to the ostia was 22.5 mm. The shape of UD was out-pouching in 11 patients (68.8%), U-shaped in four patients (25.0%) and circumferential in 1 patient (6.2%). The CT findings were confirmed by surgical findings.

Conclusions

640-MSCT is a useful tool in identifying UD’s shape and ostium (including number, location) before operation. Preoperative 640-MSCT should be an adaptable modality for clinically suspected UD patients.

Advances in knowledge

Several imaging methods have been used to diagnose female UD. 640-MSCT may be more suitable to diagnose it for its higher sensitivity and specificity in diagnosis of female UD, especially in identifying UD’s shape and number and location of ostium.

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.