evaluation and management of urethral diverticula howard b. goldman, md section of female pelvic...

Evaluation and Management of Urethral Diverticula

Howard B. Goldman, MDSection of Female Pelvic Medicine and Reconstructive Surgery

Glickman Urologic and Kidney Institute

The Cleveland Clinic

Lerner College of Medicine

Case Western Reserve University

• 32 yo woman referred for cystocele

• No pain

• No voiding complaints

• Has noticed a vaginal bulge for 6 months

• G1P1 - vaginal

urethra

Urethral Diverticulum

• Defect in the periurethral fascia with an outpouching of mucosa– Infection within periurethral glands– Obstruction and abscess formation– Rupture into urethral lumen

outpouchings

• Typically located dorsally and laterally

• Most common in 3rd to 5th decades of life

Presentation

• “Dysuria, Dyspareunia and Dribbling”• Recurrent UTIs• Urethral pain, pelvic pain, vag wall tenderness• Purulent drainage per urethra• Overactive bladder complaints: urgency,

frequency, incontinence

• Romanzi et al. (J Urol, 2000): diverse presentations, mimics other disorders

Evaluation

• History and physical exam• Careful palpation of distal anterior vaginal wall

– Milk the urethra and observe meatus

• Cystoscopy• Radiographic evaluation

– Voiding cystourethrography (VCUG)– Ultrasonography (transvaginal, endourethral)– MRI

• ? Urodynamics - fluoro– Evaluate for stress urinary incontinence

VCUG• Radiographic study of choice for years• Voiding and post-void views important

– Many patients cannot void on the table

• Blander et al. (Urology 2001): MRI and VCUG– VCUG missed 7% of diverticula and underestimated size and

complexity

VCUG

tic

Ultrasonography

• Transvaginal, endoluminal

• Relatively inexpensive, good visualization

• Operator dependant

• Siegel et al.: VCUG vs ultrasound. 13/15 diverticula detected with both modalities, but US showed extent and location better

Urethral diverticulum - UStransurethral

tic

neck

CT vs MRI

Urethral diverticulumaxial MRI

Urethral Diverticuli• Management:

– Conservative treatment measures: antibiotics, anticholinergics, anesthetics, etc..

• Acutely or for very small tics

– Operative• Spence procedure

– Very distal diverticulum

• Excision

• SUI considerations

Prepare Vaginal Wall Flap

Inicise Periurethral Fascial

Tic

Prepare Periurethral Fascial Flaps

Periurethral fascia flaps

Dissect Out and Excise Tic

Identify Ostium

Close Ostium

Closure of Dead Space

Periurethral Fascial Defect Closure

Close with Vaginal Wall Flap

*Avoid overlapping suture lines

• 32 yo woman referred for cystocele

• No pain

• No voiding complaints

• Has noticed a vaginal bulge for 6 months

• G1P1 - vaginal

urethra

Urethral diverticulumaxial MRI -saggital

Urethral diverticulumaxial MRI - saggital

ostium

Martius flap

Management of Stress Incontinence

• Faerber et al: simultaneous diverticulectomy and sling, no complications, no erosions, no SUI

• Vasavada et al: 5 diverticulectomies, xenograft tissue for sling, no erosions, no SUI

• Some controversy over whether to place sling at time of diverticulectomy – if place – never use synthetic mesh

Postoperative management

• Urethral catheter for 14 days• VCUG??• complications:

– stress incontinence (de novo)– urethrovaginal fistula– recurrence

– Evaluate path specimen

4/5 (80%) with Invasive adenoca had history of urinary retention

Long Term f/u of Diverticulum Recurrence

• N=122 50 month avg f/u

• 10.7% had surgery for recurrence– Risk factors

• Proximal diverticulum

• Multiple diverticula

• Prior vaginal or urethral surgery

• 26% persistent pain/discomfort with voiding

• 39% UTI in prior yearIngber et al, J Urol, 2011

Conclusions

• Diagnosis of urethral diverticula may be difficult• High index of suspicion• MRI is the gold standard for evaluation of suspect

diverticula• Surgery is the mainstay of therapy• Careful exposure of all layers allows proper

reconstruction• Majority successfully treated