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62-year-old woman • dysuria • dyspareunia • urinary incontinence • Dx?
THE CASE
A 62-year-old postmenopausal woman presented to the clinic as a new patient for her annual physical examination. She reported a 9-year history of symptoms including dysuria, post-void dribbling, dyspareunia, and urinary incontinence on review of systems. Her physical examination revealed an anterior vaginal wall bulge (FIGURE). Results of a urinalysis were negative. The patient was referred to Urology for further evaluation.
THE DIAGNOSIS
A pelvic magnetic resonance imaging (MRI) scan revealed a large periurethral diverticulum with a horseshoe shape.
DISCUSSION
Women are more likely than men to develop urethral diverticulum, and it can manifest at any age, usually in the third through seventh decade.4,5 It was once thought to be more common in Black women, although the literature does not support this.6 Black women are 3 times more likely to be operated on than White women to treat urethral diverticula.7
Unknown origin. Most cases of urethral diverticulum are acquired; the etiology is uncertain.8,9 The assumption is that urethral diverticulum occurs as a result of repeated infection of the periurethral glands with subsequent obstruction, abscess formation, and chronic inflammation.1,2,4 Childbirth trauma, iatrogenic causes, and urethral instrumentation have also been implicated.3,4 In rare cases of congenital urethral diverticula, the diverticula are thought to be remnants of Gartner duct cysts, and yet, incidence in the pediatric population is low.8
Diagnosis is confirmed through physical exam and imaging
The urethral diverticulum manifests anteriorly and palpation of the anterior vaginal wall may reveal a painful mass.10 A split-speculum is used for careful inspection and palpation of the anterior vaginal wall.9 If the diverticulum is found to be firm on palpation, or there is bloody urethral drainage, malignancy (although rare) must be ruled out.4,5 Refer such patients to a urologist or urogynecologist.
Radiologic imaging (eg, ultrasound,
Continue to: Nonspecific symptoms may lead to misdiagnosis
Nonspecific symptoms may lead to misdiagnosis. The symptoms associated with urethral diverticulum are diverse and linked to several differential diagnoses (TABLE).3,4,12 The most common signs and symptoms are pelvic pain, urethral mass, dyspareunia, dysuria, urinary incontinence, and post-void dribbling—all of which are considered nonspecific.3,10,11 These nonspecific symptoms (or even an absence of symptoms), along with a physician’s lack of familiarity with urethral diverticulum, can result in a misdiagnosis or even a delayed diagnosis (up to 5.2 years).3,10
Managing symptoms vs preventing recurrence
Conservative management with antibiotics, anticholinergics, and/or observation is acceptable for patients with mild symptoms and those who are pregnant or who have a current infection or serious comorbidities that preclude surgery.3,9 Complete excision of the urethral diverticulum with reconstruction is considered the most effective surgical management for symptom relief and recurrence prevention.3,4,11,14
Our patient underwent a successful transvaginal suburethral diverticulectomy.
THE TAKEAWAY
The diagnosis of female urethral diverticulum is often delayed or misdiagnosed because symptoms are diverse and nonspecific. One should have a high degree of suspicion for urethral diverticulum in patients with dysuria, dyspareunia, pelvic pain, urinary incontinence, and irritative voiding symptoms who are not responding to conservative management. Ultrasound is an appropriate first-line imaging modality. However, a pelvic MRI is the most sensitive and specific in diagnosing urethral diverticulum.12
CORRESPONDENCE
Folashade Omole, MD, FAAFP, 720 Westview Drive, Atlanta, GA 30310; fomole@msm.edu
1. Billow M, James R, Resnick K, et al. An unusual presentation of a urethral diverticulum as a vaginal wall mass: a case report. J Med Case Rep. 2013;7:171. doi: 10.1186/1752-1947-7-171
2. El-Nashar SA, Bacon MM, Kim-Fine S, et al. Incidence of female urethral diverticulum: a population-based analysis and literature review. Int Urogynecol J. 2014;25:73-79. doi: 10.1007/s00192-013-2155-2
3. Cameron AP. Urethral diverticulum in the female: a meta-analysis of modern series. Minerva Ginecol. 2016;68:186-210.
4. Greiman AK, Rolef J, Rovner ES. Urethral diverticulum: a systematic review. Arab J Urol. 2019;17:49-57. doi: 10.1080/2090598X.2019.1589748
5. Allen D, Mishra V, Pepper W, et al. A single-center experience of symptomatic male urethral diverticula. Urology. 2007;70:650-653. doi: 10.1016/j.urology.2007.06.1111
6. O’Connor E, Iatropoulou D, Hashimoto S, et al. Urethral diverticulum carcinoma in females—a case series and review of the English and Japanese literature. Transl Androl Urol. 2018;7:703-729. doi: 10.21037/tau.2018.07.08
7. Burrows LJ, Howden NL, Meyn L, et al. Surgical procedures for urethral diverticula in women in the United States, 1979-1997. Int Urogynecol J Pelvic Floor Dysfunct. 2005;16:158-161. doi: 10.1007/s00192-004-1145-9
8. Riyach O, Ahsaini M, Tazi MF, et al. Female urethral diverticulum: cases report and literature. Ann Surg Innov Res. 2014;8:1. doi: 10.1186/1750-1164-8-1
9. Antosh DD, Gutman RE. Diagnosis and management of female urethral diverticulum. Female Pelvic Med Reconstr Surg. 2011;17:264-271. doi: 10.1097/SPV.0b013e318234a242
10. Romanzi LJ, Groutz A, Blaivas JG. Urethral diverticulum in women: diverse presentations resulting in diagnostic delay and mismanagement. J Urol. 2000;164:428-433.
11. Reeves FA, Inman RD, Chapple CR. Management of symptomatic urethral diverticula in women: a single-centre experience. Eur Urol. 2014;66:164-172. doi: 10.1016/j.eururo.2014.02.041
12. Dwarkasing RS, Dinkelaar W, Hop WCJ, et al. MRI evaluation of urethral diverticula and differential diagnosis in symptomatic women. AJR Am J Roentgenol. 2011;197:676-682. doi: 10.2214/AJR.10.6144
13. Porten S, Kielb S. Diagnosis of female diverticula using magnetic resonance imaging. Adv Urol. 2008;2008:213516. doi: 10.1155/2008/213516
14. Ockrim JL, Allen DJ, Shah PJ, et al. A tertiary experience of urethral diverticulectomy: diagnosis, imaging and surgical outcomes. BJU Int. 2009;103:1550-1554. doi: 10.1111/j.1464-410X.2009.08348.x
THE CASE
A 62-year-old postmenopausal woman presented to the clinic as a new patient for her annual physical examination. She reported a 9-year history of symptoms including dysuria, post-void dribbling, dyspareunia, and urinary incontinence on review of systems. Her physical examination revealed an anterior vaginal wall bulge (FIGURE). Results of a urinalysis were negative. The patient was referred to Urology for further evaluation.
THE DIAGNOSIS
A pelvic magnetic resonance imaging (MRI) scan revealed a large periurethral diverticulum with a horseshoe shape.
DISCUSSION
Women are more likely than men to develop urethral diverticulum, and it can manifest at any age, usually in the third through seventh decade.4,5 It was once thought to be more common in Black women, although the literature does not support this.6 Black women are 3 times more likely to be operated on than White women to treat urethral diverticula.7
Unknown origin. Most cases of urethral diverticulum are acquired; the etiology is uncertain.8,9 The assumption is that urethral diverticulum occurs as a result of repeated infection of the periurethral glands with subsequent obstruction, abscess formation, and chronic inflammation.1,2,4 Childbirth trauma, iatrogenic causes, and urethral instrumentation have also been implicated.3,4 In rare cases of congenital urethral diverticula, the diverticula are thought to be remnants of Gartner duct cysts, and yet, incidence in the pediatric population is low.8
Diagnosis is confirmed through physical exam and imaging
The urethral diverticulum manifests anteriorly and palpation of the anterior vaginal wall may reveal a painful mass.10 A split-speculum is used for careful inspection and palpation of the anterior vaginal wall.9 If the diverticulum is found to be firm on palpation, or there is bloody urethral drainage, malignancy (although rare) must be ruled out.4,5 Refer such patients to a urologist or urogynecologist.
Radiologic imaging (eg, ultrasound,
Continue to: Nonspecific symptoms may lead to misdiagnosis
Nonspecific symptoms may lead to misdiagnosis. The symptoms associated with urethral diverticulum are diverse and linked to several differential diagnoses (TABLE).3,4,12 The most common signs and symptoms are pelvic pain, urethral mass, dyspareunia, dysuria, urinary incontinence, and post-void dribbling—all of which are considered nonspecific.3,10,11 These nonspecific symptoms (or even an absence of symptoms), along with a physician’s lack of familiarity with urethral diverticulum, can result in a misdiagnosis or even a delayed diagnosis (up to 5.2 years).3,10
Managing symptoms vs preventing recurrence
Conservative management with antibiotics, anticholinergics, and/or observation is acceptable for patients with mild symptoms and those who are pregnant or who have a current infection or serious comorbidities that preclude surgery.3,9 Complete excision of the urethral diverticulum with reconstruction is considered the most effective surgical management for symptom relief and recurrence prevention.3,4,11,14
Our patient underwent a successful transvaginal suburethral diverticulectomy.
THE TAKEAWAY
The diagnosis of female urethral diverticulum is often delayed or misdiagnosed because symptoms are diverse and nonspecific. One should have a high degree of suspicion for urethral diverticulum in patients with dysuria, dyspareunia, pelvic pain, urinary incontinence, and irritative voiding symptoms who are not responding to conservative management. Ultrasound is an appropriate first-line imaging modality. However, a pelvic MRI is the most sensitive and specific in diagnosing urethral diverticulum.12
CORRESPONDENCE
Folashade Omole, MD, FAAFP, 720 Westview Drive, Atlanta, GA 30310; fomole@msm.edu
THE CASE
A 62-year-old postmenopausal woman presented to the clinic as a new patient for her annual physical examination. She reported a 9-year history of symptoms including dysuria, post-void dribbling, dyspareunia, and urinary incontinence on review of systems. Her physical examination revealed an anterior vaginal wall bulge (FIGURE). Results of a urinalysis were negative. The patient was referred to Urology for further evaluation.
THE DIAGNOSIS
A pelvic magnetic resonance imaging (MRI) scan revealed a large periurethral diverticulum with a horseshoe shape.
DISCUSSION
Women are more likely than men to develop urethral diverticulum, and it can manifest at any age, usually in the third through seventh decade.4,5 It was once thought to be more common in Black women, although the literature does not support this.6 Black women are 3 times more likely to be operated on than White women to treat urethral diverticula.7
Unknown origin. Most cases of urethral diverticulum are acquired; the etiology is uncertain.8,9 The assumption is that urethral diverticulum occurs as a result of repeated infection of the periurethral glands with subsequent obstruction, abscess formation, and chronic inflammation.1,2,4 Childbirth trauma, iatrogenic causes, and urethral instrumentation have also been implicated.3,4 In rare cases of congenital urethral diverticula, the diverticula are thought to be remnants of Gartner duct cysts, and yet, incidence in the pediatric population is low.8
Diagnosis is confirmed through physical exam and imaging
The urethral diverticulum manifests anteriorly and palpation of the anterior vaginal wall may reveal a painful mass.10 A split-speculum is used for careful inspection and palpation of the anterior vaginal wall.9 If the diverticulum is found to be firm on palpation, or there is bloody urethral drainage, malignancy (although rare) must be ruled out.4,5 Refer such patients to a urologist or urogynecologist.
Radiologic imaging (eg, ultrasound,
Continue to: Nonspecific symptoms may lead to misdiagnosis
Nonspecific symptoms may lead to misdiagnosis. The symptoms associated with urethral diverticulum are diverse and linked to several differential diagnoses (TABLE).3,4,12 The most common signs and symptoms are pelvic pain, urethral mass, dyspareunia, dysuria, urinary incontinence, and post-void dribbling—all of which are considered nonspecific.3,10,11 These nonspecific symptoms (or even an absence of symptoms), along with a physician’s lack of familiarity with urethral diverticulum, can result in a misdiagnosis or even a delayed diagnosis (up to 5.2 years).3,10
Managing symptoms vs preventing recurrence
Conservative management with antibiotics, anticholinergics, and/or observation is acceptable for patients with mild symptoms and those who are pregnant or who have a current infection or serious comorbidities that preclude surgery.3,9 Complete excision of the urethral diverticulum with reconstruction is considered the most effective surgical management for symptom relief and recurrence prevention.3,4,11,14
Our patient underwent a successful transvaginal suburethral diverticulectomy.
THE TAKEAWAY
The diagnosis of female urethral diverticulum is often delayed or misdiagnosed because symptoms are diverse and nonspecific. One should have a high degree of suspicion for urethral diverticulum in patients with dysuria, dyspareunia, pelvic pain, urinary incontinence, and irritative voiding symptoms who are not responding to conservative management. Ultrasound is an appropriate first-line imaging modality. However, a pelvic MRI is the most sensitive and specific in diagnosing urethral diverticulum.12
CORRESPONDENCE
Folashade Omole, MD, FAAFP, 720 Westview Drive, Atlanta, GA 30310; fomole@msm.edu
1. Billow M, James R, Resnick K, et al. An unusual presentation of a urethral diverticulum as a vaginal wall mass: a case report. J Med Case Rep. 2013;7:171. doi: 10.1186/1752-1947-7-171
2. El-Nashar SA, Bacon MM, Kim-Fine S, et al. Incidence of female urethral diverticulum: a population-based analysis and literature review. Int Urogynecol J. 2014;25:73-79. doi: 10.1007/s00192-013-2155-2
3. Cameron AP. Urethral diverticulum in the female: a meta-analysis of modern series. Minerva Ginecol. 2016;68:186-210.
4. Greiman AK, Rolef J, Rovner ES. Urethral diverticulum: a systematic review. Arab J Urol. 2019;17:49-57. doi: 10.1080/2090598X.2019.1589748
5. Allen D, Mishra V, Pepper W, et al. A single-center experience of symptomatic male urethral diverticula. Urology. 2007;70:650-653. doi: 10.1016/j.urology.2007.06.1111
6. O’Connor E, Iatropoulou D, Hashimoto S, et al. Urethral diverticulum carcinoma in females—a case series and review of the English and Japanese literature. Transl Androl Urol. 2018;7:703-729. doi: 10.21037/tau.2018.07.08
7. Burrows LJ, Howden NL, Meyn L, et al. Surgical procedures for urethral diverticula in women in the United States, 1979-1997. Int Urogynecol J Pelvic Floor Dysfunct. 2005;16:158-161. doi: 10.1007/s00192-004-1145-9
8. Riyach O, Ahsaini M, Tazi MF, et al. Female urethral diverticulum: cases report and literature. Ann Surg Innov Res. 2014;8:1. doi: 10.1186/1750-1164-8-1
9. Antosh DD, Gutman RE. Diagnosis and management of female urethral diverticulum. Female Pelvic Med Reconstr Surg. 2011;17:264-271. doi: 10.1097/SPV.0b013e318234a242
10. Romanzi LJ, Groutz A, Blaivas JG. Urethral diverticulum in women: diverse presentations resulting in diagnostic delay and mismanagement. J Urol. 2000;164:428-433.
11. Reeves FA, Inman RD, Chapple CR. Management of symptomatic urethral diverticula in women: a single-centre experience. Eur Urol. 2014;66:164-172. doi: 10.1016/j.eururo.2014.02.041
12. Dwarkasing RS, Dinkelaar W, Hop WCJ, et al. MRI evaluation of urethral diverticula and differential diagnosis in symptomatic women. AJR Am J Roentgenol. 2011;197:676-682. doi: 10.2214/AJR.10.6144
13. Porten S, Kielb S. Diagnosis of female diverticula using magnetic resonance imaging. Adv Urol. 2008;2008:213516. doi: 10.1155/2008/213516
14. Ockrim JL, Allen DJ, Shah PJ, et al. A tertiary experience of urethral diverticulectomy: diagnosis, imaging and surgical outcomes. BJU Int. 2009;103:1550-1554. doi: 10.1111/j.1464-410X.2009.08348.x
1. Billow M, James R, Resnick K, et al. An unusual presentation of a urethral diverticulum as a vaginal wall mass: a case report. J Med Case Rep. 2013;7:171. doi: 10.1186/1752-1947-7-171
2. El-Nashar SA, Bacon MM, Kim-Fine S, et al. Incidence of female urethral diverticulum: a population-based analysis and literature review. Int Urogynecol J. 2014;25:73-79. doi: 10.1007/s00192-013-2155-2
3. Cameron AP. Urethral diverticulum in the female: a meta-analysis of modern series. Minerva Ginecol. 2016;68:186-210.
4. Greiman AK, Rolef J, Rovner ES. Urethral diverticulum: a systematic review. Arab J Urol. 2019;17:49-57. doi: 10.1080/2090598X.2019.1589748
5. Allen D, Mishra V, Pepper W, et al. A single-center experience of symptomatic male urethral diverticula. Urology. 2007;70:650-653. doi: 10.1016/j.urology.2007.06.1111
6. O’Connor E, Iatropoulou D, Hashimoto S, et al. Urethral diverticulum carcinoma in females—a case series and review of the English and Japanese literature. Transl Androl Urol. 2018;7:703-729. doi: 10.21037/tau.2018.07.08
7. Burrows LJ, Howden NL, Meyn L, et al. Surgical procedures for urethral diverticula in women in the United States, 1979-1997. Int Urogynecol J Pelvic Floor Dysfunct. 2005;16:158-161. doi: 10.1007/s00192-004-1145-9
8. Riyach O, Ahsaini M, Tazi MF, et al. Female urethral diverticulum: cases report and literature. Ann Surg Innov Res. 2014;8:1. doi: 10.1186/1750-1164-8-1
9. Antosh DD, Gutman RE. Diagnosis and management of female urethral diverticulum. Female Pelvic Med Reconstr Surg. 2011;17:264-271. doi: 10.1097/SPV.0b013e318234a242
10. Romanzi LJ, Groutz A, Blaivas JG. Urethral diverticulum in women: diverse presentations resulting in diagnostic delay and mismanagement. J Urol. 2000;164:428-433.
11. Reeves FA, Inman RD, Chapple CR. Management of symptomatic urethral diverticula in women: a single-centre experience. Eur Urol. 2014;66:164-172. doi: 10.1016/j.eururo.2014.02.041
12. Dwarkasing RS, Dinkelaar W, Hop WCJ, et al. MRI evaluation of urethral diverticula and differential diagnosis in symptomatic women. AJR Am J Roentgenol. 2011;197:676-682. doi: 10.2214/AJR.10.6144
13. Porten S, Kielb S. Diagnosis of female diverticula using magnetic resonance imaging. Adv Urol. 2008;2008:213516. doi: 10.1155/2008/213516
14. Ockrim JL, Allen DJ, Shah PJ, et al. A tertiary experience of urethral diverticulectomy: diagnosis, imaging and surgical outcomes. BJU Int. 2009;103:1550-1554. doi: 10.1111/j.1464-410X.2009.08348.x
