Introduction
The urethra is the tube-like structure that drains the bladder. In a woman, this is usually about 4cm in length. A urethral diverticulum (UD) is a pouch or pocket that may form within the urethra and is an uncommon condition. It occurs in women usually between the age of 30 and 60. This pouch can become filled with urine or pus (when infected).
Causes
The exact cause is unknown. Blocked ducts, previous urinary infections, trauma, and childbirth have all been suggested as causes.
Symptoms
Patients can present with:
- Pain when passing urine.
- Dribbling after voiding.
- Pain during sexual intercourse.
- Recurrent urinary tract infections.
- Blood in the urine.
- Urinary incontinence.
- Difficulty passing urine.
Tests
UD may not be picked up on normal vaginal examination especially if small. Occasionally, a palpable lump can be felt on the front of the vaginal wall.
These tests may be arranged by your doctor:
- Urine test to check for infection.
- Cystoscopy: to visualize the opening of the pouch into the urethra.
- Ultrasound: to detect the pouch, and check for incomplete emptying of the bladder.
- Urodynamics: to check for the pouch causing obstruction to urinary flow, incontinence or secondary bladder dysfunction such as an overactive bladder.
- MRI scan: this is the definitive test to detect and characterize the UD, which will help with pre-operative planning.
Treatment
Smaller urethral diverticuli can sometimes be observed, especially if they are not causing many symptoms. If the symptoms become bothersome, surgical repair may be needed.
These are the surgical options:
- Simple incision of the neck of the pouch to allow complete drainage. This can be done internally with a cystoscopy.
- Complete removal of the pouch (urethral diverticulectomy). This requires high technical skills by the surgeon. It is important to remove all of the wall of the pouch if possible, to prevent recurrence. Any potential opening into the urethra must be closed in a water-tight manner. If a patient has concurrent stress urinary incontinence, a pubovaginal fascial sling may be done at the same time. Sometimes to prevent the risk of a urethro-vaginal fistula (an abnormal connection between the urethra and vagina that causes leaking), a fascial sling or a flap from the fat in the labia (Martius flap), may be performed as an additional protective layer. You will be covered with antibiotics during and after the surgery and will have a period of indwelling catheterization post-operatively for about 2 to 3 weeks. A leak test or a cystoscopy may be done at the end of the catheterization period to check that the wound has healed completely, before removing the catheter.