2/1/2011
Management of Urethral Diverticula
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Suburethral diverticula usually originate from the middle or distal portion of the posterior aspect of the urethra. The majority of urethral diverticula are thought to begin as an infection in one of the periurethral glands. This is followed by abscess formation, with eventual breakthrough into the urethral lumen resulting in a pouch that becomes the diverticulum. They may also be caused by local trauma including surgery or vaginal delivery.
Although the presentation is variable; dysuria, dyspareunia, and post void dribbling is a common triad. Other urinary tract problems such as hematuria, incontinence, retention, or cystitis may also be seen. A suburethral mass is present in up to one-half of patients. Urethral diverticula are usually 0.5 to 2 cm. Palpation reveals a soft mass that often is tender. Pressure on the mass may cause the escape of urine or exudate from the urethral meatus, signaling the presence of a diverticulum.
Palpation of a firm mass should raise suspicion for a calculus or rarely, neoplasm. Other possibilities in the differential diagnosis include vaginal wall cysts, periurethral fibrosis, ectopic ureterocele, and Skene duct abscess.
The diagnosis of urethral diverticula is best confirmed by MRI. Transvaginal ultrasound can also be used but the findings are often non-specific. Use of contrast-enhanced urethrograms are no longer recommended due to limited diagnostic performance.
In some patients the diverticulum is not bothersome. Conservative management can include digital decompression post-voiding or intermittent needle drainage. Symptomatic patients as well as those with firm masses or recurrent urinary tract infection require complete excision with a catheter in place followed by closure of the defect in the urethra. A non-overlapping, multi-layer, water tight closure is recommended with the use of absorbable sutures. For diverticula close to the urethral sphincter, marsupialization is occasionally performed. Infections, such as abscess and cystitis should be treated before surgery. Preoperative antibiotics are typically administered. A catheter is usually left in place afterwards for 7-14 days. Although the cure rate is high, potential complications include fistula, stricture, recurrent urinary tract infections, and recurrent diverticula.
Further Reading:
Foley CL, Greenwall TJ, Gardiner RA. Urethral diverticula in females. BJU Int. 2011 Nov;108 Suppl 2:20-3. doi: 10.1111/j.1464-410X.2011.10714.x.
El-Nashar SA, Singh R, Bacon MM, et.al, Female Urethral Diverticulum: Presentation, Diagnosis, and Predictors of Outcomes After Surgery. Female Pelvic Med Reconstr Surg. 2016 Nov/Dec;22(6):447-452.
Original Approval February 2011. Revised September 2019; Revised May 2021.
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