Transvaginal ultrasound imaging of female urethral diverticulum before and after voiding.

Abstract

Female urethral diverticulum is a localized ‘sac-like’ herniation between the periurethral fibromuscular layer and anterior vaginal wall, which is continuous with the lumen of the urethra. It is estimated to occur in 0.6–6% of women, most commonly at 30–60 years of age1. Clinically, most women with urethral diverticulum present with multiple non-specific urological symptoms or recurrent urinary tract infections, while 20% of patients are asymptomatic. Imaging methods for the diagnosis of urethral diverticulum include ultrasonography (transvaginal, transperineal and transrectal), voiding cystourethrography, computed-tomographic voiding urethrography and magnetic resonance imaging (MRI)2-4. Standard treatment for urethral diverticulum in symptomatic patients is surgical excision (diverticulectomy), with cure rates in the literature ranging from 70% to 97%. Asymptomatic patients can be managed conservatively5. We describe a case of urethral diverticulum, with transvaginal ultrasound images obtained before and after voiding. A 54-year-old woman complained of urinary incontinence, dribbling after voiding and recurrent urinary tract infection. On pelvic examination, a slight thickening of the anterior vaginal wall was palpated, without a distinct mass. MRI demonstrated a 2-cm cystic structure posterior to the center of the urethra and anterior to the vaginal cavity. Urethral diverticulum was suspected. Before voiding, transvaginal two-dimensional and three-dimensional ultrasound demonstrated a cystic structure, measuring 3 × 6 × 11 mm, between the urethra and anterior vaginal wall. The structure had anechoic and hyperechogenic areas and no flow on Doppler examination. A thin tract connected the cyst to the urethra at mid-urethral level, reinforcing the suspected diagnosis of urethral diverticulum (Figure 1a). In a transverse section of the urethra, the diverticulum was shown to surround 30% of the urethral outer circumference. After voiding, ultrasound demonstrated a significant enlargement of the diverticulum to 15 × 14 × 16 mm, contributing to a more certain diagnosis and confirming urethral communication (Figure 1b). The patient underwent urethroscopy and cystoscopy, which demonstrated a large orifice in the posterior urethral wall, connecting the diverticulum cavity to the urethral canal (Figure 2). This report describes the symptoms and sonographic findings in a patient with a urethral diverticulum. Although research is needed to validate comparison of ultrasound findings before and after voiding as a tool for the diagnosis of urethral diverticulum, we suggest carrying out routinely a postvoiding ‘second look’ during the course of the ultrasound evaluation. This method is quick, simple, painless and does not involve radiation. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.