Diagnosis Of Urethral Diverticulum Research Articles

Diagnosis of female urethral diverticulum using pelvic floor ultrasound and comparison with voiding cystourethrogram (imaging study).

The purpose of this study was to evaluate the sensitivity and specificity of pelvic floor ultrasound (PFUS) in the diagnostic work-up of female urethral diverticulum (UD) and to compare results of PFUS with voiding cystourethrogram (VCUG). We retrospectively reviewed our database of patients, who received VCUG and PFUS for the diagnosis of UD. A total of 196 consecutive female patients with a minimum of one symptom, such as a lower urinary tract symptom (LUTS), postmicturition dribble, dyspareunia and recurrent urinary tract infection (UTI) who underwent initial diagnostics with VCUG and PFUS were selected. Diagnostic performance of both procedures, which included size, complexity, echogenicity. and content were compared. Recurrent UTI and LUTS were the most common symptoms, which were present in 165 (84%) and 163 patients (83%) respectively. Final diagnosis of UD was based on PFUS and VCUG findings in 69 (35%) and 58 (30%) cases respectively. Based on our study cohort, the sensitivity of PFUS in detecting UD was significantly higher than that of VCUG: 94% (IQR: 89-97) versus 78% (IQR: 73-85, p<0.01), with a trend toward higher specificity: 100% (IQR: 94-100) versus 84% (IQR: 78-84, p=0.05). Enabling direct UD visualisation, PFUS was associated with a positive predictive value (PPV) of 100% (IQR: 97-100) and a negative predictive value (NPV) of 88% (IQR: 78-95), whereas VCUG had an inferior accuracy with a PPV of 84 (IQR: 80-84) and a NPV of 68 (IQR: 62-79). In clinical practice, VCUG has a lower sensitivity than PFUS. Based on these results, we recommend the usage of dynamic PFUS as part of a non-invasive work-up.

Pathophysiology and Management of Long-term Complications After Transvaginal Urethral Diverticulectomy.

Female urethral diverticulum (UD) is a rare and benign condition that presents as an epithelium-lined outpouching of the urethra. It has various symptoms, of which incontinence in the form of postmicturition dribble is the most common. The gold standard for the diagnosis of UD is magnetic resonance imaging, and the treatment of choice is transvaginal diverticulectomy. Despite the high success rate of transvaginal diverticulectomy, postoperative complications such as de novo stress urinary incontinence (SUI), recurrence, urethrovaginal fistula, recurrent urinary tract infections, newly-onset urgency, and urethral stricture can occur. De novo SUI is thought to result from weakening of the anatomical support of the urethra and bladder neck or damage to the urethral sphincter mechanism during diverticulectomy. It can be managed conservatively or may require surgical treatment such as a pubovaginal sling, Burch colposuspension, or urethral bulking agent injection. Concomitant SUI can be managed by concurrent or staged anti-incontinence surgery. Recurrent UD may be a newly formed diverticulum or the result of a remnant diverticulum from the previous diverticulectomy. In cases of recurrent UD requiring surgical repair, placing a rectus fascia pubovaginal sling may be an effective method to improve the surgical outcome. Urethrovaginal fistula is a rare, but devastating complication after urethral diverticulectomy; applying a Martius flap during fistula repair may improve the likelihood of a successful result. Malignancies in UD are rarely reported, and anterior pelvic exenteration is the recommended management in such cases.

Correlation between symptoms and imaging findings including pelvic floor ultrasound to improve the symptom-based diagnosis of female urethral diverticulum (CHECK-UD study).

The objective was to establish a model to predict the presence of a female urethral diverticulum (UD) based on symptoms. A prospective CHECK-UD study (check of female urethral diverticulum) was conducted. Female patients presenting with symptoms such as lower urinary tract symptoms (LUTS), postmicturition dribble or urinary incontinence (UI), dyspareunia or pain in the pelvic area, and recurrent urinary tract infection (UTI) treated between 2015 and 2020 were included. The association between each symptom variable and the positive finding of UD was evaluated by multivariate logistic regression adjusting for age, body mass index (BMI), vaginal deliveries, previous surgery for SUI, previous pelvic surgery, and microscopic hematuria. A predictive model for the presence of UD was then created. In total, 189 female patients with a minimum of one symptom were enrolled. Pelvic floor ultrasound revealed the presence of UD in 66 out of 189 (34.92%). Of the four symptoms, the combinations "LUTS + postmicturition dribble + UTI," "postmicturition dribble + LUTS," and "UTI + LUTS" were most significantly related to positive findings and had a higher positive prognostic value for the diagnosis of UD than each individual symptom alone (OR = 13.78 [95% CI: 6.95-16.35], p < 0.001; OR = 9.94 [95% CI: 4.60-12.2], p < 0.05; and OR = 5.78 [95% CI: 1.58-6.98] p =0.05) respectively. Based on our model, the combination "LUTS + postmicturition dribble + UTI" seems to be the most sensitive combination of clinical symptoms predicting the positive finding of UD. This model could be used for patient counseling and for the identification of patients with UD.

Female Urethral Diverticula: Diagnosis, Pathology, and Surgical Outcomes at an Academic, Urban Medical Center

ObjectiveTo describe the outcomes of a series of women diagnosed with a urethral diverticulum at an urban tertiary care center. MethodsAn Institutional Review Board-approved review of a series of 78 women with a diagnosis of urethral diverticulum from 2009 to 2015 was performed. Clinical, radiographic, and pathologic data was collected by retrospective review of patient medical records. Data regarding treatment selection and postoperative outcomes were collected. A multivariable logistic regression was performed to identify preoperative variables that were associated with undergoing surgical resection. ResultsOf the 78 patients reviewed, the median age was 45.5 years (interquartile range (IQR) 36.0-53.8), median body mass index was 30.4 (IQR 24.8-34.4). The most common presenting symptoms included: incontinence (39%), recurrent urinary tract infections (23%), dysuria (18%), discharge (13%), dyspareunia (12%), and hematuria (9%). Additionally, 16 (21%) women were asymptomatic. Of these 78 cases, 40 underwent surgical excision (51%). Of the remaining 38, 13 were symptomatic and lost to follow-up, 23 were managed expectantly, and 2 underwent surgery after the study period. Review of the pathology results revealed that the most common finding was squamous metaplasia (31%). There was 1 adenocarcinoma in the series (2.5%). Of the 40 patients who had surgery, 3 (7.5%) had a diverticular recurrence and 5 (12.5%) developed stress urinary incontinence. The median follow-up was 7.5 months (IQR 1-20.25 months). ConclusionA variety of presenting symptoms existed for women with a urethral diverticulum seeking medical care at an urban medical center. When controlling for age, body mass index, and race, the presence of preoperative symptoms was associated with undergoing surgical resection.

Female Urethral Diverticulum: Presentation, Diagnosis, and Predictors of Outcomes After Surgery.

To report on clinical presentation, diagnosis, and outcomes after treatment of female urethral diverticulum (UD). Using a record linkage system, women with a new diagnosis of UD at Mayo Clinic from January 1, 1980, through December 31, 2011, were identified. The presenting symptoms, clinical characteristics, diagnosis, and management of women presenting with UD were recorded. Outcomes after surgery were assessed using survival analysis. All statistical analyses were 2-sided and P values less than 0.05 were considered significant. Statistical analysis was done using SAS version 9.2 and JMP version 9.0 (SAS Institute Inc.). A total of 164 cases were identified. Median age at diagnosis was 46 years (range, 21-83). The most common presenting symptom was recurrent urinary tract infection (98, 59.8%), followed by urinary incontinence (81, 49.4%), dysuria (62, 37.8%), dyspareunia (37, 22.6%), and hematuria (15, 9.1%). Examination revealed vaginal mass in 55 (33.5%) of the women. A significant trend was noted toward an increase in use of both magnetic resonance imaging and computed tomography (P < 0.001) along with a progressive decrease in use of urethrogram (P < 0.001) for diagnosis of UD over the years. Among 114 women who underwent surgical treatment for UD, 14(12.3%) women presented with recurrent UD and the 5-year recurrence rate after surgery for UD was 23.4% (95% confidence interval, 13.9-37.0) and a reoperation rate of 17.0% (95% confidence interval, 8.8-30.2) at 5 years. Female UD is a rare and unique condition. Clinical presentation is usually nonspecific, and magnetic resonance imaging is commonly used for confirming the diagnosis. Recurrence is not uncommon, and repeat surgical intervention might be needed.

Female Urethral Diverticulum: Current Diagnosis and Management.

While urethral diverticulum (UD) affects less than 20 per 1,000,000 women overall, it is thought to represent 1.4% of women with incontinence presenting to urology practices. It is hypothesized to evolve from periurethral glands that become obstructed, infected, and dilated over time, and patients typically present with dyspareunia, bothersome lower urinary tract symptoms (LUTS), and/or recurrent UTIs. In many patients, a periurethral mass can be appreciated on exam. In recent years, magnetic resonance imaging (MRI) has become the imaging test of choice for diagnosis of UD, but ultrasound (US) is a readily available alternative and provides good specificity at a lower cost. Surgical excision of the diverticulum with tension-free, water-tight, three-layer closure continues to be the mainstay of treatment of UD with most studies reporting cure rates of >90%. Concomitant treatment of preexisting stress incontinence with autologous fascial pubovaginal sling can be used at the time of diverticulectomy to avoid a secondary procedure. However, since secondary anti-incontinence procedures are needed in only a small number of patients, up-front stress incontinence treatment may result in significant overtreatment, and staged anti-incontinence procedures continue to be a reasonable option for patients with persistent bothersome stress urinary incontinence (SUI) after diverticulectomy.

Surgical Management of Complex Uretheral Diverticulum

Background: Urethral diverticulum is a herniation between the periurethral fibromuscular layer and anterior vaginal wall continuous with the lumen of the urethra. The incidence is 1 to 6%.It occurs commonly in the third to fifth decade of life. The condition can be acquired or congenital. The etiology is not understood. The most widely accepted theory is obstruction and subsequent infection of the periurethral glands with rupture of the abscess into the lumen. Other causes include trauma from vaginal or urethral surgery and childbirth trauma.The diagnosis of urethral diverticulum can be confused with vaginal wall inclusion cysts,mesonephric or paramesonephric cysts, Skene gland cysts, urethral caruncles, and urethroceles.

Incidence of female urethral diverticulum: a population-based analysis and literature review

Urethral diverticulum (UD) is a protrusion of the urethra through the periurethral fascia. We aimed to determine the population-based incidence of female UD. Using the records-linkage system of the Rochester Epidemiology Project (REP), we identified women 18 years and older with a new diagnosis of UD in Olmsted County, Minnesota, USA, from 1 January 1980, through 31 December 2011. We also identified cases meeting the same criteria diagnosed at Mayo Clinic, regardless of county of residency. Incidence rates were calculated and trends for changes in incidence over time were tested. We conducted a systematic search of the MEDLINE, EMBASE, Cochrane Systematic Reviews, CENTRAL, Web of Science, and Scopus databases from inception through 30 March 2013, to identify published reports of UD incidence or prevalence. We identified 164 incidence cases, including 26 women residing in Olmsted County. Age-adjusted annual incidence of UD in Olmsted County was 17.9 per 1,000,000 women (<0.02 %) per year (95 % CI, 10.9-24.9). We observed a trend toward increased incidence during the past 3 decades (P = 0.03). In our literature review, only 7 studies included an estimate of incidence or prevalence of UD; these estimates ranged from 6.4 per 1,000,000 per year (<0.01 %) having surgical intervention related to UD to a 4.7 % rate of UD diagnosed in asymptomatic women admitted for gynecological or obstetric issues. In this population-based study, female UD was a rare disease, affecting fewer than 20 per 1,000,000 women (<0.02 %) per year.

Female urethral diverticulum

; C-reactive protein, 2.3 mg/dL. Urinalysis demons-trated microscopic pyuria (50-75 white blood cells/high power field). Transabdominal ultrasonography disclosed a complex cystic mass on the base of the urinary bladder. Voiding cystourethrogram showed contrast material filling the urethral diverticulum (UD) that encircled the urethral lumen (Figure-1). Coronal and axial T2-weighted MR images demons-trated a circumferential high-signal intensity, fluid--filled lesion with fluid-debris level and confirmed the diagnosis of UD (Figure-2). Cystourethroscopy showed two orifices of the UD (Figure-3). Transvagi-nal diverticulectomy was performed and postopera-tive course was uneventful. A UD is a focal outpouching of the urethra and usually occurs in women in the 3rd-7th decade of life, with an estimated prevalence of 0.6-6% (1). The vast majority of UDs are from acquired causes, with the most widely accepted theory involving rup-ture of a chronically obstructed and infected periu-rethral gland into the urethral lumen. Risk factors for acquired UDs include repeated infection of the pe-riurethral glands, vaginal birth trauma, trauma from the prior vaginal or urethral procedures (1). The classic presentation of UD has been des-cribed historically as the “three Ds”: dysuria, dys-pareunia, and dribbling (post-void). The most useful imaging modality for UDs is MRI (2). MRI plays an important role in the diagnosis of UDs and ideally provides the surgeon with preoperative information regarding location, number, size, configuration, and communication of the UDs. Although MRI is the best preoperative diagnostic tool for evaluating the UDs, the old standby double balloon pressure urethrogra-phy (adding sky-blue or brilliant green as staining agent) is of great value of intraoperative identifica-tion of these compound diverticular sacks and facili-tating their resection (3). Complications associated with UDs include recurrent infection, urinary incontinence, calculus formation, and development of intradiverticular neoplasm. Clinicians should be aware of the possibility of a UD in women with unexplained

MRI in the diagnosis of urethral diverticulum: discrepancies between imaging and surgical findings

Imaging: MRI in the diagnosis of urethral diverticulum: discrepancies between imaging and surgical findings

Urethral Diverticula in Women: Discrepancies Between Magnetic Resonance Imaging and Surgical Findings

Some groups consider magnetic resonance imaging the gold standard to diagnose urethral diverticula with up to 100% reported sensitivity. We describe cases contradicting this paradigm and identify reasons for discrepancies. We searched a database for women who underwent urethral diverticulum surgery from 1998 to 2008 and also underwent preoperative magnetic resonance imaging. Images were reviewed by a blinded panel of urologists and a radiologist. They came to consensus on the presence or absence, site and anatomy of urethral diverticulum or cancer, and compared operative findings. Discrepancies were classified as errors in urethral diverticulum or cancer diagnosis and errors in urethral diverticulum anatomy or site. Of 76 patients who underwent diverticulectomy 41 also underwent magnetic resonance imaging, of whom 10 (24.4%) had a discrepancy between magnetic resonance imaging and surgical findings. In 6 of these cases there were diagnosis errors and diverticula were not seen on magnetic resonance imaging in 3. One urethral diverticulum each was misdiagnosed as Bartholin's cyst and as a typical post-collagen injection appearance. A sterile abscess was incorrectly diagnosed as a urethral diverticulum. In 2 patients magnetic resonance imaging did not detect cancer within the diverticulum. A major discrepancy in anatomy made intraoperative decision making difficult in 2 patients. In cases clinically suspicious for urethral diverticulum magnetic resonance imaging had a 24.4% error rate. Serious consequences are failure to detect cancer and suboptimal treatment for urethral diverticulum. The reason for the high magnetic resonance imaging accuracy rate in other series may be that in the absence of radiological confirmation some surgeons may choose not to perform surgery. Magnetic resonance imaging is useful to assess urethral diverticula but physicians should be aware of its limitations.

Transvaginal sonographic diagnosis of female urethral diverticula

We report our experience with transvaginal sonography (TVUS) in the diagnosis of female urethral diverticulum (UD). We reviewed the TVUS examinations of 4 patients with a clinical diagnosis of UD and correlated the sonographic findings with the operative findings, especially regarding the UD's size, content, and location. All UDs were demonstrated on TVUS. The size, content, and location of the UD correlated well with the operative findings. TVUS is accurate in diagnosis and determination of the size, content, and location of female UD.

Poster 45: The Utility of Magnetic Resonance Imaging for Surgical Planning Before Periurethral Diverticulectomy in Women

OBJECTIVE: The objective of this study was to assess the utility of magnetic resonance imaging (MRI) to evaluate urethral diverticulum. METHODS: With approval from the Institutional Review Board, medical records were identified by a query of billing data for CPT 53230 (urethral diverticulectomy) and ICD-9 code 599.2 (urethral diverticulum) from January 1, 2000, through December 31, 2004. Data included patient demographics, preoperative evaluation, intraoperative and postoperative complications, and surgical outcome. RESULTS: Twenty-eight women of average age 46 years (range, 21–76 years) had a diagnosis of urethral diverticulum. Of these, 21 (75%) had undergone a preoperative MRI, which detected the diverticulum in all cases. In the remaining 7, all early in this experience, diagnosis was by voiding cystourethrogram. Of the 21 patients, 10 (48%) had one or more other imaging studies before surgery. In 3 of these women, multiple other imaging studies had failed to identify the diverticulum despite clinical suspicion of its presence, and in one woman, an unsuspected intradiverticular carcinoma was imaged by the MRI. In the other 6 women, the MRI accurately identified the extent of the diverticulum and in particular its extension around the urethra, which was underestimated by other imaging studies. Twenty-six women were treated with urethral diverticulectomy (20 primary, 5 secondary, and one tertiary procedures). Average follow up was 9 months (range, 0–60 months). No patient had significant intraoperative complications and one patient (evaluated by MRI) was eventually diagnosed with a recurrent diverticulum. CONCLUSIONS: We found MRI to be superior to other imaging tools for the identification of urethral diverticulum. Additionally, its ability to identify such characteristics as true size, multiplicity, relationship to the urethra, and intraluminal complexity assists in the planning of the surgical procedure, which likely reduces surgical morbidity.

Transvaginal Ultrasound for the Diagnosis of Urethral Diverticulum

Transvaginal Ultrasound for the Diagnosis of Urethral Diverticulum

Urethral Diverticula in Pregnancy

In 4 cases, the clinical presentation of urethral diverticulum (UD) during pregnancy was a paraurethral mass (3), urinary incontinence (2), irritative symptoms (2), urinary tract infection (1), urethral pain and discharge (1) and voiding difficulty (1). The diagnosis of UD during pregnancy was made by transvaginal ultrasonography (2), cystoscopy (1), and after pregnancy by a voiding cystourethrogram (1). Management during pregnancy involved antibiotics (2), diverticulum aspiration (2) and incision and drainage (1). Delivery was by the vaginal route in 2 women with diverticular aspiration being performed during the second stage to aid delivery in 1 woman. Caesarean section was performed in the other 2 women for reasons unrelated to the presence of the UD. Three women had diverticulectomy performed following pregnancy for persisting symptoms. Although uncommon, it is important to diagnose urethral diverticula given the associated morbidity and the potential for causing complications during pregnancy.

Transrectal ultrasonography in the diagnosis of urethral diverticula in women.

The diagnosis of urethral diverticula in women can be difficult. Several imaging modalities have been described for evaluating this entity: urethrography; transabdominal, transrectal, transvaginal, and transperineal ultrasonography; computed tomography (CT); and magnetic resonance (MR) can be helpful in evaluating a diverticulum and its relationship to the urethra. We report on four women aged 36 to 42 years with urethral diverticula. Transrectal ultrasonography (TRU) was the most useful diagnostic test in our series. TRU showed 7 urethral diverticula and provided information about its shape, volume, and content as well as its spatial relationship about its shape, volume, and content as well as its spatial relationship to the urethra. In two cases, multiple diverticula were detected when only a single lesion was clinically suspected. Transabdominal sonography failed to demonstrate small diverticula. CT examination did not provide additional information except for the passage of the contrast from the urethra to the diverticulum in one of the cases. Voiding cystourethrogram was positive in only one patient.

Diagnosis of urethral diverticula in women: value of MR imaging.

The purpose of this study was to determine the role of MR imaging in the diagnosis of urethral diverticula in women. In 20 patients (mean age, 47 years), MR imaging was performed (1.5-T); unenhanced T1-weighted and T2-weighted images and contrast-enhanced T1-weighted images were obtained. MR imaging findings were compared with findings on urethrograms (including voiding cystourethrograms or double balloon catheter studies) in 16 patients, urethroscopic findings in 18, and surgical findings in 13. MR images were assessed for the presence, size, number, and location (anterior or posterior to the urethral lumen and relationship to the neck of the bladder) of diverticula, visualization of ostia, and presence of any concomitant complications. Sixteen of 20 patients had urethral diverticula: uncomplicated (simple) urethral diverticula in 13 patients; a diverticulum with a stone in one; a diverticulum with chronic granulation in one; and a diverticulum with adenocarcinoma in one. In the remaining four patients, the diagnoses included Gartner's duct cyst (one) and paraurethral cyst (one); urethras were deemed to be normal in two. In 13 patients who had surgery, MR images correctly showed the presence or absence of diverticula, whereas urethrography was correct in nine (69%) and urethroscopy in 10 (77%). Compared with surgical findings (20 diverticula in 12 patients), MR images depicted 14 (70%) of 20 diverticula and urethrography and urethroscopy each depicted 11 (55%) of 20. The ostium of the diverticulum could not be identified on MR images. The use of MR contrast material did not contribute to lesion detection, but the enhanced images were superior to unenhanced images in showing granulation tissue and carcinoma, although they did not help in their differentiation. MR imaging is accurate for showing urethral diverticula, but owing to its high cost, it should be considered only when urethroscopic or urethrographic findings are equivocal or when patients are unable to undergo these procedures and clinical findings strongly suggest a urethral diverticulum.

Simple examination techniques to aid in the diagnosis of urethral diverticulum

Patients with urethral diverticula classically present with dyspareunia, dribbling of urine, chronic dysuria, and/or a tender suburethral mass. Physical examination, urethroscopy, positive pressure urethrography, and the urethral pressure profile may not confirm the suspected diagnosis. Three simple diagnostic maneuvers are presented to aid in confirming the diagnosis before surgical exploration.

Postvoid film of intravenous pyelogram in diagnosis of urethral diverticulum

Urethral diverticulunt is a correctable cause of lower urinary tract symptoms in women. It has been found to be present in from 1.85 to 4.7 per cent of all females. The postvoid film of the intravenous urograrn (IVP) is the simplest and least invasive method available to diagnose urethral divertieula. It should be a routine part of the IVP in women with lower urinary tract symptoms.

Female urethral diverticula: double-balloon catheter study

A double-balloon catheter was used to evaluate the female urethra in 51 patients. Six different radiographic appearances were identified. Three of the categories are considered variants of normal. One of the categories consisted of eight patients with urethral diverticula. All showed large rounded or lobulated collections of contrast material which were adjacent to the urethra and which persisted on postvoid films. Other abnormalities should be closely correlated with the clinical findings to determine their significance. The diagnosis of urethral diverticulum may be missed, as physical examination and endoscopy can be negative. Therefore, the optimal method for identifying its presence and extent includes both a double-balloon catheter study and a voiding cystourethrogram.