Evaluation and Management of Urethral Diverticula Howard B. Goldman, MD Section of Female Pelvic Medicine and Reconstructive Surgery Glickman Urologic and Kidney Institute The Cleveland Clinic Lerner College of Medicine Case Western Reserve University

32 yo woman referred for cystocele No pain No voiding complaints Has noticed a vaginal bulge for 6 months G 1 P 1 - vaginal

urethra

Urethral Diverticulum Defect in the periurethral fascia with an outpouching of mucosa –Infection within periurethral glands – Obstruction and abscess formation – Rupture into urethral lumen  outpouchings Typically located dorsally and laterally Most common in 3 rd to 5 th decades of life

Presentation “Dysuria, Dyspareunia and Dribbling” Recurrent UTIs Urethral pain, pelvic pain, vag wall tenderness Purulent drainage per urethra Overactive bladder complaints: urgency, frequency, incontinence Romanzi et al. (J Urol, 2000): diverse presentations, mimics other disorders

Evaluation History and physical exam Careful palpation of distal anterior vaginal wall –Milk the urethra and observe meatus Cystoscopy Radiographic evaluation –Voiding cystourethrography (VCUG) –Ultrasonography (transvaginal, endourethral) –MRI ? Urodynamics - fluoro –Evaluate for stress urinary incontinence

VCUG Radiographic study of choice for years Voiding and post-void views important –Many patients cannot void on the table Blander et al. (Urology 2001): MRI and VCUG –VCUG missed 7% of diverticula and underestimated size and complexity

VCUG tic

Ultrasonography Transvaginal, endoluminal Relatively inexpensive, good visualization Operator dependant Siegel et al.: VCUG vs ultrasound. 13/15 diverticula detected with both modalities, but US showed extent and location better

Urethral diverticulum - US transurethral tic neck

CT vs MRI

Urethral diverticulum axial MRI

Urethral Diverticuli Management: –Conservative treatment measures: antibiotics, anticholinergics, anesthetics, etc.. Acutely or for very small tics –Operative Spence procedure –Very distal diverticulum Excision SUI considerations

Prepare Vaginal Wall Flap

Inicise Periurethral Fascial Tic

Prepare Periurethral Fascial Flaps Periurethral fascia flaps

Dissect Out and Excise Tic

Identify Ostium

Close Ostium

Closure of Dead Space

Periurethral Fascial Defect Closure

Close with Vaginal Wall Flap *Avoid overlapping suture lines

32 yo woman referred for cystocele No pain No voiding complaints Has noticed a vaginal bulge for 6 months G 1 P 1 - vaginal

urethra

Urethral diverticulum axial MRI -saggital

ostium

Martius flap

Management of Stress Incontinence Faerber et al: simultaneous diverticulectomy and sling, no complications, no erosions, no SUI Vasavada et al: 5 diverticulectomies, xenograft tissue for sling, no erosions, no SUI Some controversy over whether to place sling at time of diverticulectomy – if place – never use synthetic mesh

Postoperative management Urethral catheter for 14 days VCUG?? complications: –stress incontinence (de novo) –urethrovaginal fistula –recurrence –Evaluate path specimen

4/5 (80%) with Invasive adenoca had history of urinary retention

Long Term f/u of Diverticulum Recurrence N= month avg f/u 10.7% had surgery for recurrence –Risk factors Proximal diverticulum Multiple diverticula Prior vaginal or urethral surgery 26% persistent pain/discomfort with voiding 39% UTI in prior year Ingber et al, J Urol, 2011

Conclusions Diagnosis of urethral diverticula may be difficult High index of suspicion MRI is the gold standard for evaluation of suspect diverticula Surgery is the mainstay of therapy Careful exposure of all layers allows proper reconstruction Majority successfully treated