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.

Case study: urethral diverticulum with calcifications in a premenopausal woman

Female urethral diverticulum is a fairly rare pathology, the frequency of which ranges from 0.02 to 6.00% of women worldwide. The stones inside urethra diverticulum even more rare. The most common reasons of urethral diverticula are frequent bladder catheterizations, labour trauma, infections. Clinically is may present with the dysuria, dyspareunia, dribble, urinary incontinence, vaginal discomfort. Voiding cystourethrography and cystourethroscopy are the most accurate methods of diagnosis for urethral diverticula. The presented article describes the clinical case in women with urethral diverticulum who complained on the vaginal discomfort, dyspareunia and presentation of the brown stones in vagina and underwent surgical excision of diverticulum with urethral reconstruction.

Diagnostic tools for female urethral diverticulum: Current perspectives

Although once considered quite a rare condition in the past, female urethral diverticulum (UD) would now appear to have a higher frequency, perhaps due to greater attention from physicians. To date, there is no agreement on which is the best method for diagnosis of female UD. Traditionally, the approach was based on quite invasive techniques, such as voiding cystourethrography, and double-balloon urethrography, with satisfactory results but relevant limitations. More recent high-resolution imaging techniques, such as 2D-3D ultrasonography (US) and magnetic resonance imaging (MRI) have also been applied in the study of the abnormalities of the female urethra. US had the advantage of the outpatient setting, non-invasiveness and absence of contrast medium use; MRI, is characterized by high sensitivity thanks to multiplanar capability, with an optimal characterization of periurethral diseases or its abnormalities, and lack of ionizing radiation. A real innovation is represented by computer tomography-voiding cystourethrography, a rapid technique that allows for high quality simultaneous 2D and 3D images of the urethra, well correlated to MRI and consequently with surgical results. Here, we report and comment the available tools in the diagnosis of female UD, focusing particularly on pros and contra of different methods.