The urethra serves as a passage for urine to exit the bladder during urination. In women, the urethra is relatively short, measuring approximately 4 cm. Urethral diverticulum (UD) is a condition characterized by the formation of an abnormal pocket or sac along the urethra. Due to its location, this pocket can become filled with urine or pus, leading to the development of infections and other complications.1,2
Causes of urethral diverticulum
The exact cause of urethral diverticulum (UD) is often unknown. However, there appears to be a correlation between UDs and recurrent bladder infections, which can potentially weaken the wall of the urethra. Another possible factor contributing to UD is a blockage in the glands near the urethra.2
Signs and symptoms of urethral diverticulum
Urethral diverticula often do not exhibit noticeable symptoms, and when symptoms are present, they are often non-specific.2 This makes the diagnosis of urethral diverticula challenging, with an average delay of over 4 years between symptom presentation and diagnosis. The classical teaching suggests that urethral diverticula present with a triad of symptoms known as the 'three Ds':
- Dysuria (painful urination)
- Dyspareunia (painful sexual intercourse)
- Dribble (urine leakage)
However, data from UCLH (University College London Hospitals) indicate that less than a quarter of diverticula exhibit the classical triad of symptoms. Most diverticula present with a combination of symptoms, which may include:
- Urethral discharge
- Recurrent urinary tract infections
- Urethral pain
- Voiding dysfunction (retention)
- Urinary incontinence (in a third of patients with urethral diverticula)
Furthermore, urethral diverticula are associated with an increased risk of urethral cancer, with a risk ranging from 1-8%. Typically, the diagnosis of urethral cancer is made during the surgical removal of the diverticulum.
Management and treatment for urethral diverticulum
Surgery is often considered the most effective treatment option for urethral diverticulum (UD), although it may not be suitable for everyone.3,4 Some women may choose to wait and observe if the UD grows larger or if their symptoms worsen before deciding on surgery. Regular follow-up visits to monitor the condition are crucial in such cases.
Given the delicate nature of the area, a specialized urologist typically performs the surgery. It is essential to avoid damaging the urethra during the procedure. Depending on various factors including the size and location of the UD sac, the doctor will likely opt to remove the sac. Alternatively, they may choose to incise the neck of the sac to drain its contents or create an opening from the sac into the vagina to facilitate drainage. During UD surgery, the doctor may also address specific urinary incontinence issues.4
Following surgery, most individuals will require antibiotics for at least 24 hours and may have a catheter in their bladder to assist with urination during the healing process, typically for two to three weeks. The surgeon may order a follow-up test a few weeks after the surgery to assess the healing progress before removing the catheter.
A urethral diverticulum (UD) is typically discovered either during a routine pelvic examination or when a woman reports symptoms to her doctor. Upon suspicion of a UD, the doctor will conduct a physical examination and may order additional tests to determine the underlying cause.3
During a physical examination, the doctor will palpate the vaginal wall to identify any masses and assess the location of any discomfort. If a sac is detected, a gentle squeeze may be applied to check for the presence of accumulated urine or pus. Additionally, the doctor may order a urine analysis for further evaluation.
If the physical examination suggests a problem, the doctor may proceed with imaging tests, which can include:
- Magnetic Resonance Imaging (MRI): This non-invasive imaging test uses a powerful magnet, radio waves, and a computer to produce detailed images of the body without the use of X-rays. In the case of suspected UD, the MRI will focus on the pelvic region, particularly around the vagina, to detect the presence of any masses
- Ultrasound: This procedure employs high-frequency sound waves that are transmitted through body tissues. The echoes produced are recorded and transformed into visual images of the internal structures. Ultrasound can help identify problems with the structures surrounding the vagina, such as organ abnormalities or urine accumulation
- Cystoscopy: This diagnostic test involves visualizing the interior of the urethra or bladder to identify a diverticulum and determine its opening location. It is often performed in the doctor's office
These tests assist in confirming the presence of a UD and provide valuable information for diagnosis and treatment planning.
How can I prevent urethral diverticulum?
Managing and successfully treating bladder and urethral infections at an early stage helps to prevent the development of urethral diverticulum due to infections. Any identified anatomical anomalies that can potentially cause this condition should be addressed accordingly.
How common is urethral diverticulum?
Urethral diverticulum (UD) is considered relatively uncommon, although its diagnosis has become more frequent with the advancements in imaging techniques available today. When patients report pain in the area, doctors now have better tools to investigate and understand the issue.
However, it is believed that some cases of UD are not accurately diagnosed due to the condition's relative rarity, and doctors may not always consider it as a potential cause of symptoms. UDs are most commonly observed in women aged between 30 and 60 years.
Who is at risk of urethral diverticulum?
Females have a higher susceptibility to developing urethral diverticula compared to males.
Several factors can increase the risk of urethral diverticula, including:
- Vaginal Delivery: The stress exerted on the muscles and tissues of the urethra during vaginal childbirth can lead to bulging of the urethral wall, resulting in the formation of a diverticulum
- Recurrent Urinary Tract Infections (UTIs): Patients who experience frequent UTIs are at a higher risk. Infections can cause blockage of the periurethral glands, leading to their protrusion and the development of a diverticulum
- Urinary Retention: Holding urine for extended periods or having difficulty emptying the bladder increases pressure on the urethral muscles, which can cause them to bulge and form a diverticulum
- Certain inborn conditions like Hypospadias: This congenital condition occurs when the urethra does not fully develop, resulting in the urethral opening being located below the tip of the penis.6 Individuals post hypospadias correction have an increased risk of developing urethral diverticula
These factors contribute to the increased likelihood of developing urethral diverticula, with females and individuals with specific medical conditions or habits being more susceptible to the condition.
When should I see a doctor?
Consult your physician if you develop any urinary symptoms as described above for a proper diagnosis and early detection and management.
Urethral diverticula occurs when a pouch or sac forms near the urethra, leading to the collection of urine and an increased risk of bacterial infections. Symptoms commonly experienced by patients include pain, hematuria (blood in urine), and a burning sensation during urination. The presence of the pouch makes it difficult for the patient to empty their bladder properly. Although urethral diverticula are rare, they can lead to severe complications if not treated promptly.
It is important for patients to seek appropriate medical attention rather than assuming that antibiotics alone will resolve the condition. Surgery is generally considered the most effective treatment for urethral diverticulum. Patients should promptly notify their symptoms and consult a doctor to explore the available treatment options. When surgery is performed on time, it can yield excellent results in resolving the condition and relieving symptoms.
- Reeves FA, Inman RD, Chapple CR. Management of symptomatic urethral diverticula in women: a single-centre experience. European Urology [Internet]. 2014 Jul [cited 2023 Sep 4];66(1):164–72. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0302283814001705
- Greiman AK, Rolef J, Rovner ES. Urethral diverticulum: A systematic review. Arab J Urol [Internet]. 2019 Apr 8 [cited 2023 Sep 4];17(1):49–57. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583718/
- Hosseinzadeh K, Furlan A, Torabi M. Pre- and postoperative evaluation of urethral diverticulum. American Journal of Roentgenology [Internet]. 2008 Jan [cited 2023 Sep 4];190(1):165–72. Available from: https://www.ajronline.org/doi/10.2214/AJR.07.2094
- El-Nashar SA, Singh R, Bacon MM, Kim-Fine S, Occhino JA, Gebhart JB, et al. Female urethral diverticulum: presentation, diagnosis, and predictors of outcomes after surgery. Female Pelvic Med Reconstr Surg [Internet]. 2016 [cited 2023 Sep 4];22(6):447–52. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5367903/
- Ferreira N, Gaspar S, Oliveira P, Oliveira T, Dias JS, Lopes T. Acquired male urethral diverticula: diagnosis and surgical management. EMJ [Internet]. 2018 Aug 5 [cited 2023 Sep 4];6(1):62–6. Available from: https://www.emjreviews.com/urology/article/acquired-male-urethral-diverticula-diagnosis-and-surgical-management/