A urethral diverticulum is a condition where the urethra or the

periurethral glands In female human anatomy, Skene's glands or the Skene glands ( , also known as the lesser vestibular glands, paraurethral glands) are glands located around the lower end of the urethra. The glands are surrounded by tissue that swells with blood d ...

push into the connective tissue layers (

fascia A fascia (; plural fasciae or fascias; adjective fascial; from Latin: "band") is a band or sheet of connective tissue, primarily collagen, beneath the skin that attaches to, stabilizes, encloses, and separates muscles and other internal organs. ...

) that surround it.

Signs and symptoms

Urethral diverticula are often asymptomatic and symptoms that are present tend to be nonspecific. They can co-occur with cancer, in approximately 6-9% of cases, most commonly

adenocarcinoma Adenocarcinoma (; plural adenocarcinomas or adenocarcinomata ) (AC) is a type of cancerous tumor that can occur in several parts of the body. It is defined as neoplasia of epithelial tissue that has glandular origin, glandular characteristics, or ...

, but also including

squamous cell carcinoma Squamous-cell carcinomas (SCCs), also known as epidermoid carcinomas, comprise a number of different types of cancer that begin in squamous cells. These cells form on the surface of the skin, on the lining of hollow organs in the body, and on the ...

and transitional cell carcinoma. Approximately 10% of cases co-occur with kidney stones. There are 2 types of urethral diverticulums. Congenital and acquired. In infancy usually the urethral diverticulum is congenital but in rare instances acquired urethral diverticulum can be seen in infancy specially following traumatic catheterization. Common symptoms of urethral diverticulum include

incontinence Incontinence or Incontinent may refer to: *Fecal incontinence, the involuntary excretion of bowel contents *Urinary incontinence, the involuntary excretion of urine * Lack of moderation or self-control, especially related to sexual desire - see I ...

, urinary frequency and urgency, pain during sex, and pain during urination. Other symptoms include pain localized to the urethra or pelvis and frequent urinary tract infection. When urethral diverticulum becomes severe, a painful mass can sometimes be felt inside the introitus of the vagina, which can discharge pus. If the mass is hard or bleeds, complications like cancer or kidney stones may be present.

Causes

Few urethral diverticula are present at birth; the vast majority are acquired. Acquired urethral diverticula can be caused by trauma and/or infection. When the peri-urethral ducts become infected repeatedly, they can become blocked and eventually cause a diverticulum. They are usually found in the middle of the urethra or the end farthest from the bladder. Congenital urethral diverticula can arise from several embryological sources. These include defects in the primordial folds and remnants of Gartner's duct.

Pathology

Histopathologically, several characteristics are frequently visible in urethral diverticula. These include

nephrogenic adenoma Nephrogenic adenoma is a benign growth typically found in the urinary bladder. It is thought to result from displacement and implantation of renal tubular cells, as this entity in kidney transplant recipients has been shown to be kidney donor der ...

, chronic inflammation associated with fibrosis around the glands, small or absent

epithelium Epithelium or epithelial tissue is one of the four basic types of animal tissue, along with connective tissue, muscle tissue and nervous tissue. It is a thin, continuous, protective layer of compactly packed cells with a little intercellul ...

chronic cystitis Chronic may refer to: * Chronic (cannabis), a slang name for high quality marijuana * Chronic condition, a condition or disease that is persistent or otherwise long-lasting in its effects * Chronic toxicity, a substance with toxic effects after c ...

, cystitis cystica, cystitis glandularis, squamous metaplasia, and

adenomatous metaplasia An adenoma is a benign tumor of epithelial tissue with glandular origin, glandular characteristics, or both. Adenomas can grow from many glandular organs, including the adrenal glands, pituitary gland, thyroid, prostate, and others. Some adenomas ...

. Approximately 1/3 of diverticula are compound or multiple, and some can extend to surround the urethra.

Diagnosis

Urethral diverticulum is often an

incidental finding Incidental medical findings are previously undiagnosed medical or psychiatric conditions that are discovered unintentionally and during evaluation for a medical or psychiatric condition. Such findings may occur in a variety of settings, including ro ...

. It can be diagnosed using

magnetic resonance imaging Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio wave ...

and/or micturating cystourethrography. Other studies that can be used to diagnose urethral diverticulum include

intravenous urography Pyelogram (or pyelography or urography) is a form of imaging of the renal pelvis and ureter. Types include: * Intravenous pyelogram – In which a contrast solution is introduced through a vein into the circulatory system. * Retrograde pyelogram � ...

, urethroscopy, and/or ultrasound. Conditions that should be distinguished from urethral diverticulum in a

differential diagnosis In healthcare, a differential diagnosis (abbreviated DDx) is a method of analysis of a patient's history and physical examination to arrive at the correct diagnosis. It involves distinguishing a particular disease or condition from others that p ...

include overactive bladder,

Gartner's duct cyst A Gartner's duct cyst (sometimes incorrectly referred to as ''vaginal inclusion cyst'') is a benign vaginal cyst that originates from the Gartner's duct, which is a vestigial remnant of the mesonephric duct (wolffian duct) in females. They are typi ...

, Gartner's duct abscess, ectopic caeco-ureterocele, interstitial cystitis,

pelvic inflammatory disease Pelvic inflammatory disease, also known as pelvic inflammatory disorder (PID), is an infection of the upper part of the female reproductive system, namely the uterus, fallopian tubes, and ovaries, and inside of the pelvis. Often, there may be no ...

endometriosis Endometriosis is a disease of the female reproductive system in which cells similar to those in the endometrium, the layer of tissue that normally covers the inside of the uterus, grow outside the uterus. Most often this is on the ovaries, f ...

, and cancer.

Treatment

The primary treatment for urethral diverticulum is surgical. In women the surgery is conducted transvaginally, usually when there is no acute inflammation to better aid dissection of the delicate tissues.

Prognosis

Left untreated, urethral diverticulum can cause significant morbidity (sickness). During surgery, there is a risk for complications due to the highly vascular nature of the tissue. The urethral sphincters and its smooth muscle, as well as the neck of the bladder, can be injured regardless of the surgical approach. Other complications from surgery can include urinary incontinence,

stress incontinence Stress incontinence, also known as stress urinary incontinence (SUI) or effort incontinence is a form of urinary incontinence. It is due to inadequate closure of the bladder outlet by the urethral sphincter. Pathophysiology It is the loss of sma ...

, a

urethrovaginal fistula A urethrovaginal fistula is an abnormal passageway that may occur the urethra and the vagina. It is a sub-set of vaginal fistulas. It results in urinary incontinence as urine continually leaves the vagina. It can occur as an obstetrical complicatio ...

, or recurrent diverticula. Horseshoe-shaped diverticula and diverticula that completely surround the urethra are both associated with worse outcomes, as are those located close to the bladder, and large (over 3–4 cm) diverticula.

Epidemiology

The incidence of urethral diverticulum has been increasing in the 2000s, likely due to increasing diagnosis and detection of the condition. It is estimated to be present in as low as 0.02% of all women and as high as 6% of all women, and 40% of women with lower urinary tract symptoms. Most symptomatic urethral diverticula are present in women from 30 to 60 years old. 84% of periurethral masses are due to urethral diverticula.

In men

Urethral diverticulum can occur in men, and can cause complications including kidney stones and urinary tract infections.

References

{{Reflist Gynaecology