Female Urethral Diverticula

More female urethral diverticula are now being diagnosed than ever before because of a higher index of clinical suspicion and improved diagnostic techniques such as voiding cystourethrogram (VCUG) and transvaginal ultrasound. Because of the complexity and variability of diverticula, thorough evaluation is required to completely assess important pretreatment facors and plan appropriate management. With proper pretreatment evaluation, surgical treatment is generally associated with an excellent outcome.

The true incidence of urethral diverticulum is unknown. The reported incidence varies from 1.4% to 5% depending on the population studied. Although diverticula are reported in all age groups, they most commonly present in the third through fifth decades, and 15% to 20% of women with diverticula are nulliparous. Though they are reported to be more common in the black population, the authors have not found any racial predilection.3 Female urethral diverticulum arises from the wall of urethra and consists mainly of fibrous tissue lined with epithelium. In many cases the epithelial lining may be absent because of chronic inflammation, and the diverticulum may be adherent to the neighboring structures including the periurethral fascia and anterior vaginal wall.

Although the exact mechanism of diverticular formation is unknown, the most commonly accepted theory implicates the periurethral glands. Obstruction of the periurethral gland duct is associated with infection in the occluded gland, which results in abscess formation. The abscess subsequently ruptures into the urethral lumen, either as the result of trauma or progression of the infection, forming the diverticulum.

The complications of female urethral diverticulum include infection (either acute or chronic), stone formation, and malignancy (adenocarcinoma in 61%, transitional cell carcinoma in 27%, and squamous cell carcinoma in 12% of reported cases).

DIAGNOSIS

The presenting symptoms of urethral diverticulum vary considerably and include the three Ds (dysuria, postvoid dribbling, and dyspareunia), urinary frequency/urgency, recurrent infection, urinary incontinence (stress and urge), hematuria, anterior vaginal pain, and swelling (particularly after voiding). The symptoms of urethral diverticulum may mimic those of simple or chronic bacterial cystitis, interstitial cystitis, pelvic inflammatory disease, endometriosis, nonspecific or gonococcal urethritis, carcinoma in situ of the bladder, detrusor instability, and bladder outlet obstruction. The symptoms are related to neither the size nor the number of diverticula, but more likely, the symptoms are dictated by the size and patency of the diverticular opening and the recurrent urinary tract infections associated with the diverticula. Two percent to 11% of urethral diverticula are asymptomatic and found incidentally on routine pelvic examination, radiography such as a postvoid view of an intravenous urography (IVU) for hematuria, or VCUG performed for vesicoureteric reflux, cystocele, or recurrent urinary tract infection.

A high index of suspicion for the possibility of urethral diverticulum is essential in making the diagnosis. One should always consider the possibility of a urethral diverticulum in a woman with persistent or recurrent lower urinary tract symptoms that fail to respond to routine treatment. Physical examination of the urethra should be routinely performed by compressing the anterior vaginal wall beneath the urethra and looking for tenderness, mass, or external urethral meatus discharge. In the authors’ experience, all urethral diverticula of significant size (>1 cm×1 cm) have been suspected by demonstrating a periurethral mass on pelvic examination.

However, all periurethral masses do not represent urethral diverticula; thus, the differential diagnosis of an anterior vaginal wall mass must be considered before the physician assumes thepresence of urethral diverticulum.2 The differential diagnosis of a periurethral mass includes Skene’s gland abscess (located lateral to the urethral meatus), Gartner’s duct cyst (located in the anterior lateral vaginal wall), ectopic ureterocele (located beneath the distal urethra and filled with clear fluid), vaginal wall inclusion cyst (spontaneous or after vaginal surgery), urethral carcinoma, periurethral or vaginal fibroma or myoma, hemangioma, urethral varices, endometriosis of the urethra, sarcoma botryoides, and vaginal wall metastasis.

Compression of the mass (which is usually tender) may result in pus, blood, or urine extruding from the external urethral meatus. Anterior vaginal wall tenderness may be noticed on palpation (even without obvious swelling), and point tenderness along the urethra may indicate the presence of urethral diverticulum.

Induration or hardness in the area of diverticulum suggests the possibility of malignancy or stone. During pelvic examination, other findings such as urethral hypermobility and vaginal prolapse are also considered in order to plan appropriate investigation and treatment.

A properly performed VCUG is the best radiographic test to confirm the presence, extent, size, number, and configuration of a urethral diverticulum. In the authors’ experience, 60 of 63 diverticula were adequately demonstrated on VCUG. The VCUG should be performed under fluoroscopic control in the standing position to clearly document all the characteristics of the diverticulum. Sometimes, an “air–fluid level” may be seen within the diverticulum because of partial filling, suggesting that the diverticulum is much larger than the portion of the diverticulum seen on the x-ray. Filling defects seen within a diverticulum may suggest the possibility of stone, tumor, or inflammatory mass. The lateral straining views also provide information regarding urethral support and hypermobility, and the presence of stress incontinence with loss of contrast across the bladder neck during coughing or straining.

Occasionally, the diverticulum may be demonstrated on the postvoid film of a standard IVU. However, the area below the pubic symphysis is frequently excluded on the postvoid film. The authors perform an IVU before diverticulectomy to identify an ectopic ureterocele presenting as a periurethral mass because excision of such an unrecognized lesion would result in total incontinence. Retrograde positive-pressure urethrography is used in the investigation of urethral diverticulum in selected cases, when there is a strong suspicion of diverticulum not demonstrated by other methods. Practically, retrograde urethrography is a difficult, time-consuming, and unsatisfactory procedure.

Ultrasound examination (vaginal, perineal, translabial, transrectal, suprapubic, or urethral endoluminal1) has been increasingly used in the investigation of urethral diverticulum. Ultrasound examination not only identifies the contents of the diverticulum but may also show multiloculation within a diverticulum  or the presence of a second diverticulum that might otherwise have been missed at operation. The ultrasound also helps to differentiate urethral diverticulum from other periurethral masses, and commonly the diverticular orifice can also be visualized. Given the quality of the ultrasound images, this study should replace positive-pressure urethrography in cases with a normal VCUG when a urethral diverticulum is suspected. Ultrasound is also commonly used to confirm or augment the findings of VCUG. Although they are interesting from a research perspective, the authors do not find CT or MRI scans of the urethra to be either clinically useful or necessary in the investigation of urethral diverticulum.

In addition to radiographic and ultrasound studies, complete cystourethroscopy with a 20-Fr female “short beaked” urethroscope is performed with a 0- and 30-degree lens. The regular cystoscope will not expand the urethral wall properly because of its long beak, making diagnosis more difficult. Palpation of the suburethral mass over the instrument allows a better appreciation of the location, size, and consistency of the diverticulum. Also, endoscopic observation of the urethral lumen while the mass is compressed will frequently demonstrate the site of communication as purulent material extrudes into the urethra. Even without the ability to extrude the diverticular contents into the urethra, the communication site usually can be identified with careful observation. It is important to identify the communication site before surgery to completely excise the diverticulum and to prevent recurrence. Another essential aspect of preoperative urethroscopy is to evaluate the competence of the bladder neck and the degree of urethral hypermobility with stress. This endoscopic information is extremely useful to determine whether a suspension procedure should be combined with diverticulectomy.

Urodynamic evaluation should be considered before diverticulectomy if the patient has a history of stress or urge urinary incontinence, symptoms of bladder dysfunction such as urinary urgency or frequency, or urethral hypermobility. The presence of stress incontinence requires a simultaneous bladder neck suspension along with diverticulectomy. The presence of detrusor instability may necessitate prolonged postoperative anticholinergic therapy to prevent “breakdown” of the urethral reconstruction site secondary to high intravesical pressures and to avoid persistent irritative symptoms such as frequency, urgency, and urgency incontinence in the postoperative period. Fluoroscopic examination, if available, should be used along with urodynamic evaluation (videourodynamic studies) to differentiate “paradoxic or spurious stress incontinence” (leakage of contrast from the diverticulum with coughing or straining without any leakage across the bladder neck) from genuine stress urinary incontinence (GSUI). When videourodynamic studies are not available, one must rely on the VCUG to confirm contrast loss across the bladder neck with stress. The urethral pressure profile (UPP) is of only historical interest and has no role in the diagnosis of urethral diverticulum and stress urinary incontinence.

INDICATIONS FOR SURGERY

The authors recommend urethral diverticulectomy if the patient is symptomatic and/or the diverticulum is of significant size (more than 0.5 cm in diameter). The authors prefer transvaginal excision of diverticula with a vaginal flap technique, which provides excellent exposure and complete excision of the diverticulum with minimal risk of recurrence. A three-layer closure is performed, and overlapping sutures are avoided to minimize the risk of urethrovaginal fistula or recurrent diverticulum.

A Martius labial fat pad graft interposition is also used between the urethra and vaginal wall during wound closure after diverticulectomy in selected cases.5 The indications for the Martius graft include fibrotic and scarred tissues, history of radiation treatment, absent or tenuous periurethral fascia for the second layer of closure, and recurrent diverticula.

Along with the vaginal flap technique, simultaneous bladder neck suspension can be performed  without fear of infection spreading into the retropubic space. To prevent infection, preoperative antibiotics are given, the transvaginal needle suspension is performed before the diverticulum is manipulated, and manual compression of the diverticulum is avoided during surgery. The indications for concomitant bladder neck suspension are documented GSUI, urethral hypermobility, and large proximal urethral diverticulum (which may make the placement of the bladder neck suspension sutures in the anterior vaginal wall difficult without entering the diverticulum).

Pubovaginal sling procedures have also been performed along with diverticulectomy when the patients had either type II or type III stress urinary incontinence.9 The authors believe that it is risky to use a fascial sling over a delicate urethral closure site for fear of urethral erosion, especially in the absence of type III stress urinary incontinence or intrinsic sphincteric deficiency (ISD). In addition, the sling procedure is associated with postoperative urinary retention, and the authors are concerned regarding the potential need for self-catheterization through the “reconstructed urethra.”

Occasionally, a female urethral diverticulum presents as a large periurethral abscess that may not respond to antibiotics. The abscess may be initially drained with incision, and diverticulectomy is performed later, after satisfactory treatment of infection.

ALTERNATIVE THERAPY

Endoscopic Procedures

Lapides transurethrally “saucerized” the diverticula by opening the diverticula into the urethral lumen with a knife electrode, especially in women who had previous surgical intervention with multiple recurrent diverticula. The authors have successfully performed the saucerization technique in two distal recurrent diverticula. Other techniques include using a 10-Fr pediatric resectoscope and Collins knife or Pott scissors. Endoscopic procedures are useful mainly in diverticula situated in the distal urethra, creating a wide-mouthed diverticulum that is expected to drain freely. When these are used for mid- or proximal diverticula, the risk of urinary incontinence is greater. Endoscopic procedures do not address the need for concomitant treatment of stress urinary incontinence when a combined problem exists.

Marsupialization

Spence and Duckett described the technique of marsupialization of distal diverticula. It is basically an incision of the urethral floor through the diverticulum to the diverticular orifice. The diverticulum should be inspected thoroughly, and a biopsy should be taken from any suspicious area to exclude malignancy. The epithelium of the vagina and urethra are then co-opted by running an absorbable suture and keeping vaginal packing for 24 hours and a Foley catheter for 2 or 3 days. Though the reported incidence of stress incontinence after marsupialization of a distal diverticulum in experienced hands is as low as 0.3%, this technique should not be considered with proximal or midurethral diverticula. Other complications of this procedure include recurrent diverticula, vaginal voiding, and spraying of urine with micturition.

Miscellaneous Techniques

Ellick treated diverticulum with incision and packing of the diverticular cavity with oxidized cellulose (oxycel) or Gelfoam. Problems were encountered with a multiloculated diverticulum because the entire diverticulum was not obliterated. Tancer et al. described a partial ablation technique by transvaginally opening the diverticulum and using the sac as a second layer after closing the orifice. Periurethral injection of Polytef paste adjacent to the diverticulum was employed by Mizraki and Bitterman to collapse the diverticulum. Most diverticula contain infected material, and so, the risk of infection and abscess formation with the synthetic material is considerable.

There are several other techniques of diverticulectomy, including (a) a vertical vaginal incision, excision of the diverticulum, and closure of the periurethral fascia in vest-over-pants fashion; (b) a two-layer vaginal flap technique; (c) closure of the urethral defect, retaining a portion of the sac and marsupializing it to the vaginal mucosa to prevent extensive subtrigonal dissection; and (d) excision of the urethral floor from the external urinary meatus to the distal diverticulum and closing of the urethra in layers. The authors prefer a three-layer closure with the closures oriented in different directions to avoid overlapping sutures, which could result in urethrovaginal fistula formation.

Several techniques have also been described in the literature to define the diverticulum during surgery, including sounds, gauze packing, Foley or Fogarty balloon catheters, ureteral catheters, injecting methylene blue, coagulated cryoprecipitate, or a silicone and rubber mixture, and urethral endoluminal ultrasound. Kohom and Glickman have introduced a 7-Fr Foley catheter (with its tip cut off) through the defect of a diverticulum inadvertently opened during diverticulectomy and then inflated its balloon with saline to distend the diverticulum and facilitate continuation of dissection. In the experience of the authors, these diverticulum-defining procedures are rarely required during operation, as a thorough preoperative evaluation almost always reveals satisfactorily the diverticulum location, extent, and communication site.

SURGICAL TECHNIQUE

Preparation

At the time of preoperative consent, the patient is informed about the procedure and postoperative management in detail. Possible complications of diverticulectomy such as infection, bleeding, recurrent diverticulum, urethrovaginal fistula, and urinary incontinence are discussed. Vaginal douches and lower abdominal scrubbing are performed by the patient the night before and the morning of operation. Because most diverticula are filled with infected purulent material, perioperative parenteral antibiotics are given the morning of surgery, usually preceded by 1 week of oral suppressive antibiotic therapy. Patients are admitted the morning of surgery.

Diverticulectomy

After induction of general or spinal anesthesia, the patient is placed in the modified dorsolithotomy position after application of intermittent pneumatic calf compression. The vagina and lower abdomen are prepared and draped with isolation of the rectum from the operative field. The bladder is filled, and a 22-Fr suprapubic Foley catheter is placed as a “safety valve” for bladder drainage using a modified curved Lowsley tractor. Cystourethroscopy is performed to check the position of the suprapubic catheter and to reconfirm the site of urethral communication of the diverticulum. A 14-Fr Foley catheter is inserted transurethrally. Saline is infiltrated in the anterior vaginal wall along the site of incision, which is made in a U-shaped manner with the apex distal to the diverticulum. If a bladder neck suspension is being performed concomitantly, the suspension sutures are placed at this point.

The anterior vaginal flap is reflected toward the bladder neck with sharp, spreading dissection using scissors in the correct plane on the shiny white surface of the vaginal wall. Dissection in the wrong tissue plane (usually too deeply) results in entry into either the periurethral fascia or the diverticulum itself. Premature entry into either structure makes the remainder of the dissection more difficult. Preservation of the periurethral fascia is important to provide a second layer of closure between the urethra and the vaginal wall.

The urethral diverticulum is usually quite obvious once the vaginal flap is dissected inferiorly. Next, the periurethral fascia is incised transversely to allow subsequent exposure of the diverticulum beneath this fascial layer. The plane between the periurethral fascia and the diverticulum is defined using sharp dissection, away from the midline, with care taken not to dissect too deeply to enter into the diverticulum at this stage. Once the dissection is completed, the periurethral fascia can be opened like “leaves of a book” to completely expose the underlying diverticulum. The diverticulum is carefully dissected around until its communication with the urethra can be defined. Rarely, when there is any difficulty identifying the diverticulum or its communication site to the urethra during the operation, urethroscopy is performed, and a probe or curved pediatric sound is passed under visual control from the urethral lumen into the diverticulum for vaginal palpation. The diverticulum is then excised in its entirety with its communication with the urethra and the adjacent urethral wall, thus creating a large urethral defect. When the diverticulum is multiloculated, the diverticulum should be opened and inspected to ensure that all intercommunicating pockets are identified and removed. It is very important that all abnormal, weak, and attenuated tissue at the urethral communication site be excised to reduce the risk of recurrent diverticular formation. On the other hand, care must be exercised not to remove an excessive amount of urethral wall, or urethral closure over a 14-Fr catheter without tension may be difficult.

The urethral defect is closed vertically without tension, using a running locking 4-0 Vicryl suture starting at the proximal margin. Care is taken to incorporate both the muscular and mucosal layers of the urethral wall into the closure. A watertight closure is essential to reduce the risk of postoperative extravasation. Next, meticulous hemostasis is obtained to prevent hematoma formation and disruption of the suture lines. The periurethral fascia is closed transversely with a running 3-0 Vicryl suture. Care is taken to space the sutures to obliterate any “dead space” beneath the periurethral fascia. When indicated, a Martius labial fat pad graft is harvested and placed between the periurethral fascia and the anterior vaginal wall closure. The anterior vaginal wall is closed with a running 2-0 Vicryl suture. The wound closure is thus completed in three layers: the urethral wall vertically, the periurethral fascia horizontally, and the overlying vaginal wall flap, which covers the underlying suture lines.

The bladder neck suspension sutures, if placed, are then tied with minimal tension before the suprapubic incision is closed. At the end of the procedure, an antibiotic-soaked vaginal packing is placed, and both the suprapubic and urethral catheters are placed on gravity drainage.

Bladder Neck Suspension (Optional)

When indicated, a bladder neck suspension is performed after the initial vaginal wall incision. The bladder neck is identified by palpating the urethral Foley catheter balloon under traction. The plane between the vaginal wall and endopelvic fascia is developed laterally at the level of the bladder neck toward the pubic bone. The dissection must be in the correct plane between the vaginal wall and the medial reflection of the endopelvic fascia to avoid excessive bleeding or bladder injury. After the bladder is emptied, the endopelvic fascia is sharply or bluntly perforated laterally, entering the retropubic space. Blunt dissection is carried out with a wiping motion on the posterior aspect of the pubic bone and continued inferiorly to the level of the ischial tuberosity on each side. Blunt dissection is also continued anteriorly on each side to facilitate passage of the ligature carrier.

Number-one polypropylene sutures (Ethicon D-6731) are placed in a helical fashion incorporating the vaginal wall as the anchoring tissue at the level of bladder neck. Care is taken not to enter into the diverticulum at this point to avoid spillage of infected material from the diverticulum into the retropubic space. When a very large proximal diverticulum is present, placement of these helical sutures may be impossible without entering the diverticulum. In this situation, bladder neck suspension is deferred.

A 3- to 4-cm transverse suprapubic incision is made just above the symphysis pubis, and the anterior rectus fascia is exposed. After the bladder has been emptied, the modified Pereyra ligature carrier is transferred under finger guidance from the suprapubic area, through the retropubic space, into the vagina. Each suspension suture is threaded into the eye of the ligature carrier and pulled to the suprapubic position. Cystourethroscopy is performed to confirm the absence of bladder perforation or suture material inside the bladder, satisfactory ureteral efflux of previously injected intravenous indigo carmine, and adequate elevation of bladder neck with minimal traction on the suprapubic suspension sutures. When the bone fixation technique is used to anchor the bladder neck suspension sutures, the sutures should be passed through the pubic tubercle before the diverticulectomy is performed in order to reduce the risk of infection. In order to facilitate diverticulectomy and closure of the vaginal flap, the suspension sutures are not tied until the end of the operation.

Postoperative Care

Perioperative parenteral antibiotics are continued for 24 hours, followed by oral antibiotics until the catheters are removed. Belladonna and opium suppositories are given postoperatively until the patient can tolerate oral anticholinergics (oxybutynin and imipramine hydrochloride) to prevent bladder spasm. The vaginal packing is removed on the first postoperative day. Seven to 10 days postoperatively, after a vaginal examination has demonstrated an intact vaginal flap and suture lines, and following discontinuation of anticholinergics for 24 hours, a VCUG is performed. During the VCUG the urethral catheter is removed, and the bladder is filled with contrast through the suprapubic tube. The urethra is carefully observed fluoroscopically during voiding. Should any extravasation occur (as noted in approximately 50% of patients), the patient is asked to stop voiding, and the bladder is left on drainage via the suprapubic catheter. The urethral catheter is not replaced, and anticholinergics are restarted. The VCUG is repeated 7 to 10 days later. When there is no extravasation on the initial VCUG, the patient is allowed to empty her bladder, and if the postvoid residual urine volume is less than 100 ml, the suprapubic catheter is removed. The suprapubic catheter is removed only after satisfactory bladder emptying is established (postvoided residual urine consistently less than 100 ml). Intermittent self-catheterization is avoided for fear of disrupting the urethral reconstruction site.

OUTCOMES

Complications

The urethral diverticulum may recur as a result of incomplete excision of the diverticulum and its urethral communication site. Preoperative evaluation should identify the presence of multiple diverticula and/or communication sites for complete excision during operation. All pockets of a multiloculated diverticulum should also be removed. Care should also be taken to completely close the urethral defect after excision of the diverticulum to prevent formation of a pseudodiverticulum between the layers of closure. The VCUG should be performed postoperatively to rule out extravasation from the urethral closure site before the patient resumes voiding. Recurrence of a diverticulum is generally suggested by the presence of persistent or recurrent symptoms, periurethral mass, tenderness along the urethra, or recurrent urinary tract infection. Care should be taken in evaluating a patient with VCUG after diverticulectomy, as ballooning or irregularity of the urethra may be seen at the site of diverticulectomy and should not be mistaken for recurrence. Recurrent diverticulum may be managed with a second excision procedure with Martius fat interposition. A small distal recurrent diverticulum may also be satisfactorily treated with transurethral “saucerization” or Spence marsupialization procedure.

Urethrovaginal fistula is also a well-described complication of urethral diverticulectomy. In the authors’ experience the fistula is usually seen when a vertical vaginal incision is used for diverticulectomy with overlapping suture lines. The use of three-layer technique that avoids overlapping closures greatly minimizes the chance of fistula formation. Also, the urethral defect should be closed watertight, with care taken to avoid any tension on the suture line. Use of Martius fat interposition in selected cases (as described before) further reduces the risk of fistula. Urethrovaginal fistula can be repaired transvaginally without excising the fistula, using the three-layer anterior vaginal wall flap technique and interposition of Martius labial fat pad graft.

Bladder injury can also occur during dissection of a large proximal urethral diverticulum extending beneath the trigone, resulting in the formation of vesicovaginal fistula. Instillation of indigo carmine into the bladder and/or cystoscopy should be performed in such cases to rule out bladder injury.

Urethral diverticulectomy may be followed by urinary incontinence as the result of persisting GSUI (if simultaneous stress incontinence surgery is not performed), de novo GSUI, recurrent diverticulum with paradoxical loss with stress, urethrovaginal fistula, and/or postoperative de novo detrusor instability. Genuine SUI may develop after diverticulectomy from periurethral dis-section, further compromising the urethral support. Genuine SUI is also common after excision of a large proximal diverticulum extending beneath the proximal urethra and bladder neck area because of the extensive dissection required to remove the diverticulum. Preoperative evaluation is essential to identify individuals who may develop postoperative stress incontinence, which may be prevented with a concomitant bladder neck suspension when diverticulectomy is performed (see indications). Postoperative stress incontinence is evaluated and appropriately treated.

Irritative symptoms may be caused by urinary tract infection or bladder dysfunction. Urinary tract infection is treated with appropriate antibiotics. Preoperative evaluations including urodynamic studies are essential to identify candidates likely to develop postoperative irritative symptoms. In our recently published series, 12 women had preoperative detrusor instability during urodynamic studies, and it persisted in four women (33%) after diverticulectomy.3 Persistent detrusor instability is treated with anticholinergic medications, and postoperative de novo bladder dysfunction requires further evaluation.

Narrowing of the urethra is avoided by not excising too much of the urethral wall during excision of diverticular communication site. Sufficient urethral wall is preserved to close over a 14-Fr Foley catheter. Urethral stricture after diverticulectomy may require reconstruction of urethra.

The complications of concomitant bladder neck suspensions include bladder injury, ureteral injury, bleeding, nerve injury (secondary to patient positioning or nerve entrapment from lateral fixation of suspension sutures), acute and chronic urinary retention, immediate and late urinary incontinence, detrusor instability, and infection.

Results

In our series, urethral diverticulum was diagnosed in 63 women, and urethral diverticulectomy was performed in 56 women (88.9%), including concomitant bladder neck suspension in 27 women (48.2%). With a mean follow-up of 70 months (range 6 to 136 months), 48 women (85.7%) had relief of their presenting symptoms. Two recurrent diverticula (noted at the distal urethral closure site) were documented by periurethral mass and/or tenderness on follow-up vaginal examination. Both diverticula were managed satisfactorily with transurethral “saucerization.” Suprapubic tenderness occurred in one woman in relation to the bladder neck suspension sutures secured suprapubically. This pain resolved with conservative treatment within 6 months of the procedure. Early urinary tract infections were identified and treated satisfactorily in six women, and none of these patients developed recurrent urinary tract infections. Four women who had persistent detrusor instability after surgery noted significant urgency symptoms. No patient developed a retropubic or postoperative wound infection or urethral stricture.

In this series, the authors did not find any patient with intrinsic sphincteric deficiency (ISD) and did not use a sling procedure with diverticulectomy. The overall continence status in the treatment group of 56 women with a mean follow-up of 70 months  may be summarized as follows: totally continent or minimal incontinence (dry or no pad for protection), 45 (80.4%) women; moderate incontinence (1 or 2 minipads/day for protection), ten (17.9%) women, and severe incontinence (several pads/day for protection) in one woman (1.8%) because of detrusor hyperreflexia secondary to cerebellar degeneration.

Three of 27 patients who had diverticulectomy alone developed postoperative GSUI. Two of them had no GSUI before diverticulectomy, and the other one, as noted before, had preoperative GSUI, but simultaneous bladder neck suspension could not be performed because of the extremely large size of the diverticulum. All three women subsequently underwent bladder neck suspension with a satisfactory outcome. Six women developed recurrent GSUI after diverticulectomy and bladder neck suspension, but none had ISD. One woman in this group had a subsequent Burch colposuspension during hysterectomy, and the other five did not desire further treatment because their incontinence was significantly improved.

Female urethral diverticula are more common than previously thought, and the suspicion should always be high in the clinician’s mind. It is most important to be aware of this clinical entity in women with recurrent lower urinary tract symptoms such as urinary frequency, urgency, dysuria, postvoid dribbling, hematuria or dyspareunia, and/or urinary tract infections, with or without periurethral mass. An appropriate history coupled with vaginal examination, VCUG, endoscopic examination, and urodynamic studies will facilitate the diagnosis. With the use of the L/N/S/C3 classification all preoperative factors are easily addressed. The three layer vaginal flap technique of diverticulectomy is associated with an excellent success rate and minimal complications. Thus, the authors recommend this procedure as the treatment of choice for female urethral diverticula. In appropriate patients, diverticulectomy can be safely combined with bladder neck suspension without any significant additional risk and with a satisfactory outcome.

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