A periurethral mass in a 25-year-old woman

Barbara L. Robinson

History of present illness

A 25-year-old gravida 3, para 1 woman presents to the office complaining of a 1-year history of a vaginal bulge, dyspareu- nia, and intermittent urinary incontinence. She can feel pres- sure in the vagina but cannot see a bulge protruding from the introitus. She admits to dyspareunia with both initial insertion and deep penetration. She denies incontinence of urine with coughing, laughing, sneezing, or urgency. However, she experiences post-void dribbling. The feels as if she never com- pletely empties her bladder as she constantly feels the urge to void. She has had three urinary tract infections in the past year, but denies a history of pyelonephritis, nephrolithiasis, hema- turia, or urinary hesitancy. She is in a stable relationship with one sexual partner in the past year. She has a remote history of trichomoniasis. Otherwise her medical and surgical histories are negative.

Physical examination

General appearance:Well-nourished woman in no acute distress

Vital signs:

Temperature: 37.2°C Pulse: 68 beats/min

Blood pressure: 128/70 mmHg Respiratory rate: 18 breaths/min Oxygen saturation: 99% on room air

Abdomen:Soft, nontender, nondistended, obese, no organosplenomegaly

External genitalia:Unremarkable Bladder:Nontender, no palpable masses

Urethra:Meatus midline, suburethral fullness and

tenderness. No discharge from the meatus with compression of the midurethra

Vagina:Loss of epithelial rugations in the midurethral area, otherwise no lesions; scant clear discharge; Bartholin’s and Skene’s glands are unremarkable

Cervix:Parous, no mucopurulent discharge, no lesions Uterus:Small, anteverted, nontender, mobile

Adnexa:Nontender, no masses Laboratory studies:

Urine dipstick: Moderate leukocyte estrace, negative nitrites, pH 6.0, trace blood, specific gravity 1.015, negative ketones, negative glucose, negative bilirubin Urine culture: Negative

Cystourethroscopy was performed in the office with a rigid 30° cystourethroscope after application of 2%

lidocaine gel to the urethra Imaging:MRI was ordered

How would you manage this patient?

The diagnosis is a urethral diverticulum. Pelvic examination revealed an anterior vaginal bulge with loss of epithelial ruga- tions in the midurethral area (Fig. 83.1a,b). On cystourethro- scopy the diverticular ostium was identified in the right, posterior aspect of the midurethra (Fig. 83.2). MRI revealed a 3 cm suburethral mass with an ostium at the 7-o’clock position on the urethra. Under general anesthesia in the operating room, a urethral diverticulectomy was performed vaginally.

The patient was discharged home on the day of surgery and the Foley catheter remained in place for two weeks. Before discontinuing the Foley catheter, voiding cystourethrography (VCUG) was performed which revealed an intact repair as there was no extravasation of contrast from the urethra. The patient had an uneventful postoperative recovery.

Urethral diverticulum in a female

A urethral diverticulum is a localized protrusion or outpouch- ing of the urethral mucosa into the surrounding nonurothelial tissues [1]. Urethral diverticula are more prevalent among females and most commonly present between the ages of 20 and 60, although they have been reported in adolescents and the elderly [2,3]. Urethral diverticula are uncommon as the prevalence ranges from 0.6 to 6% in adult women, with less than 0.02% of women affected annually [2,4].

The pathogenesis of urethra diverticula remains uncertain;

however, the majority of cases are thought to be acquired rather than congenital as they rarely occur in neonates.

Congenital diverticula have been proposed to result from a remnant of Gartner’s duct, abnormal union of primordial folds or persisting cell rest, especially those of Mullerian origin [1]. Most commonly urethral diverticula are thought to develop as a result of repeated infection of the periurethral glands that become obstructed and enlarged eventually forming a suburethral abscess which eventually ruptures into the urethral lumen [2]. Other possible etiologies include trauma of the lower genital tract from obstetric injury or complication during urethral instrumentation, transurethral bulking procedures, or midurethral sling placement [2]. The majority of urethra diverticula are benign; however, 10% have

Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.

© Cambridge University Press 2015.

atypical glandularfindings, including invasive carcinoma [5].

Thus, careful assessment and follow-up is recommended for all patients with a history and examination concerning for a urethral diverticulum.

Women with urethral diverticula present with a variety of nonspecific symptoms, which may make diagnosis challenging, leading to treatment delays. The classic triad of symptoms includes post-void dribbling, dysuria, and

Fig. 83.2 Cystourethroscopy using a 30°

cystoscope. A diverticular ostium at 7-o’clock in the midurethral is identified.

(a) (b)

Fig. 83.1 (a,b) Examination of the anterior vaginal wall with a urethral diverticulum.

Case 83: A periurethral mass in a 25-year-old woman

dyspareunia. However, many women present with other com- plaints including recurrent urinary tract infections, urinary incontinence, urinary frequency and urgency, gross hematuria, urinary retention, pelvic and urethral pain, and purulent urethral discharge [2,5].

Diagnosis of a suspected urethral diverticulum begins with a thorough physical examination with emphasis on the distal genitourinary tract. The external genitalia should be inspected for lesions and anatomic anomalies. The periurethral and Bartholin’s glands should be evaluated for tenderness, erythema, and enlargement. The urethral meatus should be carefully inspected for purulent discharge, lateral deviation, or prolapse. The anterior vaginal wall should be visualized noting the presence or absence of epithelial rugations. An identified bulge should be gently palpated to assess tenderness and consistency. In 13–40% of women with urethral diver- ticulum, urine or purulent material may be expressed from the urethral meatus with gentle compression of the anterior abdominal wall mass [2]. A urinalysis should be performed and, if suspicious for infection, a culture should be sent to exclude infection.

Imaging of the urethra is typically performed to confirm the diagnosis of urethral diverticulum and to assist in surgical planning. VCUG was the initial imaging method used to evaluate the female urethra; however, the accuracy of this technique for suspected urethra diverticula is only 65–85%

[6]. Additionally, this modality requires bladder catheteriza- tion and patient voiding during the examination, which may be uncomfortable for the patient. Transvaginal ultrasound is an inexpensive and noninvasive method to visualize the urethra but its use is operator dependent and has not been well studied for diagnosis of urethral diverticula. CT voiding urethrography has been shown to have high diagnostic accur- acy; however, its disadvantages are similar to that of VCUG [6]. MRI is now considered imaging study of choice for diag- nosing urethral diverticula. It provides superb soft-tissue con- trast, which allows delineation of the urethral anatomy and its supporting structure with diagnostic sensitivity up to 100% [6].

Urethroscopy may be used as an adjunct to MRI to provide information on the anatomic relationship between the urethra and diverticular ostium. However, urethroscopy is limited in that it does not provide information on the size and

complexity of the diverticulum. It has been shown to have a diagnostic accuracy of 15–85% [6].

Expectant management with close observation is acceptable among asymptomatic women with urethral diverticula that do not have malignant characteristics. Similarly, conservative management with prophylactic antibiotics, needle aspiration, or digital compression may be used upon initial presentation.

Complete vaginal excision of the diverticulum or vaginal diver- ticulectomy is the preferred surgical treatment for women with a suburethral diverticulum. For the less common circumferen- tial or dorsal diverticula, a more invasive procedure requiring division of the urethra may be required. Genitourinary tract infections, including infectious cystitis and diverticular abscess, should be treated before proceeding with diverticulectomy.

Postoperatively a transurethral Foley catheter should be main- tained for one to three weeks to minimize the risk of urethral stricture or formation of urethrovaginalfistula. VCUG may be performed to verify the integrity of the repair before Foley removal, but such imaging is not required. Some providers choose to retrograde fill the bladder with methylene-blue or indigo carmine-dyed solution and look for extravasation of dye during the vaginal speculum examination. If there is extravasa- tion of contrast or dye on either study, the Foley catheter should be replaced for at least one additional week.

Key teaching points

The classic triad of symptoms of a urethral diverticulum includes post-void dribbling, dysuria, and dyspareunia.

However, many women present with other complaints including recurrent urinary tract infections, urinary incontinence, urinary frequency and urgency, gross hematuria, urinary retention, pelvic and urethral pain, and purulent urethral discharge.

The majority of urethra diverticula are benign; however, 10% have atypical glandularfindings, including invasive carcinoma.

MRI is considered imaging study of choice for diagnosing urethral diverticula with a diagnostic sensitivity up to 100%. Urethroscopy may be used as an adjunct to MRI to provide information on the anatomic relationship between the urethra and diverticular ostium.

References

1. Foley CL, Greenwell TJ, Gardiner RA.

Urethral diverticula in females.BJU Int 2011;108(Suppl 2):20–3.

2. Antosh DD, Gutman RE. Diagnosis and management of female urethral diverticulum.Female Pelvic Med Reconstr Surg2011;17(6):264–71.

3. Burrows LJ, Howden NL, Meyn L, Weber AM. Surgical procedures for

urethral diverticula in women in the United States, 1979–1997.Int Urogynecol J Pelvic Floor Dysfunct 2005;16(2):158–61.

4. El-Nashar SA, Bacon MM, Kim-Fine S, et al. Incidence of female urethral diverticulum: A population-based analysis and literature review.Int Urogynecol J2014;25(1):73–9.

5. Thomas AA, Rackley RR, Lee U, et al.

Urethral diverticula in 90 female patients: A study with emphasis on neoplastic alterations.J Urol2008;

180(6):2463–7.

6. Singla P, Long SS, Long CM, Genadry RR, Macura KJ. Imaging of the female urethral diverticulum.Clin Radiol 2013;68(7):e418–25.