A urethral diverticulum (UD) is a condition characterized by the formation of an abnormal pocket or sac that protrudes from the wall of the urethra. This outpouching typically maintains a connection with the urethra, which allows urine to enter and collect inside the sac during urination. Because the trapped urine does not fully empty, this anatomical abnormality can lead to a variety of uncomfortable symptoms and complications.
Anatomy and How the Condition Forms
The urethra is the tube that carries urine from the bladder outside the body. In women, the urethra is relatively short and is surrounded by tiny glands known as the periurethral glands, which include Skene’s glands. These glands drain directly into the urethral channel and are thought to be the origin point for most acquired urethral diverticula.
The formation of a UD is primarily thought to be an acquired process, often beginning with repeated infections that cause inflammation and blockage of one of these periurethral glands. This blockage causes the gland to swell, forming a cyst or abscess that eventually ruptures into the urethral lumen. The resulting opening allows urine to flow into the newly formed cavity, creating a permanent, epithelium-lined outpouching.
This condition is significantly more prevalent in adult women, affecting an estimated 1% to 6% of the female population. The anatomical differences, including the shorter length of the female urethra and the presence of these periurethral glands, contribute to this higher incidence. The consensus points to the recurrent infection and obstruction pathway as the most common mechanism.
Recognizing the Common Signs
For those who are symptomatic, the complaints often relate to the collection and retention of urine within the pocket. Many patients report experiencing irritative lower urinary tract symptoms, such as painful urination (dysuria), increased urinary frequency, and a persistent, urgent need to void.
A particularly distinctive sign is post-void dribbling, which occurs because the urine trapped in the diverticulum slowly leaks out after the person believes they have finished urinating. Recurrent urinary tract infections (UTIs) are also a frequent complaint, as the stagnant urine provides an ideal environment for bacterial growth. Other common complaints include pain during sexual intercourse (dyspareunia).
In many cases, a physical examination may reveal a palpable mass or tender area along the anterior vaginal wall, where the diverticulum often bulges. When compressed, this mass may sometimes express purulent material or old urine through the urethral opening, confirming the presence of an infected sac.
How Doctors Confirm the Diagnosis
The diagnostic process typically begins with a thorough physical examination and a detailed review of the patient’s medical history and symptoms. During the pelvic examination, a doctor will carefully palpate the anterior vaginal wall to check for a tender or firm mass near the urethra. The physical exam may also involve gently “milking” the urethra toward the opening to see if any discharge is expressed.
To definitively confirm the diagnosis and map the anatomy, imaging techniques are employed. Magnetic Resonance Imaging (MRI) has emerged as the preferred method because its superior soft tissue contrast allows for accurate visualization of the diverticulum’s size, location, and relationship to the surrounding structures.
Another imaging test, the voiding cystourethrography (VCUG), is often used and involves filling the bladder and urethra with a liquid contrast agent. The patient is then asked to urinate while X-ray images are taken, which allows the diverticulum to fill with contrast and become visible. In addition to imaging, a doctor may perform a cystoscopy, which involves inserting a thin, lighted tube into the urethra to directly inspect the lining and locate the opening of the diverticulum.
Management and Treatment Options
Treatment for a urethral diverticulum is generally determined by the severity of the patient’s symptoms. For small diverticula that are discovered incidentally and cause no discomfort or recurrent issues, a conservative approach of watchful waiting may be recommended. In these asymptomatic cases, management involves regular monitoring.
For patients experiencing bothersome symptoms, such as recurrent UTIs, pain, or post-void dribbling, surgical excision is considered the definitive treatment. The most common procedure is a diverticulectomy, which involves accessing the sac through a transvaginal approach to completely remove the diverticular wall. The surgeon then performs a watertight, multi-layered closure of the urethral wall defect.
Following the surgical repair, a temporary urinary catheter is required to allow the newly reconstructed urethral tissue to heal completely without being exposed to urine flow. This catheterization period typically lasts between seven and 14 days. If a patient also has stress urinary incontinence, a procedure to address the leakage may be performed simultaneously with the diverticulectomy. Careful dissection and multi-layered repair are important to minimize the risk of complications, such as a urethrovaginal fistula.