Mickey M. Karram, MD

Urethral diverticula are often overlooked as a source of recurrent urinary tract infection, voiding dysfunction, dyspareunia, and chronic pelvic pain. Here, in brief, is how to diagnose and manage this condition, including a look at surgical options.

What are the common complaints?

Urethral diverticula present in myriad ways—most often, as recurrent urinary tract infection, overactive bladder, stress urinary incontinence, and pelvic pain. Other common presenting symptoms include voiding dysfunction, a painful or palpable mass, and postvoid dribbling.

What can be done routinely during a pelvic exam to make the Dx?

Become accustomed to massaging the anterior vaginal wall underneath the urethra. Any discharge or excretion of fluid that you observe from the external urethral meatus as you massage is pathognomonic for urethral diverticulum. In addition, palpate the anterior vaginal wall for paraurethral masses. Sometimes, a diverticulum is ballotable but not palpable.

Which test is best?

Imaging has been used in different ways, with variable success.

• Most diverticula are well visualized by voiding cystourethrography or magnetic resonance imaging (MRI); we view these as complementary techniques, in fact, because some diverticula are visualized only by one modality or the other. MRI provides a superior examination for surgical planning because it defines urethral and diverticular anatomy most clearly
  
• Ultrasonography has been used with some success
  
• Positive-pressure urethrography, using a Tratner or double balloon catheter, is difficult to perform and uncomfortable for the patient.
  

What is the role of urethroscopy?

We find urethroscopy very helpful. One caveat: Inability to visualize a diverticulum or its opening does not, by any means, exclude a urethral diverticulum.

How should you manage a urethral diverticulum?

• Urinary tract infection should be treated with a culture-specific antibiotic; in some cases, the patient will become asymptomatic afterwards
  
• Overactive bladder symptoms can be treated with an anticholinergic
  
• In most cases, surgery proves necessary
  
• When you identify a urethral diverticulum during pregnancy, manage the patient conservatively during the antenatal period
  
• A patient who has an asymptomatic urethral diverticulum can be managed expectantly, but perform a pelvic exam periodically.
  

When is surgery appropriate? By what method?

Several observations are useful:

• Hardness or induration of the diverticular mass is extremely rare; such a finding should prompt surgical excision because it may signal cancer
  
• Marsupialization has been demonstrated to be successful for very distal and small urethral diverticula
  
• Most diverticula at the level of the midurethra and proximal urethra require some form of excision, broadly classified as partial ablation or complete excision
  
• Placement of a suburethral sling is controversial, but some experts believe that, to prevent stress incontinence, this intervention should be undertaken simultaneously with any other surgical treatment for diverticula of the proximal urethra
  
• Sometimes a Martius fat pad must be brought into the field to avoid devascularization and breakdown of the repair. When a suburethral sling is necessary, we routinely place a Martius flap between the urethra and the sling.
  

Urethral diverticula are often overlooked as a source of recurrent urinary tract infection, voiding dysfunction, dyspareunia, and chronic pelvic pain. Here, in brief, is how to diagnose and manage this condition, including a look at surgical options.

What are the common complaints?

Urethral diverticula present in myriad ways—most often, as recurrent urinary tract infection, overactive bladder, stress urinary incontinence, and pelvic pain. Other common presenting symptoms include voiding dysfunction, a painful or palpable mass, and postvoid dribbling.

What can be done routinely during a pelvic exam to make the Dx?

Become accustomed to massaging the anterior vaginal wall underneath the urethra. Any discharge or excretion of fluid that you observe from the external urethral meatus as you massage is pathognomonic for urethral diverticulum. In addition, palpate the anterior vaginal wall for paraurethral masses. Sometimes, a diverticulum is ballotable but not palpable.

Which test is best?

Imaging has been used in different ways, with variable success.

• Most diverticula are well visualized by voiding cystourethrography or magnetic resonance imaging (MRI); we view these as complementary techniques, in fact, because some diverticula are visualized only by one modality or the other. MRI provides a superior examination for surgical planning because it defines urethral and diverticular anatomy most clearly
  
• Ultrasonography has been used with some success
  
• Positive-pressure urethrography, using a Tratner or double balloon catheter, is difficult to perform and uncomfortable for the patient.
  

What is the role of urethroscopy?

We find urethroscopy very helpful. One caveat: Inability to visualize a diverticulum or its opening does not, by any means, exclude a urethral diverticulum.

How should you manage a urethral diverticulum?

• Urinary tract infection should be treated with a culture-specific antibiotic; in some cases, the patient will become asymptomatic afterwards
  
• Overactive bladder symptoms can be treated with an anticholinergic
  
• In most cases, surgery proves necessary
  
• When you identify a urethral diverticulum during pregnancy, manage the patient conservatively during the antenatal period
  
• A patient who has an asymptomatic urethral diverticulum can be managed expectantly, but perform a pelvic exam periodically.
  

When is surgery appropriate? By what method?

Several observations are useful:

• Hardness or induration of the diverticular mass is extremely rare; such a finding should prompt surgical excision because it may signal cancer
  
• Marsupialization has been demonstrated to be successful for very distal and small urethral diverticula
  
• Most diverticula at the level of the midurethra and proximal urethra require some form of excision, broadly classified as partial ablation or complete excision
  
• Placement of a suburethral sling is controversial, but some experts believe that, to prevent stress incontinence, this intervention should be undertaken simultaneously with any other surgical treatment for diverticula of the proximal urethra
  
• Sometimes a Martius fat pad must be brought into the field to avoid devascularization and breakdown of the repair. When a suburethral sling is necessary, we routinely place a Martius flap between the urethra and the sling.
  

Urethral diverticula are often overlooked as a source of recurrent urinary tract infection, voiding dysfunction, dyspareunia, and chronic pelvic pain. Here, in brief, is how to diagnose and manage this condition, including a look at surgical options.

What are the common complaints?

Urethral diverticula present in myriad ways—most often, as recurrent urinary tract infection, overactive bladder, stress urinary incontinence, and pelvic pain. Other common presenting symptoms include voiding dysfunction, a painful or palpable mass, and postvoid dribbling.

What can be done routinely during a pelvic exam to make the Dx?

Become accustomed to massaging the anterior vaginal wall underneath the urethra. Any discharge or excretion of fluid that you observe from the external urethral meatus as you massage is pathognomonic for urethral diverticulum. In addition, palpate the anterior vaginal wall for paraurethral masses. Sometimes, a diverticulum is ballotable but not palpable.

Which test is best?

Imaging has been used in different ways, with variable success.

• Most diverticula are well visualized by voiding cystourethrography or magnetic resonance imaging (MRI); we view these as complementary techniques, in fact, because some diverticula are visualized only by one modality or the other. MRI provides a superior examination for surgical planning because it defines urethral and diverticular anatomy most clearly
  
• Ultrasonography has been used with some success
  
• Positive-pressure urethrography, using a Tratner or double balloon catheter, is difficult to perform and uncomfortable for the patient.
  

What is the role of urethroscopy?

We find urethroscopy very helpful. One caveat: Inability to visualize a diverticulum or its opening does not, by any means, exclude a urethral diverticulum.

How should you manage a urethral diverticulum?

• Urinary tract infection should be treated with a culture-specific antibiotic; in some cases, the patient will become asymptomatic afterwards
  
• Overactive bladder symptoms can be treated with an anticholinergic
  
• In most cases, surgery proves necessary
  
• When you identify a urethral diverticulum during pregnancy, manage the patient conservatively during the antenatal period
  
• A patient who has an asymptomatic urethral diverticulum can be managed expectantly, but perform a pelvic exam periodically.
  

When is surgery appropriate? By what method?

Several observations are useful:

• Hardness or induration of the diverticular mass is extremely rare; such a finding should prompt surgical excision because it may signal cancer
  
• Marsupialization has been demonstrated to be successful for very distal and small urethral diverticula
  
• Most diverticula at the level of the midurethra and proximal urethra require some form of excision, broadly classified as partial ablation or complete excision
  
• Placement of a suburethral sling is controversial, but some experts believe that, to prevent stress incontinence, this intervention should be undertaken simultaneously with any other surgical treatment for diverticula of the proximal urethra
  
• Sometimes a Martius fat pad must be brought into the field to avoid devascularization and breakdown of the repair. When a suburethral sling is necessary, we routinely place a Martius flap between the urethra and the sling.
  

Voiding dysfunction—either difficulty voiding or urinary retention—after surgery for stress incontinence distresses the patient and challenges the surgeon. Here is our systematic approach to evaluating and managing such cases.

What does the operative note say?

Determine exactly what operation the patient underwent and whether appropriate steps were taken during surgery to evaluate the lower urinary tract. Remember: There are well over 30 different synthetic midurethral slings on the market; a variety of biologic materials are used for slings; and conventional suspension procedures are still being performed. Sling composition and surgical technique are the major determinants of subsequent treatment, so it is imperative to obtain the operative note.

Is intermittent self-catheterization an option?

If the patient has an indwelling catheter—of any type—remove it whenever possible and teach her intermittent self-catheterization.

Are symptoms consistent with expected outcome?

In the case of a patient who had a large cystocele repair in conjunction with an anti-incontinence procedure, for example, it is common for some form of retention or voiding dysfunction to be present for 2 weeks or longer. On the other hand, if a patient had a synthetic midurethral sling but no other procedure, it is highly unlikely, during a normal postoperative course, that she would be in retention 2 weeks after the procedure—unless the sling was placed too tightly.

Is there actual (or impending) lower-tract injury? Foreign body penetration?

Good endoscopic evaluation, with visualization of the urethra, of the vesical neck and anterolateral walls of the bladder, will answer these questions.

What is the condition of the pelvic floor?

Make certain that the patient has the ability to appropriately relax the pelvic floor when she attempts to void.

Is urethral dilatation or medication an option?

We believe that urethral dilatation is contraindicated because it might cause urethral erosion of the sling. It is also generally ineffective.

No pharmaceutical agent hastens the return of voiding. Cholinergic agents such as bethanechol are ineffective and cause considerable discomfort. Some experts recommend empiric diazepam (Valium) for patients who are unable to relax sufficiently.

Will intervention succeed?

Ultimately, you and the patient must agree on whether urethrolysis is to be performed or whether the suburethral sling or tape should be cut. Undertake a detailed discussion with her about the potential for, first, persistent voiding dysfunction and, second, recurrent stress incontinence. Cutting a synthetic, allograft, xenograft, or autologous sling will almost always result in resumption of normal voiding, provided the sling is appropriately detached from the urethra and there were no preoperative voiding symptoms. With synthetic, allograft, and xenograft slings, stress incontinence recurs in at least 50% of patients over time. With an autologous sling, the recurrence rate of stress incontinence is less than 10%.

Is it time to operate?

When urinary retention after a synthetic sling procedure is believed to be caused by obstruction, consider surgery within a few weeks. For a patient in retention who has an autologous, allograft, or xenograft sling, it is best to wait approximately 3 months before operating.

Be aware of the risk of failure!

Takedowns of Burch and Marshall-Marchetti operations are much more technically challenging, and yield a much lower success rate, than takedowns of sling procedures. No matter what the prior operation, there is a risk of recurrent sphincteric incontinence.

Voiding dysfunction—either difficulty voiding or urinary retention—after surgery for stress incontinence distresses the patient and challenges the surgeon. Here is our systematic approach to evaluating and managing such cases.

What does the operative note say?

Determine exactly what operation the patient underwent and whether appropriate steps were taken during surgery to evaluate the lower urinary tract. Remember: There are well over 30 different synthetic midurethral slings on the market; a variety of biologic materials are used for slings; and conventional suspension procedures are still being performed. Sling composition and surgical technique are the major determinants of subsequent treatment, so it is imperative to obtain the operative note.

Is intermittent self-catheterization an option?

If the patient has an indwelling catheter—of any type—remove it whenever possible and teach her intermittent self-catheterization.

Are symptoms consistent with expected outcome?

In the case of a patient who had a large cystocele repair in conjunction with an anti-incontinence procedure, for example, it is common for some form of retention or voiding dysfunction to be present for 2 weeks or longer. On the other hand, if a patient had a synthetic midurethral sling but no other procedure, it is highly unlikely, during a normal postoperative course, that she would be in retention 2 weeks after the procedure—unless the sling was placed too tightly.

Is there actual (or impending) lower-tract injury? Foreign body penetration?

Good endoscopic evaluation, with visualization of the urethra, of the vesical neck and anterolateral walls of the bladder, will answer these questions.

What is the condition of the pelvic floor?

Make certain that the patient has the ability to appropriately relax the pelvic floor when she attempts to void.

Is urethral dilatation or medication an option?

We believe that urethral dilatation is contraindicated because it might cause urethral erosion of the sling. It is also generally ineffective.

No pharmaceutical agent hastens the return of voiding. Cholinergic agents such as bethanechol are ineffective and cause considerable discomfort. Some experts recommend empiric diazepam (Valium) for patients who are unable to relax sufficiently.

Will intervention succeed?

Ultimately, you and the patient must agree on whether urethrolysis is to be performed or whether the suburethral sling or tape should be cut. Undertake a detailed discussion with her about the potential for, first, persistent voiding dysfunction and, second, recurrent stress incontinence. Cutting a synthetic, allograft, xenograft, or autologous sling will almost always result in resumption of normal voiding, provided the sling is appropriately detached from the urethra and there were no preoperative voiding symptoms. With synthetic, allograft, and xenograft slings, stress incontinence recurs in at least 50% of patients over time. With an autologous sling, the recurrence rate of stress incontinence is less than 10%.

Is it time to operate?

When urinary retention after a synthetic sling procedure is believed to be caused by obstruction, consider surgery within a few weeks. For a patient in retention who has an autologous, allograft, or xenograft sling, it is best to wait approximately 3 months before operating.

Be aware of the risk of failure!

Takedowns of Burch and Marshall-Marchetti operations are much more technically challenging, and yield a much lower success rate, than takedowns of sling procedures. No matter what the prior operation, there is a risk of recurrent sphincteric incontinence.

Voiding dysfunction—either difficulty voiding or urinary retention—after surgery for stress incontinence distresses the patient and challenges the surgeon. Here is our systematic approach to evaluating and managing such cases.

What does the operative note say?

Determine exactly what operation the patient underwent and whether appropriate steps were taken during surgery to evaluate the lower urinary tract. Remember: There are well over 30 different synthetic midurethral slings on the market; a variety of biologic materials are used for slings; and conventional suspension procedures are still being performed. Sling composition and surgical technique are the major determinants of subsequent treatment, so it is imperative to obtain the operative note.

Is intermittent self-catheterization an option?

If the patient has an indwelling catheter—of any type—remove it whenever possible and teach her intermittent self-catheterization.

Are symptoms consistent with expected outcome?

In the case of a patient who had a large cystocele repair in conjunction with an anti-incontinence procedure, for example, it is common for some form of retention or voiding dysfunction to be present for 2 weeks or longer. On the other hand, if a patient had a synthetic midurethral sling but no other procedure, it is highly unlikely, during a normal postoperative course, that she would be in retention 2 weeks after the procedure—unless the sling was placed too tightly.

Is there actual (or impending) lower-tract injury? Foreign body penetration?

Good endoscopic evaluation, with visualization of the urethra, of the vesical neck and anterolateral walls of the bladder, will answer these questions.

What is the condition of the pelvic floor?

Make certain that the patient has the ability to appropriately relax the pelvic floor when she attempts to void.

Is urethral dilatation or medication an option?

We believe that urethral dilatation is contraindicated because it might cause urethral erosion of the sling. It is also generally ineffective.

No pharmaceutical agent hastens the return of voiding. Cholinergic agents such as bethanechol are ineffective and cause considerable discomfort. Some experts recommend empiric diazepam (Valium) for patients who are unable to relax sufficiently.

Will intervention succeed?

Ultimately, you and the patient must agree on whether urethrolysis is to be performed or whether the suburethral sling or tape should be cut. Undertake a detailed discussion with her about the potential for, first, persistent voiding dysfunction and, second, recurrent stress incontinence. Cutting a synthetic, allograft, xenograft, or autologous sling will almost always result in resumption of normal voiding, provided the sling is appropriately detached from the urethra and there were no preoperative voiding symptoms. With synthetic, allograft, and xenograft slings, stress incontinence recurs in at least 50% of patients over time. With an autologous sling, the recurrence rate of stress incontinence is less than 10%.

Is it time to operate?

When urinary retention after a synthetic sling procedure is believed to be caused by obstruction, consider surgery within a few weeks. For a patient in retention who has an autologous, allograft, or xenograft sling, it is best to wait approximately 3 months before operating.

Be aware of the risk of failure!

Takedowns of Burch and Marshall-Marchetti operations are much more technically challenging, and yield a much lower success rate, than takedowns of sling procedures. No matter what the prior operation, there is a risk of recurrent sphincteric incontinence.