Urethral diverticulum

Urethral diverticulum - epidemiology, presentation, evaluation, management

1. Seminar FEMALE Urethral diverticula - Dr. Abhishek Pandey

2. Introduction Female Urethral Diverticulum (UD) – Urine-filled periurethral cystic structure Within the confines of pelvic fascia Connected to urethra via an ostium 1-6% prevalence in adult females Diagnostic & reconstructive challenge Modern era of female UD began in 1950’s – Positive pressure urethrography (PPU) by Davis & Cian

3. Anatomy Female Urethra – 4cm musculofascial tube Urethropelvic ligament – supports urethra & bladder neck to lateral pelvic wall (ATFP) Two layers of fused pelvic fascia extending bilaterally Endopelvic fascia – abdominal side Periurethral fascia – vaginal side (extension of pubocervical fascia) Within these two leaves lie the urethra & UD

4. Periurethral Glands Periurethral glands – Tubuloalveolar glands Within the vascular lamina- propria / submucosa exist over entire urethra posterolaterally most prominent over distal two thirds majority glands draining into distal third urethra Skene glands – largest & most distal glands draining outside lumen, lateral to urethral meatus

5. Pathogenesis Infectious etiology – involving periurethral glands Young (1996) – Modern hypothesis of UD pathogenesis Repeated infection-obstruction of periurethral glands Cavity expansion → disrupt urethral muscles Herniation into urethropelvic ligament Expansion m/c ventrally → classic anterior vaginal wall mass Cavity ruptures into urethral lumen → Ostia formed

6. Associated Pathology 10% case – premalignant & malignant changes m/c malignancy – Adenocarcinoma Calculi within UD – 4-10% cases Multiple UD – 6% cases Varying degrees of sphincteric compromise

7. Variable Morphology Simple Diverticulum Saddlebag Diverticulum Circumferential Diverticulum Diverticular Ostium

8. Presentation b/w 3 rd & 7 th decades of life Classic presentation – “three Ds” — dysuria , dyspareunia & dribbling ( postvoid ) – 20-25% Highly variable presentation – Diagnostic challenge 1/3 rd cases – Incontinence (UD-1.4% UI cases) Upto 20% may be completely Asymptomatic Size of UD does not correlate with symptoms Waxing & wanimg of symptoms over long durations

9. Cystourethroscopy Bladder neck compression during urethroscopy facilitates urethral distension & direct observation Urethroscope – 15° Lens with inflow at the same level as lens – facilitates direct urethral observation and distension

10. UD ostium – m/c posterolaterally at 4 & 8 o’clock positions at level of mid-urethra Variable success in identifying ostium – 15-90% Evaluate other causes of LUTS Compression of UD sac – discharge in urethra O – UD ostium of a UD L – Lumen of urethra

11. UDS 1/3 rd patients present with urinary incontinence 50% of women with UD will have SUI on UDS Urethral pressure profilometry (UPP) – continuous measurement of fluid pressure needed to just open a closed urethra Biphasic pattern – pressure drop at the level of lesion

12. Positive Pressure Urethrography (PPU) Double balloon PPU Trattner catheter Historical importance

13. MCU Sensitivity – 44-95% Voiding required to visualize (patient may not) MCU with no post-void image – non-diagnostic Inability to generate adequate flow rate during MCU Results in suboptimal filling of UD Underestimation of size & complexity

14. MRI Surface coil MRI

15. Endoluminal (vaginal coil) MRI

16. Direct contrast injection in anterior vaginal wall mass – Imaging UD

17. Differential diagnoses

18. Management

19. Surgical Procedures Hey (1805) first described Transvaginal incision with packing of UD cavity with lint Transurethral Procedures – Marsupialisation Endoscopic unroofing Fulguration Incision & obliteration with oxidised cellulose / PTFE

20. Transvaginal Procedures – Spence– Duckett procedure – UD marsupialized into vagina (very distal UD) Excision and Reconstruction Current - Excision and Reconstruction Principles of Transvaginal Urethral Diverticulectomy Well- vascularized anterior vaginal wall flaps Preservation of periurethral fascia

21. Identification & excision of neck / ostium Removal of entire UD wall or sac (mucosa) Watertight urethral closure Multilayer, nonoverlapping closure – absorbable suture Closure of dead space Preservation or creation of continence

22. Importance of preserving & reconstructing the periurethral fascia

23. Complications

24. Thank You

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