DOI:10.2214/AJR.07.2094
AJR 2008; 190:165-172
© American Roentgen Ray Society
Pre- and Postoperative Evaluation of Urethral Diverticulum
Keyanoosh Hosseinzadeh1,
Alessandro Furlan1,2 and
Maha Torabi1
1 Department of Radiology, University of Pittsburgh Medical Center, Presbyterian
Campus, 200 Lothrop St., Rm. 3950, CHP MT, UPMC, Pittsburgh, PA 15213.
2 Institute of Radiology, University of Udine, Udine, Italy.
Received February 20, 2007;
accepted after revision August 3, 2007.
Address correspondence to K. Hosseinzadeh
(hosseinzadehk{at}upmc.edu).
Abstract
OBJECTIVE. The purpose of this article is to review the diagnostic
imaging findings, differential diagnosis, complications, and postoperative
imaging appearance of urethral diverticulum.
CONCLUSION. With increased clinical awareness and advanced imaging
techniques, diagnoses of urethral diverticula are more frequent, and
radiologists need to be aware of the pre- and postoperative imaging
appearances of this disorder.
Keywords: conventional radiography • CT • diagnostic imaging • diverticulum • MRI • pelvis • sonography • urethra • urethral diverticulum
Introduction
Urethral diverticulum may be defined as a localized outpouching of
tissue from the urethra into the urethrovaginal potential space. It is a
relatively common finding among women with chronic genitourinary conditions,
but the diagnosis and management remain problematic
[1,
2]. Widespread clinical
awareness and recent developments in imaging, including sonography and MRI,
have greatly improved the diagnosis and management of this condition,
providing information for surgical planning, such as location, number, size,
configuration, and communication with the urethra, and the presence of stones
or neoplasms [1]. This article
reviews the diagnostic imaging findings, differential diagnosis,
complications, and postoperative imaging appearance of urethral
diverticula.
Epidemiology
Urethral diverticula occur more frequently in middle-aged women, with an
estimated prevalence of 0.6-6.0%
[1], which increases to 40%
among patients with chronic genitourinary conditions such as recurrent
infections, postvoid dribbling, and dyspareunia
[2]. However, the true
prevalence of the disorder is probably much higher because of the large number
of asymptomatic or misdiagnosed cases.
Pathophysiology
Urethral diverticula may be congenital or acquired. Congenital diverticula
are rare, likely arising from persistent embryologic remnants
[3]. Theories for acquired
diverticula postulate infectious, inflammatory, or traumatic causes.
Periurethral glands (Skene's glands) are tubuloalveolar structures along the
dorsolateral aspect that drain into the distal two thirds of the urethra.
Repeated infection and obstruction of these glands lead to formation of
suburethral cysts or abscesses that can rupture into the urethral lumen
[4]
(Fig. 1). The anatomic location
of most urethral diverticula corresponds to the location of the Skene's
glands.
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Fig. 1 —Pathogenesis of urethral diverticulum. A, Infection of distal
Skene's gland drains into urethra. B and C, Ductal obstruction
leads to formation of suburethral cyst or abscess (B) that eventually
ruptures into urethral lumen (C).
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Clinical Presentation
The classic clinical triad of dysuria, postvoid dribbling, and dyspareunia
is infrequently observed [1].
The most common finding is a painful mass in the anterior wall of the vagina
that may discharge urine or purulent material after palpation
[1]. Some patients are
asymptomatic; many of these diverticula are small (2-16 mm) and are discovered
incidentally. The nonspecificity of the clinical presentation is responsible
for extensive workup and delayed diagnosis
[5].
Treatment
Surgery is the treatment of choice for symptomatic urethral diverticula and
includes complete or partial excision or marsupialization, depending mainly on
the location of the diverticulum along the urethra
[1,
6]. If the diverticulum opens
into the middle or proximal third of the urethra, the treatment of choice is
urethral diverticulectomy, which is usually performed transvaginally. For
diverticula emptying into the distal third of the urethra, marsupialization
into the vagina is an option. Although transurethral procedures have been
proposed, they may be less effective in preventing recurrence of the
diverticulum [1].
Imaging Evaluation
Various imaging techniques are available, including voiding
cystourethrography (VCUG), sonography, CT, and MRI. However, the accuracy of
some of these studies is operator-dependent and is affected by the size of the
diverticulum and the size and patency of the opening into the urethra. When
possible, imaging should provide the surgeon with information regarding
location, number, size, configuration, and communication of the diverticulum.
Associated intradiverticular lesions such as malignancy and calculi should be
recognized [1].
Voiding Cystourethrography
VCUG is a commonly used imaging study in the workup of suspected urethral
diverticula; it has an overall accuracy of approximately 65%
[1]. A patent neck is necessary
for diagnosis in order for contrast material to enter the diverticulum
[7]. This technique is also
used for the postoperative evaluation of diverticula (Fig.
2A,
2B). The technique requires
catheterization, which has the associated risk of infection. In addition, the
patient may be inhibited from voiding in an unfamiliar environment
[1]. Double-balloon
urethrography is reported to offer better diagnostic accuracy than VCUG
[7]. However, the procedure is
technically demanding, requires specialized equipment, and is not routinely
performed [1]. Increasingly,
MRI and sonography have been shown to provide better anatomic detail than VCUG
and double-balloon urethrography
[6].
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Fig. 2A —55-year-old woman with urethral diverticulum who underwent
diverticulectomy. Voiding phase of voiding cystourethrography (VCUG) shows
contrast material filling urinary diverticulum (arrowheads) that
encircles urethral lumen (arrow). Filling started on right lateral
aspect of urethra and extended to fill remaining diverticulum.
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Sonography
Sonography of urethral diverticula can be performed using transvaginal,
transperineal, endorectal and, less commonly, endourethral techniques; it
compares favorably with VCUG
[8,
9]. The best route for
examining potential diverticula by sonography has not been established. In our
institution, sonography is performed using a high-frequency endovaginal probe
that is commonly placed on the external urethra meatus between the labia
minora (Fig. 3A,
3B,
3C,
3D,
3E). Sonography is noninvasive,
obviating catheterization, and can provide measurements of the size, number of
loculations, and location with respect to the urethra. However, sonography is
operator-dependent, and distinguishing the diverticulum from other cystic
lesions and visualizing the neck can be challenging.
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Fig. 3A —46-year-old woman with urethral diverticulum who presented with
dysuria and palpable mass on anterior wall of vagina. Transverse translabial
color-flow sonogram shows complex cystic lesion anterior to vagina,
representing palpable mass (outlined by calipers).
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Fig. 3B —46-year-old woman with urethral diverticulum who presented with
dysuria and palpable mass on anterior wall of vagina. Sagittal translabial
sonogram after insertion of Foley catheter (arrow) shows anechoic
lesions (arrowheads) encircling urethral lumen. B = Foley balloon in
urinary bladder.
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Fig. 3C —46-year-old woman with urethral diverticulum who presented with
dysuria and palpable mass on anterior wall of vagina. Transverse
contrast-enhanced CT scan shows fluid-filled diverticular sac
(asterisk) in enlarged urethra. Mucosal and submucosal component of
urethra is displaced to left (arrow).
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Fig. 3D —46-year-old woman with urethral diverticulum who presented with
dysuria and palpable mass on anterior wall of vagina. Coronal (D) and
transverse (E) fast spin-echo T2-weighted MR images confirm diagnosis
of high-signal-intensity, fluid-filled diverticulum (asterisk) with
fluid-debris level (white arrow, E). Note displaced urethra
(black arrow) and anterior septation (arrowhead,
E).
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Fig. 3E —46-year-old woman with urethral diverticulum who presented with
dysuria and palpable mass on anterior wall of vagina. Coronal (D) and
transverse (E) fast spin-echo T2-weighted MR images confirm diagnosis
of high-signal-intensity, fluid-filled diverticulum (asterisk) with
fluid-debris level (white arrow, E). Note displaced urethra
(black arrow) and anterior septation (arrowhead,
E).
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MRI
Studies are increasingly reporting improved detection and characterization
of urethral diverticula for surgical planning with high-spatial-resolution
multiplanar MRI when compared with VCUG, double-balloon urethrography
[6,
10,
11], and sonography
[10]. VCUG and double-balloon
urethrography require a patent diverticulum orifice to make a diagnosis, and
sonography is operator-dependent; distinguishing a diverticulum from a vaginal
wall cyst can be difficult. MRI best assesses the extent, structure, and
complexity of diverticula and enables visualization of the neck. Because of
the characteristic relationship of the diverticulum to the urethra,
visualization of the neck is not necessary to make a confident diagnosis. MRI
serves as the primary technique at our institution and may be performed using
a conventional surface (Fig.
3A,
3B,
3C,
3D,
3E) or the latest but invasive
endoluminal (endorectal or endovaginal) coils for improved signal-to-noise
ratio and spatial resolution
[6,
10,
12] (Fig.
4A,
4B,
4C). Ultimately, the choice of
coil configuration may not alter surgical planning because of the excellent
anatomic detail attained with both configurations
[6].
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Fig. 4A —38-year-old woman with urethral diverticulum who presented with
recurrent urinary tract infections. EV = endovaginal probe. (Courtesy of Bae
KT, Pittsburgh, PA) Sagittal fast spin-echo T2-weighted endovaginal MR image
shows high-signal-intensity, fluid-filled diverticulum (asterisk) in
posterior aspect of urethra (arrow) that contains multiple thin
septations (arrowheads). Note elevation of bladder dome by
diverticulum. B = urinary bladder.
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Fig. 4B —38-year-old woman with urethral diverticulum who presented with
recurrent urinary tract infections. EV = endovaginal probe. (Courtesy of Bae
KT, Pittsburgh, PA) Transverse unenhanced (B) and gadolinium-enhanced
(C) gradient-echo T1-weighted endovaginal MR images show enhancement of
urethral tissues (arrow) and posterior septation (arrowhead)
of diverticulum (asterisk).
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Fig. 4C —38-year-old woman with urethral diverticulum who presented with
recurrent urinary tract infections. EV = endovaginal probe. (Courtesy of Bae
KT, Pittsburgh, PA) Transverse unenhanced (B) and gadolinium-enhanced
(C) gradient-echo T1-weighted endovaginal MR images show enhancement of
urethral tissues (arrow) and posterior septation (arrowhead)
of diverticulum (asterisk).
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CT
CT has a limited role in the characterization of urethral abnormalities
[12] (Fig.
3A,
3B,
3C,
3D,
3E), with most diverticula
discovered incidentally in relation to the large number of pelvic CT studies
performed. However, CT can reliably show calculi in diverticula
(Fig. 5).
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Fig. 5 —46-year-old woman with urethral diverticulum who presented with
urinary frequency and painful mass in anterior wall of vagina. Transverse
contrast-enhanced CT scan of pelvis shows multiple dependent calculi
(arrowheads) within fluid-filled urethral diverticulum
(asterisk) that displaces urethra (arrow) to the right.
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Differential Diagnosis
The differential diagnosis of a urethral diverticulum includes vaginal wall
cysts such as müllerian cysts, Gartner's cysts, Bartholin's gland cysts,
and vaginal inclusion cysts; ectopic ureterocele; and endometriomas of the
urethra. The diagnosis is made by the location and lack of communication of
the cysts with the urethra (Fig.
6A,
6B). Gartner's cysts (Fig.
7A,
7B) typically occur in the
anterolateral aspect of the proximal third of the vagina, whereas vaginal
inclusion cysts are commonly located in the lower posterior or lateral vaginal
wall at the sites of previous trauma or surgery. Bartholin's gland cysts (Fig.
8A,
8B,
8C) are typically located in
the posterolateral introitus medial to the labia minora
[12,
13].
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Fig. 6A —Typical anatomic locations of urethral diverticulum, Gartner's cyst,
and Bartholin's gland cyst. Axial illustration through bladder neck, upper
vagina, and rectum depicts Gartner's cyst in anterolateral or anterior wall of
proximal third of vagina.
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Fig. 6B —Typical anatomic locations of urethral diverticulum, Gartner's cyst,
and Bartholin's gland cyst. Axial illustration at or below inferior ramus,
distal urethra, lower vagina, and anus depicts Bartholin's gland cyst in
posterolateral wall of lower vagina at level of introitus. Anteriorly,
crescent-shaped cystic structure containing fluid-fluid level encircles and
connects to distal urethra via narrow orifice, which is consistent with
urethral diverticulum.
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Fig. 7A —32-year-old woman with Gartner's cyst who presented with dysuria and
dyspareunia. Transverse fast spin-echo T2-weighted MR image with fat
suppression shows well-defined high-signal-intensity fluid-filled rounded mass
(asterisk) arising from right anterolateral wall of upper vagina and
displacing high-signal-intensity vaginal mucosa (arrow) to the left.
Mass was clearly separate from urethra.
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Fig. 7B —32-year-old woman with Gartner's cyst who presented with dysuria and
dyspareunia. Sagittal fast spin-echo T2-weighted MR image shows fluid-filled
mass (asterisk) displacing vaginal mucosa posteriorly (white
arrow). Urethra (black arrow) is displaced anteriorly.
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Fig. 8A —31-year-old woman with Bartholin's gland cyst that presented as mass
in posterolateral introitus. Urethral diverticulum was incidentally
discovered. V = vagina. Transverse fast spin-echo T2-weighted MR image shows
high-signal-intensity fluid-filled urethral diverticulum (arrow) with
neck (arrowhead) connecting to urethra.
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Fig. 8B —31-year-old woman with Bartholin's gland cyst that presented as mass
in posterolateral introitus. Urethral diverticulum was incidentally
discovered. V = vagina. Transverse (B) and coronal (C) fast
spin-echo T2-weighted MR images show lobulated septate cystic mass
(arrow) representing Bartholin's gland cyst and located
posterolaterally in left lower third of vagina below symphysis pubis and
immediately inferior to urethral diverticulum. Arrowheads in C indicate
lateral fornices of vagina.
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Fig. 8C —31-year-old woman with Bartholin's gland cyst that presented as mass
in posterolateral introitus. Urethral diverticulum was incidentally
discovered. V = vagina. Transverse (B) and coronal (C) fast
spin-echo T2-weighted MR images show lobulated septate cystic mass
(arrow) representing Bartholin's gland cyst and located
posterolaterally in left lower third of vagina below symphysis pubis and
immediately inferior to urethral diverticulum. Arrowheads in C indicate
lateral fornices of vagina.
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In addition, solid urethral masses (Fig.
9A,
9B,
9C) such as carcinoma,
nephrogenic adenoma, mesonephric adenocarcinoma, and embryonal cell
rhabdomyoma may be mistaken for urethral diverticula.
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Fig. 9A —50-year-old woman with high-grade squamous cell carcinoma (SCC) of
urethra causing dysuria. EV = endovaginal probe. (Courtesy of Bae KT,
Pittsburgh, PA) Transverse unenhanced (A) and gadolinium-enhanced
(B) gradient-echo T1-weighted endovaginal MR images show
intermediate-signal-intensity urethral mass (asterisk, A) that
enhances heterogeneously (asterisk, B). Urethroscopy and
biopsy confirmed SCC. Arrow indicates Foley catheter in urethra.
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Fig. 9B —50-year-old woman with high-grade squamous cell carcinoma (SCC) of
urethra causing dysuria. EV = endovaginal probe. (Courtesy of Bae KT,
Pittsburgh, PA) Transverse unenhanced (A) and gadolinium-enhanced
(B) gradient-echo T1-weighted endovaginal MR images show
intermediate-signal-intensity urethral mass (asterisk, A) that
enhances heterogeneously (asterisk, B). Urethroscopy and
biopsy confirmed SCC. Arrow indicates Foley catheter in urethra.
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Fig. 9C —50-year-old woman with high-grade squamous cell carcinoma (SCC) of
urethra causing dysuria. EV = endovaginal probe. (Courtesy of Bae KT,
Pittsburgh, PA) Transverse gadolinium-enhanced gradient-echo T1-weighted
endovaginal MR image shows anterior vaginal wall invasion (white
arrow). Black arrow indicates Foley catheter in urethra.
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Pre- and Postoperative Complications
Complications associated with urethral diverticula include urinary
incontinence (60%), recurrent urinary tract infections (UTIs) (30%)
[3], and formation of calculi
(10%) [14]
(Fig. 5). Malignancy arising
in a urethral diverticulum is rare, but the most common cell type is
adenocarcinoma (61%) [15]
(Fig. 10A,
10B).
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Fig. 10A —52-year-old woman with development of adenocarcinoma in remnant
urethral diverticulum 4 years after resection. V = vagina. Transverse
unenhanced T1-weighted MR image shows intermediate-signal-intensity urethral
mass (asterisk) in known remnant diverticulum. Note fatty tissue
(arrow) in urethrovaginal space resulting from Martius flap (labial
fat interposed between urethra and vagina), a normal postprocedural
finding.
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Fig. 10B —52-year-old woman with development of adenocarcinoma in remnant
urethral diverticulum 4 years after resection. V = vagina. Transverse
gadolinium-enhanced T1-weighted MR image confirms lesion appearing as
circumferential enhancing mass (asterisk). Surgery confirmed
diagnosis of adenocarcinoma. Note susceptibility artifact from remote
diverticular resection (arrowhead). Again noted is surgically
interposed fat (arrow) between urethra and enhancing vagina.
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Postoperative complication rates have been reported to range between 5% and
46% [1]. Complications include
urinary incontinence, urethrovaginal fistula, urethral stricture, recurrent
UTIs, and recurrent urethral diverticula
[1]. Recurrence of diverticula
occurs in 1-29% of cases, most commonly after resection of a proximal
diverticulum as a result of a difficult excision
[1] (Figs.
11A,
11B,
11C,
11D and
12A,
12B,
12C,
12D,
12E). Many patients with
recurrence of diverticula undergo reoperation, which is the most likely cause
of residual symptoms. A technically successful first operation in experienced
centers may limit these complications
[16].
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Fig. 11A —49-year-old woman with recurrence of urethral diverticulum and
interval increase in size that is causing recurrent urinary tract infections.
Coronal fast spin-echo T2-weighted MR image obtained before diverticulectomy
shows high-signal-intensity fluid-filled urethral diverticulum
(asterisk) and urethra (arrow).
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Fig. 11B —49-year-old woman with recurrence of urethral diverticulum and
interval increase in size that is causing recurrent urinary tract infections.
Voiding cystourethrography performed in immediate postoperative period shows
linear contrast collection (arrowhead) to right of urethral lumen
(arrow), representing residual diverticular neck.
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Fig. 11C —49-year-old woman with recurrence of urethral diverticulum and
interval increase in size that is causing recurrent urinary tract infections.
Transverse (C) and sagittal (D) fast spin-echo T2-weighted MR
images obtained 16 (C) and 24 (D) months after diverticulectomy
show recurrent fluid-filled right posterolateral diverticulum with progressive
increase in size of diverticular sac (asterisks) and displacement of
urethra to left (arrow, C) and anteriorly (arrow,
D). Note septation in diverticular sac (arrowhead,
D).
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Fig. 11D —49-year-old woman with recurrence of urethral diverticulum and
interval increase in size that is causing recurrent urinary tract infections.
Transverse (C) and sagittal (D) fast spin-echo T2-weighted MR
images obtained 16 (C) and 24 (D) months after diverticulectomy
show recurrent fluid-filled right posterolateral diverticulum with progressive
increase in size of diverticular sac (asterisks) and displacement of
urethra to left (arrow, C) and anteriorly (arrow,
D). Note septation in diverticular sac (arrowhead,
D).
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Fig. 12B —39-year-old woman with asymptomatic urethral diverticular
recurrence. Pelvic sonograms obtained 4 months after diverticulectomy for
evaluation of ovaries show incidental cystic lesion (outlined by
calipers) anterior to vagina. V = vagina, SAG = sagittal, TRV =
transverse.
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Fig. 12C —39-year-old woman with asymptomatic urethral diverticular
recurrence. Pelvic sonograms obtained 4 months after diverticulectomy for
evaluation of ovaries show incidental cystic lesion (outlined by
calipers) anterior to vagina. V = vagina, SAG = sagittal, TRV =
transverse.
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Fig. 12D —39-year-old woman with asymptomatic urethral diverticular
recurrence. Coronal (D) and transverse (E) fast spin-echo
T2-weighted MR images confirm recurrence of small high-signal-intensity
diverticulum (open arrow) with fluid-filled neck (arrowhead,
D) connecting to urethra (solid arrow). V = vagina.
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Fig. 12E —39-year-old woman with asymptomatic urethral diverticular
recurrence. Coronal (D) and transverse (E) fast spin-echo
T2-weighted MR images confirm recurrence of small high-signal-intensity
diverticulum (open arrow) with fluid-filled neck (arrowhead,
D) connecting to urethra (solid arrow). V = vagina.
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Summary
With increased clinical awareness and advanced imaging techniques, the
diagnosis of urethral diverticula is more frequent. MRI provides the most
comprehensive evaluation before and after surgery. Although there remains a
lack of standardized practice, MRI is the preferred technique or can be
pursued as a secondary investigation if other techniques fail to detect a
diverticulum and clinical suspicion remains high.
Acknowledgments
We thank Kyongtae Ty Bae for Figures
4A,
4B,
4C and
9A,
9B,
9C and Eric Jablonowski for
the illustrations in this article.
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Abstract
Introduction
