Posts Tagged ‘female urology’

Female Urethral Diverticula: What You Need to Know

December 15, 2018

Andrew Siegel MD  12/15/2018

This is a continuation of entries that deal with female urogenital maladies.  Today’s entry is on the topic of urethral diverticula, out-pouchings of the inner lining of the urethral channel that cause a vaginal bulge and often makes for an unhappy patient.  The good news is that this situation can be readily fixed.  (For the record, diverticulum is singular, diverticula is plural.)

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I’m not much of an artist, but I tried my best.  On left is cross section of the urethra and on right side view of bladder and urethra. 

The urethra is the channel that conducts urine from the urinary bladder to its external opening on the vestibule.  A urethral diverticulum is an out-pouching or herniation of the inner lining (mucosa) of the urethra through a defect in the outer urethral supporting tissue (peri-urethral fascia) causing a mass in the top wall of the vagina.  Most urethral diverticula are located in the mid or terminal part of the urethra.

Urethral diverticula, many of which are small and not symptomatic, occur in up to 5% or so of adult females. The average age at presentation is 40 years old. They commonly cause a mass or lump in the anterior (top) vaginal wall as well as dribbling of urine after urinating, burning or pain with urination and pain with sexual intercourse.  They often cause urinary infections that are unresponsive or poorly responsive to antibiotic treatment. On occasion, a urethral diverticulum may cause obstructive lower urinary tract symptoms (a hesitant, weak, intermittent spraying quality urinary stream) and rarely, the inability to urinate.

The classic 3 Ds of urethral diverticula:

  • dysuria (painful and burning urination)
  • dribbling (urinary leakage after finishing urinating)
  • dyspareunia (painful sexual intercourse)

The underlying cause of urethral diverticula is often infection and/or obstruction in the para-urethral glands.  These glands surround the urethra and communicate with it via ducts.  When these ducts become obstructed, the glands can become infected and lead to abscess formation which subsequently ruptures into the urethra. During the healing phase, the cells that line the urethra can then grow out into the cavity formed by the ruptured abscess, forming a urethral diverticulum.

Pelvic exam typically reveals a tender, firm, cystic swelling of the anterior vaginal wall. When the swelling is manipulated, urine or possibly pus may be expressed through the urethra. MRI is the imaging test of choice for further evaluating the anatomical details, location and complexity of urethral diverticula. The MRI will show whether the diverticulum is simple or complex, as occasionally they may be multiple, may encircle the urethra (“saddlebag” diverticulum) or may involve the bladder neck or sphincter. Another important test is urethroscopy, a visual inspection of the urethra using a small, lighted instrument to establish the location of the connection site between the diverticulum and the urethra.

Not all urethral diverticula require treatment, particularly if they are small and not symptomatic. Conservative measures that may relieve symptoms include compressing the diverticulum after urinating to preclude the post-void dribbling, antibiotics and using a needle and syringe to aspirate the contents.

Surgical management of symptomatic urethral diverticula involves excision of the diverticulum (urethral diverticulectomy) with repair of the urethra (urethroplasty). The surgery is performed via a vaginal incision and requires complete removal of the diverticular sac(s) down to the connection with the urethra with a multi-layered, tension-free closure. In the event of an infected diverticulum, it is important to treat with antibiotics prior to the surgery to eradicate the infection as best as possible. The procedure is generally done on an outpatient basis and requires a urinary catheter (typically for 7–14 days) antibiotics, pain medication, and a bladder relaxant.

Urethral diverticulectomy has a high success rate with respect to alleviation of the presenting symptoms and resumption of normal urinary function. As in any surgical procedure, there is always a small risk of complications. In general, the closer a urethral diverticulum is located to the bladder neck (where the urethra and bladder meet), the greater the risk for complications. Risks include bladder or ureteral injury, urinary incontinence, urethral stricture (scarring resulting in narrowing of the channel), urethral-vaginal or vesico-vaginal fistulas (abnormal connection between the vagina and the urethra or the vagina and bladder) and recurrence of the urethral diverticulum.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

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These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

New video on female pelvic floor exercises:  Learn about your pelvic floor

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Sage Words Of A Surgeon

December 21, 2013

Blog # 133  Andrew Siegel, MD

Dr. Ray Lee was an obstetrician-gynecologist at the Mayo Clinic who died in 2012.  At the Mayo Clinic he was awarded “Teacher of the Year” as well as “Distinguished Clinician.”  He was instrumental in developing the subspecialty of female pelvic medicine and reconstructive pelvic surgery (my sub-specialty in Urology and that which I received board certification in in 2013, the first time the board exam was offered).

He spoke using many aphorisms that will be shared here  (this information is abstracted from an article that appeared in International Journal of Uro-gynecology, written by John Gebhart: Int Urogynecol J (2013) 24:1263-1264).  He taught compassion, pride, humility, and integrity–character traits important for surgeons, but equally important in all aspects of life. His words are in boldface and my explanations are in parentheses in order to help explain some of the lines that are most relevant to the context of the operating room and may not be understood by non-surgeons.

  • Never operate on a stranger.  (Really get to know your patient before applying the knife; have enough contact and contact time so that all parties are very comfortable with each other.)
  • Communication will be critical to your practice. Be an excellent listener.
  • You have a tremendous responsibility and a privilege in the care of the sick. Kindness has not gone out of style. It is better to have your name etched in the heart of your patient than having it engraved in granite outside of the building.
  • Anyone can operate with good exposure and it’s a shame not everyone tries it. (Exposure is creating the greatest amount of visibility of the operative field through the use of retractors.)
  • Avoid following complications with complications. (If a complication does occur, fix it definitively.)
  • Your true measure as a surgeon will be determined by your performance during the most adverse circumstances. These experiences will develop your character and better prepare you for the next challenge.
  • Pay strict attention to details, keep the operative field dry (free of bleeding), re-check the operative site… ensure that the anastomosis (the suturing of one hollow organ to another, typically bowel to bowel) shows perfect approximation… free of tension and perfect hemostasis (free of bleeding).
  • There is nothing hemostatic about a well-placed drain. (A surgical drain is used to avoid fluids accumulating within the operative site…it should not be used as a substitute for thoroughly stopping bleeding before closing the incision).
  • Do your work in such a way that you would be willing to sign your name to it…the operation was performed by me.
  • I’m convinced surgeons are made and not born. Be an active learner for the rest of your life. Commit yourself to staying up-to-date in this fast-changing arena.
  • Many times it will be more difficult not to operate than it will be to operate. It is important to learn the things not to do.
  • Errors and failures will make an indelible mark on your heart, and they should. Like a broken bone, it is better to experience this when you are young; albeit painful, it will heal faster. Be sure to learn something from each of your errors.  You will never become so accomplished that there will not be room for improvement.
  • With success, never forget who you are, for we all have numerous reasons to be humble. Never let arrogance creep into your practice. Success can be more dangerous than occasional failure. Recognize areas of weakness so they can be identified, and goals can be set to correct them.
  • Applaud your colleagues in public; criticize them behind closed doors, one-on-one. When giving advice, be aware that it may be least appreciated by those who need it the most.

Andrew Siegel, M.D.

Facebook Page: Our Greatest Wealth Is Health

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Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; in press and available in e-book and paperback formats in January 2014.

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