Urethral diverticulum in women: Diverse presentations resulting in diagnostic delay and mismanagement

Purpose: We describe various clinical presentations of urethral diverticulu m, which may mimic other pelvic floor disorders and result in diagnostic de lay. Management and outcome results are reported. Materials and Methods: We reviewed retrospectively 46 consecutive cases of urethral diverticulum. Patient characteristics, history, clinical evaluatio n, management and long-term followup are reported. Results: Mean patient age plus or minus standard deviation was 36.3 +/- 11. 7 years. Most (83%) cases were referred as diagnostic dilemmas with symptom s present for 3 months to 27 years. Mean interval between onset of symptoms to diagnosis was 5.2 years. The most common symptoms were pain (48% of cas es), urinary incontinence (35%), dyspareunia (24%) and frequency/urgency (2 2%). The number of physicians previously consulted ranged from 3 to 20 and prior therapies included oral and/or vaginal medications, anti-incontinence surgery and psychotherapy. The diverticulum was palpable on examination in 24 patients (52%), in only 6 of whom was it possible to "milk" contents pe r meatus. Of these 24 palpable diverticula 2 contained malignancy, and 2 ot hers contained endometriosis and stones, respectively. Diagnosis was made b y voiding cystourethrography in 30 cases (65%), double balloon urethrograph y in 5 (11%) and transvaginal ultrasound or magnetic resonance imaging in 7 (15%). Diverticula were incidental findings during vaginal surgery in 4 ca ses (9%). Treatment consisted of diverticulectomy and/or Martius flap, pubo vaginal sling and urethral reconstructive procedures when indicated in 35 c ases (76%), and 2 other patients underwent radical surgery for diverticular malignancy. Subsequently all but 2 patients with pain were cured. In anoth er patient de novo stress incontinence developed postoperatively. None of t he patients who underwent concomitant pubovaginal sling had postoperative i ncontinence. Conclusions: The symptoms of urethral diverticulum may mimic other disorder s. This condition should be considered in women with pelvic pain, urinary i ncontinence and irritative voiding symptoms not responding to therapy. Surg ical treatment is usually effective in alleviating associated symptoms.