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Acquired Male Urethral Diverticulum
Vol. 118, November Printed in U.SA.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
ACQUIRED MALE URETHRAL DIVERTICULUM S. K. S. MARYA, SHAVINDER KUMAR
AND
SWATANTAR SINGH
From the Department of Surgery, Medical College, Rohtak, India
ABSTRACT
_Four case~ of_acquired urethral diverticula in male subjects are reviewed. All patients presented with c?mp~1cat10n~ sue~ as urinary tract infection, urethral fistulas and stone or sequestrum form_at10n m the d1verticulum. The recommended treatment is excision of the diverticulum and repair of the urethra. The relevant literature has been reviewed. Urethral diverticula are pouches opening into the urethral canal that may be either acquired or congenital. Diverticula of the fe_male urethra are fairly common. 1- 5 However, a survey of the literature reveals a limited number of cases in male subjects. Pate and Bunts collected only 197 cases of urethral diverticulum after an intensive review of the literature 102 of which were in the anterior urethra and 95 in the post~rior urethra. 6 CASE REPORTS
Case 1. J.C., a 35-year-old man, was hospitalized on March 22, 1968, complaining of dribbling of urine since a bus accident 1½ years earli~r. The patient had noticed a swelling at the ro?t. of the pems. Pressure on the swelling resulted in urine ~xit~ng through the external urinary meatus. Physical exammat10n confirmed this observation. A preoperative culture of urine specimens yielded Pseudomonas pyocyanea. A cystour~thro~am revealed a large diverticulum at the penoscrotal Junction. On August 30 a 4 cm. diverticulum was excised and the urethral defect was repaired over a Foley catheter. There was no stricture. Convalescence was uneventful and the patient has remained free of symptoms. Ca_se 2. R. K., a 12-year-old boy, was admitted to the hospital on June 25, 1970, following repeated attacks of dy~uria a:~1d pyuria associated with occasional dribbling of urm~, which had been noticed since a pelvic injury 7 years prev10usly. Excretory urography and voiding cystourethrography revea~ed a urethral diverticulum in the perineal region. A preoperative culture of urine specimens yielded Escherichia coli. Excision of the urethral diverticulum and removal of a 1.2 by 0_.7 cm. irregular sequestrum were done on July 24. The patient was free of symptoms without any dilatation 6 years later. Case 3. ~- L., a 10-year-old boy, was hospitalized on July 14, 1972 with scrotal swelling 20 days in duration. The swelling was incised exteriorly, resulting in a urethral fistula in that region. X-rays revealed a stone in the urethral diverticulu_m. l!rethrolithotomy was done with excision of a 5 by 7 cm. diverticulum. The urethral defect was repaired over a Kg~ cathe~er. The patient had slight leakage at the operative site, which stopped gradually. Currently, the patient is free of symptoms. Case 4. R. L., A 60-year-old man, was admitted to the hospi~al on Sept:mber 6, 1973, complaining of dribbling and occas10na_l re~ent10n of urine. There was no history of trauma. On exammat10n a stone could be palpated in the urethra so a ure~hrolithotomy was done. The stone was in a 2.5 by 2.5 cm. permeal urethral diverticulum. A preoperative culture of urine specimens yielded E. coli and Streptococcus faecalis. A stricture of the urethra was found distally. Repair of the stricture was done with a rotational flap from the wall of the Accepted for publication December 3, 1976.
diverticulum. The urethra was closed over a Gibbons' catheter. Convalescence was uneventful and the patient is free of symptoms. DISCUSSION
Congenital urethral diverticula occur in the anterior rather than the posterior urethra. They are lined by urethral mucosa and contain muscle in their walls. Congenital diverticula of the male urethra can result from either faulty closure of urethral folds, for example hypospadias, 7 or persistent embryonic epithelial rests. 8 Acquired diverticula of the male urethra, which constitute more than 90 per cent of the total diverticula, develop after periurethral suppuration and abscess formation as a sequela to infection of the periurethral glands, prostatic abscess, infection from a hematoma and schistosomiasis. Other causative factors include obstruction caused by stricture or an impacted stone in the urethra, a Cunningham clamp or the condom penile sheaths frequently used in paraplegics to check incontinence and constant dribbling, and trauma of the urethra, which may be direct by instrumentation or external violence and indirect owing to pelvic fractures associated with sheering of the triangular ligament or perforation with a fragment of bone. Acquired urethral diverticula can occur in any portion of the urethra. They are lined by septic granulation tissue and, rarely, by epithelium. Their walls are devoid of muscle fibers. All 4 patients in our series had acquired diverticula: 2 post-injury and 2 with associated stones in the urethral diverticulum. The distribution was penoscrotal in 1 patient, perineal in 2 and bulbar in 1. No age group is exempt from the development of urethral diverticula. Maged reviewed 8 cases of male urethral diverticula and found that 1 case had associated fracture of the pelvis, while another had a stone in the urethral diverticulum. 9 Usually, the stones are in the diverticulum and do not cause obstruction to urinary flow. The stones have been in situ as long as 53 years without causing symptoms. 10 The presence of a sequestrum (case 2) is extremely rare and we have not found such a report in the literature. Small uninfected urethral diverticula are silent and, therefore, difficult to suspect. When the diverticula increase in size the patient notices involuntary dribbling of urine. Further swelling makes the diverticulum palpable after micturition, when the urine can be emptied by pressing the diverticulum (case 1). When infection occurs the frequency of symptoms, such as dysuria, frequency and urgency, increases. All of our cases had established urinary tract infection: cultures from cases 1, 2 and 4 yielded pyogenic organisms, while case 3 exhibited periurethral suppuration and a urethral fistula. The objectives in the treatment of symptomatic urethral diverticula are 1) relief of distal obstruction, 2) control of infection, 3) removal of all calculi and other foreign bodies
765
766
MARYA, KUMAR AND SINGH
present, 4) excision of the diverticulum and 5) closure of the urethral defect without embarrassment of the lumen. Excision of the diverticulum with repair of the urethra was done in all 4 of our cases without any recurrence or stricture formation. Most of the diverticula are infected and, therefore, culture:,, of urine specimens and appropriate preoperative antibiotics are recommended. REFERENCES
1. Davis, H.J. and TeLinde, R. W.: Urethral diverticula: an assay of 121 cases. J. Urol., 80: 34, 1958. 2. Mackinnon, M., Pratt, J. H. and Pool, T. L.: Diverticulum of
the female urethra. Surg. Clin. N. Amer., 39: 953, 1959. 3. Pathak, U. N. and House, M. J.: Diverticulum of the female urethra. Obst. Gynec., 36: 789, 1970. 4. Spraitz, A. F., Jr. and Welch, J. S.: Diverticulum of the female urethra. Amer. J. Obst. Gynec., 91: 1013, 1965. 5. Wharton, L. R. and Kearns, W.: Diverticula of the female urethra. J. Urol., 63: 1063, 1950. 6. Pate, V. A., Jr. and Bunts, R. C.: Urethral diverticula in paraplegics. J. Urol., 65: 108, 1951. 7. Voillemier: Cited by Maged. 9 8. Johnson: Cited by Maged. 9 9. Maged, A.: Urethral diverticula in males. (With a report of eight cases.) Brit. J. Urol., 37: 560, 1965. 10. Hirsch, C. S.: Cited by Maged.•
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
ACQUIRED MALE URETHRAL DIVERTICULUM S. K. S. MARYA, SHAVINDER KUMAR
AND
SWATANTAR SINGH
From the Department of Surgery, Medical College, Rohtak, India
ABSTRACT
_Four case~ of_acquired urethral diverticula in male subjects are reviewed. All patients presented with c?mp~1cat10n~ sue~ as urinary tract infection, urethral fistulas and stone or sequestrum form_at10n m the d1verticulum. The recommended treatment is excision of the diverticulum and repair of the urethra. The relevant literature has been reviewed. Urethral diverticula are pouches opening into the urethral canal that may be either acquired or congenital. Diverticula of the fe_male urethra are fairly common. 1- 5 However, a survey of the literature reveals a limited number of cases in male subjects. Pate and Bunts collected only 197 cases of urethral diverticulum after an intensive review of the literature 102 of which were in the anterior urethra and 95 in the post~rior urethra. 6 CASE REPORTS
Case 1. J.C., a 35-year-old man, was hospitalized on March 22, 1968, complaining of dribbling of urine since a bus accident 1½ years earli~r. The patient had noticed a swelling at the ro?t. of the pems. Pressure on the swelling resulted in urine ~xit~ng through the external urinary meatus. Physical exammat10n confirmed this observation. A preoperative culture of urine specimens yielded Pseudomonas pyocyanea. A cystour~thro~am revealed a large diverticulum at the penoscrotal Junction. On August 30 a 4 cm. diverticulum was excised and the urethral defect was repaired over a Foley catheter. There was no stricture. Convalescence was uneventful and the patient has remained free of symptoms. Ca_se 2. R. K., a 12-year-old boy, was admitted to the hospital on June 25, 1970, following repeated attacks of dy~uria a:~1d pyuria associated with occasional dribbling of urm~, which had been noticed since a pelvic injury 7 years prev10usly. Excretory urography and voiding cystourethrography revea~ed a urethral diverticulum in the perineal region. A preoperative culture of urine specimens yielded Escherichia coli. Excision of the urethral diverticulum and removal of a 1.2 by 0_.7 cm. irregular sequestrum were done on July 24. The patient was free of symptoms without any dilatation 6 years later. Case 3. ~- L., a 10-year-old boy, was hospitalized on July 14, 1972 with scrotal swelling 20 days in duration. The swelling was incised exteriorly, resulting in a urethral fistula in that region. X-rays revealed a stone in the urethral diverticulu_m. l!rethrolithotomy was done with excision of a 5 by 7 cm. diverticulum. The urethral defect was repaired over a Kg~ cathe~er. The patient had slight leakage at the operative site, which stopped gradually. Currently, the patient is free of symptoms. Case 4. R. L., A 60-year-old man, was admitted to the hospi~al on Sept:mber 6, 1973, complaining of dribbling and occas10na_l re~ent10n of urine. There was no history of trauma. On exammat10n a stone could be palpated in the urethra so a ure~hrolithotomy was done. The stone was in a 2.5 by 2.5 cm. permeal urethral diverticulum. A preoperative culture of urine specimens yielded E. coli and Streptococcus faecalis. A stricture of the urethra was found distally. Repair of the stricture was done with a rotational flap from the wall of the Accepted for publication December 3, 1976.
diverticulum. The urethra was closed over a Gibbons' catheter. Convalescence was uneventful and the patient is free of symptoms. DISCUSSION
Congenital urethral diverticula occur in the anterior rather than the posterior urethra. They are lined by urethral mucosa and contain muscle in their walls. Congenital diverticula of the male urethra can result from either faulty closure of urethral folds, for example hypospadias, 7 or persistent embryonic epithelial rests. 8 Acquired diverticula of the male urethra, which constitute more than 90 per cent of the total diverticula, develop after periurethral suppuration and abscess formation as a sequela to infection of the periurethral glands, prostatic abscess, infection from a hematoma and schistosomiasis. Other causative factors include obstruction caused by stricture or an impacted stone in the urethra, a Cunningham clamp or the condom penile sheaths frequently used in paraplegics to check incontinence and constant dribbling, and trauma of the urethra, which may be direct by instrumentation or external violence and indirect owing to pelvic fractures associated with sheering of the triangular ligament or perforation with a fragment of bone. Acquired urethral diverticula can occur in any portion of the urethra. They are lined by septic granulation tissue and, rarely, by epithelium. Their walls are devoid of muscle fibers. All 4 patients in our series had acquired diverticula: 2 post-injury and 2 with associated stones in the urethral diverticulum. The distribution was penoscrotal in 1 patient, perineal in 2 and bulbar in 1. No age group is exempt from the development of urethral diverticula. Maged reviewed 8 cases of male urethral diverticula and found that 1 case had associated fracture of the pelvis, while another had a stone in the urethral diverticulum. 9 Usually, the stones are in the diverticulum and do not cause obstruction to urinary flow. The stones have been in situ as long as 53 years without causing symptoms. 10 The presence of a sequestrum (case 2) is extremely rare and we have not found such a report in the literature. Small uninfected urethral diverticula are silent and, therefore, difficult to suspect. When the diverticula increase in size the patient notices involuntary dribbling of urine. Further swelling makes the diverticulum palpable after micturition, when the urine can be emptied by pressing the diverticulum (case 1). When infection occurs the frequency of symptoms, such as dysuria, frequency and urgency, increases. All of our cases had established urinary tract infection: cultures from cases 1, 2 and 4 yielded pyogenic organisms, while case 3 exhibited periurethral suppuration and a urethral fistula. The objectives in the treatment of symptomatic urethral diverticula are 1) relief of distal obstruction, 2) control of infection, 3) removal of all calculi and other foreign bodies
765
766
MARYA, KUMAR AND SINGH
present, 4) excision of the diverticulum and 5) closure of the urethral defect without embarrassment of the lumen. Excision of the diverticulum with repair of the urethra was done in all 4 of our cases without any recurrence or stricture formation. Most of the diverticula are infected and, therefore, culture:,, of urine specimens and appropriate preoperative antibiotics are recommended. REFERENCES
1. Davis, H.J. and TeLinde, R. W.: Urethral diverticula: an assay of 121 cases. J. Urol., 80: 34, 1958. 2. Mackinnon, M., Pratt, J. H. and Pool, T. L.: Diverticulum of
the female urethra. Surg. Clin. N. Amer., 39: 953, 1959. 3. Pathak, U. N. and House, M. J.: Diverticulum of the female urethra. Obst. Gynec., 36: 789, 1970. 4. Spraitz, A. F., Jr. and Welch, J. S.: Diverticulum of the female urethra. Amer. J. Obst. Gynec., 91: 1013, 1965. 5. Wharton, L. R. and Kearns, W.: Diverticula of the female urethra. J. Urol., 63: 1063, 1950. 6. Pate, V. A., Jr. and Bunts, R. C.: Urethral diverticula in paraplegics. J. Urol., 65: 108, 1951. 7. Voillemier: Cited by Maged. 9 8. Johnson: Cited by Maged. 9 9. Maged, A.: Urethral diverticula in males. (With a report of eight cases.) Brit. J. Urol., 37: 560, 1965. 10. Hirsch, C. S.: Cited by Maged.•