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Diverticulum of the female urethra
Diverticulum ANTON JOHN
F.
SPRAITZ,
S. WELCH,
Rochester,
of the female urethra JR.,
M.D.*
M.D.
Minnesota
D IVERTI c u L u M of the urethra seems to be a rarely considered disease. Several reasons probably account for this: Medical schools do not always include the study of this condition in either their urologic or their gynecologic curriculum, and diverticulum as a topic is omitted from many standard texts. Many physicians, therefore, are totally unaware of this condition. Urethral diverticulum is not a common ailment, and its diagnosis probably is not considered often by the physician even when suggestive symptoms should alert him. Furthermore, the actual diagnosis may be somewhat laborious to establish, particularly when short-term therapy with common antibiotics often brings temporary relief. It is’ not life endangering and there is not much controversy regarding diverticulum to stimulate the clinician’s interest. The purpose of this paper is to discuss the etiologic, pathologic, and clinical features of this condition as well as to present the findings in a series of 94 patients in an effort to stimulate physicians to consider urethral diverticulum in cases of recurrent urinary tract symptoms. Etiologic
vaginal cysts. Linnet-Jepsen? cited the histologic demonstration of all layers of the urethra-in particular, all of the muscular layers -in the diverticular wall as evidence favoring a congenital basis in the etiology of diverticulum. In spite of these reports, there seems to be strong evidence that diverticula are acquired. Huffman’s classic study of the female adult urethra of 11 subjects at necropsy (in which he demonstrated numerous paraurethral ducts and glands and found cystic dilatations of these ducts in several specimens) is a cornerstone for the acquired theory. It is postulated that infection and obstruction of the urethral glands result in the formation of cysts, which may subsequently rupture into the urethral lumen and give rise to diverticulum. Hence, some of the causes predisposing to diverticulum formation are obstetrical or surgical trauma, urethral stone, urethral stricture, instrumentation of the urethra, and gonococcal or nonspecific infection, Pathologic features The lining of the diverticular sac may include squamous or transitional epithelium and smooth muscle. Usually, however, marked inflammatory changes prevail and may make identification of the epithelium impossible. The majority of diverticula are 1 to 2% cm. in diameter, although some have been reported as large as 8 cm.4 The ostia into the urethral tube usually are 1 to 3 mm. in size, occasionally being 1 or more centimeters. The openings may be present anywhere along the urethra although the majority seem to be in the middle one
features
The etiology of urethral diverticulum is still obscure. Parmenterl lists several possible sources for congenital diverticulum : Gartner’s ducts, cysts formed by faulty union of primal folds, cell nests, Wolffian ducts, and
From the Sections of Obstetrics Gynecology and Surgery, Mayo and Mayo Foundation. *Fellow
in Obstetrics
and Clinic
and Gynecology. 1013
1014
Spraitz
and
Welch
Table I. Urethral diverticulum: Distribution of 94 patients according to a,ge at time of diagnosis ( 1953 through 1954) Ace
iv.
No.
)
of aatients
oto 9 10 to 19 20 to ‘9 30 to 39 40 to 49 50 to 59 60 to 69
1
(I :i “1 33
“9 7
Total
Table pelvic (1953
9-4
II. Urethral diverticulum: Previous surgical procedures in 58 patients through 1962) Procedure
No.
I
Hysterectomy Previous excision of urethral diverticulum Vterine suspension Salpingo-oophorectomy Cesarean section .4nterior vaginal repair Bladder polyps Drainage of urethral abscess Ectopic pregnancy Removal of cervical stump Rectovaginal repairs Ureterolysis Excision of ureteral stump Myomectomy Bartholin abscess Pararectal abscess
26
Total
95
11 10 10 8 8 6 -t 3 2 2 1 1 I 1 1
third. Although an ostium rarely is encountered on the anterior wall of the urethra, the great majority are found in the floor or the posterior lateral wall. Calculi may form in the diverticulum, and occasionally a urethrovaginal fistula may result from rupture of the diverticulum into the vagina. Carcinoma in a urethral diverticulum
is extremely
knowledge in a urethral has
Clinical
rare,
of 12 patients diverticulum.
although
Nourse;’
with
carcinoma
features
The “typical” patient with a urethral diverticulum is in her fourth, fifth, or sixth decade of life and has a long history of
urinary complaints. She usually has sren several doctors who have treated her for urinary tract infections with some decree of success. Most commonly, symptoms include the triad of dysuria, frequency. and urcenc> but they may be present in \,aried patterns. Physical examination often is unrr\-raling, although a dou,qhy mass in the urethral region may br sllggestivc of a di\~c.rticulum. Purulent material obtained by strippinK the urethra or an exquisite tenderness on palpation also may be suggestive of a divc~rticulum. The diagnosis is made by noting thr orifice of the diverticulum during cystourethroscopy by means of the panendoscope or by the direct vision cystoscope as suggested by (:oo~.~ Koentgenologic examination, which is not always necessary. may be helpful in outlining the siTe of the pocket and determining whether or not it is multiloculatrd. The majority of urethroa\,is and Cian;’ has been used lvith SIICCW on occasion. Sur,qical escision through the anterior \-aginal wall, with accurate approximation of the urethra and vaginal wall reconstrllction, is the preferred method of management. The surgical technique has been described previously by Mackinnon. Pratt. and Po01.~ Occasionally. incision of a diverticulum with a Collin knife has proved successful. and one patient in our present series was treated by a rctropubic rscision of the divcrticulum, a technique first described by Arcadi.! Another patient had a recurrent diverticulum that was treated by transurethral es&ion of the diverticulum. Present
study
Mackinnon. Pratt, and Pool” previously reported on 204 patients with urethral divcrtic&m seen at the Mayo Clinic from 1935 through 3955. The present study includes those patients seen in the last 3 years of that period ( 1953 through 1955) and an additional 52 seen from 1956 through 1962. Thus, the present study includes 94 patients.
Volume Number
91 7
The average age of the patients in our series was 46 years, with an age range of 9 through 69 years. Eighty-three of the 94 patients (88 per cent) were in the fourth, fifth, or sixth decade of life at the time of diagnosis (Table I). Thirty-seven patients (39 per cent) were nulliparous; this surprisingly high percentage leads one to believe that obstetrical trauma probably is insignificant as a predisposing factor in urethral diverticulum, although one patient clearly dated the onset of her symptoms from her last childbirth. Thirty-six (38 per cent) of the patients had no history of previous gynecologic or urologic surgery. The remaining 58 patients had had a total of 95 pelvic procedures, exclusive of uterine curettage and cystoscopy (Table II). Four patients dated the onset of symptoms as after hysterectomy (two vaginal and two abdominal); one noted commencement of difficulty after a rectovaginal repair for a third-degree laceration, and one after drainage of a urethral abscess. Four of the 94 patients admitted previous gonococcal infection, and 5 gave a history of syphilis. The significance of previous venereal disease, in these few cases, as a possible causative factor of the diverticulum is impossible to appraise. A wide range of signs and symptoms was presented by the patients in our series (Table III). In addition to the nonspecific triad of dysuria, frequency, and urgency, it appeared that nocturia, urinary incontinence, and local pain occurred commonly in urethral diverticulum. The range of duration of symptoms was from 3 days to 22 years, and 45 patients (48 per cent) have had symptoms for more than 1 year. At examination, 64 of the patients (68 per cent) had no physical findings that were clearly indicative of urethral diverticulum. Thirty patients (32 per cent) had physical findings that were compatible with the diagnosis of urethral diverticulum; a mass was noted in each of 24 patients, exquisite tenderness was elicited on urethral palpation in five patients, and pus was stripped from the urethra in one.
Diverticulum
of female
urethra
1015
Table III.
Urethral diverticulum: Predominant signs and symptoms* patients? (1953 through 1962) Skn
in 91
1
or svmbtom
Dysuria Frequency Nocturia Urgency Incontinence Local pain Pyuria Dyspareunia Hematuria Urethral discharge Suprapubic pain Incomplete voiding Mass in vagina Odiferous urine Bearing down sensation Difficulty in starting stream Chills and fever Fatigue *Most ?Three
patients patients
had had
multiple no
No. 60
51 31 30 30 26
11 10 8 8 5
5 3 2 2 2 1 1 urinary
symptoms.
symptoms.
Cultures of catheterized urine specimens grew no pathogens in 64 cases and were not performed in three cases. In the 27 patients with positive cultures, Escherichia coli was the predominant organism in 18, Streptococcus faecalis in 3, Proteus in 3, Aerobactcr aerogenes in 2, and Pseudomonas in one. Cystoscopy was a useful diagnostic tool for practically every patient in this group. Diverticular ostia were located posteriorly in the middle one third of the urethra in the great majority of patients and were located less often in the distal third and the proximal third of the urethra. The distal and proximal locations were of approximately equal frequency. In only one patient was an ostium noted to arise from the anterior portion of the urethra. Diverticula were demonstrated radiographically in 50 patients by means of a ureteral catheter coiled in the diverticulum and in another 4 by use of the two-balloon technique. Urethrograms were noncontributory in 10 patients and were considered unnecessary in 30. The treatment was vaginal excision of the diverticulum in 92 patients, retropubic excision in one, and simple incision with the Collin knife in one. The average hos-
1016
Spraitz
and
Welch
pita1 stay for these patients was 9 days. No mortalit)occurred, and minor postoperative morbidity was noted in only 3. Pathologically. the largest diverticulum leas recorded as being 5 by 4 by 4 cm., with most reported as being 1 to 2% cm. in diameter. No unusual pathologic features were noted in the specimens. Stones were present in 7 of the patients. Roth squamous and transitional epithelium were found on occasion together with smooth muscle, infammatory changes, sinus tracts, periurethral abscesses. or squamous metaplasia. A carcinoma was not found in any specimen. Thus. not a sin,qle instance of carcinoma was reported for any of the 256 patients with diverticulum of the urethra seen at the clinic since 1935. An extensive follow-up was considered unnecessary in this series, but a review of the records of these patients revealed some interestinc: facts. Twenty-seven patients were doing well when dismissed from the hospital. with no further adequate follow-up. Another patient, who was doin,F well, died shortly after dismissal from causes unrelated to her surgical procedure. Information concerning 25 patients was a\-ailable bp record from 1 month to 1 year after surgery. Twenty-three of these patients were doing well: one had some urinary
REFERENCES
1. Parmenter. F. J.: J. Urol. 45: 479. 1941. 2. Linnet-Jepsen, Peder: Danish M. Bull. 7: ‘204. 1960. 3. Huffman. J. W.: .4x. J. OBST. & GYNEC. 55: 86, 1948. -f. Wharton, L. R., and Kearns. Walter: J. IJrol. 63: 1063, 1950.
stress incontinence but otherwise was symptom free, and another had had a recurrence of her symptoms 2 months after the surgical procedure but was not seen later to determine the cause. Forty-one patients were seen for later evaluation from 1 to 9 years after their surgery. Twenty-nine of these patients have done well since their operation. Five patients had recurrence of their diverticulum and were re-treated. After the initial procedures. urethrovaginal fistulas devclopcd in 4 patients. The fistulas in 3 were repaired successfully, and the fourth fistula is to be repaired at a later date. Two additional patients had had a recurrence of some of their urinary symptoms but have not been seen for e\.aluation. Summary
The etiologic, pathologic, and clinical features of diverticulum of the female urethra have been presented along with the findings in 94 patients with this condition in an effort to stress the need for awareness on the part of the physician in cases of recurrent symptoms of the urinary tract. The majority of these 94 patients seen at the Mayo Clinic during the years 1953 through 1962 were treated successfully with surgical excision of the diverticulum.
5. 6. 7.
8. 9.
Nourse, M. H.: West. J. Surg. 69: 286, 1961. Cook, E. N.: Surg. Gynec. & Obst. 99: 273, 1954. Davis, H. J.. and Cian. L. G.: J. Ural. 75: 7.53, 1956. Mackinnon, Margaret, Pratt. J. H., and Pool, T. L.: S. Clin. North America 39: 953, 1959. Arcadi, J. -4.: J. Urol. 85: 593, 1961.
F.
SPRAITZ,
S. WELCH,
Rochester,
of the female urethra JR.,
M.D.*
M.D.
Minnesota
D IVERTI c u L u M of the urethra seems to be a rarely considered disease. Several reasons probably account for this: Medical schools do not always include the study of this condition in either their urologic or their gynecologic curriculum, and diverticulum as a topic is omitted from many standard texts. Many physicians, therefore, are totally unaware of this condition. Urethral diverticulum is not a common ailment, and its diagnosis probably is not considered often by the physician even when suggestive symptoms should alert him. Furthermore, the actual diagnosis may be somewhat laborious to establish, particularly when short-term therapy with common antibiotics often brings temporary relief. It is’ not life endangering and there is not much controversy regarding diverticulum to stimulate the clinician’s interest. The purpose of this paper is to discuss the etiologic, pathologic, and clinical features of this condition as well as to present the findings in a series of 94 patients in an effort to stimulate physicians to consider urethral diverticulum in cases of recurrent urinary tract symptoms. Etiologic
vaginal cysts. Linnet-Jepsen? cited the histologic demonstration of all layers of the urethra-in particular, all of the muscular layers -in the diverticular wall as evidence favoring a congenital basis in the etiology of diverticulum. In spite of these reports, there seems to be strong evidence that diverticula are acquired. Huffman’s classic study of the female adult urethra of 11 subjects at necropsy (in which he demonstrated numerous paraurethral ducts and glands and found cystic dilatations of these ducts in several specimens) is a cornerstone for the acquired theory. It is postulated that infection and obstruction of the urethral glands result in the formation of cysts, which may subsequently rupture into the urethral lumen and give rise to diverticulum. Hence, some of the causes predisposing to diverticulum formation are obstetrical or surgical trauma, urethral stone, urethral stricture, instrumentation of the urethra, and gonococcal or nonspecific infection, Pathologic features The lining of the diverticular sac may include squamous or transitional epithelium and smooth muscle. Usually, however, marked inflammatory changes prevail and may make identification of the epithelium impossible. The majority of diverticula are 1 to 2% cm. in diameter, although some have been reported as large as 8 cm.4 The ostia into the urethral tube usually are 1 to 3 mm. in size, occasionally being 1 or more centimeters. The openings may be present anywhere along the urethra although the majority seem to be in the middle one
features
The etiology of urethral diverticulum is still obscure. Parmenterl lists several possible sources for congenital diverticulum : Gartner’s ducts, cysts formed by faulty union of primal folds, cell nests, Wolffian ducts, and
From the Sections of Obstetrics Gynecology and Surgery, Mayo and Mayo Foundation. *Fellow
in Obstetrics
and Clinic
and Gynecology. 1013
1014
Spraitz
and
Welch
Table I. Urethral diverticulum: Distribution of 94 patients according to a,ge at time of diagnosis ( 1953 through 1954) Ace
iv.
No.
)
of aatients
oto 9 10 to 19 20 to ‘9 30 to 39 40 to 49 50 to 59 60 to 69
1
(I :i “1 33
“9 7
Total
Table pelvic (1953
9-4
II. Urethral diverticulum: Previous surgical procedures in 58 patients through 1962) Procedure
No.
I
Hysterectomy Previous excision of urethral diverticulum Vterine suspension Salpingo-oophorectomy Cesarean section .4nterior vaginal repair Bladder polyps Drainage of urethral abscess Ectopic pregnancy Removal of cervical stump Rectovaginal repairs Ureterolysis Excision of ureteral stump Myomectomy Bartholin abscess Pararectal abscess
26
Total
95
11 10 10 8 8 6 -t 3 2 2 1 1 I 1 1
third. Although an ostium rarely is encountered on the anterior wall of the urethra, the great majority are found in the floor or the posterior lateral wall. Calculi may form in the diverticulum, and occasionally a urethrovaginal fistula may result from rupture of the diverticulum into the vagina. Carcinoma in a urethral diverticulum
is extremely
knowledge in a urethral has
Clinical
rare,
of 12 patients diverticulum.
although
Nourse;’
with
carcinoma
features
The “typical” patient with a urethral diverticulum is in her fourth, fifth, or sixth decade of life and has a long history of
urinary complaints. She usually has sren several doctors who have treated her for urinary tract infections with some decree of success. Most commonly, symptoms include the triad of dysuria, frequency. and urcenc> but they may be present in \,aried patterns. Physical examination often is unrr\-raling, although a dou,qhy mass in the urethral region may br sllggestivc of a di\~c.rticulum. Purulent material obtained by strippinK the urethra or an exquisite tenderness on palpation also may be suggestive of a divc~rticulum. The diagnosis is made by noting thr orifice of the diverticulum during cystourethroscopy by means of the panendoscope or by the direct vision cystoscope as suggested by (:oo~.~ Koentgenologic examination, which is not always necessary. may be helpful in outlining the siTe of the pocket and determining whether or not it is multiloculatrd. The majority of urethro
study
Mackinnon. Pratt, and Pool” previously reported on 204 patients with urethral divcrtic&m seen at the Mayo Clinic from 1935 through 3955. The present study includes those patients seen in the last 3 years of that period ( 1953 through 1955) and an additional 52 seen from 1956 through 1962. Thus, the present study includes 94 patients.
Volume Number
91 7
The average age of the patients in our series was 46 years, with an age range of 9 through 69 years. Eighty-three of the 94 patients (88 per cent) were in the fourth, fifth, or sixth decade of life at the time of diagnosis (Table I). Thirty-seven patients (39 per cent) were nulliparous; this surprisingly high percentage leads one to believe that obstetrical trauma probably is insignificant as a predisposing factor in urethral diverticulum, although one patient clearly dated the onset of her symptoms from her last childbirth. Thirty-six (38 per cent) of the patients had no history of previous gynecologic or urologic surgery. The remaining 58 patients had had a total of 95 pelvic procedures, exclusive of uterine curettage and cystoscopy (Table II). Four patients dated the onset of symptoms as after hysterectomy (two vaginal and two abdominal); one noted commencement of difficulty after a rectovaginal repair for a third-degree laceration, and one after drainage of a urethral abscess. Four of the 94 patients admitted previous gonococcal infection, and 5 gave a history of syphilis. The significance of previous venereal disease, in these few cases, as a possible causative factor of the diverticulum is impossible to appraise. A wide range of signs and symptoms was presented by the patients in our series (Table III). In addition to the nonspecific triad of dysuria, frequency, and urgency, it appeared that nocturia, urinary incontinence, and local pain occurred commonly in urethral diverticulum. The range of duration of symptoms was from 3 days to 22 years, and 45 patients (48 per cent) have had symptoms for more than 1 year. At examination, 64 of the patients (68 per cent) had no physical findings that were clearly indicative of urethral diverticulum. Thirty patients (32 per cent) had physical findings that were compatible with the diagnosis of urethral diverticulum; a mass was noted in each of 24 patients, exquisite tenderness was elicited on urethral palpation in five patients, and pus was stripped from the urethra in one.
Diverticulum
of female
urethra
1015
Table III.
Urethral diverticulum: Predominant signs and symptoms* patients? (1953 through 1962) Skn
in 91
1
or svmbtom
Dysuria Frequency Nocturia Urgency Incontinence Local pain Pyuria Dyspareunia Hematuria Urethral discharge Suprapubic pain Incomplete voiding Mass in vagina Odiferous urine Bearing down sensation Difficulty in starting stream Chills and fever Fatigue *Most ?Three
patients patients
had had
multiple no
No. 60
51 31 30 30 26
11 10 8 8 5
5 3 2 2 2 1 1 urinary
symptoms.
symptoms.
Cultures of catheterized urine specimens grew no pathogens in 64 cases and were not performed in three cases. In the 27 patients with positive cultures, Escherichia coli was the predominant organism in 18, Streptococcus faecalis in 3, Proteus in 3, Aerobactcr aerogenes in 2, and Pseudomonas in one. Cystoscopy was a useful diagnostic tool for practically every patient in this group. Diverticular ostia were located posteriorly in the middle one third of the urethra in the great majority of patients and were located less often in the distal third and the proximal third of the urethra. The distal and proximal locations were of approximately equal frequency. In only one patient was an ostium noted to arise from the anterior portion of the urethra. Diverticula were demonstrated radiographically in 50 patients by means of a ureteral catheter coiled in the diverticulum and in another 4 by use of the two-balloon technique. Urethrograms were noncontributory in 10 patients and were considered unnecessary in 30. The treatment was vaginal excision of the diverticulum in 92 patients, retropubic excision in one, and simple incision with the Collin knife in one. The average hos-
1016
Spraitz
and
Welch
pita1 stay for these patients was 9 days. No mortalit)occurred, and minor postoperative morbidity was noted in only 3. Pathologically. the largest diverticulum leas recorded as being 5 by 4 by 4 cm., with most reported as being 1 to 2% cm. in diameter. No unusual pathologic features were noted in the specimens. Stones were present in 7 of the patients. Roth squamous and transitional epithelium were found on occasion together with smooth muscle, infammatory changes, sinus tracts, periurethral abscesses. or squamous metaplasia. A carcinoma was not found in any specimen. Thus. not a sin,qle instance of carcinoma was reported for any of the 256 patients with diverticulum of the urethra seen at the clinic since 1935. An extensive follow-up was considered unnecessary in this series, but a review of the records of these patients revealed some interestinc: facts. Twenty-seven patients were doing well when dismissed from the hospital. with no further adequate follow-up. Another patient, who was doin,F well, died shortly after dismissal from causes unrelated to her surgical procedure. Information concerning 25 patients was a\-ailable bp record from 1 month to 1 year after surgery. Twenty-three of these patients were doing well: one had some urinary
REFERENCES
1. Parmenter. F. J.: J. Urol. 45: 479. 1941. 2. Linnet-Jepsen, Peder: Danish M. Bull. 7: ‘204. 1960. 3. Huffman. J. W.: .4x. J. OBST. & GYNEC. 55: 86, 1948. -f. Wharton, L. R., and Kearns. Walter: J. IJrol. 63: 1063, 1950.
stress incontinence but otherwise was symptom free, and another had had a recurrence of her symptoms 2 months after the surgical procedure but was not seen later to determine the cause. Forty-one patients were seen for later evaluation from 1 to 9 years after their surgery. Twenty-nine of these patients have done well since their operation. Five patients had recurrence of their diverticulum and were re-treated. After the initial procedures. urethrovaginal fistulas devclopcd in 4 patients. The fistulas in 3 were repaired successfully, and the fourth fistula is to be repaired at a later date. Two additional patients had had a recurrence of some of their urinary symptoms but have not been seen for e\.aluation. Summary
The etiologic, pathologic, and clinical features of diverticulum of the female urethra have been presented along with the findings in 94 patients with this condition in an effort to stress the need for awareness on the part of the physician in cases of recurrent symptoms of the urinary tract. The majority of these 94 patients seen at the Mayo Clinic during the years 1953 through 1962 were treated successfully with surgical excision of the diverticulum.
5. 6. 7.
8. 9.
Nourse, M. H.: West. J. Surg. 69: 286, 1961. Cook, E. N.: Surg. Gynec. & Obst. 99: 273, 1954. Davis, H. J.. and Cian. L. G.: J. Ural. 75: 7.53, 1956. Mackinnon, Margaret, Pratt. J. H., and Pool, T. L.: S. Clin. North America 39: 953, 1959. Arcadi, J. -4.: J. Urol. 85: 593, 1961.