Diverticulum of the Female Urethra; Review of Literature with Case Report

Diverticulum of the Female Urethra; Review of Literature with Case Report

DIVERTICl7L-UM OF THE FEMALE URETHRA; REVIEvV OF LITERATURE WITH CASE REPORT IRA G. DOWNER From the Department of AND FRANK D. VIRGILIO Alexander ...

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DIVERTICl7L-UM OF THE FEMALE URETHRA; REVIEvV

OF LITERATURE WITH CASE REPORT IRA G. DOWNER From the Department of

AND

FRANK D. VIRGILIO

Alexander Blain Hospital and Jefferson Nlichi(!an

The earliest available information on diverticulum of the fomale urethra wa,s that of a case reported by Hey 1 in 1786 (cited by Hyman 2). Since then there has been considerable cliscussion as to the exact terminology. Such nomenclature as urine pockets (Jarecki 3 ), prolapse, urethrocele, and suburethral abscess have been used interchangeably by different writers. However, the term diverticulum seems more appropriate and is generally used by the most recent observers of this condition. Diverticulum of the female urethra has been described as a pouch or sacculation formed by a dilatation of a circumscribed portion of the inferior wall of the urethra. Lowsley and Kirwin 4 define it as a pouch formed by dilatation of a portion of the urethro-vaginal septum and communicating with the urethral canal. The pouch may communicate widely with the urethra or it niay have a narrow or tubular opening into it. Cabot 5 classifies diverticulum of the female urethra into true, false and incomplete urethro-vaginal fistulae. The basis for this classification depends on the extent of involvement of the protruded urethral wall; that is, the sac may represent all the layers of the urethral wan, or it may show a break in continuity of the muscularis, or there may be a loss in continuity of all layers of the urethral wall, the pocket ending blindly in the urethro-vaginal septum. This condition is, in fact, not a diverticulum at all. Although this classification may be important from a pathological standpoint, clinically it is merely of academic interest. A differentiation of true or false cannot be made from a macroscopic appearance. Diverticulum of the urethra in women is uncommon, but not rare. In 1894 Cullen 6 collected 36 cases from the literature; four of these contained calculi, three of the cases listed (Englisch 7, Foucher 8, Galabin °) contained a description of anterior vaginal -wall tumors which did not communicate with the urethra 1 Hey, W,: Practical observations in Surgery. On collections of pus in the Vagina, Case 2. London, p. 488. 1803. 2 Hyman, A., and Leiter, H. E.: Diverticulum of the female urethra . .J. _Mt. Sinai Hosp., 6: 190-193, 1939. 3 Jarecki, Max: Concerning diverticula and other urine pockets or the female urethra. Zt,chr. L urol. Chir., 3: 241-273, 1914. 4 Lowsley, 0. W_ and Kirwin, T. J.: Clinical Urology. Baltimore: Williams & Wilkins Co., 1: 747, 1940. 5 Cabot, Hugh: Modern Urology. Philadelphia: Lea & Febiger, 1: 396, 1924_ ' Cullen, T. S.: Abscess in urethro vaginal septum, BulL Johns Hopkins Hosp-, 5: 45, 1894. 7 Englisch: Wiener medizinische Presse. Ein Fall von liner Cyste in der Wand rler weiblichen Hornrohe, 22: 599-634, 1881. 8 Foucher: Winkel, in Billroth und Leucke. Handbuch der Frauen Krankhe1ten. "Diverticulum of the urethra in the female." III: S_ 362. 9 Gala.bin: Chronic abscess of the female urethra. London Obst, Tran-, 27: 186, 1886.

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IR.\ G. DOWNER AND FRANK D. VIRGILIO

and can hardly be called diverticula. Parmenter 10 states that only 15 cases were found in a ten-year period at the Mayo Clinic. At the Cleveland Clinic 8 cases were observed during a period of 22 years, since 1921. Cone 11 reported the sixth case at the John Sealey Hospital. Higgins12 reported the thirty-ninth incident of diverticulum with calculi. Lane 13 recorded a patient with multiple calculi formation in a diverticulum. Most recently Menville 14 made a comprehensive and detailed study of 69 case reports, adding to this eleven of his own. There are a few scattered cases to be found in foreign literature. The exact statistics as to the frequency of this lesion are not available. Urethral diverticula in women are either acquired or congenital in origin. The acquired forms occur most commonly in women who have borne several children and in whom trauma to the anterior vaginal wall has injured the urethral mucosa. A break in the urethral musculature may be caused by instrumentation. The passage of a calculus may also be a factor to consider in intra-urethral injury in the female. Infection is a very important agent in the acquired type. Furniss 15 believes that most of these diverticula are secondary to an inflammatory process started in an infected occluded urethral duct with subsequent suppuration and rupture into the urethral lumen. A sac may become increasingly large by repetition of these events. Higgins 12 believes stone formation in a diverticulum is probably due to local urinary stasis with infection which allows for the precipitation of urinary salts. The rarity of such calculi is probably a result of the periodic emptying of the diverticulum with change of posture, coitus, etc. It is conceivable that a stone descending from the upper urinary tract may become lodged in a preformed diverticulum, where it increases in size by accretion. If such is the case, Bibus16 believes that multiple stones may be found. (Lane13 ). The congenital type is less frequent but it does occur. Many writers question the congenital theory of origin. Holline believed the case he reported to be definitely of congenital origin. Veit reported a diverticulum with a double orifice leading into the urethra. He suggested the diverticulum might have originated from Gartner's ducts. Fromme 17 reported a patient with a supernumerary ureter opening into a urine pocket (Jarecki 3 ). He looked on this finding as proof of Y eit's contention that some diverticula of the female urethra ,rnre of congenital origin. The congenital variety (Hyman 2 ) may be secondary to Gartner's duct, Wolffian duct, cell rests, vaginal cysts, and faulty union of Parmenter, F. J.: Diverticulum of female urethra . .J. Urol., 45: 476-496, 1941. Cone, R. E.: Diverticulum of female urethra. Urol. & Cutan. Rev., 40: 803, 1936. 12 Higgens, Charles C.: Calculus containing urethral diverticulum in a woman. .J. Urol., 49: 715-720, 1943. 13 Lane, Clayton: Diverticulum of the female urethra with multiple calculi. Urol. & Cut. Rev., 47: 463-364, 1943. 14 Men ville, .John G. and Mitchell, .Joseph D., .Jr.: Diverticulum of the Female Urethra. J. Urol., 51: 411-423. 1944. 15 Furniss, H. D.: Suburethral abscesses and diverticula in the female urethra. J. Urol., 33: 498, 1935. 16 Bi bus, B.: Zur Klinik der Harnriihrensteine beim Weibe. Ztschr. f. Urol., 31: 473-479, 1937. 17 Fromme: Diverticula of urethra. Ztschr. f. Gebwitsch. U. Gynak, 74: 143, 1913. 10 ll

DIVER'l'ICUL UM OF FEMALE URETHRA

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the primary folds in the midline (Johnson18 ). Cases of diverticula in the newborn and in a child one year of age have been reported (De Bary19 ). Symptoms are manifested late rather than early and vary according to the extent of the pathology present. The smaller pouches may be asymptomatic. As they get larger a patient may notice a vaginal mass which causes painful coitus. Dribbling or leakage following the emptying of the bladder is a common occurrence when the patient assumes a standing position. The patient may experience relief from emptying the sac by digital pressure on the anterior vaginal wall. Urinaiy disturbance, such as frequency, dysuria and burning urination depend on the degree of infection present.

Frn. 1

FIG. 2

Fm. 1. Mass bulging from the anterior vaginal wall

Frn. 2. Cannula passed into the pouch.

Diverticulum filled with opaque oil

On physical examination, with the patient in lithotomy position, the diverticulum presents itself as a tumefaction on the anterior vaginal wall (fig. 1). The mass may feel cystic or firm, depending on its contents, e.g. calcareous material or fluid. Pressure on the bulging mass causes cloudy fluid to exude from the external meatus. A probe may be passed freely transurethrally into the pouch and felt vaginally. Diagnosis may be confirmed by urethrocystoscopy and urethrocystography. Roentgenograms will give an exact definition of the condition which is suggested by vaginal inspection and palpation (figs. 2 and 3). Cysts of the vaginal wall and vesicovaginal septum, calculus retained in the urethra, and various degrees of cystocele should be kept in mind in diagnosing a diverticulum. Johnson, C. M.: Diverticula and cyst of the female urethra. J. Urol., S9: 506. 1938. De Bary: Ueber Zevei Falle von Cysten in der Wand der Weiblichen Harnrohe. Arch. F. path. Anat., B. D. 106, S. 65. 18

19

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IRA G. DOWNER AND FRANK D. VIRGILIO

The smaller types of diverticula may be treated conservatively. Dilatation of the opening leading into the pouch followed by irrigation with some urinary antiseptics may suffice to clear the infection and stimulate healing. Young 20 successfully treated a case hy simple incision and carbolization of the sac. However, since most of the smaller pouches become increasingly larger, surgery is the treatment of choice. Hyams 21 believes that invagination and obliteration of the sac precludes the need for cyRtotomy and eliminates complications such

Fro. 4 FIG. 3 FIG. 3. Foley catheter distended with sodium bromide solution. Screw clamp at the external meatus. Diverticulum distended with opaque medium. Fm. 4. Diverticulum in the female urethra

as urinary fistula or stricture. Surgical exciRion has been more widely m,ed with spectacular relief of the patient's symptoms. Many other interesting discussions of the subject are to be found in the literature. 22 - 31 Young, B. R. and McCrea, L. E.: Urol. and Cutan. Rev., 4: 91-93, 1937. Hyams, J. A. and Hyams, M. K.: A new operative procedure for the treatment of diverticulum of the female urethra. Urol & Cu tan. Rev., 43: 573-577, 1939. 22 Young, Hugh H. and Davis, D. M.: Young's Practice of Urology. Philadelphia: W. B. Saunders Co., 1926. 23 Engel, W. J.: Diverticulum of the female urethra . .J. Urol., 45: 703-709, 1941. 2 ·1 Shivers, C.H. and Cooney, C. J.: The formation of calculi in urethral diverticulum of the female; Report of a case. J.A.M.A., 102: 997, 1934. 25 Hall, E. R.: Diverticulum of female urethra. Xort-hwest Med., 35: 379--380, rn:36. 26 Huddy, G. P. B.: Urethral pouches. Brit. J. Surg., 13: 50-57, 1925-26. 27 Earlam, M. S. S.: Diverticula of the female urethra. Australian and K. Zealand J. Surg., 4: 396-403, 1935. 28 Gaston, Eugene A. and Ferrucci, Joseph: Calculus formation in a urethral diverticulum in a woman. New Eng; . .J. Med., 221: 379-383, 1939. 29 Hunner, Guy L.: Calculus formation in a urethral diverticulum in women; Report of 3 cases. Urol. & Cutan. Rev. 1938. 30 McNally, A.: Diverticulum of the female urethra. Ill. M . .f., 69: 23c!-237, 1936. 31 McNally, A.: Diverticulum of the female urethra. Am. ,J. Surg., 28: 177--181, Hl35. 20 21

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CASE REPOR'r

E. M., a housewife, aged 36, was seen in this clinic for the first time on September 12, 1944. She. complained of a tumor in her vagina, and dribbling of urine following the emptying of her bladder. She had this mass for 15 years but did not seek medical aid lintil about 2 years ago, when coitus became very painful. About this time she also noticed leakage of urine after voiding. During the past 6 months the size of the tumor and the dribbling of urine became very annoying and patient decided to have something done. · About 17 years ago the patient was confined to bed for 42 days with an inflammation of the vagina and pelvis associated with urinary disturbances, such as frequency and painful micturition. Her only pregnancy was terminated at 3 months (abortion) . Except for these facts, which may serve as a probable source of infection, the past history is irrelevant. Physical examination was essentially negative except for the pelvis. Inspection revealed a mass, about the size of a walnut, bulging from the anterior vaginal wall in its distal third (fig. 1). On digital pressure it felt cystic and turbid urine exuded from the external meatus. Bimanual examination revealed pelvic inflammatory disease. Cystoscopic examination showed a normal bladder with clear urine. The ureteral orifices appeared normal and clear urine was seen from both sides at regular intervals. Upon withdrawing the cystoscope to the middle third of the urethra an opening, about 0.5 cm. in diameter, could be seen to the right of the midline. Turbid urine escaped through this opening when pressure was made on the anterior vaginal wall tumor. The cystoscope was withdrawn. A cannula was then passed transurethrally into the pouch and the contents estimated at 8 cc. by means of a syringe. Opaque oil was injected into the diverticulum sac and in the antero-posterior views (fig. 2) there was visible an oval shadow of opaque medium having diameters of about 2 by 4 cm. and lying directly beneath the symphysis pubis. (Clinically, of course, it lies between the bladder, urethra and vagina.) In figure 3 another attempt was made to visualize the size and exact location of the diverticulum. A Foley catheter was inserted into the bladder and the diverticulum distended with opaque medium. The catheter was pulled down and a small screw clamp was placed on the catheter at the external meatus. The urethral diverticulum is somewhat oval and slightly irregular in outline, and is roughly one-third of the way from the internal sphincter to the end of the urethra. The urine showed a faint trace of albumin, and about 25- 30 white blood cells per high power field. The blood chemistry was essentially normal. Operation: Under nitrous oxide and oxygen anesthesia the patient was placed in lithotomy position. A Foley catheter was inserted into the bladder. The vagina was prepared for surgery. A 3 inch longitudinal incision was made over the bulging tumor through the thickness of the vaginal mucosa. The sac was dissected down to the neck and excised. The opening into the urethra was then closed over with interrupted sutures of chromic 4-0. The vaginal

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layers were approximated with interrupted chromic O catgut. The vagina was packed with gauze which was removed in 4 days and the indwelling catheter was taken out on the 10th day. Pathological report (Dr. D. C. Beaver): The specimen consists of an irregular segment of tissue, measuring 5.5 by 2 cm. One surface appears to have a smooth lining. The consistency is quite firm. Microscopic sections reveal the mucous membrane to be covered by transitional stratified epithelium which, for the most part, is desquamated. The bare surface is composed of fibrous and granulation tissue. The latter apparently represents chronic ulceration. The ulcerated areas are invaded by polymorphonuclear leukocytes and lymphocytes with considerable extravasation of erythrocytes. Beneath the epithelium, in the submucosa, there is similar but less severe inflammatory reaction. The muscular coat is well defined and is composed of muscle bundles of mixed longitudinal and transverse distribution. The outer coat is composed of fibrous tissue with a number of large vessels present. Diverticulum of urethra with pyogenic infection and ulceration. The postoperative course was uneventful. The wound healed completely in 11 days. She was last seen in the clinic on November 16, 1944 at which time she was completely cured. SUMMARY AND CONCLUSIONS

Literature on diverticulum of the female urethra has been reviewed in reference to definition, incidence, etiology, symptoms, diagnosis and treatment. Attention again is called to this condition by th~ presentation of a recent case. Perhaps this urological pathological entity would become. more common than one is led to believe if every case that came under observation would be reported. Exact statistics as to the frequency of this lesion are not available. The vast majority of the cases are acquired, either from inflammatory process or trauma. Cases believed to be of congenital origin have been reported. We believe the lesion in our patient was of acquired and infectious origin. Diagnosis is not difficult if the condition is borne in mind. It may be made absolute by urethroscopy and urethrography. Excision of the sac is the treatment of choice and results in prompt relief of symptoms.