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Diverticulum of the Female Urethra1
DIVERTICULUM OF THE FEMALE URETHRA1 LT. JOHN G. MENVILLE, MC., U. S. N. R.,
AND
JOSEPH D. MITCHELL, JR.
From the Department of Surgery, Division of Urology, Tulane University School of Medicine, and Charity Hospital of Louisiana, New Orleans, La. ·
Diverticulum of the female urethra produces annoying symptoms, is easyto, diagnose, relatively easy to treat, yet is often overlooked. This latter statement; is so true that for many years this condition was considered rare. Historically,. the first published description of diverticulum of the female urethra appears to, be that of Sir Charles Mansfield Clarke in 1814, while the article of Bozeman in 1871 is credited as being the first American contribution on this subject. Previous to 1935, cases appeared sporadically in the literature, but since then the number of reports has increased to the extent of dispelling the myth that diverticulum of the female urethra is rare. At the University of California Hospital only 2 cases appeared in their records up to May 1936, yet in the following year 9 cases were recognized (Johnson). In an effort to obtain a more accurate picture of the subject, a detailed study was made of 69 case reports readily obtained from the literature, together with 11 cases of our own which we are reporting. Statistics were compiled from these reports. It is acknowledged that some case reports are not as complete as others, and for this reason statistics may seem misleading. However, in the absence of other sources of information, it is felt that such a study may add to the knowledge of diverticula of the female urethra. CASE REPORTS
Case 1. N. D., 50-year-old colored female, complained of a painful lump in the vagina for 10 days. She had borne 1 child, but gave no other history of trauma or infection. Examination revealed a soft, fluctuating mass, about the size of a walnut, below and connected with the urethra. Urine was expelled from the urethral orifice whenever pressure was made over the mass. Operation consisted of dissecting the sac free, ligating the base, excising the distal portion, and reinforcing the urethra with inverting sutures. The patient was discharged on the fifth postoperative day. Case 2. F. L., a 25-year-old colored female, complained of a swelling on the · anterior vaginal wall, for 4 years. She said that the mass enlarged during the act of micturition and that local pressure produced a flow of purulent urine from the urethra and a reduction in the size of the mass. The patient had given birth to 3 children, the last 2 of whom were twins, and she dated her illness back to that event. Examination revealed a tender mass in the anterior vaginal wall which, on pressure, caused urine to flow from the urethra. The patient was discharged for some unknown reason and failed to return for treatment. Case 3. M. M., a 52-year-old female, complained of intermittent pain on 1 The opinions and assertions contained herein are the private views of the writers and are not to be considered as official or reflecting the views of the Navy Department or the Naval Service at large. 411
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urination for many years and hematuria for 4 days. Although married for 30 years she had never been pregnant. Examination revealed a fluctuating mass, the size of a lemon, located on the anterior vaginal wall at about the mid-portion of the urethra. Blood was seen to flow from the urethral orifice. Cystourethroscopy revealed an opening into a diverticulum which extended posteriorly. The diverticulum was filled with blood clots and showed evidence of fresh unclotted blood. The patient was very uncooperative, refusing further examination or treatment and deserting the hospital. This case represents one of the complications of a diverticulum. The presence of fluctuation and the absence of induration are factors against the possibility of malignancy. Case 4- N. P., a 42-year-old colored female complained of a lump in the vagina for 2 days with no associated urologic symptoms. The patient had 1 child, 22 years of age. Examination revealed a fluctuating mass, 2 cm. in di-
FIG. 1. Case 5.
Antero-posterior urethrogram showing a heart-shaped diverticulum
ameter, located below the urethra. Operation consisted in making a vertical incision over the mass and bluntly dissecting it from the surrounding tissues. The sac was thin walled and the opening in the urethra small. The sac was obliterated by serial purse-string sutures. The postoperative course was uneventful and the patient was discharged on the seventh day with good results. Case 5. F. F., a 49-year-old white female, complained of pain on urination and defecation for 3 months. She had borne 2 children. Examination revealed a bulging, extremely tender mass in the vagina below the urethra. No pus or urine could be expressed by pressure over the mass. Urethroscopy revealed an opening into a diverticulum located at the junction of the anterior and middle thirds of the floor of the urethra. A catheter was inserted into the opening and radiopaque material injected. Roentgenograms revealed a heart-shaped diverticulum 3 by 2.5 cm. in the region of the urethra (fig. 1). Operation consisted of a longitudinal incision over the mass, isolation of the sac, and excision at its
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junction with the urethra. The sac was thick walled and so firmly adherent to the surrounding tissue that sharp dissection was neccessary. The opening in the urethra was closed in a transverse direction ,vith interrupted silk sutures followed by reinforcing sutures of chromic No. 2 catgut. An indwelling catheter was used for postoperative drainage and an iodoform pack was left in the vagina. Good results were obtained and the patient was discharged ten days after operation. Case 6. N. S., a 54-year-old colored female, complained of intermittent attacks of difficulty in starting and maintaining the urinary stream, burning and frequency for 1½ years. She had never had any children. Examination failed to reveal any evidence of a vaginal mass. A routine urethroscopic examination revealed 3 small openings on the floor of the posterior urethra, one on the right postero-lateral wall and two on the left postero-lateral wall. A cystourethrogram
Fro. 2. Case 7.
Antero-posterior urethrogram showing a globular shaped diverticulum containing a coiled urethral catheter
was then made by injecting a 5 per cent skiodan solution into the bladder and a 10 per cent skiodan jelly into the urethra. Roentgenograms showed a diverticulum in the region of the urethra. The patient -was discharged to the clinic but she failed to return. Case 7. M. G., a 20-year-old colored female, complained of burning and frequency for 2 days and hematuria for 1 day. She had borne 1 child 10 months previously. Examination revealed a firm, tender mass, about 2 cm. in diameter, located in the midline of the vaginal roof, below the urethral orifice. Pressure over the mass released pus and blood from the meatus. Panendoscopy revealed a minute opening on the right lateral ,rnll of the floor of the posterior urethra. A ureteral catheter was passed through the opening and 5 per cent sodium iodide was injected. Roentgenograms revealed a rounded, globular mass 2.5 by 2.5 cm. in the region of the urethra (fig. 2). Operation consisted of a longitudinal incision over the mass, isolation and excision of the sac. The neck of the sac
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was inverted with a purse-string linen suture, followed by reinforcing linen sutures. The sac was thin walled. An indwelling Foley catheter was inserted and left in place for 10 days, at which time it was removed and the patient discharged. Subsequent examinations 3 and 6 months later revealed excellent functional and anatomic results. Case 8. E. D., a 32-year-old colored female, complained of local pain and tenderness at the urethral orfice without urinary symptoms for l½ months. She had had 7 children and one ruptured tubal pregnancy. Examination revealed a firm, very tender mass, 2 by 2.5 cm., on the anterior vaginal wall in the region of the mid-urethra. Pressure over the mass resulted in the flow of clear urine from the urethral orifice. Panendoscopic examination revealed a minute opening on the right lateral floor of the mid-urethra. Repeated attempts to catheterize the opening were unsuccessful. Urethrograms made by injecting radiopaque solution into the bladder and radiopaque jelly into the urethra revealed a round diverticulum 2.5 by 2 cm. in the region of the urethra. Opera-
Fw. 3. Case 9.
Right oblique cystogram showing an ovoid diverticulum of the urethra
tion consisted of a longitudinal incision over the mass, isolation and excision of the sac at its neck. The neck was inverted by a purse-string linen suture, followed by reinforcing catgut sutures. The sac was thin walled. The operation was facilitated by traction on a Foley catheter. The catheter was left as an indwelling one for 10 days, and the patient was discharged from the hospital. A subsequent examination 3 months later revealed excellent anatomic and physiologic results. Microscopic examination of the specimen showed chronic inflammation and fibrosis of the walls of a diverticulum with no evidence of mucosa. Case 9. M. S., a 69-year-old colored female, complained of intermittent attacks of dysuria, frequency, burning, and dribbling for I½ years. She had had 10 children. Examination revealed a tender, fluctuating mass, 1 by 2 cm., in the anterior vaginal wall in the mid-third of the urethra. Pressure over the mass resulted in pus and urine flmving from the meatus. Urethroscopic examination showed a minute opening on the mid-third of the floor of the urethra. Re-
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peated attempts to catheterize the opening were unsuccessful. A cystogram revealed an ovoid diverticulum 1 by 1.5 cm. in the region of the urethra (fig. 3). The patient was discharged to the clinic for further observation. Case 10. L. P., a 36-year-old colored female, complained of passing feces through the vagina without any urologic symptoms. She had borne 5 children. Examination revealed a complete perineal tear in the posterior vagina and a mass in the anterior vaginal wall below the urethral meatus. Pressure over the mass resulted in a flow of pus from the urethra. Operation consisted of a vaginal hysterectomy, followed by excision of a urethral diverticulum and a repair of the perineal laceration. The diverticulum was excised and the opening closed by interrupted cotton sutures. Subsequent examination three months later revealed good functional results. Case 11. F. S., a 35-year-old white female, complained of dysuria, occasional hematuria, localized burning, and a lump in the vagina for 7 years. She had borne 3 children, the youngest of whom was 7 years of age. Examination revealed a non-tender, fluctuating mass, 2 by 2 cm., in the anterior wall of the vagina approximately 2 cm. from the urethral meatus. Urethroscopic examination showed 2 openings in the middle third of the urethra on the left lateral wall. These openings could not be visualized by a foroblique cystoscopic lens, but could be seen by a right angle lens. They would not admit a No. 4 F. urethral catheter. A urethrogram was made by forcing radiopaque dye through a perforated Foley catheter, the bag of which occluded the bladder neck, while a snug-fitting perforated soft rubber nozzle was held against the meatus. The roentgenogram revealed a diverticulum, 2 by 2 cm., in the region of the mid-portion of the urethra. Through a transverse vaginal incision, a thin-walled sac was obliterated by chromic catgut mattress sutures. An indwelling urethral catheter was inserted, to be removed on the eleventh post-operative day. Subsequent examination six weeks after operation revealed complete healing, with no constriction of the urethra. INCIDENCE
At Charity Hospital of Louisiana, in New Orleans, there were 510,585 female admissions from January 1, 1922 to June 1, 1943. The white females numbered 265,815 as compared to 244,770 colored females. Among this group, 13 cases of urethral diverticulum, 2 cases of periurethral abscess, and 5 cases of periurethral cysts were recognized. Two of the cases of urethral diverticulum contained calculi and are to be reported separately. We believe that these cases seen and recognized in no way represent the true incidence of these conditions at this institution. RACE
Facts of racial incidence cannot be obtained from the literature because of insufficient data. However, it is significant that in this series, collected from a relatively equal number of white and colored patients, the ratio was found to be 8 colored to 3 white.
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JOHN G. MENVILLE AND JOSEPH D. MITCHELL, JR. AGE
Of the 80 cases reviewed (inclusive of the 11 cases reported in this paper), age was mentioned in 79, and the average was found to be 38.8 years. The eldest was 69 and the youngest 20 years. ETIOLOGY
Opinion concerning the etiology of diverticula of the female urethra is divided. Johnson and Parmenter believed that most are congenital in origin and, with others, suggest Gaertner's duct, Wolffian duct, cell rests, and congenital cysts as possible causes. By analogy, it has been argued that since many diverticula of the male urethra are considered congenital in origin, such a condition may also exist in the female It must be remembered, however, that the anatomy of the urethra and its surrounding structures in each sex are different, and that the female urethra develops from the vesico-urethral portion of the cloaca and is homologous only with that part of the male urethra extending from the internal urethral orifice to the prostatic utricle. That the posterior urethra is not a frequent site for congenital diverticula is borne out by Kaufman, who stated that, to be congenital, a diverticulum of the male urethra must be in the pendulous portion. A most convincing argument against the congenital origin in females is the absence of any reported case in an infant. Such an instance is credited to Johnson, but, in reality, the case in question involved a cyst and not a diverticulum. From this, it may be inferred that such a lesion is not congenital in origin, yet case reports of an aberrant ureter opening into a urine pocket or diverticulum, by Fromme and Folsom, lend credence to the belief that, for instance, a congenital theory is justified. In support of a congenital theory, Earlum suggested congenital structural weakness of the urethra. In contrast to the above, there is the prevailing opinion that the majority of diverticula are acquired. Gorowitz, Furniss and others believed that all are acquired. The frequency with which urethral and periurethral glands are mentioned as factors in the acquired theory is evidence that the presence of such glands was accepted by many. Cabot and Shoemaker, however, in an original study concluded that normally there are no important glandular structures in the proximal two-thirds of the female urethra. In a similar study, MacKenzie and Beck reported inconstant findings of periurethral tubular structures in female infants distinct from Skene's glands. Recently, Beneventi found true prostatic glandular tisssue in the posterior urethra of the female newborn in 2 cases. In 24 reported cases showing microscopic sections of diverticula excised, only two of such cases presented glandular epithelium. On the other hand, rnultilocular diverticulum cavities (Engel, Schmitz and Nelson, Parmenter, the work of Beneventi, and the case report of Folsom and O'Brien showing tissue removed from a female bladder neck which has an appearance similar to that of prostatic hyperplasia) suggest that, in instances, it is possible to have glandular structures, other than a Skene's gland, adjacent to the female urethra. Opinions regarding the acquired theory are as follows: Routh believed that
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the lesions resulted from closed ducts of pre-existing glands, with the formation of cysts which, later, ruptured into the urethra. Rupture of blood cysts and pseudo-cysts were also considered as possibilities. Latzko and Engel believed in a glandular-cyst theory, but also included periurethral abscess in that category. Latzko felt that obstetrical trauma was a factor. Lewis, likewise, adhered to the glandular-cyst theory. Rupture of suburethral abscess into the urethra is mentioned prominently in the literature as a causative factor, and the history recorded in the cases presented by Engel, Furniss, and McNally substantiates this contention. The possibility of traction on the urethra by scar tissue resulting from periurethritis was suggested by Hirsch. Among other possibilities mentioned are vaginal cysts. Lewis and others believed that trauma played a part in the etiology. Trauma as a factor is proved in one of Walters and Thiessen's cases in which a diverticulum resulted at the site of the fulguration of a urethral polyp. Among other types of trauma mentioned are instrumentation, passage of stones and foreign bodies, rough packing of the vagina, coitus and childbirth. The latter undoubtedly plays a part in certain cases, for occasionally the onset of symptoms dates back to such an event. Catheterization and infection of the urethra associated with childbirth should be considered equal in importance to the trauma of childbirth. The majority of the types of trauma mentioned are so frequently experienced, with no resulting diverticulum, that they should be . considered as predisposing or aggravating factors only. Of the 80 cases studied, 38 gave a history of childbirth, 7 specifically stated that there were no deliveries, while no data were available in the remaining 35. Twenty of the cases were multipara and, of these, 2 were decapara. Fifteen of the parous women gave histories of additional trauma, e.g., forcep delivery, dystocia, podalic version, vaginal tears, periurethral abscess, and cysts. With the exception of 3 instances of miscarriage, the multipara gave no history of trauma. Of the 35 patients giving no data regarding children, 11 gave a history of trauma, while 4 additional patients reported miscarriage or abortion. Resistance to the outflow of urine, felt to he so important in the development of diverticulum of the bladder, should be considered. In a few instances strictures of the urethra have been associated with diverticulum of the female urethra. Interestingly enough, Furniss reported such a case, in which the history of a tight urethra dated back 19 years. Lower not only felt that obstruction to the fl.ow . of urine played a part, but reminded us that the meatus is the narrowest portion of the urethra. It must be remembered, however, that relatively few of the cases reported in the literature gave a history of obstruction or presented constriction of the meatus or urethra. There was no such obstruction in our series, but four were mentioned in the literature. Although merely of academic importance, the question of true versus false diverticulum is often raised. The diagnosis of a true diverticulum based on the presence of an epithelial lining is inaccurate, for a well drained false diverticulum may acquire an epithelial lining and a true diverticulum may lose its lining in the presence of infection, stone, or both. These latter factors may also destroy the orignal walls of a diverticulum. On the basis of microscopic sections of the walls
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of diverticula removed, one may say that the majority are false, for, in 24 cases, only three presented evidence of muscle fibres. SYMPTOMS
Although the size of the diverticulum influences the symptoms, it is probable that the presence of infection and the ability of the diverticulum to empty itself or to be emptied play the most important roles. Symptoms of a diverticulum are predominantly local and are referable to the lower urinary tract. They are variable, intermittent, multiple, and usually of long duration. All diverticula do not cause symptoms. In the early stages they are non-infected, or only mildly so, and consequently produce few symptoms. A typical history is exemplified by intermittent attacks of dysuria, frequency, fluctuating mass in the anterior vaginal wall, partial incontinence, discharge of pus or a cloudly urine from the urethra, and pain in the urethra. If the pain is severe, the patient may also note discomfort on walking or sitting, and may also complain of dyspareunia. Of these, the only pathognomonic symptom is a mass which empties on pressure. Occasionally, the patient may learn that pressure over the "bulge" in the anterior vaginal region gives relief of her symptoms. An intelligent patient may also note an enlargement of the mass after voiding. It is possible that symptoms from a tight meatus or stricture of the urethra may dominate those of a diverticulum. In addition to infection, such complications as calculus, blood clot, and epithelioma (reported by Walters and Thiessen) contribute to the clinical picture. 80
SYMPTOMS IN
Dysuria, 56 Frequency, 32 Lump in vagina, 18 N octuria, 12 Partial incontinence, 12 Intermittent discharge from urethra, 11 Difficulty on urination, 10 Pain on urination, 9 Hematuria, 9 Painful lump in vagina, 8 Painful coitus, 6 Pain in region of urethra, 6 Soreness of vagina, 5 Upper lumbar pain, 5 Suprapubic pain, 5 Bearing-down sensation, 5 Backache, 4
CASES
Fluctuating mass, 3 Acute retention, 3 Urgency, 3 Decrease of mass on pressure, 2 Soreness of vagina on sitting, 2 Pain in vagina on walking, 2 Chronic retention of urine, 2 Pain at start of urination, 1 Soiling of clothing on coughing or sneezing, 1 Rupture of periurethral abscess, 1 Increase of mass during micturition, 1 Bloody urethral discharge, 1 Stricture of urethra, 1 Cloudy urine, 1 Pain over coccyx, 1 Vague pelvic pains, 1 SIGNS
Diverticula generally assume a rounded, saccular form but a variety of shapes may be found. Some sacs may encircle the urethra (Engel), while others undermine the internal sphincter and trigone (Parmenter). The fact that a mass may not be palpable is borne out by 4 case reports in the literature. The size is variable and ranges from a "pea" to that of a "hen's egg." In addition to these descriptive terms, reported cases have been described as follows: marble, lima bean, almond, olive, walnut., plum, and lemon. The size, as mentioned in
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the metric system, was so seldom stated that in this report figures were incorporated in the "household system" for the purpose of statistics. As a basis, "marble" is used for "small," "walnut" for "medium," and "lemon" for "large." In 80 cases, 14 were small, 19 medium, and 12 large. No mass was found in 4 and no mention of size in 31. On palpation the most typical sign is a fluctuating, mobile mass, with or without tenderness, which empties on pressure. A discharge from the urethra of foul urine or pus usually results from pressure on the vaginal mass. There are exceptions to this, however; in one of our cases pressure over the mass failed to produce a discharge and did not reduce the size of the mass. In another case, pressure over the mass produced a bloody discharge. Not infrequently the lesion, as a result of chronic infection, presents a thickened wall, with areas of firmness along its edges. When complicated by calculi, the lesions are hard and associated with crepitation. Findings on palpation may be more accurately interpreted by having a urethral catheter or sound in place. DIAGNOSIS
The four important points in the diagnosis are: (1) a careful history which often creates a suspicion of the lesion, (2) a thorough physical examination, (3) urethroscopic examination, and (4) urethrography. To these may be added a plain roentgenogram when a calculus is suspected. It may be necessary to examine a patient on more than 1 occasion, for the diverticulum may be empty on the first examination and filled on the second. Such a case was reported by Schmitz and Nelson. A similar instance was a source of embarrassment to Priestly, who invited a consultation on one of his cases: much to his chagrin, the mass had disappeared when the consultant arrived. In distinguishing a diverticulum from periurethral pathology not communicating with the urethra, a careful urethroscopic examination is necessary. This is best carried out with a panendoscope. The location of the diverticulum opening in the urethra was mentioned in 43 cases of the present study, and was found to be predominantly in the middle third. The locations were as follows: Anterior third, 2 cases; junction of anterior and middle thirds, 5 cases; middle third, 20 cases; junction of middle and posterior thirds, 9 cases; posterior third, 7 cases. Multiple openings were found in 8 of the reviewed cases. Openings in the urethra may be partially hidden by a fold of mucosa or they may be in the midst of granulation tissue. In one of our cases an opening could not be seen with a foroblique lens but could be observed with a right angle lens. If small openings point toward the bladder, a retrograde lens may be necessary. When possible, a urethral catheter should be fed into the opening and a plain roentgenogram made of the coiled catheter in place. By injecting a radiopaque solution through the catheter one obtains a most satisfactory visualization of the sac. The above method has its failings, because the openings may not be located and, in instances, only one opening may be detected when actually there are more. In such cases resort may be had to a urethrogram. Furniss used this method in visualizing 3 diverticula in a case in which only one urethral opening was seen.
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A urethrogram may be made in a number of ways. Schulz demonstrated that a diverticulum may be filled by injecting radiopaque solution into the urethra and having the patient void against the pressure. It may also be accomplished by exerting traction on a small Foley bag and injecting the urethra alongside the catheter. A method also used is to fill the bladder with radiopaque solution and have the patient void the bladder contents. In two of his cases, Townsend used radiopaque jelly in a syringe with good results. Diverticula must be distinguished from cystocele, prolapse of the anterior vaginal wall, vaginal cysts, periurethral abscess, granular urethritis, infections of the urethra, cysts and abscesses of Skene's glands, stricture and malignancy of the urethra. The most common complication of diverticulum of the female urethra is infection, although calculus formation in a diverticulum is not uncommon. Fistulre, hemorrhage, and malignancy have also been reported. TREATMENT
Treatment may be divided into (1) conservative, and (2) radical. The conservative may be subdivided into (a) surgical, and (b) non-surgical. Conservative non-surgical treatment consists of periodic dilatation of the urethra, together with urethral irrigations or injections with an appropriate antiseptic. Such a procedure is not satisfactory and is seldom advocated, but is nevertheless resorted to when patients refuse a more radical procedure. The use of a cystoscopic cautery knife to enlarge the urethral opening of a diverticulum is a conservative surgical procedure which promotes better surgical drainage but does not cure, and, at best, merely lessens the chances of infection by creating an environment less compatible with an infectious process. It may be used to advantage when a more radical procedure is contra-indicated and in a diverticulum which drains poorly. Pugh used this method with success in 1 case, while Parmenter reported a failure in 1 case. A second conservative surgical procedure is one of incision and drainage through the vaginal route. Parmenter and Furniss have both reported failures with this procedure. We feel that this method should be reserved for poorly draining diverticula harboring an acute suppurative process pointing into the vagina. If used in such cases, a secondary closure can be made at a later date. A third conservative surgical procedure is invagination and obliteration of the sac by a series of purse-string sutures, as advocated by Hyams and Hyams. In the latters' case report, the narrow neck of the diverticulum prevented the intrusion of the impacted saccular mass into the urethra. A variation of this procedure was successfully used in one of our cases, but proved to be a failure in a case of Walters and Thiessen. Invagination of the sac should prove successful if the sac is thin and its neck small. Radical treatment consists of excision of the sac. It is the method in which a cure can be expected and is the procedure of choice. Exceptions to this include old persons with mild symptoms, particularly poor operative risks; and patients whose diverticula present a clinical picture comparable to a periurethral abscess. The operative procedure is facilitated by traction on the bladder neck with a
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balloon-type catheter or a prostatic retractor. This brings the lesion into a more favorable position and serves as a guide to the urethra during the operation. The most widely accepted incision is a vertical one over the mass, but transverse, T-shaped, and a vertical incision lateral to the midline have been employed. The most popular disposal of the sac is amputation, followed by closure of the urethral defect. Redundant vaginal mucosa is excised and the wound closed in two or three layers. The urethral defect is usually closed with fine chromic catgut sutures. The vaginal wound may be closed with non-absorbable or absorbable sutures; the reported results with both are approximately the same. Drainage of the wound is unnecessary except for hemorrhage or infection. A relaxed sphincter or one damaged at operation should beshortened by interrupted non-absorbable sutures. Postoperative packing of the vagina with gauze may be used (Hunner, Parmenter, Lower and Tormey, Rashbaum and Seley and others). Suprapubic drainage, to facilitate healing of the urethral defect, was used by Furniss and by Shivers and Cooney, but it is questionable whether this extensive procedure is advisable in the face of good results obtained by urethral catheter drainage. A self-retaining catheter for from 7 to 10 days after operation is believed to be adequate. Plain rubber cathethers should be used in individuals susceptible to latex rubber. We feel that successful wound closure is synonymous with proper mobilization of tissues and the absence of tension on suture lines. This can be acomplished in closure of the urethral defect by inverting the proximal end of the neck of the sac. A part of the sac was used in the closure of one of Cone's cases, while Hunner and Parmenter each inverted a part of the neck with a purse-string suture. We believe that a large urethral defect, associated with a thick neck and chronic inflammatory changes in the suburethral tissue, is best closed by destroying the lining membrane of the neck and that portion of the membrane bordering the urethra with a light cautery, followed by ligation of the stump. Such a procedure should be free from any resulting stricture of the urethra at the operative site. Preoperative strictures of the urethra should receive periodic dilatations after operation, and all operative cases should be checked post-operatively for stricture formation of the urethra. PATHOLOGY
Unfortunately, there is insufficient evidence in the literature and in our series to warrant any dogmatlic statements concerning the pathology of the cases seen and reported. However, it is our impression that the majority of the diverticula have thickened fibrous walls, with chronic inflammatory changes. In addition to our cases, .Johnson, Parmenter, McNally, H. H. Young, Engel, Schmitz and Nelson, and Rashbaum and Seley have together reported microscopic sections in 24 cases. In 16, a lining membrane was noted and this varied as follows: squamous, cuboid, columnar, transitional, stratified squamous, pseudo-stratified squamous, and endothelial. Every case, excepting that of Young, showed inflammatory changes. Muscle fibres were reported in three cases (Parmenter, Cromer and Belt, and McNally). The remainder of the cases showed either
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granulation or fibrous tissue or both. Glandular tissue was reported in two cases (Parmenter and Engel). In one case (Schmitz and Nelson), the pathologic report mentioned only the lining of the sac. Multilocular sacs have been reported by Parmenter, Engel, and Schmitz and Nelson. DISCUSSION
In rare instances it is believed that a urethral diverticulum may be congenital in origin. After studying the cases presented in this paper and many case reports, no clue was found which explained the origin of all diverticula. The multiplicity of factors noted and the variety of findings suggest a number of causes. The history and findings prominent in one case are absent in another, and vice versa. Of the findings, trauma and infection seem to play the leading r6les. With exceptions, the formation of a suburethral sac or diverticulum is due to a bulge in the floor of the urethra, which occurs in a weakened area, carrying with it the anatomical structures of the urethra, or to a dilatation of a pre-existing tubule or gland or both. The virtual absence of muscle fibres and variation in the membranous lining of the sacs examined microscopically support our contention that most of the diverticula reported are false. Because the openings in the urethra of the glands of Littre, the follicles of Morgagni and possibly other inconstant glandular structures around the urethra may be plugged so easily, these structures are logical sites of cystic dilatation. This cystic dilatation may or may not be infected. If the dilatations are acutely infected and the drainage into the urethra is poor, a periurethral abscess results. This close association between an infected, dilated sac or diverticulum and an abscess may explain their confusion in the literature. Once a pocket is formed, it is easy to see how trauma and the accumulation of urine could cause a weakening of the walls and dilatation along the lines of least resistance. When infection begins, the walls of the sac are invaded and become thickened by chronic inflammatory changes. Interestingly enough, we have failed to obtain evidence of infected diverticula acting as foci of infection. We believe this interpretation to be the basis for the formation of the majority of diverticula of the female urethra. CONCLUSIONS
Eleven cases of diverticulum of the female urethra are reported. At Charity Hospital of Louisiana, in New Orleans, the incidence was found to be predominantly in the colored race. The lesion is acquired in the vast majority of cases and almost invariably becomes infected. The pathognomonic sign is a fluctuating mass which empties on pressure. The treatment of choice is excision of the sac. REFERENCES BENEVENTI, F. A.: A study of posterior urethra in the newborn female. Surg., Gynec. and Obst., 76: 64-76, 1943. BozEMAN, N.: Urethrocoele, catarrh, and ulceration of the bladder in females. Am. J. Obst., 3: 656, 1871.
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CABOT, H., AND SHOEMAKER, R.: The r6le of glands of the female urethra in the production of infection of the urinary tract. Trans. Am. Assoc. Genito-urin. Surg., 29: 461, 1936. CLARKE, Sm CHARLES M.: On Diseases of Females. London; Longman & Co., 1814, p. 269. Quoted by Young and McCrae. CoNE, R. E.: Diverticulum of the female urethra. Urol. and Cut. Rev., 40: 803, 1936. CROMER, J. K., AND BELT, N.: Diverticulum of the female urethra. Med. Ann. of Dist. of Columbia, 8: 173, 1939. EARLUM, M. S. S.: Diverticulum of the female urethra. Aust. and New Zeal. J. Surg., 4: 396, 1935. ENGEL, W. J.: Diverticulum of the female urethra. J. Urol., 45: 703, 1941. FOLSOM, A. I.: Discussion of sub-urethral abscesses and diverticula in the female urethra, by H. D. Furniss. J. Urol., 33: 498, 1935. FOLSOM, A. I., AND O'BRIEN, H. A.: The female obstructing prostate. J. A. M. A., 121: 573, 1943. FROMME, F.: Ueber Harniihrendivertikel. Ztschr. f. Geburtsh. u. Gynak., 74: 143, 1913. FuRNISS, H. D. :__ Diverticulumin the female urethra. Am. J. Surg., 28: 177, 1935. GoROWITZ, P.: Uber Divertikel der Weiblichen Harnriihre. Ztschr. f. urol. Chir., 22: 183, 1928. HALL, E. R.: Diverticulum offemale urethra. Northwest. Med., 35: 379, 1936. HrnscH, E. F.: Quoted by McNally. HuNNER, G. L.: Calculus formation in a urethral diverticulum in women. Urol. and Cut. Rev., 42: 336, 1938. HYAMS, J. A., AND HYAMS, M. N.: Anew operative procedure for the treatment of diverticulum of the female urethra. Urol. and Cut. Rev., 43: 573, 1939. HYMAN, A., AND LEITER, H. E.: Diverticulum of the female urethra. J. Mt. Sinai Hosp., 6: 190, 1939. JOHNSON, C. M.: Diverticula and cysts of the female urethra. J. Urol., 39: 506, 1938. KAUFMAN, C.: Verleitzungen und Krankheiten des Mannlichen Harnriihre und des Penis. Deutsche Chir., 1886. Quoted by McNally. LATZKO, W.: Handbuch der Urologie. A. von Lichtenberg, F. Voelcker, und H. Wildbolz. 1: 921, 1928. LEWIS, E. C.: Urology in Women. London: Bailliere, Tindall & Cox, 2nd Ed., 1936, p. 15. LOWER, W. E., AND TORMEY, T. W.: Diverticulum of the female urethra. Ann. Surg., 107: 923, 1938. MACKENZIE, D. W., AND BECK, S.: A histopathological study of the female bladder neck and urethra. Trans. Am. Assoc. Genitourinary Surg., 29: 227, 1936. McNALLY, A.: Diverticula of the female urethra. Am. J. Surg., 28: 177, 1935. McNALLY, A.: Diverticula of the female urethra. Ill. M. J., 69: 234, 1936. NEEL, J. C.: Diverticula of the female urethra. Calif. St. J. Med., 16: 494, 1918. PARMENTER, F. J.: Diverticulum of the female urethra. J. Urol., 45: 479, 1941. PRATT, J.P.: Diverticulum of the female urethra. Urol. and Cut. Rev., 42: 803, 1938. PRIESTLY, W. 0.: Examples of cyst formation in the neighborhood of the female urethra. Brit. M. J., 1: 6, 1869. PUGH, W. S.: Strictures and urethral abscesses in women. Am. Med., 38: 156, 1932. RASHBAUM, M., AND SELEY, G. P.: Diverticulum of female urethra. N. Y. St. J.M., 42: 243, 1942. ROUTH, A.: Urethral diverticula. Trans. Obst. Soc. London, 32: 69, 1890. SCHMITZ, H. E., AND NELSON, P.A.: Suburethral abscesses, urine pockets, and diverticula in the female urethra. Am. J. Obst. and Gynec., 38: 707, 1939. SCHULZ: Quoted by Johnson. SHIER, R. V. B.: A case of diverticulum of the urethra in the female. Canad. Med. Assoc. J., 22: 539, 1930. SHIVERS, C.H., AND CooNEY, C. J.: The formation of calculi in urethral diverticula of the female. J. A. M.A., 102: 997, 1934. TOWNSEND, J.M.: Diverticulum of the female urethra. Urol. and Cut. Rev., 42: 706, 1938. WALTERS, W., AND THIESSEN, N. W.: Urethral diverticulum. Minn. Med., 19: 218, 1936. YouNG H. H.: Diverticulum of the female urethra. South. Med. J., 31: 1043, 1938. YouNG; B. R., AND McCRAE, L. E.: Urethrocoele; urethral. diverti_culum; sub-urethral abscess in the female: roentgen appearance; treatment; review of literature; report of a case. Urol. and Cut. Rev., 41: 91, 1937.
AND
JOSEPH D. MITCHELL, JR.
From the Department of Surgery, Division of Urology, Tulane University School of Medicine, and Charity Hospital of Louisiana, New Orleans, La. ·
Diverticulum of the female urethra produces annoying symptoms, is easyto, diagnose, relatively easy to treat, yet is often overlooked. This latter statement; is so true that for many years this condition was considered rare. Historically,. the first published description of diverticulum of the female urethra appears to, be that of Sir Charles Mansfield Clarke in 1814, while the article of Bozeman in 1871 is credited as being the first American contribution on this subject. Previous to 1935, cases appeared sporadically in the literature, but since then the number of reports has increased to the extent of dispelling the myth that diverticulum of the female urethra is rare. At the University of California Hospital only 2 cases appeared in their records up to May 1936, yet in the following year 9 cases were recognized (Johnson). In an effort to obtain a more accurate picture of the subject, a detailed study was made of 69 case reports readily obtained from the literature, together with 11 cases of our own which we are reporting. Statistics were compiled from these reports. It is acknowledged that some case reports are not as complete as others, and for this reason statistics may seem misleading. However, in the absence of other sources of information, it is felt that such a study may add to the knowledge of diverticula of the female urethra. CASE REPORTS
Case 1. N. D., 50-year-old colored female, complained of a painful lump in the vagina for 10 days. She had borne 1 child, but gave no other history of trauma or infection. Examination revealed a soft, fluctuating mass, about the size of a walnut, below and connected with the urethra. Urine was expelled from the urethral orifice whenever pressure was made over the mass. Operation consisted of dissecting the sac free, ligating the base, excising the distal portion, and reinforcing the urethra with inverting sutures. The patient was discharged on the fifth postoperative day. Case 2. F. L., a 25-year-old colored female, complained of a swelling on the · anterior vaginal wall, for 4 years. She said that the mass enlarged during the act of micturition and that local pressure produced a flow of purulent urine from the urethra and a reduction in the size of the mass. The patient had given birth to 3 children, the last 2 of whom were twins, and she dated her illness back to that event. Examination revealed a tender mass in the anterior vaginal wall which, on pressure, caused urine to flow from the urethra. The patient was discharged for some unknown reason and failed to return for treatment. Case 3. M. M., a 52-year-old female, complained of intermittent pain on 1 The opinions and assertions contained herein are the private views of the writers and are not to be considered as official or reflecting the views of the Navy Department or the Naval Service at large. 411
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urination for many years and hematuria for 4 days. Although married for 30 years she had never been pregnant. Examination revealed a fluctuating mass, the size of a lemon, located on the anterior vaginal wall at about the mid-portion of the urethra. Blood was seen to flow from the urethral orifice. Cystourethroscopy revealed an opening into a diverticulum which extended posteriorly. The diverticulum was filled with blood clots and showed evidence of fresh unclotted blood. The patient was very uncooperative, refusing further examination or treatment and deserting the hospital. This case represents one of the complications of a diverticulum. The presence of fluctuation and the absence of induration are factors against the possibility of malignancy. Case 4- N. P., a 42-year-old colored female complained of a lump in the vagina for 2 days with no associated urologic symptoms. The patient had 1 child, 22 years of age. Examination revealed a fluctuating mass, 2 cm. in di-
FIG. 1. Case 5.
Antero-posterior urethrogram showing a heart-shaped diverticulum
ameter, located below the urethra. Operation consisted in making a vertical incision over the mass and bluntly dissecting it from the surrounding tissues. The sac was thin walled and the opening in the urethra small. The sac was obliterated by serial purse-string sutures. The postoperative course was uneventful and the patient was discharged on the seventh day with good results. Case 5. F. F., a 49-year-old white female, complained of pain on urination and defecation for 3 months. She had borne 2 children. Examination revealed a bulging, extremely tender mass in the vagina below the urethra. No pus or urine could be expressed by pressure over the mass. Urethroscopy revealed an opening into a diverticulum located at the junction of the anterior and middle thirds of the floor of the urethra. A catheter was inserted into the opening and radiopaque material injected. Roentgenograms revealed a heart-shaped diverticulum 3 by 2.5 cm. in the region of the urethra (fig. 1). Operation consisted of a longitudinal incision over the mass, isolation of the sac, and excision at its
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junction with the urethra. The sac was thick walled and so firmly adherent to the surrounding tissue that sharp dissection was neccessary. The opening in the urethra was closed in a transverse direction ,vith interrupted silk sutures followed by reinforcing sutures of chromic No. 2 catgut. An indwelling catheter was used for postoperative drainage and an iodoform pack was left in the vagina. Good results were obtained and the patient was discharged ten days after operation. Case 6. N. S., a 54-year-old colored female, complained of intermittent attacks of difficulty in starting and maintaining the urinary stream, burning and frequency for 1½ years. She had never had any children. Examination failed to reveal any evidence of a vaginal mass. A routine urethroscopic examination revealed 3 small openings on the floor of the posterior urethra, one on the right postero-lateral wall and two on the left postero-lateral wall. A cystourethrogram
Fro. 2. Case 7.
Antero-posterior urethrogram showing a globular shaped diverticulum containing a coiled urethral catheter
was then made by injecting a 5 per cent skiodan solution into the bladder and a 10 per cent skiodan jelly into the urethra. Roentgenograms showed a diverticulum in the region of the urethra. The patient -was discharged to the clinic but she failed to return. Case 7. M. G., a 20-year-old colored female, complained of burning and frequency for 2 days and hematuria for 1 day. She had borne 1 child 10 months previously. Examination revealed a firm, tender mass, about 2 cm. in diameter, located in the midline of the vaginal roof, below the urethral orifice. Pressure over the mass released pus and blood from the meatus. Panendoscopy revealed a minute opening on the right lateral ,rnll of the floor of the posterior urethra. A ureteral catheter was passed through the opening and 5 per cent sodium iodide was injected. Roentgenograms revealed a rounded, globular mass 2.5 by 2.5 cm. in the region of the urethra (fig. 2). Operation consisted of a longitudinal incision over the mass, isolation and excision of the sac. The neck of the sac
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was inverted with a purse-string linen suture, followed by reinforcing linen sutures. The sac was thin walled. An indwelling Foley catheter was inserted and left in place for 10 days, at which time it was removed and the patient discharged. Subsequent examinations 3 and 6 months later revealed excellent functional and anatomic results. Case 8. E. D., a 32-year-old colored female, complained of local pain and tenderness at the urethral orfice without urinary symptoms for l½ months. She had had 7 children and one ruptured tubal pregnancy. Examination revealed a firm, very tender mass, 2 by 2.5 cm., on the anterior vaginal wall in the region of the mid-urethra. Pressure over the mass resulted in the flow of clear urine from the urethral orifice. Panendoscopic examination revealed a minute opening on the right lateral floor of the mid-urethra. Repeated attempts to catheterize the opening were unsuccessful. Urethrograms made by injecting radiopaque solution into the bladder and radiopaque jelly into the urethra revealed a round diverticulum 2.5 by 2 cm. in the region of the urethra. Opera-
Fw. 3. Case 9.
Right oblique cystogram showing an ovoid diverticulum of the urethra
tion consisted of a longitudinal incision over the mass, isolation and excision of the sac at its neck. The neck was inverted by a purse-string linen suture, followed by reinforcing catgut sutures. The sac was thin walled. The operation was facilitated by traction on a Foley catheter. The catheter was left as an indwelling one for 10 days, and the patient was discharged from the hospital. A subsequent examination 3 months later revealed excellent anatomic and physiologic results. Microscopic examination of the specimen showed chronic inflammation and fibrosis of the walls of a diverticulum with no evidence of mucosa. Case 9. M. S., a 69-year-old colored female, complained of intermittent attacks of dysuria, frequency, burning, and dribbling for I½ years. She had had 10 children. Examination revealed a tender, fluctuating mass, 1 by 2 cm., in the anterior vaginal wall in the mid-third of the urethra. Pressure over the mass resulted in pus and urine flmving from the meatus. Urethroscopic examination showed a minute opening on the mid-third of the floor of the urethra. Re-
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peated attempts to catheterize the opening were unsuccessful. A cystogram revealed an ovoid diverticulum 1 by 1.5 cm. in the region of the urethra (fig. 3). The patient was discharged to the clinic for further observation. Case 10. L. P., a 36-year-old colored female, complained of passing feces through the vagina without any urologic symptoms. She had borne 5 children. Examination revealed a complete perineal tear in the posterior vagina and a mass in the anterior vaginal wall below the urethral meatus. Pressure over the mass resulted in a flow of pus from the urethra. Operation consisted of a vaginal hysterectomy, followed by excision of a urethral diverticulum and a repair of the perineal laceration. The diverticulum was excised and the opening closed by interrupted cotton sutures. Subsequent examination three months later revealed good functional results. Case 11. F. S., a 35-year-old white female, complained of dysuria, occasional hematuria, localized burning, and a lump in the vagina for 7 years. She had borne 3 children, the youngest of whom was 7 years of age. Examination revealed a non-tender, fluctuating mass, 2 by 2 cm., in the anterior wall of the vagina approximately 2 cm. from the urethral meatus. Urethroscopic examination showed 2 openings in the middle third of the urethra on the left lateral wall. These openings could not be visualized by a foroblique cystoscopic lens, but could be seen by a right angle lens. They would not admit a No. 4 F. urethral catheter. A urethrogram was made by forcing radiopaque dye through a perforated Foley catheter, the bag of which occluded the bladder neck, while a snug-fitting perforated soft rubber nozzle was held against the meatus. The roentgenogram revealed a diverticulum, 2 by 2 cm., in the region of the mid-portion of the urethra. Through a transverse vaginal incision, a thin-walled sac was obliterated by chromic catgut mattress sutures. An indwelling urethral catheter was inserted, to be removed on the eleventh post-operative day. Subsequent examination six weeks after operation revealed complete healing, with no constriction of the urethra. INCIDENCE
At Charity Hospital of Louisiana, in New Orleans, there were 510,585 female admissions from January 1, 1922 to June 1, 1943. The white females numbered 265,815 as compared to 244,770 colored females. Among this group, 13 cases of urethral diverticulum, 2 cases of periurethral abscess, and 5 cases of periurethral cysts were recognized. Two of the cases of urethral diverticulum contained calculi and are to be reported separately. We believe that these cases seen and recognized in no way represent the true incidence of these conditions at this institution. RACE
Facts of racial incidence cannot be obtained from the literature because of insufficient data. However, it is significant that in this series, collected from a relatively equal number of white and colored patients, the ratio was found to be 8 colored to 3 white.
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JOHN G. MENVILLE AND JOSEPH D. MITCHELL, JR. AGE
Of the 80 cases reviewed (inclusive of the 11 cases reported in this paper), age was mentioned in 79, and the average was found to be 38.8 years. The eldest was 69 and the youngest 20 years. ETIOLOGY
Opinion concerning the etiology of diverticula of the female urethra is divided. Johnson and Parmenter believed that most are congenital in origin and, with others, suggest Gaertner's duct, Wolffian duct, cell rests, and congenital cysts as possible causes. By analogy, it has been argued that since many diverticula of the male urethra are considered congenital in origin, such a condition may also exist in the female It must be remembered, however, that the anatomy of the urethra and its surrounding structures in each sex are different, and that the female urethra develops from the vesico-urethral portion of the cloaca and is homologous only with that part of the male urethra extending from the internal urethral orifice to the prostatic utricle. That the posterior urethra is not a frequent site for congenital diverticula is borne out by Kaufman, who stated that, to be congenital, a diverticulum of the male urethra must be in the pendulous portion. A most convincing argument against the congenital origin in females is the absence of any reported case in an infant. Such an instance is credited to Johnson, but, in reality, the case in question involved a cyst and not a diverticulum. From this, it may be inferred that such a lesion is not congenital in origin, yet case reports of an aberrant ureter opening into a urine pocket or diverticulum, by Fromme and Folsom, lend credence to the belief that, for instance, a congenital theory is justified. In support of a congenital theory, Earlum suggested congenital structural weakness of the urethra. In contrast to the above, there is the prevailing opinion that the majority of diverticula are acquired. Gorowitz, Furniss and others believed that all are acquired. The frequency with which urethral and periurethral glands are mentioned as factors in the acquired theory is evidence that the presence of such glands was accepted by many. Cabot and Shoemaker, however, in an original study concluded that normally there are no important glandular structures in the proximal two-thirds of the female urethra. In a similar study, MacKenzie and Beck reported inconstant findings of periurethral tubular structures in female infants distinct from Skene's glands. Recently, Beneventi found true prostatic glandular tisssue in the posterior urethra of the female newborn in 2 cases. In 24 reported cases showing microscopic sections of diverticula excised, only two of such cases presented glandular epithelium. On the other hand, rnultilocular diverticulum cavities (Engel, Schmitz and Nelson, Parmenter, the work of Beneventi, and the case report of Folsom and O'Brien showing tissue removed from a female bladder neck which has an appearance similar to that of prostatic hyperplasia) suggest that, in instances, it is possible to have glandular structures, other than a Skene's gland, adjacent to the female urethra. Opinions regarding the acquired theory are as follows: Routh believed that
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the lesions resulted from closed ducts of pre-existing glands, with the formation of cysts which, later, ruptured into the urethra. Rupture of blood cysts and pseudo-cysts were also considered as possibilities. Latzko and Engel believed in a glandular-cyst theory, but also included periurethral abscess in that category. Latzko felt that obstetrical trauma was a factor. Lewis, likewise, adhered to the glandular-cyst theory. Rupture of suburethral abscess into the urethra is mentioned prominently in the literature as a causative factor, and the history recorded in the cases presented by Engel, Furniss, and McNally substantiates this contention. The possibility of traction on the urethra by scar tissue resulting from periurethritis was suggested by Hirsch. Among other possibilities mentioned are vaginal cysts. Lewis and others believed that trauma played a part in the etiology. Trauma as a factor is proved in one of Walters and Thiessen's cases in which a diverticulum resulted at the site of the fulguration of a urethral polyp. Among other types of trauma mentioned are instrumentation, passage of stones and foreign bodies, rough packing of the vagina, coitus and childbirth. The latter undoubtedly plays a part in certain cases, for occasionally the onset of symptoms dates back to such an event. Catheterization and infection of the urethra associated with childbirth should be considered equal in importance to the trauma of childbirth. The majority of the types of trauma mentioned are so frequently experienced, with no resulting diverticulum, that they should be . considered as predisposing or aggravating factors only. Of the 80 cases studied, 38 gave a history of childbirth, 7 specifically stated that there were no deliveries, while no data were available in the remaining 35. Twenty of the cases were multipara and, of these, 2 were decapara. Fifteen of the parous women gave histories of additional trauma, e.g., forcep delivery, dystocia, podalic version, vaginal tears, periurethral abscess, and cysts. With the exception of 3 instances of miscarriage, the multipara gave no history of trauma. Of the 35 patients giving no data regarding children, 11 gave a history of trauma, while 4 additional patients reported miscarriage or abortion. Resistance to the outflow of urine, felt to he so important in the development of diverticulum of the bladder, should be considered. In a few instances strictures of the urethra have been associated with diverticulum of the female urethra. Interestingly enough, Furniss reported such a case, in which the history of a tight urethra dated back 19 years. Lower not only felt that obstruction to the fl.ow . of urine played a part, but reminded us that the meatus is the narrowest portion of the urethra. It must be remembered, however, that relatively few of the cases reported in the literature gave a history of obstruction or presented constriction of the meatus or urethra. There was no such obstruction in our series, but four were mentioned in the literature. Although merely of academic importance, the question of true versus false diverticulum is often raised. The diagnosis of a true diverticulum based on the presence of an epithelial lining is inaccurate, for a well drained false diverticulum may acquire an epithelial lining and a true diverticulum may lose its lining in the presence of infection, stone, or both. These latter factors may also destroy the orignal walls of a diverticulum. On the basis of microscopic sections of the walls
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of diverticula removed, one may say that the majority are false, for, in 24 cases, only three presented evidence of muscle fibres. SYMPTOMS
Although the size of the diverticulum influences the symptoms, it is probable that the presence of infection and the ability of the diverticulum to empty itself or to be emptied play the most important roles. Symptoms of a diverticulum are predominantly local and are referable to the lower urinary tract. They are variable, intermittent, multiple, and usually of long duration. All diverticula do not cause symptoms. In the early stages they are non-infected, or only mildly so, and consequently produce few symptoms. A typical history is exemplified by intermittent attacks of dysuria, frequency, fluctuating mass in the anterior vaginal wall, partial incontinence, discharge of pus or a cloudly urine from the urethra, and pain in the urethra. If the pain is severe, the patient may also note discomfort on walking or sitting, and may also complain of dyspareunia. Of these, the only pathognomonic symptom is a mass which empties on pressure. Occasionally, the patient may learn that pressure over the "bulge" in the anterior vaginal region gives relief of her symptoms. An intelligent patient may also note an enlargement of the mass after voiding. It is possible that symptoms from a tight meatus or stricture of the urethra may dominate those of a diverticulum. In addition to infection, such complications as calculus, blood clot, and epithelioma (reported by Walters and Thiessen) contribute to the clinical picture. 80
SYMPTOMS IN
Dysuria, 56 Frequency, 32 Lump in vagina, 18 N octuria, 12 Partial incontinence, 12 Intermittent discharge from urethra, 11 Difficulty on urination, 10 Pain on urination, 9 Hematuria, 9 Painful lump in vagina, 8 Painful coitus, 6 Pain in region of urethra, 6 Soreness of vagina, 5 Upper lumbar pain, 5 Suprapubic pain, 5 Bearing-down sensation, 5 Backache, 4
CASES
Fluctuating mass, 3 Acute retention, 3 Urgency, 3 Decrease of mass on pressure, 2 Soreness of vagina on sitting, 2 Pain in vagina on walking, 2 Chronic retention of urine, 2 Pain at start of urination, 1 Soiling of clothing on coughing or sneezing, 1 Rupture of periurethral abscess, 1 Increase of mass during micturition, 1 Bloody urethral discharge, 1 Stricture of urethra, 1 Cloudy urine, 1 Pain over coccyx, 1 Vague pelvic pains, 1 SIGNS
Diverticula generally assume a rounded, saccular form but a variety of shapes may be found. Some sacs may encircle the urethra (Engel), while others undermine the internal sphincter and trigone (Parmenter). The fact that a mass may not be palpable is borne out by 4 case reports in the literature. The size is variable and ranges from a "pea" to that of a "hen's egg." In addition to these descriptive terms, reported cases have been described as follows: marble, lima bean, almond, olive, walnut., plum, and lemon. The size, as mentioned in
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the metric system, was so seldom stated that in this report figures were incorporated in the "household system" for the purpose of statistics. As a basis, "marble" is used for "small," "walnut" for "medium," and "lemon" for "large." In 80 cases, 14 were small, 19 medium, and 12 large. No mass was found in 4 and no mention of size in 31. On palpation the most typical sign is a fluctuating, mobile mass, with or without tenderness, which empties on pressure. A discharge from the urethra of foul urine or pus usually results from pressure on the vaginal mass. There are exceptions to this, however; in one of our cases pressure over the mass failed to produce a discharge and did not reduce the size of the mass. In another case, pressure over the mass produced a bloody discharge. Not infrequently the lesion, as a result of chronic infection, presents a thickened wall, with areas of firmness along its edges. When complicated by calculi, the lesions are hard and associated with crepitation. Findings on palpation may be more accurately interpreted by having a urethral catheter or sound in place. DIAGNOSIS
The four important points in the diagnosis are: (1) a careful history which often creates a suspicion of the lesion, (2) a thorough physical examination, (3) urethroscopic examination, and (4) urethrography. To these may be added a plain roentgenogram when a calculus is suspected. It may be necessary to examine a patient on more than 1 occasion, for the diverticulum may be empty on the first examination and filled on the second. Such a case was reported by Schmitz and Nelson. A similar instance was a source of embarrassment to Priestly, who invited a consultation on one of his cases: much to his chagrin, the mass had disappeared when the consultant arrived. In distinguishing a diverticulum from periurethral pathology not communicating with the urethra, a careful urethroscopic examination is necessary. This is best carried out with a panendoscope. The location of the diverticulum opening in the urethra was mentioned in 43 cases of the present study, and was found to be predominantly in the middle third. The locations were as follows: Anterior third, 2 cases; junction of anterior and middle thirds, 5 cases; middle third, 20 cases; junction of middle and posterior thirds, 9 cases; posterior third, 7 cases. Multiple openings were found in 8 of the reviewed cases. Openings in the urethra may be partially hidden by a fold of mucosa or they may be in the midst of granulation tissue. In one of our cases an opening could not be seen with a foroblique lens but could be observed with a right angle lens. If small openings point toward the bladder, a retrograde lens may be necessary. When possible, a urethral catheter should be fed into the opening and a plain roentgenogram made of the coiled catheter in place. By injecting a radiopaque solution through the catheter one obtains a most satisfactory visualization of the sac. The above method has its failings, because the openings may not be located and, in instances, only one opening may be detected when actually there are more. In such cases resort may be had to a urethrogram. Furniss used this method in visualizing 3 diverticula in a case in which only one urethral opening was seen.
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A urethrogram may be made in a number of ways. Schulz demonstrated that a diverticulum may be filled by injecting radiopaque solution into the urethra and having the patient void against the pressure. It may also be accomplished by exerting traction on a small Foley bag and injecting the urethra alongside the catheter. A method also used is to fill the bladder with radiopaque solution and have the patient void the bladder contents. In two of his cases, Townsend used radiopaque jelly in a syringe with good results. Diverticula must be distinguished from cystocele, prolapse of the anterior vaginal wall, vaginal cysts, periurethral abscess, granular urethritis, infections of the urethra, cysts and abscesses of Skene's glands, stricture and malignancy of the urethra. The most common complication of diverticulum of the female urethra is infection, although calculus formation in a diverticulum is not uncommon. Fistulre, hemorrhage, and malignancy have also been reported. TREATMENT
Treatment may be divided into (1) conservative, and (2) radical. The conservative may be subdivided into (a) surgical, and (b) non-surgical. Conservative non-surgical treatment consists of periodic dilatation of the urethra, together with urethral irrigations or injections with an appropriate antiseptic. Such a procedure is not satisfactory and is seldom advocated, but is nevertheless resorted to when patients refuse a more radical procedure. The use of a cystoscopic cautery knife to enlarge the urethral opening of a diverticulum is a conservative surgical procedure which promotes better surgical drainage but does not cure, and, at best, merely lessens the chances of infection by creating an environment less compatible with an infectious process. It may be used to advantage when a more radical procedure is contra-indicated and in a diverticulum which drains poorly. Pugh used this method with success in 1 case, while Parmenter reported a failure in 1 case. A second conservative surgical procedure is one of incision and drainage through the vaginal route. Parmenter and Furniss have both reported failures with this procedure. We feel that this method should be reserved for poorly draining diverticula harboring an acute suppurative process pointing into the vagina. If used in such cases, a secondary closure can be made at a later date. A third conservative surgical procedure is invagination and obliteration of the sac by a series of purse-string sutures, as advocated by Hyams and Hyams. In the latters' case report, the narrow neck of the diverticulum prevented the intrusion of the impacted saccular mass into the urethra. A variation of this procedure was successfully used in one of our cases, but proved to be a failure in a case of Walters and Thiessen. Invagination of the sac should prove successful if the sac is thin and its neck small. Radical treatment consists of excision of the sac. It is the method in which a cure can be expected and is the procedure of choice. Exceptions to this include old persons with mild symptoms, particularly poor operative risks; and patients whose diverticula present a clinical picture comparable to a periurethral abscess. The operative procedure is facilitated by traction on the bladder neck with a
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balloon-type catheter or a prostatic retractor. This brings the lesion into a more favorable position and serves as a guide to the urethra during the operation. The most widely accepted incision is a vertical one over the mass, but transverse, T-shaped, and a vertical incision lateral to the midline have been employed. The most popular disposal of the sac is amputation, followed by closure of the urethral defect. Redundant vaginal mucosa is excised and the wound closed in two or three layers. The urethral defect is usually closed with fine chromic catgut sutures. The vaginal wound may be closed with non-absorbable or absorbable sutures; the reported results with both are approximately the same. Drainage of the wound is unnecessary except for hemorrhage or infection. A relaxed sphincter or one damaged at operation should beshortened by interrupted non-absorbable sutures. Postoperative packing of the vagina with gauze may be used (Hunner, Parmenter, Lower and Tormey, Rashbaum and Seley and others). Suprapubic drainage, to facilitate healing of the urethral defect, was used by Furniss and by Shivers and Cooney, but it is questionable whether this extensive procedure is advisable in the face of good results obtained by urethral catheter drainage. A self-retaining catheter for from 7 to 10 days after operation is believed to be adequate. Plain rubber cathethers should be used in individuals susceptible to latex rubber. We feel that successful wound closure is synonymous with proper mobilization of tissues and the absence of tension on suture lines. This can be acomplished in closure of the urethral defect by inverting the proximal end of the neck of the sac. A part of the sac was used in the closure of one of Cone's cases, while Hunner and Parmenter each inverted a part of the neck with a purse-string suture. We believe that a large urethral defect, associated with a thick neck and chronic inflammatory changes in the suburethral tissue, is best closed by destroying the lining membrane of the neck and that portion of the membrane bordering the urethra with a light cautery, followed by ligation of the stump. Such a procedure should be free from any resulting stricture of the urethra at the operative site. Preoperative strictures of the urethra should receive periodic dilatations after operation, and all operative cases should be checked post-operatively for stricture formation of the urethra. PATHOLOGY
Unfortunately, there is insufficient evidence in the literature and in our series to warrant any dogmatlic statements concerning the pathology of the cases seen and reported. However, it is our impression that the majority of the diverticula have thickened fibrous walls, with chronic inflammatory changes. In addition to our cases, .Johnson, Parmenter, McNally, H. H. Young, Engel, Schmitz and Nelson, and Rashbaum and Seley have together reported microscopic sections in 24 cases. In 16, a lining membrane was noted and this varied as follows: squamous, cuboid, columnar, transitional, stratified squamous, pseudo-stratified squamous, and endothelial. Every case, excepting that of Young, showed inflammatory changes. Muscle fibres were reported in three cases (Parmenter, Cromer and Belt, and McNally). The remainder of the cases showed either
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granulation or fibrous tissue or both. Glandular tissue was reported in two cases (Parmenter and Engel). In one case (Schmitz and Nelson), the pathologic report mentioned only the lining of the sac. Multilocular sacs have been reported by Parmenter, Engel, and Schmitz and Nelson. DISCUSSION
In rare instances it is believed that a urethral diverticulum may be congenital in origin. After studying the cases presented in this paper and many case reports, no clue was found which explained the origin of all diverticula. The multiplicity of factors noted and the variety of findings suggest a number of causes. The history and findings prominent in one case are absent in another, and vice versa. Of the findings, trauma and infection seem to play the leading r6les. With exceptions, the formation of a suburethral sac or diverticulum is due to a bulge in the floor of the urethra, which occurs in a weakened area, carrying with it the anatomical structures of the urethra, or to a dilatation of a pre-existing tubule or gland or both. The virtual absence of muscle fibres and variation in the membranous lining of the sacs examined microscopically support our contention that most of the diverticula reported are false. Because the openings in the urethra of the glands of Littre, the follicles of Morgagni and possibly other inconstant glandular structures around the urethra may be plugged so easily, these structures are logical sites of cystic dilatation. This cystic dilatation may or may not be infected. If the dilatations are acutely infected and the drainage into the urethra is poor, a periurethral abscess results. This close association between an infected, dilated sac or diverticulum and an abscess may explain their confusion in the literature. Once a pocket is formed, it is easy to see how trauma and the accumulation of urine could cause a weakening of the walls and dilatation along the lines of least resistance. When infection begins, the walls of the sac are invaded and become thickened by chronic inflammatory changes. Interestingly enough, we have failed to obtain evidence of infected diverticula acting as foci of infection. We believe this interpretation to be the basis for the formation of the majority of diverticula of the female urethra. CONCLUSIONS
Eleven cases of diverticulum of the female urethra are reported. At Charity Hospital of Louisiana, in New Orleans, the incidence was found to be predominantly in the colored race. The lesion is acquired in the vast majority of cases and almost invariably becomes infected. The pathognomonic sign is a fluctuating mass which empties on pressure. The treatment of choice is excision of the sac. REFERENCES BENEVENTI, F. A.: A study of posterior urethra in the newborn female. Surg., Gynec. and Obst., 76: 64-76, 1943. BozEMAN, N.: Urethrocoele, catarrh, and ulceration of the bladder in females. Am. J. Obst., 3: 656, 1871.
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CABOT, H., AND SHOEMAKER, R.: The r6le of glands of the female urethra in the production of infection of the urinary tract. Trans. Am. Assoc. Genito-urin. Surg., 29: 461, 1936. CLARKE, Sm CHARLES M.: On Diseases of Females. London; Longman & Co., 1814, p. 269. Quoted by Young and McCrae. CoNE, R. E.: Diverticulum of the female urethra. Urol. and Cut. Rev., 40: 803, 1936. CROMER, J. K., AND BELT, N.: Diverticulum of the female urethra. Med. Ann. of Dist. of Columbia, 8: 173, 1939. EARLUM, M. S. S.: Diverticulum of the female urethra. Aust. and New Zeal. J. Surg., 4: 396, 1935. ENGEL, W. J.: Diverticulum of the female urethra. J. Urol., 45: 703, 1941. FOLSOM, A. I.: Discussion of sub-urethral abscesses and diverticula in the female urethra, by H. D. Furniss. J. Urol., 33: 498, 1935. FOLSOM, A. I., AND O'BRIEN, H. A.: The female obstructing prostate. J. A. M. A., 121: 573, 1943. FROMME, F.: Ueber Harniihrendivertikel. Ztschr. f. Geburtsh. u. Gynak., 74: 143, 1913. FuRNISS, H. D. :__ Diverticulumin the female urethra. Am. J. Surg., 28: 177, 1935. GoROWITZ, P.: Uber Divertikel der Weiblichen Harnriihre. Ztschr. f. urol. Chir., 22: 183, 1928. HALL, E. R.: Diverticulum offemale urethra. Northwest. Med., 35: 379, 1936. HrnscH, E. F.: Quoted by McNally. HuNNER, G. L.: Calculus formation in a urethral diverticulum in women. Urol. and Cut. Rev., 42: 336, 1938. HYAMS, J. A., AND HYAMS, M. N.: Anew operative procedure for the treatment of diverticulum of the female urethra. Urol. and Cut. Rev., 43: 573, 1939. HYMAN, A., AND LEITER, H. E.: Diverticulum of the female urethra. J. Mt. Sinai Hosp., 6: 190, 1939. JOHNSON, C. M.: Diverticula and cysts of the female urethra. J. Urol., 39: 506, 1938. KAUFMAN, C.: Verleitzungen und Krankheiten des Mannlichen Harnriihre und des Penis. Deutsche Chir., 1886. Quoted by McNally. LATZKO, W.: Handbuch der Urologie. A. von Lichtenberg, F. Voelcker, und H. Wildbolz. 1: 921, 1928. LEWIS, E. C.: Urology in Women. London: Bailliere, Tindall & Cox, 2nd Ed., 1936, p. 15. LOWER, W. E., AND TORMEY, T. W.: Diverticulum of the female urethra. Ann. Surg., 107: 923, 1938. MACKENZIE, D. W., AND BECK, S.: A histopathological study of the female bladder neck and urethra. Trans. Am. Assoc. Genitourinary Surg., 29: 227, 1936. McNALLY, A.: Diverticula of the female urethra. Am. J. Surg., 28: 177, 1935. McNALLY, A.: Diverticula of the female urethra. Ill. M. J., 69: 234, 1936. NEEL, J. C.: Diverticula of the female urethra. Calif. St. J. Med., 16: 494, 1918. PARMENTER, F. J.: Diverticulum of the female urethra. J. Urol., 45: 479, 1941. PRATT, J.P.: Diverticulum of the female urethra. Urol. and Cut. Rev., 42: 803, 1938. PRIESTLY, W. 0.: Examples of cyst formation in the neighborhood of the female urethra. Brit. M. J., 1: 6, 1869. PUGH, W. S.: Strictures and urethral abscesses in women. Am. Med., 38: 156, 1932. RASHBAUM, M., AND SELEY, G. P.: Diverticulum of female urethra. N. Y. St. J.M., 42: 243, 1942. ROUTH, A.: Urethral diverticula. Trans. Obst. Soc. London, 32: 69, 1890. SCHMITZ, H. E., AND NELSON, P.A.: Suburethral abscesses, urine pockets, and diverticula in the female urethra. Am. J. Obst. and Gynec., 38: 707, 1939. SCHULZ: Quoted by Johnson. SHIER, R. V. B.: A case of diverticulum of the urethra in the female. Canad. Med. Assoc. J., 22: 539, 1930. SHIVERS, C.H., AND CooNEY, C. J.: The formation of calculi in urethral diverticula of the female. J. A. M.A., 102: 997, 1934. TOWNSEND, J.M.: Diverticulum of the female urethra. Urol. and Cut. Rev., 42: 706, 1938. WALTERS, W., AND THIESSEN, N. W.: Urethral diverticulum. Minn. Med., 19: 218, 1936. YouNG H. H.: Diverticulum of the female urethra. South. Med. J., 31: 1043, 1938. YouNG; B. R., AND McCRAE, L. E.: Urethrocoele; urethral. diverti_culum; sub-urethral abscess in the female: roentgen appearance; treatment; review of literature; report of a case. Urol. and Cut. Rev., 41: 91, 1937.