Urinary Symptoms Before and After Female Urethral Diverticulectomy— Can We Predict De Novo Stress Urinary Incontinence? Kobi Stav,* Peter L. Dwyer, Anne Rosamilia and Fay Chao From the Department of Urogynaecology, Mercy Hospital for Women (KS, PLD) and Monash Medical Centre (AR, FC), Melbourne, Australia, and Department of Urology, Assaf Harofeh Medical Center, Zeriffin, and Sackler School of Medicine, Tel Aviv University, Israel (KS)
Purpose: We assessed preoperative and postoperative urinary symptoms, and determined risk factors for de novo stress urinary incontinence after transvaginal urethral diverticulectomy. Materials and Methods: We reviewed the case records of 25 consecutive women who had transvaginal urethral diverticulectomy. Urinary symptoms were documented before and after surgery with a structured history and examination pro forma. Demographic, clinical and imaging parameters were reviewed to determine any association with preoperative and postoperative symptoms as well as possible risk factors for postoperative stress urinary incontinence. Results: The most common presenting symptoms were urinary urgency and frequency (60%), and dyspareunia (56%). On physical examination the most common findings were a tender anterior vaginal wall mass (88%) and urethral discharge (40%). At a mean followup of 15.1 ⫾ 14.9 months (median 12) the rate of urgency-frequency symptoms and dyspareunia decreased significantly from 60% to 16% and from 56% to 8%, respectively. All the patients who had urge incontinence were cured of this symptom after the operation. De novo stress urinary incontinence developed in 4 patients (16%) postoperatively, and it was mild and only necessitated surgical treatment in 1 patient. A diverticulum larger than 30 mm and proximal urethral location were significant factors (p ⬍0.05) for the development of de novo stress urinary incontinence. Conclusions: Irritative bladder symptoms are common in woman with urethral diverticulum and usually resolve after surgical excision. Stress urinary incontinence developed immediately after the operation, and had a significant association with a proximal urethral location and ultrasonically measured size greater than 30 mm. Key Words: diverticulum; urethra; urinary incontinence, stress; risk factors; female
emale urethral diverticulum is a localized outpouching of the urethra into the anterior vaginal wall. The causation of UD is poorly understood but currently the most accepted theory is obstruction and infection of a periurethral gland.1,2 UD is considered a rare finding and is often difficult to diagnose. However, increased physician awareness and the development of new imaging modalities such as transvaginal ultrasound3,4 and magnetic resonance imaging have improved diagnostic accuracy.5,6 The condition frequently presents with nonspecific symptoms which leads to incorrect and delayed diagnosis. Presenting urinary symptoms are recurrent infections, post-void dribbling and urinary frequency-urgency symptoms. In women with persistent irritable lower urinary tract symptoms prevalence rates of 16% and 40% have been reported, and so a high level of suspicion is needed in these patients.7 Other common presenting symptoms are a vaginal mass or pain frequently with sexual intercourse.
Submitted for publication March 4, 2008. Nothing to disclose. Study received local ethics committee approval. * Correspondence: Urogynaecology Department, Mercy Hospital for Women, 163 Studley Rd., Heidelberg, Victoria 3084, Australia (telephone: ⫹61  61395238380; FAX: ⫹61  394162472; e-mail: [email protected]
0022-5347/08/1805-2088/0 THE JOURNAL OF UROLOGY® Copyright © 2008 by AMERICAN UROLOGICAL ASSOCIATION
Multiple open surgical and endoscopic approaches have been described for the treatment of urethral diverticulum.8 –10 At present complete transvaginal excision of the diverticulum is considered the procedure of choice because of its high success and low complication rates. Some clinicians treat coexisting SUI simultaneously with a pubovaginal sling or bladder neck suspension, or even recommend stress incontinence surgery to prevent the development of de novo SUI postoperatively.11–14 De novo SUI has been reported in the literature to occur in 1.7% to 20.3% of patients.14 –19 In this study we assessed urinary symptoms before and after transvaginal urethral diverticulectomy, and looked for clinical associations with preoperative and postoperative urinary symptoms, particularly in women with UD in whom SUI might develop de novo after surgical excision. MATERIALS AND METHODS We reviewed the medical records of 25 consecutive women who underwent transvaginal urethral diverticulectomy at 2
Editor’s Note: This article is the third of 5 published in this issue for which category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 2266 and 2267.
Vol. 180, 2088-2090, November 2008 Printed in U.S.A. DOI:10.1016/j.juro.2008.07.049
PREDICTING STRESS URINARY INCONTINENCE medical centers from 1998 to 2007 after approval of the local ethics committee. The assessment included demographic information, medical history, urinary symptoms evaluation, physical examination, urodynamics, imaging, cystourethroscopy, and surgical and pathological reports. Data were assembled into a database using an Excel spreadsheet. Raw distributions and frequencies were calculated and tested for significant differences. Statistical analyses were performed using SPSS® software (version 12.0, 2004). A p value of less than 0.05 was considered significant. We used the Fisher exact test to evaluate risk factors for the development of de novo SUI after surgery. Analysis was performed for the risk factors of age, time to diagnosis, preoperative symptoms, number of previous pregnancies and deliveries, previous hysterectomy, physical findings, size and urethral location of the diverticulum, and histopathology of the surgical specimen. Patients were taken off antiaggregation or anticoagulation medications 10 days before the operation. Any urinary tract infection present preoperatively was treated with an appropriate antibiotic. All patients received prophylactic second generation cephalosporin antibiotic before the anesthetic induction. Standard transvaginal excision of the diverticulum was performed. The bladder was drained using a urethral or suprapubic catheter in 18 and 7 patients, respectively. Concomitant pubovaginal rectus fascial sling was performed in 1 patient who had urodynamic stress incontinence and intrinsic sphincter deficiency (leak point pressure of 42 cm H2O and maximal urethral closure pressure of 18 cm H2O). A Martius labial fat pad graft was used in 2 cases with large UD where further reinforcement of the suburethral dissection and repair was considered appropriate. Patients were usually discharged home the following day with an indwelling catheter for an average of 7 days (range 3 to 21). RESULTS The demographic and clinical characteristics appear in table 1. Mean patient age was 41.7 ⫾ 11.6 years. The time from
TABLE 1. Demographic and clinical variables Pt age: Mean ⫾ SD Median (range) Body mass index: Mean ⫾ SD Median (range) Pregnancies: Mean ⫾ SD Median (range) Deliveries: Mean ⫾ SD Median (range) No. premenopausal (%) No. previous hysterectomy (%) No. smokers (%) No. diabetes mellitus (%) No. hypertension (%) Diverticulum diameter (mm) by ultrasound: Mean ⫾ SD Median (range) Operative mins: Mean ⫾ SD Median (range) Days with catheter: Mean ⫾ SD Median (range)
41.7 ⫾ 11.6 41 (21–74) 28.3 ⫾ 3.4 27 (22.3–34.9) 2.1 ⫾ 1.3 2 (0–5) 2 2 19 4 4 2 3
⫾ 1.2 (0–40) (76) (16) (16) (8) (12)
22.8 ⫾ 10.1 21 (9–43) 105.7 ⫾ 30.3 95 (75–180) 7.3 ⫾ 4.2 7 (3–21)
TABLE 2. Preoperative and postoperative symptoms
SUI Urge urinary incontinence Urgency/frequency Dysuria Voiding difficulty Post-void dribbling Dyspareunia Recurrent urinary tract infection Vaginal discharge
No. Preop (%)
No. Postop (%)
2 (8) 3 (12) 15 (60) 11 (44) 6 (24) 7 (28) 14 (56) 11 (44) 8 (32)
6 (24) 0 (0) 4 (16) 2 (8) 0 (0) 0 (0) 2 (8) 1 (4) 0 (0)
initial symptoms to definite diagnosis was 2.2 ⫾ 1.4 years (median 2, range 1 to 5). Most of the women were premenopausal (76%) and none of them had anti-incontinence or vaginal surgery previously. Twelve patients underwent urodynamic assessment before the procedure. Mean cystometric capacity was 410 ⫾ 56 ml. Two patients had symptoms of SUI which was also demonstrated by urodynamics (8%). Three patients had detrusor overactivity (12%). None of the patients had urodynamic evidence of obstructed voiding. The diverticulum was demonstrated by ultrasound in all 25 cases (10 transperineal, 15 transvaginal). Double balloon positive pressure urethrography using a Trattner catheter was performed in 14 women, demonstrating a diverticular sac in all. In 2 cases stones were seen inside the sac and their presence was confirmed during the operation. Two patients had horseshoe (partial circumferential)-shaped diverticulum. Communication between the sac and the urethra could be seen in 8 cases on ultrasound scan. The diverticular orifice could be demonstrated by urethroscopy in 11 of 25 patients (44%). Mean operating time was 105.7 ⫾ 30.3 minutes (range 75 to 180). In 5 patients (20%) the diverticulum was in the proximal third of the urethra, and in 7 and 12 patients it had a mid and distal urethral location, respectively. No major intraoperative or perioperative complications were documented. Two patients had postoperative urinary infections which resolved with oral antibiotics. Table 2 lists preoperative and postoperative urinary symptoms. The most common presenting symptoms were urinary urgency and frequency (60%), and dyspareunia (56%). Two women had stress incontinence. On physical examination the most common findings were anterior vaginal wall mass or tenderness (22, 88%) and discharge on urethral expression (10, 40%). After a mean followup of 15.1 ⫾ 14.9 months (median 12, range 6 to 80) the rate of urgency-frequency symptoms and dyspareunia decreased significantly from 60% to 16% and from 56% to 8%, respectively. All the patients who had urge incontinence were cured of this symptom after the operation. Of the 2 women who had SUI before surgery 1 had a concomitant pubovaginal sling and was dry 1 year after the operation, and in the other the SUI resolved after excision of the UD. Two patients had recurrent UD diagnosed 2 months (1) and 6 months (1) after the first operation. Both patients had successful repeat surgery, and are currently free of symptoms and without evidence of recurrence on imaging. None of the patients experienced urethral stricture, voiding difficulties or urethrovaginal fistula. SUI developed de novo in 4 patients (16%) postoperatively. In 3 of the 4 women the symptoms of SUI were mild, requiring only conservative treatment, and 1 woman under-
PREDICTING STRESS URINARY INCONTINENCE
went a tension-free vaginal tape procedure 8 months postoperatively with a good result. In all 4 cases the diverticulum was located at the proximal urethra and the diverticular sac measured by ultrasound was larger than 30 mm. Those 2 factors were statistically significant (p ⬍0.05) for the development of de novo SUI after surgery. None of the patients in whom de novo SUI developed had a horseshoe-shaped diverticulum. Of the patients in whom de novo SUI did not develop there was only 1 who had a proximal diverticulum and 1 other who had a diverticulum larger than 30 mm. DISCUSSION Our study indicates that after surgery most of the irritative and obstructive urinary symptoms associated with UD disappear. The postoperative de novo SUI rate in our group was 16% but was usually not bothersome and during followup SUI surgery was only necessary in 1 case (4%). Previous studies demonstrated that SUI can develop after urethral diverticulectomy in up to 20.3% of patients.14 –19 Our results indicate that proximal UD and size larger than 3 cm have a significant association with the development of de novo SUI following transvaginal surgical excision of the sac. To our knowledge only 1 previous study tried to define risk factors for complications after surgery for UD in women.18 Porpiglia et al retrospectively evaluated postoperative complications in 18 women with a followup of 44 to 121 months.18 They recorded 1 urethrovaginal fistula, 2 cases of new onset SUI and 1 recurrent diverticulum. They concluded that the most important risk factors were delayed diagnosis (more than 12 months), size (larger than 4 cm) and horseshoe shape of the diverticulum. The pathophysiology of SUI after urethral diverticulectomy is unclear. We assume that a large diverticulum requires more extensive suburethral dissection, and a proximal location may jeopardize the anatomical support of the urethra and bladder neck or may cause damage to the urethral sphincter mechanism. The urethral musculature and the bladder neck may also be damaged by the inflammation and diverticulum mass itself, causing stress incontinence. An important practical implication of our findings is the greater possibility of de novo SUI in women with a large proximal UD and the need for preoperative discussion on this matter. Meticulous periurethral dissection, wide dissection around the UD and layered closure of the urethral defect without tension by experienced surgeons is necessary if there are to be low rates of postoperative SUI, urethral stricture and fistula formation. The case for a fascial sling performed simultaneously with diverticulum excision even in patients at high risk for SUI does not appear warranted by our findings. Retropubic urethral suspension procedures are technically difficult and often unsatisfactory when performed in women at transvaginal urethral diverticulectomy because of the limited mobility of the vaginal wall.
vaginal excision of urethral diverticulum. In all cases the incontinence developed immediately after the operation, did not resolve spontaneously after a mean followup of 15 months but only required SUI surgery in 4%. We found that proximal urethral location and diverticulum larger than 30 mm have a significant association with postoperative de novo SUI.
Abbreviations and Acronyms SUI ⫽ stress urinary incontinence UD ⫽ urethral diverticulum REFERENCES 1.
7. 8. 9. 10. 11.
15. 16. 17. 18.
CONCLUSIONS In our study irritative bladder symptoms are common in women with UD and usually resolve after surgical excision. We found that SUI developed in 16% of women after trans-
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