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Management of Urethral Diverticula

Feb 2011 – by P. DiSaia, MD

Suburethal Diverticula originate from the upper two thirds of the posterior urethral wall and may extend upward to involve the region beneath the vesicle neck. Although a congenital ideology has been proposed for some cases, most are thought to begin as an infection in one of the tubular peri- urethral glands followed by abscess formation with the eventual breakthrough into the urethral lumen. The abscess walls then form a pouch or a diverticulum suburethral.

Dysuria, urgency, frequency and sometime hematuria occur in 90 % of cases of urethral diverticula. Some patients present with a lump in the vaginia caused by a protrusion of the diverticulum sac into the vaginia. Still other patients present with dyspareunia or even pain on walking. Depending on the location of the opening of the diverticulum into the urethra the patient may have pus migrate back into the bladder or leak through the urethral meatus. A positive urine culture is common.

Urethral diverticula are usually very small, 0.5 to 2 cm. and palpation of the suburethral mass is associated with tenderness. Pressure on the mass may cause the escape of urine or exudate from the urethral meatus signaling the presence of a diverticulum. The diagnosis of urethral diverticula is definitely established by means of a positive pressure urethrogram. A special catheter is used to block the urethra on at both ends and then fill the urethra under pressure with water-soluble contrast medium demonstrating the diverticulum on x-ray.

In some patients the diverticulum is asymptomatic. Since the complication rate of excision of the diverticulum is in the neighbor of 20% it may be prudent not to operate on asymptomatic patients. Many clinicians believe only patients experience acute or recurrent symptoms should have urethral surgery.

A diverticula that requires treatment must be completely excised before a defect in the urethra can be closed permanently. Failure to remove the entire diverticulum will result in a recurrence. Diverticula that are close to the urethral meatus sometimes are easily treated by extending the utheral meatus into the pouch of the diverticulum and allowing healing by secondary intention. More complicated diverticula need to be treated surgically with excision and a layered closure over a urethral catheter functioning as a stent for several weeks.