Urethral diverticulum is a sac–like depression in the wall of the urethra, communicating with it through a narrow neck. Clinical manifestations of urethral diverticulum include dysuria, urine leakage after urination, dyspareunia. Diagnosis is based on the data of urethral palpation, urethroscopy, miction and retrograde cystourethrography. In women, differentiation with gynecological pathology is carried out. Treatment of urethral diverticula is operative – diverticulectomy or endoscopic dissection of the cavity.
Meaning
In clinical urology, urethral diverticulum are more often detected in women. Among other urological pathology, this disease is diagnosed in 1.4-5% of cases, mainly at the age of 30 to 60 years. The dimensions of the diverticulum cavity are on average 2-3 cm in diameter; it can be located in any part of the urethra, in most cases – in the area of the posterior wall. As a rule, urethral diverticula are single, less common are multiple diverticula of the urethra.
When urinating, the urethral diverticulum increases, filling with urine, then decreases again. Part of the urine may linger in the pathological cavity, and then be released from the urethra in separate drops. The danger of diverticula of the urethra lies in the presence of conditions for the development of urethritis, diverticulitis, cystitis, abscesses, the formation of concretions, the formation of benign tumors.
Causes
Taking into account etiofactors and morphological structure, acquired (false) and congenital (true) diverticula of the urethra are distinguished. The cause of congenital pathology is dysembriogenetic disorders – residual Gartner duct, improper fusion of primordial folds, dilation of paraurethral cysts, etc.
Much more often, urologists have to deal with acquired urethral diverticula. In these cases, the causes of the disease may be birth trauma; intraurethral interventions (for example, rough catheterization of the bladder, urethral augmentation), infection of the paraurethral glands with microbial flora in nonspecific urethritis, chlamydia, gonorrhea; abscess of the urethral glands.
Symptoms
The course of the disease may be asymptomatic for a long time. Noticeable manifestations develop, as a rule, with a complicated course of diverticula – inflammation, infravesical obstruction, stone formation, malignancy. Among the symptoms of the urethral diverticulum, the most characteristic are pain in the ilio-inguinal region, dysuria, pollakiuria (increased urination), urinary incontinence.
Urination usually occurs painfully, with difficulty, in an intermittent stream, but even after its termination, the urge persists and the urine continues to leak. Urinary incontinence can be provoked even by minor physical exertion. In the case of emptying of an infected diverticulum, hematuria or pyuria may be observed, the discharge of pus drops from the urethra. Large protrusions of the urethra cause difficulty in sexual intercourse due to soreness and swelling of the anterior vaginal wall.
Complications
The presence of infected urine in the cavity of the urethral diverticulum can provoke the development of diverticulitis, the formation of concretions, abscessing. One of the complications of urethral diverticula is the development of malignant neoplasms (adenocarcinomas) in them.
Diagnostics
In the process of diagnosing diverticula of the urethra, it is important to differentiate from periaginal cysts, benign vaginal tumors, and cystocele. Therefore, women with the above complaints need to consult a gynecologist and conduct a vaginal examination. Signs of a urethral diverticulum are a painful tumor-like formation of the anterior vaginal wall, having an elastic consistency, when pressed on which urine is released from the urethra, often with an admixture of pus.
The study of clinical urine analysis allows you to detect leukocyturia, hematuria, pyuria. With bacteriological seeding of urine and examination of a smear from the urethra, the causative agent of the inflammatory process can be identified. Ultrasound with a vaginal, endourethral or rectal sensor is also used in the diagnosis of pathology. Since urinary incontinence is noted in the presence of a diverticulum, video-dynamic studies are required.
The leading role in the urethral diverticulum is assigned to endoscopy (urethroscopy) and contrast radiography (urethrography). With a wide urethral diverticulum neck, urethroscopy allows you to detect the entrance to the pathological cavity, inflammatory changes in the mucosa, stones, papillary tumors. The most accurate information about the localization, size and pathological formations of the urethral diverticulum is provided by performing descending and, if necessary, retrograde urethrography.
Treatment
In case of detection of an infectious process, antibiotic therapy is prescribed taking into account the isolated bacterial flora. Further surgical intervention is indicated. The operation can be performed by transurethral or extra-vaginal (in women) access. Transvaginal diverticulectomy is performed by dissecting the anterior vaginal wall above the diverticulum cavity. Diverticulum is isolated and carefully excised without injuring the back wall of the bladder. Single catgut sutures are applied to the urethra, then the integrity of the vaginal wall is restored.
When the diverticulum is located close to the external opening of the urethra, it is sometimes resorted to its marsupialization (bagging) into the vagina by dissecting the urethrovaginal septum. Endoscopic incision of the diverticulum mouth through the urethroscope allows you to create a wide communication with the urethral lumen and improve drainage of protrusion in the urethral wall.
Prognosis and prevention
In most cases, surgical treatment of the urethral diverticulum gives a satisfactory result. Diverticulectomy can be complicated by the formation of a urethral fistula, urethral stricture, urinary incontinence, recurrence of urethral diverticulum, frequent urinary tract infections. Prevention of the formation of urethral diverticula requires non-traumatic management of childbirth and performing urological manipulations, prevention of infections of the urogenital tract.