Monday, December 15, 2008

Urethral Diverticulum




More on urethral abnormalities.

A urethral diverticulum in women is usually an acquired condition. It is believed to be a gland along the urethra that pushes out and creates an out-pouching. This out-pouching, the diverticulum, may be asymptomatic if small, can contain pus, urinary stones, or even very rarely, a polyp. Regardless, they are believed to form from chronic infection, but remain a relatively uncommon entity.




When large they are palpable on pelvic exam. When present, however, thay usually present with the "Three D's" triad: Dysuria (burning with urination), Dribbling (of urine), and Dyspareunia (pain with sex). Not all three must be present, but a thorough history and physical exam will pick it up. Patients will complain of recurrent UTI's, burning with urination that is not alleviated by antibiotics, pain with sex, urinary stream issues, and the like.




On exam, they may mimic vaginal wall cysts which are congenital. It may simply look like a vaginal wall mass and can be tender. If compressed with a finger during exam, sometimes secretions, such as pus, can be expressed. This would be disgnostic.




If the exam is difficult, or when planning surgery, and x-ray should be obtained and cystoscopy performed.




Some other common symptoms include: irritative urinary symptoms such as frequency and urgency. Dyspareunia is noted in 12-24% of patients, and 5-32% of patients will complain of post-void dribbling. As mentioned, recurrent urinary tract infection is a frequent complaint in one-third of patients. In addition, women may experience pain, hematuria (blood in the urine), vaginal discharge, obstructive urinary flow or inablility to urinate (retention). Stress and urge incontinence may also occur. However, a urethral diverticulum can be asymptomatic in up to 20%.




Sometimes, but not always, during cystoscopy the opening to the diverticulum can be seen within the urethra. Several x-ray tests exist to visualize the diverticulum, but the most reliable is an MRI of the pelvis, which will show the size and location of the diverticulum.




When symptomatic, surgical removal is necessary and is peformed through the vagina.

49 comments:

kinandkenia said...

Hello! My mother is 74 years old and will have a surgery this summer to treat her urethral diverticulum. She will be going home with 2 catheters and expect to have them for 3 weeks. How is the post-op recovery like? would she be able to walk? or will she need bed rest the entire time? Any information regarding the recovery will be appreciated.

Thanks.

KS.

Anonymous said...

I had been diagnosed with urethral diverticulum and had it removed in January of this year. Lately I have been seeing an increase in the same symptoms I had before and I can feel masses forming. I have been trying to find some information on the implications of recurrence of urethral diverticulum on-line and have found nothing. Is there anything you can tell me?

Matthew E. Karlovsky, M.D. said...

In response to kinandkenia:
Generally, the catheters are the biggest hinderance- she can do simple walking and should expect some blood in the urine.

For Anonymous:
You should have a repeat exam and tests to see if it recurred.

Anonymous said...

Thank you, I have an appointment coming up, I was just curious as my primary care is also sending me to check for endometriosis. I just turned 25 and I feel like I am too young to be having all of these problems... Does having recurring diverticulum make me at higher risk for anything else? Is it possible that it is related to endometriosis?

Matthew E. Karlovsky, M.D. said...

To Anonymous:

A recurrenct tic can lead to infection, pain with sex or urinary dribbling.

needs a repeat work up. Its not related to endometriosis

mary_keifer said...

I haven't been diagnosed with anything. I have reoccurring swelling in the urethral/clitoral area. I went to the ob/gyn the first time and all I was told was that I didn't have a yeast infection. (I could have told her that) I couldn't get her to feel the pea size hard "thing" in that area. Took a bit, but it went away and I haven't had it happen for about a year. After wearing a pain of tight swim shorts (once) it happened again.(don't normally wear tight pants) The clitoral urethra area swelled up and then drained on its own and went away. That was in the end of Aug. It has happened twice since then, currently dealing with the second one. This time the swelling was a bit worse and the hard pea size ??? is closer to the opening and I keep draining it through out the day. It is puss like, no solids in it and very little blood at the end of the draining.
What can I do? I have a call into my ob/gyn, but little faith in her and she is also on vacation this week. My clitoris is swollen at the tip and has been for a week or more.
Thanks for any help/advice you can give me. Mary

Anonymous said...

I was diagnosed with a urethral diverticulum 3 years ago. I had an MRI which indicated a "cluster" of them. Surgery was recommended but I opted not to have it and to just have yearly exams to keep and eye on it. I had another MRI 2 weeks ago and the results were that the diverticulum has disappeared. Is this possible?

Anonymous said...

I was diagnosed by MRI three years ago with a urethral diverticulum. I chose not to have surgery but to keep an eye on it with early visits to my urologist. Two weeks ago I had another MRI and I was told that the diverticulum has disappeared. Is this possible

Anonymous said...

Hello. I'm a 19 year old female diagnosed with a urethral diverticulum in December of 2009. In March of 2010 a transvaginal removal of the diverticulum occurred. 2 months post-operative a recurrence was discovered. I am 7 weeks post-op from my last surgery and another diverticulum has occurred. My surgeon no longer knows what to do for me. The diverticulum was completely excised yet the diverticulum has in fact returned. What should be my next step in getting this fixed? It has been impacting my life severely for the past year, will I have to live in pain forever?

Matthew E. Karlovsky, M.D. said...

This subject has spurred many comments: generally, a thorough re-work up is needed to see if it has recurred. This may included a VCUG xray, MRI of pelivs and/or a cystoscopy, all depending on what your doctor suspects. One complication of urethral diverticular surgery is in fact recurrence.

Anonymous said...

I was first diagnosed with UD 23 years ago at age 26. I also discovered I was 2 weeks pregnant with my son. I had the surgery and had a carher for several weeks. I have had 2-4 reaccurrent UD's every year since. I have also developed urinary incontience. The pain increases as the cyst grows until it ruptures and drains leaving tenderness and mild to moderate pain for another 1-2 weeks. Treatment is usually antibiotics and 800 mg of Ibuprofen. I've learned to live with this condition, like my hypertension.

Anonymous said...

hi i am having tests for a urethal diverticuler.the two i have already had (xrays where they put dye in your bladder and a look in my bladder with a flexy tube with a camera attached)dont show any diverticuler so i have to have a mri scan.i first noticed a small soft lump on my uretha which isnt causing me any problems except nowing it is there.if it isnt a diverticuler has anyone got any other suggestions.

Crissysmith said...

I am 29 years old and currently 31 weeks pregnant with my 4th daughter. 2 days ago my dr discovered that I have UD. She said mine is near the tip and she said I will have to have surgery after I have the baby. I am really nervous because I have never had to have any kind of surgery of any kind except dental. Can someone who has had the surgery let me know more about UD, how the surgery is done, how bad is the pain after surgery, its it an inpatient it outpatient surgery, and anything else I may need to know? You can contact me at shaneandcrissy@yahoo.com our reply on here. thanks so much.

Matthew E. Karlovsky, M.D. said...

After you deliver the baby, the diagnosis of whether or not you have a UD can be confirmed with a repeat pelvic exam, and some xrays such as a cystogram and an MRI of the pelvis.

Anonymous said...

I am 28 and have had small problems here and there with a diverticulum for about five years (less than one occurence per year), then when I was a month pregnant it kept acting up for the duration of my pregnancy (getting infected, at one point the size of an egg protruding from my vagina, and expelling pus after urination). They put me under when I was four months pregnant to drain it when they thought it was a gland abcess, put me on antibiotics afterwards and as soon as the antibiotics were done, it swelled right back up and got infected. So, today my baby is four months old and I'm three weeks post op on my diverticulectomy. On the positive side, I'm sitting on a wooden chair in front of the computer and it doesn't feel like I'm sitting on a robin's egg. On the negative side, the recovery is pretty rough. I'm very active and fiercly independent and being on a catheter was so difficult. Now I'm dealing with the pain of the incision, the nausea from the pain pills, a terrible rash covering my whole bottom, and pain from constipation that I've had from the surgery. I cry every day, my boyfriend is wonderful but this is taking its toll on our relationship. I'm in law school and my finals are this week. I only missed a week of school. I guess I'm just trying to say, it's scary, painful, but so is living with pain and infection in your body...just don't go into the surgery lightly, thinking it's like draining an abcess, that's what I did and boy was I wrong!

adrian said...

I'm 34 I noticed what looked to me like a tiny little penis growing right below my urethra opening it didn't bother my and I've had it about two years now I though it was caused by the strain of carrying twins I went to the urologist to see if he could lance it but he told me it was no cyst and I needed to have surgery that was two months ago I go for surgery next month but it appears to have gotten bigger should I be worried that this UD could be cancerous?

Suhair said...

im 26 years old and i do the surgery 6 months ago, oh me God i didnt want to remamber that , it was too hard, the urgency, the catheters, the pain, and the drugs all of this makes me tired . now my diverticulum returns, im suffering emotionally and physically.want to know why its returns???

Matthew E. Karlovsky, M.D. said...

@ Adrian from 12/19/11: it may be a urethral diverticulum, a vaginal wall cyst or a periurethral cyst. an MRI of the pelvis can help differentiate

Matthew E. Karlovsky, M.D. said...

@ Suhair from 12/24/11: if the diverticulum is assumed to have recurred, then repeat the work up to prove it, and it may need to be removed again if bothersome. If not bothersome, observe.

Anonymous said...

I am 23 weeks pregnant and the doctors believe I have a UD. They want to do surgery at the beginning of the third trimester. I am nervous about this because of all the risks, including the cathetar, possible infections, etc. Is it possible to have a normal vaginal childbirth with the UD. Its about 1-1.5 inches long protruding outside. It doesn't bother me and i have no other symptoms. Any extra info would be great!

terri said...

Chrissy- they found my ud when i was in labor with my son! I had the surgery a year later after all my texts were done. went home the same day as surgery. I had to have a catheter in for 10 days. Very sore after surgery, but no pain the next day. My son is now 21, n I have had no problems since then. Good luck to u, n if u have any more questions my email is Terribug@sprint.blackberry.net

Helen said...

Have been suffering urethral syndrome since july02.Have had many treatments for this condition.My urogyne said i'm the worst case his ever know,and has even done a case study on me..My condition went into remission for five yrs.This was wonderful i actually got my life back!but then sadly the symptoms returned in august2010 with recurrent uti's!So i was sent for an MRI scan,which revealed a small proximal urethral diverticulum..I had the diverticulum removed in june 2011 The surgery was extremely painful in my case,I spent ten nights in hospital on morphine and the catheter remained in place for two wks.I cried every day for ten days!i couldn't believe the pain i was experiencing,nor could my consultant...I had to take 8 weeks off work...I made a full recovery, but then started to experience stress incontinence,which i'd never experienced befor but was told a risk from the diverticulum surgery...So dec 2011 i had a mini arc sling procedure..all went well until a week after surgery when i experienced severe heavy blood and had to be rushed to A&E..No one could explain why it had happened, only that it had come from the vaginal incision site...The bleeding settled down and i went home 36hrs later...My consultant was out the country at the time so i saw him a week later for check a
up..When all seemed fine.
A week after that i caught a severe infection and since that infection the stress incontinence has returned and now i can feel a small mass in my urethra again!!and i have all the same symptoms i had when i had urethral diverticulum last year..Surely i couldn't get another one so quicky after the last one?I'm due to have a cystoscopy next week...I'm praying i'm wrong and its just inflammation that i can feel...
Iv'e found both conditions, urethral diverticulum and urethral syndrome both very isolating.and im extremely worried that the more episodes inflammation i get the more chance of it turning cancerous..I know its rare but urethral syndrome ad proximal diverticulum are rare also and i end up with both...so is a constant worry....I wish i had something positive to say about these two conditions....but i don't...Both conditions have had a massive impact on my life...

Matthew E. Karlovsky, M.D. said...

A UD should be reomved by someone who has experience. The entire UD must be removed otherwise it may recur. But a new UD can always occur. If it is small, and not bothersome, it can be observed. Excision of a UD should be left till after pregnancy, esp since a complex vaginal surgery may be "ruined" by a vaginal birth, but also, since it is not an emergency, it can wait till after birth. And if it is not bothering you, it can be deferred till after birth.

TJ said...

I seem to have a condition for which I can get little understanding or certainty of a diagnosis but I'm wondering if it might simply be a case of UD?

When I was in my mid-20s (and after having 2 children), I began to have a problem with bleeding while urinating. It did not hurt to urinate or to hold my urine in my bladder. It was only when I tried to STOP urinating (such as when I was finished) and I felt the urethral sphincter contract that I would feel a sharp pain. When I would wipe, there would be blood on the tissue paper. I saw several urologists who treated me for "recurrent UTI" but could not understand what was causing it. One urologist finally decided I had interstitial cystitis. I strongly disagreed as my symptoms did not match any of the classic symptoms of IC. The problem then suddenly stopped.

Now it has been over 10 years later and, today, I find the same symptom. I have been healthy with no illness. Very low blood pressure. I'm about 5'7" and weigh about 123 lbs. Very healthy, fit, and NO UTIs in the past decade. No kidney stones, nada... I did donate a kidney to someone in 2005 but have had great, healthy protein levels which are checked yearly.

The only change has been in the past 3 weeks when I started using a kegelmaster to strength my pbc muscles. In the past couple of days, I have noticed a small discomfort when I do the kegels, but no bleeding or anything I felt serious concern over. I also noticed some pain during intercourse, but again...nothing I felt serious concern over.

Within a few days of these events, my undiagnosed problem seems to have reappeared after 10+ years. There is no pain to hold urine and I don't really feel any urgency to go more than normal. When I urinate, there is no pain. Most of the time, my urine looks normal. Normal color, no odor, etc.. But when I feel that sharp, stabbing pain that seems to correspond to the contraction of my urethral sphincter muscles, I get bleeding. Sometimes it bleeds so much that when I urinate again later, I am voiding blood clots too.

Could these all be symptoms of UD? Or are there other urethral diseases that I should have a local urologist look for?

I have taken 3 days of amoxicillin followed by at least 2 days (and counting) of nitrofurantoin with no improvement in the pain or bleeding. Logic tells me that the problem isn't a UTI (which may be occurring as a secondary issue) but perhaps something like a cyst or lesion?

Matthew E. Karlovsky, M.D. said...

@TJ:

What you have does not sound like a UD. there are blood vessels all around the BN and sphincter and can bleed if the sphincter spasms hard. To rule other diseases a cystoscopy and pelvic exam should be performed in order to make sure that the condition is benign and not attributed to other causes.

Anonymous said...

Hi, Im 31 years old. About 8 months ago, I developed a lump on my vaginal area (urethra) which at the time was not bothersome and only grew during my menstrual cycles (and went down when my menstrual was over). My gyne thought it was a cyst. However, after several months, it started getting larger with each menstrual, in addition, to having vaginal odor, reoccurring yeast infections and occasionally sharp pain when I urinate. Ive since seen a urologist which said it is a UD and surgery is needed. I have had a MRI and have a scheduled colonoscopy in a few weeks. Is surgery at this time the only option? My other concern is that these symptoms/issues didnt begin occuring until after I had the Mirena put in. Im a pretty healthy person, 2 children (vaginal deliveries), never had a UTI and very seldomly had yeast infections (1 with each pregnacy).So Im getting the Mirena taken out next week to see if my symptoms clear up. Could the Mirena be the cause? And Im worried about post op complications and this UD coming back.

Anonymous said...

Wow! I did not know UD existed, and am wondering a few questions myself. I was just diagnosed with UD and because it was infected I had had it drained. But now there is a pocket there that keeps filling up? Is this Urine? It is still protruding out of my Vaginal opening. My doctor doesnt know much and says he will send me to a urologist. But What happens if I dont have the durgery? Do i have this vaginal filled sack for the rest of my life? How is this safe for infection?

Matthew E. Karlovsky, M.D. said...

@ Anon from March 14 and 20: A growing mass near the urethra can be a UD, but can alos be vaginal wall cyst that is a simpler problem. Go thru the work up of MRI and cysto to see what you have. It may ir may not be Mirena. Stopping it may be instructive.

If the UD is removed in its entirety, then it should not grow back.

Anonymous said...

I had a big ud removed in November and I have pain every day and the Dr does not know why, I have to alternate standing and laying down all day because the pain is so excruciating, from Sharp pains, muscle spasms, numbness and fullness feelings, it feels like the ud has came back. Dr did ct last week and says nothing is wrong with me. Can the Dr see with ct scan if ud has came back ?

Berni said...

I have a UD and 90% of the time I'm in chronic pain. I have to take Vicodin just to function. I'm in pain after bowel movements, sneezing, and sex is no longer an option. But most of the time it hurts for no reason. Passing urine is just as painful. Unfortnately my employer does not offer health insurance. Is there anything I do about the pain so my quality of life can be returned?

Matthew E. Karlovsky, M.D. said...

@Berni: Since it is painful adnd affecting quality of life, it should be removed. Get insurance.

Anonymous said...

I'm from the UK and unfortunately there is very little information about UD. I have been having urinary issues for a while, mostly a sore urethra, having to urinate frequently and not feeling that my bladder empties completely even though I have had an ultrasound performed on my bladder which shows that my bladder does empty properly. I do not really know whether I do have a UD or not. What tests are performed to diagnose a UD?

Anonymous said...

I know this is kinda late, but i was diagnosed when i was about 31 weeks pregnant as well. My baby is now 8 months old. I didnt get it taken care of right away due to fear of the 'c' word. Was curious is you had it taken care of? I just had the surgery yesterday...and everything went fine. Im a little sore, and cant really life my baby, so i would recomend getting some help with him/her!!! Let me know if there is anything i can do to help. Erirene2003@yahoo.com

Anonymous said...

I just had this surgery 12 days ago and am perusing the Internet trying to find out how soon I can get back to riding my bike and exercising.
I was diagnosed 4 years ago via MRI. The pain went away for three years and then BAM! No sex, no exercising, extreme vaginal pain after urination. I would have to have someone help me walk to the bed to lay down until the pain went away. It was awful and interfering with quality of life. So if you are in pain, I would recommend finding a good urologist to perform it.
I get my indwelling catheter out in 2 days and cannot wait! LOL I would agree that the catheter is the worse part of recovery. I only had to take Vicodin for about 4 days post op and then was completely pain free.
I just really, really want to know when it is safe to ride my bike and have intercourse again.
Julie

Anonymous said...

I'm 15 and have a small pinkish red mass by the entrance to my urethra. It expels pus and is extremely sensitive to the touch. It doesn't expel pus a lot, only occasionally is this UD? Also, it itches. Oh and I have they almost cauliflower looking zit type tiny bumps all over my vulva. When I wear tight pants my vulva itches and turns bright red. Also, it's often very dry or sticky down there. Oh, and one of my labia minora is bigger than the other and slightly purplish and itches badly when I wear tight pants. I went to my gyno, but she said I didn't have a yeast infection, urinary infection, or ingrown hairs. She gave me yeast infection medicine anyway, but it didn't help. This has been going on for two years now. The symptoms are off and on. I don't know what to do, does anyone know what this sounds like?

Anonymous said...

this sounds like a bartholin cyst

Matthew E. Karlovsky, M.D. said...

Go back to the textbooks- a Bartholin cyst is on the labia minora. This post is about urethral diverticula.

Matthew E. Karlovsky, M.D. said...

@ Anon on June 22:

Sounds like a Skene's duct cyst/abscess- if this is true--> see a urologist adn antibiotics will be necessary. tight pants will lead to "heat rash" and small bumps on the vulva- Avoid tight pants

Matthew E. Karlovsky, M.D. said...

@ Anon June 9- 6 weeks after surgery is probably Ok depending if the area is healed after an exam by the urologist

Anonymous said...

I'm 20 yrs old and have been just diagnosed with UD. My doctor is completely against surgery, saying the likelihood that it'll come back is too high. The pain is bearable. And there is pain during sex but also still bearable for now. I don't want to live with this forever! Is there anything I can do to try to help it go away? Or should I wait a little longer to see if it maybe goes away (it's only been 2 days since I was diagnosed)? My doctor also made it seem like it's absolutely nothing serous, no big deal, and I shouldn't worry about it. I just want it to go away. Help!

Matthew E. Karlovsky, M.D. said...

You can potentially monitor it for pain, discharge, infection, and growth. See a urologist for a thorough exam.

Anonymous said...

I am 32 years old and had this every since i was 19 years old. Was told it was something else until age 31. Sometimes it blows up like a balloon and i drain it out and lite green comes out and urine. Also some time pain full when having sex. I am scared to have surgery can i get cancer if i do not get it removed.

Matthew E. Karlovsky, M.D. said...

See a urologist and have a surgical discussion. Cancer is these is rare.

Anonymous said...

Dear Dr. Karlovsky,

I was just diagnosed with UD by gynecology. I am being referred to urology for surgery as I have bothersome symptoms. I will have to wait some time to see the urologist (Canada has lengthly wait time for specialist appointments). In the meantime, I am very curious about the surgery itself. How long will I have to stay in hospital? Am I to understand that I will be going home with a cathedar? If there are no complications, how long will I have to recover at home afterward before returning to work? Answers to these questions will greatly assist in my initial planning for the care of my young daughter while I recuperate. Thank you!!

Matthew E. Karlovsky, M.D. said...

Usually a cathteter is necessary for 3 weeks, then removed. Depending on the size and level of difficulty of removing the tic, you may need to stay overnight. Usually after these surgeries I tell patients to avoid heavy housework, sports, sex, pools/baths for total 6 weeks.

Anonymous said...

Hi I am a 42 years old and just was diagnosed with UD. My Gyno started me on Bactrim for seven days and made me an appt with a Urologist. I only had dribbled once or twice nO other symptoms. Could the antibiotic take this away ? Thanks so much !!

Matthew E. Karlovsky, M.D. said...

@Anon Aug 9- Antibiotics will not take away a diverticulum. However, be sure you actually have one. They are not that common. And, if it is not causing symptoms too frequently it can be observed.

Anonymous said...

Hello. It is possible for UD to disappear? Could it "heal" on its own? Thanks.

18

Matthew E. Karlovsky, M.D. said...

@Anon Seot 30: a UD can wax and wane in size. yes it can shrink, but its still there. If its not causing pain, dribbling, infections--> leave it alone