Monday, December 15, 2008
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.
Posted by Matthew E. Karlovsky, M.D. at 4:47 AM