Female urethral diverticulum associated with a large urinary calculus

case report
Female urethral diverticulum associated with
a large urinary calculus
Divertículo de uretra feminina associado a grande cálculo urinário
Alexandre Oliveira Rodrigues1, Maria Claudia Bicudo2, Rafaela Rosalba de Mendonça3, Carlos Alberto Bezerra4, Antonio Carlos Lima Pompeo5, Eric Roger Wroclawski 6†
ABSTRACT
The diverticula of female urethra are very uncommon, but more
frequently found between the third and fifth decade of life. Diverticula
area mostly relate to repeated urinary infections of the periurethral
glands or urethra’s trauma. The diverticula may cause infection,
calculus formation and rarely endometriosis or cancer. A case of a
65-year old Caucasian female with vaginal mass over six months
is herein reported. There was no urinary loss, urethral secretion or
urinary symptoms. A cystourethrography showed diverticula with
calculus inside. The patient was submitted to surgery and dismissed
from the hospital on the first postoperative day. The pathologic
examination revealed no malignancy. In six months of follow-up, the
patient was continent with no complaints.
Keywords: Diverticulum; Urethral diseases; Lithiasis; Urinary bladder
calculi; Urologic diseases; Case reports
Resumo
Os divertículos de uretra feminina são incomuns, porém mais
frequentes entre a terceira e a quinta década de vida. A maioria dos
divertículos de uretra está relacionada a infecções recorrentes das
glândulas periuretrais ou traumatismo uretral. Os divertículos podem
ser sítio de infecções, formação de cálculos e, mais raramente,
endometriose ou neoplasia. Relata-se o caso de paciente de 65 anos,
branca, com queixa de nódulo em parede vaginal notado há seis
meses. Negava incontinência urinária, derrame uretral e sintomas
urinários de armazenamento ou de esvaziamento. A uretrocistografia
miccional revelou divertículo uretral associado a cálculo. Submetida
à cirurgia, teve alta hospitalar no primeiro dia pós-operatório. O
resultado do exame anatomopatológico não evidenciou malignidade.
Após seis meses de seguimento, a paciente encontra-se sem queixas
urinárias ou vaginais e com continência urinária preservada.
Descritores: Divertículo; Doenças uretrais; Litíase; Cálculos da
bexiga urinária; Doenças urológicas; Relatos de casos
INTRODUCTION
Female urethral diverticula are uncommon, but occur
more frequently between the third and fifth decades
of life, although there are reports of congenital
diverticula in newborns and young women(1). It is
more prevalent in the black population and the
overall prevalence based on autopsy ranges from 0.6
to 4.7%(2). Most urethral diverticula are associated
with recurrent periurethral gland infections or
periurethral trauma by labor, surgery, or intermittent
use of catheters(1).
Diverticula may be the site of infections, calculus
formation and, more rarely, of endometriosis or
neoplasm. The association between diverticulum and
calculus ranges from 1.5 to 10%(3).
The classic triad of urethral diverticulum – dysuria,
dyspareunia and postvoid dribbling – is not very
common. Symptoms such as periurethral mass, pain or
urethral discharge may be suggestive of the presence of
a urethral diverticulum, but most patients only present
bladder storage or emptying symptoms, or repeated
urinary infections, thus making diagnosis difficult. Some
patients are asymptomatic, especially if the diverticulum
is small (2 a 16 mm)(1,4).
Clinical and surgical details about the approach of
a large urethral diverticulum with a calculus inside are
presented.
1
Assistant Physician of the Group of Female Urology of Faculdade de Medicina do ABC – FMABC, Santo André (SP), Brazil.
2
Preceptor of Urology of Faculdade de Medicina do ABC – FMABC, Santo André (SP), Brazil.
3
Resident of Urology of Faculdade de Medicina do ABC – FMABC, Santo André (SP), Brazil.
4
Head of the Clinical Division of the Department of Urology of Faculdade de Medicina do ABC – FMABC, Santo André (SP), Brazil.
5
Adjunct and Regent professor of Urology of Faculdade de Medicina do ABC – FMABC, Santo André (SP), Brazil.
6†
In memoriam; Post-doctorate degree; Full professor of the Department of Urology of Faculdade de Medicina do ABC – FMABC, Santo André (SP), Brazil.
Corresponding author: Alexandre Oliveira Rodrigues – Rua Venezuela, 557/121 – Centro - CEP 09030-310 – Santo André (SP), Brazil – Tel.: (11) 4438-6333 – e-mail: [email protected]
Received on: May 12, 2009 – Accepted on: Oct 7, 2009
einstein. 2009; 7(4 Pt 1):512-4
Female urethral diverticulum associated with a large urinary calculus
CASE REPORT
Case of a 65-year-old Caucasian patient complaining
of a nodule on the vaginal wall noticed six months ago.
She denied urinary incontinence, urethral discharge
and bladder storage or emptying symptoms. The patient
presented a history of three pregnancies (two vaginal
deliveries and one miscarriage) and underwent total
hysterectomy 35 years ago.
Upon gynecologic examination, topic urethral
meatus and bulging of the anterior vaginal wall with
a cystic consistence, measuring approximately 8 cm
(diameter), and containing mobile stony material
roughly measuring 2.5 cm (diameter). Associated
vaginal prolapse, urine loss or urethral discharge was not
observed. The voiding urethrocystography confirmed
the diagnosis of urethral diverticulum associated with
calculus (Figures 1 and 2).
513
After discussing with the patient, surgical
management was chosen and urethrocystoscopy was
performed at the beginning of the procedure. Urethral
diverticular ostium was evidenced close to the bladder
neck. An inverted U-shaped incision was performed on
the anterior vaginal wall, followed by dissection of the
diverticular wall fascia, resection of the diverticulum,
and the specimen was sent to pathology (Figure 3).
Figure 3. View of surgery field after dissecting and opening the diverticular wall,
showing the urinary calculus
Figure 1. Plain radiography of the pelvis showing radiopaque image at the pubis
measuring 22 x 23 mm
Figure 2. Voiding urethrocystography clearly shows a diverticular formation in
middle urethra
The urethra was sutured with Monocryl 5.0 in
separate stitches, after placing a 16-French indwelling
catheter. Pubocervical fascia and pubococcygeal
muscles were sutured before closing the vaginal wall.
No anti-incontinence mechanism was used. The patient
was discharged on the first preoperative day and was
asymptomatic.
The indwelling catheter was removed after 14 days.
Pathology examination showed no malignancy. At the
sixth month of follow-up, she has no urinary or vaginal
complaints and is continent.
DISCUSSION
This patient presented anterior vaginal wall bulging
leading to presumptive diagnosis of urethral diverticulum,
which was confirmed by voiding urethrocystography.
Suspicion of urethral diverticulum is not always evident,
but it should be remembered in incontinent women
presenting repeated urinary infections or bladder
storage or emptying symptoms. Gomez Gallo reported
a similar case of a 50-year-old patient complaining of
dyspareunia and increased abdominal wall volume.
Upon gynecologic examination, a mass of approximately
three centimeters was observed closely to the urethra.
Excretion urography showed a 3-cm calculus(5).
einstein. 2009; 7(4 Pt 1):512-4
514
Rodrigues AO, Bicudo MC, Mendonça RR, Bezerra CA, Pompeo ACL, Wroclawski ER
The literature shows that it is difficult to demonstrate
the presence of female urethral diverticulum through
complementary examinations. The diverticulum ostium
is not visualized in urethrocystoscopy in several cases
due to associated inflammation. Some series reported
sensitivity of urethrocystoscopy of approximately 15% as
compared to 45 to 65% of voiding urethrocystography.
Sensitivity significantly increases when using a doubleballoon catheter inflated at the bladder neck and
urethral meatus(6). Magnetic resonance imaging has high
sensitivity and is used in cases in which other diagnostic
methods do not confirm the presumptive diagnosis(1).
The transvaginal approach by an inverted U-shape
incision is the most appropriate technique to excise
female urethral diverticulum, except in distally located
diverticula, when marsupialization is an excellent
alternative.
Suturing in several layers using pubocervical fascia
and pubococcygeal muscles, with well irrigated and not
tense tissues, is essential for a successful urethral repair,
thus avoiding urinary fistulas, which generally represent
challenging complications regarding therapy. In more
complex cases, it is possible to interpose some tissues,
such as labial fat or the bulbospongiosus muscle.
Anti-incontinence surgery concurrent to the
treatment of diverticulum should only be performed in
einstein. 2009; 7(4 Pt 1):512-4
women with previous incontinence and in cases of large
reconstructions of the urethra or bladder neck, in whom
there is a risk of sphincter lesion(7).
Although rare, one should remember that urethral
diverticulum may be the site of neoplams. Therefore,
anatomopathological examination of the excised
material is obligatory. REFERENCES
1. Romanzi JL, Groutz A, Blaivas GJ. Urethral diverticulum in women: diverse
presentations resulting in diagnostic delay and mismanagement. J Urol.
2000;164(2):428-33.
2. Ramirez Backaus M, Trassierra Villa M, Broseta Rico E, Gimeno Argente V,
Arlandis Guzman S, et al. Divertículos uretrales. Revision de nuestra casuistica
y la literatura. Actas Urol Esp. 2007;31(8):863-71.
3. Beatrice J, Strebel RT. Giant calculi in urethral diverticula. CMAJ.
2008;178(8):994.
4. Hosseinzadeh K, Furlan A, Torabi M. Pre and postoperative evaluation of
urethral diverticulum. AJR AM J Roentgenol. 2008;190(1):165-72.
5. Gómez Gallo A, Valdevenito Sepúlveda JP, San Martín Montes M. Giant
lithiasis in a female urethral diverticulum. Eur Urol.2007;51(2):556-8.
6. Jacoby K, Rowbotham RK. Double balloon positive pressure urethrography is
a more sensitive test than voiding cystourethrography for diagnosing urethral
diverticulum in women. J Urol. 1999;162(6):2066-9.
7. Blaivas GJ, Heritz DM. Vaginal flap reconstruction of the urethra and vesical
neck in women: a report of 49 cases. J Urol. 1996;155(3):1014-7.