A Unique Case of Large Female Urethral Diverticulum

Dr Yogesh Bhandari *

Corresponding Author: Dr Yogesh Bhandari, MS, DNB, FRCS( Urol), Consultant Urologist, NMC Speciality Hospital, NMC Healthcare, Abudhai, UAE.

Copy Right: © 2023 Dr Yogesh Bhandari, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: March 16, 2023

Published Date: April 01, 2023

Case Report

49 years female referred from gynecology department for evaluation of recurrent urinary tract infections. Patient was treated with culture specific antibiotics since 2 years. She also had post micturition dribbling. General examination was normal. Per vaginal examination revealed a large cystic swelling in the anterior vagina close to the mid and distal urethra. Upon pressing on the swelling, urine used to come out of the external urethral meatus suggestive of urethral communication.

Imaging studies

Transvaginal USG - An anechoic cyst measuring 2.5 x 1.2 x 1.8 cm seen in relation to the vagina wall.

MRI pelvis - Cystic lesion noted in the midline between urethra and vagina at the level of the pelvic floor; anteriorly encasing the distal urethra and posteriorly indenting the anterior vaginal wall - could suggest urethral diverticulum.

Complete urodynamic evaluation done – normal bladder capacity, normal complaince, no detrussor overactivity, normal capacity with no stress urinary incontinence.

Working diagnosis of female urethral diverticulum was made and patient consented for excision of diverticulum with interposition graft to prevent uretrocutaneous fistula.

Surgery

Complete excision of diverticulum with transfixation of the neck of diverticulum with closure of urethra in two layers with interposition of right labial fat pad (Martius flap) based on superior labial artery done under GA.

Midline incision taken over the anterior vaginal wall and vaginl wall flaps were created. Diverticular wall is dissected from all around. Midline incision taken to open the diverticulum. Connection between the diverticulum and urethral identified and it is disconnected and opening is closed with purse string absorbable suture. The urethra over the diverticular opening is closed in two layers. Excess diverticular wall excised and sent for histopathological examination. Right vertical incision taken over the labia and labial fat pad dissected circumferentially from the underneath pubic ramus. It is disconnected at lower end. Pedicled graft is developed based on superior labial artery. Window created between the labial minora and anterior vaginal wall and graft is delivered in the bed of urethra. Martuis fap is sutured to the surrounding tissue over the closed urethra to prevent development of urethrocutaneopus fistula and anterior vaginal wall is closed.

Catheter kept of 2 week and micturating urethrogram done after catheter removal revealed normal urethra with no leak. Patient is passing urine with normal stream with no incontinence.

Discussion

Female urethral diverticulum (UD) is a rare and unique clinical entity with an annual incidence of 17.9 per 1,000,000(0.02%) per year. Urethral diverticulum can be congenital or acquired. The diagnosis of UD may be suggested by a thorough clinical history and physical examination but often imaging is required to confirm the findings of clinical evaluation. As a consequence of delayed diagnosis, women may encounter several complications, such as recurrent urinary tract infections, stone formation, and more rarely, malignancy. Treatment options for UD can range from conservative management to extensive surgery including diverticulectomy, martius flap, and rectus fascia pubovaginal sling surgery. In the index case, there were similar findings of recutternt UTI and  anterior vaginal wall cystic swelling which was confirmed by MRI as urethral diverticulum. Complete excision with Martuis flal interposition gave her complete relief of symptoms and total continence.

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