Congenital UDs (10% cases):Due to a developmental defect of urethral folds on its ventral aspect leading to a segmental defect of the urethral wall, most commonly at the peno-scrotal junction. It is characterized by true epithelial lining and wall made up of full thickness urethral musculature.
Acquired UDs (90% cases):Lined by epithelium and granulation tissue, and the UD wall lacks smooth muscle fibers.
UD are thought to arise from repeated obstruction, infection and subsequent rupture of periurethral glands into the urethral lumen, resulting in an epithelialised cavity that communicates with the urethra.
UD is more common in women secondary to poor anatomical support of the urethra, it is a rare finding in men.
Most patients with UD present between the third and seventh decade of life, with a median age of 40 years, but presentation can occur at any age.
Asymptomatic presentation:Up to 20% of patients lack symptoms, with UD being an incidental finding on imaging.
Classic triad ‘three Ds’:Seen in only 5% cases
- Dyspareunia (12–24% cases)
- Dribbling (post-void)
Other features:UD present in a myriad of ways including: asymptomatic and incidentally found lesions, painful vaginal masses, bothersome LUTS, stones, or malignancy.
- Irritative LUTS (lower urinary tract symptoms)
- Recurrent UTIs (⅓ cases): Due to urine stasis
- Palpable anterior vaginal wall mass (exude retained urine/debris per urethral meatus upon compression)
The vague and overlapping nature of symptoms frequently delays the diagnosis of UD by 2–5 years, with the mean interval between onset of symptoms and diagnosis of 5.2 years.
Urinalysis & culture:
- M/C organism isolated in patients with UD: E. coli
Cystourethroscopy:Visualise location of diverticular ostium and to evaluate for other causes of irritative/obstructive voiding symptoms
Voiding cystourethrogram (VCUG):
- Vaginal wall cysts
- Skene gland abnormalities
- Gartner’s duct abnormalities
- Urethral prolapse
- Urethral caruncle
Nonoperative management:For UDs that could be successfully emptied with manual compression (absence of urethral obstruction)
- Prophylactic antibiotic therapy
Surgical management:Indications for urethroplasty included recurrent UTIs despite antibiotic therapy, obstructive voiding or a stone in the UD
- Urethral diverticulectomy & reconstruction
- Urinary diversion