A female urethral diverticulum (UD) is a urine-filled periurethral cystic structure connected to the urethra by an ostium. Most are acquired from infected periurethral (Skene) glands and present with the classic triad of storage LUTS, pain, and infection — though size does not correlate with symptoms.
Background and Anatomy
- Prevalence up to 1–6% of adult women; most present in the 3rd–7th decade; the vast majority are acquired.
- Most acquired UD arise from infection of the periurethral (Skene) glands.
- The ostium lies postero/ventrolaterally at the 4 and 8 o'clock positions in the mid- or distal urethra in >90%. Two-thirds show inflammatory changes; most are benign, but premalignant/malignant change occurs — the most common malignancy in a urethral diverticulum is adenocarcinoma (recall: most common female urethral cancer is squamous; male is urothelial).
Differential Diagnosis — Periurethral Masses (7)
Periurethral bulking agents, vaginal leiomyoma, Skene gland abnormalities, Gartner duct abnormalities, vaginal-wall cysts, urethral mucosal prolapse, and urethral caruncle.
- Urethral caruncle — an inflammatory lesion of the distal urethra, most common in postmenopausal women; focal (vs circumferential urethral prolapse). Treat conservatively first (topical estrogen/anti-inflammatory creams, sitz baths); excise large/refractory/atypical lesions.
Diagnosis and Evaluation
- Symptoms span asymptomatic (up to 20%) to debilitating masses; the most common (3) are storage LUTS, pain, and infection — recurrent cystitis should raise suspicion. Other symptoms: dysuria, hematuria, post-void dribbling, retention, stress/urge incontinence, dyspareunia, a vaginal mass (compression may express urine/pus), and discharge (vaginal pruritus is not a symptom). Size does not correlate with symptoms.
- Exam — the urethra can be "stripped" to express pus/urine.
- Imaging (no gold standard; 5 options): double-balloon positive-pressure urethrography, VCUG, IV urography, ultrasound, MRI — none reliably diagnoses malignancy.
- Cystourethroscopy — the ostium can be hard to find; stones are found in 4–10%.
Management
Options: observation, or surgical excision and reconstruction (most common), marsupialization, endoscopic unroofing, fulguration, or incision/obliteration.
- Observation — natural history is poorly known; counsel on malignancy risk; non-operative care uses low-dose antibacterial suppression and post-void digital stripping.
- Diverticulectomy — principles (8): mobilize a well-vascularized anterior vaginal-wall flap; preserve the periurethral fascia; identify and excise the neck/ostium; remove the entire sac; watertight urethral closure; multilayer non-overlapping absorbable closure; close dead space; preserve/create continence. Successful excision removes the ostium (often with the urethral catheter seen in the lumen); additional procedures (buccal graft, Martius/vaginal flaps) are not needed to close the urethra. Do not place synthetic mid-urethral mesh synchronously (erosion/infection risk). Adverse events: recurrent UTI, incontinence, recurrent diverticulum, and (uncommon) urethrovaginal fistula — diverticulum size does correlate with recurrence risk.
Self-Test
1. How do female urethral diverticula usually develop? From infection of the periurethral (Skene) glands.
2. Where is the ostium usually located? Postero/ventrolaterally at 4 and 8 o'clock in the mid- or distal urethra.
3. Most common malignancy histology in a urethral diverticulum, female urethral cancer, and male urethral cancer? Adenocarcinoma; squamous (female urethra); urothelial (male urethra).
4. Signs and symptoms of female urethral diverticulum? Storage LUTS, pain, infection, dysuria, hematuria, post-void dribbling, retention, incontinence, dyspareunia, vaginal mass/discharge.
5. Lymphatic drainage of the female urethra? Proximal → external iliac nodes; distal → superficial inguinal nodes.
6. Lymphatic drainage of the male urethra? Posterior → pelvic nodes; anterior → superficial inguinal nodes.
7. Differential diagnosis of a periurethral mass? Vaginal leiomyoma, Skene gland abnormalities, Gartner duct abnormalities, vaginal-wall cysts, urethral mucosal prolapse, urethral caruncle, periurethral bulking agents.
8. Most common surgical approach? Excision and reconstruction (diverticulectomy).