3. The normal female urethra is a musculo fascial tube
approximately 3 to 4 cm in length, extending from the
bladder neck to the external urethral meatus,
suspended from the pelvic sidewall and pelvic fascia
(tendinous arc of the obturator muscle) by a sheet of
connective tissue known as the urethro pelvic
ligament. The urethro pelvic ligament is composed of
two layers of fused pelvic fascia that extend toward the
pelvic sidewall bilaterally .
Anatomy of the Female Urethra
4. This structure can be considered to have an abdominal
side (the endopelvic fascia and a vaginal side (the
periurethral fascia). Within and between these two
leaves of fascia lie the urethra and the location of most
urethral diverticulum ( UD ).
5. The urethral lumen is lined by a urothelial layer
proximally and a non keratinized stratified squamous
cell type distally. The urethra can be described as a
rich, vascular, spongy cylinder surrounded by an
envelope consisting of smooth and skeletal muscle and
fibro elastic tissue (Young et al, 1996). Within the
thick, vascular lamina propria/submucosal layer are
the periurethral glands.
6. These tubuloalveolar glands exist over the entire
length of the urethra postero laterally; however, they
are most prominent over the distal two thirds,
with the majority of the glands draining into the
distal one third of the urethra.
7. The Skene glands are the largest and most distal of
these glands. These glands drain outside the urethral
lumen, lateral to the urethral meatus. It is from
pathologic processes involving the peri urethral glands
that most acquired female UD are thought to
originate.
8. A urethral diverticulum (UD) in the female is a
variably sized urine-filled peri urethral cystic structure
adjacent to the urethra within the confines of the
pelvic fascia, connected to the urethra via an ostium.
FEMALE URETHRAL DIVERTICULA
9. The exact origin of UD is still unproven. A major
debate in the early part of the 20th century focused on
whether UD were congenital or acquired lesions
(Johnson, 1938; Gilbert and Rivera Cintron, 1954;
Pinkerton, 1963). Although this condition exists in
children, the diagnosis may represent a different
clinical entity from adult female UD.
Pathophysiology and Etiology :
10. The vast majority of UD, however, are classified as
acquired and are diagnosed in adult females. There are
multiple theories regarding the formation of acquired
UD. For many years, acquired UD were believed to be
most likely due to trauma from vaginal childbirth
(McNally, 1935). It was postulated that mechanical
trauma during vaginal delivery resulted in herniation
of the urethral mucosa through the muscular layers of
the urethra with the subsequent development of a UD.
11. Although there are probably other unknown factors
that may facilitate the initiation, formation, or
propagation of UD, infection of the peri urethral
glands seems to the most generally accepted common
etiologic factor in most cases. UD have been
attributed historically to recurrent infection of
the peri urethral glands, with obstruction, sub
urethral abscess formation, and subsequent
rupture of these infected glands into the urethral
lumen
12. UD have been attributed historically to recurrent
infection of the peri urethral glands, with obstruction,
sub urethral abscess formation, and subsequent
rupture of these infected glands into the urethral
lumen. Continual filling and pooling of urine in the
resultant cavity may lead to stasis, recurrent infection,
and eventual epithelialization of the cavity, forming a
permanent UD.
18. Evaluation and Diagnosis :
1-History and Physical Examination :
-LUTS & urinary incontinence and its type
-Sexual symptoms e.g dysparunia
-Pelvic surgery e.g incontinence surgery .
-During physical examination, the anterior vaginal wall
should be carefully palpated for masses and
tenderness.
19. The location, size, and consistency of any suspected
UD should be recorded. Most UD are located ventrally
over the middle and proximal portions of the urethra,
corresponding to the area of the anterior vaginal wall 1
to 3 cm inside the introitus near the urethral meatus or
distorting the urethral meatus are likely Skene gland
cysts or abscesses.
20. Only about one third of UD present with a tender
anterior vaginal wall mass (Ganabathi et al, 1994).
However, UD may also be located anterior to the
urethra or extend partially or completely around the
urethral lumen. UD may also extend proximally
toward the bladder neck.
21. During physical examination, the urethra may be
gently “stripped” or “milked” distally in an attempt to
express purulent material or urine from within the UD
cavity.
22. 2-Urine Studies. Urine analysis and culture should be
performed. The most common organism isolated in
patients with UD is E. coli. However, other gram-
negative enteric flora, as well as N. gonorrhoeae,
Chlamydia, streptococci, and staphylococci, are often
present
23. 3-Cystourethroscopy:. Cystourethroscopy is
performed in an attempt to visualize the UD ostium as
well as to evaluate for other causes for the patient’s
lower urinary tract symptoms. The UD ostium is most
often located postero laterally at the 4 and 8 o’clock
positions at level of the mid-urethra but can be very
difficult to identify in some patients (Fig. 90-19).
24.
25. 4-Urodynamics: For patients with UD and urinary
incontinence or significant voiding dysfunction, a
urodynamic study may be helpful in accurately
characterizing these symptoms (Bhatia et al, 1981;
Reid et al, 1986; Summitt and Stovall, 1992).
Urodynamics may document the presence or absence
of stress urinary incontinence (SUI) prior to repair
26. For patients undergoing surgery for UD who have
coexistent symptomatic SUI demonstrated on physical
examination or urodynamically demonstrable SUI a
concomitant anti-incontinence surgery can be offered.
Synthetic materials (e.g., mid-urethral polypropylene
mesh) should not be used in an anti-incontinence
procedure synchronously with UD surgery because of
the potentially increased risk of urethral erosion and
infection
27. Imaging :
1-Diagnostic Contrast Radiography. A number of
imaging techniques have been applied to the study of
female UD, and no single study can be considered the
gold standard or optimal imaging study for the
evaluation of UD
28. Currently available techniques for the evaluation of
UD include double-balloon catheter(Trattner
catheter),VCUG, intravenous urography,
ultrasonography, and MRI with or without an
endoluminal coil.
29.
30.
31. Ultrasonography : Abdominal, transvaginal, and
transurethral techniques have been described in
assessment of vaginal masses and UD. Transvaginal
imaging often provides information regarding the
size and location of UD. On ultrasonographic
imaging, the UD appears as an anechoic or hypo
echoic area with enhanced through transmission.
32. Magnetic Resonance Imaging :A distinct advantage
of MRI compared with VCUG is that successful
imaging of UD is wholly independent of voiding
and that it is free from ionizing radiation. Surface
techniques have been described. Endoluminal
magnetic resonance imaging (eMRI) places the
magnetic coil into a body cavity adjacent to the area of
interest.
33. Both surface coil MRI and eMRI appear to be superior
to VCUG in the evaluation of UD, but the technology
is expensive and not widely available. Notably, there
are several lesions, including peri urethral bulking
agents, that can be misdiagnosed as UD on MRI, and
this imaging technique may be inadequate in the
diagnosis of malignancy within UD, a rare but
important finding (Chung et al, 2010).
34.
35. Treatment :
Excision and Reconstruction.:
Excision and reconstruction is probably the most
common surgical approach to UD in the modern era.
The principles of the urethral diverticulectomy
operation have been well described (Box 90-2). There
are only a few minor issues about which some surgeons
may disagree, including the type of vaginal incision
(inverted “U” vs. inverted “T”), whether it is necessary
to remove the entire mucosalized portion of the lesion,
and, finally, the optimal type of postoperative catheter
drainage (urethra only vs. urethra and suprapubic).
36.
37.
38. Vaginal Leiomyoma :
Vaginal leiomyomata are benign mesenchyma tumors
of the vaginal wall that arise from smooth muscle
elements. They commonly present as a smooth, firm,
round mass on the anterior vaginal wall (Fig. 90-24).
Vaginal leiomyoma is an uncommon lesion, with
approximately 300 cases reported in the literature
(Young et al, 1991).
39.
40.
41. These masses were all apparent on physical
examination as freely mobile, firm, non tender masses
on the anterior vaginal wall. They may b misdiagnosed
as UD (Shirvani and Winters, 2000). Symptoms, if
they exist, are usually related to the size of the lesion
and include a mass effect, obstruction, pain, and
dyspareunia.
42. They commonly present in the fourth to fifth decade.
Similar to uterine leiomyoma, these lesions are usually
estrogen dependent and have been demonstrated to
regress during menopause. Excision or enucleation
(Young et al, 1991) through a vaginal approach is
often curative and is recommended to confirm the
diagnosis, to exclude malignant histology, and also to
alleviate symptoms.
43. Skene Gland Abnormalities
Skene gland cysts and abscesses are similar lesions that
are differentiated based on clinical findings (Fig. 90-
25). Both lesions generally present as small, cystic
masses just lateral or infero lateral to the urethral
meatus. They may be lined with transitional or
stratified squamous epithelium. Abscesses may be
extremely tender and inflamed, and, in some cases,
purulent fluid can be expressed from the ductular
orifice. Classically, in contrast to UD, these lesions
do not communicate with the urethral lumen.
44.
45. Skene gland cysts are not uncommonly noted in
neonatal girls and young to middle-age female
patients (Lee and Kim, 1992). Symptoms may include
dysuria, dyspareunia, obstruction, and pain.
Differentiation from UD can often be made on
physical examination, because these lesions are
located relatively distally on the urethra, often
distorting the urethral meatus, as compared with
UD, which most commonly occur over the mid
and proximal urethra.
46. Various treatments for Skene gland abnormalities have
been described, including aspiration,
marsupialization, incision and drainage, and simple
excision. Surgical excision is curative.
Adenocarcinoma arising in Skene glands has been
reported. Because of homology with the prostate,
these patients may demonstrate elevated prostate-
specific antigen levels that normalize with treatment
(Dodson et al, 1994).
47. Gartner Duct Abnormalities
Gartner duct cysts represent mesonephric
remnants and are found on the anterolateral
vaginal wall from the cervix to the introitus.
Because these are mesonephric remnants, they
may drain ectopic ureters from poorly functioning
or non functioning upper pole moieties in
duplicated systems (Fig. 90-26). They have also been
reported with single-system ectopia, although this is
much less common in females.
48.
49. Treatment depends on symptoms and association with
ectopic ureters. If the lesions are asymptomatic and
are associated with a nonfunctioning renal moiety,
they can be observed. Aspiration followed by
sclerotherapy has been successful (Abd-Rabbo and
Atta, 1991). Simple excision or marsupialization has
also been recommended for symptomatic lesions. If
the cyst is associated with a functioning renal moiety,
treatment must be individualized.
50. Vaginal Wall Cysts.
Vaginal wall cysts usually present as small
asymptomatic masses on the anterior vaginal wall
(Deppisch, 1975) but may enlarge to cause lower
urinary tract symptoms or dyspareunia (Fig. 90-27).
They may arise from multiple cell types:
mesonephric (Gartner duct cysts), paramesonephric
(mullerian) , endometriotic, urothelial, or epidermoid
(inclusion cyst).
51. A specific diagnosis cannot be reliably made until the
specimen is removed and examined by a
pathologist.As with other peri urethral masses, they
must be differentiated from UD. Treatment is usually
by simple excision in symptomatic patients.
52.
53. Urethral Mucosal Prolapse
Urethral prolapse presents as a circumferential
herniation or eversion of the urethral mucosa at the
urethral meatus. The prolapsed mucosa commonly
appears as a beefy red lesion that completely
surrounds the urethral meatus. It may be
asymptomatic or present with bleeding, spotting, pain,
or urinary symptoms
54. It is commonly noted in two separate populations:
postmenopausal women and prepubertal girls. In
children, it is often causally related to Valsalva voiding
or constipation. Eversion of the mucosa may then
occur as a result of a pathologically loose attachment
between smooth muscle layers of the urethra (Lowe et
al, 1986). Etiology is much less clear for
postmenopausal women, although it has been
epidemiologically linked to estrogen deficiency.
55. Treatment may be medical or surgical. Medical
treatment involves topical creams (estrogen,
anti-inflammatory) and/or sitz baths. Various
surgical techniques have been described,
including cauterization, ligation around a Foley
catheter, and complete circumferential excision.
Circumferential excision with suture re
approximation of the remaining urethral mucosa to
the vaginal wall can be performed with few
complications.
56. Urethral Caruncle
Urethral caruncle is an inflammatory lesion of the
distal urethra that is most commonly diagnosed in
postmenopausal women. It usually appears as a
reddish exophytic mass at the urethral meatus, which
is covered with mucosa. These lesions are often
symptomatic and noted incidentally on gynecologic
examination. When irritated, they may cause
underwear spotting or become painful. Less commonly
they may cause voiding symptoms
57. Rarely, these lesions may thrombose, resulting in a
discolored periurethral mass (Fig. 90-28).
Etiologically, they are related to mucosal
prolapse. Chronic irritation contributes to
hemorrhage, necrosis, and inflammatory growth of
the tissue that corresponds to the histology of excised
lesions.
58.
59. Most authors recommend initial conservative
management with topical estrogen or anti-
inflammatory creams and sitz baths. Large or
refractory lesions may be managed with simple
excision. The tip of the lesions should be grasped and
traction employed to fully expose the base of the
caruncle. The lesion can then easily be excised. If a
large defect remains, the mucosa may be re
approximated with absorbable suture. In most
instances, the urethral mucosa will heal around a Foley
catheter, which may be left in place for several days.
60. Peri urethral Bulking Agents
The transurethral or peri urethral injection of bulking
agents for the treatment of stress incontinence may
result in an anterior vaginal wall mass that appears
cystic on imaging, consistent with a UD (Clemens
and Bushman, 2001; Bridges et al, 2005; Castillo-
Vico et al, 2007). A careful history will elicit this
possibility. Typically, these lesions do not
communicate with the urethra and are largely
asymptomatic. Symptomatic lesions may be surgically
excised transvaginally (Kumar et al, 2011).
61. Female urethral carcinoma
Female urethral carcinoma is rare condition and
accounts for approximately 0.02% of female cancers
(Fagan and Hertig, 1955) and less than 1% of cancers in
the female genitourinary tract (Srinivas and Khan,
1987).
62. Although the cause of urethral carcinoma in women
has not been identified, several factors have been
implicated. Etiologic factors associated with the
development of urethral carcinoma include
leukoplakia, chronic irritation, caruncles, polyps,
parturition, and human papilloma virus infection
or other viral infections (Mevorach et al, 1990;
Grigsby and Herr, 2000).
63. It is commonly believed that squamous cell carcinoma
appears to be the most common histologic type,
accounting for 30% to 70% of all cases. Urothelial
carcinoma and adenocarcinomas are thought to be the
next most common cell types (10% to 25% each).
64. Other rarer cell types include lymphoma, neuro
endocrine carcinoma, sarcomas, paragangliomas,
melanoma, and metastasis (Johnson and O’Connell,
1983; Grabstald et al, 1966; Foens et al, 1991;
Forman and Lichter, 1992; Grigsby and Herr, 2000;
Swartz et al, 2006).
65. Within urethral diverticula, an increased incidence of
adenocarcinomas seems to exist, substantiating the
theory that urethral diverticula in some women may
arise from a glandular origin, such as the Skene glands
66. Diagnosis :
The evaluation of women with suspected urethral
carcinoma includes a thorough pelvic examination,
evaluating for a palpable anterior vaginal mass for
which the differential should include urethral
diverticulum, urethral cancer, urethral polyp, or other
benign neoplasm, such as a leiomyoma. Speculum
examination should visualize the urethral meatus
directly and evaluate for potential involvement of the
vaginal wall and vulva.
67. Diagnostic studies include cystourethroscopy and
examination under anesthesia. MRI has been used to
evaluate pelvic lesions because soft tissue contrast is
superior to that with CT and it gives the best anatomic
detail in this area. Additionally, MRI can assess local
extension and lymph node involvement.
