Urethral diverticulum in women is a rare condition and is associated with urinary incontinence both at presentation and after urethral diverticulectomy. We report our large, updated series of patients undergoing urethral diverticulum excision over a 13 year period focusing on continence outcomes.

We retrospectively reviewed all patients undergoing urethral diverticulum excision at a large tertiary referral unit between 2005 and 2018. 122 consecutive patients were identified. Data collected included presentation, co-morbidities, operative intervention, post-operative outcomes and any subsequent treatment required. Except for 7 patients diagnosed early in the series, all patients underwent Video Urodynamics (VUDs) and MRI imaging of the diverticulum.

122 patients underwent surgical excision of urethral diverticulum with Martius fat pad interposition. Mean age was 45.2 years (range 19-73). All patients had a minimum follow-up of 12months. 4 patients had malignancy within the diverticulum and were excluded from further analysis. 7 patients early in the series did not have VUDs - symptomatic stress urinary incontinence was observed in 3 and urge urinary incontinence in 1. 

Pre-operative VUDs were available for the remaining 111 patients. Urodynamic stress urinary incontinence (USUI) was found in 25.2% (n=28). Detrusor over-activity incontinence (DOI) was shown in 1.8% (n=2). 2.7% (n=3) had mixed urinary incontinence (MUI). 60.6% (n=66/109) had bladder outlet obstruction secondary to the diverticulum. 

Post-operatively 37.2% (n=44) had USUI – 16.1% (n=19) persistent USUI and 22.5% (n=25) with de novo USUI. 3.6% (n=4) had post-operative DOI - 1.8% (n=2) persistent DOI and 1.8% (n=2) de novo DOI. MUI was found de novo in 0.9% (n=1) and post-operative MUI in the context of pre-operative USUI seen in 1.8% (n=2).

Pelvic floor exercises were successful in 50% of cases (n=22) for post-operative USUI. When required, surgical intervention cured USUI in 79% (15/19) cases. Post-operative DOI resolved with conservative measures (n=2) or intravesical botulinum toxin injections (n=2) in all cases. MUI was treated with combination intervention for both USUI and DOI in 2 cases with success in one and ongoing DOI in the 2nd case. Sacral neuromodulation was used with success in the remaining case of urge predominant MUI.

Due to the large size of our cohort these results give an idea of the true incidence of incontinence in patients with urethral diverticulum. The majority of our cohort had complex diverticula and post-operative incontinence rates should be interpreted with this in mind. However, with a third of patients having resolution of their incontinence with excision of the diverticulum alone and, of those symptomatic post-operatively, 50% improving with conservative measures alone, our results support our current strategy to treat the diverticulum first and any subsequent incontinence later. Our study also shows that surgical management of ongoing incontinence after diverticulectomy is effective with success rates comparable to anti-incontinence procedures in patients with primary USUI/DOI.

Urinary incontinence is commonly associated with urethral diverticulum and is found in 31.4% at presentation and 43.2% after urethral diverticulectomy. Pre-operative USUI will resolve in 35.3% of cases without any intervention. Conservative treatments for post-operative urinary incontinence are successful in 47% of all cases, and the remainder are able to achieve continence in 79.2% with surgical intervention.