We aimed to describe the presentation, investigations, and management of patients with urethral diverticula and to review the importance of magnetic resonance imaging (MRI) in the diagnosis and surgical management of urethral diverticula.

This was a retrospective study of female patients who underwent urethral diverticulectomy between 2010 and 2018 by a single surgeon with subspecialty training in functional and reconstructive urology. This study was approved by the Research Ethics review board. Clinical data was collected on patient demographics, presenting symptoms, investigations performed, operative technique, and minimum of two-year follow-up. A 2 Tesla MRI pelvis with T1 fat suppressed sequence and T2 void phase was performed for all patients and reviewed by experienced uroradiologists.

A total of 17 patients were included in this study, with a median age was 43 years. Most patients (70%) presented with a palpable vaginal lump; 64% presented with either lower urinary tract symptoms (LUTS) or recurrent urinary tract infections (UTIs). 12% presented with stress urinary incontinence. All women had a palpable lump, 29% of which were painful on palpation. All but one patient underwent a preoperative MRI, which demonstrated that 59% of diverticula were distal and 53% were locally round. These imaging findings were consistent with the operative findings. MRI also demonstrated communication between the urethral diverticulum and the urethral lumen in 80% of cases, compared to only 47% endoscopically. All women underwent a transvaginal approach to the excision of their urethral diverticulum. Eight women also had a Martius flap. Mean length of hospital stay was 2 days. Mean postoperative follow-up ranged from 6 months to 24 months with a mean follow-up period of 12 months. There were no postoperative complications or recurrences

Urethral diverticula are an uncommon urological pathology and diagnosis can be challenging. The most common presentation of our patients was with a either a palpable vaginal lump, LUTS, or recurrent UTIs. We did not find the classically described “3 Ds” of dysuria, dyspareunia and post-void dribbling associated with urethral diverticula to be applicable.[1] Imaging modalities such as double-balloon test, voiding cystourethrograms and ultrasound and as well as endoscopic investigation have been superseded by MRI. It has become the gold standard for the diagnosis of urethral diverticulum and exclude other causes of vaginal lumps. In our case series it was superior to endoscopy in locating the ostium and demonstrated a high degree of concordance with operative findings.

Patients with urethral diverticulum do not present with typically described clinical features and a high index of clinical suspicion is required. Preoperative MRI provides vital information on the characteristics of the urethral diverticulum which is important for patient counselling and surgical planning as well as excluding alternative pathologies. MRI should be considered in patients who experience LUTS or recurrent UTIs and vaginal examination reveals a palpable lump.

Baradaran N, Chiles LR, Freilich DA, Rames RA, Cox L, Rovner ES. Female Urethral Diverticula in the Contemporary Era: Is the Classic Triad of the "3Ds" Still Relevant? Urology. 2016 Aug;94:53-6.