Urethral Diverticulum

Clinical lack of awareness about urethral diverticulum has lead to this relatively common condition remaining under-diagnosed in women with chronic genitourinary conditions. Women with recurrent infections, retro pubic pressure, urethral pain, delayed voiding, frequency urgency, post-void dribbling and painful sex (without vaginal infection) are often given the blanket diagnosis of ‘urethral syndrome’.

The urethra is surrounded by microscopic paraurethral glands concentrated around the lower third of the urethra and drain into the Skene ducts, adjacent to the urethral opening. Infection in these glands is relatively common and under diagnosed. One or more glands become infected and obstructed, forming a pouch that consequently bursts into the urethral lining. Re-growth of tissue over the resulting paraurethral cavity causes recurrent infection and enlargement of the diverticulum. When the pouch remains open it repeatedly fills with urine during voiding (because of its connection to the urethra).

Urethral diverticulum is diagnosed by various imaging techniques and careful pinpoint palpation of the urethra through the front vaginal wall. The female urethra is embedded in the anterior vaginal wall, and slopes downwards and forward. Careful palpation of the sides of the distal urethra up to 3 centimeters along the front vaginal wall identifies specific tenderness indicative of paraurethral gland infection. When a large gland is present gentle compression or ‘milking’ may discharge retained urine or infected fluid through the urethral opening.

Some effective treatments are: antibiotics for acute infection, urethral milking for removing infected fluids and hot baths for soothing relief of muscle spasms. Avoiding saturated fat, caffeine, alcohol, sugar and white flour products reduces systemic inflammation. Cellular acidity is reduced through increased vegetable intake (an acidic environment allows inflammation to proliferate). Herbalists advise willow bark, meadowsweet, ginger, bromelain (pineapple), licorice, turmeric and ginseng to reduce pain-producing prostaglandins.

Muscular over activity is a natural reaction of the pelvic floor muscles to pain, infection and urine loss. When symptoms are chronic, the muscles react with prolonged tightening and develop heightened resting tone. Treatment with a women’s health physiotherapist to reduce pelvic floor muscle tone and prevent painful trigger points is recommended.

Surgical treatment includes excision of periurethral tissue, internal urethral cutting procedures and forceful urethral dilation. Surgical excision should be approached with caution due to the risk of post surgically compromised urethral function, re-occurrence of diverticulum, stress incontinence, urethro-vaginal fistula formation and occasional re-construction of a new urethra.

For more information:

www.obgynresidents.stanford.edu/documents/femaleurethraldiverticula.pdf

www.ajronline.org/cgi/content/full/190/1/165