Pre- and Postoperative Evaluation of Urethral Diverticulum

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1 Hosseinzadeh et al. Urethral Diverticulum Genitourinary Imaging Pictorial Essay 165.fm 11/29/07 Keyanoosh Hosseinzadeh 1 lessandro Furlan 1,2 Maha Torabi 1 Hosseinzadeh K, Furlan, Torabi M Keywords: conventional radiography, CT, diagnostic imaging, diverticulum, MRI, pelvis, sonography, urethra, urethral diverticulum DOI: /JR Received February 20, 2007; accepted after revision ugust 3, Department of Radiology, University of Pittsburgh Medical Center, Presbyterian Campus, 200 Lothrop St., Rm. 3950, CHP MT, UPMC, Pittsburgh, P ddress correspondence to K. Hosseinzadeh (hosseinzadehk@upmc.edu). 2 Institute of Radiology, University of Udine, Udine, Italy. JR 2008; 190: X/08/ merican Roentgen Ray Society Pre- and Postoperative Evaluation of Urethral Diverticulum OJECTIVE. The purpose of this article is to review the diagnostic imaging findings, differential diagnosis, complications, and postoperative imaging appearance of urethral diverticulum. CONCLUSION. With increased clinical awareness and advanced imaging techniques, diagnoses of urethral diverticula are more frequent, and radiologists need to be aware of the preand postoperative imaging appearances of this disorder. rethral diverticulum may be defined as a localized outpouching U of tissue from the urethra into the urethrovaginal potential space. It is a relatively common finding among women with chronic genitourinary conditions, but the diagnosis and management remain problematic [1, 2]. Widespread clinical awareness and recent developments in imaging, including sonography and MRI, have greatly improved the diagnosis and management of this condition, providing information for surgical planning, such as location, number, size, configuration, and communication with the urethra, and the presence of stones or neoplasms [1]. This article reviews the diagnostic imaging findings, differential diagnosis, complications, and postoperative imaging appearance of urethral diverticula. Epidemiology Urethral diverticula occur more frequently in middle-aged women, with an estimated prevalence of % [1], which increases to 40% among patients with chronic genitourinary conditions such as recurrent infections, postvoid dribbling, and dyspareunia [2]. However, the true prevalence of the disorder is probably much higher because of the large number of asymptomatic or misdiagnosed cases. Pathophysiology Urethral diverticula may be congenital or acquired. Congenital diverticula are rare, likely arising from persistent embryologic remnants [3]. Theories for acquired diverticula postulate infectious, inflammatory, or traumatic causes. Periurethral glands (Skene s glands) are tubuloalveolar structures along the dorsolateral aspect that drain into the distal two thirds of the urethra. Repeated infection and obstruction of these glands lead to formation of suburethral cysts or abscesses that can rupture into the urethral lumen [4] (Fig. 1). The anatomic location of most urethral diverticula corresponds to the location of the Skene s glands. Clinical Presentation The classic clinical triad of dysuria, postvoid dribbling, and dyspareunia is infrequently observed [1]. The most common finding is a painful mass in the anterior wall of the vagina that may discharge urine or purulent material after palpation [1]. Some patients are asymptomatic; many of these diverticula are small (2 16 mm) and are discovered incidentally. The nonspecificity of the clinical presentation is responsible for extensive workup and delayed diagnosis [5]. Treatment Surgery is the treatment of choice for symptomatic urethral diverticula and includes complete or partial excision or marsupialization, depending mainly on the location of the diverticulum along the urethra [1, 6]. If the diverticulum opens into the middle or proximal third of the urethra, the treatment of choice is urethral diverticulectomy, which is usually performed transvaginally. For diverticula emptying into the distal third of the urethra, marsupialization into the vagina is an option. lthough transurethral procedures have been proposed, they may be less effective in preventing recurrence of the diverticulum [1]. JR:190, January

2 Hosseinzadeh et al. Imaging Evaluation Various imaging techniques are available, including voiding cystourethrography (VCUG), sonography, CT, and MRI. However, the accuracy of some of these studies is operator-dependent and is affected by the size of the diverticulum and the size and patency of the opening into the urethra. When possible, imaging should provide the surgeon with information regarding location, number, size, configuration, and communication of the diverticulum. ssociated intradiverticular lesions such as malignancy and calculi should be recognized [1]. Voiding Cystourethrography VCUG is a commonly used imaging study in the workup of suspected urethral diverticula; it has an overall accuracy of approximately 65% [1]. patent neck is necessary for diagnosis in order for contrast material to enter the diverticulum [7]. This technique is also used for the postoperative evaluation of diverticula (Fig. 2). The technique requires catheterization, which has the associated risk of infection. In addition, the patient may be inhibited from voiding in an unfamiliar environment [1]. Double-balloon urethrography is reported to offer better diagnostic accuracy than VCUG [7]. However, the procedure is technically demanding, requires specialized equipment, and is not routinely performed [1]. Increasingly, MRI and sonography have been shown to provide better anatomic detail than VCUG and doubleballoon urethrography [6]. Sonography Sonography of urethral diverticula can be performed using transvaginal, transperineal, endorectal and, less commonly, endourethral techniques; it compares favorably with VCUG [8, 9]. The best route for examining potential diverticula by sonography has not been established. In our institution, sonography is performed using a high-frequency endovaginal probe that is commonly placed on the external urethra meatus between the labia minora (Fig. 3). Sonography is noninvasive, obviating catheterization, and can provide measurements of the size, number of loculations, and location with respect to the urethra. However, sonography is operator-dependent, and distinguishing the diverticulum from other cystic lesions and visualizing the neck can be challenging. MRI Studies are increasingly reporting improved detection and characterization of urethral diverticula for surgical planning with highspatial-resolution multiplanar MRI when compared with VCUG, double-balloon urethrography [6, 10, 11], and sonography [10]. VCUG and double-balloon urethrography require a patent diverticulum orifice to make a diagnosis, and sonography is operator-dependent; distinguishing a diverticulum from a vaginal wall cyst can be difficult. MRI best assesses the extent, structure, and complexity of diverticula and enables visualization of the neck. ecause of the characteristic relationship of the diverticulum to the urethra, visualization of the neck is not necessary to make a confident diagnosis. MRI serves as the primary technique at our institution and may be performed using a conventional surface (Fig. 3) or the latest but invasive endoluminal (endorectal or endovaginal) coils for improved signal-tonoise ratio and spatial resolution [6, 10, 12] (Fig. 4). Ultimately, the choice of coil configuration may not alter surgical planning because of the excellent anatomic detail attained with both configurations [6]. CT CT has a limited role in the characterization of urethral abnormalities [12] (Fig. 3), with most diverticula discovered incidentally in relation to the large number of pelvic CT studies performed. However, CT can reliably show calculi in diverticula (Fig. 5). Differential Diagnosis The differential diagnosis of a urethral diverticulum includes vaginal wall cysts such as müllerian cysts, Gartner s cysts, artholin s gland cysts, and vaginal inclusion cysts; ectopic ureterocele; and endometriomas of the urethra. The diagnosis is made by the location and lack of communication of the cysts with the urethra (Fig. 6). Gartner s cysts (Fig. 7) typically occur in the anterolateral aspect of the proximal third of the vagina, whereas vaginal inclusion cysts are commonly located in the lower posterior or lateral vaginal wall at the sites of previous trauma or surgery. artholin s gland cysts (Fig. 8) are typically located in the posterolateral introitus medial to the labia minora [12, 13]. In addition, solid urethral masses (Fig. 9) such as carcinoma, nephrogenic adenoma, mesonephric adenocarcinoma, and embryonal cell rhabdomyoma may be mistaken for urethral diverticula. Pre- and Postoperative Complications Complications associated with urethral diverticula include urinary incontinence (60%), recurrent urinary tract infections (UTIs) (30%) [3], and formation of calculi (10%) [14] (Fig. 5). Malignancy arising in a urethral diverticulum is rare, but the most common cell type is adenocarcinoma (61%) [15] (Fig. 10). Postoperative complication rates have been reported to range between 5% and 46% [1]. Complications include urinary incontinence, urethrovaginal fistula, urethral stricture, recurrent UTIs, and recurrent urethral diverticula [1]. Recurrence of diverticula occurs in 1 29% of cases, most commonly after resection of a proximal diverticulum as a result of a difficult excision [1] (Figs. 11 and 12). Many patients with recurrence of diverticula undergo reoperation, which is the most likely cause of residual symptoms. technically successful first operation in experienced centers may limit these complications [16]. Summary With increased clinical awareness and advanced imaging techniques, the diagnosis of urethral diverticula is more frequent. MRI provides the most comprehensive evaluation before and after surgery. lthough there remains a lack of standardized practice, MRI is the preferred technique or can be pursued as a secondary investigation if other techniques fail to detect a diverticulum and clinical suspicion remains high. cknowledgments We thank Kyongtae Ty ae for Figures 4 and 9 and Eric Jablonowski for the illustrations in this article. References 1. Lee JW, Fynes MM. Female urethral diverticula. est Pract Res Clin Obstet Gynaecol 2005; 19: Stewart M, retland PM, Stidolph NE. Urethral diverticula in the adult female. r J Urol 1981; 53: Ganabathi K, Leach GE, Zimmern PE, Dmochowski R. Experience with the management of urethral diverticulum in 63 women. J Urol 1994; 152: spera M, Rackley RR, Vasavada SP. Contemporary evaluation and management of the female urethral diverticulum. Urol Clin North m 2002; 29: Romanzi LJ, Groutz, laivas JG. Urethral diverticulum in women: diverse presentations resulting in diagnostic delay and mismanagement. J Urol 2000; 164: Patel K, Chapple CR. Female urethral diverticula. 166 JR:190, January 2008

Urethral Diverticulum Curr Opin Urol 2006; 16:248 254 7. Golomb J, Leibovitch I, Mor Y, Moraq, Ramon J.

Siegel CL, Middleton WD, Teefey S, Wainstein M, McDougall EM, Klutke CG. Sonography of the female urethra. JR 1998; 170:1269 1274 9.

Foster RT, mundsen CL, Webster GD. The utility of magnetic resonance imaging for diagnosis and surgical planning before transvaginal periurethral diverticulectomy in women.

3 Urethral Diverticulum Curr Opin Urol 2006; 16: Golomb J, Leibovitch I, Mor Y, Moraq, Ramon J. Comparison of voiding cystourethrography and double-balloon urethrography in the diagnosis of complex female urethral diverticula. Eur Radiol 2003; 13: Siegel CL, Middleton WD, Teefey S, Wainstein M, McDougall EM, Klutke CG. Sonography of the female urethra. JR 1998; 170: Vargas-Serrano, Cortina-Moreno, Rodriguez- Romero R, Ferreiro-rguellas I. Transrectal ultrasonography in the diagnosis of urethral diverticula in women. J Clin Ultrasound 1997; 25: Foster RT, mundsen CL, Webster GD. The utility of magnetic resonance imaging for diagnosis and surgical planning before transvaginal periurethral diverticulectomy in women. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18: Neitlich JD, Foster HE, Glickman MG, et al. Detection of urethral diverticula in women: comparison of high resolution fast spin echo technique with double balloon urethrography. J Urol 1998; 159: Prasad SR, Menias CO, Narra VR, et al. Cross-sectional imaging of the female urethra: technique and results. RadioGraphics 2005; 25: Eilber KS, Raz S. enign cystic lesions of the vagina: a literature review. J Urol 2003; 170: ragona F, Mangano M, rtibani W, Passerini Glazel G. Stone formation in a female urethral diverticulum: review of the literature. Int Urol Nephrol 1989; 21: Seballos RM, Rich RR. Clear cell adenocarcinoma arising from a urethral diverticulum. J Urol 1995; 153: Ljungqvist L, Peeker R, Fall M. Female urethral diverticulum: 26-year follow-up of a large series. J Urol 2007; 177: Fig. 1 Pathogenesis of urethral diverticulum., Infection of distal Skene s gland drains into urethra. and C, Ductal obstruction leads to formation of suburethral cyst or abscess () that eventually ruptures into urethral lumen (C). Fig year-old woman with urethral diverticulum who underwent diverticulectomy., Voiding phase of voiding cystourethrography (VCUG) shows contrast material filling urinary diverticulum (arrowheads) that encircles urethral lumen (arrow). Filling started on right lateral aspect of urethra and extended to fill remaining diverticulum., Voiding phase of VCUG after diverticulum resection shows normal appearance of urethra (arrow). JR:190, January

representing palpable mass (outlined by calipers).

(arrowheads) encircling urethral lumen. = Foley balloon in urinary bladder.

urethra. Mucosal and submucosal component of urethra is displaced to left (arrow).

highsignal-intensity, fluid-filled diverticulum (asterisk) with fluid debris level (white arrow, E).

4 38-year-old woman with urethral diverticulum who presented with recurrent urinary tract infections.

(Courtesy of ae KT, Pittsburgh, P), Sagittal fast spin-echo T2-weighted endovaginal MR image shows

4 Hosseinzadeh et al. C D E Fig year-old woman with urethral diverticulum who presented with dysuria and palpable mass on anterior wall of vagina., Transverse translabial color-flow sonogram shows complex cystic lesion anterior to vagina, representing palpable mass (outlined by calipers)., Sagittal translabial sonogram after insertion of Foley catheter (arrow) shows anechoic lesions (arrowheads) encircling urethral lumen. = Foley balloon in urinary bladder. C, Transverse contrast-enhanced CT scan shows fluidfilled diverticular sac (asterisk) in enlarged urethra. Mucosal and submucosal component of urethra is displaced to left (arrow). D and E, Coronal (D) and transverse (E) fast spin-echo T2-weighted MR images confirm diagnosis of highsignal-intensity, fluid-filled diverticulum (asterisk) with fluid debris level (white arrow, E). Note displaced urethra (black arrow) and anterior septation (arrowhead, E). C Fig year-old woman with urethral diverticulum who presented with recurrent urinary tract infections. EV = endovaginal probe. (Courtesy of ae KT, Pittsburgh, P), Sagittal fast spin-echo T2-weighted endovaginal MR image shows high-signal-intensity, fluid-filled diverticulum (asterisk) in posterior aspect of urethra (arrow) that contains multiple thin septations (arrowheads). Note elevation of bladder dome by diverticulum. = urinary bladder. and C, Transverse unenhanced () and gadolinium-enhanced (C) gradient-echo T1-weighted endovaginal MR images show enhancement of urethral tissues (arrow) and posterior septation (arrowhead) of diverticulum (asterisk). 168 JR:190, January 2008

Transverse contrastenhanced CT scan of pelvis shows multiple dependent calculi (arrowheads) within fluid-filled urethral diverticulum

6 Typical anatomic locations of urethral diverticulum, Gartner s cyst, and artholin s gland cyst.

is consistent with urethral diverticulum. Fig. 7 32-year-old woman with Gartner s cyst who presented with dysuria and dyspareunia.

(asterisk) arising from right anterolateral wall of upper vagina and displacing high-signal-intensity vaginal mucosa (arrow) to the left.

, Sagittal fast spin-echo T2-weighted MR image shows fluid-filled mass (asterisk) displacing vaginal mucosa posteriorly (white arrow).

5 Urethral Diverticulum Fig year-old woman with urethral diverticulum who presented with urinary frequency and painful mass in anterior wall of vagina. Transverse contrastenhanced CT scan of pelvis shows multiple dependent calculi (arrowheads) within fluid-filled urethral diverticulum (asterisk) that displaces urethra (arrow) to the right. Fig. 6 Typical anatomic locations of urethral diverticulum, Gartner s cyst, and artholin s gland cyst., xial illustration through bladder neck, upper vagina, and rectum depicts Gartner s cyst in anterolateral or anterior wall of proximal third of vagina., xial illustration at or below inferior ramus, distal urethra, lower vagina, and anus depicts artholin s gland cyst in posterolateral wall of lower vagina at level of introitus. nteriorly, crescent-shaped cystic structure containing fluid fluid level encircles and connects to distal urethra via narrow orifice, which is consistent with urethral diverticulum. Fig year-old woman with Gartner s cyst who presented with dysuria and dyspareunia., Transverse fast spin-echo T2-weighted MR image with fat suppression shows well-defined high-signalintensity fluid-filled rounded mass (asterisk) arising from right anterolateral wall of upper vagina and displacing high-signal-intensity vaginal mucosa (arrow) to the left. Mass was clearly separate from urethra., Sagittal fast spin-echo T2-weighted MR image shows fluid-filled mass (asterisk) displacing vaginal mucosa posteriorly (white arrow). Urethra (black arrow) is displaced anteriorly. C Fig year-old woman with artholin s gland cyst that presented as mass in posterolateral introitus. Urethral diverticulum was incidentally discovered. V = vagina., Transverse fast spin-echo T2-weighted MR image shows high-signal-intensity fluid-filled urethral diverticulum (arrow) with neck (arrowhead) connecting to urethra. and C, Transverse () and coronal (C) fast spin-echo T2-weighted MR images show lobulated septate cystic mass (arrow) representing artholin s gland cyst and located posterolaterally in left lower third of vagina below symphysis pubis and immediately inferior to urethral diverticulum. rrowheads in C indicate lateral fornices of vagina. JR:190, January

Hosseinzadeh et al. C Fig. 9 50-year-old woman with high-grade squamous cell carcinoma (SCC) of urethra causing dysuria. EV = endovaginal probe.

intermediate-signal-intensity urethral mass (asterisk, ) that enhances heterogeneously (asterisk, ). Urethroscopy and biopsy confirmed SCC.

C, Transverse gadolinium-enhanced gradient-echo T1-weighted endovaginal MR image shows anterior vaginal wall invasion (white arrow). lack a Fig.

, Transverse unenhanced T1-weighted MR image shows intermediate-signal-intensity urethral mass (asterisk) in known remnant diverticulum.

6 Hosseinzadeh et al. C Fig year-old woman with high-grade squamous cell carcinoma (SCC) of urethra causing dysuria. EV = endovaginal probe. (Courtesy of ae KT, Pittsburgh, P) and, Transverse unenhanced () and gadolinium-enhanced () gradient-echo T1-weighted endovaginal MR images show intermediate-signal-intensity urethral mass (asterisk, ) that enhances heterogeneously (asterisk, ). Urethroscopy and biopsy confirmed SCC. rrow indicates Foley catheter in urethra. C, Transverse gadolinium-enhanced gradient-echo T1-weighted endovaginal MR image shows anterior vaginal wall invasion (white arrow). lack arrow indicates Foley catheter in urethra. Fig year-old woman with development of adenocarcinoma in remnant urethral diverticulum 4 years after resection. V = vagina., Transverse unenhanced T1-weighted MR image shows intermediate-signal-intensity urethral mass (asterisk) in known remnant diverticulum. Note fatty tissue (arrow) in urethrovaginal space resulting from Martius flap (labial fat interposed between urethra and vagina), a normal postprocedural finding., Transverse gadolinium-enhanced T1-weighted MR image confirms lesion appearing as circumferential enhancing mass (asterisk). Surgery confirmed diagnosis of adenocarcinoma. Note susceptibility artifact from remote diverticular resection (arrowhead). gain noted is surgically interposed fat (arrow) between urethra and enhancing vagina. 170 JR:190, January 2008

urethral diverticulum (asterisk) and urethra (arrow).

to right of urethral lumen (arrow), representing residual diverticular neck.

7 Urethral Diverticulum C D Fig year-old woman with recurrence of urethral diverticulum and interval increase in size that is causing recurrent urinary tract infections., Coronal fast spin-echo T2-weighted MR image obtained before diverticulectomy shows high-signalintensity fluid-filled urethral diverticulum (asterisk) and urethra (arrow)., Voiding cystourethrography performed in immediate postoperative period shows linear contrast collection (arrowhead) to right of urethral lumen (arrow), representing residual diverticular neck. C and D, Transverse (C) and sagittal (D) fast spin-echo T2-weighted MR images obtained 16 (C) and 24 (D) months after diverticulectomy show recurrent fluidfilled right posterolateral diverticulum with progressive increase in size of diverticular sac (asterisks) and displacement of urethra to left (arrow, C) and anteriorly (arrow, D). Note septation in diverticular sac (arrowhead, D). JR:190, January

for evaluation of ovaries show incidental cystic lesion (outlined

V = vagina, SG = sagittal, TRV = transverse.

8 Hosseinzadeh et al. C D E Fig year-old woman with asymptomatic urethral diverticular recurrence., Voiding cystourethrography performed in immediate postoperative period appears unremarkable. and C, Pelvic sonograms obtained 4 months after diverticulectomy for evaluation of ovaries show incidental cystic lesion (outlined by calipers) anterior to vagina. V = vagina, SG = sagittal, TRV = transverse. D and E, Coronal (D) and transverse (E) fast spin-echo T2-weighted MR images confirm recurrence of small high-signal-intensity diverticulum (open arrow) with fluid-filled neck (arrowhead, D) connecting to urethra (solid arrow). V = vagina. 172 JR:190, January 2008

MR of the Urethra 20 th Annual Summer Practicum SCBT-MR Jackson Hole August 11, Evan S. Siegelman MD University of Pennsylvania Medical Center

MR of the Urethra 20 th Annual Summer Practicum SCBT-MR Jackson Hole August 11, 2010 Evan S. Siegelman MD University of Pennsylvania Medical Center MR of the urethra Normal Anatomy Urethral Diverticula