Department of Urology, National Cheng Kung University Hospital, Tainan, Taiwan

 

Objective: Female urethra diverticula are rare lesions, and most of them are believed to be derived from the peri-urethral glands after recurrent infections. The classic triad of three D's (Dysuria, Dysparunia, and Dribbling), are presented only in about one third of cases. The remaining two third of patients may present as vaginal mass, fullness discomfort over perineum, lower urinary tract symptoms, and recurrent urinary tract infections. We describe a young female with a urethra diverticulum who presented with intermittent urinary retention and successfully treated with surgery.

The case is a 23-year-old female without significant underlying disease. She first visited our out-patient department in 2015/10, about one month after she had vaginal delivery. She complained about a palpable nodule near her urethra meatus, over 6 o’clock direction. When she palpated the nodule, some discharge was found from the urethra meatus. The nodule usually enlarged after several episodes of voiding, and caused voiding difficulty and incomplete emptying. She used to squeeze the nodule to make it smaller before and during voiding in order to void completely. She did not have any dysuria, dysparunia, or dribbling. A magnetic resonance imaging (MRI) of pelvis was done which showed a well-defined cystic structure with high T2 signal posterior to the distal urethra, which peri-urethral cyst or diverticulum was favored. A VCUG was also done but could not identify the connection between the cyst and the urethra. She lost follow-up for about 1 year after then, and visited our out-patient department again around 2016/12 due to aggravated condition with intermittent urinary retention. She could not void any more when the mass enlarged, and she need repetitively squeeze the nodule for voiding completely.

Cystourethroscopy was performed using 4.5 Fr. Rigid cystoscope, which revealed a tiny opening over posterior wall of the distal urethra. Trans-vaginal excision of diverticulum was done through an inverted U-shaped incision over the anterior vaginal wall. Vaginal flaps were raised and carefully dissection of the diverticulum up to its neck. Diverticulum was excised and repair of the urethra was done over a 14 Fr Foley catheter. The urethral catheter was removed 2 weeks later. She is now completely recovered and voiding normally.

Conclusion: Female urethral diverticulum is a rare condition in our clinical practice. It is extremely rare to cause bladder outlet obstruction. For them, careful history taking and physical examination are vital for its diagnosis. Magnetic resonance imaging is good to identify the lesion by using T2-weighted image. Surgical excision and urethral reconstruction remains the most reasonable choice of treatment.