case report
Female urethral diverticulum associated with a large urinary calculus Divertículo de uretra feminina associado a grande cálculo urinário Alexandre Oliveira Rodrigues1, Maria Claudia Bicudo2, Rafaela Rosalba de Mendonça3, Carlos Alberto Bezerra4, Antonio Carlos Lima Pompeo5, Eric Roger Wroclawski 6†
ABSTRACT The diverticula of female urethra are very uncommon, but more frequently found between the third and fifth decade of life. Diverticula area mostly relate to repeated urinary infections of the periurethral glands or urethra’s trauma. The diverticula may cause infection, calculus formation and rarely endometriosis or cancer. A case of a 65-year old Caucasian female with vaginal mass over six months is herein reported. There was no urinary loss, urethral secretion or urinary symptoms. A cystourethrography showed diverticula with calculus inside. The patient was submitted to surgery and dismissed from the hospital on the first postoperative day. The pathologic examination revealed no malignancy. In six months of follow-up, the patient was continent with no complaints. Keywords: Diverticulum; Urethral diseases; Lithiasis; Urinary bladder calculi; Urologic diseases; Case reports
Resumo Os divertículos de uretra feminina são incomuns, porém mais frequentes entre a terceira e a quinta década de vida. A maioria dos divertículos de uretra está relacionada a infecções recorrentes das glândulas periuretrais ou traumatismo uretral. Os divertículos podem ser sítio de infecções, formação de cálculos e, mais raramente, endometriose ou neoplasia. Relata-se o caso de paciente de 65 anos, branca, com queixa de nódulo em parede vaginal notado há seis meses. Negava incontinência urinária, derrame uretral e sintomas urinários de armazenamento ou de esvaziamento. A uretrocistografia miccional revelou divertículo uretral associado a cálculo. Submetida à cirurgia, teve alta hospitalar no primeiro dia pós-operatório. O resultado do exame anatomopatológico não evidenciou malignidade. Após seis meses de seguimento, a paciente encontra-se sem queixas urinárias ou vaginais e com continência urinária preservada.
Descritores: Divertículo; Doenças uretrais; Litíase; Cálculos da bexiga urinária; Doenças urológicas; Relatos de casos
INTRODUCTION Female urethral diverticula are uncommon, but occur more frequently between the third and fifth decades of life, although there are reports of congenital diverticula in newborns and young women(1). It is more prevalent in the black population and the overall prevalence based on autopsy ranges from 0.6 to 4.7%(2). Most urethral diverticula are associated with recurrent periurethral gland infections or periurethral trauma by labor, surgery, or intermittent use of catheters(1). Diverticula may be the site of infections, calculus formation and, more rarely, of endometriosis or neoplasm. The association between diverticulum and calculus ranges from 1.5 to 10%(3). The classic triad of urethral diverticulum – dysuria, dyspareunia and postvoid dribbling – is not very common. Symptoms such as periurethral mass, pain or urethral discharge may be suggestive of the presence of a urethral diverticulum, but most patients only present bladder storage or emptying symptoms, or repeated urinary infections, thus making diagnosis difficult. Some patients are asymptomatic, especially if the diverticulum is small (2 a 16 mm)(1,4). Clinical and surgical details about the approach of a large urethral diverticulum with a calculus inside are presented.
1
Assistant Physician of the Group of Female Urology of Faculdade de Medicina do ABC – FMABC, Santo André (SP), Brazil.
2
Preceptor of Urology of Faculdade de Medicina do ABC – FMABC, Santo André (SP), Brazil.
3
Resident of Urology of Faculdade de Medicina do ABC – FMABC, Santo André (SP), Brazil.
4
Head of the Clinical Division of the Department of Urology of Faculdade de Medicina do ABC – FMABC, Santo André (SP), Brazil.
5
Adjunct and Regent professor of Urology of Faculdade de Medicina do ABC – FMABC, Santo André (SP), Brazil.
6†
In memoriam; Post-doctorate degree; Full professor of the Department of Urology of Faculdade de Medicina do ABC – FMABC, Santo André (SP), Brazil.
Corresponding author: Alexandre Oliveira Rodrigues – Rua Venezuela, 557/121 – Centro - CEP 09030-310 – Santo André (SP), Brazil – Tel.: (11) 4438-6333 – e-mail:
[email protected] Received on: May 12, 2009 – Accepted on: Oct 7, 2009
einstein. 2009; 7(4 Pt 1):512-4
Female urethral diverticulum associated with a large urinary calculus
CASE REPORT Case of a 65-year-old Caucasian patient complaining of a nodule on the vaginal wall noticed six months ago. She denied urinary incontinence, urethral discharge and bladder storage or emptying symptoms. The patient presented a history of three pregnancies (two vaginal deliveries and one miscarriage) and underwent total hysterectomy 35 years ago. Upon gynecologic examination, topic urethral meatus and bulging of the anterior vaginal wall with a cystic consistence, measuring approximately 8 cm (diameter), and containing mobile stony material roughly measuring 2.5 cm (diameter). Associated vaginal prolapse, urine loss or urethral discharge was not observed. The voiding urethrocystography confirmed the diagnosis of urethral diverticulum associated with calculus (Figures 1 and 2).
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After discussing with the patient, surgical management was chosen and urethrocystoscopy was performed at the beginning of the procedure. Urethral diverticular ostium was evidenced close to the bladder neck. An inverted U-shaped incision was performed on the anterior vaginal wall, followed by dissection of the diverticular wall fascia, resection of the diverticulum, and the specimen was sent to pathology (Figure 3).
Figure 3. View of surgery field after dissecting and opening the diverticular wall, showing the urinary calculus
Figure 1. Plain radiography of the pelvis showing radiopaque image at the pubis measuring 22 x 23 mm
Figure 2. Voiding urethrocystography clearly shows a diverticular formation in middle urethra
The urethra was sutured with Monocryl 5.0 in separate stitches, after placing a 16-French indwelling catheter. Pubocervical fascia and pubococcygeal muscles were sutured before closing the vaginal wall. No anti-incontinence mechanism was used. The patient was discharged on the first preoperative day and was asymptomatic. The indwelling catheter was removed after 14 days. Pathology examination showed no malignancy. At the sixth month of follow-up, she has no urinary or vaginal complaints and is continent.
DISCUSSION This patient presented anterior vaginal wall bulging leading to presumptive diagnosis of urethral diverticulum, which was confirmed by voiding urethrocystography. Suspicion of urethral diverticulum is not always evident, but it should be remembered in incontinent women presenting repeated urinary infections or bladder storage or emptying symptoms. Gomez Gallo reported a similar case of a 50-year-old patient complaining of dyspareunia and increased abdominal wall volume. Upon gynecologic examination, a mass of approximately three centimeters was observed closely to the urethra. Excretion urography showed a 3-cm calculus(5). einstein. 2009; 7(4 Pt 1):512-4
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Rodrigues AO, Bicudo MC, Mendonça RR, Bezerra CA, Pompeo ACL, Wroclawski ER
The literature shows that it is difficult to demonstrate the presence of female urethral diverticulum through complementary examinations. The diverticulum ostium is not visualized in urethrocystoscopy in several cases due to associated inflammation. Some series reported sensitivity of urethrocystoscopy of approximately 15% as compared to 45 to 65% of voiding urethrocystography. Sensitivity significantly increases when using a doubleballoon catheter inflated at the bladder neck and urethral meatus(6). Magnetic resonance imaging has high sensitivity and is used in cases in which other diagnostic methods do not confirm the presumptive diagnosis(1). The transvaginal approach by an inverted U-shape incision is the most appropriate technique to excise female urethral diverticulum, except in distally located diverticula, when marsupialization is an excellent alternative. Suturing in several layers using pubocervical fascia and pubococcygeal muscles, with well irrigated and not tense tissues, is essential for a successful urethral repair, thus avoiding urinary fistulas, which generally represent challenging complications regarding therapy. In more complex cases, it is possible to interpose some tissues, such as labial fat or the bulbospongiosus muscle. Anti-incontinence surgery concurrent to the treatment of diverticulum should only be performed in
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women with previous incontinence and in cases of large reconstructions of the urethra or bladder neck, in whom there is a risk of sphincter lesion(7). Although rare, one should remember that urethral diverticulum may be the site of neoplams. Therefore, anatomopathological examination of the excised material is obligatory.
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