Urethral Diverticula - Causes, Risk Factors, Diagnosis, and Management

What Are Urethral Diverticula?

The urinary system contains organs that work to filter the blood, form urine, and maintain the fluid and electrolyte levels of the body. The urethra is a tube-like structure and is a crucial organ of the urogenital tract. It carries the urine outside the body from the urinary bladder. There are numerous glands, known as the periurethral glands, present near the urethra. They secrete mucus and protect the inner lining of the urethra from the effects of urine. Sometimes, these glands become enlarged and protrude outward near the urethra, forming a pouch. This pouch formed near the urethra is known as the urethral diverticulum. As the pouch is present close to the urethra, the urine gets collected in it, resulting in infections of the urinary tract. If the patient is suffering from a urethral diverticulum, he must undergo treatment as soon as possible to avoid complications.

What Are the Causes of Urethral Diverticula?

The urethral diverticulum is present by birth or acquired by the individual during his lifetime. The factors responsible for urethral diverticulum by birth have been explained below:

• Corpus Spongiosum - It occurs due to a defect in the corpus spongiosum. The layer of tissue present around the urethra is known as the corpus spongiosum. If this layer is damaged, the urethra becomes thin, and a bulge or a pouch is formed near it, known as the diverticulum.

• Vaginal Cysts - Vaginal cysts have also been linked to the formation of the urethral diverticulum in females. The cysts are fluid-filled sac-like structures that form anywhere in the body. If these cysts form in the vagina and enlarge to the extent that they block the urinary system, the urethral diverticulum can develop.

The mechanism by which the urethral diverticulum is formed in adults has been described below:

• The urethra is surrounded by numerous tube-like glands known as the periurethral glands. These glands are present on the inner lining of the urethra.

• Under normal conditions, the periurethral glands protect the urethral lining from getting damaged by urine.

• However, when these glands are infected, they become obstructed. Due to recurrent urinary tract infections, these glands become enlarged and form urethral cysts or cavities.

• The cavity ruptures into the urethra, and communication is established between the urethra and the cyst.

• When this urethral cyst gets filled with urine, a pouch known as a urethral diverticulum is formed.

What Are the Risk Factors of Urethral Diverticula?

Females are at a higher risk of developing urethral diverticula compared to males. The factors that increase the risk of urethral diverticula are listed below:

1. Suppose the child is delivered vaginally; the stress on the muscles and tissues of the urethra increases. As a result, the tissues of the urethral wall bulge resulting in a urethral diverticulum.

2. Patients suffering from recurrent urinary tract infections are at the highest risk as the periurethral glands get blocked due to infections and bulge out.

3. If a person has the habit of holding the urine for long or is unable to empty the bladder, the pressure on the urethral muscles increases resulting in their outpouching.

4. A condition known as hypospadias occurs when the urethra has not completely developed by birth. The opening of the urethra is under the penis and not at the tip, which increases the risk of the urethral diverticulum.

What Are the Symptoms of Urethral Diverticula?

The symptoms of urethral diverticula depend upon its severity. Some patients might not present with any symptoms at all. However, the following symptoms are seen in severe cases:

• Recurrent urinary tract infections.

• The patient might feel the need to urinate frequently.

• Pelvic pain is commonly seen.

• Problems in urination.

• Nocturia or the urge to pass urine at night.

• The patient might feel pain at the time of intercourse.

• The urine might accidentally leak out before reaching the toilet (urinary incontinence).

• The patient feels pain and a burning sensation while passing urine.

• Females might notice an irregular discharge from the vagina.

• It becomes difficult to empty the bladder.

What Methods Are Used to Diagnose Urethral Diverticula?

The diagnosis of the urethral diverticula is made based on medical history, physical examination, laboratory tests, and imaging tests. The diagnostic methods have been listed below:

1) Medical History - The medical history is crucial to determine the general health of the patient. The following questions are asked while recording the history:

• What are the symptoms of the condition?

• When did the symptoms appear first?

• Did the patient take any medications for the same?

• How many times does the patient urinate throughout the day and night?

• Does the urine leak before reaching the toilet?

2) Physical Examination - The doctor examines the physical signs of the urethral diverticulum, like pelvic pain, vaginal discharge, and swelling present in the region of the urethra or vagina. If a pouch or sac is felt, the doctor tries to squeeze it a little to check if the pus or urine comes out. If pus comes out, a urine test, and main urinalysis, is recommended.

3) Laboratory Tests - The laboratory tests mentioned below are usually recommended:

• Urinalysis - The patient collects urine in a container or a sterile bag provided by the hospital. The urine sample is further evaluated in the laboratory. It helps to detect blood, bacteria, pus, and white blood cells in the urine.

• Blood Tests - A blood test is usually advised for the patient with urethral diverticula.

3) Imaging Tests - The following imaging tests are usually recommended:

• Double-Balloon Positive-Pressure Urethrography(PPU) - It is the most frequently used test in patients with urethral diverticulum. In this procedure, a double-balloon catheter is inserted into the urinary bladder through the urethra. Next, a contrast material is injected into the urinary tract through the catheter. X-rays are then obtained from different angulations. The images obtained are examined to get a better idea about the urethra and the other organs.

• Voiding Cystourethrography - In this procedure, a special type of liquid is inserted into the urinary system through a catheter. X-rays are taken as the bladder becomes full. Next, the patient is asked to urinate, and the X-rays are taken again. If a urethral diverticulum is present, the urine will collect in the pouch, and that will be visible on the X-rays.

How Is a Urethral Diverticulum Managed?

The best way to treat the urethral diverticulum is surgery. However, not all cases require surgical intervention because sometimes, the patients do not present with any symptoms. The urethral diverticulum might be an incidental finding on the radiograph while other conditions are being diagnosed. Some patients do not prefer to undergo surgery and like to remain on antibiotics because they help them relieve the symptoms. However, the underlying abnormality remains; that is, the diverticulum does not subside after antibiotics. Hence, surgery is the only option left, and the surgical procedures are listed below:

• Transurethral Saucerization - It is a surgical procedure to convert the narrow neck of the urethral diverticula into a wide one. However, the procedure should be performed carefully as it increases the risk of urinary incontinence (urine leakage).

• Marsupialization - It is a procedure wherein the neck of the urethral diverticulum is cut in a way that drains into the vagina. The contents of the diverticular sac pass through the vagina.

• Surgical Resection - A surgical resection procedure aims to remove the urethral diverticulum completely. The urethral communication and the vaginal wall are closed with the help of a layer from the tissues around the urethra. This procedure does not allow abnormal communication between the urethra and the vagina.

What Happens After the Surgery?

After the surgery is complete, a tube known as a catheter is inserted into the urinary bladder through the urethra. It allows the drainage of urine as the patient will not be able to urinate normally for a few days. The antibiotics need to be taken 24 hours after the procedure. The medications, mainly Belladonna and Opium, are recommended as they help to relax the bladder muscles. A voiding cystourethrogram test is done 14 days after the surgery to check if the urine leaks or flows normally. If the urine leaks, the catheter is allowed to remain for a few more days. If the urine normally flows without any leakage, the catheter is removed.

What Are the Complications of Surgery?

There are no major complications of the surgery if performed correctly. However, the following complications arise after the surgery:

• The risk of urinary tract infections increases because bacteria can easily enter the urinary system through the catheter.

• If a transurethral resection is done, the patient is at a higher risk of developing urinary incontinence (leakage of urine).

• Urethral stricture or narrowing of the urethra can occur during the surgical resection procedure.

• The most common complication of diverticular surgery is the urethrovaginal fistula. It is an abnormal communication between the urethra and the vagina. As a result, the contents of the urethra leak into the vagina.

Conclusion:

Urethral diverticula occurs when a pouch or a sac is present near the urethra. The urine gets collected in this pouch and increases the risk of bacterial infections. The patient presents with symptoms of pain, hematuria, and a burning sensation while passing urine. Since urine gets collected in the pouch, it becomes difficult for the patient to urinate. Though the condition rarely occurs, it can cause severe complications if the treatment is not done at the right time. Some patients ignore the condition thinking it will subside with antibiotics, but that is wrong. Surgery is the best possible way to treat the urethral diverticulum. The patient must notify the symptoms and consult the doctor at the earliest to know about the treatment options. The results of surgery are great if performed at the right time.