The urethral divericulum are more frequent between the third and fifth decade of life. In a series described, the average age was 37.5 years old 8. In another series 15 to 20 % of the patients were nulliparous with an average age of 29.8 years contrasting with the 42 years of age of women with multiple deliveries 9. In a more recent report of 63 cases, the average age described was of 47 years old 10. The incidence in the black race seems to be 2 to 6 times higher than in most white women 11 but this opinion is not shared by other authors 10.
The urethral diverticulum symptoms are extremely variable. Its symptomatology can simulate bacterian cystitis,intersistial cystitis, chronic inflammatory illness, endometriosis, gonococcal or nonspecific urethritis, vesical carcinoma in situ, detrusor instability or even vesicle obstruction symptoms. The symptoms are dictated by the size of the diverticulum, its position and mainly by the way it opens by the urethra. The degree of the inflammatory process is also responsible for part of the symptoms. In the revision of 627 cases of divericulum, it was observed that 50% of the patients presented dysuria complaints and polyuria. Repetition urinary infection was diagnosed in 40% of the patients, 30% of the patients complained of stress urinary incontinence and the presence of anterior vaginal mass was observed in 35% of the cases 11,12. Other symptoms that may exist are urination urgency, terminal dripping, dyspareunia, hematuria 11,12.
Revising the described cases the most important symptomatology described was polyuria, dysuria, urination urgency and urinary incontinence. Recurrent urinary infection was observed in 45% of the cases 13.
To make a divirticulum diagnosis is necessary a high index of suspicion in relation to this pathology. For this, it is important to consider all cases of recurrent urinary infection that fail in the usual therapy and exlude this diagnosis. The urethras physical exam must be done as a usual practice, passing a finger on the anterior wall of the vagina in the extension of the urethra. Davis & Telinde made the diagnosis of the diverticulum only with a physical exam in 63% of the cases 14. The larger diverticulum of 1x1 cm. are easier to diagnose, feeling the periurethral mass on the anterior wall of the vagina.
Not all periurethral masses represent diverticulum. Because of this we must make a differential diagnosis of the gland abscess of Skene ( localized lateraly to the meatus urinarius, duct cyst of Gartner ( localized on the lateroanterior wall of the vagina ), ectopic ureterocele, inclusion cyst of the vaginal wall, urethral carcinoma, hemangioma, urethral varix, urethral endometriosis.
The expression of the mass, that generally is soft, reveals a purulent matter, sanguine or urine loss. The presence of hardening may reveal lithiasis in the interior of the diverticulum or neoplasia. In our interpretation, in all the cases there was a palbalble mass on the anterior wall of the vagina and, in four of them the consistency was hardened due to the presence of lithiasis inside of the diverticulum.
During the exam of the pelvic region it is important to observe other findings, such as, urethral hypermobility and vaginal prolapse, that must be considered in the investigation and treatment.
A well done voiding cysturethrography is capable of diagnosing a great percentage of diverticulum. The exam may confirm the presence of size , number and configuration
15. The voiding cysturethrography diagnosed 60 of 63 cases related by Ganabathi & col. These authors alert that this exam must be done with patients in orthostatic position and with a fluoroscopic control (Fig.1). The x rays done in a lateral position, also may inform about the urethral support, hypermobiliity and the presence of stress incontinence 10.
The retrograde urethrogram with a possitive pressure was introduced in 1956 by Davis & Cian and was described as having 90% of accuracy 16. Nowadays, this exam is in disuse in consequence of a better tecnical urination cystogram and a trans vaginal ultrasound.
The utilization of the ultrasound increased the urethral diveriticulum diagnosis 17,18,19. The achievement of the ultrasound may complement the radiological study or as is very frequent nowadays to be used as the only image exam in the diagnosis (Fig.2) The reason for this propaedeutics option is based on the easiness of the realization of the exam, adequate cost and the best tecnical standards.
Starting from the most frequent moment of its application, the transvaginal ultrasound confirmed the diagnosis in all cases, showing that it is an excellent method of diagnosis for this pathology 13.
The voiding cystourethrography with a short sheath urethroscope may help in the evaluation of the diverticulum. The palpation of this on the instrument permits a better apreciation of where its localized, the size and consistency of the diverticulum. It is also possible, compressing the periurethral mass, to identify in some cases the localization of the exit of the purulent material, indicating the place of comunication with the urethra. The identification of the place of comunication with the urethra is important so the divericulum can be completely removed surgically. Another utilization of the endoscopic exam is the possibility to exclude any vesical pathology and to evaluate the competence of the bladder neck and the presence of urethral hypermobility with increase of abdominal pressure. These informations are extremely important so it can be decided if there should be the realization of the suspension of the urethra and the neck of the urinary bladder simultaneously.
Patients with complaints of urinary urgency, polyuria, urge incontinence, stress incontinence and urethral hypermobility, should be submitted to a urodinamic evaluation in the pre-operational stage.
The surgical treatment most used at the moment is the removal of the diverticulum by the vagina 13,20. This technique described by Leach, seems to be ideal in most cases. In cases of pre-operational stress urinary incontinence or in cases of great dissections for diverticulum removal, should be done concomitantly with the suspension of the neck of the urinary bladder and urethra by the Raz technique 21. Antibiotics must be used routinely in the post-operation.
In great size diverticulum marsupialization technique can be used in some cases 22. This procedure must be done mainly in the diverticulum localized in the two third distals of the urethra to avoid urinary stress incontinence. The urethral floor is incised and the margins of the urethra and the vagina are set together with a continous suture with polyglycolic acid thread.
Endoscopic techniques may also be used. Lapides described with success the endoscopic treatment in the recurrent diverticulum 23. This technique was also used for diverticulum in the urethral wall that had calculus. The fundament of the endoscopic treatment is to increase the ostium of the diverticulum to give better drainage and for the infection to get better.The very small diverticulum, can be treated in a traditional way.
The most frequent complications are: recurrent urinary infection, urethrovaginal fistula, recurrent diverticulum, post-operatory urinary stress incontinence. Stress urinary incontinence results in the loss of the urethral suport, mainly in the cases of diverticulum localized in the urethra near the neck of the urinary bladder. Other complications include total urinary incontinence, urethral stenosis, traumatic lesion of the bladder and persistent urinary symptoms.
In our interpretation of cases we had no fistula case, diverticulum relapse or post-operatory urinary incontinence. In the follow up of the patients was diagnosed noncomplicated urinary infestion in 5 cases.
We must remember of the presence of urethral divericulum in women with repetition cystitis, dyspareunia, polyuria and dysuria. The diagnosis is very simple through a physical exam and transvaginal ultrasound. With this we may be able to have more frequent and accurate diagnosis, having better and effective treatment for the patients.