Female urethral diverticula Anand K. Patel and Christopher R. Chapple

Transcription

1 Female urethral diverticula Anand K. Patel and Christopher R. Chapple Purpose of review The purpose of this review is to summarize the presentation, investigation and management of female urethral diverticulum, a condition often overlooked and frequently misdiagnosed. Hopefully, greater awareness will lead to more timely diagnosis and appropriate treatment. Recent findings Recently there has been considerable emphasis on correctly identifying this condition. Newer imaging modalities such as magnetic resonance imaging are now widely available and urethral diverticula that previously were unrecognized, such as noncommunicating diverticula, can now be more easily detected. The character of the diverticula can be accurately determined with appropriate imaging and this can lead to improved preoperative planning. Summary Traditional contrast studies are now being superseded by advanced cross-sectional imaging such as magnetic resonance imaging and even virtual computed tomography urethroscopy. These provide much greater tissue definition; however, very few studies directly compare the myriad of contrast-based, ultrasonographic and cross-sectional investigations that are available. Therefore, although the condition is eminently treatable, there remains little standardization in the investigation of this condition. The greatest single improvement, however, in management would come from more widespread clinical awareness of the condition and its presentation. Keywords diverticulectomy, lower urinary tract symptoms, Martius flap, urethral diverticula, urethrovaginal fistula Curr Opin Urol 16: ß 2006 Lippincott Williams & Wilkins. Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK Correspondence to Christopher R. Chapple BSc MD FRCS (Urol) FEBU, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Trust, Glossop Road, Sheffield S10 2JF, UK Tel: ; fax: ; c.r.chapple@sheffield.ac.uk Current Opinion in Urology 2006, 16: Abbreviations CT computed tomography DBU double-balloon urethrogram MRI magnetic resonance imaging SUI stress urinary incontinence UTI urinary tract infection VCUG voiding cystourethrogram ß 2006 Lippincott Williams & Wilkins Introduction Urethral diverticula are estimated to occur in 1 6% of women; although usually diagnosed between the third and fifth decade of life they can affect all age groups [1]. Many are asymptomatic or misdiagnosed; therefore the true prevalence is likely to be much higher. A recent nationwide analysis of 18 years of discharge data from US hospitals found inpatient surgical treatment of urethral diverticula was three times as high in black women, probably representing a greater prevalence in this population [2 ]. The condition frequently presents with nonspecific and nonclassical symptoms and this leads to incorrect and delayed diagnosis. Prevalence in patients with recurrent urinary infection may be as high as 40% [3,4]. A high level of suspicion and appropriate imaging are the critical steps in establishing the diagnosis [5]. Clinical presentation Classically, the presenting symptoms have been summarized as the three Ds : Dysuria, postvoid Dribbling and Dyspareunia. Unfortunately, this presentation is seen only in the minority of patients and was only diagnostically meaningful in the preimaging era [6 ]. Usually an array of nonspecific genitourinary symptoms predominate [7]. The most frequent being frequency/urgency (40 100%), dysuria (30 70%), recurrent urinary tract infection (UTI) (30 50%), postmicturition dribble (10 30%), dyspareunia (10 25%) and haematuria (10 25%) [8]. It may also present with a tender mass (35%), urinary incontinence (32%) [9], stones (1 10%), discharge of pus per urethra (12%) and retention (4%). Quality of life may be severely compromised by these symptoms and many patients seek multiple consultations and inadequate treatments before a correct diagnosis is established. Frequently symptoms are episodic with many patients reporting months or years of quiescence between flares [10]. When investigating chronic pelvic pain, voiding dysfunction and recurrent UTIs, urethral diverticulum is often overlooked and diagnosis is unduly delayed [5,8]. In one recent series [11], the median time from presentation to diagnosis was 9.5 months but in many instances it is much longer than this. Careful palpation of the anterior vaginal wall may reveal a mass or tenderness. Urethral diverticula are usually located ventrally over the middle portion of the urethra, corresponding to the area of the anterior vaginal wall 2 3 cm inside the introitus. A tender cystic mass that expresses pus or cloudy urine via the meatus when milked is the classical sign. Again this symptom is 248

2 Female urethral diverticula Patel and Chapple 249 not present in the majority of cases and it is only possible to express contents from 25% of these masses [10]. A firm mass should arouse suspicion of carcinoma or calculi [5]. Owing to the predominance of nonclassical symptoms and a normal examination many clinicians fail to perform any further evaluation to exclude urethral diverticula [12]. Diagnosis is further complicated by the vast number of potential differential diagnoses in this overlapping territory, managed by both urologists and gynaecologists [8]. These include vaginal wall cyst, Skene s gland abscess, ectopic ureterocoele, periurethral fibrosis, carcinoma, chronic cystitis, interstitial cystitis, trigonitis, urethral syndrome, urgency incontinence and stress incontinence [13]. Additionally, many patients with refractory nonspecific symptoms who evade diagnosis are labelled as having an idiopathic pelvic pain syndrome or a psychosomatic disorder; urethral diverticula must be excluded before attributing symptoms to such conditions. A lack of awareness is likely the greatest reason for delayed or misdiagnosis of the condition and the frequency of diagnosis is probably more closely related to the level of clinical awareness than to the true underlying prevalence [8]. Aetiology Urethral diverticula usually communicate with the urethral lumen and protrude through and stretch the periurethral smooth muscle. Occasionally, they extend proximally beneath the bladder neck and trigonal area. They are often isolated cyst-like appendages with a single connection (ostium) to the urethral lumen. Complicated anatomical patterns, however, may exist with multiple ostia, in some cases the urethral diverticula may extend partially ( saddlebag, horseshoe ) or circumferentially around the urethra [14]. These complex configurations have significant implications when undertaking surgical excision and reconstruction. Recently, noncommunicating urethral diverticula have also been demonstrated by the latest imaging modalities [15]. If they represent a forme fruste of urethral diverticula is unclear. The aetiology of urethral diverticula remains largely unknown. It has been suggested that they are congenital in origin due to the persistent embryological remnants, yet they are rarely found in children [9]; however, this does not preclude the fact that an early diverticulum or weakness might have been present, albeit undiagnosed. Trauma of childbirth has also been proposed and although urethral diverticula are often present following childbirth, a high prevalence in nulliparous patients also occurs. The current prevailing view is that repeated infection and obstruction of the periurethral and urethral glands (Skene s glands) results in cyst/abscess formation, these eventually rupture into the urethral lumen and remain as an outpouching, which epithelializes to become a true diverticulum as opposed to a urethrocoele or pseudodiverticulum [5]. Urethral diverticula characteristically are lined by urothelium, but squamous and glandular metaplasia can occur, probably in response to chronic inflammation [16]. The periurethral glands are tubuloalveolar structures located medially and posterolaterally that predominate in the distal two-thirds of the urethra; not surprisingly, up to 90% of urethral diverticula open into this region [17]. Reinfection, inflammation and recurrent obstruction of the neck are theorized to result in episodic symptoms and enlargement of the urethral diverticula. Iatrogenic causes such as instrumentation have been also implicated, and recently collagen injection therapy has been described to be a rare cause of urethral diverticula [18]. Complications of urethral diverticula Urinary stasis causes recurrent UTIs and this is a frequent presenting feature occurring in about one-third of patients [9]. Stagnant urine, salt deposition and urothelial mucus also predispose to calculus formation in % of urethral diverticula [19]. Additionally, obstruction to the bladder outlet may occur by virtue of the size of a urethral diverticulum or if there is an associated stricture secondary to malignancy. Inflammation and chronic irritation within the urethral diverticulum may lead to malignant transformation including adenocarcinoma [20 22], transitional cell carcinoma or squamous cell carcinoma [23]. These tumours are extremely rare with fewer than 100 reported cases. The majority are adenocarcinomas, further supporting the hypothesis of a glandular cause for urethral diverticula. Successful treatments using surgery, radiotherapy, chemotherapy and multimodality therapy have all been described. Owing to the rarity of these tumours, no standard protocols have been developed, however, it remains important that they are detected early and treated aggressively. They must not be overlooked when investigating women with suspected urethral diverticula. The development of voiding symptoms, haematuria and a periurethral mass should raise the suspicion of carcinoma [22,24,25]. Investigations Appropriate investigations play an important role in the diagnosis of urethral diverticula and ideally should provide the surgeon with information regarding location, number, size, configuration and communication of the urethral diverticulum [6 ]. It should also identify associated calculi or neoplasms. It is equally as important to diagnose accurately large urethral diverticula, which require extensive dissection, as it is to identify difficult-to-diagnose small or noncommunicating urethral diverticula [17].

3 250 Female urology Urethroscopy Urethroscopy is an invasive test that allows direct inspection of the urethra, including locating the position of the ostia. Although frequently performed, it usually fails to be helpful, particularly if the urethral diverticulum is collapsed and the ostium is not visible [26]. It may be possible to express contents by diverticular compression during the urethroscopy to aid in identifying the ostium [27]. It is of little use in assessing the size or shape of the diverticulum and any concurrent inflammation may further obscure the visualization [6 ]. Voiding cystourethrogram A voiding cystourethrogram (VCUG) is a radiographic study that allows the anatomy of the diverticulum to be assessed with contrast medium. In addition to radiation exposure, this is an invasive technique that requires catheterisation and can be difficult to perform. Also, voiding in an unfamiliar environment may not reflect the natural voiding process [6,28]. For some time VCUG has been considered the investigation of choice for identifying urethral diverticula with a sensitivity of approximately 65% [6 ], but now many feel that the study is equivocal and additional imaging studies are usually necessary [17]. Double balloon urethrogram A double-balloon urethrogram (DBU), also known as a positive-pressure urethrogram, differs from a VCUG in that a double-balloon catheter is inserted into the urethra and contrast medium is injected at high pressure within the isolated urethra, allowing filling of any urethral communications. This technique was previously considered the gold standard investigation. In addition to radiation exposure and invasiveness, there is significant discomfort for the patient and it has the potential for urethral injury [29]. DBU has been compared with other imaging modalities in a number of small-scale studies. Some have found that a DBU has the highest accuracy and sensitivity [30]. There are, however, an increasing number of studies showing greater urethral diverticula detection with other modalities such as magnetic resonance imaging (MRI) [31]. The fact that cross-sectional imaging can give much greater anatomical detail than these traditional radiographic studies is of little doubt. A retrospective series of 12 patients compared VCUG with DBU and found DBU had a sensitivity of 100% compared to 66.7% with VCUG, and DBU provided much better data regarding the extent and characteristics of any urethral diverticulum that it detected. As this is a retrospective analysis, this study fails to take into account any noncommunicating urethral diverticula, which were missed with both these modalities. A prospective study compared DBU and VCUG in 32 patients. Sensitivity confirmed by surgery was 100% with DBU compared with 44% with VCUG (P ¼ 0.002). The cases missed by VCUG tended to be of smaller urethral diverticula (12.4 mm compared with 24.2 mm; P ¼ 0.018) [12]. Therefore, it is likely that DUB has better diagnostic validity and VCUG should therefore be reserved for evaluating the bladder for vesicoureter reflux and the bladder outlet for stress urinary incontinence (SUI) [12]. Urodynamics Sixty per cent of urethral diverticula may be associated with incontinence [6 ]. Many patients have paradoxical incontinence (the intermittent loss of urine from the urethral diverticulum with stress manoeuvres) and additionally approximately 50% of women with urethral diverticula will demonstrate genuine SUI [9,32]. It is important to distinguish between these conditions as paradoxical incontinence will resolve with excision of the urethral diverticula alone, but concomitant SUI may require additional treatment [27], such as a simultaneous sling procedure [5]. Video urodynamics combines both an anatomical assessment (VCUG) and an urodynamic pressure study and therefore has two potential utilities in this condition. In addition to visualizing if leakage is across the bladder neck or from the urethral diverticulum, it may also diagnose other common causes of urinary incontinence such as idiopathic detrusor contractions, which are also unlikely to resolve following urethral diverticula excision [27]. A small number of patients may have evidence of bladder outlet obstruction due to the obstructive effects of the urethral diverticulum. It should be noted that SUI may coexist with obstruction [33]. It is essential that radiographic pictures are taken during voiding when performing VCUG or video urodynamics as some urethral diverticula empty at the termination of voiding and will be missed if only filling and postvoid films are taken [34]. Ultrasound A number of ultrasonographic techniques have been described. Transvaginal [35], transperineal and endourethral ultrasound were all compared with VCUG by Siegel et al. [36]. Both modalities identified 13 out of 15 urethral diverticula; however, ultrasonography identified the neck in all the detected cases, whereas the neck was identified by VCUG in only two patients. Ultrasound was also able to detect other nearby disorders such as infected periurethral cysts and leiomyomas, which were all missed by VCUG. Transvaginal ultrasound was studied in a retrospective series of 25 patients with suspected urethral diverticula by Gerrard et al. [37]. Ten patients were confirmed to have urethral diverticula and all of these were diagnosed

4 Female urethral diverticula Patel and Chapple 251 with ultrasound with no missed diagnoses, whereas there were three missed diagnoses with cystoscopy, three with VCUG and eight with video urodynamics. Transvaginal ultrasound allows the evaluation of the entire urethra from the meatus to the bladder neck. In addition, the ability to image in different orientations helps clarify the spatial relationships of any urethral diverticula detected [37]. Transvaginal ultrasound, however, can cause direct urethral compression [38]. Transrectal ultrasonography has been also shown to give valuable information regarding urethral diverticula characteristics [39]. All of these ultrasound techniques are safe, relatively inexpensive and provide rapid realtime information regarding the diverticulum and surrounding structures. They involve no radiation and have a reduced risk of infection compared with catheter-based investigations. Precise measurements of diverticular size are achievable and occasionally it is possible to visualize the communication. Ultrasound may be of particular benefit in differentiating a septated urethral diverticulum from multiple urethral diverticula, compared with MRI [8]. The principal drawback is that these techniques are operator dependent [5]. Intraoperative endoluminal ultrasound has been described in a series of seven patients. Improved identification of the size, orientation and contents of the urethral diverticula were shown. Diverticulum wall thickness and the distance between the diverticulum wall and the urethral lumen were also determined as was the extent of any periurethral inflammation. Use of this technique intraoperatively allowed complete anatomical dissection and the avoidance of injury to the urethra and bladder neck. When retrospectively compared to other techniques, there were false-negative results with VCUG, transvaginal ultrasound and DBU [40]. In this limited series, the specificity and sensitivity were 100% and it may therefore have diagnostic validity in addition to this intraoperative usage to improve tissue dissection. Magnetic resonance imaging A number of MRI techniques have been described to image the female urethra including endoluminal [41], endovaginal [42], endorectal [15] and external coil. Advantages of MRI are that it resolves normal anatomy and urethral pathology with excellent multiplanar resolution. In addition to accurate diagnosis, this increased spatial information allows much better preoperative planning [27,41,43,44]. Other advantages are that the patient does not require catheterization and is not required to void for the study. There is no radiation exposure and the study can be rapidly performed in three breath-hold sequences [27]. Initially held back because of cost, MRI has now become the imaging study of choice in a number of centres. MRI should always be used in recurrent or suspected complex cases due to the better preoperative planning afforded with this technique. There remains debate in female urology as to which mode of MRI (T1 or T2) gives the best images and some disagreement as to the necessity for endocoils, with newer studies suggesting that equally good images can be obtained without them [45]. In our centre, we routinely use a postvoiding sagittal sequence. MRI has a high sensitivity and excellent positive and negative predictive values in detecting urethral diverticula [37,46]. When endoluminal MRI was compared to VCUG, it was found that VCUG missed 7% of the diverticula and underestimated their size and complexity [41]. Endocoils may be of particular use in detecting smaller lesions with the three-dimensional appearance of the urethral wall allowing the exact location of the ostia to be visualized [15]. Even with the increased resolution with endocoils, however, the resolution is not always sufficient to detect the ostia [47 ]. Endoluminal coil MRI may also be of particular use in characterizing complex circumferential urethral diverticula [14]. A recent study repeated endorectal coil MRI (ERC-MRI) in patients with persistent symptoms but with no diagnosis. In this small subgroup, one urethral diverticulum was discovered that was not detected with the initial ERC-MRI. Retrospective reevaluation of the initial study again failed to detect the urethral diverticulum, presumably because the contents had drained at the time of the initial investigation. Thus, even this advanced technique is not infallible and patients with persistent symptoms may require reimaging [48]. It must be remembered that MRI of urethral diverticula requires appropriately experienced radiologists [6 ]. When MRI is not available or there is inadequate expertise, ultrasound may be a more appropriate investigation. Virtual computed tomography urethroscopy Recent technological advances have led to the development of this new diagnostic technique. Computed tomography (CT) urethrography consists of thin-section transverse images of VCUG on a high-speed CT scan. Reformatted images are then viewed interactively on a workstation [49 ]. It has the advantage of being noninvasive and can identify the anatomy and pathology of extraluminal organs better than urethroscopy. A reported case study [49 ] detected a horseshoe-shaped diverticulum with a clearly identified orifice in the mid-urethra. This diverticulum was missed on urethroscopy and VCUG. Another series [47 ] reported two cases with improved ability to detect the ostia compared with MRI. The position of the ostium is one of the most crucial pieces of information for a surgeon planning a procedure. In addition, it is possible to clearly visualize the neck of the urethral diverticulum using this investigation.

5 252 Female urology Virtual CT urethroscopy is still experimental and is time consuming and some patients have difficulty voiding whilst on the CT table. In addition, there is a significant radiation exposure with many suspected patients being of reproductive age [47 ]. Nonsurgical treatment There is no indication for treatment in asymptomatic urethral diverticula and patients with only mild symptoms may be followed and treated symptomatically with antibiotics and anticholinergics [30]. A high index of suspicion for carcinoma, however, should be present if any insidious signs are present. Surgical treatment Most patients with symptoms attributable to their urethral diverticulum want definitive treatment. Preoperative preparation includes treating any acute suppuration and inflammation with a short course of antibiotics [27]. If there is significant infection, then incision and drainage may be required before formal surgery. A decision is also required regarding whether to perform concomitant sling surgery if SUI or an open bladder neck is detected on preoperative evaluation [5]. Multiple authors [9,32,50,51] have described successful concomitant surgery. Although we tend to treat the urethral diverticulum in the first instance and then reassess the appropriateness for sling insertion later. In many instances a subsequent sling procedure has not proved necessary. Generally three surgical options are available: (a) transurethral incision of the urethral communication, thereby transforming a narrow diverticulum into a wide-mouthed diverticulum; (b) marsupialization of the diverticulum sac into the vagina by incising the urethrovaginal septum; and (c) diverticulectomy with or without a reconstructive procedure [5]. We have not found transurethral incision to be necessary but instead allow infected diverticula to settle with antibiotic therapy. Marsupialization of a diverticulum is one of the commonest causes of development of a urethrovaginal fistulae as diverticula usually extend through all layers of the urethra. Therefore, our standard management is to perform a diverticulectomy via the vaginal approach in the prone position, using a technique similar to that reported by Leach et al. [52]. The prone position gives an excellent exposure of the surgical field. Complete excision of the urethral diverticulum with a full opening of the urethra gives a cure rate of approximately 70% [8], but this does carry with it considerable morbidity even in experienced hands. Following discussion, most patients elect for a simple diverticulectomy with insertion of a Martius flap between the periurethral fascial closure and the vaginal wall. Often patients have poor quality tissue due to repeated inflammation. The insertion of a Martius flap not only prevents fistula formation [53] and adds bulk that helps mitigate against SUI, but also facilitates subsequent surgery by preventing excessive periurethral fibrosis. Complications of transvaginal urethral diverticulectomy Risk factors for the development of postoperative complications are delayed diagnosis (>12 months), size (>4 cm) and complex configuration (e.g. horseshoe) [54]. Large and complex diverticula increase the difficulty of the dissection and subsequent reconstruction. Common complications arising from this procedure are urinary incontinence ( %), urethrovaginal fistula ( %), urethral stricture (0 5.2%), recurrent urethral diverticula (1 25%) and recurrent UTI (0 31.3%). Prior to surgery patients should be warned that there is a risk of incontinence either due to unmasking as a consequence of removing the enlarged urethral diverticulum in a patient with a tendency towards SUI, or from intraoperative damage to the urethral sphincter mechanism. Patients should be aware that a secondary incontinence procedure may be necessary at a later date and this is facilitated by the positioning of the Martius flap at the time of the diverticulectomy. Urethrovaginal fistulae are a devastating complication, however, we have found that they are exceedingly rare when using the surgical technique described, with a Martius flap to provide a well vascularized additional tissue layer. This should be combined with meticulous surgical technique, good haemostasis, avoidance of infection, preservation of a well vascularized anterior vaginal wall flap and a multilayered closure. The discovery of a urethral diverticulum following a presumably successful diverticulectomy may occur as a result of a new diverticulum or, alternatively, as a result of recurrence. Recurrence may be due to incomplete excision, active infection, difficult dissection, inadequate or excessive suture line tension, residual dead space or other technical factors [5]. Repeat diverticulectomy can be carried out if necessary. Conclusion Urethral diverticula, although comparatively rare, are frequently underdiagnosed due to a lack of clinical awareness. The true prevalence remains uncertain but is likely to be much greater than currently reported. Many sufferers are mislabelled as having interstitial cystitis, chronic pelvic pain and urethral syndrome among others Therefore, a high index of suspicion is required in all patients with refractory nonspecific symptoms and it must be actively excluded in the absence of other causes for their symptomatology.

6 Female urethral diverticula Patel and Chapple 253 Excellent results are obtainable with the correct surgical technique and complications can be minimized; therefore, the greatest challenge remains in detecting and treating the condition in a timely fashion. A number of investigations can be used to detect and characterize urethral diverticula and initial negative studies should not dissuade the clinician from pursuing further investigations or even repeating investigations [12]. The most comprehensive evaluation is afforded by multiplanar cross-sectional imaging such as with MRI [55 ]. This is now the investigation of choice and its use should be considered both as an initial investigation if available and as a secondary investigation following failure to detect pathology by other modalities. Its use is also strongly advocated prior to performing any surgery. Large-scale critical analysis of investigations and management, however, have not been performed, and there remains a lack of standardization of practice. This along with increasing clinicians awareness of the condition are the areas requiring the most attention. References and recommended reading Papers of particular interest, published within the annual period of review, have been highlighted as: of special interest of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 313). 1 Martensson O, Duchek M. Translabial ultrasonography with pulsed colour- Doppler in the diagnosis of female urethral diverticula. Scand J Urol Nephrol 1994; 28: Burrows LJ, Howden NL, Meyn L, et al. Surgical procedures for urethral diverticula in women in the United States, Int Urogynecol J Pelvic Floor Dysfunct 2005; 16: Largest analysis of discharge data following surgery that has been reported for this condition. Found a higher prevalence in the black population. 3 Greenberg M, Stone D, Cochran ST, et al. Female urethral diverticula: doubleballoon catheter study. AJR Am J Roentgenol 1981; 136: Stewart M, Bretland PM, Stidolph NE. Urethral diverticula in the adult female. Br J Urol 1981; 53: Aspera AM, Rackley RR, Vasavada SP. Contemporary evaluation and management of the female urethral diverticulum. Urol Clin North Am 2002; 29: Lee JW, Fynes MM. Female urethral diverticula. Best Pract Res Clin Obstet Gynaecol 2005; 19: Extensive evidence-based review of investigation and management of this condition. 7 Leng WW, McGuire EJ. Management of female urethral diverticula: a new classification. J Urol 1998; 160: Bennett SJ. Urethral diverticula. Eur J Obstet Gynecol Reprod Biol 2000; 89: Ganabathi K, Leach GE, Zimmern PE, et al. Experience with the management of urethral diverticulum in 63 women. J Urol 1994; 152: Romanzi LJ, Groutz A, Blaivas JG. Urethral diverticulum in women: diverse presentations resulting in diagnostic delay and mismanagement. J Urol 2000; 164: Rufford J, Cardozo L. Urethral diverticula: a diagnostic dilemma. BJU Int 2004; 94: Jacoby K, Rowbotham RK. Double balloon positive pressure urethrography is a more sensitive test than voiding cystourethrography for diagnosing urethral diverticulum in women. J Urol 1999; 162: Dmochowski RR, Ganabathi K, Zimmern PE, et al. Benign female periurethral masses. J Urol 1994; 152: Rovner ES, Wein AJ. Diagnosis and reconstruction of the dorsal or circumferential urethral diverticulum. J Urol 2003; 170:82 86 [discussion 86]. 15 Daneshgari F, Zimmern PE, Jacomides L. Magnetic resonance imaging detection of symptomatic noncommunicating intraurethral wall diverticula in women. J Urol 1999; 161: [discussion ]. 16 Cocco AE, MacLennan GT. Unusual female suburethral mass lesions. J Urol 2005; 174: Golomb J, Leibovitch I, Mor Y, et al. Comparison of voiding cystourethrography and double-balloon urethrography in the diagnosis of complex female urethral diverticula. Eur Radiol 2003; 13: Clemens JQ, Bushman W. Urethral diverticulum following transurethral collagen injection. J Urol 2001; 166: Martinez-Maestre A, Gonzalez-Cejudo C, Canada-Pulido E, et al. Giant calculus in a female urethral diverticulum. Int Urogynecol J Pelvic Floor Dysfunct 2000; 11: Hickey N, Murphy J, Herschorn S. Carcinoma in a urethral diverticulum: magnetic resonance imaging and sonographic appearance. Urology 2000; 55: Davis R, Peterson AC, Lance R. Clear cell adenocarcinoma in a female urethral diverticulum. Urology 2003; 61: von Pechmann WS, Mastropietro MA, Roth TJ, et al. Urethral adenocarcinoma associated with urethral diverticulum in a patient with progressive voiding dysfunction. Am J Obstet Gynecol 2003; 188: Shalev M, Mistry S, Kernen K, et al. Squamous cell carcinoma in a female urethral diverticulum. Urology 2002; 59: Ghoniem G, Khater U, Hairston J, et al. Urinary retention caused by adenocarcinoma arising in recurrent urethral diverticulum. Int Urogynecol J Pelvic Floor Dysfunct 2004; 15: Rajan N, Tucci P, Mallouh C, et al. Carcinoma in female urethral diverticulum: case reports and review of management. J Urol 1993; 150: Saito S. Usefulness of diagnosis by the urethroscopy under anesthesia and effect of transurethral electrocoagulation in symptomatic female urethral diverticula. J Endourol 2000; 14: Scarpero HM, Dmochowski RR, Leu PB. Female urethral diverticula. Atlas Urol Clin 2004; 12: Reid RE, Gill B, Laor E, et al. Role of urodynamics in management of urethral diverticulum in females. Urology 1986; 28: Lang EK, Davis HJ. Positive pressure urethrography: a roentgenographic diagnostic method for urethral diverticula in the female. Radiology 1959; 72: Fortunato P, Schettini M, Gallucci M. Diagnosis and therapy of the female urethral diverticula. Int Urogynecol J Pelvic Floor Dysfunct 2001; 12: Neitlich JD, Foster HE Jr, Glickman MG, et al. Detection of urethral diverticula in women: comparison of a high resolution fast spin echo technique with double balloon urethrography. J Urol 1998; 159: Bass JS, Leach GE. Surgical treatment of concomitant urethral diverticulum and stress incontinence. Urol Clin North Am 1991; 18: Bradley CS, Rovner ES. Urodynamically defined stress urinary incontinence and bladder outlet obstruction coexist in women. J Urol 2004; 171: [discussion ]. 34 Goldfarb S, Mieza M, Leiter E. Postvoid film of intravenous pyelogram in diagnosis of urethral diverticulum. Urology 1981; 17: Baert L, Willemen P, Oyen R. Endovaginal sonography: new diagnostic approach for urethral diverticula. J Urol 1992; 147: Siegel CL, Middleton WD, Teefey SA, et al. Sonography of the female urethra. AJR Am J Roentgenol 1998; 170: Gerrard ER Jr, Lloyd LK, Kubricht WS, et al. Transvaginal ultrasound for the diagnosis of urethral diverticulum. J Urol 2003; 169: Keefe B, Warshauer DM, Tucker MS, et al. Diverticula of the female urethra: diagnosis by endovaginal and transperineal sonography. AJR Am J Roentgenol 1991; 156: Vargas-Serrano B, Cortina-Moreno B, Rodriguez-Romero R, et al. Transrectal ultrasonography in the diagnosis of urethral diverticula in women. J Clin Ultrasound 1997; 25: Chancellor MB, Liu JB, Rivas DA, et al. Intraoperative endo-luminal ultrasound evaluation of urethral diverticula. J Urol 1995; 153: Blander DS, Rovner ES, Schnall MD, et al. Endoluminal magnetic resonance imaging in the evaluation of urethral diverticula in women. Urology 2001; 57: Nezu FM, Vasavada SP. Evaluation and management of female urethral diverticulum. Tech Urol 2001; 7:

7 254 Female urology 43 Blander DS, Broderick GA, Rovner ES. Images in clinical urology. Magnetic resonance imaging of a saddle bag urethral diverticulum. Urology 1999; 53: Siegelman ES, Banner MP, Ramchandani P, et al. Multicoil MR imaging of symptomatic female urethral and periurethral disease. Radiographics 1997; 17: Stewart LH, Brush JP. Magnetic resonance imaging for urinary incontinence. Curr Opin Urol 2002; 12: Yang JM, Huang WC, Yang SH. Transvaginal sonography in the diagnosis, management and follow-up of complex paraurethral abnormalities. Ultrasound Obstet Gynecol 2005; 25: Kim SH, Kim SH, Park BK, et al. CT voiding cystourethrography using 16- MDCT for the evaluation of female urethral diverticula: initial experience. AJR Am J Roentgenol 2005; 184: Evaluated the experimental technique of CT voiding cystourethrography in two patients. 48 Lorenzo AJ, Zimmern P, Lemack GE, et al. Endorectal coil magnetic resonance imaging for diagnosis of urethral and periurethral pathologic findings in women. Urology 2003; 61: [discussion ]. 49 Chou CP, Huang JS, Yu CC, et al. Urethral diverticulum: diagnosis with virtual CT urethroscopy. AJR Am J Roentgenol 2005; 184: First description of virtual CT urethroscopy to detect urethral diverticula. 50 Faerber GJ. Urethral diverticulectomy and pubovaginal sling for simultaneous treatment of urethral diverticulum and intrinsic sphincter deficiency. Tech Urol 1998; 4: Swierzewski SJ 3rd, McGuire EJ. Pubovaginal sling for treatment of female stress urinary incontinence complicated by urethral diverticulum. J Urol 1993; 149: Leach GE, Schmidbauer CP, Hadley HR, et al. Surgical treatment of female urethral diverticulum. Semin Urol 1986; 4: Leach GE. Urethrovaginal fistula repair with Martius labial fat pad graft. Urol Clin North Am 1991; 18: Porpiglia F, Destefanis P, Fiori C, et al. Preoperative risk factors for surgery female urethral diverticula. Our experience. Urol Int 2002; 69: Prasad SR, Menias CO, Narra VR, et al. Cross-sectional imaging of the female urethra: technique and results. Radiographics 2005; 25: This article summarizes the imaging techniques that are currently available to image the female urethra.