Urethral Diverticulum

Overview

A urethral diverticulum is an abnormal pouch or sac that forms along the urethra, the tube that carries urine from the bladder out of the body. This condition primarily affects women and develops when one of the small periurethral glands becomes blocked and infected, eventually forming an outpouching that connects to the urethral canal. The diverticulum fills with urine during voiding and empties afterward, causing the characteristic symptom of post-void dribbling.

Urethral diverticulum is often called the “great mimicker” because its symptoms overlap with many other conditions, including recurrent urinary tract infections, overactive bladder, and interstitial cystitis. Many women see multiple doctors over several years before receiving an accurate diagnosis. The condition affects an estimated 1-6% of adult women, most commonly those aged 30-60, and rarely occurs in men due to anatomical differences.

Diverticula are classified by location and complexity. Most occur in the mid-urethral region where periurethral glands are concentrated. Simple diverticula have a single chamber with one opening into the urethra, while complex diverticula may have multiple chambers, several openings, or encircle the urethra in a horseshoe configuration. Complex diverticula require more extensive surgical repair.

Symptoms

The classic presentation of urethral diverticulum includes the “3 Ds”: dysuria (painful urination), dyspareunia (painful intercourse), and dribbling after urination. However, symptoms vary considerably, and some women have no symptoms at all.

Urinary symptoms predominate in most cases. Post-void dribbling is the most characteristic finding, occurring when urine trapped in the diverticulum leaks out after the bladder has emptied. Women frequently present with recurrent urinary tract infections that respond temporarily to antibiotics but keep returning. Other common symptoms include burning or pain during urination, frequent urination, sudden urges to void, and involuntary urine leakage.

Pelvic symptoms often accompany urinary complaints. Women may notice a tender lump or fullness along the front vaginal wall, particularly noticeable during intercourse or self-examination. Pelvic pain can be constant or intermittent. Some women report purulent or bloody discharge from the urethra, especially when pressure is applied to the mass.

Because these symptoms overlap with interstitial cystitis, painful bladder syndrome, chronic urinary tract infections, and overactive bladder, women with urethral diverticulum are often initially misdiagnosed. If you’ve been treated for these conditions without improvement, urethral diverticulum should be considered.

Causes

The most widely accepted theory for how urethral diverticula form involves infection and obstruction of the periurethral glands. The Skene’s glands or other small glands along the urethra become blocked, allowing bacteria to multiply in the obstructed gland. An abscess develops, which eventually ruptures into the urethral lumen. The remaining cavity persists as a permanent outpouching.

Several factors increase the risk of developing a urethral diverticulum. Vaginal childbirth, particularly difficult or prolonged deliveries, can cause trauma to the periurethral tissues. Perineal tears, episiotomies, and multiple vaginal deliveries all contribute to risk. Prior urinary tract infections, urethral surgery, urethral dilation procedures, and catheterization trauma can also damage the periurethral glands and trigger diverticulum formation.

The female urethra is surrounded by periurethral glands analogous to the male prostate, making women much more susceptible to this condition. The shorter female urethra also increases susceptibility to infection. In rare cases, a congenital weakness in the periurethral tissue may predispose to diverticulum formation.

Diagnosis

Diagnosing urethral diverticulum can be challenging due to symptom overlap with other conditions, but a thorough evaluation combining physical examination and imaging typically confirms the diagnosis.

On pelvic examination, the hallmark finding is a tender, soft mass along the anterior vaginal wall beneath the urethra. When the examiner presses on this mass, pus or cloudy urine may be expressed from the urethral opening. This “milking” sign is highly suggestive of urethral diverticulum. The mass may increase in size when the patient strains.

MRI is the gold standard imaging study for urethral diverticulum. It provides detailed images showing the size, location, and relationship of the diverticulum to surrounding structures. MRI can identify complex or multilocular diverticula and detect the rare occurrence of cancer developing within the diverticulum. Voiding cystourethrogram, an X-ray study performed during urination, may show contrast filling the diverticulum but is less sensitive than MRI. Transvaginal ultrasound can identify the diverticulum as a cystic mass but may miss smaller lesions.

Urethroscopy allows direct visualization of the inside of the urethra to confirm the presence of a diverticulum opening, assess the urethral mucosa, rule out other pathology, and help plan surgical repair. Urinalysis, urine culture, and culture of any expressible discharge help identify active infection. Urodynamic studies may be performed before surgical planning if urinary incontinence is present.

Treatment

Treatment depends on symptom severity, diverticulum size and complexity, and patient preferences. The options range from observation to surgical excision.

Observation. For small, asymptomatic diverticula, watchful waiting may be appropriate. This approach involves regular follow-up examinations, monitoring for symptom changes or growth, and treating any urinary tract infections as they occur. Observation may also suit patients with mild symptoms, those who are not surgical candidates, or those who prefer conservative management.

Medical Management. Antibiotics can treat active infections and may temporarily control symptoms, but they do not address the underlying anatomical abnormality. Symptoms typically recur after antibiotic courses end. Repeated antibiotic treatment carries the risk of antibiotic resistance.

Surgical Excision. Diverticulectomy is the definitive treatment for symptomatic urethral diverticulum. The surgery involves dissecting and removing the diverticulum sac, closing the urethral defect, and performing multi-layer tissue closure to prevent fistula formation while preserving urethral function. Success rates are excellent, with 70-90% of patients experiencing complete symptom resolution. The recurrence rate is approximately 5-15%, and most complications are minor and manageable.

Marsupialization. This less common procedure involves incising the diverticulum and suturing the edges open rather than excising the sac entirely. It requires less tissue dissection but has a higher recurrence rate. Marsupialization may be appropriate in specific situations where full excision poses greater risk.

Recovery after surgical excision typically involves catheter placement for one to three weeks, restricted activities for four to six weeks, and pelvic rest without intercourse for six to eight weeks. Potential complications include urethrovaginal fistula, urethral stricture, diverticulum recurrence, new-onset stress urinary incontinence, and urinary tract infection. Most complications can be managed successfully with appropriate treatment.

When to See a Doctor

Seek evaluation if you experience recurrent urinary tract infections that don’t respond to appropriate treatment, persistent painful urination, pain during intercourse, a noticeable lump or mass in the vaginal area, urine dribbling after you’ve finished urinating, or unexplained pelvic pain.

Seek urgent care for high fever with urinary symptoms, severe pelvic or abdominal pain, inability to urinate, large amounts of blood in urine, or a rapidly enlarging or extremely painful vaginal mass.

Urethral diverticulum is best managed by specialists with experience in this condition, including urogynecologists and urologists with expertise in female urology. Academic medical centers with high volumes of reconstructive cases often have surgeons with the most experience. Don’t hesitate to seek a second opinion if you’ve been experiencing symptoms for a long time without diagnosis or if you’re uncertain about treatment recommendations. Early diagnosis and appropriate treatment can relieve symptoms and prevent complications such as infection, stone formation, and the rare development of cancer within the diverticulum.