Diverticula of the male urethra: a review of 61 cases

Acquired Urethral Diverticulum After Holmium Laser Enucleation of the Prostate: A Case Report

Acquired urethral diverticula (UD) in males is an uncommon entity, and it is rarely reported after an open simple prostatectomy or transurethral resection of the prostate. Here, we report a unique case of a UD presenting after holmium laser enucleation of the prostate (HoLEP) in a 69-year-old male with a prostate of 372 g who had five episodes of urine retention over one year despite combined medical treatment with tamsulosin 0.8 mg and finasteride 5 mg. The patient also has elevated prostate-specific antigen (PSA) with five negative prostate biopsies over the last few years. The procedure lasted six hours with difficult morcellation due to beach balls that took 3.5 hours. There were no intraoperative complications. However, he continued to have mixed urine incontinence and recurrent (six) episodes of urinary tract infection (UTI) in the first postoperative year. On evaluation, his urodynamic study did not reproduce stress urinary incontinence (SUI); however, cystoscopy and retrograde urethrogram diagnosed a 6-cm UD in the bulbar penile urethra with penoscrotal mass. The patient underwent urethral diverticulectomy and urethroplasty with a buccal mucosa graft to correct the defect. Six months after his urethral reconstruction, he continued to have mixed urine incontinence needing two pads/day. Although male UD is a rare condition, our case report seeks to heighten awareness of such a potential rare complication in men with recurrent UTIs and refractory urinary incontinence after prolonged HoLEP for extremely large prostates.

Contrast-enhanced voiding urosonography (CEVUS) as a novel technique for evaluation in a case of male urethral diverticulum

Male urethral diverticulum is an uncommon entity, the abnormality being more frequently encountered in females. The pathology may be congenital or acquired and the more frequent acquired type usually occurs following trauma. Afflicted patients usually lack specific symptoms, although in a few instances, symptoms of lower urinary tract obstruction, calculi, or infection may prevail. Imaging investigations utilizing a composite Retrograde urethrography (RGU)– Voiding cystourethrography (VCUG) protocol are accepted as standard approach and ultrasound is considered a secondary supplementary investigation. However, recent literature reports the utility of contrast-enhanced ultrasound (CEUS) as a novel technique in the evaluation of urinary bladder and urethra, for vesico-ureteric reflux (VUR) in children and for urethral diverticula in women. We report a case of acquired post-traumatic urethral diverticulum in an adult male patient and document a relatively unexplored novel application of contrast enhanced voiding uro-sonography (CEVUS) for the evaluation of this malady.

Congenital urethral diverticulum with infertility in an adult man and review of the literature

Introduction

Congenital anterior urethral diverticula in adult males are infrequent urological diseases, which they were mainly found in women. The etiology of female diverticula is that (Mohan et al. in J Urol 123(4):592–594, 1980) women have anatomically poorly supported urethral. Clinical presentation frequently involves urinary urgency, polyuria, postmicturition dribble, and hematuria.

Case description

A 37 year-old male was presented to us complaining of infertility about 6 years after marriage.

Discussion and Evaluation

However, the complaint of infertility is extremely rare. Diagnostic imaging is useful to effectively confirm this disease in most cases. A complete review of the literature on this topic was also carried out.

Conclusion

Manifestation as complaining of infertility is extremely rare among the congenital patients. The purpose of the operation is to complete the removal of the urethral diverticulum, reconstruct the urethra and maintain urinary tract unobstructed. This article and the operation could help the patient resolve the problem of infertility and dissatisfactory with the ejaculation.

Risk factors of urethral diverticula in male patients with spinal cord injury

STUDY DESIGN

A case-control study in a series of 55 males with urethral diverticula (UD) and their correspondent control, matched by age and time of radiological assessments.

OBJECTIVES

To evaluate the risk factors to develop UD in males with spinal cord injury (SCI) and the place in the urethra where they are, most commonly, allocated.

SETTING

Toledo, Spain.

METHODS

Clinical histories and urodynamic studies, of all patients, were reviewed. The study was completed with a telephone survey according to an established protocol.

RESULTS

The univariate analysis study showed the following risk factors: the age of onset of the spinal injury, the sphincterotomy procedure, personal history of lower urinary tract infections (LUTIs) and the chronic need of either indwelling catheter (IC) or the external condom drainage (ECD). Regarding the location of the UD, we have found the stress urinary incontinence as the only risk factor to develop UD in the prostatic urethra.On the other hand, we can conclude that the sphincterotomy, the ECD, the personal history of LUTIs and the detrusor external sphincter dyssynergia seem to be risk factors to develop diverticula in the bulbo-membranous urethra. Finally, we could point out the IC as the only risk factor for penile UD. Multivariate analysis showed that all of these risk factors were independent among them except the age of the onset of the injury and the ECD for UD in the bulbo-membranous urethra.

CONCLUSION

According to our study, there is evidence of some specific risk factors for the development of UD in male patients with SCI, and therefore we should adopt the appropriate preventive measures to prevent them.

Study of the prevalence and interobserver reproducibility of radiologic images suggestive of urethral diverticula in men with spinal cord injury

OBJECTIVES

To determine the prevalence of radiologic images suggestive of urethral diverticula (UD) in men with spinal cord injury (SCI) and to study the interobserver diagnostic reproducibility.

METHODS

Radiological studies (i.e. voiding cystourethrography and retrograde urethrography) performed over 1 year on men with SCI were independently reviewed by 3 researchers (1 urologist and 2 radiologists).

RESULTS

The prevalence of UD was found to be between 4.2 and 9.8% of the patients, the higher figure obtained when including also the doubtful images. The kappa index of agreement between the researchers was low (between 0.15 and 0.40). The factors that significantly influenced agreement were localization in the prostatic urethra (p = 0.021), localization in the penile urethra (p = 0.000) and fusiform morphology (p = 0.004). Logistic regression analysis showed that the variables that independently influenced diagnostic agreement were the following: localization in the penile urethra (in favor of agreement) and fusiform morphology (against agreement).

CONCLUSIONS

Radiologic images suggestive of UD constitute a frequent finding in men with SCI and raise important diagnostic problems.

Acquired male urethral diverticula: presentation, diagnosis and management

PURPOSE

We describe the etiology, presentation, treatment and outcomes of men diagnosed with an acquired urethral diverticulum.

MATERIALS AND METHODS

We retrospectively analyzed the records of men with an acquired urethral diverticulum in an 11-year period (2000 to 2011) at a tertiary care reconstructive practice. Patient demographics, history, presentation, anatomical details such as diverticulum size and location, management and outcomes were recorded. Technical success was defined as unobstructed urination without urinary tract infection.

RESULTS

A total of 22 men with an acquired urethral diverticulum were included in analysis. Median age at presentation was 48.5 years (range 18 to 86). Most commonly, patients presented with recurrent urinary tract infection, urinary dribbling, incontinence or a weak urinary stream. Of the 22 men 12 (54.5%) underwent urethral diverticulectomy and urethroplasty, 3 (13.5%) underwent ileal conduit urinary diversion and 7 (32%) were treated nonoperatively. Select cases were managed conservatively when the urethral diverticulum was confirmed in a nonobstructed urethra, it was small or asymptomatic and it could be manually emptied after voiding. At a mean followup of 2.3 years there was a 91% urethral diverticulum recurrence-free rate.

CONCLUSIONS

Acquired male urethral diverticula are rare but should be considered when there is recurrent urinary tract infection, obstructive voiding symptoms, a history of hypospadias, urethral stricture or trauma, or prolonged urethral catheterization. Treatment options may include surgical excision of the urethral diverticulum or urinary diversion. Some patients may be adequately treated nonoperatively with post-void manual decompression.

An unusual cause of pelvic pain and fever: periurethral abscess from an infected urethral diverticulum

BACKGROUND

The evaluation of patients with pelvic pain is a common task for emergency physicians. Accurate diagnosis of the underlying cause of pelvic pain in women is often difficult given the diversity of pathology that can generate pelvic pain.

OBJECTIVE

To report a rare but clinically significant cause of acute pelvic pain in women.

CASE REPORT

We describe a rare case of a periurethral abscess secondary to an infected urethral diverticulum in a 41-year-old woman. She presented to our Emergency Department with pelvic pain, dysuria, and fever of 4 days duration.

CONCLUSION

Physical examination, imaging studies, and surgery aided in confirming the diagnosis of a periurethral abscess.

Surgical reconstruction of the male urethral diverticulum

OBJECTIVES

To describe the outcomes and reconstructive techniques used for men with symptomatic urethral diverticula in an attempt to standardize treatment based on the length of the urethral defect after diverticulum excision and the type of repair used. Urethral diverticula are rare in men and may be either congenital or acquired.

METHODS

Between 2003 and 2008, 13 men were treated surgically for symptomatic urethral diverticula at a single institution by a single surgeon (C.M.G.). A total of 6 (46.2%) patients had urethral defects of < 4 cm and underwent excision of the diverticulum with primary anastomosis. Substitution urethroplasty using either penile skin or buccal mucosa was used in 7 (53.8%) patients with urethral defects of >or= 4 cm. Demographic and preoperative characteristics were compared among patients according to the length of the urethral defect.

RESULTS

The mean age of men at the time of surgery was 38.4 years (+/- 13.0; range, 20.4-63.7), with a median follow-up time of 21.7 (+/- 29.0; range, 0.9-84.0) months. Neither age at the time of surgery, length of follow-up, or diverticulum volume was significantly different between men who underwent primary repair vs substitution urethroplasty. The overall success rate was 92% (12/13) with an overall complication rate of 42% at intermediate follow-up.

CONCLUSIONS

Outcomes after excision and primary anastomosis for diverticula associated with defects of < 4 cm were similar to outcomes after diverticulum excision and substitution urethroplasty for defect of >or= 4 cm.

Management of urethral diverticulum complicating hypospadias repair

BACKGROUND

Urethral diverticula can occur after hypospadias repair, and may lead to stone formation, incomplete voiding, infection, postvoid dribbling, haematuria and other problems. We previously reviewed our experience with hypospadias complications. We separately analyzed those patients who developed urethral diverticula to attempt to identify predisposing factors and appropriate management strategies.

PATIENTS AND METHODS

We reviewed the available medical records and charts of 123 patients undergoing re-operation for hypospadias complications at The Children's Mercy Hospital from 1 May 1984 until 1 January 2003. Hypospadias cripples, traumatic fistulae, complications after circumcision and true intersex patients were excluded.

RESULTS

Diverticula accounted for 11% of all complications (13 patients). The patients with diverticula were more likely to have perineal/proximal hypospadias. The initial repair was island tube urethroplasty in five, island onlay urethroplasty in seven and bladder mucosal graft in one child. The repair of the diverticulum in one stage was successful in 10 of the 13 patients. There was one recurrent diverticulum and two fistulas. A stricture was present in only one of the 13 patients but was detected overall in 14 of the 123 patients (11%).

CONCLUSION

Diverticula are uncommon after hypospadias repair, accounting for 11% of all complications in the present series. The stricture was not causative in 12 of 13 children. Repair of the diverticulum was successful after one attempt in 10 of 13 patients. The management of this complication is discussed.

Anterior urethral valves and diverticula in children: a result of ruptured Cowper's duct cyst?

OBJECTIVE

To review a series of children with anterior urethral valves and diverticula, to elucidate the pathophysiology and optimal management of this entity.

PATIENTS AND METHODS

Nine cases (all boys; 1963 to 2003) were reviewed retrospectively.

RESULTS

Seven of nine boys had bulbar diverticula. Continuity between Cowper's duct and the diverticulum was noted endoscopically in two and confirmed radiographically in one. Initially, open surgery was curative but more recently endoscopic management has been the procedure of choice.

CONCLUSION

This series indicates that the distal lip of a ruptured syringocele may function as a flap-valve, leading to anterior urethral obstruction. Advances in imaging and endoscopic instruments have altered the mode of presentation and management of this entity.

Anterior urethral diverticulum produced by Cowper's gland duct cyst

A case of congenital urethral diverticulum is presented. The patient was a 16-year-old boy with the chief complaint of dribbling urine since he was 14 years old. A retrograde urethrogram revealed a diverticulum of the bulbar urethra, which had been produced by a cystic dilation of the Cowper's gland duct. The walls of the diverticulum were resected endoscopically.