Female urethral diverticula are not frequently seen in every day urological practice. Most patients present with lower urinary tract symptoms, dyspareunia, urethral discharge, urethral pain and/or swelling or recurrent urinary tract infections [1,2]. Due to the nonspecific character of these symptoms and the rare occurrence of urethral diverticula, women are often misdiagnosed and complaints can be present for a long time before the correct diagnosis is established. As a consequence of the rare condition of urethral diverticula, clinical cohorts are small and therefore publications of the surgical treatment and its outcome are sparse. This study evaluates the clinical presentation and treatment of a urethral diverticulum and assesses the effect of diverticulectomy on symptomatology.

In this retrospective study patient files were analysed from female patients from two tertiary hospitals who underwent an excision of a urethral diverticulum. Both primary diverticula and recurrences were included. Excision was performed in lithotomy position and consisted of a vaginal approach with a reversed U-incision to radically resect the diverticulum with  reconstruction of the urethra if needed. From patient files data on demography, presurgical presentation, concomitant diseases and complaints, surgery reports and post operative outcome were extracted. Also, when patients gave their consent, the present medical condition was evaluated by a telephone survey. Initial symptoms and the effect of surgical treatment of the urethral diverticulum on the symptoms were assessed as well as the surgical technique and complications.

A total of 21 patients with a urethral diverticulum were enrolled in this study from 2011 to 2021. 3 of them presented with a recurrence. The median age was 44 years (range 24-69). The median time from first presentation in the hospital until diagnosis was 9 months (range 0-120).Urethral swelling (48%) or vaginal pain (33%) were the most prevalent main symptom at presentation. Urge incontinence was seen in 10% of the patients. Recurrent urinary tract infections were less often (14%) the main reason to consult a doctor. All patients underwent a preoperative MRI and most of them also underwent a cystoscopy (67%) or a transvaginal ultrasound (57%). During excision discontinuation of the urethra with consequently a reconstruction occurred in 85% of the patients. Postoperatively patients had an indwelling catheter for an average of 9 days (95% CI 5.9-11.2) and a vaginal wick for 0.8 days (95% CI 0.6-1.1). The mean hospital stay was 1.7 days (95% CI 1.1-2.3). A total of 6 postoperative early complications (5 urinary tract infections, 1 wound infections, 0 urinary retentions, 0 fistulas) were registered. 20 patients gave their consent to evaluate their symptoms at long term. The mean follow-up was 36 months (range 6-78). 50% of the patients were without complaints after excision at long term follow-up. Another 37% still expressed complaints such as frequency or urgency, but those symptoms were less bothering than the symptoms before surgery. The outcome of primary surgery versus redo surgery did not affect the subjective outcome (48% vs. 50% free of symptoms, p=0.91). The most common de novo symptom at long term follow-up was mild stress incontinence (45%). At follow-up, in 19% of the patients a recurrence was confirmed by MRI after a median duration of follow-up of 11 months (range 4-38).

We found that women with a urethral diverticulum present mainly with a urethral swelling or vaginal pain. Urethral discharge, dysuria or recurrent urinary tract infections were also present in many patients, but were not their major complaint. 
In line with other literature stress incontinence was the most frequently seen de novo complaint after diverticulectomy. In our study a relatively high percentage of de novo stress incontinence (45%) was found. In the literature 10-33% de novo stress incontinence is reported [3]. However, in other studies the severity of stress incontinence was not listed. Following our data all women with de novo stress incontinence had mild complaints, requiring less than 4 panty liners a day. For none of them another operation was needed to resolve the incontinence. A comparison of different studies is challenging due to the diversity in definitions or measurements of incontinence. 
Nevertheless, considering the considerable chance to develop de novo stress incontinence, the importance of precisely identifying the sphincter during operation is emphasized. And although the majority of women stated to experience a significant relieve of their symptoms after the operation, they should be carefully counselled for this risk pre-operatively.

A urethral diverticulum in women often reveals itself by a urethral swelling or vaginal pain. Excision of the diverticulum results in 87% of the patients to fewer or complete resolution of complaints. However, there is a considerable chance of de novo stress incontinence. Patients should therefore properly consulted before they decide to undergo surgery.

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