Urethral Diverticulum: Symptoms, Types, Causes and Treatment

Urethral diverticulum is a condition characterized by an outpouching or sac-like protrusion of the urethral wall. Though relatively rare, especially in men, it can lead to a complex array of symptoms that often overlap with other pelvic and urinary disorders. Because of its variable presentation and potential to mimic other conditions, urethral diverticulum frequently results in delayed diagnosis and mismanagement. In this article, we explore the key symptoms, diverse types, underlying causes, and current treatment options for urethral diverticulum, drawing on evidence from recent clinical studies and systematic reviews.

Symptoms of Urethral Diverticulum

Urethral diverticulum can be a diagnostic challenge due to its wide range of symptoms, many of which are nonspecific and overlap with other urogenital conditions. For patients, this can mean years of discomfort and ineffective treatments before the correct diagnosis is made. Understanding the hallmark symptoms and their combinations is essential for early recognition and improved patient outcomes.

Symptom	Description	Frequency/Significance	Source(s)
Pain	Discomfort or pain in pelvic/urethral area	Common, often chronic	1, 3, 4
Urinary Incontinence	Uncontrolled leakage of urine	Frequently reported	1, 2, 3, 10
Recurrent UTI	Multiple episodes of urinary infection	Strongly associated with UD	2, 3, 4, 5
Dyspareunia	Pain during sexual intercourse	Notable symptom, especially in women	1, 2, 9
Dysuria	Painful or difficult urination	Sometimes present	3, 5
Post-void Dribbling	Leakage after urination	Diagnostic clue	4, 5, 10
Palpable Mass	Detectable lump on exam (anterior vagina in women)	May be present	1, 3, 5
Hematuria	Blood in urine	Less common, but possible	5

Table 1: Key Symptoms

Overview of Major Symptoms

The clinical presentation of urethral diverticulum is highly variable. Pain—particularly chronic pelvic or urethral pain—is often the most prominent complaint, followed closely by urinary incontinence and persistent urinary tract infections (UTIs) 1, 3, 4. Other symptoms, such as post-void dribbling, dyspareunia, and the presence of a palpable mass, are also frequently reported but may not always be present in every case 1, 2, 3, 5, 10.

The "Classic Triad" and Its Limitations

Traditionally, the "classic triad" of urethral diverticulum symptoms includes dysuria, dyspareunia, and dribbling. However, studies reveal that this triad is present in only a minority of patients 3, 9. Instead, combinations of symptoms—particularly lower urinary tract symptoms (LUTS) with post-micturition dribble and recurrent UTI—are more predictive of the disorder 4.

Why Diagnosis is Often Delayed

• Symptoms are often mistaken for other pelvic or urinary conditions, such as uncomplicated UTIs or incontinence 1, 3.
• Many patients undergo years of ineffective treatments—including surgery for incontinence—before the correct diagnosis is made 1, 3.
• Physical examination may reveal a mass or tenderness, but imaging is usually needed for confirmation 1, 5.

Key Symptom Combinations

A recent prospective study found that the combination of LUTS, post-micturition dribble, and recurrent UTI was the most sensitive predictor of urethral diverticulum, significantly increasing the likelihood of diagnosis compared to any single symptom alone 4.

Types of Urethral Diverticulum

While all urethral diverticula involve an abnormal outpouching of the urethral wall, they are not all the same. The types can vary according to their origin, anatomical location, and structural features, each with different implications for diagnosis and treatment.

Type	Description	Patient Group / Etiology	Source(s)
Congenital	Present from birth; due to developmental defects	Mostly in children (rare in adults)	6, 8
Acquired	Develops after birth; most common type	Adults, especially women; due to infection, trauma, or surgery	1, 6, 8, 11
Simple	Single sac, single neck	Any group; easier to treat	9, 12
Complex/Multiloculated	Multiple sacs or septations	More challenging, higher complication risk	9, 2

Table 2: Types of Urethral Diverticulum

Congenital vs. Acquired

• Congenital diverticula are rare and typically found in children. They result from developmental anomalies, such as incomplete closure of the urethral folds 6, 8. In males, they may be associated with other urogenital abnormalities 8.
• Acquired diverticula are far more common, particularly in adult women. They are usually the consequence of infection, trauma, childbirth, or surgical interventions 1, 6, 11.

Simple vs. Complex Diverticula

• Simple (unilocular) diverticula consist of a single pouch with a single connection (neck) to the urethra. These tend to be more straightforward to excise surgically and generally have a lower risk of recurrence or complications 9, 12.
• Complex (multiloculated) diverticula involve multiple sacs, internal septations, or more than one neck. These are often associated with higher surgical difficulty, increased risk of postoperative complications, and may require more specialized surgical approaches 2, 9.

Location-Based Classification

Diverticula can form anywhere along the urethra but are most commonly found in the mid- or distal urethra in women 1, 5, 9. In men, they may occur anywhere along the anterior urethra, particularly after trauma or surgical intervention 6, 8, 11.

Causes of Urethral Diverticulum

The development of a urethral diverticulum is influenced by a combination of structural, infectious, and traumatic factors. Knowing the underlying causes helps inform both prevention and tailored treatment strategies.

Cause	Mechanism or Risk Factor	Typical Patient Group	Source(s)
Infection	Recurrent periurethral gland infection leads to abscess and wall weakness	Women (most common)	1, 5, 12
Childbirth Trauma	Injury to urethra or periurethral tissues during delivery	Women, postpartum	1, 5
Iatrogenic	Surgical procedures, catheterization, or instrumentation causing tissue damage	Both genders; post-surgery	6, 8, 11
Urethral Stricture	Chronic obstruction leading to increased pressure and outpouching	Men (especially post-stricture surgery)	8, 11
Congenital Defects	Developmental anomaly of urethral wall	Children, rare in adults	6, 8

Table 3: Main Causes

Infection and Inflammation

The most widely accepted theory for acquired urethral diverticulum—particularly in women—is that repeated infection of the periurethral glands leads to abscess formation. Over time, these abscesses rupture into the urethral lumen, creating a persistent outpouching 1, 5, 12.

Trauma and Childbirth

• Vaginal childbirth can cause direct trauma to the urethra, leading to weakening of the wall and subsequent diverticulum formation 1, 5.
• In men and children, traumatic events—including rough catheterization or surgical procedures—can similarly lead to diverticulum development 6, 8, 11.

Iatrogenic Factors

• Repeated or improper instrumentation of the urinary tract, such as catheterization or urethral surgery, is a recognized risk factor for acquired diverticula, especially in men 6, 8, 11.
• Postoperative complications, such as after repair of hypospadias or artificial urinary sphincter implantation, have also been implicated 8.

Congenital Anomalies

Although rare, some individuals are born with a urethral diverticulum due to incomplete formation of the urethral wall during fetal development. These are typically diagnosed in childhood 6, 8.

Treatment of Urethral Diverticulum

Timely and effective treatment of urethral diverticulum is crucial for symptom relief and prevention of complications. Surgical excision remains the gold standard, but not all cases require the same approach. The choice of treatment depends on the size, complexity, symptoms, and underlying causes.

Treatment	Description / Indication	Outcomes / Risks	Source(s)
Diverticulectomy	Surgical removal via transvaginal approach (women) or perineal approach (men)	High cure rates, low recurrence	1, 2, 9, 10, 12
Martius Flap	Interposition of labial fat pad to reinforce repair	Reduces fistula risk, helps continence	2, 10, 12
Urethral Reconstruction	For complex or large defects post-excision	Needed in select cases	1, 10, 12
Anti-incontinence Sling	Pubovaginal sling for stress incontinence (often staged)	Avoids overtreatment; staged if SUI persists	1, 10, 12
Conservative Management	Manual decompression, observation in small/asymptomatic cases	Reserved for select patients	11
Urinary Diversion	For severe, recurrent, or malignant cases	Rare, last-resort	11, 10

Table 4: Treatment Options

Surgical Excision (Diverticulectomy)

• The mainstay of treatment for symptomatic urethral diverticulum is surgical excision, most often performed via a transvaginal approach in women, or perineally in men 1, 2, 9, 10, 12.
• Key surgical principles include complete removal of the diverticulum, watertight closure, and multi-layered repair to minimize fistula or stricture formation 9, 12.
• The use of a Martius labial fat pad flap can reinforce the repair and reduce the risk of postoperative fistula, particularly in complex cases 2, 10, 12.

Continence Management

• Some women with pre-existing stress urinary incontinence (SUI) may experience improvement after diverticulectomy alone, particularly if a Martius flap is used 2.
• For persistent or severe SUI, a pubovaginal sling (using the patient’s own tissue) may be placed, often as a second-stage procedure after diverticulectomy to avoid overtreatment 1, 10, 12.

Conservative and Alternative Approaches

• Small or asymptomatic diverticula, particularly in men, may be managed conservatively with post-void manual decompression and observation 11.
• Urinary diversion (e.g., ileal conduit) is rarely required and reserved for cases with severe complications or malignancy 11, 10.

Complications and Recurrence

• Surgical outcomes are generally excellent, with cure rates exceeding 90% in most series 2, 10, 12.
• Potential complications include new-onset SUI, urethrovaginal fistula, urethral stricture, and, rarely, recurrence of the diverticulum 2, 9, 10.
• Malignancy within a diverticulum is rare but should be considered, especially in cases with atypical features or failure to improve after treatment 1, 10.

Conclusion

Urethral diverticulum poses a unique diagnostic and therapeutic challenge due to its diverse symptoms and underlying causes. Early recognition and individualized treatment are key to optimal outcomes. Here’s a summary of the main points:

• Symptoms are diverse: Pain, incontinence, recurrent UTIs, dyspareunia, and post-void dribbling are leading features. Symptom combinations are more predictive than individual complaints.
• Types vary: Diverticula may be congenital or acquired, simple or complex, with anatomical location influencing management.
• Causes are multifactorial: Most cases are acquired due to infection, trauma, or childbirth; congenital cases are rare.
• Treatment is usually surgical: Diverticulectomy (with or without reconstructive techniques) offers high cure rates. Conservative management is reserved for select asymptomatic patients.

Ultimately, a high index of suspicion, careful examination, and appropriate imaging are essential to avoid misdiagnosis and ensure that patients receive the care they need for this often-overlooked condition.