Urinary Symptoms Before
and After Female Urethral Diverticulectomy—
Can We Predict De Novo Stress Urinary Incontinence?
Kobi Stav,* Peter L. Dwyer, Anne Rosamilia and Fay Chao
From the Department of Urogynaecology, Mercy Hospital for Women (KS, PLD) and Monash Medical Centre (AR, FC), Melbourne,
Australia, and Department of Urology, Assaf Harofeh Medical Center, Zeriffin, and Sackler School of Medicine, Tel Aviv University,
Purpose: We assessed preoperative and postoperative urinary symptoms, and determined risk factors for de novo stress
urinary incontinence after transvaginal urethral diverticulectomy.
Materials and Methods: We reviewed the case records of 25 consecutive women who had transvaginal urethral diverticu-
lectomy. Urinary symptoms were documented before and after surgery with a structured history and examination pro forma.
Demographic, clinical and imaging parameters were reviewed to determine any association with preoperative and postop-
erative symptoms as well as possible risk factors for postoperative stress urinary incontinence.
Results: The most common presenting symptoms were urinary urgency and frequency (60%), and dyspareunia (56%). On
physical examination the most common findings were a tender anterior vaginal wall mass (88%) and urethral discharge
(40%). At a mean followup of 15.1 ? 14.9 months (median 12) the rate of urgency-frequency symptoms and dyspareunia
decreased significantly from 60% to 16% and from 56% to 8%, respectively. All the patients who had urge incontinence were
cured of this symptom after the operation. De novo stress urinary incontinence developed in 4 patients (16%) postoperatively,
and it was mild and only necessitated surgical treatment in 1 patient. A diverticulum larger than 30 mm and proximal
urethral location were significant factors (p ?0.05) for the development of de novo stress urinary incontinence.
Conclusions: Irritative bladder symptoms are common in woman with urethral diverticulum and usually resolve after
surgical excision. Stress urinary incontinence developed immediately after the operation, and had a significant association
with a proximal urethral location and ultrasonically measured size greater than 30 mm.
Key Words: diverticulum; urethra; urinary incontinence, stress; risk factors; female
the most accepted theory is obstruction and infection of a
periurethral gland.1,2UD is considered a rare finding and is
often difficult to diagnose. However, increased physician
awareness and the development of new imaging modalities
such as transvaginal ultrasound3,4and magnetic resonance
imaging have improved diagnostic accuracy.5,6The condi-
tion frequently presents with nonspecific symptoms which
leads to incorrect and delayed diagnosis. Presenting urinary
symptoms are recurrent infections, post-void dribbling and
urinary frequency-urgency symptoms. In women with per-
sistent irritable lower urinary tract symptoms prevalence
rates of 16% and 40% have been reported, and so a high level
of suspicion is needed in these patients.7Other common
presenting symptoms are a vaginal mass or pain frequently
with sexual intercourse.
emale urethral diverticulum is a localized outpouch-
ing of the urethra into the anterior vaginal wall. The
causation of UD is poorly understood but currently
Multiple open surgical and endoscopic approaches have
been described for the treatment of urethral diverticu-
lum.8–10At present complete transvaginal excision of the
diverticulum is considered the procedure of choice because of
its high success and low complication rates. Some clinicians
treat coexisting SUI simultaneously with a pubovaginal
sling or bladder neck suspension, or even recommend stress
incontinence surgery to prevent the development of de novo
SUI postoperatively.11–14De novo SUI has been reported in
the literature to occur in 1.7% to 20.3% of patients.14–19In
this study we assessed urinary symptoms before and after
transvaginal urethral diverticulectomy, and looked for clin-
ical associations with preoperative and postoperative uri-
nary symptoms, particularly in women with UD in whom
SUI might develop de novo after surgical excision.
MATERIALS AND METHODS
We reviewed the medical records of 25 consecutive women
who underwent transvaginal urethral diverticulectomy at 2
Submitted for publication March 4, 2008.
Nothing to disclose.
Study received local ethics committee approval.
* Correspondence: Urogynaecology Department, Mercy Hospital
for Women, 163 Studley Rd., Heidelberg, Victoria 3084, Australia
(telephone: ?61  61395238380; FAX: ?61  394162472; e-mail:
Editor’s Note: This article is the third of 5 published in
this issue for which category 1 CME credits can be
earned. Instructions for obtaining credits are given
with the questions on pages 2266 and 2267.
THE JOURNAL OF UROLOGY®
Copyright © 2008 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 180, 2088-2090, November 2008
Printed in U.S.A.
medical centers from 1998 to 2007 after approval of the local
ethics committee. The assessment included demographic in-
formation, medical history, urinary symptoms evaluation,
physical examination, urodynamics, imaging, cystourethros-
copy, and surgical and pathological reports. Data were as-
sembled into a database using an Excel spreadsheet. Raw
distributions and frequencies were calculated and tested for
significant differences. Statistical analyses were performed
using SPSS® software (version 12.0, 2004). A p value of less
than 0.05 was considered significant. We used the Fisher
exact test to evaluate risk factors for the development of de
novo SUI after surgery. Analysis was performed for the risk
factors of age, time to diagnosis, preoperative symptoms,
number of previous pregnancies and deliveries, previous
hysterectomy, physical findings, size and urethral location of
the diverticulum, and histopathology of the surgical speci-
Patients were taken off antiaggregation or anticoagula-
tion medications 10 days before the operation. Any urinary
tract infection present preoperatively was treated with an
appropriate antibiotic. All patients received prophylactic
second generation cephalosporin antibiotic before the anes-
thetic induction. Standard transvaginal excision of the di-
verticulum was performed. The bladder was drained using a
urethral or suprapubic catheter in 18 and 7 patients, respec-
tively. Concomitant pubovaginal rectus fascial sling was
performed in 1 patient who had urodynamic stress inconti-
nence and intrinsic sphincter deficiency (leak point pressure
of 42 cm H2O and maximal urethral closure pressure of 18
cm H2O). A Martius labial fat pad graft was used in 2 cases
with large UD where further reinforcement of the subure-
thral dissection and repair was considered appropriate. Pa-
tients were usually discharged home the following day with
an indwelling catheter for an average of 7 days (range 3
The demographic and clinical characteristics appear in table 1.
Mean patient age was 41.7 ? 11.6 years. The time from
initial symptoms to definite diagnosis was 2.2 ? 1.4 years
(median 2, range 1 to 5). Most of the women were premeno-
pausal (76%) and none of them had anti-incontinence or
vaginal surgery previously.
Twelve patients underwent urodynamic assessment be-
fore the procedure. Mean cystometric capacity was 410 ? 56
ml. Two patients had symptoms of SUI which was also
demonstrated by urodynamics (8%). Three patients had de-
trusor overactivity (12%). None of the patients had urody-
namic evidence of obstructed voiding. The diverticulum was
demonstrated by ultrasound in all 25 cases (10 transperi-
neal, 15 transvaginal). Double balloon positive pressure ure-
thrography using a Trattner catheter was performed in 14
women, demonstrating a diverticular sac in all. In 2 cases
stones were seen inside the sac and their presence was
confirmed during the operation. Two patients had horseshoe
(partial circumferential)-shaped diverticulum. Communica-
tion between the sac and the urethra could be seen in 8 cases
on ultrasound scan. The diverticular orifice could be demon-
strated by urethroscopy in 11 of 25 patients (44%).
Mean operating time was 105.7 ? 30.3 minutes (range 75
to 180). In 5 patients (20%) the diverticulum was in the
proximal third of the urethra, and in 7 and 12 patients it had
a mid and distal urethral location, respectively. No major
intraoperative or perioperative complications were docu-
mented. Two patients had postoperative urinary infections
which resolved with oral antibiotics.
Table 2 lists preoperative and postoperative urinary
symptoms. The most common presenting symptoms were
urinary urgency and frequency (60%), and dyspareunia
(56%). Two women had stress incontinence. On physical
examination the most common findings were anterior vagi-
nal wall mass or tenderness (22, 88%) and discharge on
urethral expression (10, 40%).
After a mean followup of 15.1 ? 14.9 months (median 12,
range 6 to 80) the rate of urgency-frequency symptoms and
dyspareunia decreased significantly from 60% to 16% and
from 56% to 8%, respectively. All the patients who had urge
incontinence were cured of this symptom after the operation.
Of the 2 women who had SUI before surgery 1 had a con-
comitant pubovaginal sling and was dry 1 year after the
operation, and in the other the SUI resolved after excision of
the UD. Two patients had recurrent UD diagnosed 2 months
(1) and 6 months (1) after the first operation. Both patients
had successful repeat surgery, and are currently free of
symptoms and without evidence of recurrence on imaging.
None of the patients experienced urethral stricture, voiding
difficulties or urethrovaginal fistula.
SUI developed de novo in 4 patients (16%) postopera-
tively. In 3 of the 4 women the symptoms of SUI were mild,
requiring only conservative treatment, and 1 woman under-
TABLE 1. Demographic and clinical variables
Mean ? SD
Body mass index:
Mean ? SD
Mean ? SD
Mean ? SD
No. premenopausal (%)
No. previous hysterectomy (%)
No. smokers (%)
No. diabetes mellitus (%)
No. hypertension (%)
Diverticulum diameter (mm) by ultrasound:
Mean ? SD
Mean ? SD
Days with catheter:
Mean ? SD
41.7 ? 11.6
28.3 ? 3.4
2.1 ? 1.3
22.8 ? 10.1
105.7 ? 30.3
7.3 ? 4.2
TABLE 2. Preoperative and postoperative symptoms
No. Preop (%)No. Postop (%)
Urge urinary incontinence
Recurrent urinary tract infection
PREDICTING STRESS URINARY INCONTINENCE 2089
went a tension-free vaginal tape procedure 8 months post- Download full-text
operatively with a good result. In all 4 cases the diverticulum
was located at the proximal urethra and the diverticular sac
measured by ultrasound was larger than 30 mm. Those 2
factors were statistically significant (p ?0.05) for the devel-
opment of de novo SUI after surgery. None of the patients in
whom de novo SUI developed had a horseshoe-shaped diver-
ticulum. Of the patients in whom de novo SUI did not de-
velop there was only 1 who had a proximal diverticulum and
1 other who had a diverticulum larger than 30 mm.
Our study indicates that after surgery most of the irritative
and obstructive urinary symptoms associated with UD dis-
appear. The postoperative de novo SUI rate in our group was
16% but was usually not bothersome and during followup
SUI surgery was only necessary in 1 case (4%). Previous
studies demonstrated that SUI can develop after urethral
diverticulectomy in up to 20.3% of patients.14–19
Our results indicate that proximal UD and size larger
than 3 cm have a significant association with the develop-
ment of de novo SUI following transvaginal surgical excision
of the sac. To our knowledge only 1 previous study tried to
define risk factors for complications after surgery for UD in
women.18Porpiglia et al retrospectively evaluated postoper-
ative complications in 18 women with a followup of 44 to 121
months.18They recorded 1 urethrovaginal fistula, 2 cases of
new onset SUI and 1 recurrent diverticulum. They con-
cluded that the most important risk factors were delayed
diagnosis (more than 12 months), size (larger than 4 cm) and
horseshoe shape of the diverticulum.
The pathophysiology of SUI after urethral diverticulec-
tomy is unclear. We assume that a large diverticulum re-
quires more extensive suburethral dissection, and a proxi-
mal location may jeopardize the anatomical support of the
urethra and bladder neck or may cause damage to the ure-
thral sphincter mechanism. The urethral musculature and
the bladder neck may also be damaged by the inflammation
and diverticulum mass itself, causing stress incontinence.
An important practical implication of our findings is the
greater possibility of de novo SUI in women with a large
proximal UD and the need for preoperative discussion on
this matter. Meticulous periurethral dissection, wide dissec-
tion around the UD and layered closure of the urethral
defect without tension by experienced surgeons is necessary
if there are to be low rates of postoperative SUI, urethral
stricture and fistula formation. The case for a fascial sling
performed simultaneously with diverticulum excision even
in patients at high risk for SUI does not appear warranted
by our findings. Retropubic urethral suspension procedures
are technically difficult and often unsatisfactory when per-
formed in women at transvaginal urethral diverticulectomy
because of the limited mobility of the vaginal wall.
In our study irritative bladder symptoms are common in
women with UD and usually resolve after surgical excision.
We found that SUI developed in 16% of women after trans-
vaginal excision of urethral diverticulum. In all cases the
incontinence developed immediately after the operation, did
not resolve spontaneously after a mean followup of 15
months but only required SUI surgery in 4%. We found that
proximal urethral location and diverticulum larger than 30
mm have a significant association with postoperative de
Abbreviations and Acronyms
stress urinary incontinence
1.Dmochowski R: Urethral diverticula: evolving diagnostics and
improved surgical management. Curr Urol Rep 2001; 2:
Bennett SJ: Urethral diverticula. Eur J Obstet Gynecol Reprod
Biol 2000; 89: 135.
Siegel CL, Middleton WD, Teefey SA, Wainstein MA, McDougall
EM and Klutke CG: Sonography of the female urethra. AJR
Am J Roentgenol 1998; 170: 1269.
Fontana D, Porpiglia F, Morra I and Destefanis P: Transvag-
inal ultrasonography in the assessment of organic diseases
of female urethra. J Ultrasound Med 1999; 18: 237.
Siegelman ES, Banner MP, Ramchandani P and Schnall MD:
Multicoil MR imaging of symptomatic female urethral and
periurethral disease. Radiographics 1997; 17: 349.
Khati NJ, Javitt MC, Schwartz AM and Berger BM: MR im-
aging diagnosis of a urethral diverticulum. Radiographics
1998; 18: 517.
Stewart M, Bretland PM and Stidolph NE: Urethral divertic-
ula in the adult female. Br J Urol 1981; 53: 353.
Spencer WF and Streem SB: Diverticulum of the female ure-
thral roof managed endoscopically. J Urol 1987; 138: 147.
Davis BL and Robinson DG: Diverticula of the female urethra:
assay of 120 cases. J Urol 1970; 104: 850.
Lichtman AS and Robertson JR: Suburethral diverticula
treated by marsupialization. Obstet Gynecol 1976; 47: 203.
Leach GE, Schmidbauer CP, Hadley HR, Staskin DR, Zim-
mern P and Raz S: Surgical treatment of female urethral
diverticulum. Semin Urol 1986; 4: 33.
Leng WW and McGuire EJ: Management of female urethral
diverticula: a new classification. J Urol 1998; 160: 1297.
Romanzi LJ, Groutz A and Blaivas JG: Urethral diverticulum
in women: diverse presentations resulting in diagnostic
delay and mismanagement. J Urol 2000; 164: 428.
Ganabathi K, Leach GE, Zimmern PE and Dmochowski R:
Experience with the management of urethral diverticulum
in 63 women. J Urol 1994; 152: 1445.
Wharton LR Jr and Te Linde RW: Urethral diverticulum.
Obstet Gynecol 1956; 7: 503.
Boatwright DC and Moore V: Suburethral diverticula in the
female. J Urol 1963; 89: 581.
Ward JN: Technique to visualize urethral diverticula in female
patients. Surg Gynecol Obstet 1989; 168: 278.
Porpiglia F, Destefanis P, Fiori C and Fontana D: Preoperative
risk factors for surgery female urethral diverticula. Our
experience. Urol Int 2002; 69: 7.
Ljungqvist L, Peeker R and Fall M: Female urethral divertic-
ulum: 26-year followup of a large series. J Urol 2007; 177:
PREDICTING STRESS URINARY INCONTINENCE 2090