Radiologic diagnosis and surgical treatment of urethral diverticulum in women: A reappraisal of voiding cystourethrography and positive pressure urethrography

OBJECTIVE: To reappraise the optimum radiologic procedure for the diagnosis of urethral diverticula in women and to assess the results of surgery. STUDY DESIGN: From January 1994 to December 1997, 132 urine- continent women with pelvic prolapse and the most characteristic symptoms of urethral diverticulum underwent pelvic repair. In addition to routine urologic evaluations and pelvic examinations, the women underwent voiding cystourethrography (VCUG) and positive pressure urethrography (PPUG) with a double-balloon catheter. The x-ray examination was scheduled as follows. One hundred thirty-two women initially underwent VCUG followed by a PPUG. Another VCUG was subsequently performed on women with a negative PPUG finding. Twelve patients were excluded because they were unable to urinate for the first VCUG; thus, the study group was composed of the remaining 120 patients. Subsequently those patients underwent various pelvic operations, including total abdominal/vaginal hysterectomy, abdominal colposacropexy, Manchester's operation, sacrospinous ligament suspension, diverticulectomy and colporrhaphy. RESULTS: Both VCUG and PPUG were able to demonstrate the diverticula in 20 of the 120 women. Another 13 women showed positive findings on PPUG. Ten of the 87 cases with a negative PPUG had a positive finding in the subsequent VCUG. Forty-two diverticula were detected in 39 patients during pelvic repair. The only complication of urethral diverticulectomy was urethrovaginal fistula, which occurred in 3 of the 39 patients. CONCLUSION: Though VCUG is not as sensitive as PPUG, it still has merits and can be used as a screening test. If VCUG is inconclusive but clinical suspicion persists, particularly when PPUG is doubtful, magnetic resonance imaging should be considered.