What is the next step in managing a 29-year-old woman with recurrent Urinary Tract Infections (UTIs) and a diagnosed urethral diverticulum with an anterior vaginal wall mass?

Management of Urethral Diverticulum in a Young Woman with Recurrent UTIs

The next step in managing this 29-year-old woman with recurrent UTIs and confirmed urethral diverticulum on MRI is surgical excision via transvaginal urethral diverticulectomy. 1, 2

Rationale for Surgical Management

• MRI has already confirmed the diagnosis, showing the urethral diverticulum presenting as an anterior vaginal wall mass
• The patient's recurrent UTIs are likely directly related to the diverticulum, as 30-50% of patients with urethral diverticula experience recurrent UTIs 1
• Surgical excision is the definitive treatment for symptomatic urethral diverticula 2, 3
• Conservative management is unlikely to resolve the underlying anatomical issue

Pre-Surgical Considerations

• Review the MRI findings to assess:

  • Size and complexity of the diverticulum
  • Location relative to the urethral sphincter
  • Number of diverticula (single vs. multiple)
  • Presence of calculi within the diverticulum
  • Communication with the urethra

• Ensure urine culture is obtained before surgery to treat any active infection

• Consider urodynamic testing to assess for concurrent stress urinary incontinence 4

Surgical Approach

The recommended surgical technique includes:

• Transvaginal approach (standard of care) 2, 3
• Complete excision of the diverticulum 2
• Layered closure of the defect 2
• Consider Martius flap interposition if a large defect is present after excision 2

Expected Outcomes and Potential Complications

• Success rate: Approximately 72% of patients achieve complete symptom resolution and continence 2
• Potential complications to discuss with the patient:
  • De novo stress urinary incontinence (13-15% of cases) 2, 4
  • Recurrence (3.4% of cases may have residual diverticulum) 2
  • Urethrovaginal fistula (rare but serious complication) 4
  • Urethral stricture 4
  • Rare possibility of unexpected pathology (2.2% of cases) 2

Important Caveats

• Surgery should be performed at a center with expertise in female urethral surgery 2
• Ensure complete excision to minimize recurrence risk
• If concurrent stress urinary incontinence is present, consider staged approach with anti-incontinence surgery performed 6 months after diverticulectomy 4
• Patients who develop de novo SUI after surgery may require subsequent anti-incontinence procedures 2, 4

While urethral dilation has been reported as a conservative management option in select cases 5, particularly in older patients with comorbidities, this approach is not recommended as first-line therapy for a young patient with a clearly identified diverticulum and recurrent UTIs, as it typically provides only temporary relief without addressing the underlying anatomical defect.