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

Management of Urethral Diverticulum in a 29-Year-Old Woman with Recurrent UTIs

The next step in managing this 29-year-old woman with recurrent UTIs and a tender anterior vaginal wall mass due to urethral diverticulum is transvaginal excision (option E).

Diagnostic Confirmation

The patient has already had appropriate diagnostic workup:

• Clinical presentation of recurrent UTIs and tender anterior vaginal wall mass
• Pelvic MRI confirming urethral diverticulum

This diagnostic approach aligns with current guidelines, as MRI is considered the optimal imaging modality for assessment of urethral diverticula 1. MRI provides excellent evaluation of the structure and complexity of urethral diverticula, allowing for accurate diagnosis and improved surgical planning.

Management Algorithm

1. Confirm diagnosis: MRI is the gold standard (already completed)
2. Determine if symptomatic: Patient has recurrent UTIs and tenderness (symptomatic)
3. Select appropriate treatment:
   • For symptomatic urethral diverticula → surgical management
   • For asymptomatic cases → conservative management

Rationale for Transvaginal Excision

Transvaginal diverticulectomy (excision) is the treatment of choice for symptomatic urethral diverticula 2. This approach is preferred because:

• It provides direct access to the diverticulum
• It allows complete removal of the diverticular sac
• It has the highest success rate for symptom resolution
• It addresses the underlying cause of recurrent UTIs

Other options are inappropriate:

• Biopsy of mass (option A): Unnecessary when MRI has already confirmed urethral diverticulum. Biopsy could potentially cause complications like infection or fistula formation.
• Percutaneous aspiration (option B): Only provides temporary relief and risks infection, recurrence, and fistula formation.
• Transurethral incision (option C): Not recommended as primary treatment as it may lead to urethrovaginal fistula.
• Distal marsupialization (option D): Not appropriate for urethral diverticula as it may lead to persistent drainage and infection.

Expected Outcomes and Success Rates

Transvaginal diverticulectomy has a high success rate:

• Approximately 72% of patients achieve complete dryness and symptom resolution 3
• Recurrence rates are low at approximately 3.4% 3

Potential Complications and Management

Patients should be counseled about potential complications:

1. De novo stress urinary incontinence (SUI): Occurs in approximately 15% of patients 3

   • May require subsequent anti-incontinence surgery if bothersome

2. Recurrence: Rare (3.4%) 3

   • May require repeat diverticulectomy

3. Urethrovaginal fistula: Uncommon but serious complication

   • May require additional repair with tissue interposition (e.g., Martius flap)

4. Urethral stricture: Can occur following surgery

   • May require urethral dilation if symptomatic

5. Persistent UTIs: Usually resolve after diverticulectomy but may persist in some cases

Special Considerations

• In cases with large defects after excision, a Martius flap may be interposed to strengthen the repair 3
• Conservative management with urethral dilation has been reported in select cases of infected diverticula in patients with significant comorbidities 4, but is not appropriate as first-line therapy in this young, otherwise healthy patient
• Rare cases (2.2%) may reveal unexpected pathology such as leiomyoma or carcinoma 3, highlighting the importance of pathological examination of the excised specimen

In conclusion, transvaginal excision is clearly the most appropriate next step for this patient with symptomatic urethral diverticulum confirmed by MRI.