What is the next step for a 29-year-old woman with recurrent Urinary Tract Infections (UTIs) and a tender anterior vaginal wall mass?

Management of a 29-Year-Old Woman with Recurrent UTIs and Tender Anterior Vaginal Wall Mass

The next step for a 29-year-old woman with recurrent UTIs and a tender anterior vaginal wall mass should be a pelvic MRI to evaluate for urethral diverticulum, as this is the most likely diagnosis given her presentation. 1

Diagnostic Considerations

• Recurrent UTIs in a young woman with a tender anterior vaginal wall mass strongly suggests the presence of a urethral diverticulum, which is present in 30-50% of patients with this condition 1
• MRI is the optimal imaging modality for assessment of urethral diverticula, allowing for accurate diagnosis and improved surgical planning 1
• The presence of a tender mass along the anterior vaginal wall in a patient with recurrent UTIs is a classic presentation of urethral diverticulum, which acts as a reservoir for bacteria and leads to recurrent infections 2

Diagnostic Algorithm

1. Pelvic MRI: First-line imaging for suspected urethral diverticulum

   • Provides excellent soft-tissue contrast for evaluating the structure and complexity of urethral diverticula 1
   • Has been shown to alter surgical management in 15% of patients 1
   • Superior to double-balloon urethrography which can be technically difficult and uncomfortable for the patient 1

2. Urine Culture and Sensitivity Testing:

   • Should be obtained before initiating treatment to guide antimicrobial therapy 3
   • Common causative organisms include E. coli, Proteus mirabilis, Klebsiella, Enterococcus faecalis, and Staphylococcus saprophyticus 1

3. Cystoscopy:

   • May be considered after imaging to directly visualize the urethral diverticulum opening and assess for other bladder abnormalities 2
   • Particularly useful in complicated UTIs that don't respond to conventional therapy 1

Management Considerations

• Surgical Intervention: If urethral diverticulum is confirmed, surgical excision is typically required to prevent ongoing infections 2
• Antimicrobial Therapy: For acute UTI episodes while awaiting definitive management:
  • Nitrofurantoin 50-100 mg four times daily for 5 days 3
  • Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days 3, 4
  • Fosfomycin trometamol 3 g single dose 3

Important Caveats

• Urethral diverticula are often missed on routine examination and require a high index of suspicion, especially in women with recurrent UTIs 2, 5
• Failure to diagnose and treat urethral diverticulum will result in continued recurrent UTIs despite appropriate antibiotic therapy 2
• While other imaging modalities like CT urography might be considered for complicated UTIs, MRI is specifically preferred for suspected urethral diverticulum due to superior soft tissue contrast 1
• Extensive routine workup is not recommended for uncomplicated recurrent UTIs, but the presence of a tender anterior vaginal wall mass indicates a complicated UTI requiring thorough evaluation 3, 2