What is the management approach for a 29-year-old woman with recurrent Urinary Tract Infections (UTIs) and a tender anterior vaginal wall mass, with Pelvic Magnetic Resonance Imaging (MRI) results available?

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

For a 29-year-old woman with recurrent UTIs and a tender anterior vaginal wall mass, MRI findings are highly suggestive of a urethral diverticulum, which requires definitive surgical management following appropriate antimicrobial therapy for active infection. 1

Diagnosis

• The combination of recurrent UTIs with a tender anterior vaginal wall mass strongly suggests a urethral diverticulum, which is present in 30-50% of patients with this clinical presentation 1
• Pelvic MRI is the optimal first-line imaging modality for suspected urethral diverticulum due to its excellent soft-tissue contrast, allowing accurate diagnosis and improved surgical planning 1
• MRI provides superior evaluation of the structure and complexity of urethral diverticula compared to other imaging modalities like CT urography 1, 2
• MRI findings can alter surgical management in approximately 15% of patients with urethral diverticula 1

Initial Management

• Obtain urine culture and sensitivity testing before initiating treatment to guide antimicrobial therapy 1
• Common causative organisms include E. coli, Proteus mirabilis, Klebsiella, Enterococcus faecalis, and Staphylococcus saprophyticus 1
• For acute UTI episodes while awaiting definitive management, appropriate antimicrobial options include:
  • Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days 1, 3
  • Nitrofurantoin 50-100 mg four times daily for 5 days 1
  • Fosfomycin trometamol 3 g single dose 1

Definitive Management

• Surgical excision of the urethral diverticulum is the definitive management approach 1
• Complete preoperative MRI evaluation is essential to characterize the diverticulum's size, location, and complexity to guide surgical planning 1, 2
• Ensure resolution of active infection before proceeding with surgical intervention 1

Important Considerations

• Urethral diverticula are often missed or misdiagnosed, leading to persistent symptoms and recurrent UTIs 1, 4
• The American College of Radiology recommends imaging studies for patients with complicated UTIs, including those with frequent reinfections or relapses 5
• While pelvic examination can provide valuable information, it has limited diagnostic utility compared to MRI for urethral diverticula 4
• Without appropriate treatment, recurrent UTIs can lead to more serious consequences, including kidney damage and renal failure 6

Follow-up

• Monitor for symptom resolution following definitive surgical management 1
• Consider long-term follow-up to assess for recurrence of symptoms or complications 1
• Evaluate for any other anatomic or functional abnormalities that may contribute to recurrent UTIs 5, 7