How to manage a 45-day-old infant with an asymptomatic significant bulbar urethral diverticulum?

Management of Asymptomatic Bulbar Urethral Diverticulum in a 45-Day-Old Infant

In an asymptomatic 45-day-old infant with a significant bulbar urethral diverticulum, conservative observation with close monitoring is the appropriate initial management approach, reserving surgical intervention only if complications develop.

Initial Diagnostic Confirmation

• Obtain retrograde urethrogram (RGU) and voiding cystourethrogram (VCUG) to fully characterize the diverticulum's size, location, and relationship to the urethral lumen, as these are the gold standard imaging modalities for urethral diverticula 1, 2.
• Assess for associated urethral strictures or other anatomical abnormalities that may influence management decisions 1.
• Evaluate for vesicoureteral reflux (VUR) given the age and potential for associated urinary tract anomalies, though this is more relevant if urinary tract infections develop 3.

Conservative Management Strategy for Asymptomatic Cases

Since the infant is asymptomatic, conservative management with surveillance is appropriate 1, 2. This approach is justified because:

• Conservative management is possible for uncomplicated asymptomatic urethral diverticula if the patient (family) consents to follow-up 1.
• Surgical intervention carries risks in this age group and should be reserved for symptomatic or complicated cases 2.
• Many congenital urethral diverticula in infants can be monitored safely without immediate intervention 2.

Monitoring Protocol

• Monitor for development of symptoms including:

  • Urinary tract infections (fever, irritability, poor feeding) 2
  • Post-void dribbling or urinary retention 2
  • Painful urination (difficult to assess in infants but may manifest as crying during voiding) 2
  • Swelling or changes in the penile/perineal area 2

• Schedule regular clinical follow-up every 3-6 months initially to assess for:

  • Growth and development parameters 3
  • Signs of urinary obstruction or infection 2
  • Changes in voiding pattern reported by parents 2

• Repeat imaging (ultrasound or RGU) at 6-12 months to assess for changes in diverticulum size or development of complications 1, 2.

Indications for Surgical Intervention

Surgery should be considered if any of the following develop:

• Recurrent urinary tract infections despite appropriate antibiotic treatment 2, 4.
• Urinary retention or significant obstructive symptoms 2.
• Stone formation within the diverticulum (rare but reported) 4.
• Progressive enlargement of the diverticulum on serial imaging 2.
• Development of urethrocutaneous fistula or other complications 1.

Surgical Options When Indicated

If surgery becomes necessary, the approach depends on the specific anatomy:

• Diverticulectomy with primary urethral reconstruction is the standard approach for symptomatic cases 1, 2.
• Endoscopic resection may be considered for smaller diverticula without associated strictures 5.
• Substitution urethroplasty (using buccal mucosa graft or other tissue) is reserved for cases with concurrent urethral stricture 1.
• Multi-layered closure with dartos flap coverage helps prevent complications and recurrence 2.

Critical Pitfalls to Avoid

• Do not rush to surgery in asymptomatic cases – the natural history in infants may be more benign than in adults, and unnecessary surgery carries morbidity 1, 2.
• Do not miss associated urethral strictures – always evaluate the entire urethra with adequate imaging before any intervention 1.
• Do not ignore signs of infection – even subtle changes in feeding, irritability, or fever warrant prompt evaluation and urine culture 2.
• Ensure adequate follow-up is arranged – families must understand the importance of monitoring and have clear instructions on when to seek urgent care 3.

Family Counseling

• Explain that asymptomatic diverticula can often be safely observed with appropriate monitoring 1, 2.
• Discuss warning signs that should prompt immediate medical attention (fever, difficulty urinating, visible swelling changes) 2.
• Emphasize that surgical intervention may become necessary if complications develop, but is not required at this time 1, 2.
• Ensure parents understand the follow-up schedule and have access to care if concerns arise 3.