Female urethral diverticulum with calculus

Clinical History

A 45-year-old female patient presented with complaints of repeated episodes of dysuria, recurrent abdominal pain, obstructive voiding symptoms and a feeling of incomplete bladder emptying. There was also a history of 2-3 episodes of haematuria in the past 6 months.

Imaging Findings

Initially, no abnormalities were found at abdominal ultrasound, except for postmicturition bladder residue. On a plain X-ray, an opacity projected at the level of pubic symphysis (Fig. 1). A transperineal ultrasound performed with an endovaginal transducer demonstrated a calculus of 24 mm diameter in the urethra (Fig. 3). MCUG showed a urethral diverticulum with filling defect due to calculus (Fig. 2).

Discussion

The definition of a diverticulum is a pouch or sac occurring as a variant or by herniation of the mucosal membrane through a defect in the muscular wall of a tubular organ. A urethral diverticulum by definition is an outpouching from the urethra into the urethro-vaginal space. Studies have shown the incidence of urethral diverticulum ranging from 0.5% to 6% in women with recurrent lower urinary tract infections [1]. Complication by a calculus can be expected in 5%-10% of the cases [2].
The common presenting complaints of urethral diverticulum include dysuria, recurrent urinary tract infections, cystitis, postvoiding dribbling, dyspareunia, haematuria and symptoms related to incomplete evacuation of bladder [3]. Urethral diverticulum should be suspected in all women presenting with one of or a combination of these symptoms, in particular those not responding to appropriate symptomatic treatment [4]. The clinical features and physical findings of a urethral diverticulum vary widely and depend on the size and site of the diverticulum. In addition, antibiotic therapy can interfere with the features [5]. Infection, inflammation, calculi, neoplasia and urinary incontinence are complications of urethral diverticulum [6]. Urinary stasis and deposition of salts are causative factors for calculus formation in urethral diverticulum [7]. Urethral calculi are classified into native or migratory depending on whether they have formed in the urethra or descended from the kidney or bladder. The diagnosis of urethral diverticulum with or without calculus can be obtained by all imaging modalities, including plain X-rays, ultrasound, CT and MRI. Some urologists still prefer micturition cystograms to evaluate the diverticulum. Two and three-dimensional reformatted CT images may show the presence of diverticulum and diverticular orifice [8]. Magnetic resonance imaging has become the modality of choice to confirm the presence of a diverticulum, to evaluate the size and its complications [9]. The management of diverticulum includes the treatment of urinary tract infections, and symptomatic relief of symptoms. The curative treatment involves surgical excision of the diverticulum [10].

Differential Diagnosis List

Final Diagnosis

Female urethral diverticulum complicated with calculus

URL:	https://www.eurorad.org/case/13795
DOI:	10.1594/EURORAD/CASE.13795
ISSN:	1563-4086