Double balloon positive pressure urethrography is a more sensitive test than voiding cystourethrography for diagnosing urethral diverticulum in women

PURPOSE: We determined the relative sensitivity of double balloon positive pressure urethrography and voiding cystourethrography for diagnosing urethral diverticula in women, and for evaluating which presenting symptoms should be considered clinically suspicious for even smaller diverticula.

MATERIALS AND METHODS: The series comprised 32 women, including those with new onset urinary tract infections not related to intercourse, menopause or catheters, those with urethral symptoms, such as point urethral tenderness or a mass, urethral pain, dysuria, dyspareunia or post-void dribbling, and those with new onset urgency and frequency. All patients underwent a history and physical examination by the same physician. Each patient underwent double balloon urethrography and voiding cystourethrography on the same day at a single radiology department.

RESULTS: Of the 32 women 30 (94%) were diagnosed with at least 1 diverticulum by double balloon urethrography. In 22 of these cases voiding cystourethrography failed to show the diverticulum. Only 11 of these patients (37%) had a palpable mass on clinical examination. The most common presenting symptoms in patients diagnosed with a diverticulum were recurrent urinary tract infection (52%), dysuria (52%), urgency (41%), frequency (38%), stress incontinence (38%) and urge incontinence (34%). Only 3 patients (9%) presented with 1 symptom. Diverticulectomy was performed in 16 patients. Double balloon urethrography had greater sensitivity (100%) than voiding cystourethrography (44%) relative to a confirmed surgical diagnosis (z test p = 0.002). Of 9 diverticula missed by voiding cystourethrography in the surgery group the maximum diameter was less than 15 mm. in 5. Average followup in the surgery cases is 34 months (median 35, range 17 to 50). None of these patients has had new symptoms suggestive of recurrent diverticulum, failure, new urethritis or new stress urinary incontinence. Conservative therapy consisted of long-term antibiotics in 6 patients and symptomatic treatment with short-term antibiotics in the remaining 8. Conservative therapy offered symptomatic relief in most cases but did not prevent recurrent symptoms.

CONCLUSIONS: A diverticulum should be suspected in patients with new onset urinary tract infection, urgency and frequency as well as dyspareunia, post-void dribbling and dysuria. Double balloon urethrography is a more sensitive diagnostic test than voiding cystourethrography for diagnosing urethral diverticula. Patients with mild symptoms may be treated with conservative therapy, although we believe that satisfactory long-term treatment of diverticula is best achieved by surgical excision.