QUEBEC CITY, Que. Speaking here at Urogynecology Quebec 2007, Dr. J. Christian Winters reviewed the differential diagnosis of urethral and periurethral masses. Dr. Winters, who is professor and chairman at Louisiana State University Health Sciences Center, New Orleans, LA, described the following:
1. Vaginal leiomyoma
A benign mesenchymal tumor of the vaginal wall arising from smooth muscle, vaginal leiomyoma usually presents as a smooth, firm mass on the anterior vaginal wall. With only 300 cases reported to date, the true incidence of this tumor remains unknown. These estrogen-dependent masses may be asymptomatic or can cause obstruction, leading to pain and dyspareunia. Curative treatment is by excision using a transvaginal approach.
2. Skene’s gland cysts
These small, cystic masses lateral or interolateral to the urethral meatus can become infected and exquisitely tender. They are often mistaken for a diverticulum, said Dr. Winters. “Larger Skene’s gland masses may actually require marsupialization, aspiration or incision and drainage due to extensive infection,” he noted. While excision is the treatment of choice in less complicated cases, entry into the distal urethra is not uncommon during excision even though these masses don’t communicate with the urethra. Reports of adenocarcinoma associated with a Skene’s gland cystic mass are extremely rare.
3. Vaginal wall cysts
Vaginal wall cysts can arise from multiple cell-type origins and usually present as small asymptomatic masses on the anterior vaginal wall. When sufficiently enlarged, they can cause local symptoms. Diagnosis is made after excision and pathologic confirmation.
4. Urethral mucosal prolapse
These lesions, which don’t represent a true prolapse of the distal urethra, present as a red, engorged circumferential or donut-shaped lesion that completely surrounds the urethral meatus. The mass may be asymptomatic or cause bleeding, pain or local urinary symptoms, and require treatment.
Urethral mucosal prolapse is most commonly diagnosed in postmenopausal women possibly aggravated by an estrogen deficiency and in prepubertal girls as a result of a deficiency of the muscular attachments of the urethral smooth muscle, possibly aggravated by Valsalva maneuvers or chronic constipation.
Topical application of estrogen cream and warm baths may reduce inflammation, noted Dr. Winters. And while there are a number of ways to accomplish removal of urethral prolapse, including cauterization techniques and ligation, the preferred method is simple circumferential excision with suture re-approximation of the urethral mucosa with or without an in-dwelling catheter.
5. Urethral caruncle
This inflammatory condition of the distal urethra usually presents as an engorged exophytic mass at the urethral meatus. Thought to be etiologically related to urethral prolapse, it doesn’t represent a true prolapse of the distal urethra, noted Dr. Winters. “Chronic inflammation can be associated with hemorrhage, swelling, edema and this inflamed tissue may expand from the urethral meatus due to already weakened muscular and connective tissue.”
Observation and reassurance and/or treatment with topical estrogen is usually sufficient for most asymptomatic cases; larger, symptomatic lesions can be easily excised. “Traction on the caruncle will expose the base,” said Dr. Winters, “below which it can be excised. Re-approximation of the mucosa can then follow with fine absorbable suture.”
6. Urethral diverticula
This epithelial-lined, sac-like out-pouching that arises from the urethral wall is usually acquired. However, in some instances, it may be congenital. Since many small diverticuli are thought to go undetected, the true incidence is not known.
An infection or obstruction of the periurethral glands can lead to the formation of a periurethral cyst, which gradually enlarges, and ruptures into the urethral wall. Urine gets trapped in the cyst where it pools. Epithethelization then transforms the cyst into a diverticulum. Infection can cause recurrent UTI, stone formation, the development of fistulae and in rare cases, malignancy.
Be aware, noted Dr. Winters, that the classic triad of dysurea, dribbling and dyspareunia is not always seen. In fact, up to 30% of women are asymptomatic. Instead, be highly suspicious of diverticuli in any female patient with a history of recurrent UTI or dyspareunia. Symptoms of a vaginal mass, vaginal pain or persistent OUTS may also be associated with diverticuli.
During physical examination, compression of a suburethral mass may result in the appearance of urine or purulent fluid exiting the urethral meatus “if you’re lucky,” said Dr. Winters. More often, however, this finding is not present.
Imaging can assist in the detection of diverticuli, and it is important to localize and stage diverticuli prior to surgery. Although positive-pressure urethrography is associated with a sensitivity of 85-100%, Dr. Winters said he is no longer doing this in his practice “….because I certainly wouldn’t want this done to me.”
Transvaginal ultrasonography has a reported sensitivity of greater than 90%, but it is an imaging modality that is highly operator-dependent, noted Dr. Winters. Instead, he favours MRI since it permits a non-invasive, high resolution and multi-planar imaging study of diverticuli with the best anatomic detail and diagnostic accuracy. “MRI has become the gold standard,” said Dr. Winters. “When I go in I know the location and extent of the diverticuli and can map surgical repair. It makes me a better surgeon.”
For women with incontinence, pelvic pain, urinary urgency and incomplete emptying, urodynamics will help determine whether the source of incontinence is bladder neck opening and leakage, for instance, or a diverticulum.
“Ganabathi et al reported that only 37% of women with diverticuli had normal urodynamics, 49% had stress incontinence and 10% had detrusor overactivity,” said Dr. Winters. “These findings are important as several authors have documented the safety and efficacy of performing a simultaneous anti-incontinence procedure with a diverticulectomy.”
Transvaginal urethral diverticulectomy can be performed in conjunction with an anti-incontinence procedure with an autologous pubovaginal sling. Steer clear of synthetic slings in this population, said Dr. Winters. The sling should be positioned outside the periurethral fascia before closing the urethra, he said.