Excision of Urethral Diverticulum
Urethra = the tube through which one urinates
Diverticulum = an out pouching or small pocket due to a defect in the wall of the urethra
Urethral diverticula are far more common in women than in men. Their exact cause is unknown but may include one or a combination of infections in urethral glands, trauma from childbirth, or prior disposition from congenital (born with) defects in the wall of the urethra. The symptoms may be any one or a combination of chronic (persistent) or recurrent urinary tract infections (UTIs), symptoms that mimic infection, dyspareunia (painful intercourse),discharge of pus from the urethra, or post-void (after urination) dribbling of urine. Because urine pools (sits at the bottom) in a diverticulum, the urine may grow bacteria and become a constant source of irritation and infection. The most common symptoms of urinary tract infections are:
- urinary frequency
- urinary urgency (a frequent sensation of a need to urinate or a need to get to the bathroom quickly)
- dysuria (burning with urination)
A urethral diverticulum is an anatomic defect, and so surgery may be necessary if a patient is symptomatic from its presence and does not respond to antibiotic therapy. The diagnosis of adiverticulum may be easy if it is large and tender. In this instance, the urologist may feel it during a pelvic examination. Often the urethra is very tender and may express discharge when a finger is pushing up on it. When it is not as apparent, but there is suspicion, a special type of contrast (dye) x-ray called a urethrogram may confirm its presence. A urethrogram involves a catheter in the urethra with injection of a dye in the catheter. Sometimes, a highly specialized test called an MRI (magnetic resonance imaging) can confirm the diagnosis. Occasionally, cystoscopy (looking in the urethra with a small telescope) is helpful. In many instances all tests are negative, and only the patient's symptoms and the urologist's suspicion will suggest the diagnosis.
There is no particular preparation for this procedure.
As with any procedure in which anesthesia is administered,
you will be asked not to eat or drink anything after
midnight on the evening prior to your surgery. You may
brush your teeth in the morning but not swallow the water.
If you are on medications that must be taken, you will
have discussed this with us and/or the anesthesiologist
and instructions will have been given to you. The procedure
will not be performed if you are currently taking, or
have recently taken any medication that may interfere
with your ability to clot your blood ("blood thinners,
aspirin, anti-inflammatory medicines, etc."). The
most common of these medications are aspirin and all
related pain relievers or anti-inflammatory compounds
(whether prescription or over-the-counter).
Please refer to the attached list and tell us if you took any of these within the past ten days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.
*It is usually to your advantage not to strain to have a bowel movement in the week after the procedure. We recommend that for the entire week before the procedure, you avoid constipating foods such as rice, bananas, and red meat. You should be eating lots of fruits and vegetables as well as oatmeal and cereals. If you have a known problem of constipation, you should administer an enema one hour before bed the night before your procedure.
To review the basics of what we discussed in the office: The actual procedure usually takes one to two hours. The procedure can be done under general anesthesia (complete sleep), a spinal (numb from the waist down), sedation (near complete sleep), and often with just local anesthesia (injection of numbing medicine directly into the operative area). The anesthetic type will depend on your preference as well as on the suggestion of the surgeon.
You will be placed in the lithotomy position (lying down on your back with your legs fairly elevated in holsters called stirrups). Prior to beginning, we may want to repeat the urethrogram (special x-ray using injection of contrast dye into the urethra) to re-establish the exact location of the diverticulum. A catheter is then placed into the bladder so that it can act as a guide to the urethral surgery. There are times in which the urologist may decide to place a suprapubic tube (tube in the bladder that is placed through a small hole in the lower abdomen) as well. This is often done when: the diverticulum is very large, proximal (closer to the bladder than to the far end of the urethra), associated with significantly infected tissue, or is an operation for a recurrence of the diverticulum.
A diverticulectomy (removal of the diverticulum) is most commonly done through a small incision directly over the diverticulum. Dissection is performed so that the entire wall of the diverticulum is separated from the normal healthy surrounding urethral tissue. Once the diverticulum is excised, the urethra and overlying tissue (in most cases the vaginal tissue since this procedure is so rarely done in men), are sutured together in overlapping layers. A catheter is left in the bladder so that urine does not flow past the surgical area for several days to a couple of weeks depending on the particular circumstances. In some instances, a gauze packing is placed in the vagina as well. It can be removed the following day or two by you (if at home)if directed by your physician. If you are admitted to the hospital, it may be removed by one of the doctors or nurses.
If during the surgery the tissue appears unhealthy or thin, it may be necessary to use healthy tissue from a nearby area of the body in the repair of the urethra. The most common tissue used is fat tissue from the labia majora (outer vaginal lip). This is brought over from an incision in the labia.
After the procedure, you will be in the recovery room until you are ready to be discharged home. It is less common to require hospital admission. It is normal for you to feel a sense of urgency to urinate. This is from the procedure and from the presence of the catheter. In most patients this goes away within a couple of hours, but could last until the catheter is removed.
The catheter may remain for up to a week depending on the size of the diverticulum, the quality of the tissue sutured, and your surgeon's preference. Some patients require medication to help relax the bladder while the catheter is in. It will be connected to a small bag that can be strapped to your leg and easily concealed under your clothing. You will be shown how to empty the catheter bag. You may also be given a larger bag to attach to the catheter for overnight drainage while you are sleeping. We assure you that it is quite simple.
There may be some blood staining, and so you are encouraged to wear protective liners or pads for a few days. The urine is usually clear, but do not be surprised if it is slightly blood-tinged in the first few days. You may shower but no bathing or swimming for at least one week (unless otherwise indicated). Some surgeons will instruct you to take warm baths a couple of times per day a few days after the surgery. We ask that you refrain from very strenuous activity until your follow-up office visit. You might be a bit sore for a couple of days and so when you sit, you may want to put a soft pillow down on the chair.
*You must refrain from any type of sexual activity until otherwise instructed.
We strongly encourage you to take a few days off from work and perhaps more if your occupation requires strenuous activity or heavy lifting. We may provide you with a prescription for pain medication although significant pain is unusual. An antibiotic prescription may also be given and should be taken until completion. If any side-effects occur, contact our office immediately.
We use absorbable (self-dissolving) suture material and so there are no sutures to remove. They will break and fall out or dissolve on their own within 2-3 weeks.
Expectations of Outcome
Diverticulectomy is usually a successful operation. if the entire diverticulum is excised, it rarely recurs. Some diverticula are quite extensive (occupying a long segment of the urethra or encircling the entire urethra) or associated with grossly inflamed or infected adjacent tissues. In these cases. the repair could be unexpectedly more complex and require tissue flaps or staged procedures (more than one time n the operating room). These cases can sometimes require an unexpected hospital admission, and are usually associated with higher complication rates.
Persistence of the symptoms for a few days or longer after the catheter is removed is not uncommon. It is due to the swelling from the surgery and the presence of the catheter. In other words, you may still have urinary frequency, urgency and some burning.
Possible Complications of the Procedure
ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:
- Urinary Tract Infection or Sepsis: Although we may give you antibiotics prior to and after the operation, it is still possible for you to get an infection. The most common type is a simple bladder infection (after the catheter is removed) that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you might feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may require a short hospitalization for intravenous antibiotics, fluids, and observation. This problem is more common in diabetics, patients on long-term steroids, or patients with disorders of the immune system. Wound Infection: The incision sites can become infected. While it typically resolves with antibiotics and local wound care, occasionally, part or all of the incision may open and require revision and or catheter replacement.
*If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.
- Recurrent Diverticulum: This is rare. When present, it may also represent a new diverticulum. In either instance, a second procedure may be necessary.
- Urethral Stenosis or Stricture: When the urethra is closed in layers, we attempt to keep the urethral width a certain size. Over time, however, the area can scar down and cause an obstruction to urine flow. If significant, a one-time, or even periodic, office dilatation (spreading) could be necessary. It would be quite unusual (but possible) to require a surgical procedure to open the urethral channel.
- Vesicovaginal Fistula: If the diverticulum was large or the surrounding tissue thin or unhealthy, the sutured tissues could break down. If this happens, there would be a fistula (abnormal communicating channel or hole) between the urethra and the vagina. If the hole is proximal (closer to the bladder) to the sphincter, you could have a problem with leakage of urine (incontinence) until repaired at a later date. Usually, if the neck of the bladder is healthy, there would not be incontinence. A catheter in the urethra may be placed for an extended period of time.
- Urinary Incontinence: Urinary incontinence (the involuntary loss of urine) is rare after this surgery. If present before the operation, it is usually due to a pre-existing condition other than the diverticulum. After the surgery, however, it could be made worse when the diverticulum is extensive (occupying a long section of the urethra) or proximal (on the portion of the urethra that is close to the bladder neck). A secondary procedure could be necessary to correct this problem.
- Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): In any operation(especially longer operations), you can develop a clot in a vein of your leg (DVT).Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.
We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).
The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While Delta Medix endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. Delta Medix cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.
Delta Medix, P.C.