A 54-year-old woman, gravida 2 para 2, comes to the office for evaluation of leakage of urine. Over the past 2 years, the patient has had increasingly frequent involuntary loss of urine and now wears a sanitary napkin to prevent urine from dribbling on her clothes after she voids. For the past week, she has had burning with urination but no frequency or urgency. In the last year, the patient has had 3 urinary tract infections that were treated with antibiotics. The patient had 2 term vaginal deliveries in her 30s. She has no chronic medical conditions and has had no prior surgeries. Blood pressure is 118/64 mm Hg and pulse is 82/min. BMI is 33 kg/m². On pelvic examination, the patient does not leak urine with Valsalva and the vagina is dry and atrophic. A 2-cm tender anterior vaginal mass is palpable and causes expression of a bloody discharge at the urethral meatus. Postvoid residual is 50 mL. Which of the following is the most likely cause of this patient's symptoms?

Question

Quizplus · Accepted Answer

11ec25c8_d9e7_3d9a_bc81_c3aa9419aaa9_MD0003_00 This patient has a urethral diverticulum, an abnormal localized urethral mucosa due to recurrent periurethral gland infection along the anterior vaginal wall. The recurrent infection and inflammation of the urethral tissue creates the abnormal outpouching that can collect and store urine, resulting in postvoid dribbling and recurrent lower urinary tract infections (eg, dysuria). Infection of the urethral diverticulum can also result in tenderness, often presenting as dyspareunia or a tender anterior vaginal wall mass with an associated expressed purulent or bloody urethral discharge. Diagnosis is confirmed with a pelvic MRI, and treatment is via surgical excision of the diverticulum. urethral diverticulum (Choice A) Vesicovaginal fistula, an abnormal tract between the bladder and vagina, typically presents with constant, rather than intermittent, leakage of urine due to continuous drainage of the bladder into the vagina. In addition, there is no associated anterior vaginal wall mass or purulent urethral discharge. Vesicovaginal fistula (Choice B) Acute infection of the lower urinary tract (ie, cystitis, urethritis) can cause dysuria and urinary incontinence; however, patients often also have urgency, frequency, and no tender anterior vaginal wall mass. (Choice C) Stress urinary incontinence, caused by hypermobility of the urethra and bladder neck, is common in multiparous and obese patients, such as this one. Patients typically have urinary leakage with increased intraabdominal pressure (eg, Valsalva), which is not seen in this case. (Choice D) Overflow incontinence, which is due to impaired bladder detrusor contractility, can occur in postmenopausal women. Patients typically have constant dribbling of urine from incomplete bladder emptying and chronic urinary retention (ie, overflow). This diagnosis is unlikely because this patient has a normal postvoid residual (ie, no retention). Educational objective: A urethral diverticulum is an abnormal localized outpouching of the urethral mucosa that can collect urine, resulting in inflammation of the surrounding tissue. Patients often exhibit dysuria, postvoid dribbling, dyspareunia, and a tender anterior vaginal wall mass that expresses a purulent or bloody urethral discharge. References: Female urethral diverticulum: presentation, diagnosis, and predictors of outcomes after surgery. (http://www.ncbi.nlm.nih.gov/pubmed/27636213) Female urethral diverticula in the contemporary era: is the classic triad of the "3Ds" still relevant? (http://www.ncbi.nlm.nih.gov/pubmed/27079128) Female urethral diverticulum: current diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/26267225)

A 54-Year-Old Woman, Gravida 2 Para 2, Comes to the Office