A 38-year-old woman, gravida 3 para 3, comes to the office due to a 2-week history of dysuria and pain on deep penetration during sexual intercourse. Urine dribbling has occurred after voiding for the past few months. The patient has no fever, chills, hematuria, nocturia, or increased urinary frequency. Her medical history is notable for multiple urinary tract infections. The patient has had a bilateral tubal ligation and a laparoscopic appendectomy. Her last menstrual period was 2 weeks ago; menses are regular and last 4 days. The patient's last pregnancy was 4 years ago; all pregnancies resulted in uncomplicated term vaginal deliveries. She does not use tobacco, alcohol, or illicit drugs. The patient has no known drug allergies. Temperature is 36.7 C (98 F) , blood pressure is 120/80 mm Hg, and pulse is 78/min. BMI is 23 kg/m². The abdomen is soft and nontender, with no palpable masses or hepatosplenomegaly. There is no costovertebral angle tenderness. Pelvic examination reveals fullness at the anterior vaginal wall. The uterus is small, mobile, and nontender; there are no adnexal masses. Laboratory results are as follows:

Which of the following is the most likely diagnosis for this patient?

Question

A 38-year-old woman, gravida 3 para 3, comes to the office due to a 2-week history of dysuria and pain on deep penetration during sexual intercourse. Urine dribbling has occurred after voiding for the past few months. The patient has no fever, chills, hematuria, nocturia, or increased urinary frequency. Her medical history is notable for multiple urinary tract infections. The patient has had a bilateral tubal ligation and a laparoscopic appendectomy. Her last menstrual period was 2 weeks ago; menses are regular and last 4 days. The patient's last pregnancy was 4 years ago; all pregnancies resulted in uncomplicated term vaginal deliveries. She does not use tobacco, alcohol, or illicit drugs. The patient has no known drug allergies. Temperature is 36.7 C (98 F) , blood pressure is 120/80 mm Hg, and pulse is 78/min. BMI is 23 kg/m². The abdomen is soft and nontender, with no palpable masses or hepatosplenomegaly. There is no costovertebral angle tenderness. Pelvic examination reveals fullness at the anterior vaginal wall. The uterus is small, mobile, and nontender; there are no adnexal masses. Laboratory results are as follows:

Which of the following is the most likely diagnosis for this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1c7_cd64_8f63_2b5330ea496c_MD0005_00 Urethral diverticulum typically presents with dysuria, postvoid dribbling, dyspareunia, and an anterior vaginal mass. The diverticulum is a herniation of the urethral mucosa through the muscle wall into the surrounding tissue. Urethral diverticula in women form due to repeated infection, inflammation, and trauma of the urethra from previous pelvic trauma (eg, vaginal delivery) or surgery. Symptoms typically develop due to infection and distension of the diverticulum with purulent fluid. Hematuria, recurrent urinary tract infections, and stress urinary incontinence are also associated with urethral diverticula. Physical examination typically reveals a tender anterior wall vaginal mass that expresses bloody, purulent fluid on manipulation of the urethra. (Choice A) Endometriosis, endometrial gland implantation outside the uterus, may present with deep dyspareunia but does not typically have associated urinary symptoms. Symptoms do include dysmenorrhea and dyschezia. Physical examination typically reveals an immobile uterus, tender adnexal mass (eg, endometrioma), and nodularity along the posterior cul-de-sac, which are not present in this patient. (Choice B) Pelvic inflammatory disease is a complication of untreated Chlamydia trachomatis or Neisseria gonorrhoeae infection, resulting in polymicrobial infection of the upper reproductive tract (eg, uterus, fallopian tubes). This condition presents with fever, dyspareunia, abdominopelvic pain, mucopurulent cervical discharge, and cervical motion tenderness (eg, chandelier sign). (Choice C) A posterior urethral valve is a congenital malformation that obstructs the flow of urine; its typical presentation includes recurrent urinary tract infections, incontinence, strained voiding, and bilateral hydronephrosis. This malformation is most common in male infants. posterior urethral valve (Choice D) Stress urinary incontinence is characterized by loss of urine with increased intraabdominal pressure (eg, Valsalva maneuver). There is no associated dysuria, dyspareunia, or vaginal wall mass. Educational objective: Urethral diverticulum presents with postvoid dribbling, dysuria, dyspareunia, and an anterior vaginal wall mass on pelvic examination. References: Presentation of female urethral diverticulum is usually not typical. (http://www.ncbi.nlm.nih.gov/pubmed/18204232) A tertiary experience of urethral diverticulectomy: diagnosis, imaging and surgical outcomes. (http://www.ncbi.nlm.nih.gov/pubmed/19191783)

A 38-Year-Old Woman, Gravida 3 Para 3, Comes to the Office