Mugdha Kulkarni and Anna Rosamilia Benign urethral and vaginal lesions are commonly encountered in the urogynaecology clinic setting. With the advent of ambulatory urogynaecology many of these conditions can be managed as day care procedures. This chapter will cover some of the common benign urethral and vaginal lesions: urethral caruncle, urethral prolapse, urethral diverticulum, urethral fistula, Skene’s duct cyst, Bartholin’s cyst, Gartner’s duct cyst, and periurethral lesions. It is beyond the scope of this chapter to cover any malignant lesions. A review of the embryology and anatomy of the urethra and vagina helps to understand the pathology and management of urethral and vaginal lesions. The caudal portion of the vesicourethral canal forms the female urethra. It is 3–5 cm long and about 5–7 mm in diameter. The urethra is embedded in the adventitia of the anterior vaginal wall, perforates the perineal membrane and ends with the external orifice in the vestibule above the vaginal opening. The urethra has intrinsic and extrinsic sphincter mechanisms which aid in maintaining continence. Urethral smooth muscles, along with the detrusor from the bladder base form the intrinsic sphincter. The extrinsic sphincter is composed of two portions: the inner portion of striated muscles within and adjacent to the urethral wall and the outer portion of skeletal muscle fibres of the pelvic diaphragm. The urethra is surrounded by multiple periurethral ducts and glands. Skene’s glands are adjacent to the distal urethra and are the largest. The urethra lies in close proximity to the vagina. Vaginal epithelium is lined by loose connective tissue called lamina propria and does not contain any glands. Vaginal lubrication occurs as a transudate from vessels, cervix, and the Bartholin’s and Skene’s glands. A urethral caruncle is the most common female urethral lesion and is usually seen in post‐menopausal women. It is a benign condition resulting from the eversion of the distal portion of the posterior urethral meatus. A caruncle is usually small, soft, smooth or friable, and bright pink to dark. Usually single, it can be pedunculated and grow up to 1–2 cm long. Histologically, a caruncle contains blood vessels, loose connective tissue and is covered by urothelium and squamous epithelium. The pathogenesis of a urethral caruncle is not clearly understood. It is thought to result from oestrogen deficiency in the postmenopausal woman leading to atrophy of urothelium and retraction of the vagina. Most women are asymptomatic and caruncles are usually an incidental finding on genital examination. Though most often seen in postmenopausal women, it can also occur in premenopausal and prepubertal girls. Symptoms described have been that of a lump, bleeding, dysuria, and pain. A study looked at the effects of asymptomatic caruncles on micturition and found that 6%of women who presented with urinary incontinence were noted to have caruncles, but there was no effect on micturition when caruncles measured<1 cm. However, some sources have reported voiding dysfunction in association with a caruncle. Diagnosis is clinical and based on the characteristic appearance of a pink, soft, sessile or pedunculated mass protruding from the urethral meatus, usually on the posterior aspect. Biopsy is not necessary unless diagnosis is uncertain or if there is a suspicion of malignancy. There are no large studies or randomised controlled trials (RCTs) evaluating various treatment strategies. Asymptomatic women do not require treatment. A conservative approach with regular clinical observation or self‐observation is suggested. In women who are symptomatic, initial management is topical oestrogen cream for two to three months. In cases of large, persistent lesions, speciality referral to a urogynaecologist or urologist should be considered. If initial therapy of topical oestrogen fails, surgical treatment can be offered. Surgical treatment involves initial cystourethroscopy to assess the urethra and bladder, followed by catheterisation. Removal of a caruncle is either by excision and ligation or diathermy of the base under local or general anaesthesia. Following the procedure, the patient can be discharged home with an indwelling catheter for planned removal in the next 24–48 hours. Risks associated with the procedure include bleeding or rarely external urethral meatal stenosis. Urethral prolapse is uncommon and defined as eversion of the urethral mucosa circumferentially through the distal urethra. It is usually seen in prepubertal and postmenopausal women. One theory suggests that prolapse occurs as a result of separation of the two muscular layers of the urethra, which can be congenital or acquired. Other theories are similar to the one proposed for urethral caruncle, based on a lack of oestrogen leading to urothelium atrophy and retraction of the vaginal epithelium. This also fits with the bimodal age distribution. Urethral prolapse can also occur as a consequence of obstetric trauma. Prepubertal girls are usually asymptomatic and this is an incidental finding on examination. The most common symptom is vaginal bleeding along with a urethral mass. In contrast, postmenopausal women are often symptomatic with vaginal bleeding and voiding symptoms being a common presentation. Diagnosis is by clinical examination. The urethral prolapse appears as a circumferential, small doughnut shaped mass protruding from the anterior vaginal wall with the external urethral meatus in the middle (Figure 9.1). It can be erythematous, congested, infected, or even ulcerated. Postmenopausal women are usually treated initially with topical oestrogen therapy, but if unresponsive or large, surgical excision should be considered. Excisional biopsy should be considered and is mandatory if malignancy is suspected. Surgical excision is indicated for young symptomatic patients and for recurrent urethral prolapse. An indwelling Foley catheter at the beginning of the procedure is helpful, though it may be difficult to place it when tissue is oedematous. The prolapsed mucosal tissue is excised using scissors or cautery in a circumferential manner. Using stay sutures around the mucosa at 12, 3, and 9 o’clock position during the excision helps in traction and prevents the mucosal edge from retracting. The urethral mucosa and the vaginal tissue edges are approximated with interrupted sutures as the excision proceeds from anterior to posterior with 4–0 vicryl. The catheter is left in place for 24 hours but patients can be discharged home the same day, with adequate analgesia. Figure 9.1 Urethral prolapse. A urethral diverticulum is the localised outpouching of the urethral mucosa into the surrounding non‐urothelial tissues (Figure 9.2). This is a relatively uncommon condition and it is difficult to estimate its true prevalence due to the difficulty in diagnosis. Prevalence reported on basis of a urethrography series is 1–5%. Urethral diverticula can be congenital or acquired. The congenital diverticulae are thought to be remnants of the Gartner’s duct, but most are likely to be acquired rather than congenital. The proposed theory is that the diverticulum develops as a result of chronic infection of periurethral glands. This subsequently leads to obstruction and enlargement of glands and abscess formation. Once this abscess ruptures into the urethral lumen, it leads to a communication between the two forming a diverticulum. Various studies have supported this theory, finding chronic inflammation on histology that results in fibrosis within and surrounding the diverticulum. Other theories proposed are trauma or injury during childbirth or vaginal and urethral surgery. A diverticular opening into the urethra from a small diverticulum is usually via a single ostium but it is not unusual to find multiple ostia and loculated diverticulae. Figure 9.2 Urethral diverticulum on cystoscopy. The symptoms are highly variable. The most common symptoms are lower urinary tract complaints of frequency and urgency, in addition to recurrent urinary tract infections and dysuria. The classic triad of dyspareunia, post‐micturition dribble, and dysuria are seen in approximately 35% of patients. Haematuria, urinary incontinence, vaginal mass, vaginal pain, discharge, and urinary retention can be other symptoms of an urethral diverticulum. Diagnosis requires a high index of suspicion. Apart from history, a thorough physical examination is essential because, in most cases, there will be a palpable mass in the sub‐urethral region in the anterior vaginal wall. Diverticulae are usually present in the distal or middle portion of the posterior aspect of the urethra, about 2–3 cm proximal to the urethral opening. The pathognomonic finding of urethral discharge expressed by pressure on the suburethral mass is present in only 25% of cases. The mass is usually soft but can be firm to hard in the presence of a calculus or malignant change.
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Common Urethral and Vaginal Lesions in Ambulatory Urogynaecology
Introduction
Embryology and Anatomy of Urethra
Benign Urethral Lesions
Urethral Caruncle
Urethral Prolapse
Urethral Diverticulum
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