Vol. XXIII, No.5 Printed in U.S.A.
Journal of the American Geriatrics Society Copyright © 1975 by the American Geriatrics Society
Anterior Urethral Diverticulum in the Male: Report of Two Cases BARTON TANENBAUM, MD* AND MILTON E. KLINGER, MDt
Jewish Hospital and Medical Center of Brooklyn, NY ABSTRACT: Anterior urethral diverticulum in the male is relatively uncommon; 2 additional cases are presented. One of the patients had a unique fusiform dilatation of the urethra, the first to be reported in an adult as an acquired diverticulum. Features distinguishing acquired from congenital urethral diverticula are discussed. operative period the patient's temperature rose as high as 103 0 F in a spiking pattern. E. coli was cultured from the urine. The catheter was removed on the fifth postoperative day and the fever promptly disappeared. The pathology report was: prostate gland with fibromuscular and adenomatous hyperplasia, focal nonspecific inflammation, and several fragments containing foci of adenocarcinoma, grade I. To ascertain whether additional carcinomatous tissue was present in the gland, transrectal biopsy with four-quadrant transurethral biopsy of the prostate was performed. No carcinoma was found. Once more the fever spiked to 103.60 F, and subsided upon removal of the Foley catheter. The patient was discharged without further therapy. Urinary control was only fair. He was seen in the clinic once and failed to keep further appointments. He came to the emergency room on May 14, 1971 with a fever of 107 0 F (rectal). He complained of vomiting, diffuse abdominal pain's and distention. Paralytic ileus was suspected. A urinary-tract infection (Proteus) was found, and cystoscopy revealed a rigid bladder neck. Bladder neck resection was performed. Dribbling of urine persisted after discharge on June 18, 1971. At a clinic follow-up visit, E. coli was found in the urine. He claimed improved urinary control, though dribbling was evident by his wet pants. On August 15, 1971, he was readmitted for the third time, with a fever of 106.6° F (rectal). He complained of abdominal pains and vomiting. Proteus was cultured from both blood and urine. He was treated with cephalo-
Diverticulum of the anterior male urethra is an uncommon disorder, only 236 cases being reported in the literature up to 1955 (1, 2) and 55 cases subsequently (3-17). This report concerns the diagnosis and treatment of 2 additional cases. CASE REPORTS
Case 1 A 60-year-old Negro male was admitted for the first time to the Jewish Hospital and Medical Center of Brooklyn on July 13, 1970, with acute urinary retention. In the emergency room neither a urethral catheter nor a filiform bougie could be advanced beyond the midportion of the penile urethra. A mass was palpated at that point in the urethra. As it was suspected that a urethral calculus was occluding the passage, a urethrotomy was performed. No calculus was found and a #16 Foley catheter was passed with ease to decompress the bladder. An intravenous pyelogram demonstrated a normal upper urinary tract, but there was a large prostatic impression at the base of the bladder. An electrocardiogram revealed left ventricular hypertrophy and ischemic changes. Cystoscopic examination was followed by transurethral resection of the prostate. In the immediate post-
* Formerly Chief Resident, Urology, Jewish Hospital and Medical Center of Brooklyn. Present address: 435 North Roxbury Drive (Suite 102), Beverly Hills, CA 90210. t Chief, Division of Urology, Department of Surgery, Jewish Hospital and Medical Center of Brooklyn. 234
May 1975
URETHRAL DIVERTICULUM IN THE MALE
thin (Keflin) and catheter drainage. A "voiding" cystourethrogram demonstrated a urethral diverticulum in the midportion of the penile urethra. (Fig. 1, A and B). Urethral diverticulectomy was performed on September 3, 1971. Pseudomonas was cultured from the urine and responded to a course of gentamicin. At the time of his discharge on September 23,1971, he was continent on voiding. One week later, in the clinic, he voided with a good stream, demonstrating fair sphincteric control, and claimed to have only stress incontinence. He failed to return for clinic visits. Case
2
A 68-year-old white male was admitted to the Jewi~h Hospital and Medical Center of Brooklyn with nocturia and frequency. Examination of the prostate led to the suspicion of carcinoma. Intravenous pyelography showed a normal upper urinary tract. The laboratory data were unremarkable. The patient underwent a transurethral resection of the prostate. Pathologic examination of the tissue revealed carcinoma. Metastatic evaluation was undertaken but no distant tumor was detected. On the fourth postoperative day a radical perineal
prostatectomy was performed. The patient made a good recovery in the postoperative period and was discharged with a fair degree of urinary continence. Follow-up visits demonstrated good control of urination. Six months after discharge the patient was readmitted with dysuria and incontinence of recent onset. Physical examination revealed a mass at the root of the penis which extended in the midline for a short distance along the shaft. Palpation resulted in expression of fluid. A "voiding" cystourethrogram and a retrograde urethogram outlined a fusiform dilatation of the pendulous urethra. (Fig. 2, A and B). This lesion was explored and excised. It was found to extend from the bulbous urethra to the fossa navicularis. The postoperative course was uneventful and the patient was able to void without difficulty until the time of his death in April 1973 from metastatic prostatic carcinoma. DISCUSSION Anterior urethral diverticulum can be either congenital or acquired. The congenital type is most common in the first two decades of life whereas the acquired type is most common in the third and fourth decades. Acquired diver-
Fig. 1 (A and B). Note anterior urethral diverticulum (arrow) with narrow neck, as demonstrated by "voiding" cystourethrogram.
235
TANENBAUM AND KLINGER
Vol. XXIII
Fig. 2 (A and B). Fusiform dilatation of anterior urethra demonstrated by retrograde urethrogram (anteroposterior and oblique views).
ticula usually are located in the bulbous urethra whereas congenital diverticula are located in the pendulous urethra. Histologically, the congenital diverticulum is encompassed by the muscular coat of the urethra. The acquired type has a fibrous wall and mayor may not include a mucosal lining. The pathogenesis of the acquired anterior urethral diverticulum is related to obstruction, inflammation, injury or neurogenic dysfunction, whereas that of congenital diverticulum is related to either arrest or faulty development of the anterior urethra. The symptomatology varies, according to the degree of obstruction caused by the diverticulum. A mass may be noted, which on palpation releases urine or pus. Postmicturitional dribbling or urinary incontinence may be present. The diverticulum is apt to be infected, may contain calculi, and may rupture. Surgical excision of the diverticulum is the treatment of choice. Pate and Bunts (18), re-
236
porting on a series of paraplegic patients with urethral diverticula, suggested careful observation when the diverticulum is small and asymptomatic. Both of the cases reported here were evidently acquired. The first patient underwent a urethrotomy at the site of an indurated area induced perhaps by multiple attempts at catheterization or to relieve prior stricture formation. It is conceivable that a congenital diverticulum may have existed in that area, but it is unlikely to have been asymptomatic until the age of 60. The urethra was incised and an indwelling catheter was passed with ease to decompress the urinary bladder. The presence of an occult carcinoma and the careful observations undertaken in its therapy obscured the cause of the urinary incontinence. There were two admissions for urosepsis within a short period before the diagnosis was made. Diverticulectomy cured the patient's incontinence and forestalled further urinary-tract infection. ~
May 1975
URETHRAL DIVERTICULUM IN THE MALE
The second patient presented with a fusiform dilatation of the urethra, similar to the formation of a urethrocele or mega-urethra following a radical perineal prostatectomy. The urethra was dilated from the fossa navicularis to the bulb; there was no distal obstruction. It is tempting to relate this finding to the nerve interruption which occurs after radical perineal prostatectomy. Urethral plication effected a cure.
REFERENCES 1. Abeshouse BS: Diverticulum of the anterior urethra in the male: A report of four cases and a review of the literature, Urol & Cutan Rev 55: 690,1951. 2. Warren JW: Congenital diverticulum of the urethra, Amer Surgeon 21: 385,1955. 3. Edling NPG: The radiological appearances of diverticula of the male cavernous urethra, Acta Radiol 40: 1,1953. 4. Williams DI: Discussion of lower urinary obstruction, Arch Dis Child 37: 132,1962. 5. Goldberg HW and Grove JS: Acquired diverticulum of the male urethra with calculi formation, Chicago Med Sch Quart 24: 30,1964. 6. Mandler JI and Pool TL: Primary diverticulum of
the male urethra, J Urol 96: 336, 1966. 7. Maged A: Urethral diverticulum in males, Brit J Urol 37: 560,1965. 8. Boissonat P and Duhamel B: Congenital diverticulum of the anterior urethra associated with aplasia of the abdominal muscles in a male infant, Brit J Urol 34: 59,1962. 9. Demos NJ, Gillis DA and Barber KE: Congenital diverticulum of the anterior urethra in male infants: report of two cases, J Urol 88: 252, 1962. 10. Sweetser TH: Congenital urethral diverticulum in the male patient, J Urol 97: 93-95, 1967. 11. Williams DJ and Retik AB: Congenital valves and diverticula of the anterior urethra, Brit J Urol 41: 228,1968. 12. Goren N: Diverticulo de uretra masculina, Rev Argent Urol 27: 315, 1958. 13. Ouradou J and Gzenai M: Un cas de diverticule uretral chez un garcon de 11 ans, Maroc Med 39: 260,1960. 14. Moucha D: Volumineux diverticule urethral scrotal chez un garcon de deux ans, J Chir (Paris) 81: 581, 1961. 15. Padeira F: Un caso de diverticulo de uretra anterior, Acta Iber Radiol Cancerol 20: 123, 1964. 16. van Frank R: Un cas de diverticule de I'uretre masculin, Acta Urol Belg 32: 48, 1964. 17. Lemaitre G and Ramez J: Obstruction urinaire par diverticule de I'uretre anterieur, J Radiol d'Electr Med Nucl 45: 323, 1964. 18. Pate VA and Bunts RC: Urethral diverticula in paraplegics, J Uro165: 108,1951.
237
Journal of the American Geriatrics Society Copyright © 1975 by the American Geriatrics Society
Anterior Urethral Diverticulum in the Male: Report of Two Cases BARTON TANENBAUM, MD* AND MILTON E. KLINGER, MDt
Jewish Hospital and Medical Center of Brooklyn, NY ABSTRACT: Anterior urethral diverticulum in the male is relatively uncommon; 2 additional cases are presented. One of the patients had a unique fusiform dilatation of the urethra, the first to be reported in an adult as an acquired diverticulum. Features distinguishing acquired from congenital urethral diverticula are discussed. operative period the patient's temperature rose as high as 103 0 F in a spiking pattern. E. coli was cultured from the urine. The catheter was removed on the fifth postoperative day and the fever promptly disappeared. The pathology report was: prostate gland with fibromuscular and adenomatous hyperplasia, focal nonspecific inflammation, and several fragments containing foci of adenocarcinoma, grade I. To ascertain whether additional carcinomatous tissue was present in the gland, transrectal biopsy with four-quadrant transurethral biopsy of the prostate was performed. No carcinoma was found. Once more the fever spiked to 103.60 F, and subsided upon removal of the Foley catheter. The patient was discharged without further therapy. Urinary control was only fair. He was seen in the clinic once and failed to keep further appointments. He came to the emergency room on May 14, 1971 with a fever of 107 0 F (rectal). He complained of vomiting, diffuse abdominal pain's and distention. Paralytic ileus was suspected. A urinary-tract infection (Proteus) was found, and cystoscopy revealed a rigid bladder neck. Bladder neck resection was performed. Dribbling of urine persisted after discharge on June 18, 1971. At a clinic follow-up visit, E. coli was found in the urine. He claimed improved urinary control, though dribbling was evident by his wet pants. On August 15, 1971, he was readmitted for the third time, with a fever of 106.6° F (rectal). He complained of abdominal pains and vomiting. Proteus was cultured from both blood and urine. He was treated with cephalo-
Diverticulum of the anterior male urethra is an uncommon disorder, only 236 cases being reported in the literature up to 1955 (1, 2) and 55 cases subsequently (3-17). This report concerns the diagnosis and treatment of 2 additional cases. CASE REPORTS
Case 1 A 60-year-old Negro male was admitted for the first time to the Jewish Hospital and Medical Center of Brooklyn on July 13, 1970, with acute urinary retention. In the emergency room neither a urethral catheter nor a filiform bougie could be advanced beyond the midportion of the penile urethra. A mass was palpated at that point in the urethra. As it was suspected that a urethral calculus was occluding the passage, a urethrotomy was performed. No calculus was found and a #16 Foley catheter was passed with ease to decompress the bladder. An intravenous pyelogram demonstrated a normal upper urinary tract, but there was a large prostatic impression at the base of the bladder. An electrocardiogram revealed left ventricular hypertrophy and ischemic changes. Cystoscopic examination was followed by transurethral resection of the prostate. In the immediate post-
* Formerly Chief Resident, Urology, Jewish Hospital and Medical Center of Brooklyn. Present address: 435 North Roxbury Drive (Suite 102), Beverly Hills, CA 90210. t Chief, Division of Urology, Department of Surgery, Jewish Hospital and Medical Center of Brooklyn. 234
May 1975
URETHRAL DIVERTICULUM IN THE MALE
thin (Keflin) and catheter drainage. A "voiding" cystourethrogram demonstrated a urethral diverticulum in the midportion of the penile urethra. (Fig. 1, A and B). Urethral diverticulectomy was performed on September 3, 1971. Pseudomonas was cultured from the urine and responded to a course of gentamicin. At the time of his discharge on September 23,1971, he was continent on voiding. One week later, in the clinic, he voided with a good stream, demonstrating fair sphincteric control, and claimed to have only stress incontinence. He failed to return for clinic visits. Case
2
A 68-year-old white male was admitted to the Jewi~h Hospital and Medical Center of Brooklyn with nocturia and frequency. Examination of the prostate led to the suspicion of carcinoma. Intravenous pyelography showed a normal upper urinary tract. The laboratory data were unremarkable. The patient underwent a transurethral resection of the prostate. Pathologic examination of the tissue revealed carcinoma. Metastatic evaluation was undertaken but no distant tumor was detected. On the fourth postoperative day a radical perineal
prostatectomy was performed. The patient made a good recovery in the postoperative period and was discharged with a fair degree of urinary continence. Follow-up visits demonstrated good control of urination. Six months after discharge the patient was readmitted with dysuria and incontinence of recent onset. Physical examination revealed a mass at the root of the penis which extended in the midline for a short distance along the shaft. Palpation resulted in expression of fluid. A "voiding" cystourethrogram and a retrograde urethogram outlined a fusiform dilatation of the pendulous urethra. (Fig. 2, A and B). This lesion was explored and excised. It was found to extend from the bulbous urethra to the fossa navicularis. The postoperative course was uneventful and the patient was able to void without difficulty until the time of his death in April 1973 from metastatic prostatic carcinoma. DISCUSSION Anterior urethral diverticulum can be either congenital or acquired. The congenital type is most common in the first two decades of life whereas the acquired type is most common in the third and fourth decades. Acquired diver-
Fig. 1 (A and B). Note anterior urethral diverticulum (arrow) with narrow neck, as demonstrated by "voiding" cystourethrogram.
235
TANENBAUM AND KLINGER
Vol. XXIII
Fig. 2 (A and B). Fusiform dilatation of anterior urethra demonstrated by retrograde urethrogram (anteroposterior and oblique views).
ticula usually are located in the bulbous urethra whereas congenital diverticula are located in the pendulous urethra. Histologically, the congenital diverticulum is encompassed by the muscular coat of the urethra. The acquired type has a fibrous wall and mayor may not include a mucosal lining. The pathogenesis of the acquired anterior urethral diverticulum is related to obstruction, inflammation, injury or neurogenic dysfunction, whereas that of congenital diverticulum is related to either arrest or faulty development of the anterior urethra. The symptomatology varies, according to the degree of obstruction caused by the diverticulum. A mass may be noted, which on palpation releases urine or pus. Postmicturitional dribbling or urinary incontinence may be present. The diverticulum is apt to be infected, may contain calculi, and may rupture. Surgical excision of the diverticulum is the treatment of choice. Pate and Bunts (18), re-
236
porting on a series of paraplegic patients with urethral diverticula, suggested careful observation when the diverticulum is small and asymptomatic. Both of the cases reported here were evidently acquired. The first patient underwent a urethrotomy at the site of an indurated area induced perhaps by multiple attempts at catheterization or to relieve prior stricture formation. It is conceivable that a congenital diverticulum may have existed in that area, but it is unlikely to have been asymptomatic until the age of 60. The urethra was incised and an indwelling catheter was passed with ease to decompress the urinary bladder. The presence of an occult carcinoma and the careful observations undertaken in its therapy obscured the cause of the urinary incontinence. There were two admissions for urosepsis within a short period before the diagnosis was made. Diverticulectomy cured the patient's incontinence and forestalled further urinary-tract infection. ~
May 1975
URETHRAL DIVERTICULUM IN THE MALE
The second patient presented with a fusiform dilatation of the urethra, similar to the formation of a urethrocele or mega-urethra following a radical perineal prostatectomy. The urethra was dilated from the fossa navicularis to the bulb; there was no distal obstruction. It is tempting to relate this finding to the nerve interruption which occurs after radical perineal prostatectomy. Urethral plication effected a cure.
REFERENCES 1. Abeshouse BS: Diverticulum of the anterior urethra in the male: A report of four cases and a review of the literature, Urol & Cutan Rev 55: 690,1951. 2. Warren JW: Congenital diverticulum of the urethra, Amer Surgeon 21: 385,1955. 3. Edling NPG: The radiological appearances of diverticula of the male cavernous urethra, Acta Radiol 40: 1,1953. 4. Williams DI: Discussion of lower urinary obstruction, Arch Dis Child 37: 132,1962. 5. Goldberg HW and Grove JS: Acquired diverticulum of the male urethra with calculi formation, Chicago Med Sch Quart 24: 30,1964. 6. Mandler JI and Pool TL: Primary diverticulum of
the male urethra, J Urol 96: 336, 1966. 7. Maged A: Urethral diverticulum in males, Brit J Urol 37: 560,1965. 8. Boissonat P and Duhamel B: Congenital diverticulum of the anterior urethra associated with aplasia of the abdominal muscles in a male infant, Brit J Urol 34: 59,1962. 9. Demos NJ, Gillis DA and Barber KE: Congenital diverticulum of the anterior urethra in male infants: report of two cases, J Urol 88: 252, 1962. 10. Sweetser TH: Congenital urethral diverticulum in the male patient, J Urol 97: 93-95, 1967. 11. Williams DJ and Retik AB: Congenital valves and diverticula of the anterior urethra, Brit J Urol 41: 228,1968. 12. Goren N: Diverticulo de uretra masculina, Rev Argent Urol 27: 315, 1958. 13. Ouradou J and Gzenai M: Un cas de diverticule uretral chez un garcon de 11 ans, Maroc Med 39: 260,1960. 14. Moucha D: Volumineux diverticule urethral scrotal chez un garcon de deux ans, J Chir (Paris) 81: 581, 1961. 15. Padeira F: Un caso de diverticulo de uretra anterior, Acta Iber Radiol Cancerol 20: 123, 1964. 16. van Frank R: Un cas de diverticule de I'uretre masculin, Acta Urol Belg 32: 48, 1964. 17. Lemaitre G and Ramez J: Obstruction urinaire par diverticule de I'uretre anterieur, J Radiol d'Electr Med Nucl 45: 323, 1964. 18. Pate VA and Bunts RC: Urethral diverticula in paraplegics, J Uro165: 108,1951.
237
