Most patients with UD present between the 3rd and 7th decades of life [10–14]. The classic presentation has been historically described as the “three Ds”: dysuria, dyspareunia, and dribbling (post-void). However, none of these symptoms are sensitive or specific for UD. Although presentation is quite variable, the most common symptoms are irritative (frequency, urgency, etc.) lower urinary tract symptoms (LUTS), pain, and infection [7, 15–17]. Dyspareunia will be noted by 12–24 % of patients [15, 16]. Approximately 5–32 % of patients complain of post-void dribbling [11, 15]. Recurrent cystitis or urinary tract infection is also a frequent presentation in one-third of subjects [11, 15] likely due to stasis of urine in the UD. Multiple bouts of recurrent cystitis should alert the physician to the possibility of a UD. Other complaints include vaginal pain or mass, hematuria, vaginal discharge, obstructive symptoms, urinary retention, and incontinence (stress or urge). Up to 20 % of patients diagnosed with UD might be completely asymptomatic. Some patients may present with a tender or non-tender anterior vaginal wall mass, which upon gentle compression may reveal retained urine or purulent discharge per the urethral meatus. Although spontaneous rupture of UD is extremely rare, urethrovaginal fistula may result under these circumstances [18].

The size of the diverticulum does not correlate with symptoms. Finally, symptoms may wax and wane, and even resolve for long periods of time. This may be related to periodic and repeated episodes of infection and inflammation.

As many symptoms associated with UD are not specific, patients often can be misdiagnosed and treated for years before the diagnosis of UD is made. In one series of 46 consecutive women eventually diagnosed with UD, the mean interval from onset of symptoms to diagnosis was 5.2 years [19]. This underscores the importance of a baseline level of suspicion and a thorough pelvic exam in patients complaining of LUTS or other symptoms potentially associated with UD.

During physical examination, the anterior vaginal wall should be palpated for masses and tenderness. The location, size, and consistency of a suspected UD should be noted. Most UD are located ventrally over the middle and proximal portions of the urethra, corresponding to the area of the anterior vaginal wall 1–3 cm inside the introitus (Fig. 11.3). Configuration of the UD may have significant implications when undertaking surgical excision and reconstruction. UD may also extend proximally towards the bladder neck. Such UD may produce distortion of the bladder outlet and trigone on cystoscopy or on radiographic imaging and special care should be taken during surgical excision and reconstruction due to concerns for bladder and ureteral injury as well as the potential development of postoperative voiding dysfunction and incontinence. Distal vaginal masses or perimeatal masses may represent other lesions, including Skene’s glands abnormalities. The differentiation between these lesions often cannot be made by physical examination alone, and may require additional radiological imaging. A particularly hard anterior vaginal wall mass may indicate a calculus, vaginal wall fibroid, or cancer within the UD and mandates further investigation. During physical exam, the urethra may be gently “stripped” or “milked” distally in an attempt to express purulent material or urine from within the UD cavity. Although often described for the evaluation of UD, this maneuver does not produce the diagnostic discharge per urethral meatus in the majority of patients [20].

Vaginal walls should be assessed for atrophy, rugation, and elasticity. Poorly estrogenized, atrophic tissues are important to note if surgery is being considered. These tissues are often surgically mobilized and may be used for flaps during excision and reconstruction. The distal vagina and vaginal introitus are also assessed for capacity. These factors may impact surgical planning, as a narrow introitus can make surgical exposure difficult and may mandate an episiotomy. Finally, during physical examination, a provocative maneuver to elicit stress incontinence should be performed as well as an assessment of any vaginal prolapse.

Urinalysis and urine culture should be performed. The most common organism isolated in patients with UD is E. coli. However, other gram negative enteric flora as well as N. gonorrhea, Chlamydia, Streptococcus, and Staphylococcus are often present [16, 21]. A sterile urine culture does not exclude infection, as these patients are often on antibiotic therapy at presentation. In patients with irritative symptoms or where there is suspicion of malignancy, a urine cytology can be checked.

Cystourethroscopy is performed, both in an attempt to visualize the UD ostia, as well as to evaluate for other potential causes of the patient’s LUTS. A flexible cystoscope or a specially designed rigid female cystoscope is most helpful in evaluating the female urethra. The short beak maintains the flow of the irrigation solution immediately adjacent to the lens and thus aids in distention of the relatively short (as compared to the male) urethra, permitting improved visualization. It may also be advantageous to compress the bladder neck while simultaneously applying pressure to the diverticular sac with an assistant’s finger. Luminal discharge of purulent material can often be seen with this maneuver or with digital compression of the UD during urethroscopy. Again, the UD ostia is most often located posterolaterally at the level of the midurethra, but can be very difficult to identify in some patients. The success in identifying a diverticular ostia on cystourethroscopy is quite variable, and reported to be between 15 % and 89 % [11, 15, 20]. Failure to visualize an ostia on cystourethroscopy should not influence the decision to proceed with further investigations or surgical repair.

For patients with UD and urinary incontinence or significant voiding dysfunction, a urodynamic study may be helpful [22–24]. Urodynamics can document the presence or absence of stress urinary incontinence prior to repair. Approximately 50 % of women with UD will demonstrate SUI on urodynamic evaluation [11, 25]. A videourodynamic study combines both a voiding cystourethrogram and a urodynamic study, thus consolidating the diagnostic evaluation and decreasing the number of required urethral catheterizations during the patient’s work-up. For patients undergoing surgery for UD with coexistent bothersome stress urinary incontinence demonstrated on physical examination, or urodynamically demonstrable SUI, or those found to have an open bladder neck on preoperative evaluation, a concomitant anti-incontinence surgery can be offered. Multiple authors have described successful concomitant repair of urethral diverticula and stress incontinence in the same operative setting [11, 25–27]. Alternatively, on urodynamic evaluation, a small number of patients may have evidence of bladder outlet obstruction due to the obstructive or mass effects of the UD on the urethra. It should be noted that SUI may coexist with obstruction [28, 29] but nevertheless, both conditions can be treated successfully with a carefully planned operation.

A number of imaging techniques have been applied to the study of female UD. Currently available techniques for the evaluation of UD include double-balloon positive-pressure urethrography (PPU), voiding cystourethrography (VCUG) (Fig. 11.4), intravenous urography (IVU), ultrasound (US), and magnetic resonance imaging (MRI) (Fig. 11.5), with or without an endoluminal coil (eMRI). MRI has become the imaging modality of choice in many centers due to its relatively noninvasive nature, and ability to visualize the anatomy in multiple planes [30–32].

Although often highly symptomatic, not all urethral diverticula mandate surgery. Some patients may be asymptomatic at presentation, with the lesion diagnosed incidentally. Whether these lesions will progress in size, symptoms or complexity over time is not known. For these reasons, and due to the lack of symptoms in selected cases, some patients may not desire surgical therapy. However, it should be noted that there are multiple reports in the literature of carcinomas arising in UD [29, 33–40] which may be asymptomatic and may not be prospectively identified on radiologic imaging [41].

Symptomatic patients, including those with dysuria, refractory bothersome post-void dribbling, recurrent UTIs, dyspareunia and pelvic pain, may be offered surgical excision. Those with UD and symptomatic bothersome stress urinary incontinence can be considered for a concomitant anti-incontinence procedure at the time of UD excision.