diverticula of the female urethra are rare lesions occurring predominantly in the distal two thirds of the urethra .
they are thought to be derived from the periurethral glands as a result of recurrent infections .
urethral diverticula ( ud ) have historically been described with the classic triad of three d 's e.g. dysuria , dysparunia , and dribbling , which are present only in about one third of cases .
they can be asymptomatic and incidentally detected or may present with symptoms like painful vaginal mass , chronic pelvic pain , refractory lower urinary tract symptoms , and recurrent urinary tract infections ( uti ) .
they predominantly affect females in third to fifth decade of life with overall incidence of 1 6% .
they tend to be acquired with age ; however , rarely they have been described in neonates and children .
we herein describe a young female with a giant ud measuring 7.3  6.2 cm who presented with acute urinary retention ( aur ) and had successful outcome after surgery .
female ud presenting with bladder outlet obstruction is very rare and should be kept in mind while evaluating any female with aur .
this case is unique because of its age of occurrence , presentation , and largest size reported till date .
a 20-year - old unmarried girl presented to emergency with painful urinary retention since 8 h. she had history of similar episode 2 months back for which she was catheterized for 1 week .
she also complained of frequency , poor stream , straining , incomplete voiding , and dysuria for 2 years .
there was no history of hematuria , flank pain , urinary incontinence , menstrual disturbances , or sexual contact .
urinary bladder was palpable on abdominal examination and genital examination revealed a large non - tender cystic mass over anterior vaginal wall .
urine examination revealed 5 - 8 pus cells per high power field and sterile culture .
transvaginal sonography performed with broadband 9- to 5-mhz tightly curved array probe revealed a hypoechoic cystic structure posterior to urinary bladder and urethra with enhanced through - transmission and a small echogenic structure within it , possibly a stone .
a magnetic resonance imaging ( mri ) of pelvis was done which showed a well - defined cystic structure posterior to urinary bladder measuring 7.3  6.2 cm displacing the uterus superiorly and vagina and cervix posteriorly with no obvious connection with urethra or urinary bladder seen [ figure 1 ] .
cystourethroscopy was performed using 15f flexible cystoscope with simultaneous digital compression over the bladder neck area and diverticulum .
it revealed a large ud opening into the urethra in the right postero - lateral wall of the middle third .
a rubber catheter tip measuring about 1 cm was seen inside the diverticulum , a retained foreign body from previous catheterization .
( a ) t1-weighted mri image showing the urethral diverticulum ( ud ) and urinary bladder ( ub ) in the sagittal plane . ( b ) t2-weighted cross - sectional image showing the diverticulum .
( c , d ) reconstructed t2-weighted mri images showing relationship of urethral diverticulum with urinary bladder trans - vaginal excision of diverticulum was done through an inverted u - shaped incision over the anterior vaginal wall .
vaginal flaps were raised with careful preservation of the periurethral fascia and meticulous dissection of the diverticulum up to the neck .
diverticulum was excised and repair was done over 14f catheter in four layers , e.g. urethra , periurethral fascia , martius flap , and vaginal tissue [ figures 2a , b ] .
suprapubic catheter was not placed and anticholinergics were given in the post - op period for three weeks .
the urethral catheter was removed at 3 weeks , after voiding cystourethrogram ( vcug ) revealed no extravasation [ figures 2c , d ] .
since the first description of ud by william hey in 1805 , increasing number of cases is being reported , especially in last two decades .
this is partly because of increased awareness among physicians and increased use of improved radiological investigations .
although usually single , globular , and small , uds may be multiple , may attain various shapes and grow to large sizes . in our patient
, it was extending from the external urerthral meatus up to trigone of bladder and displacing adjacent structures .
the ud described in our patient is the largest one reported till date [ table 1 ] .
female ud is a very rare cause of urinary retention and should always be considered in the differential diagnosis . about 4% of female ud cause urinary retention .
groutz et al showed that ud contributed to 3% of cases of female bladder outlet obstruction defined as persistent noninvasive maximum flow rate less than 12 ml / s combined with a detrusor pressure at maximum measured flow rate of more than 20 cm h2o in a pressure - flow study .
sizes of urethral diverticula in different case series strong clinical suspicion based on history , with focussed physical examination and appropriate radiological investigations is vital for the diagnosis of ud .
it should be differentiated from vaginal leiomyoma , skene 's gland cysts , and abscesses , gartner 's duct cysts , vaginal wall cysts , and ectopic ureterocele .
although transvaginal ultrasonography , vcug , and positive pressure urethrography have traditionally been used in the diagnosis of ud , mri is regarded as the investigation of choice by many with 100% reported sensitivity .
moreover , it is non - invasive , free from ionising radiations , does not depend on voiding of the patient and gives an excellent anatomical picture of the ud and adjacent pelvic structures .
uds appear as areas of decreased signal intensity on t1-weighted images compared with the surrounding soft tissues , and they have high signal intensity on t2-weighted images .
although endoluminal coil modalities have been described , surface coil non - contrast mri is used in majority of the centers .
pre - operative video urodynamics is required in patients with symptomatic stress urinary incontinence and may delineate the ud under fluoroscopy in many cases .
although very rare , malignant tumors , calculi and foreign bodies are to be ruled out in all cases of ud . in our patient , a broken catheter tip was recovered from the diverticular cavity .
surgery is the mainstay of treatment for ud and surgical excision and urethral reconstruction remains the most popular modality though selected patients may be managed by transurethral or open marsupialisation .
total excision of the diverticulum , preservation of periurethral fascia , and watertight and tension - free closure with non - overlapping suture lines are vital for optimal surgical outcome .
simultaneous anti - incontinence surgery may be done in patients with symptomatic stress urinary incontinence .
 female urethral diverticulum is a rare entity with diverse spectrum of clinical manifestations . 
 it is a very rare cause of bladder outlet obstruction and should be considered as a differential diagnosis in females presenting with acute urinary retention associated with a vaginal mass . 
 strong clinical suspicion combined with thorough physical examination and focused radiological investigations are vital for its diagnosis . 
 herein we report a case of giant urethral diverticulum presenting with acute urinary retention in a young female . 
 it was managed by excision and urethral closure , and is the largest urethral diverticulum reported till date in the literature . 
INTRODUCTION
CASE REPORT
DISCUSSION