Evaluation and management of urethral and periurethral masses in women

Purpose of reviewFemale periurethral masses are an uncommon occurrence. The purpose of this review is to describe etiologies of female urethral and periurethral masses and to provide an update on diagnosis and management.The most common causes of periurethral and urethral masses in women are urethral caruncles, urethral diverticula, and Skene's gland cysts. Urethral meatal lesions such as urethral caruncles and prolapse can be managed conservatively with topical estrogen therapy and close follow-up or should be excised in the setting of thrombosis, significant or recurrent bleeding, acute urinary retention, or persistent pain. Benign periurethral gland masses, such as Skene's gland cysts, Gartner's duct cysts, and Mullerian duct cysts, remain rare. Recent case series reveal a high rate of surgical management of these lesions with few complications. Urethral malignancy or malignant transformation of benign etiologies are even rarer but can be aggressive in nature and should be treated promptly.Nonspecific urinary and vaginal symptoms as well as similar physical presentations make diagnosis of urethral and periurethral lesions in females difficult. Magnetic resonance imaging is useful for differentiation of periurethral masses. The decision for conservative or surgical management is typically guided by patient symptom bother, as well as concern for urethral malignancy.Papers of particular interest, published within the annual period of review, have been highlighted as:An infrequent occurrence in females, urethral and periurethral masses can be challenging to diagnose and differentiate. Such lesions can be benign or malignant and can arise from the urethra, vagina, or other nearby structures (Fig. 1). In a case series of 126 women, the most common etiologies of periurethral masses were urethral diverticula (39.7%) and Skene's gland cysts or abscesses (30.2%), followed by Gartner cysts (7.1%), Mullerian cysts (4.0%), and epidermal inclusion cysts and abscesses (3.2%) [1]. The most common lesion of the female urethra is a urethral caruncle, which is typically found in postmenopausal women. Given that it is commonly asymptomatic, the exact prevalence of urethral caruncles is unknown but may be as high as 67% in women 65 years of age and older [2]. Although malignancy is exceedingly rare in women who present with a urethral or periurethral mass, it should not be missed. no caption availableCauses of urethral and periurethral masses in women.This article will review urethral anatomy, describe common etiologies of female urethral and periurethral masses, and provide an update on diagnosis and management (Table 1). In this article, we discuss the anatomy of biologically female persons whom we refer to interchangeably as women or female.Diagnosis and management of common causes of female urethral and periurethral massesIf unable to adequately diagnose on physical exam, additional imaging (such as magnetic resonance imaging, transvaginal and transperineal ultrasound) can be used for diagnosis.Due to the low incidence of urethral carcinoma, evidence-based guidelines are limited.A 3-4 cm tubular structure about 6 mm in diameter, the female urethra is embedded in the adventitia of the anterior vagina and surrounded by numerous periurethral ducts and glands along its length (Fig. 2). The largest of these are the Skene's glands which have ostia located laterally to the urethral meatus. The urethra has four distinct layers: inner-most mucosa, submucosa with its rich venous plexus, internal sphincter (composed of two smooth muscle layers: inner longitudinal, outer circular), and outer external striated sphincter. The proximal lumen of the female urethra is lined with transitional epithelium, while the distal one-third of the urethral lumen is lined with stratified and pseudostratified columnar and squamous epithelium. Of note, the distal one-third of the female urethra can be excised without disrupting continence [3].Anatomy of female urethra and vulva. On the left: vulva with relevant anatomy labeled and common gland locations delineated with colored dots. On the right: female urethra with relevant anatomy labeled.Urethral and periurethral masses are first identified using patient history and physical examination. The most common presenting symptom is that of a palpable mass, but half of women may also present with dyspareunia and/or vaginal discharge [1]. Urinary symptoms such as frequency and urgency, dysuria, or stress urinary incontinence may occur in 15-40.5% of patients [1,4]. Similarly, 11.1-36.7% of women may present with pelvic or urethral pain, especially in the setting of an infection [1,5]. Women presenting with pain are more likely to require surgical management [6].Pelvic examination should be performed to assess the location of the lesion in relation to the urethra. The mass should be palpated, and any purulence, tenderness, or erythema should be noted. Sometimes diagnosis can be challenging clinically due to the short length of the female urethra and potentially sporadic presence of the mass. In these cases, imaging is recommended. Additionally, although experienced clinicians may be able to diagnose symptomatic periurethral and urethral lesions correctly up to 80% of the time, many find imaging to be helpful for the purposes of surgical planning and patient counseling [7]. For masses that are intermittent, it is important to perform imaging when the mass is present.There is no well defined protocol for accurate diagnosis and management of female periurethral and urethral lesions. Imaging modalities include magnetic resonance imaging (MRI), pelvic ultrasonography (US) via transvaginal or transperineal approach, computed tomography (CT), voiding cystourethrography (VCUG), and double-balloon catheter urethrography (DBU). MRI has the highest sensitivity for urethral pathology and is therefore the imaging modality of choice for diagnosis and preoperative planning [8,9]. On MRI T2-weighted sequences, the urethra has a target-shaped appearance with the outer and inner-most layers appearing hypointense (darker) and the middle submucosal layer appearing hyperintense (brighter).High-resolution transvaginal and transperineal 2D and 3D US can also be used to identify urethral and periurethral lesions. In addition to being radiation-free like MRI, US is portable, can capture both static and dynamic images, is better tolerated by patients, and is cheaper than MRI. Recent studies have found US to be comparable to MRI in terms of diagnosis of urethral and periurethral female masses [4,7,10]. US is also the recommended imaging modality for assessment of midurethral sling location and function. However, US is highly operator-dependent and requires extensive training which limits its use. VCUG can provide dynamic evaluation of the female urethra and is useful for the visualization of urethral diverticular necks and postoperatively to ensure adequate healing of the urethra [11]. Purpose of reviewFemale periurethral masses are an uncommon occurrence. The purpose of this review is to describe etiologies of female urethral and periurethral masses and to provide an update on diagnosis and management.The most common causes of periurethral and urethral masses in women are urethral caruncles, urethral diverticula, and Skene's gland cysts. Urethral meatal lesions such as urethral caruncles and prolapse can be managed conservatively with topical estrogen therapy and close follow-up or should be excised in the setting of thrombosis, significant or recurrent bleeding, acute urinary retention, or persistent pain. Benign periurethral gland masses, such as Skene's gland cysts, Gartner's duct cysts, and Mullerian duct cysts, remain rare. Recent case series reveal a high rate of surgical management of these lesions with few complications. Urethral malignancy or malignant transformation of benign etiologies are even rarer but can be aggressive in nature and should be treated promptly.Nonspecific urinary and vaginal symptoms as well as similar physical presentations make diagnosis of urethral and periurethral lesions in females difficult. Magnetic resonance imaging is useful for differentiation of periurethral masses. The decision for conservative or surgical management is typically guided by patient symptom bother, as well as concern for urethral malignancy.Papers of particular interest, published within the annual period of review, have been highlighted as:An infrequent occurrence in females, urethral and periurethral masses can be challenging to diagnose and differentiate. Such lesions can be benign or malignant and can arise from the urethra, vagina, or other nearby structures (Fig. 1). In a case series of 126 women, the most common etiologies of periurethral masses were urethral diverticula (39.7%) and Skene's gland cysts or abscesses (30.2%), followed by Gartner cysts (7.1%), Mullerian cysts (4.0%), and epidermal inclusion cysts and abscesses (3.2%) [1]. The most common lesion of the female urethra is a urethral caruncle, which is typically found in postmenopausal women. Given that it is commonly asymptomatic, the exact prevalence of urethral caruncles is unknown but may be as high as 67% in women 65 years of age and older [2]. Although malignancy is exceedingly rare in women who present with a urethral or periurethral mass, it should not be missed. no caption availableCauses of urethral and periurethral masses in women.This article will review urethral anatomy, describe common etiologies of female urethral and periurethral masses, and provide an update on diagnosis and management (Table 1). In this article, we discuss the anatomy of biologically female persons whom we refer to interchangeably as women or female.Diagnosis and management of common causes of female urethral and periurethral massesIf unable to adequately diagnose on physical exam, additional imaging (such as magnetic resonance imaging, transvaginal and transperineal ultrasound) can be used for diagnosis.Due to the low incidence of urethral carcinoma, evidence-based guidelines are limited.A 3-4 cm tubular structure about 6 mm in diameter, the female urethra is embedded in the adventitia of the anterior vagina and surrounded by numerous periurethral ducts and glands along its length (Fig. 2). The largest of these are the Skene's glands which have ostia located laterally to the urethral meatus. The urethra has four distinct layers: inner-most mucosa, submucosa with its rich venous plexus, internal sphincter (composed of two smooth muscle layers: inner longitudinal, outer circular), and outer external striated sphincter. The proximal lumen of the female urethra is lined with transitional epithelium, while the distal one-third of the urethral lumen is lined with stratified and pseudostratified columnar and squamous epithelium. Of note, the distal one-third of the female urethra can be excised without disrupting continence [3].Anatomy of female urethra and vulva. On the left: vulva with relevant anatomy labeled and common gland locations delineated with colored dots. On the right: female urethra with relevant anatomy labeled.Urethral and periurethral masses are first identified using patient history and physical examination. The most common presenting symptom is that of a palpable mass, but half of women may also present with dyspareunia and/or vaginal discharge [1]. Urinary symptoms such as frequency and urgency, dysuria, or stress urinary incontinence may occur in 15-40.5% of patients [1,4]. Similarly, 11.1-36.7% of women may present with pelvic or urethral pain, especially in the setting of an infection [1,5]. Women presenting with pain are more likely to require surgical management [6].Pelvic examination should be performed to assess the location of the lesion in relation to the urethra. The mass should be palpated, and any purulence, tenderness, or erythema should be noted. Sometimes diagnosis can be challenging clinically due to the short length of the female urethra and potentially sporadic presence of the mass. In these cases, imaging is recommended. Additionally, although experienced clinicians may be able to diagnose symptomatic periurethral and urethral lesions correctly up to 80% of the time, many find imaging to be helpful for the purposes of surgical planning and patient counseling [7]. For masses that are intermittent, it is important to perform imaging when the mass is present.There is no well defined protocol for accurate diagnosis and management of female periurethral and urethral lesions. Imaging modalities include magnetic resonance imaging (MRI), pelvic ultrasonography (US) via transvaginal or transperineal approach, computed tomography (CT), voiding cystourethrography (VCUG), and double-balloon catheter urethrography (DBU). MRI has the highest sensitivity for urethral pathology and is therefore the imaging modality of choice for diagnosis and preoperative planning [8,9]. On MRI T2-weighted sequences, the urethra has a target-shaped appearance with the outer and inner-most layers appearing hypointense (darker) and the middle submucosal layer appearing hyperintense (brighter).High-resolution transvaginal and transperineal 2D and 3D US can also be used to identify urethral and periurethral lesions. In addition to being radiation-free like MRI, US is portable, can capture both static and dynamic images, is better tolerated by patients, and is cheaper than MRI. Recent studies have found US to be comparable to MRI in terms of diagnosis of urethral and periurethral female masses [4,7,10]. US is also the recommended imaging modality for assessment of midurethral sling location and function. However, US is highly operator-dependent and requires extensive training which limits its use. VCUG can provide dynamic evaluation of the female urethra and is useful for the visualization of urethral diverticular necks and postoperatively to ensure adequate healing of the urethra [11]. Purpose of reviewFemale periurethral masses are an uncommon occurrence. The purpose of this review is to describe etiologies of female urethral and periurethral masses and to provide an update on diagnosis and management.The most common causes of periurethral and urethral masses in women are urethral caruncles, urethral diverticula, and Skene's gland cysts. Urethral meatal lesions such as urethral caruncles and prolapse can be managed conservatively with topical estrogen therapy and close follow-up or should be excised in the setting of thrombosis, significant or recurrent bleeding, acute urinary retention, or persistent pain. Benign periurethral gland masses, such as Skene's gland cysts, Gartner's duct cysts, and Mullerian duct cysts, remain rare. Recent case series reveal a high rate of surgical management of these lesions with few complications. Urethral malignancy or malignant transformation of benign etiologies are even rarer but can be aggressive in nature and should be treated promptly.Nonspecific urinary and vaginal symptoms as well as similar physical presentations make diagnosis of urethral and periurethral lesions in females difficult. Magnetic resonance imaging is useful for differentiation of periurethral masses. The decision for conservative or surgical management is typically guided by patient symptom bother, as well as concern for urethral malignancy.Papers of particular interest, published within the annual period of review, have been highlighted as:An infrequent occurrence in females, urethral and periurethral masses can be challenging to diagnose and differentiate. Such lesions can be benign or malignant and can arise from the urethra, vagina, or other nearby structures (Fig. 1). In a case series of 126 women, the most common etiologies of periurethral masses were urethral diverticula (39.7%) and Skene's gland cysts or abscesses (30.2%), followed by Gartner cysts (7.1%), Mullerian cysts (4.0%), and epidermal inclusion cysts and abscesses (3.2%) [1]. The most common lesion of the female urethra is a urethral caruncle, which is typically found in postmenopausal women. Given that it is commonly asymptomatic, the exact prevalence of urethral caruncles is unknown but may be as high as 67% in women 65 years of age and older [2]. Although malignancy is exceedingly rare in women who present with a urethral or periurethral mass, it should not be missed. no caption availableCauses of urethral and periurethral masses in women.This article will review urethral anatomy, describe common etiologies of female urethral and periurethral masses, and provide an update on diagnosis and management (Table 1). In this article, we discuss the anatomy of biologically female persons whom we refer to interchangeably as women or female.Diagnosis and management of common causes of female urethral and periurethral massesIf unable to adequately diagnose on physical exam, additional imaging (such as magnetic resonance imaging, transvaginal and transperineal ultrasound) can be used for diagnosis.Due to the low incidence of urethral carcinoma, evidence-based guidelines are limited.A 3-4 cm tubular structure about 6 mm in diameter, the female urethra is embedded in the adventitia of the anterior vagina and surrounded by numerous periurethral ducts and glands along its length (Fig. 2). The largest of these are the Skene's glands which have ostia located laterally to the urethral meatus. The urethra has four distinct layers: inner-most mucosa, submucosa with its rich venous plexus, internal sphincter (composed of two smooth muscle layers: inner longitudinal, outer circular), and outer external striated sphincter. The proximal lumen of the female urethra is lined with transitional epithelium, while the distal one-third of the urethral lumen is lined with stratified and pseudostratified columnar and squamous epithelium. Of note, the distal one-third of the female urethra can be excised without disrupting continence [3].Anatomy of female urethra and vulva. On the left: vulva with relevant anatomy labeled and common gland locations delineated with colored dots. On the right: female urethra with relevant anatomy labeled.Urethral and periurethral masses are first identified using patient history and physical examination. The most common presenting symptom is that of a palpable mass, but half of women may also present with dyspareunia and/or vaginal discharge [1]. Urinary symptoms such as frequency and urgency, dysuria, or stress urinary incontinence may occur in 15-40.5% of patients [1,4]. Similarly, 11.1-36.7% of women may present with pelvic or urethral pain, especially in the setting of an infection [1,5]. Women presenting with pain are more likely to require surgical management [6].Pelvic examination should be performed to assess the location of the lesion in relation to the urethra. The mass should be palpated, and any purulence, tenderness, or erythema should be noted. Sometimes diagnosis can be challenging clinically due to the short length of the female urethra and potentially sporadic presence of the mass. In these cases, imaging is recommended. Additionally, although experienced clinicians may be able to diagnose symptomatic periurethral and urethral lesions correctly up to 80% of the time, many find imaging to be helpful for the purposes of surgical planning and patient counseling [7]. For masses that are intermittent, it is important to perform imaging when the mass is present.There is no well defined protocol for accurate diagnosis and management of female periurethral and urethral lesions. Imaging modalities include magnetic resonance imaging (MRI), pelvic ultrasonography (US) via transvaginal or transperineal approach, computed tomography (CT), voiding cystourethrography (VCUG), and double-balloon catheter urethrography (DBU). MRI has the highest sensitivity for urethral pathology and is therefore the imaging modality of choice for diagnosis and preoperative planning [8,9]. On MRI T2-weighted sequences, the urethra has a target-shaped appearance with the outer and inner-most layers appearing hypointense (darker) and the middle submucosal layer appearing hyperintense (brighter).High-resolution transvaginal and transperineal 2D and 3D US can also be used to identify urethral and periurethral lesions. In addition to being radiation-free like MRI, US is portable, can capture both static and dynamic images, is better tolerated by patients, and is cheaper than MRI. Recent studies have found US to be comparable to MRI in terms of diagnosis of urethral and periurethral female masses [4,7,10]. US is also the recommended imaging modality for assessment of midurethral sling location and function. However, US is highly operator-dependent and requires extensive training which limits its use. VCUG can provide dynamic evaluation of the female urethra and is useful for the visualization of urethral diverticular necks and postoperatively to ensure adequate healing of the urethra [11]. Purpose of reviewFemale periurethral masses are an uncommon occurrence. The purpose of this review is to describe etiologies of female urethral and periurethral masses and to provide an update on diagnosis and management.The most common causes of periurethral and urethral masses in women are urethral caruncles, urethral diverticula, and Skene's gland cysts. Urethral meatal lesions such as urethral caruncles and prolapse can be managed conservatively with topical estrogen therapy and close follow-up or should be excised in the setting of thrombosis, significant or recurrent bleeding, acute urinary retention, or persistent pain. Benign periurethral gland masses, such as Skene's gland cysts, Gartner's duct cysts, and Mullerian duct cysts, remain rare. Recent case series reveal a high rate of surgical management of these lesions with few complications. Urethral malignancy or malignant transformation of benign etiologies are even rarer but can be aggressive in nature and should be treated promptly.Nonspecific urinary and vaginal symptoms as well as similar physical presentations make diagnosis of urethral and periurethral lesions in females difficult. Magnetic resonance imaging is useful for differentiation of periurethral masses. The decision for conservative or surgical management is typically guided by patient symptom bother, as well as concern for urethral malignancy.Papers of particular interest, published within the annual period of review, have been highlighted as:An infrequent occurrence in females, urethral and periurethral masses can be challenging to diagnose and differentiate. Such lesions can be benign or malignant and can arise from the urethra, vagina, or other nearby structures (Fig. 1). In a case series of 126 women, the most common etiologies of periurethral masses were urethral diverticula (39.7%) and Skene's gland cysts or abscesses (30.2%), followed by Gartner cysts (7.1%), Mullerian cysts (4.0%), and epidermal inclusion cysts and abscesses (3.2%) [1]. The most common lesion of the female urethra is a urethral caruncle, which is typically found in postmenopausal women. Given that it is commonly asymptomatic, the exact prevalence of urethral caruncles is unknown but may be as high as 67% in women 65 years of age and older [2]. Although malignancy is exceedingly rare in women who present with a urethral or periurethral mass, it should not be missed. no caption availableCauses of urethral and periurethral masses in women.This article will review urethral anatomy, describe common etiologies of female urethral and periurethral masses, and provide an update on diagnosis and management (Table 1). In this article, we discuss the anatomy of biologically female persons whom we refer to interchangeably as women or female.Diagnosis and management of common causes of female urethral and periurethral massesIf unable to adequately diagnose on physical exam, additional imaging (such as magnetic resonance imaging, transvaginal and transperineal ultrasound) can be used for diagnosis.Due to the low incidence of urethral carcinoma, evidence-based guidelines are limited.A 3-4 cm tubular structure about 6 mm in diameter, the female urethra is embedded in the adventitia of the anterior vagina and surrounded by numerous periurethral ducts and glands along its length (Fig. 2). The largest of these are the Skene's glands which have ostia located laterally to the urethral meatus. The urethra has four distinct layers: inner-most mucosa, submucosa with its rich venous plexus, internal sphincter (composed of two smooth muscle layers: inner longitudinal, outer circular), and outer external striated sphincter. The proximal lumen of the female urethra is lined with transitional epithelium, while the distal one-third of the urethral lumen is lined with stratified and pseudostratified columnar and squamous epithelium. Of note, the distal one-third of the female urethra can be excised without disrupting continence [3].Anatomy of female urethra and vulva. On the left: vulva with relevant anatomy labeled and common gland locations delineated with colored dots. On the right: female urethra with relevant anatomy labeled.Urethral and periurethral masses are first identified using patient history and physical examination. The most common presenting symptom is that of a palpable mass, but half of women may also present with dyspareunia and/or vaginal discharge [1]. Urinary symptoms such as frequency and urgency, dysuria, or stress urinary incontinence may occur in 15-40.5% of patients [1,4]. Similarly, 11.1-36.7% of women may present with pelvic or urethral pain, especially in the setting of an infection [1,5]. Women presenting with pain are more likely to require surgical management [6].Pelvic examination should be performed to assess the location of the lesion in relation to the urethra. The mass should be palpated, and any purulence, tenderness, or erythema should be noted. Sometimes diagnosis can be challenging clinically due to the short length of the female urethra and potentially sporadic presence of the mass. In these cases, imaging is recommended. Additionally, although experienced clinicians may be able to diagnose symptomatic periurethral and urethral lesions correctly up to 80% of the time, many find imaging to be helpful for the purposes of surgical planning and patient counseling [7]. For masses that are intermittent, it is important to perform imaging when the mass is present.There is no well defined protocol for accurate diagnosis and management of female periurethral and urethral lesions. Imaging modalities include magnetic resonance imaging (MRI), pelvic ultrasonography (US) via transvaginal or transperineal approach, computed tomography (CT), voiding cystourethrography (VCUG), and double-balloon catheter urethrography (DBU). MRI has the highest sensitivity for urethral pathology and is therefore the imaging modality of choice for diagnosis and preoperative planning [8,9]. On MRI T2-weighted sequences, the urethra has a target-shaped appearance with the outer and inner-most layers appearing hypointense (darker) and the middle submucosal layer appearing hyperintense (brighter).High-resolution transvaginal and transperineal 2D and 3D US can also be used to identify urethral and periurethral lesions. In addition to being radiation-free like MRI, US is portable, can capture both static and dynamic images, is better tolerated by patients, and is cheaper than MRI. Recent studies have found US to be comparable to MRI in terms of diagnosis of urethral and periurethral female masses [4,7,10]. US is also the recommended imaging modality for assessment of midurethral sling location and function. However, US is highly operator-dependent and requires extensive training which limits its use. VCUG can provide dynamic evaluation of the female urethra and is useful for the visualization of urethral diverticular necks and postoperatively to ensure adequate healing of the urethra [11]. Purpose of reviewFemale periurethral masses are an uncommon occurrence. The purpose of this review is to describe etiologies of female urethral and periurethral masses and to provide an update on diagnosis and management.The most common causes of periurethral and urethral masses in women are urethral caruncles, urethral diverticula, and Skene's gland cysts. Urethral meatal lesions such as urethral caruncles and prolapse can be managed conservatively with topical estrogen therapy and close follow-up or should be excised in the setting of thrombosis, significant or recurrent bleeding, acute urinary retention, or persistent pain. Benign periurethral gland masses, such as Skene's gland cysts, Gartner's duct cysts, and Mullerian duct cysts, remain rare. Recent case series reveal a high rate of surgical management of these lesions with few complications. Urethral malignancy or malignant transformation of benign etiologies are even rarer but can be aggressive in nature and should be treated promptly.Nonspecific urinary and vaginal symptoms as well as similar physical presentations make diagnosis of urethral and periurethral lesions in females difficult. Magnetic resonance imaging is useful for differentiation of periurethral masses. The decision for conservative or surgical management is typically guided by patient symptom bother, as well as concern for urethral malignancy.Papers of particular interest, published within the annual period of review, have been highlighted as:An infrequent occurrence in females, urethral and periurethral masses can be challenging to diagnose and differentiate. Such lesions can be benign or malignant and can arise from the urethra, vagina, or other nearby structures (Fig. 1). In a case series of 126 women, the most common etiologies of periurethral masses were urethral diverticula (39.7%) and Skene's gland cysts or abscesses (30.2%), followed by Gartner cysts (7.1%), Mullerian cysts (4.0%), and epidermal inclusion cysts and abscesses (3.2%) [1]. The most common lesion of the female urethra is a urethral caruncle, which is typically found in postmenopausal women. Given that it is commonly asymptomatic, the exact prevalence of urethral caruncles is unknown but may be as high as 67% in women 65 years of age and older [2]. Although malignancy is exceedingly rare in women who present with a urethral or periurethral mass, it should not be missed. no caption availableCauses of urethral and periurethral masses in women.This article will review urethral anatomy, describe common etiologies of female urethral and periurethral masses, and provide an update on diagnosis and management (Table 1). In this article, we discuss the anatomy of biologically female persons whom we refer to interchangeably as women or female.Diagnosis and management of common causes of female urethral and periurethral massesIf unable to adequately diagnose on physical exam, additional imaging (such as magnetic resonance imaging, transvaginal and transperineal ultrasound) can be used for diagnosis.Due to the low incidence of urethral carcinoma, evidence-based guidelines are limited.A 3-4 cm tubular structure about 6 mm in diameter, the female urethra is embedded in the adventitia of the anterior vagina and surrounded by numerous periurethral ducts and glands along its length (Fig. 2). The largest of these are the Skene's glands which have ostia located laterally to the urethral meatus. The urethra has four distinct layers: inner-most mucosa, submucosa with its rich venous plexus, internal sphincter (composed of two smooth muscle layers: inner longitudinal, outer circular), and outer external striated sphincter. The proximal lumen of the female urethra is lined with transitional epithelium, while the distal one-third of the urethral lumen is lined with stratified and pseudostratified columnar and squamous epithelium. Of note, the distal one-third of the female urethra can be excised without disrupting continence [3].Anatomy of female urethra and vulva. On the left: vulva with relevant anatomy labeled and common gland locations delineated with colored dots. On the right: female urethra with relevant anatomy labeled.Urethral and periurethral masses are first identified using patient history and physical examination. The most common presenting symptom is that of a palpable mass, but half of women may also present with dyspareunia and/or vaginal discharge [1]. Urinary symptoms such as frequency and urgency, dysuria, or stress urinary incontinence may occur in 15-40.5% of patients [1,4]. Similarly, 11.1-36.7% of women may present with pelvic or urethral pain, especially in the setting of an infection [1,5]. Women presenting with pain are more likely to require surgical management [6].Pelvic examination should be performed to assess the location of the lesion in relation to the urethra. The mass should be palpated, and any purulence, tenderness, or erythema should be noted. Sometimes diagnosis can be challenging clinically due to the short length of the female urethra and potentially sporadic presence of the mass. In these cases, imaging is recommended. Additionally, although experienced clinicians may be able to diagnose symptomatic periurethral and urethral lesions correctly up to 80% of the time, many find imaging to be helpful for the purposes of surgical planning and patient counseling [7]. For masses that are intermittent, it is important to perform imaging when the mass is present.There is no well defined protocol for accurate diagnosis and management of female periurethral and urethral lesions. Imaging modalities include magnetic resonance imaging (MRI), pelvic ultrasonography (US) via transvaginal or transperineal approach, computed tomography (CT), voiding cystourethrography (VCUG), and double-balloon catheter urethrography (DBU). MRI has the highest sensitivity for urethral pathology and is therefore the imaging modality of choice for diagnosis and preoperative planning [8,9]. On MRI T2-weighted sequences, the urethra has a target-shaped appearance with the outer and inner-most layers appearing hypointense (darker) and the middle submucosal layer appearing hyperintense (brighter).High-resolution transvaginal and transperineal 2D and 3D US can also be used to identify urethral and periurethral lesions. In addition to being radiation-free like MRI, US is portable, can capture both static and dynamic images, is better tolerated by patients, and is cheaper than MRI. Recent studies have found US to be comparable to MRI in terms of diagnosis of urethral and periurethral female masses [4,7,10]. US is also the recommended imaging modality for assessment of midurethral sling location and function. However, US is highly operator-dependent and requires extensive training which limits its use. VCUG can provide dynamic evaluation of the female urethra and is useful for the visualization of urethral diverticular necks and postoperatively to ensure adequate healing of the urethra [11]. Purpose of reviewFemale periurethral masses are an uncommon occurrence. The purpose of this review is to describe etiologies of female urethral and periurethral masses and to provide an update on diagnosis and management.The most common causes of periurethral and urethral masses in women are urethral caruncles, urethral diverticula, and Skene's gland cysts. Urethral meatal lesions such as urethral caruncles and prolapse can be managed conservatively with topical estrogen therapy and close follow-up or should be excised in the setting of thrombosis, significant or recurrent bleeding, acute urinary retention, or persistent pain. Benign periurethral gland masses, such as Skene's gland cysts, Gartner's duct cysts, and Mullerian duct cysts, remain rare. Recent case series reveal a high rate of surgical management of these lesions with few complications. Urethral malignancy or malignant transformation of benign etiologies are even rarer but can be aggressive in nature and should be treated promptly.Nonspecific urinary and vaginal symptoms as well as similar physical presentations make diagnosis of urethral and periurethral lesions in females difficult. Magnetic resonance imaging is useful for differentiation of periurethral masses. The decision for conservative or surgical management is typically guided by patient symptom bother, as well as concern for urethral malignancy.Papers of particular interest, published within the annual period of review, have been highlighted as:An infrequent occurrence in females, urethral and periurethral masses can be challenging to diagnose and differentiate. Such lesions can be benign or malignant and can arise from the urethra, vagina, or other nearby structures (Fig. 1). In a case series of 126 women, the most common etiologies of periurethral masses were urethral diverticula (39.7%) and Skene's gland cysts or abscesses (30.2%), followed by Gartner cysts (7.1%), Mullerian cysts (4.0%), and epidermal inclusion cysts and abscesses (3.2%) [1]. The most common lesion of the female urethra is a urethral caruncle, which is typically found in postmenopausal women. Given that it is commonly asymptomatic, the exact prevalence of urethral caruncles is unknown but may be as high as 67% in women 65 years of age and older [2]. Although malignancy is exceedingly rare in women who present with a urethral or periurethral mass, it should not be missed. no caption availableCauses of urethral and periurethral masses in women.This article will review urethral anatomy, describe common etiologies of female urethral and periurethral masses, and provide an update on diagnosis and management (Table 1). In this article, we discuss the anatomy of biologically female persons whom we refer to interchangeably as women or female.Diagnosis and management of common causes of female urethral and periurethral massesIf unable to adequately diagnose on physical exam, additional imaging (such as magnetic resonance imaging, transvaginal and transperineal ultrasound) can be used for diagnosis.Due to the low incidence of urethral carcinoma, evidence-based guidelines are limited.A 3-4 cm tubular structure about 6 mm in diameter, the female urethra is embedded in the adventitia of the anterior vagina and surrounded by numerous periurethral ducts and glands along its length (Fig. 2). The largest of these are the Skene's glands which have ostia located laterally to the urethral meatus. The urethra has four distinct layers: inner-most mucosa, submucosa with its rich venous plexus, internal sphincter (composed of two smooth muscle layers: inner longitudinal, outer circular), and outer external striated sphincter. The proximal lumen of the female urethra is lined with transitional epithelium, while the distal one-third of the urethral lumen is lined with stratified and pseudostratified columnar and squamous epithelium. Of note, the distal one-third of the female urethra can be excised without disrupting continence [3].Anatomy of female urethra and vulva. On the left: vulva with relevant anatomy labeled and common gland locations delineated with colored dots. On the right: female urethra with relevant anatomy labeled.Urethral and periurethral masses are first identified using patient history and physical examination. The most common presenting symptom is that of a palpable mass, but half of women may also present with dyspareunia and/or vaginal discharge [1]. Urinary symptoms such as frequency and urgency, dysuria, or stress urinary incontinence may occur in 15-40.5% of patients [1,4]. Similarly, 11.1-36.7% of women may present with pelvic or urethral pain, especially in the setting of an infection [1,5]. Women presenting with pain are more likely to require surgical management [6].Pelvic examination should be performed to assess the location of the lesion in relation to the urethra. The mass should be palpated, and any purulence, tenderness, or erythema should be noted. Sometimes diagnosis can be challenging clinically due to the short length of the female urethra and potentially sporadic presence of the mass. In these cases, imaging is recommended. Additionally, although experienced clinicians may be able to diagnose symptomatic periurethral and urethral lesions correctly up to 80% of the time, many find imaging to be helpful for the purposes of surgical planning and patient counseling [7]. For masses that are intermittent, it is important to perform imaging when the mass is present.There is no well defined protocol for accurate diagnosis and management of female periurethral and urethral lesions. Imaging modalities include magnetic resonance imaging (MRI), pelvic ultrasonography (US) via transvaginal or transperineal approach, computed tomography (CT), voiding cystourethrography (VCUG), and double-balloon catheter urethrography (DBU). MRI has the highest sensitivity for urethral pathology and is therefore the imaging modality of choice for diagnosis and preoperative planning [8,9]. On MRI T2-weighted sequences, the urethra has a target-shaped appearance with the outer and inner-most layers appearing hypointense (darker) and the middle submucosal layer appearing hyperintense (brighter).High-resolution transvaginal and transperineal 2D and 3D US can also be used to identify urethral and periurethral lesions. In addition to being radiation-free like MRI, US is portable, can capture both static and dynamic images, is better tolerated by patients, and is cheaper than MRI. Recent studies have found US to be comparable to MRI in terms of diagnosis of urethral and periurethral female masses [4,7,10]. US is also the recommended imaging modality for assessment of midurethral sling location and function. However, US is highly operator-dependent and requires extensive training which limits its use. VCUG can provide dynamic evaluation of the female urethra and is useful for the visualization of urethral diverticular necks and postoperatively to ensure adequate healing of the urethra [11]. Purpose of reviewFemale periurethral masses are an uncommon occurrence. The purpose of this review is to describe etiologies of female urethral and periurethral masses and to provide an update on diagnosis and management.The most common causes of periurethral and urethral masses in women are urethral caruncles, urethral diverticula, and Skene's gland cysts. Urethral meatal lesions such as urethral caruncles and prolapse can be managed conservatively with topical estrogen therapy and close follow-up or should be excised in the setting of thrombosis, significant or recurrent bleeding, acute urinary retention, or persistent pain. Benign periurethral gland masses, such as Skene's gland cysts, Gartner's duct cysts, and Mullerian duct cysts, remain rare. Recent case series reveal a high rate of surgical management of these lesions with few complications. Urethral malignancy or malignant transformation of benign etiologies are even rarer but can be aggressive in nature and should be treated promptly.Nonspecific urinary and vaginal symptoms as well as similar physical presentations make diagnosis of urethral and periurethral lesions in females difficult. Magnetic resonance imaging is useful for differentiation of periurethral masses. The decision for conservative or surgical management is typically guided by patient symptom bother, as well as concern for urethral malignancy.Papers of particular interest, published within the annual period of review, have been highlighted as:An infrequent occurrence in females, urethral and periurethral masses can be challenging to diagnose and differentiate. Such lesions can be benign or malignant and can arise from the urethra, vagina, or other nearby structures (Fig. 1). In a case series of 126 women, the most common etiologies of periurethral masses were urethral diverticula (39.7%) and Skene's gland cysts or abscesses (30.2%), followed by Gartner cysts (7.1%), Mullerian cysts (4.0%), and epidermal inclusion cysts and abscesses (3.2%) [1]. The most common lesion of the female urethra is a urethral caruncle, which is typically found in postmenopausal women. Given that it is commonly asymptomatic, the exact prevalence of urethral caruncles is unknown but may be as high as 67% in women 65 years of age and older [2]. Although malignancy is exceedingly rare in women who present with a urethral or periurethral mass, it should not be missed. no caption availableCauses of urethral and periurethral masses in women.This article will review urethral anatomy, describe common etiologies of female urethral and periurethral masses, and provide an update on diagnosis and management (Table 1). In this article, we discuss the anatomy of biologically female persons whom we refer to interchangeably as women or female.Diagnosis and management of common causes of female urethral and periurethral massesIf unable to adequately diagnose on physical exam, additional imaging (such as magnetic resonance imaging, transvaginal and transperineal ultrasound) can be used for diagnosis.Due to the low incidence of urethral carcinoma, evidence-based guidelines are limited.A 3-4 cm tubular structure about 6 mm in diameter, the female urethra is embedded in the adventitia of the anterior vagina and surrounded by numerous periurethral ducts and glands along its length (Fig. 2). The largest of these are the Skene's glands which have ostia located laterally to the urethral meatus. The urethra has four distinct layers: inner-most mucosa, submucosa with its rich venous plexus, internal sphincter (composed of two smooth muscle layers: inner longitudinal, outer circular), and outer external striated sphincter. The proximal lumen of the female urethra is lined with transitional epithelium, while the distal one-third of the urethral lumen is lined with stratified and pseudostratified columnar and squamous epithelium. Of note, the distal one-third of the female urethra can be excised without disrupting continence [3].Anatomy of female urethra and vulva. On the left: vulva with relevant anatomy labeled and common gland locations delineated with colored dots. On the right: female urethra with relevant anatomy labeled.Urethral and periurethral masses are first identified using patient history and physical examination. The most common presenting symptom is that of a palpable mass, but half of women may also present with dyspareunia and/or vaginal discharge [1]. Urinary symptoms such as frequency and urgency, dysuria, or stress urinary incontinence may occur in 15-40.5% of patients [1,4]. Similarly, 11.1-36.7% of women may present with pelvic or urethral pain, especially in the setting of an infection [1,5]. Women presenting with pain are more likely to require surgical management [6].Pelvic examination should be performed to assess the location of the lesion in relation to the urethra. The mass should be palpated, and any purulence, tenderness, or erythema should be noted. Sometimes diagnosis can be challenging clinically due to the short length of the female urethra and potentially sporadic presence of the mass. In these cases, imaging is recommended. Additionally, although experienced clinicians may be able to diagnose symptomatic periurethral and urethral lesions correctly up to 80% of the time, many find imaging to be helpful for the purposes of surgical planning and patient counseling [7]. For masses that are intermittent, it is important to perform imaging when the mass is present.There is no well defined protocol for accurate diagnosis and management of female periurethral and urethral lesions. Imaging modalities include magnetic resonance imaging (MRI), pelvic ultrasonography (US) via transvaginal or transperineal approach, computed tomography (CT), voiding cystourethrography (VCUG), and double-balloon catheter urethrography (DBU). MRI has the highest sensitivity for urethral pathology and is therefore the imaging modality of choice for diagnosis and preoperative planning [8,9]. On MRI T2-weighted sequences, the urethra has a target-shaped appearance with the outer and inner-most layers appearing hypointense (darker) and the middle submucosal layer appearing hyperintense (brighter).High-resolution transvaginal and transperineal 2D and 3D US can also be used to identify urethral and periurethral lesions. In addition to being radiation-free like MRI, US is portable, can capture both static and dynamic images, is better tolerated by patients, and is cheaper than MRI. Recent studies have found US to be comparable to MRI in terms of diagnosis of urethral and periurethral female masses [4,7,10]. US is also the recommended imaging modality for assessment of midurethral sling location and function. However, US is highly operator-dependent and requires extensive training which limits its use. VCUG can provide dynamic evaluation of the female urethra and is useful for the visualization of urethral diverticular necks and postoperatively to ensure adequate healing of the urethra [11]. Purpose of reviewFemale periurethral masses are an uncommon occurrence. The purpose of this review is to describe etiologies of female urethral and periurethral masses and to provide an update on diagnosis and management.The most common causes of periurethral and urethral masses in women are urethral caruncles, urethral diverticula, and Skene's gland cysts. Urethral meatal lesions such as urethral caruncles and prolapse can be managed conservatively with topical estrogen therapy and close follow-up or should be excised in the setting of thrombosis, significant or recurrent bleeding, acute urinary retention, or persistent pain. Benign periurethral gland masses, such as Skene's gland cysts, Gartner's duct cysts, and Mullerian duct cysts, remain rare. Recent case series reveal a high rate of surgical management of these lesions with few complications. Urethral malignancy or malignant transformation of benign etiologies are even rarer but can be aggressive in nature and should be treated promptly.Nonspecific urinary and vaginal symptoms as well as similar physical presentations make diagnosis of urethral and periurethral lesions in females difficult. Magnetic resonance imaging is useful for differentiation of periurethral masses. The decision for conservative or surgical management is typically guided by patient symptom bother, as well as concern for urethral malignancy.Papers of particular interest, published within the annual period of review, have been highlighted as:An infrequent occurrence in females, urethral and periurethral masses can be challenging to diagnose and differentiate. Such lesions can be benign or malignant and can arise from the urethra, vagina, or other nearby structures (Fig. 1). In a case series of 126 women, the most common etiologies of periurethral masses were urethral diverticula (39.7%) and Skene's gland cysts or abscesses (30.2%), followed by Gartner cysts (7.1%), Mullerian cysts (4.0%), and epidermal inclusion cysts and abscesses (3.2%) [1]. The most common lesion of the female urethra is a urethral caruncle, which is typically found in postmenopausal women. Given that it is commonly asymptomatic, the exact prevalence of urethral caruncles is unknown but may be as high as 67% in women 65 years of age and older [2]. Although malignancy is exceedingly rare in women who present with a urethral or periurethral mass, it should not be missed. no caption availableCauses of urethral and periurethral masses in women.This article will review urethral anatomy, describe common etiologies of female urethral and periurethral masses, and provide an update on diagnosis and management (Table 1). In this article, we discuss the anatomy of biologically female persons whom we refer to interchangeably as women or female.Diagnosis and management of common causes of female urethral and periurethral massesIf unable to adequately diagnose on physical exam, additional imaging (such as magnetic resonance imaging, transvaginal and transperineal ultrasound) can be used for diagnosis.Due to the low incidence of urethral carcinoma, evidence-based guidelines are limited.A 3-4 cm tubular structure about 6 mm in diameter, the female urethra is embedded in the adventitia of the anterior vagina and surrounded by numerous periurethral ducts and glands along its length (Fig. 2). The largest of these are the Skene's glands which have ostia located laterally to the urethral meatus. The urethra has four distinct layers: inner-most mucosa, submucosa with its rich venous plexus, internal sphincter (composed of two smooth muscle layers: inner longitudinal, outer circular), and outer external striated sphincter. The proximal lumen of the female urethra is lined with transitional epithelium, while the distal one-third of the urethral lumen is lined with stratified and pseudostratified columnar and squamous epithelium. Of note, the distal one-third of the female urethra can be excised without disrupting continence [3].Anatomy of female urethra and vulva. On the left: vulva with relevant anatomy labeled and common gland locations delineated with colored dots. On the right: female urethra with relevant anatomy labeled.Urethral and periurethral masses are first identified using patient history and physical examination. The most common presenting symptom is that of a palpable mass, but half of women may also present with dyspareunia and/or vaginal discharge [1]. Urinary symptoms such as frequency and urgency, dysuria, or stress urinary incontinence may occur in 15-40.5% of patients [1,4]. Similarly, 11.1-36.7% of women may present with pelvic or urethral pain, especially in the setting of an infection [1,5]. Women presenting with pain are more likely to require surgical management [6].Pelvic examination should be performed to assess the location of the lesion in relation to the urethra. The mass should be palpated, and any purulence, tenderness, or erythema should be noted. Sometimes diagnosis can be challenging clinically due to the short length of the female urethra and potentially sporadic presence of the mass. In these cases, imaging is recommended. Additionally, although experienced clinicians may be able to diagnose symptomatic periurethral and urethral lesions correctly up to 80% of the time, many find imaging to be helpful for the purposes of surgical planning and patient counseling [7]. For masses that are intermittent, it is important to perform imaging when the mass is present.There is no well defined protocol for accurate diagnosis and management of female periurethral and urethral lesions. Imaging modalities include magnetic resonance imaging (MRI), pelvic ultrasonography (US) via transvaginal or transperineal approach, computed tomography (CT), voiding cystourethrography (VCUG), and double-balloon catheter urethrography (DBU). MRI has the highest sensitivity for urethral pathology and is therefore the imaging modality of choice for diagnosis and preoperative planning [8,9]. On MRI T2-weighted sequences, the urethra has a target-shaped appearance with the outer and inner-most layers appearing hypointense (darker) and the middle submucosal layer appearing hyperintense (brighter).High-resolution transvaginal and transperineal 2D and 3D US can also be used to identify urethral and periurethral lesions. In addition to being radiation-free like MRI, US is portable, can capture both static and dynamic images, is better tolerated by patients, and is cheaper than MRI. Recent studies have found US to be comparable to MRI in terms of diagnosis of urethral and periurethral female masses [4,7,10]. US is also the recommended imaging modality for assessment of midurethral sling location and function. However, US is highly operator-dependent and requires extensive training which limits its use. VCUG can provide dynamic evaluation of the female urethra and is useful for the visualization of urethral diverticular necks and postoperatively to ensure adequate healing of the urethra [11]. Purpose of reviewFemale periurethral masses are an uncommon occurrence. The purpose of this review is to describe etiologies of female urethral and periurethral masses and to provide an update on diagnosis and management.The most common causes of periurethral and urethral masses in women are urethral caruncles, urethral diverticula, and Skene's gland cysts. Urethral meatal lesions such as urethral caruncles and prolapse can be managed conservatively with topical estrogen therapy and close follow-up or should be excised in the setting of thrombosis, significant or recurrent bleeding, acute urinary retention, or persistent pain. Benign periurethral gland masses, such as Skene's gland cysts, Gartner's duct cysts, and Mullerian duct cysts, remain rare. Recent case series reveal a high rate of surgical management of these lesions with few complications. Urethral malignancy or malignant transformation of benign etiologies are even rarer but can be aggressive in nature and should be treated promptly.Nonspecific urinary and vaginal symptoms as well as similar physical presentations make diagnosis of urethral and periurethral lesions in females difficult. Magnetic resonance imaging is useful for differentiation of periurethral masses. The decision for conservative or surgical management is typically guided by patient symptom bother, as well as concern for urethral malignancy.Papers of particular interest, published within the annual period of review, have been highlighted as:An infrequent occurrence in females, urethral and periurethral masses can be challenging to diagnose and differentiate. Such lesions can be benign or malignant and can arise from the urethra, vagina, or other nearby structures (Fig. 1). In a case series of 126 women, the most common etiologies of periurethral masses were urethral diverticula (39.7%) and Skene's gland cysts or abscesses (30.2%), followed by Gartner cysts (7.1%), Mullerian cysts (4.0%), and epidermal inclusion cysts and abscesses (3.2%) [1]. The most common lesion of the female urethra is a urethral caruncle, which is typically found in postmenopausal women. Given that it is commonly asymptomatic, the exact prevalence of urethral caruncles is unknown but may be as high as 67% in women 65 years of age and older [2]. Although malignancy is exceedingly rare in women who present with a urethral or periurethral mass, it should not be missed. no caption availableCauses of urethral and periurethral masses in women.This article will review urethral anatomy, describe common etiologies of female urethral and periurethral masses, and provide an update on diagnosis and management (Table 1). In this article, we discuss the anatomy of biologically female persons whom we refer to interchangeably as women or female.Diagnosis and management of common causes of female urethral and periurethral massesIf unable to adequately diagnose on physical exam, additional imaging (such as magnetic resonance imaging, transvaginal and transperineal ultrasound) can be used for diagnosis.Due to the low incidence of urethral carcinoma, evidence-based guidelines are limited.A 3-4 cm tubular structure about 6 mm in diameter, the female urethra is embedded in the adventitia of the anterior vagina and surrounded by numerous periurethral ducts and glands along its length (Fig. 2). The largest of these are the Skene's glands which have ostia located laterally to the urethral meatus. The urethra has four distinct layers: inner-most mucosa, submucosa with its rich venous plexus, internal sphincter (composed of two smooth muscle layers: inner longitudinal, outer circular), and outer external striated sphincter. The proximal lumen of the female urethra is lined with transitional epithelium, while the distal one-third of the urethral lumen is lined with stratified and pseudostratified columnar and squamous epithelium. Of note, the distal one-third of the female urethra can be excised without disrupting continence [3].Anatomy of female urethra and vulva. On the left: vulva with relevant anatomy labeled and common gland locations delineated with colored dots. On the right: female urethra with relevant anatomy labeled.Urethral and periurethral masses are first identified using patient history and physical examination. The most common presenting symptom is that of a palpable mass, but half of women may also present with dyspareunia and/or vaginal discharge [1]. Urinary symptoms such as frequency and urgency, dysuria, or stress urinary incontinence may occur in 15-40.5% of patients [1,4]. Similarly, 11.1-36.7% of women may present with pelvic or urethral pain, especially in the setting of an infection [1,5]. Women presenting with pain are more likely to require surgical management [6].Pelvic examination should be performed to assess the location of the lesion in relation to the urethra. The mass should be palpated, and any purulence, tenderness, or erythema should be noted. Sometimes diagnosis can be challenging clinically due to the short length of the female urethra and potentially sporadic presence of the mass. In these cases, imaging is recommended. Additionally, although experienced clinicians may be able to diagnose symptomatic periurethral and urethral lesions correctly up to 80% of the time, many find imaging to be helpful for the purposes of surgical planning and patient counseling [7]. For masses that are intermittent, it is important to perform imaging when the mass is present.There is no well defined protocol for accurate diagnosis and management of female periurethral and urethral lesions. Imaging modalities include magnetic resonance imaging (MRI), pelvic ultrasonography (US) via transvaginal or transperineal approach, computed tomography (CT), voiding cystourethrography (VCUG), and double-balloon catheter urethrography (DBU). MRI has the highest sensitivity for urethral pathology and is therefore the imaging modality of choice for diagnosis and preoperative planning [8,9]. On MRI T2-weighted sequences, the urethra has a target-shaped appearance with the outer and inner-most layers appearing hypointense (darker) and the middle submucosal layer appearing hyperintense (brighter).High-resolution transvaginal and transperineal 2D and 3D US can also be used to identify urethral and periurethral lesions. In addition to being radiation-free like MRI, US is portable, can capture both static and dynamic images, is better tolerated by patients, and is cheaper than MRI. Recent studies have found US to be comparable to MRI in terms of diagnosis of urethral and periurethral female masses [4,7,10]. US is also the recommended imaging modality for assessment of midurethral sling location and function. However, US is highly operator-dependent and requires extensive training which limits its use. VCUG can provide dynamic evaluation of the female urethra and is useful for the visualization of urethral diverticular necks and postoperatively to ensure adequate healing of the urethra [11]. Purpose of reviewFemale periurethral masses are an uncommon occurrence. The purpose of this review is to describe etiologies of female urethral and periurethral masses and to provide an update on diagnosis and management.The most common causes of periurethral and urethral masses in women are urethral caruncles, urethral diverticula, and Skene's gland cysts. Urethral meatal lesions such as urethral caruncles and prolapse can be managed conservatively with topical estrogen therapy and close follow-up or should be excised in the setting of thrombosis, significant or recurrent bleeding, acute urinary retention, or persistent pain. Benign periurethral gland masses, such as Skene's gland cysts, Gartner's duct cysts, and Mullerian duct cysts, remain rare. Recent case series reveal a high rate of surgical management of these lesions with few complications. Urethral malignancy or malignant transformation of benign etiologies are even rarer but can be aggressive in nature and should be treated promptly.Nonspecific urinary and vaginal symptoms as well as similar physical presentations make diagnosis of urethral and periurethral lesions in females difficult. Magnetic resonance imaging is useful for differentiation of periurethral masses. The decision for conservative or surgical management is typically guided by patient symptom bother, as well as concern for urethral malignancy.Papers of particular interest, published within the annual period of review, have been highlighted as:An infrequent occurrence in females, urethral and periurethral masses can be challenging to diagnose and differentiate. Such lesions can be benign or malignant and can arise from the urethra, vagina, or other nearby structures (Fig. 1). In a case series of 126 women, the most common etiologies of periurethral masses were urethral diverticula (39.7%) and Skene's gland cysts or abscesses (30.2%), followed by Gartner cysts (7.1%), Mullerian cysts (4.0%), and epidermal inclusion cysts and abscesses (3.2%) [1]. The most common lesion of the female urethra is a urethral caruncle, which is typically found in postmenopausal women. Given that it is commonly asymptomatic, the exact prevalence of urethral caruncles is unknown but may be as high as 67% in women 65 years of age and older [2]. Although malignancy is exceedingly rare in women who present with a urethral or periurethral mass, it should not be missed. no caption availableCauses of urethral and periurethral masses in women.This article will review urethral anatomy, describe common etiologies of female urethral and periurethral masses, and provide an update on diagnosis and management (Table 1). In this article, we discuss the anatomy of biologically female persons whom we refer to interchangeably as women or female.Diagnosis and management of common causes of female urethral and periurethral massesIf unable to adequately diagnose on physical exam, additional imaging (such as magnetic resonance imaging, transvaginal and transperineal ultrasound) can be used for diagnosis.Due to the low incidence of urethral carcinoma, evidence-based guidelines are limited.A 3-4 cm tubular structure about 6 mm in diameter, the female urethra is embedded in the adventitia of the anterior vagina and surrounded by numerous periurethral ducts and glands along its length (Fig. 2). The largest of these are the Skene's glands which have ostia located laterally to the urethral meatus. The urethra has four distinct layers: inner-most mucosa, submucosa with its rich venous plexus, internal sphincter (composed of two smooth muscle layers: inner longitudinal, outer circular), and outer external striated sphincter. The proximal lumen of the female urethra is lined with transitional epithelium, while the distal one-third of the urethral lumen is lined with stratified and pseudostratified columnar and squamous epithelium. Of note, the distal one-third of the female urethra can be excised without disrupting continence [3].Anatomy of female urethra and vulva. On the left: vulva with relevant anatomy labeled and common gland locations delineated with colored dots. On the right: female urethra with relevant anatomy labeled.Urethral and periurethral masses are first identified using patient history and physical examination. The most common presenting symptom is that of a palpable mass, but half of women may also present with dyspareunia and/or vaginal discharge [1]. Urinary symptoms such as frequency and urgency, dysuria, or stress urinary incontinence may occur in 15-40.5% of patients [1,4]. Similarly, 11.1-36.7% of women may present with pelvic or urethral pain, especially in the setting of an infection [1,5]. Women presenting with pain are more likely to require surgical management [6].Pelvic examination should be performed to assess the location of the lesion in relation to the urethra. The mass should be palpated, and any purulence, tenderness, or erythema should be noted. Sometimes diagnosis can be challenging clinically due to the short length of the female urethra and potentially sporadic presence of the mass. In these cases, imaging is recommended. Additionally, although experienced clinicians may be able to diagnose symptomatic periurethral and urethral lesions correctly up to 80% of the time, many find imaging to be helpful for the purposes of surgical planning and patient counseling [7]. For masses that are intermittent, it is important to perform imaging when the mass is present.There is no well defined protocol for accurate diagnosis and management of female periurethral and urethral lesions. Imaging modalities include magnetic resonance imaging (MRI), pelvic ultrasonography (US) via transvaginal or transperineal approach, computed tomography (CT), voiding cystourethrography (VCUG), and double-balloon catheter urethrography (DBU). MRI has the highest sensitivity for urethral pathology and is therefore the imaging modality of choice for diagnosis and preoperative planning [8,9]. On MRI T2-weighted sequences, the urethra has a target-shaped appearance with the outer and inner-most layers appearing hypointense (darker) and the middle submucosal layer appearing hyperintense (brighter).High-resolution transvaginal and transperineal 2D and 3D US can also be used to identify urethral and periurethral lesions. In addition to being radiation-free like MRI, US is portable, can capture both static and dynamic images, is better tolerated by patients, and is cheaper than MRI. Recent studies have found US to be comparable to MRI in terms of diagnosis of urethral and periurethral female masses [4,7,10]. US is also the recommended imaging modality for assessment of midurethral sling location and function. However, US is highly operator-dependent and requires extensive training which limits its use. VCUG can provide dynamic evaluation of the female urethra and is useful for the visualization of urethral diverticular necks and postoperatively to ensure adequate healing of the urethra [11]. Purpose of reviewFemale periurethral masses are an uncommon occurrence. The purpose of this review is to describe etiologies of female urethral and periurethral masses and to provide an update on diagnosis and management.The most common causes of periurethral and urethral masses in women are urethral caruncles, urethral diverticula, and Skene's gland cysts. Urethral meatal lesions such as urethral caruncles and prolapse can be managed conservatively with topical estrogen therapy and close follow-up or should be excised in the setting of thrombosis, significant or recurrent bleeding, acute urinary retention, or persistent pain. Benign periurethral gland masses, such as Skene's gland cysts, Gartner's duct cysts, and Mullerian duct cysts, remain rare. Recent case series reveal a high rate of surgical management of these lesions with few complications. Urethral malignancy or malignant transformation of benign etiologies are even rarer but can be aggressive in nature and should be treated promptly.Nonspecific urinary and vaginal symptoms as well as similar physical presentations make diagnosis of urethral and periurethral lesions in females difficult. Magnetic resonance imaging is useful for differentiation of periurethral masses. The decision for conservative or surgical management is typically guided by patient symptom bother, as well as concern for urethral malignancy.Papers of particular interest, published within the annual period of review, have been highlighted as:An infrequent occurrence in females, urethral and periurethral masses can be challenging to diagnose and differentiate. Such lesions can be benign or malignant and can arise from the urethra, vagina, or other nearby structures (Fig. 1). In a case series of 126 women, the most common etiologies of periurethral masses were urethral diverticula (39.7%) and Skene's gland cysts or abscesses (30.2%), followed by Gartner cysts (7.1%), Mullerian cysts (4.0%), and epidermal inclusion cysts and abscesses (3.2%) [1]. The most common lesion of the female urethra is a urethral caruncle, which is typically found in postmenopausal women. Given that it is commonly asymptomatic, the exact prevalence of urethral caruncles is unknown but may be as high as 67% in women 65 years of age and older [2]. Although malignancy is exceedingly rare in women who present with a urethral or periurethral mass, it should not be missed. no caption availableCauses of urethral and periurethral masses in women.This article will review urethral anatomy, describe common etiologies of female urethral and periurethral masses, and provide an update on diagnosis and management (Table 1). In this article, we discuss the anatomy of biologically female persons whom we refer to interchangeably as women or female.Diagnosis and management of common causes of female urethral and periurethral massesIf unable to adequately diagnose on physical exam, additional imaging (such as magnetic resonance imaging, transvaginal and transperineal ultrasound) can be used for diagnosis.Due to the low incidence of urethral carcinoma, evidence-based guidelines are limited.A 3-4 cm tubular structure about 6 mm in diameter, the female urethra is embedded in the adventitia of the anterior vagina and surrounded by numerous periurethral ducts and glands along its length (Fig. 2). The largest of these are the Skene's glands which have ostia located laterally to the urethral meatus. The urethra has four distinct layers: inner-most mucosa, submucosa with its rich venous plexus, internal sphincter (composed of two smooth muscle layers: inner longitudinal, outer circular), and outer external striated sphincter. The proximal lumen of the female urethra is lined with transitional epithelium, while the distal one-third of the urethral lumen is lined with stratified and pseudostratified columnar and squamous epithelium. Of note, the distal one-third of the female urethra can be excised without disrupting continence [3].Anatomy of female urethra and vulva. On the left: vulva with relevant anatomy labeled and common gland locations delineated with colored dots. On the right: female urethra with relevant anatomy labeled.Urethral and periurethral masses are first identified using patient history and physical examination. The most common presenting symptom is that of a palpable mass, but half of women may also present with dyspareunia and/or vaginal discharge [1]. Urinary symptoms such as frequency and urgency, dysuria, or stress urinary incontinence may occur in 15-40.5% of patients [1,4]. Similarly, 11.1-36.7% of women may present with pelvic or urethral pain, especially in the setting of an infection [1,5]. Women presenting with pain are more likely to require surgical management [6].Pelvic examination should be performed to assess the location of the lesion in relation to the urethra. The mass should be palpated, and any purulence, tenderness, or erythema should be noted. Sometimes diagnosis can be challenging clinically due to the short length of the female urethra and potentially sporadic presence of the mass. In these cases, imaging is recommended. Additionally, although experienced clinicians may be able to diagnose symptomatic periurethral and urethral lesions correctly up to 80% of the time, many find imaging to be helpful for the purposes of surgical planning and patient counseling [7]. For masses that are intermittent, it is important to perform imaging when the mass is present.There is no well defined protocol for accurate diagnosis and management of female periurethral and urethral lesions. Imaging modalities include magnetic resonance imaging (MRI), pelvic ultrasonography (US) via transvaginal or transperineal approach, computed tomography (CT), voiding cystourethrography (VCUG), and double-balloon catheter urethrography (DBU). MRI has the highest sensitivity for urethral pathology and is therefore the imaging modality of choice for diagnosis and preoperative planning [8,9]. On MRI T2-weighted sequences, the urethra has a target-shaped appearance with the outer and inner-most layers appearing hypointense (darker) and the middle submucosal layer appearing hyperintense (brighter).High-resolution transvaginal and transperineal 2D and 3D US can also be used to identify urethral and periurethral lesions. In addition to being radiation-free like MRI, US is portable, can capture both static and dynamic images, is better tolerated by patients, and is cheaper than MRI. Recent studies have found US to be comparable to MRI in terms of diagnosis of urethral and periurethral female masses [4,7,10]. US is also the recommended imaging modality for assessment of midurethral sling location and function. However, US is highly operator-dependent and requires extensive training which limits its use. VCUG can provide dynamic evaluation of the female urethra and is useful for the visualization of urethral diverticular necks and postoperatively to ensure adequate healing of the urethra [11]. Purpose of reviewFemale periurethral masses are an uncommon occurrence. The purpose of this review is to describe etiologies of female urethral and periurethral masses and to provide an update on diagnosis and management.The most common causes of periurethral and urethral masses in women are urethral caruncles, urethral diverticula, and Skene's gland cysts. Urethral meatal lesions such as urethral caruncles and prolapse can be managed conservatively with topical estrogen therapy and close follow-up or should be excised in the setting of thrombosis, significant or recurrent bleeding, acute urinary retention, or persistent pain. Benign periurethral gland masses, such as Skene's gland cysts, Gartner's duct cysts, and Mullerian duct cysts, remain rare. Recent case series reveal a high rate of surgical management of these lesions with few complications. Urethral malignancy or malignant transformation of benign etiologies are even rarer but can be aggressive in nature and should be treated promptly.Nonspecific urinary and vaginal symptoms as well as similar physical presentations make diagnosis of urethral and periurethral lesions in females difficult. Magnetic resonance imaging is useful for differentiation of periurethral masses. The decision for conservative or surgical management is typically guided by patient symptom bother, as well as concern for urethral malignancy.Papers of particular interest, published within the annual period of review, have been highlighted as:An infrequent occurrence in females, urethral and periurethral masses can be challenging to diagnose and differentiate. Such lesions can be benign or malignant and can arise from the urethra, vagina, or other nearby structures (Fig. 1). In a case series of 126 women, the most common etiologies of periurethral masses were urethral diverticula (39.7%) and Skene's gland cysts or abscesses (30.2%), followed by Gartner cysts (7.1%), Mullerian cysts (4.0%), and epidermal inclusion cysts and abscesses (3.2%) [1]. The most common lesion of the female urethra is a urethral caruncle, which is typically found in postmenopausal women. Given that it is commonly asymptomatic, the exact prevalence of urethral caruncles is unknown but may be as high as 67% in women 65 years of age and older [2]. Although malignancy is exceedingly rare in women who present with a urethral or periurethral mass, it should not be missed. no caption availableCauses of urethral and periurethral masses in women.This article will review urethral anatomy, describe common etiologies of female urethral and periurethral masses, and provide an update on diagnosis and management (Table 1). In this article, we discuss the anatomy of biologically female persons whom we refer to interchangeably as women or female.Diagnosis and management of common causes of female urethral and periurethral massesIf unable to adequately diagnose on physical exam, additional imaging (such as magnetic resonance imaging, transvaginal and transperineal ultrasound) can be used for diagnosis.Due to the low incidence of urethral carcinoma, evidence-based guidelines are limited.A 3-4 cm tubular structure about 6 mm in diameter, the female urethra is embedded in the adventitia of the anterior vagina and surrounded by numerous periurethral ducts and glands along its length (Fig. 2). The largest of these are the Skene's glands which have ostia located laterally to the urethral meatus. The urethra has four distinct layers: inner-most mucosa, submucosa with its rich venous plexus, internal sphincter (composed of two smooth muscle layers: inner longitudinal, outer circular), and outer external striated sphincter. The proximal lumen of the female urethra is lined with transitional epithelium, while the distal one-third of the urethral lumen is lined with stratified and pseudostratified columnar and squamous epithelium. Of note, the distal one-third of the female urethra can be excised without disrupting continence [3].Anatomy of female urethra and vulva. On the left: vulva with relevant anatomy labeled and common gland locations delineated with colored dots. On the right: female urethra with relevant anatomy labeled.Urethral and periurethral masses are first identified using patient history and physical examination. The most common presenting symptom is that of a palpable mass, but half of women may also present with dyspareunia and/or vaginal discharge [1]. Urinary symptoms such as frequency and urgency, dysuria, or stress urinary incontinence may occur in 15-40.5% of patients [1,4]. Similarly, 11.1-36.7% of women may present with pelvic or urethral pain, especially in the setting of an infection [1,5]. Women presenting with pain are more likely to require surgical management [6].Pelvic examination should be performed to assess the location of the lesion in relation to the urethra. The mass should be palpated, and any purulence, tenderness, or erythema should be noted. Sometimes diagnosis can be challenging clinically due to the short length of the female urethra and potentially sporadic presence of the mass. In these cases, imaging is recommended. Additionally, although experienced clinicians may be able to diagnose symptomatic periurethral and urethral lesions correctly up to 80% of the time, many find imaging to be helpful for the purposes of surgical planning and patient counseling [7]. For masses that are intermittent, it is important to perform imaging when the mass is present.There is no well defined protocol for accurate diagnosis and management of female periurethral and urethral lesions. Imaging modalities include magnetic resonance imaging (MRI), pelvic ultrasonography (US) via transvaginal or transperineal approach, computed tomography (CT), voiding cystourethrography (VCUG), and double-balloon catheter urethrography (DBU). MRI has the highest sensitivity for urethral pathology and is therefore the imaging modality of choice for diagnosis and preoperative planning [8,9]. On MRI T2-weighted sequences, the urethra has a target-shaped appearance with the outer and inner-most layers appearing hypointense (darker) and the middle submucosal layer appearing hyperintense (brighter).High-resolution transvaginal and transperineal 2D and 3D US can also be used to identify urethral and periurethral lesions. In addition to being radiation-free like MRI, US is portable, can capture both static and dynamic images, is better tolerated by patients, and is cheaper than MRI. Recent studies have found US to be comparable to MRI in terms of diagnosis of urethral and periurethral female masses [4,7,10]. US is also the recommended imaging modality for assessment of midurethral sling location and function. However, US is highly operator-dependent and requires extensive training which limits its use. VCUG can provide dynamic evaluation of the female urethra and is useful for the visualization of urethral diverticular necks and postoperatively to ensure adequate healing of the urethra [11]. Purpose of reviewFemale periurethral masses are an uncommon occurrence. The purpose of this review is to describe etiologies of female urethral and periurethral masses and to provide an update on diagnosis and management.The most common causes of periurethral and urethral masses in women are urethral caruncles, urethral diverticula, and Skene's gland cysts. Urethral meatal lesions such as urethral caruncles and prolapse can be managed conservatively with topical estrogen therapy and close follow-up or should be excised in the setting of thrombosis, significant or recurrent bleeding, acute urinary retention, or persistent pain. Benign periurethral gland masses, such as Skene's gland cysts, Gartner's duct cysts, and Mullerian duct cysts, remain rare. Recent case series reveal a high rate of surgical management of these lesions with few complications. Urethral malignancy or malignant transformation of benign etiologies are even rarer but can be aggressive in nature and should be treated promptly.Nonspecific urinary and vaginal symptoms as well as similar physical presentations make diagnosis of urethral and periurethral lesions in females difficult. Magnetic resonance imaging is useful for differentiation of periurethral masses. The decision for conservative or surgical management is typically guided by patient symptom bother, as well as concern for urethral malignancy.Papers of particular interest, published within the annual period of review, have been highlighted as:An infrequent occurrence in females, urethral and periurethral masses can be challenging to diagnose and differentiate. Such lesions can be benign or malignant and can arise from the urethra, vagina, or other nearby structures (Fig. 1). In a case series of 126 women, the most common etiologies of periurethral masses were urethral diverticula (39.7%) and Skene's gland cysts or abscesses (30.2%), followed by Gartner cysts (7.1%), Mullerian cysts (4.0%), and epidermal inclusion cysts and abscesses (3.2%) [1]. The most common lesion of the female urethra is a urethral caruncle, which is typically found in postmenopausal women. Given that it is commonly asymptomatic, the exact prevalence of urethral caruncles is unknown but may be as high as 67% in women 65 years of age and older [2]. Although malignancy is exceedingly rare in women who present with a urethral or periurethral mass, it should not be missed. no caption availableCauses of urethral and periurethral masses in women.This article will review urethral anatomy, describe common etiologies of female urethral and periurethral masses, and provide an update on diagnosis and management (Table 1). In this article, we discuss the anatomy of biologically female persons whom we refer to interchangeably as women or female.Diagnosis and management of common causes of female urethral and periurethral massesIf unable to adequately diagnose on physical exam, additional imaging (such as magnetic resonance imaging, transvaginal and transperineal ultrasound) can be used for diagnosis.Due to the low incidence of urethral carcinoma, evidence-based guidelines are limited.A 3-4 cm tubular structure about 6 mm in diameter, the female urethra is embedded in the adventitia of the anterior vagina and surrounded by numerous periurethral ducts and glands along its length (Fig. 2). The largest of these are the Skene's glands which have ostia located laterally to the urethral meatus. The urethra has four distinct layers: inner-most mucosa, submucosa with its rich venous plexus, internal sphincter (composed of two smooth muscle layers: inner longitudinal, outer circular), and outer external striated sphincter. The proximal lumen of the female urethra is lined with transitional epithelium, while the distal one-third of the urethral lumen is lined with stratified and pseudostratified columnar and squamous epithelium. Of note, the distal one-third of the female urethra can be excised without disrupting continence [3].Anatomy of female urethra and vulva. On the left: vulva with relevant anatomy labeled and common gland locations delineated with colored dots. On the right: female urethra with relevant anatomy labeled.Urethral and periurethral masses are first identified using patient history and physical examination. The most common presenting symptom is that of a palpable mass, but half of women may also present with dyspareunia and/or vaginal discharge [1]. Urinary symptoms such as frequency and urgency, dysuria, or stress urinary incontinence may occur in 15-40.5% of patients [1,4]. Similarly, 11.1-36.7% of women may present with pelvic or urethral pain, especially in the setting of an infection [1,5]. Women presenting with pain are more likely to require surgical management [6].Pelvic examination should be performed to assess the location of the lesion in relation to the urethra. The mass should be palpated, and any purulence, tenderness, or erythema should be noted. Sometimes diagnosis can be challenging clinically due to the short length of the female urethra and potentially sporadic presence of the mass. In these cases, imaging is recommended. Additionally, although experienced clinicians may be able to diagnose symptomatic periurethral and urethral lesions correctly up to 80% of the time, many find imaging to be helpful for the purposes of surgical planning and patient counseling [7]. For masses that are intermittent, it is important to perform imaging when the mass is present.There is no well defined protocol for accurate diagnosis and management of female periurethral and urethral lesions. Imaging modalities include magnetic resonance imaging (MRI), pelvic ultrasonography (US) via transvaginal or transperineal approach, computed tomography (CT), voiding cystourethrography (VCUG), and double-balloon catheter urethrography (DBU). MRI has the highest sensitivity for urethral pathology and is therefore the imaging modality of choice for diagnosis and preoperative planning [8,9]. On MRI T2-weighted sequences, the urethra has a target-shaped appearance with the outer and inner-most layers appearing hypointense (darker) and the middle submucosal layer appearing hyperintense (brighter).High-resolution transvaginal and transperineal 2D and 3D US can also be used to identify urethral and periurethral lesions. In addition to being radiation-free like MRI, US is portable, can capture both static and dynamic images, is better tolerated by patients, and is cheaper than MRI. Recent studies have found US to be comparable to MRI in terms of diagnosis of urethral and periurethral female masses [4,7,10]. US is also the recommended imaging modality for assessment of midurethral sling location and function. However, US is highly operator-dependent and requires extensive training which limits its use. VCUG can provide dynamic evaluation of the female urethra and is useful for the visualization of urethral diverticular necks and postoperatively to ensure adequate healing of the urethra [11]. Purpose of reviewFemale periurethral masses are an uncommon occurrence. The purpose of this review is to describe etiologies of female urethral and periurethral masses and to provide an update on diagnosis and management.The most common causes of periurethral and urethral masses in women are urethral caruncles, urethral diverticula, and Skene's gland cysts. Urethral meatal lesions such as urethral caruncles and prolapse can be managed conservatively with topical estrogen therapy and close follow-up or should be excised in the setting of thrombosis, significant or recurrent bleeding, acute urinary retention, or persistent pain. Benign periurethral gland masses, such as Skene's gland cysts, Gartner's duct cysts, and Mullerian duct cysts, remain rare. Recent case series reveal a high rate of surgical management of these lesions with few complications. Urethral malignancy or malignant transformation of benign etiologies are even rarer but can be aggressive in nature and should be treated promptly.Nonspecific urinary and vaginal symptoms as well as similar physical presentations make diagnosis of urethral and periurethral lesions in females difficult. Magnetic resonance imaging is useful for differentiation of periurethral masses. The decision for conservative or surgical management is typically guided by patient symptom bother, as well as concern for urethral malignancy.Papers of particular interest, published within the annual period of review, have been highlighted as:An infrequent occurrence in females, urethral and periurethral masses can be challenging to diagnose and differentiate. Such lesions can be benign or malignant and can arise from the urethra, vagina, or other nearby structures (Fig. 1). In a case series of 126 women, the most common etiologies of periurethral masses were urethral diverticula (39.7%) and Skene's gland cysts or abscesses (30.2%), followed by Gartner cysts (7.1%), Mullerian cysts (4.0%), and epidermal inclusion cysts and abscesses (3.2%) [1]. The most common lesion of the female urethra is a urethral caruncle, which is typically found in postmenopausal women. Given that it is commonly asymptomatic, the exact prevalence of urethral caruncles is unknown but may be as high as 67% in women 65 years of age and older [2]. Although malignancy is exceedingly rare in women who present with a urethral or periurethral mass, it should not be missed. no caption availableCauses of urethral and periurethral masses in women.This article will review urethral anatomy, describe common etiologies of female urethral and periurethral masses, and provide an update on diagnosis and management (Table 1). In this article, we discuss the anatomy of biologically female persons whom we refer to interchangeably as women or female.Diagnosis and management of common causes of female urethral and periurethral massesIf unable to adequately diagnose on physical exam, additional imaging (such as magnetic resonance imaging, transvaginal and transperineal ultrasound) can be used for diagnosis.Due to the low incidence of urethral carcinoma, evidence-based guidelines are limited.A 3-4 cm tubular structure about 6 mm in diameter, the female urethra is embedded in the adventitia of the anterior vagina and surrounded by numerous periurethral ducts and glands along its length (Fig. 2). The largest of these are the Skene's glands which have ostia located laterally to the urethral meatus. The urethra has four distinct layers: inner-most mucosa, submucosa with its rich venous plexus, internal sphincter (composed of two smooth muscle layers: inner longitudinal, outer circular), and outer external striated sphincter. The proximal lumen of the female urethra is lined with transitional epithelium, while the distal one-third of the urethral lumen is lined with stratified and pseudostratified columnar and squamous epithelium. Of note, the distal one-third of the female urethra can be excised without disrupting continence [3].Anatomy of female urethra and vulva. On the left: vulva with relevant anatomy labeled and common gland locations delineated with colored dots. On the right: female urethra with relevant anatomy labeled.Urethral and periurethral masses are first identified using patient history and physical examination. The most common presenting symptom is that of a palpable mass, but half of women may also present with dyspareunia and/or vaginal discharge [1]. Urinary symptoms such as frequency and urgency, dysuria, or stress urinary incontinence may occur in 15-40.5% of patients [1,4]. Similarly, 11.1-36.7% of women may present with pelvic or urethral pain, especially in the setting of an infection [1,5]. Women presenting with pain are more likely to require surgical management [6].Pelvic examination should be performed to assess the location of the lesion in relation to the urethra. The mass should be palpated, and any purulence, tenderness, or erythema should be noted. Sometimes diagnosis can be challenging clinically due to the short length of the female urethra and potentially sporadic presence of the mass. In these cases, imaging is recommended. Additionally, although experienced clinicians may be able to diagnose symptomatic periurethral and urethral lesions correctly up to 80% of the time, many find imaging to be helpful for the purposes of surgical planning and patient counseling [7]. For masses that are intermittent, it is important to perform imaging when the mass is present.There is no well defined protocol for accurate diagnosis and management of female periurethral and urethral lesions. Imaging modalities include magnetic resonance imaging (MRI), pelvic ultrasonography (US) via transvaginal or transperineal approach, computed tomography (CT), voiding cystourethrography (VCUG), and double-balloon catheter urethrography (DBU). MRI has the highest sensitivity for urethral pathology and is therefore the imaging modality of choice for diagnosis and preoperative planning [8,9]. On MRI T2-weighted sequences, the urethra has a target-shaped appearance with the outer and inner-most layers appearing hypointense (darker) and the middle submucosal layer appearing hyperintense (brighter).High-resolution transvaginal and transperineal 2D and 3D US can also be used to identify urethral and periurethral lesions. In addition to being radiation-free like MRI, US is portable, can capture both static and dynamic images, is better tolerated by patients, and is cheaper than MRI. Recent studies have found US to be comparable to MRI in terms of diagnosis of urethral and periurethral female masses [4,7,10]. US is also the recommended imaging modality for assessment of midurethral sling location and function. However, US is highly operator-dependent and requires extensive training which limits its use. VCUG can provide dynamic evaluation of the female urethra and is useful for the visualization of urethral diverticular necks and postoperatively to ensure adequate healing of the urethra [11]. Purpose of reviewFemale periurethral masses are an uncommon occurrence. The purpose of this review is to describe etiologies of female urethral and periurethral masses and to provide an update on diagnosis and management.The most common causes of periurethral and urethral masses in women are urethral caruncles, urethral diverticula, and Skene's gland cysts. Urethral meatal lesions such as urethral caruncles and prolapse can be managed conservatively with topical estrogen therapy and close follow-up or should be excised in the setting of thrombosis, significant or recurrent bleeding, acute urinary retention, or persistent pain. Benign periurethral gland masses, such as Skene's gland cysts, Gartner's duct cysts, and Mullerian duct cysts, remain rare. Recent case series reveal a high rate of surgical management of these lesions with few complications. Urethral malignancy or malignant transformation of benign etiologies are even rarer but can be aggressive in nature and should be treated promptly.Nonspecific urinary and vaginal symptoms as well as similar physical presentations make diagnosis of urethral and periurethral lesions in females difficult. Magnetic resonance imaging is useful for differentiation of periurethral masses. The decision for conservative or surgical management is typically guided by patient symptom bother, as well as concern for urethral malignancy.Papers of particular interest, published within the annual period of review, have been highlighted as:An infrequent occurrence in females, urethral and periurethral masses can be challenging to diagnose and differentiate. Such lesions can be benign or malignant and can arise from the urethra, vagina, or other nearby structures (Fig. 1). In a case series of 126 women, the most common etiologies of periurethral masses were urethral diverticula (39.7%) and Skene's gland cysts or abscesses (30.2%), followed by Gartner cysts (7.1%), Mullerian cysts (4.0%), and epidermal inclusion cysts and abscesses (3.2%) [1]. The most common lesion of the female urethra is a urethral caruncle, which is typically found in postmenopausal women. Given that it is commonly asymptomatic, the exact prevalence of urethral caruncles is unknown but may be as high as 67% in women 65 years of age and older [2]. Although malignancy is exceedingly rare in women who present with a urethral or periurethral mass, it should not be missed. no caption availableCauses of urethral and periurethral masses in women.This article will review urethral anatomy, describe common etiologies of female urethral and periurethral masses, and provide an update on diagnosis and management (Table 1). In this article, we discuss the anatomy of biologically female persons whom we refer to interchangeably as women or female.Diagnosis and management of common causes of female urethral and periurethral massesIf unable to adequately diagnose on physical exam, additional imaging (such as magnetic resonance imaging, transvaginal and transperineal ultrasound) can be used for diagnosis.Due to the low incidence of urethral carcinoma, evidence-based guidelines are limited.A 3-4 cm tubular structure about 6 mm in diameter, the female urethra is embedded in the adventitia of the anterior vagina and surrounded by numerous periurethral ducts and glands along its length (Fig. 2). The largest of these are the Skene's glands which have ostia located laterally to the urethral meatus. The urethra has four distinct layers: inner-most mucosa, submucosa with its rich venous plexus, internal sphincter (composed of two smooth muscle layers: inner longitudinal, outer circular), and outer external striated sphincter. The proximal lumen of the female urethra is lined with transitional epithelium, while the distal one-third of the urethral lumen is lined with stratified and pseudostratified columnar and squamous epithelium. Of note, the distal one-third of the female urethra can be excised without disrupting continence [3].Anatomy of female urethra and vulva. On the left: vulva with relevant anatomy labeled and common gland locations delineated with colored dots. On the right: female urethra with relevant anatomy labeled.Urethral and periurethral masses are first identified using patient history and physical examination. The most common presenting symptom is that of a palpable mass, but half of women may also present with dyspareunia and/or vaginal discharge [1]. Urinary symptoms such as frequency and urgency, dysuria, or stress urinary incontinence may occur in 15-40.5% of patients [1,4]. Similarly, 11.1-36.7% of women may present with pelvic or urethral pain, especially in the setting of an infection [1,5]. Women presenting with pain are more likely to require surgical management [6].Pelvic examination should be performed to assess the location of the lesion in relation to the urethra. The mass should be palpated, and any purulence, tenderness, or erythema should be noted. Sometimes diagnosis can be challenging clinically due to the short length of the female urethra and potentially sporadic presence of the mass. In these cases, imaging is recommended. Additionally, although experienced clinicians may be able to diagnose symptomatic periurethral and urethral lesions correctly up to 80% of the time, many find imaging to be helpful for the purposes of surgical planning and patient counseling [7]. For masses that are intermittent, it is important to perform imaging when the mass is present.There is no well defined protocol for accurate diagnosis and management of female periurethral and urethral lesions. Imaging modalities include magnetic resonance imaging (MRI), pelvic ultrasonography (US) via transvaginal or transperineal approach, computed tomography (CT), voiding cystourethrography (VCUG), and double-balloon catheter urethrography (DBU). MRI has the highest sensitivity for urethral pathology and is therefore the imaging modality of choice for diagnosis and preoperative planning [8,9]. On MRI T2-weighted sequences, the urethra has a target-shaped appearance with the outer and inner-most layers appearing hypointense (darker) and the middle submucosal layer appearing hyperintense (brighter).High-resolution transvaginal and transperineal 2D and 3D US can also be used to identify urethral and periurethral lesions. In addition to being radiation-free like MRI, US is portable, can capture both static and dynamic images, is better tolerated by patients, and is cheaper than MRI. Recent studies have found US to be comparable to MRI in terms of diagnosis of urethral and periurethral female masses [4,7,10]. US is also the recommended imaging modality for assessment of midurethral sling location and function. However, US is highly operator-dependent and requires extensive training which limits its use. VCUG can provide dynamic evaluation of the female urethra and is useful for the visualization of urethral diverticular necks and postoperatively to ensure adequate healing of the urethra [11]. Purpose of reviewFemale periurethral masses are an uncommon occurrence. The purpose of this review is to describe etiologies of female urethral and periurethral masses and to provide an update on diagnosis and management.The most common causes of periurethral and urethral masses in women are urethral caruncles, urethral diverticula, and Skene's gland cysts. Urethral meatal lesions such as urethral caruncles and prolapse can be managed conservatively with topical estrogen therapy and close follow-up or should be excised in the setting of thrombosis, significant or recurrent bleeding, acute urinary retention, or persistent pain. Benign periurethral gland masses, such as Skene's gland cysts, Gartner's duct cysts, and Mullerian duct cysts, remain rare. Recent case series reveal a high rate of surgical management of these lesions with few complications. Urethral malignancy or malignant transformation of benign etiologies are even rarer but can be aggressive in nature and should be treated promptly.Nonspecific urinary and vaginal symptoms as well as similar physical presentations make diagnosis of urethral and periurethral lesions in females difficult. Magnetic resonance imaging is useful for differentiation of periurethral masses. The decision for conservative or surgical management is typically guided by patient symptom bother, as well as concern for urethral malignancy.Papers of particular interest, published within the annual period of review, have been highlighted as:An infrequent occurrence in females, urethral and periurethral masses can be challenging to diagnose and differentiate. Such lesions can be benign or malignant and can arise from the urethra, vagina, or other nearby structures (Fig. 1). In a case series of 126 women, the most common etiologies of periurethral masses were urethral diverticula (39.7%) and Skene's gland cysts or abscesses (30.2%), followed by Gartner cysts (7.1%), Mullerian cysts (4.0%), and epidermal inclusion cysts and abscesses (3.2%) [1]. The most common lesion of the female urethra is a urethral caruncle, which is typically found in postmenopausal women. Given that it is commonly asymptomatic, the exact prevalence of urethral caruncles is unknown but may be as high as 67% in women 65 years of age and older [2]. Although malignancy is exceedingly rare in women who present with a urethral or periurethral mass, it should not be missed. no caption availableCauses of urethral and periurethral masses in women.This article will review urethral anatomy, describe common etiologies of female urethral and periurethral masses, and provide an update on diagnosis and management (Table 1). In this article, we discuss the anatomy of biologically female persons whom we refer to interchangeably as women or female.Diagnosis and management of common causes of female urethral and periurethral massesIf unable to adequately diagnose on physical exam, additional imaging (such as magnetic resonance imaging, transvaginal and transperineal ultrasound) can be used for diagnosis.Due to the low incidence of urethral carcinoma, evidence-based guidelines are limited.A 3-4 cm tubular structure about 6 mm in diameter, the female urethra is embedded in the adventitia of the anterior vagina and surrounded by numerous periurethral ducts and glands along its length (Fig. 2). The largest of these are the Skene's glands which have ostia located laterally to the urethral meatus. The urethra has four distinct layers: inner-most mucosa, submucosa with its rich venous plexus, internal sphincter (composed of two smooth muscle layers: inner longitudinal, outer circular), and outer external striated sphincter. The proximal lumen of the female urethra is lined with transitional epithelium, while the distal one-third of the urethral lumen is lined with stratified and pseudostratified columnar and squamous epithelium. Of note, the distal one-third of the female urethra can be excised without disrupting continence [3].Anatomy of female urethra and vulva. On the left: vulva with relevant anatomy labeled and common gland locations delineated with colored dots. On the right: female urethra with relevant anatomy labeled.Urethral and periurethral masses are first identified using patient history and physical examination. The most common presenting symptom is that of a palpable mass, but half of women may also present with dyspareunia and/or vaginal discharge [1]. Urinary symptoms such as frequency and urgency, dysuria, or stress urinary incontinence may occur in 15-40.5% of patients [1,4]. Similarly, 11.1-36.7% of women may present with pelvic or urethral pain, especially in the setting of an infection [1,5]. Women presenting with pain are more likely to require surgical management [6].Pelvic examination should be performed to assess the location of the lesion in relation to the urethra. The mass should be palpated, and any purulence, tenderness, or erythema should be noted. Sometimes diagnosis can be challenging clinically due to the short length of the female urethra and potentially sporadic presence of the mass. In these cases, imaging is recommended. Additionally, although experienced clinicians may be able to diagnose symptomatic periurethral and urethral lesions correctly up to 80% of the time, many find imaging to be helpful for the purposes of surgical planning and patient counseling [7]. For masses that are intermittent, it is important to perform imaging when the mass is present.There is no well defined protocol for accurate diagnosis and management of female periurethral and urethral lesions. Imaging modalities include magnetic resonance imaging (MRI), pelvic ultrasonography (US) via transvaginal or transperineal approach, computed tomography (CT), voiding cystourethrography (VCUG), and double-balloon catheter urethrography (DBU). MRI has the highest sensitivity for urethral pathology and is therefore the imaging modality of choice for diagnosis and preoperative planning [8,9]. On MRI T2-weighted sequences, the urethra has a target-shaped appearance with the outer and inner-most layers appearing hypointense (darker) and the middle submucosal layer appearing hyperintense (brighter).High-resolution transvaginal and transperineal 2D and 3D US can also be used to identify urethral and periurethral lesions. In addition to being radiation-free like MRI, US is portable, can capture both static and dynamic images, is better tolerated by patients, and is cheaper than MRI. Recent studies have found US to be comparable to MRI in terms of diagnosis of urethral and periurethral female masses [4,7,10]. US is also the recommended imaging modality for assessment of midurethral sling location and function. However, US is highly operator-dependent and requires extensive training which limits its use. VCUG can provide dynamic evaluation of the female urethra and is useful for the visualization of urethral diverticular necks and postoperatively to ensure adequate healing of the urethra [11]. Purpose of reviewFemale periurethral masses are an uncommon occurrence. The purpose of this review is to describe etiologies of female urethral and periurethral masses and to provide an update on diagnosis and management.The most common causes of periurethral and urethral masses in women are urethral caruncles, urethral diverticula, and Skene's gland cysts. Urethral meatal lesions such as urethral caruncles and prolapse can be managed conservatively with topical estrogen therapy and close follow-up or should be excised in the setting of thrombosis, significant or recurrent bleeding, acute urinary retention, or persistent pain. Benign periurethral gland masses, such as Skene's gland cysts, Gartner's duct cysts, and Mullerian duct cysts, remain rare. Recent case series reveal a high rate of surgical management of these lesions with few complications. Urethral malignancy or malignant transformation of benign etiologies are even rarer but can be aggressive in nature and should be treated promptly.Nonspecific urinary and vaginal symptoms as well as similar physical presentations make diagnosis of urethral and periurethral lesions in females difficult. Magnetic resonance imaging is useful for differentiation of periurethral masses. The decision for conservative or surgical management is typically guided by patient symptom bother, as well as concern for urethral malignancy.Papers of particular interest, published within the annual period of review, have been highlighted as:An infrequent occurrence in females, urethral and periurethral masses can be challenging to diagnose and differentiate. Such lesions can be benign or malignant and can arise from the urethra, vagina, or other nearby structures (Fig. 1). In a case series of 126 women, the most common etiologies of periurethral masses were urethral diverticula (39.7%) and Skene's gland cysts or abscesses (30.2%), followed by Gartner cysts (7.1%), Mullerian cysts (4.0%), and epidermal inclusion cysts and abscesses (3.2%) [1]. The most common lesion of the female urethra is a urethral caruncle, which is typically found in postmenopausal women. Given that it is commonly asymptomatic, the exact prevalence of urethral caruncles is unknown but may be as high as 67% in women 65 years of age and older [2]. Although malignancy is exceedingly rare in women who present with a urethral or periurethral mass, it should not be missed. no caption availableCauses of urethral and periurethral masses in women.This article will review urethral anatomy, describe common etiologies of female urethral and periurethral masses, and provide an update on diagnosis and management (Table 1). In this article, we discuss the anatomy of biologically female persons whom we refer to interchangeably as women or female.Diagnosis and management of common causes of female urethral and periurethral massesIf unable to adequately diagnose on physical exam, additional imaging (such as magnetic resonance imaging, transvaginal and transperineal ultrasound) can be used for diagnosis.Due to the low incidence of urethral carcinoma, evidence-based guidelines are limited.A 3-4 cm tubular structure about 6 mm in diameter, the female urethra is embedded in the adventitia of the anterior vagina and surrounded by numerous periurethral ducts and glands along its length (Fig. 2). The largest of these are the Skene's glands which have ostia located laterally to the urethral meatus. The urethra has four distinct layers: inner-most mucosa, submucosa with its rich venous plexus, internal sphincter (composed of two smooth muscle layers: inner longitudinal, outer circular), and outer external striated sphincter. The proximal lumen of the female urethra is lined with transitional epithelium, while the distal one-third of the urethral lumen is lined with stratified and pseudostratified columnar and squamous epithelium. Of note, the distal one-third of the female urethra can be excised without disrupting continence [3].Anatomy of female urethra and vulva. On the left: vulva with relevant anatomy labeled and common gland locations delineated with colored dots. On the right: female urethra with relevant anatomy labeled.Urethral and periurethral masses are first identified using patient history and physical examination. The most common presenting symptom is that of a palpable mass, but half of women may also present with dyspareunia and/or vaginal discharge [1]. Urinary symptoms such as frequency and urgency, dysuria, or stress urinary incontinence may occur in 15-40.5% of patients [1,4]. Similarly, 11.1-36.7% of women may present with pelvic or urethral pain, especially in the setting of an infection [1,5]. Women presenting with pain are more likely to require surgical management [6].Pelvic examination should be performed to assess the location of the lesion in relation to the urethra. The mass should be palpated, and any purulence, tenderness, or erythema should be noted. Sometimes diagnosis can be challenging clinically due to the short length of the female urethra and potentially sporadic presence of the mass. In these cases, imaging is recommended. Additionally, although experienced clinicians may be able to diagnose symptomatic periurethral and urethral lesions correctly up to 80% of the time, many find imaging to be helpful for the purposes of surgical planning and patient counseling [7]. For masses that are intermittent, it is important to perform imaging when the mass is present.There is no well defined protocol for accurate diagnosis and management of female periurethral and urethral lesions. Imaging modalities include magnetic resonance imaging (MRI), pelvic ultrasonography (US) via transvaginal or transperineal approach, computed tomography (CT), voiding cystourethrography (VCUG), and double-balloon catheter urethrography (DBU). MRI has the highest sensitivity for urethral pathology and is therefore the imaging modality of choice for diagnosis and preoperative planning [8,9]. On MRI T2-weighted sequences, the urethra has a target-shaped appearance with the outer and inner-most layers appearing hypointense (darker) and the middle submucosal layer appearing hyperintense (brighter).High-resolution transvaginal and transperineal 2D and 3D US can also be used to identify urethral and periurethral lesions. In addition to being radiation-free like MRI, US is portable, can capture both static and dynamic images, is better tolerated by patients, and is cheaper than MRI. Recent studies have found US to be comparable to MRI in terms of diagnosis of urethral and periurethral female masses [4,7,10]. US is also the recommended imaging modality for assessment of midurethral sling location and function. However, US is highly operator-dependent and requires extensive training which limits its use. VCUG can provide dynamic evaluation of the female urethra and is useful for the visualization of urethral diverticular necks and postoperatively to ensure adequate healing of the urethra [11].