The Art of Practicing Medicine (Or how I figured out I still had a sketchy vagina bump)

There is never a great time to have a surgery, or a subsequent catheterization, but as detailed here, it was a particularly crummy time for mine. I had a surgery, a 7 day check up, a 17 day checkup, a 30 day check up when the catheter finally came out, and on day 35 I moved to Charleston, SC for a clinical rotation.

On day 30, when the catheter was gone for good, I asked my surgeon: “How long until I should feel normal?” While completely elated to pee in a toilet, I still felt off. The kind of off that was burning with urination. She told me that once the last stitch fell out I would be as healed as I was going to get. She told me about how I could check for the stitches with my fingers in the shower. She told me it looked like I might currently have a UTI, which wouldn’t be surprising given the amount of time I had a foreign object living in my urethra. She gave me a referral to a lab to follow up with if I still had symptoms in a week and she sent me on my way.

That night in the shower, I was assessing my stitches, and feeling what my new and “improved” parts were like. I was surprised to find that I still had the weird nodule thing that clued me in to there being an issue in the first place. It hadn’t moved, but had gotten harder and was really painful to touch. I guessed that maybe I had developed scar tissue in the spot she performed surgery on, even though my stitches were deeper in the vaginal canal. At this point, I was in Charleston and there wasn’t anything I could do shy of driving 5 hours to see my urologist in Atlanta. I didn’t have much choice but to basically ignore it. I started working in a skilled nursing facility where I was on my feet for 10 hours a time. I got back in the gym. I picked up zumba classes. I felt marginally better than before I had the surgery – I no longer had pain in my low abdomen/suprapubic area. I had significantly less anxiety about the nodule, appeased by the idea that it had been diagnosed and dealt with by a well-known, well educated surgeon. I continued to have painful and slightly burning urination, even after my UTI tests came back negative. I still constantly felt the need to pee, even after I had just gone. My urine smelled weird. Sound Familiar? Additionally, I had a difficult time holding my bladder, sometimes just barely making it to the bathroom and getting my pants off in time. I had tailbone pain that I associated with sitting poorly with my butt tucked under me for over a month. I tried to find a pelvic floor physical therapist to see that summer, but while I was there there was exactly one in the entire city of Charleston, and life got away from me.

When I got back to ATL for my follow up appointment, I updated the surgeon on my progress. She had a nurse test my ability to void completely via a bladder scanner, which she had done at my first appointment, and then she gave me a physical exam. I knew that my voiding (aka peeing) was dysfunctional – that morning alone I had gone to use the restroom 4 times during the time I was in the office (although I had been there for 2 hours, that’s another issue). My bladder immediately after voiding was holding 100 ccs of urine. That’s right on the upper edge of normal, but was 7x more than I had at my first appointment. The doctor recommended that she dilate my urethra* in order to improve my ability to empty my bladder – she commented on how small my urethra is at that time, definitely smaller than before the surgery (another story for another time).

When asked about the nodule, she told me that she felt a very small bump where I was describing. I asked her to be more specific, and she pointed to the size of her stud earring. It became immediately clear that we were NOT talking about the same bump. My nodule was about the size of a pea, and it was hard. She had me show her exactly what I was talking about when my verbal directions weren’t cutting it. (There just aren’t a lot of landmarks to go by, you know? Left by the broken down fence, right by the McDonalds, stop when you find the pea-sized hard painful lump that’s been in my vagina for months). When she locates it, she says one of the most horrific things I think I’ve heard to date, “This is not where I repaired your urethral diverticulum”. 

This is the point where everyone asks how that could possibly happen. This is what I can gather: When she first diagnosed my diverticulum, she did it via a vaginal exam. When she was palpating my vaginal wall, she found an area that she described as “boggy” and “pillowy,” a tell-tale sign of a UD. I remember these exact phrases because I responded by saying that, “I was surprised to hear you say pillowy, because I would have called it hard,” and she responded that it could be soft or hard depending on the amount of fluid it was holding at any given time. In this moment, her fingers were about 2.5 inches into my vaginal canal, and she was commenting on the consistency of the tissue beneath her fingertips, while I was talking about a hard nodule much less deep. But when she examined me, I thought we were talking about the same place because she was contacting my bump with the base of her fingers.

Medical practice really is just that – practice. I’ve read a disheartening amount of research on the topic of UD since diagnosis and the reality is that they are difficult to diagnose because they can have large degrees of variation in presentation. Their incidence is reported as 1-6% in the literature, but given their under diagnosis that number is probably wrong. They are typically found in females 30 – 60 years old, but there are plenty of documented cases of them being found in younger individuals. There is no doubt in my mind that I had a urethral diverticulum, but unfortunately I don’t have any proof that it happened to be causing my symptoms. I’ve been asked if I find fault with the surgeon who did my surgery, and I don’t fault her at all for her diagnosis or the surgery, but I continue to find fault with how she responded when we both realized she didn’t fix my problem.

*Urethral dilation involves the placement of metal rods of increasing size into the urethra with the goal of stretching it out. It can be done with local anesthetic or under sedation.