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Bladder Diverticulum

Diverticulum of the Bladder

A bladder diverticulum is an outpouching of the bladder wall that is either congenital or acquired. Bladder diverticula can be clinically silent or cause symptoms related to obstruction, urinary stasis, and other mechanisms as well. In many cases, it is diagnosed accidentally.


Presentation

A bladder diverticulum is defined as the herniation of mucosal tissue through the bladder wall, hence creating an outpouching of the wall. Bladder diverticula are either congenital (primary) or acquired (secondary) [1] and the size and number are variable. The former type includes primary congenital bladder diverticulum (PCBD) and congenital syndromes such as Ehlers-Danlos syndrome, Prune-belly syndrome, Diamond-Blackfan syndrome, and others as well. The bladder outpouching in PCBD is not related to obstruction but is a consequence of an inadequate bladder wall due to a deficiency in the detrusor layer [2]. Investigators in one study managing predominantly male children with PCBD revealed that common manifestations included urinary tract infection with fever and hydronephrosis [3].

The acquired form is more common and develops in response to high pressure on the trabeculated bladder wall, which is typically secondary to bladder outlet obstruction in the setting of benign prostatic hypertrophy (BPH) [4]. Although BPH accounts for most cases of bladder diverticula [4], other causes include urethral stricture, bladder neck stenosis, neurogenic bladder, posterior urethral valves, and ureterocele. Diverticula may also result as a postoperative complication.

Regarding the clinical presentation, a majority of diverticula do not produce symptoms and are found incidentally through evaluation for hematuria, urinary tract infection, or bladder outlet obstruction [1]. Men with obstruction secondary to BPH will report trouble with urination and incomplete voiding [4].

Complications

Due longstanding urinary stasis, patients with bladder diverticula are at risk for developing bladder stones and infection [1]. Other serious complications include bladder rupture [5] and intra-diverticular transitional cell carcinoma [6].

Recurrent Urinary Tract Infection
  • A large bladder diverticulum, responsible for incomplete bladder emptying and recurrent urinary tract infections in an 87-year-old man, was successfully excised endoscopically. The technique and possible future indications are described.[ncbi.nlm.nih.gov]
  • The major clinical conditions are recurrent urinary tract infection (UTI) and voiding dysfunction. This report describes a 15-year-old male adolescent who developed sudden visual disturbance resulting from hypertensive retinopathy.[ncbi.nlm.nih.gov]
  • Since then he had been suffering from recurrent urinary tract infections and urinary leak, which used to be treated symptomatically.[ncbi.nlm.nih.gov]
  • Our patient was a 64-year-old male with a history of lower urinary tract symptoms secondary to benign prostatic enlargement for 6 years with recurrent urinary tract infection.[ncbi.nlm.nih.gov]
  • Recurrent urinary tract infections and voiding dysfunction in pediatric population should always be evaluated for congenital bladder diverticulum.[ncbi.nlm.nih.gov]
Hypertensive Retinopathy
  • This report describes a 15-year-old male adolescent who developed sudden visual disturbance resulting from hypertensive retinopathy. The cause of hypertension was bilateral obstructive uropathy caused by enlarged paraureteral bladder diverticula.[ncbi.nlm.nih.gov]
  • Retinopathy. ( 29441752 ) Kim S....Han H.S. 2018 5 Labial swelling; anterior perineal herniation of urinary bladder diverticulum. ( 29604286 ) Khan I....Shah O.A. 2018 6 Congenital Bladder Diverticulum in Adults: A Case Report and Review of the Literature[malacards.org]
Neglect
  • Urinary bladder diverticulum should neither be neglected nor ignored. Appropriate early treatment (including the cause) of the diverticulum should be undertaken to avoid complications like malignancy which will finally ensure longevity.[ncbi.nlm.nih.gov]
  • Urinary fistulaeCongenital urinary fistula Ectopia vesicae; in association with imperforate anusTraumatic urinary fistulaVesicovaginal fistulaEtiology Obstetrics — the usual cause is protracted or neglected labour; Gynaecological — the operations chiefly[slideshare.net]
Hematuria
  • A 77-year-old man was referred to the urological clinic with asymptomatic gross hematuria. Cystoscopy revealed a papillary tumor within the diverticulum of the bladder.[ncbi.nlm.nih.gov]
  • A 56-year-old man presented with intermittent hematuria. Ultrasound examination indicated primary carcinoma in the urinary bladder diverticulum. Diagnosis was confirmed with cystoscopy and computed tomography.[ncbi.nlm.nih.gov]
  • An 87-year-old man presented with hematuria and dysuria. An endoscopic examination revealed a bladder mucosa which was almost entirely occupied by diverticula.[ncbi.nlm.nih.gov]
  • A 47-year-old man presented with hematuria and dysuria. He was found to have a carcinosarcoma originating from a bladder diverticulum. He underwent a partial cystectomy and received postoperative chemotherapy.[ncbi.nlm.nih.gov]
  • Surgical treatment should be considered when recurrent episodes of hematuria, infection or obstruction develop. Conflict of interest: None declared.[qjmed.oxfordjournals.org]
Urinary Incontinence
  • It may cause VUR, recurrent urinary tract infection, stone formation and urinary incontinence.[indianjurol.com]
  • Particular attention is paid to the treatment of patients with tumors of the urinary tract, kidneys, urolithiasis, prostate diseases, treatment of urinary incontinence/neurourology, andrology and pediatric urology.[bookinghealth.com]
  • Urinary Incontinence: Urinary incontinence (the involuntary loss of urine) is rare after this surgery. If present before the operation, it is usually due to a pre-existing condition other than the diverticulum.[deltamedix.com]
  • Urinary incontinence 2. ED 3. Retrograde ejaculation 4. UTI 5. Bladder neck contracture 6. Urethral stricture 7. Hemorrhage: 5-10% need for blood transfusion 8. VTE: DVT and PE What are hemostatic maneuvers to use during open prostatectomy? 1.[quizlet.com]
Nocturia
  • Urethral diverticulum may cause a myriad of symptoms, such as: dysuria nocturia flank pain hematuria pelvic pain dyspareunia incontinence urinary retention recurrent cystitis frequent, urgent urination frequent urinary tract infections Many diverticulum[healthblurbs.com]
  • Liu A previously healthy 73-year-old man visited our clinic for 2 weeks history of dysuria and nocturia. Physical examination revealed a palpable mass, sized 12 cm without tenderness, over the supra-pubic area.[qjmed.oxfordjournals.org]
  • His symptoms of difficulty of urination, increased urinary frequency, nocturia and urgency became worse when the groin swelling increased in size. The patient used to reduce the swelling manually to improve the symptoms.[wjes.biomedcentral.com]

Workup

While many bladder diverticula are typically discovered incidentally during a workup for urinary features [7], symptomatic cases associated with congenital syndromes, BPH, or other causes should raise the clinician's suspicion for this bladder defect. The diagnosis is confirmed through imaging studies as well as the patient's history and physical exam.

Imaging

Very importantly, investigations such as the voiding cystourethrography (VCUG), ultrasonography (abdominal and bladder), and a nuclear renal scan will collectively guide the urologic team with preoperative and postoperative assessment [8]. Specifically, VCUG is the superior imaging technique for the diagnosis of bladder diverticula [9]. This test produces optimal results when lateral and obliques views are obtained and fluoroscopy is used throughout the procedure [10].

Bladder ultrasonography with color doppler enhancement is another beneficial modality since it helps detect the defect, differentiates it from other lesions, and identifies dilated distal ureters [11]. Furthermore, an intravenous pyelography (IVP) is particularly useful in diagnosing lateral bladder diverticula. Finally, the upper urinary tract should be imaged since bladder diverticula can lead to hydroureteronephrosis [7].

Treatment

  • In the past misdiagnosis and delayed treatment led to significant mortality. However, the prognosis currently is better due to the use of broad-spectrum antibiotics, better radiological imaging studies, and earlier diagnosis and treatment.[ncbi.nlm.nih.gov]
  • Its treatment should include surgery, chemotherapy and radiotherapy.[ncbi.nlm.nih.gov]
  • Treatment regimens vary based on the stage of the disease. However, choosing the best option for treatment is still unclear, due to the scarcity of cases available.[ncbi.nlm.nih.gov]
  • Two years after initial treatment, the patient was well without evidence of tumor relapse.[ncbi.nlm.nih.gov]
  • High association with recognizable clinical symptoms and additional urinary tract abnormalities leads to early identification and treatment.[ncbi.nlm.nih.gov]

Prognosis

  • Small cell carcinoma of the urinary bladder is a mass with swiftly aggressive and metastatic, and with a poor prognosis.[ncbi.nlm.nih.gov]
  • However, the prognosis currently is better due to the use of broad-spectrum antibiotics, better radiological imaging studies, and earlier diagnosis and treatment.[ncbi.nlm.nih.gov]
  • Compared to urothelial bladder carcinoma, urinary bladder osteosarcomas have a poorer prognosis. Biopsy and immunochemical staining are critical for the diagnosis. Treatment regimens vary based on the stage of the disease.[ncbi.nlm.nih.gov]
  • In view of the early invasive behavior of carcinosarcoma/sarcomatoid carcinoma combined with the paucity of the muscular layer in the diverticulum wall, a graver prognosis was expected for this aggressive tumor that occurred in this unusual site.[ncbi.nlm.nih.gov]

Etiology

  • This case demonstrates that spontaneous bladder rupture may be a rare cause of abdominal complaints and sepsis when the etiology at first seems unclear.[ncbi.nlm.nih.gov]
  • An overview of the etiology, histopathology, complications, management and imaging of urine bladder diverticulum is also presented.[ncbi.nlm.nih.gov]
  • Pathogenesis Etiology Urachus allows communication between urinary bladder and allantoic sac in fetus. At birth urachus is non-functional and all urine flows through urethra in normal animals.[vetstream.com]
  • Vesical Diverticulum : Etiology, Diagnosis, Tumorigenesis and Treatment : Analysis of 74 cases. Urology 1987; 15 : 453. Charles V Mann, Russell RCG, Norman S William.[bhj.org.in]

Epidemiology

  • Are examined the epidemiological data (age, gender), the given clinics (functional and physical signs), means of diagnosis and therapeutic results. In this study, only large diverticulums were considered.[afrjpaedsurg.org]
  • Pytel and Pytel [ 6 ]) False or acquired UBD develop in patients who have had a long-term disturbance of urine discharge from the bladder which appears as urinary difficulty that is most often observed in patients with benign prostate hyperplasia. 3.1 Epidemiology[radiologykey.com]
  • Epidemiology and risk factors of urothelial bladder cancer . Eur. Urol. 63 , 234–241 (2013). 18. Das, S. S. & Amar, A. D. A. Vesical diverticulum associated with bladder carcinoma: therapeutic implications . J. Urol. 136 , 1013–1014 (1986). 19.[nature.com]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology Vestigial outpouching of bladder wall at urachal attachment. Diverticulum failure to void all urine from bladder development of UTI scarring of bladder wall increased risk of UTI.[vetstream.com]
  • Anatomy, Physiology, and Pathophysiology Bladder diverticulae represent a herniation of the bladder urothelium through the muscularis propria of the bladder wall.[laparoscopy.blogs.com]

Prevention

  • It prevents bladder from emptying completely and leads to infection. Treatment - Removing obstruction or surgical removal of the diverticulum.[medindia.net]
  • This periureteral diverticulum causes vesico-ureteral reflux because it prevents the normal valve mechanism of the distal ureter.[meddean.luc.edu]
  • View Article Google Scholar Martin CM, Bookrajian EN: Bacteriuria prevention after indwelling urinary catheterization. Arch Intern Med. 1962, 110: 703-711.[casesjournal.biomedcentral.com]

References

Article

  1. Pham KN, Jeldres C, Hefty T, Corman JM. Endoscopic Management of Bladder Diverticula. Rev Urol. 2016;18(2):114-117.
  2. Psutka SP, Cendron M. Bladder diverticula in children. J Pediatr Urol. 2013;9(2):129–38.
  3. Macedo A, Garrone G, Ottoni SL, et al. Primary congenital bladder diverticula: Where does the ureter drain? Afr J Paediatr Surg. 2015;12(4):280-5.
  4. Omari AH, Alghazo MA. Urinary bladder diverticulum as a content of femoral hernia: a case report and review of literature. World J Emerg Surg. 2013;8(1):20.
  5. Kivlin D, Ross C, Lester K, Metro M, Ginsberg P. Curr Urol. 2015;8(1):53-6.
  6. Golijanin D, Yossepowitch O, Beck S, Sogani P, Dalbagni G. Carcinoma in a bladder diverticulum: presentation and treatment outcome. J Urol. 2003;170(5):1761-4.
  7. Vaddi S, Pogula V, Devraj R, Sreedhar A. Congenital bladder diverticulum – a rare adult presentation. J Surg Case Rep. 2011;2011(4):8.
  8. Khemakhem R1, Ghorbel S, Jlidi S, et al. Management of congenital bladder diverticulum in children: A report of seven cases. Afr J Paediatr Surg. 2013;10(2):160-3.
  9. Hernanz-Schulman M, Lebowitz RL. The elusiveness and importance of bladder diverticula in children. Pediatr Radiol. 1985; 15(6):399–402.
  10. Corbett HJ, Talwalker A, Shabani A, Dickson AP. Congenital diverticulum of the bladder mimicking tumour. J Pediatr Urol. 2007;3(4):323-5.
  11. Maynor CH, Kliewer MA, Hertzberg BS, et al. Urinary bladder diverticula: sonographic diagnosis and interpretive pitfalls. J Ultrasound Med. 1996;15(3):189-94.

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Last updated: 2018-06-22 03:16