Bladder diverticulum is a sac–like depression in the wall of the bladder, which communicates with the main cavity of the organ through the channel – the neck of the diverticulum. The disease is manifested by difficulty urinating, carried out in two doses; it can be complicated by the development of cystitis, urolithiasis, pyelonephritis. Disease is recognized during ultrasound of the bladder, examination cystoscopy, cystography, tomographic studies. The treatment of pathology consists in performing diverticulectomy, transurethral dissection of the neck of the bladder diverticulum.
ICD 10
N32.3 Bladder diverticulum
Meaning
Bladder diverticulum is a prolapse of the bladder wall with the formation of an additional pathological sac-like cavity. The diverticulum cavity communicates with the bladder through the neck connecting them. The presence of protrusion contributes to the stagnation of urine and, as a consequence, the development of inflammatory urological diseases (cystitis, pyelonephritis), the formation of concretions in the bladder (urolithiasis), the development of hydronephrosis.
Usually a diverticulum is formed in the area of the posterior and lateral walls of the bladder, near the mouth of the ureter; less often – in the area of the bottom or tip of the bladder. It may be small or have dimensions exceeding the volume of the bladder. In men, diverticula of the bladder develop 15 times more often than in women, which is associated with prostate diseases.
Causes
Congenital bladder diverticulum is formed as a result of dysembriogenetic abnormality of the development of the bladder wall – detrusor weakness. Acquired pathology develops due to a prolonged increase in intravesical pressure, overstretching of the wall and divergence of the fibers of the muscle layer. This condition is most often caused by infravesical obstruction with prostate adenoma, urethral stricture, bladder neck sclerosis, and other causes that prevent the free outflow of urine. The need for straining during urination leads to a gradual weakening and stretching of the bladder wall, i.e. the formation of a diverticulum.
Classification
According to the etiology and time of development, diverticula of the bladder are divided into congenital (primary) and acquired (secondary). Specialists in the field of clinical urology are more likely to encounter acquired protrusions. Depending on the number of additional cavities, diverticula can be single or multiple. With multiple diverticula, pathology is regarded as diverticulosis of the bladder.
By their structure, diverticula are true and false. In the case of a true diverticulum, its wall is represented by the same layers as the bladder wall (mucous membrane, submucosal base, muscular and external adventitial membranes). In a false diverticulum, the wall is formed only by the mucous layer of the organ, which, like a hernia, protrudes through the fibers of the detrusor. Acquired protrusions, as a rule, are false, and congenital ones are true.
Symptoms
A small single bladder diverticulum may not cause any symptoms. The disease becomes clinically significant with an increase in size, when the protrusion serves as an obstacle to the complete emptying of the bladder. The leading manifestations of diverticulum are dysuric disorders and urostasis. The patient cannot empty the bladder at the same time: urination occurs in two steps – first the urine flows out of the bladder, and then from the diverticulum cavity. The duration of the act of urination also increases; there may be hematuria, terminal pyuria (pus is released at the end of urination), sometimes there is a complete urinary retention.
Complications
Stagnation of urine in the diverticulum leads to the addition of a secondary infection and the development of persistent, untreatable, cystitis and diverticulitis, the formation of concretions or tumors. In the event that the mouth of the ureter opens into the diverticulum cavity, vesicoureteral reflux develops, which is fraught with the occurrence of pyelonephritis, hydronephrosis and renal failure.
Diagnostics
The detection of a bladder diverticulum often occurs during a patient’s examination for frequent recurrent cystitis and pyelonephritis. The main diagnostic methods are ultrasound of the bladder, cystoscopy and cystography. In the process of cystography, the bladder is filled with a radiopaque substance, then a series of images is taken. When emptying the bladder, the contrast is delayed in the diverticulum, and therefore its shadow looks denser compared to the shadow of the bladder cavity. The shadow of the bulge is usually defined in a lateral or oblique projection.
Cystoscopy allows to identify the isthmus connecting the bladder with the diverticulum. If the cystoscope can be inserted into the diverticulum cavity, then it is possible to determine the presence of vesicoureteral reflux and additional neoplasms, the type of diverticulum (false, true). Echography (ultrasound) of the bladder helps to assess the location, size, shape of the formation, the size of its neck, allows you to judge the spatial relationship with the surrounding structures, the presence of tumors, stones. To determine the infravesical obstruction, it is mandatory to conduct urodynamic studies – uroflowmetry, cystometry, etc.
Treatment
A small diverticulum that does not cause dysuric phenomena and recurrent inflammation can be left under the dynamic supervision of a urologist. When determining the presence of residual urine, concretions, tumors, a significant size of the diverticulum, the clinic of compression of neighboring organs, an operational manual is used. Surgical operations can be performed by endoscopic or open access.
- Endoscopic technique. Endoscopic (transurethral) operations are resorted to to perform plastic surgery of the neck of the true diverticulum: the channel of the pathological cavity is dissected and an adequate communication of the diverticulum with the bladder is created.
- Open diverticulectomy. More often in urological practice, an open operation is required – diverticulectomy. The operation is performed through a suprapubic incision. After the bladder is isolated, its anterior wall is opened, the location of the diverticulum is determined and it is cut off at the confluence with the bladder. The wound is stitched and drained in layers. In the postoperative period, prolonged catheterization of the bladder is performed.
In the presence of a ureter opening into the diverticulum, it is transplanted into the bladder wall – ureterocystoneoanastomosis is formed. With false (acquired) diverticula, surgical elimination of the cause of the infravesical obstruction is required.
Prognosis and prevention
Prevention of acquired diverticula requires timely elimination of the causes contributing to the occurrence of pathology (prostate hyperplasia, bladder neck sclerosis, urethral strictures, etc.). Surgical treatment gives good results and avoids the development of urolithiasis, recurrent pyelonephritis, cystitis, diverticulitis, urolithiasis, hydronephrosis and renal failure.