Urinary Bladder Diverticulum: Causes, Symptoms & Treatment

Urinary bladder diverticula are protrusions on the bladder wall that have the shape of a sac. It is important to distinguish between true diverticula and pseudodiverticula.

What are urinary bladder diverticula?

Urinary bladder diverticula or bladder diverticula are sac-like protrusions that occur on the wall of the urinary bladder. Depending on whether only the bladder mucosa or all layers of the wall prolapse, we speak of true diverticula or pseudodiverticula. Doctors distinguish between urinary bladder diverticula according to whether the diverticula are congenital or acquired in the course of life. Congenital bladder diverticula affect the entire wall of the urinary bladder. As a result, the structure of the diverticular wall is similar to that of the bladder wall. Congenital bladder diverticula are found on the muscles of the bladder wall, more specifically on the ureteric hiatus. Acquired urinary bladder diverticula also bear the name pseudodiverticula. They occur at muscular weak points of the bladder mucosa.

Causes

Urinary bladder diverticula have existed in some cases since birth. Not infrequently, they are associated with vesicoureteral reflux. Concrete symptoms usually become apparent after the age of 10. Congenital weaknesses in the wall of the urinary bladder are a frequent cause of diverticular formation. This applies primarily to the ureteral orifice. In addition, malformations of the urachus in the urinary bladder roof can be responsible for congenital diverticula. However, some urinary bladder diverticula are diverticula in which there is herniation at all wall layers. Acquired bladder diverticula form mostly due to neurogenic diseases of the urinary bladder. In most cases, there is a constant increase in pressure in the bladder of the affected person. This pressure causes the mucosa of the urinary bladder to bulge out through open areas on the muscle wall. The most common triggers include neurogenic dysfunction as in detrusor-sphincter dyssynergia, benign enlargement of the prostate (prostate gland) affecting older men over the age of 50, and urethral valves occurring in children. Likewise, an insufficient urinary bladder suture may be responsible for diverticulum formation. Congenital urinary bladder diverticula are both true diverticula and pseudodiverticula. In some cases, there is also an orifice of the ureter (ureter) into the diverticulum. The term pseudodiverticulum is commonly used when herniation is not present in all layers of the urinary bladder wall. The wall of the diverticulum is composed of connective tissue, mucosa and some smooth muscle parts. During the formation of the diverticulum, a pseudocapsule is also formed around its wall. This aids in the resection of the diverticulum. In addition, a diverticular neck, which presents as narrow and sphincter-like, is considered typical. It has a reinforcing effect on urinary stasis within the diverticulum.

Symptoms, complaints, and signs

Because urinary bladder diverticula do not cause specific symptoms, they often go unnoticed by affected individuals. Occasionally, however, urine may accumulate in a pocket-shaped diverticulum. This quantity is not affected by the elimination of urine during urination. Because of the residual urine, patients often feel that they have not completely emptied the bladder. In addition, urinary bladder diverticula can be responsible for chronic urinary tract infections. In some cases, urinary stones even form within the diverticula. Only extremely rarely does a tumor develop on the floor of a diverticulum.

Diagnosis and course

To diagnose urinary bladder diverticula, the treating physician first reviews the patient’s medical history (anamnesis). This is followed by a physical examination. It is considered helpful for the diagnosis to perform imaging examination procedures such as an X-ray contrast examination. Also useful is sonography (ultrasound examination). In this way, the urinary bladder diverticula can be easily detected in a filled state. The diagnosis can be confirmed by a micturition cystourethrogram (MCU). Here, assessing the extent of diverticular filling is considered important after micturition has ceased. Both the diverticulum and the mucosa of the urinary bladder can be assessed during cystoscopy (cystoscopy of the bladder).If certain sections appear suspicious, a biopsy (tissue sampling) may be performed. If the urinary bladder diverticula are treated, this results in a positive outcome in most cases. Thus, they can usually be removed without major problems. In the case of congenital diverticula, even no therapy is often necessary, provided there is no vesicorenal reflux.

Complications

In most cases, urinary bladder diverticula do not cause specific symptoms or pain. Therefore, this condition is rarely recognized or specifically diagnosed, so early treatment of urinary bladder diverticula is not possible in most cases. Similarly, the patient’s urination is not affected by the disease, with no change in volume. However, the affected person always experiences a feeling of not having emptied the bladder completely. In the long term, this feeling can lead to psychological discomfort or depression and has a negative effect on the patient’s everyday life. It is not uncommon for those affected to deliberately drink less so that they do not have to urinate frequently. Urinary bladder diverticula increase the risk of the formation of kidney stones, so that these can also occur in the further course of the disease. Treatment of urinary bladder diverticula usually does not lead to complications. In most cases, surgical interventions are used to resolve the symptoms. In severe cases, the patient is dependent on a catheter, which makes daily life relatively stiff. Life expectancy is usually unaffected by the disease.

When should you see a doctor?

If, after urinating, there is a recurring feeling that the bladder has not emptied completely, a urinary bladder diverticulum may be present. A doctor should be consulted if the symptoms have not subsided after one week at the latest. If signs of a urinary tract infection develop, medical advice is needed. Urinary stones can also indicate a diverticulum and should be examined by a urologist or internist and removed if necessary. If a urinary bladder diverticulum is not removed, a tumor may develop in the worst case. Warning signs of such a severe progression include pain and retention during urination, frequent urination, and increasing pressure pain in the bladder area. If these symptoms are noticed, the family doctor must be consulted immediately. If the symptoms are severe, a visit to the hospital is indicated. In case of doubt, the emergency medical service can be contacted first. In general, a urinary bladder diverticulum must be clarified and removed to allow for a speedy recovery and to avoid further complications.

Treatment and therapy

Various measures are used to treat urinary bladder diverticula. In patients in whom surgical removal is deemed too risky, indwelling catheterization is performed. In some cases, intermittent self-catheterization is also possible. To resect an excessively narrow diverticular neck, treatment with an endoscope can be performed. This method occurs in borderline significant diverticula. Coagulation also takes place, which initiates scarring shrinkage of the bladder diverticulum. In most cases, surgery is performed with the goal of removing the urinary bladder diverticula, which is especially true for extensive diverticula. Different methods are used for this purpose. Smaller diverticula are treated by open surgical transvesical diverticulotomy. This is often done in conjunction with a transvesical prostate adenomectomy. Extravesical diverticulotomy can be considered as another surgical treatment method. It is particularly suitable in the presence of larger bladder diverticula. This method is performed either minimally invasively by laparoscopy with a special endoscope or openly. This depends on whether implantation of a ureter or prostatic deobstruction is required at the same time.

Outlook and prognosis

The prognosis for urinary bladder diverticula is favorable. If they are discovered and treated early, freedom from symptoms occurs within a short time. In a large number of cases, surgical procedures are performed for complete removal of the foreign body. As with any surgery, this is associated with the usual risks and side effects.If there are no complications and the wound heals well, the patient can usually be expected to recover within a few weeks. For smaller urinary bladder diverticula, laser treatment is often sufficient. The foreign bodies are shattered by the action of the laser beam and are subsequently removed from the body and excreted by the organism on its own. If there is no restructuring of the patient’s living conditions and health care, recurrence of the urinary bladder diverticulum is likely. If the foreign body recurs, the prognosis is also favorable. The sooner the diagnosis is made, the better and easier the treatment. Without treatment, there is a continuous increase in symptoms. In severe cases, a backlog of urine is to be expected. Bacteria and germs develop as a result, so that secondary diseases develop. In addition, organ damage is possible, which always poses a potential threat to life and contributes to a shortening of the patient’s expected lifespan.

Prevention

Because urinary bladder diverticula are often congenital, there are no appropriate preventive measures. To counteract acquired bladder diverticula, the precipitating conditions would have to be avoided, but this is difficult.

Follow-up

The measures of diagnosis usually depend on the severity of the diverticula, so no general prediction can be made in this regard. In general, an early diagnosis and detection of the symptoms has a very positive effect on the further course of the disease, so that the affected person should contact a doctor at the first symptoms and complaints. The earlier the disease is detected by a doctor, the better the further course of the disease usually is. In most cases, the person affected by this disease is dependent on a surgical intervention, which can provide lasting relief from the symptoms. After such an operation, bed rest should be observed, and the affected person should rest and avoid stressful or physical activities. Likewise, even after a successful procedure, regular check-ups and examinations by a physician are very important and can prevent further complications or discomfort. The life expectancy of the affected person is usually not reduced by the disease. Antibiotics should be taken after the surgical procedure to prevent infections or inflammations. Care should be taken to use the correct dosage and also to take them regularly.

What you can do yourself

If a urinary bladder diverticulum has been diagnosed, the first priority for the affected person is to take it easy until the diverticulum is surgically removed or treated with the help of a permanent catheter. Once diagnosed, precautions must also be taken for hospitalization. The urinary bladder must not be subjected to further stress to avoid an increase in symptoms and any complications. Patients should therefore take care not to develop a flu-like infection or any other illness that could cause additional damage to the urinary bladder or tract. Apart from this, the usual measures must be initiated. For example, relatives and friends must be informed about the hospital stay, as well as the employer and the health insurance company, which usually covers the costs of the operation. After an operation, the affected person should initially take it easy. The surgical wound needs at least a week to heal. After that, the patient can slowly return to everyday life. When it is possible to return to work depends on the type of treatment and the course of events after the operation. Affected persons are best advised to talk to the doctor in charge and clarify any activities in advance.