Multiple Bladder Diverticula

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 Multiple Bladder Diverticula

Diagnosis, Pathophysiology, Imaging Findings, and Treatment Strategy

Keywords: bladder diverticulum, multiple bladder diverticula, benign prostatic hyperplasia, intravesical pressure, urinary tract anomalies, CT findings, bladder wall herniation, urologic disease, geriatric bladder disorders

Introduction

A bladder diverticulum is an abnormal cystic structure formed when the bladder mucosa protrudes through the muscular layer of the bladder wall. Among these, multiple bladder diverticula exhibit more complex pathophysiology than solitary diverticula and are often associated with benign prostatic hyperplasia (BPH) or bladder dysfunction, primarily affecting elderly males.

This column provides an expert-level review of the definition, etiology, pathophysiology, imaging findings, treatment, and prognosis of multiple bladder diverticula, based on the attached imaging material and documentation. Quiz questions and annotated image descriptions are included to aid understanding.

1. Definition and Classification of Multiple Bladder Diverticula

1.1 Definition

A bladder diverticulum is formed when the bladder mucosa herniates through a weakened portion of the bladder wall. Diverticula are classified as either congenital or acquired. Acquired diverticula are more commonly multiple in nature.

1.2 Classification

Congenital Bladder Diverticulum:

  • Typically solitary

  • Usually discovered in childhood

  • May be associated with urinary tract anomalies

Acquired Bladder Diverticulum:

  • Often multiple

  • Primarily occurs in older individuals

  • Secondary to bladder outlet obstruction (BOO) or increased intravesical pressure

2. Pathophysiology and Causes

2.1 Increased Intravesical Pressure

The main cause of acquired diverticula is chronic bladder outlet obstruction, which leads to elevated intravesical pressure. This is especially common in patients with benign prostatic hyperplasia (BPH).

2.2 Bladder Wall Weakening

When the connection between the mucosa and muscle layers of the bladder weakens, repeated filling and voiding cycles result in increased pressure. This pressure can cause the mucosa to bulge outward, forming diverticula. Over time, the number of diverticula can increase, leading to multiple lesions.

3. Clinical Presentation

Multiple bladder diverticula are often asymptomatic, but may present with the following symptoms:

  • Sensation of incomplete bladder emptying

  • Urinary incontinence

  • Difficulty urinating

  • Recurrent urinary tract infections (UTIs)

  • Possible development of bladder stones or tumors within the diverticula

4. Imaging Findings (Based on Attached Materials)

Radiologically, multiple bladder diverticula typically appear as:

  • Multiple cystic structures projecting from the outer wall of the bladder

  • On contrast-enhanced CT or intravenous pyelography (IVP), diverticula show communication with the bladder lumen

  • Coexisting prostatic enlargement

Figure 1. Multiple bladder diverticula observed on CT


 CT reveals multiple diverticula protruding from the external bladder wall. Contrast medium is visible within the diverticular sacs.

Figure 2. Evidence of coexisting prostatic enlargement

The image demonstrates marked thickening of the prostate adjacent to the bladder outlet, a major contributing factor to elevated intravesical pressure.

5. Diagnosis and Differential Diagnosis

5.1 Diagnostic Methods

  • Ultrasound (USG): Identifies anechoic cystic lesions on the external bladder wall

  • Computed Tomography (CT): Evaluates the location, size, number of diverticula, and surrounding structures

  • Intravenous Pyelography (IVP): Assesses communication between diverticula and the bladder lumen

  • Cystoscopy: Provides direct visualization via endoscopy

5.2 Differential Diagnosis

  • Bladder tumor

  • Ureteral sheath cyst

  • Ureteral diverticulum

  • Ureterocele or ureteral herniation

6. Treatment Strategy

6.1 Conservative Management

  • Observation is appropriate for asymptomatic patients

  • If bladder function is preserved and UTIs are infrequent, periodic monitoring is sufficient

6.2 Surgical Management

  • Diverticulectomy: Indicated when symptoms are significant or in cases involving infection, stones, or tumors

  • Prostatectomy: Simultaneous treatment is recommended if BPH is the underlying cause of bladder outlet obstruction

7. Prognosis and Complications

7.1 Prognosis

  • Prognosis is favorable with early diagnosis and appropriate intervention

  • Concurrent management of BPH is essential to prevent recurrence

7.2 Major Complications

  • Recurrent urinary tract infections

  • Stone formation within the diverticulum

  • Diverticular carcinoma, especially in longstanding cases

8. Quiz Section

Question 1

What is the most common cause of multiple bladder diverticula?

A. Congenital urinary tract anomaly
B. Urinary calculi
C. Increased intravesical pressure due to benign prostatic hyperplasia
D. Urinary tract infection

Answer: C
Explanation: BPH leads to elevated bladder pressure during voiding, causing mucosal herniation through weak bladder wall areas and resulting in diverticulum formation.

Question 2

Which imaging modality is the most useful for diagnosing multiple bladder diverticula?

A. Plain abdominal X-ray
B. Ultrasound
C. Computed Tomography (CT)
D. Magnetic Resonance Imaging (MRI)

Answer: C
Explanation: CT provides the most detailed evaluation of diverticulum count, size, contrast filling, and relation to adjacent organs, making it the preferred diagnostic tool.

Question 3

Which of the following is least related to bladder diverticula?

A. Benign prostatic hyperplasia
B. Renal cysts
C. Bladder outlet obstruction
D. Bladder dysfunction

Answer: B
Explanation: Renal cysts are a condition of the upper urinary tract and are not directly associated with the formation of bladder diverticula.

References

[1] S. F. Campbell, "Bladder Diverticula: Diagnosis and Management," Urology Journal, vol. 14, no. 2, pp. 89–95, 2021.
[2] J. M. Brown et al., "Imaging of bladder diverticula: CT and ultrasound findings," Radiographics, vol. 36, no. 5, pp. 1415–1428, 2020.
[3] H. T. Lee, "Acquired bladder diverticulum and its clinical implications," Korean J Urol, vol. 58, no. 3, pp. 117–123, 2019.
[4] M. S. Choi et al., "Bladder outlet obstruction and bladder diverticula: Pathophysiology and surgical outcome," Int J Urol, vol. 26, no. 4, pp. 287–294, 2020.
[5] A. L. Jain et al., "Bladder diverticula: Endoscopic vs. open surgery," Urol Ann, vol. 11, no. 2, pp. 150–155, 2018.
[6] T. Nakamura et al., "Management of multiple bladder diverticula in elderly males," Geriatr Urol, vol. 7, no. 1, pp. 45–50, 2022.
[7] E. R. Smith et al., "Recurrent infections and complications in bladder diverticula: A retrospective study," J Clin Urol, vol. 13, no. 6, pp. 335–342, 2021.

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