What is Bladder Diverticulum?
Bladder diverticula are bulges that form in the bladder lining and pass through the bladder’s muscle wall, resulting in a thin-walled pouch connected to the bladder’s interior. This structure often doesn’t empty completely during urination. There can either be present from birth (congenital), or develop with age (acquired). They can happen in both adults and children. However, for adults, there’s usually a blockage or nerve disorder causing them, while for children, they can occur because of an underdeveloped muscle layer in the bladder wall.
These bladder bulges are more common in adults and tend to affect men more than women. Generally, they appear above and to the side of the tube that drains urine from the kidney to the bladder, near the point where this tube connects to the bladder. Often, bladder diverticula are only found by accident during tests for bloody pee (hematuria), signs of urinary tract issues (like going to the toilet often, or having a weak urine stream), or infections.
What Causes Bladder Diverticulum?
Bladder diverticula, which are pockets in the bladder, can be either present at birth (congenital) or develop later in life (acquired). They can look different based on their cause, and scans of the bladder can help doctors tell the difference between the two. Congenital bladder diverticula are not very common, estimated to occur in about 1.7 percent of people, and are more likely to be found in children under ten years old. These usually appear as a single pocket and are more common in boys. They are generally located next to the place where the ureter (tube that carries urine from the kidneys to the bladder) enters the bladder and are often associated with a condition where urine can flow back up into the kidneys (vesicoureteral reflux).
In contrast to adults, who usually have diverticula due to a nerve-related disorder or blockage in the lower urinary tract, they are typically caused by a congenital weakness of the bladder muscle in children. This weakness is often at the point where the ureter enters the bladder (ureterovesical junction).
Acquired diverticula mostly develop in men over 60, and these pockets are commonly found along the side of the bladder. This is similar to what happens in babies with a congenital condition that causes a blockage in the back of the tube that carries urine from the bladder (posterior urethral valves). It’s believed to happen when the pressure within the bladder increases due to other underlying conditions, like prostate disease or neurological disorders. This increased pressure pushes the inner lining of the bladder (mucosa) between muscle bundles, creating a sac that can eventually form into a diverticulum.
Risk Factors and Frequency for Bladder Diverticulum
Bladder diverticula, a type of bladder issue, can happen to anyone, children or adults. However, they are mostly seen in adults, accounting for about 90 percent of all cases. Moreover, they are more common in men than in women. The ratio is approximately 9 to 1 across all ages, for both adults and children.
Signs and Symptoms of Bladder Diverticulum
Bladder diverticula are often discovered by chance when examining for other unrelated conditions, such as urinary tract infections. These bladder pouches don’t typically cause noticeable symptoms as they can empty slowly or incompletely after urination. If symptoms do occur, it’s usually due to urine being stagnant inside the bladder pouch or because of the mass effect it has in the lower belly area.
Patients may report feeling like they don’t completely empty their bladder, experiencing fullness in the lower abdomen, or needing to void twice.. However, these complaints are often vague and can also be associated with prostate enlargement, blockage, or other issues with the urinary tract. Bladder diverticula most commonly cause urinary tract infections due to stagnant urine. Symptoms less frequently include blood in the urine, discomfort in the abdomen, or a palpable mass in the abdomen.
- Feeling of incomplete bladder emptying
- Fullness in the lower abdomen
- Need for double voiding
- Urinary tract infections
- Blood in the urine (less common)
- Abdominal discomfort (less common)
- Palpable abdominal mass (less common)
Testing for Bladder Diverticulum
If you are experiencing symptoms such as recurring infections, pain during urination, and a swollen belly, this might suggest a condition called bladder diverticulum, which often occurs due to blockage in the bladder outlet and urine retention. To diagnose this condition, your doctor will first take a detailed medical history and carry out a physical examination, including a digital rectal examination. For men, a test called a prostate-specific antigen test may be performed. This procedure involves evaluating your lower urinary tract system as it can help reveal any previously undetected neurological issues or any past surgeries on the lower urinary tract.
Your doctor will likely conduct urine tests, urine cultures, and urine cytology – a type of test to examine cells in your urine – especially if your treatment does not involve surgery. This is because abnormalities in the urine – such as the presence of white blood cells (pyuria) or blood (hematuria) – are common in patients with bladder diverticula.
Imaging methods like radiographs (X-rays) and endoscope-based examinations are crucial for diagnosing bladder diverticula. Often, these outpouchings in the bladder are found unexpectedly during X-ray evaluations done because of frequent urinary tract infections or other unclear symptoms related to the lower urinary tract. One type of X-ray test, known as fluoroscopically monitored voiding cystourethrography, is effective for spotting bladder diverticula – it gives detailed information about the location, shape, and size of the diverticulum. Other imaging techniques that provide a cross-sectional view of the lower urinary system can also assist in the diagnosis. Bladder diverticula can be spotted during an endoscopic examination, where a thin tube with a light and camera is inserted into the bladder. This exam allows your doctor to check if there are any stones or unusual tissue within the diverticula.
Treatment Options for Bladder Diverticulum
Bladder diverticula are pouches in the bladder that can cause issues such as urinary infections, stones, or cancer. Treating these pouches can be done through non-surgical therapy, surgery, or endoscopy. Cancer is a significant concern because the pouch does not have a muscular wall beyond the innermost layer, making it easier for cancer to spread outside the bladder.
People who have minor symptoms or no symptoms at all, and no other aggravating conditions, might choose monitoring and check-ups as a way to manage the condition. They should be made aware that having these pouches can increase the risk of cancer, and they should watch out for symptoms, such as blood in urine, painful urination, or other discomfort related to urination. Regular check-ups would include symptom reviews, urine tests, and regular ‘cystoscopy’ examinations (a procedure where a thin tube with a camera is used to look inside your bladder). If they aren’t able to have surgery or if they still have symptoms despite the underlying cause being addressed, they can use a method called clean intermittent catheterization, where a tube is inserted into the bladder to empty it of urine.
Surgery is typically offered to people who experience symptoms due to the pouches not emptying properly. Before surgery, each individual’s condition is assessed to determine the best treatment options.
There are various minimally invasive ways to remove these bladder pouches, including using an endoscope (a flexible tube with a camera) to remove the pouch, injecting filler materials at the pouch’s neck, or using heat to destroy the pouch (fulguration).
In patients who are not suited to long surgeries, the pouch can be addressed using an endoscope. Several different techniques have been described, including using heat to destroy the pouch or the neck of the pouch, or removing the neck of the pouch.
Surgery to remove these pouches can be performed through an open approach, using small incisions with a laparoscope (a tube with a camera), or using a robot. In open surgical approaches, the surgeon can make an incision into the bladder and remove the pouch. If the pouch is large or stuck to nearby structures, a combined approach might be used.
Performing this surgery through small incisions is possible, but can be tricky. Using a flexible tube with a camera during surgery can help find the pouch. Even though it’s a technically complex surgery with longer surgery time, on average, patients have a shorter hospital stay and less requirement for pain medication.
Surgeries using robots to assist have shown equally promising results, with generally short hospital stays. Robot-assisted surgery offers the benefit of improved ergonomics, better visualization and precision.
In children, the reasons for surgery are the same as in adults. However, because children with these pouches often have genetic syndromes that impact healing after surgery and increase the risk of having surgery, it’s usually better to manage these cases through observation and non-surgical methods.
What else can Bladder Diverticulum be?
Bladder diverticula are usually found by chance during an scan and show up as a liquid-filled formation close to the bladder. Here are some other conditions that might also appear in similar ways:
- Abnormalities in the uterus, ovaries, and fallopian tubes
- Urachal cysts, which are fluid-filled pockets near the bellybutton
- Ectopic ureter, where a urine-draining tube is not connected to the bladder correctly
- Ureterocoele, or a swelling at the bottom of one of the tubes that carry urine from the kidney to the bladder
- Mullerian cysts, fluid-filled sacs in the lower abdomen or pelvis
- Changes after surgery, such as lymphocele, a build-up of lymph fluid
Surgical Treatment of Bladder Diverticulum
Unfortunately, growths or tumors in the bladder, particularly in an area known as the bladder diverticulum, account for about 2 to 10% of all the tumors found in the bladder. If the tumors detected are of lower grade (Ta/T1), they can be managed by removing them via the urinary tract with a procedure known as transurethral resection. For situations where carcinoma in situ (a term for early stage cancer) is detected, extra treatments known as adjuvant intravesical chemotherapy or bacillus Calmette-Guérin immunotherapy need to be added to help fight against the disease.
In cases where the tumors have spread to nearby areas (locally progressed), their grade is high, there are multiple sores (or ulcers) in different areas of the bladder, or the patient has various spots of cancer coupled with bladder problems, a more rigorous surgical treatment called radical cystectomy could be helpful. This procedure involves the total removal of the bladder and can be done via an open surgery, using a scope (laparoscopically), or with a robot. After this operation, the patient would have to adjust to a different way of controlling urine flow, which will be decided based on the patient’s needs and preferences.
It’s important to note, though, that radical cystectomy surgery carries certain risks and can significantly impact a patient’s quality of life, due to the changes they would have to make in the way they handle their urine elimination.
What to expect with Bladder Diverticulum
Treatment is usually successful and can help ease your symptoms. Sometimes, once your diverticulum (a small pouch or sac forming in the wall of an organ) has been treated, such as when a blockage in your bladder is fixed, you might not need any further treatment. A tool called a cystoscope might be used to examine the diverticulum. This tool is inserted through the urethra, the tube that carries urine from your bladder out of your body, for a closer look.
Possible Complications When Diagnosed with Bladder Diverticulum
Urine can get stuck in the diverticula, or out-pouchings of the bladder, which can lead to various issues like stone formation, urinary tract infections, and even cancers due to chronic inflammation. Tumors can occur in 2 to 10% of people with diverticula, but it’s often hard to treat them successfully because they lack a certain muscle layer. Without this muscle layer, there’s a higher risk of these tumors infiltrating the bladder wall and possibly spreading to other parts of the body. However, exactly how aggressive these tumors are, how likely they are to spread, and what their effects are is still unclear.
Cancerous growths of the cells lining the urinary tract (urothelial cell carcinoma) are the most common type found in people with these diverticula, often affecting individuals aged between 65 and 75. The second most common type is squamous cell carcinoma.
Details of Complications:
- Stone formation due to urine being stuck
- Urinary tract infections
- Cancer due to chronic inflammation
- Tumors infiltrating the bladder wall
- Potential spread of tumors to other parts of the body
- Most commonly affects individuals between the ages of 65 and 75.
Preventing Bladder Diverticulum
Once a person is diagnosed with bladder diverticulum, a condition where pouches form in the bladder wall, their chances of developing severe medical conditions like cancer and lower urinary tract infections are elevated. Therefore, it’s crucial to guide these individuals and stress the importance of regular check-ups and re-evaluations. Additionally, they should be aware of warning signs like an increase in problems related to the lower urinary tract and the presence of blood in their urine.
