Bladder Diverticula

8/3/2019 Bladder Diverticula

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CC: TESTICULAR PAIN

R.S71/M/M

Brgy Balabag, Anilao, Iloilo


3/23

History of Present Illness

1 day pta:

(+) testicular pain, on and off

(+) hypogastric pain (+) blood in the urine

(+) pain upon urination

(-) fever

(-) chills

Immediately brought to this institution


4/23

Past Medical History

3 years pta: the patient was diagnosed tohave BPH and was appraised for surgicaloperation, the patient refused. He wasgiven unrecalled medications.


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Personal/ Social History

(+) smoker 1 pack per day since 25 y.o

(+) occasional alcoholic drinker


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Scout FilmGas & feces-filled non-dilated loops.

The flank stripes areintact. Renal & psoasshadows are partly

obscured by the overlyingbowel loops.

There is an ovoid calcificdensity within the pelvis

meas. 1.9 x 1.8 (LxW).There are osteophytic

spurs in the lumbar area.


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The right kidneymeas. 13.5x 6.1 cm

(LxW) while the leftkidney meas,12.7x7.0 cm. there isprompt opacification

of both pelvocalycealsystems and thesegmentallyvisualized uretersdown to theirrespectiveureteovesicaljunctions.


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The minor calycesare well cupped.The major calycesare not dilated.The ureters are

normal in size andwithin theirnormalanatomical

course.


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Left

ObliqueThere is anoutpouching in theposterolateral portion

of the urinarybladder, meas. 2.4x4.6 cm(LxW), a stalkapp. meas 2.5 cm inlength. There is alsoindentation in theposterior inferiorportion of the urinarybladder.


10/23

Post Void

Shows minimal retention of urine,

there is persistence of the contrastfilled outpouching.


11/23

Case

Discussion


12/23

IVP

Used most widely for detection anddiagnosis of the urinary tract

It demonstrates the gross anatomicfeatures of both the renal parenchymaand the urinary transport system.


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Excretory Urogram

Provides important information about thefunctional capacity of the urinary systemto make, transport and store urine.


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Excretory Urogram

Scout film (AP)

Contrast medium is

injectedUreteral compressionis applied

Film centered andconed to demonstratethe kidneys, areexposed 5 and 10 minsafter injection with thecompression on.

After the 10 mins film,the compression deviceis released and a noncompression film is

exposed

The final film centeredto demonstrate the

bladder is exposedapp. 20 mins afterinjection


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Case Discussion

DIVERTICULA Herniations of the bladder mucosa

between interlacing muscle bundles.

Most are located posterolaterally, near theureterovesical junction

May contain stones, tumor & occasionallydo not fill on cystograms


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Case Discussion

Acquired or congenital

Acquired: are outpouchings through a focal weakness in

bladder muscle associated with chronically raisedintravesical pressure.

Congenital: also arise through muscular defects in the bladder

wall

Majority are located paraureterally (Hutchsdiverticulum) often causes reflux.


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Case Discussion

Most acquired are secondary to eitherobstruction to vesical neck or upper motorneuron type of neurogenic bladder

intravesical pressure causes vesicalmucosa to insinuate itself betweenhypertrophied muscle bundles, so that amucosal extravesical sac develops


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Case Discussion

Are rare in women Congenital: solitary & common among

boys less than 10 years old

Causes: (congenital)1. congenital weakness at the level ofureterovesicular junction

2. aberrant voiding dynamics

3. anatomy


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Case Discussion

Acquired: usually among males >60

Often multiple & commonly in lateralbladder walls

Causes:1. Bladder outlet obstruction

2. Neurogenic vesico-urethraldysfunction

3. Iatrogenic


20/23

Case Discussion

Large ones often displace the ureters &bladder

Narrow neck ones likely urinary stasis,

thus infection may follow Common presenting signs:

1. Recurring UTI

2. Hematuria (due to stone)3. Passing of urine twice


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Case Discussion

Metaplasia & tumor can occur withlikelihood of spread beyond the bladdersince it contains only urothelium without

muscle. Can be evaluated with

1. cytogram

2. ultrasound

3. CT scan

4. cystoscopy


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Case Discussion

Complications:1.Urinary stasis

2.Infection3.Stone formation

4.Vesicoureteral reflux

5.Bladder outlet obstruction


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Case Discussion

Surgical Indications:1. persistent/recurrent UTI2. presence of stones in adiverticulum

3. tumor development in adiverticulum

4. lower urinary tract symptoms

5. voiding dysfunction6. Vesico-ureteral reflux

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Bladder Diverticula