Mickey Mouse bladder-Hutch diverticulum

A 56-year-old male presented with complains of straining and pain during micturation since 20 days. Patient has history of pulmonary tuberculosis 30 years back, completed anti-tubercular treatment.

VCUG shows 2 well defined symmetrical contrast filled outpouchings seen arising from posterosuperior aspect of urinary bladder.

Ultrasonography shows 2 fluid-filled outpouchings noted at both vesico-ureteric junctions at posterolateral walls of urinary bladder.

Hutch diverticula(HD) are rare congenital juxtameatal diverticula of urinary bladder near vesicoureteral junction. Waldeyer sheath anatomically covers the space between the intravesical ureter and muscular layer of the bladder[1]. Hutch diverticulum as considered to be defect in development of normal musculature around ureteral orifice with resultant periureteral diverticulum. Congenital bladder diverticula that are not associated with posterior urethral valves or neuropathic bladder are uncommon but not rare[1]. They occur almost exclusively in men, arising as a result of herniation of the bladder mucosa through the detrusor muscle. The wall of the diverticulum is usually quite thin but does contain muscle, adventitia and bladder mucosa. They are characteristically located laterally and cephalad to the ureteral orifice [1].

Usually, Patients with Hutch diverticulum are asymptomatic and are detected incidentally on imaging. However, they can present with diverse symptoms due to obstruction due to compression of ureteral orifice, repeated infections due to urine retention within the diverticulum or stone formation [2].

Voiding cystourethrogram (VCUG) is the investigation of choice to diagnose HD. In addition to the standard anteroposterior view, oblique and lateral films must be obtained to demonstrate the diverticula. VCUG is also useful in demonstrating vesicoureteric reflux, bladder neck and urethral anatomy in relation to the diverticula [3]. Ultrasonography shows round or oval anechoic outpouchings at the base of bladder at the region of vesico-ureteric junction, which may constantly vary in size [4]. CT IVU helps in better delineation of the local anatomy and its relation with lower end of the ureter4. Cystoscopy is invasive and is performed just before surgery. It helps in assessing the size of the diverticulum, intradiverticula pathology such as stone or malignancy, relation of ureteric orifice to the diverticula and the appearance of the bladder neck and urethra.

Small asymptomatic diverticula can be managed conservatively. Giant diverticulum (>1/3rd size of bladder), persistent or recurrent UTI, interference with bladder emptying or outlet obstruction and ureteral obstruction or reflux, presence of intradiverticular disease (tumour or stones) or spontaneous diverticular rupture are absolute indications for surgery[5].