Teaching Case

A 52-year-old female presented with lower urinary tract symptoms and a history of recurrent urinary tract infections. She has no history of chronic illnesses such as diabetes mellitus or hypertension.

Abdominal and pelvic ultrasound showed the liver, gallbladder, intrahepatic and extrahepatic biliary tree, pancreas, and spleen to be unremarkable. Both kidneys exhibited moderate hydronephrosis (Grade II) with normal size, echo pattern, and corticomedullary differentiation. The urinary bladder was optimally full with normal wall thickness and no evidence of stones. Bilateral diverticula were noted: one on the right posterior wall (7.5 x 2.8 cm) and one on the left lateral wall (8.5 x 5.5 cm).

Background

Bladder diverticula can be either acquired or congenital. Primary (congenital) bladder diverticula are thought to result from an inherent weakness in the musculature of the bladder wall [1], which is usually present during childhood [2], and do not pose a risk for malignancy, unlike the secondary acquired type [3]. Secondary (acquired) bladder diverticula are typically multiple and more prevalent than congenital types. These diverticula are commonly caused by increased pressure within the bladder due to lower urinary tract obstructions, with benign prostatic hypertrophy (BPH) accounting for up to 80% of cases [6].

Clinical Perspective

The most common presentation is recurrent urinary tract infections (UTIs) secondary to urinary stasis in the diverticulum [4]. Other presentations may include acute urinary retention [5]. However, alternative diagnoses must be considered, particularly in patients with similar presentations. The differential diagnoses in our case included:

• Ureterocoele – A cystic dilatation of the distal ureter that can result in blockage and symptoms related to the urinary system. Near the trigone’s edge and adjacent to a dilated ureter, a ureterocoele appears as a cyst-like intravesical mass [7] but was excluded here due to the absence of such a cystic structure on ultrasound evaluation.
• Bladder cyst – Also known as Brunn’s cyst, is a rare cystic lesion in the bladder wall. The exact aetiology is not fully understood; however, they are believed to result from partial exclusion of epithelial cells from urothelial buds, and subsequent overgrowth forming a submucosal cyst [8]. In our case, no fluid-filled mass was observed on imaging, making this diagnosis less likely.
• Bladder tumour – Often presenting as an irregular, solid mass with symptoms such as haematuria [9]. A bladder tumour was excluded due to the absence of any solid mass or suspicious features on ultrasound and the lack of haematuria in the patient’s clinical history.
• Perivesical abscess – This would typically present with symptoms of infection and localised pain, as well as a mass adjacent to the bladder on imaging [10]. No such findings were present, allowing this diagnosis to be excluded.
• Bladder hernia – A rare condition where part of the bladder herniates through the abdominal wall or into the inguinal canal [11]. This condition was ruled out due to the lack of evidence of herniation on imaging.

Imaging Perspective

Bladder diverticula can be identified using ultrasonography, CT, and MRI. Voiding cystourethrogram is particularly effective, as it allows for the visualisation of the diverticula by examining the relationship between the ureteral orifice and the diverticulum opening, as well as measuring the diverticulum’s size during endoscopy [6].

Outcome

Surgical options for treating bladder diverticula include open diverticulectomy (which can be performed intra or extravesically) and laparoscopic procedures [1]. Our patient was managed conservatively due to the incidental nature of the findings and the absence of severe symptoms directly attributable to the diverticula. Monitoring and managing the underlying cause of increased bladder pressure, such as recurrent UTIs, were advised. Surgical intervention would be considered if complications or significant symptoms develop.

Take Home Message / Teaching Points

Multiple bladder diverticula are rare and often discovered incidentally. Imaging plays a crucial role in diagnosing and managing these cases, particularly in patients with recurrent urinary symptoms. Proper identification and management can prevent potential complications associated with large diverticula.

All patient data have been completely anonymised throughout the entire manuscript and related files.