60 year old patient with one episode of painless hematuria.
60 year old male patient presented with painless hematuria. Urinalysis, urine cultures and cytology were negative. An intravenous urogram (IVU) was performed for further evaluation. It showed multiple small outpouchings (1-3 mm in size) in the bilateral mid ureters (as indicated by arrows) which are more evident on the left side. The characteristics of bilaterality, multiplicity, small size, upper and middle ureteral location, and left ureteral predilection are characteristic of ureteral pseudodiverticulosis.
Ureteral pseudodiverticulosis as a gross and pathologic entity was first described by the Italian physician Pepere in 1908. However, it was not until the mid 20th century when ureteral psuedodiverticulosis was studied in a clinical setting. Culp produced the original classification of ureteral diverticula where full thickness protrusions of the ureteral wall were designated true diverticula and mucosal outpouchings into the muscularis were categorized as false diverticula. Pseudodiverticula occupy a third classification as they represent mucosal protrusions into the loose connective tissue of the lamina propria.
Studies have suggested that pseudodiverticula arise as the consequence of an inflammatory or infectious process because they contain hyperplastic epithelium as demonstrated on pathologic studies. Their increased identification in older patients also suggests that they are not congenital in origin.
Because ureteral pseudodiverticulosis is an uncommon entity, the condition’s clinical importance has been somewhat difficult to ascertain. There is an association with urinary tract infection possibly both as a causative and promulgating factor. Most importantly, studies indicate an increased incidence of transitional cell carcinoma with pseudodiverticula, but the risk is difficult to quantify because of the rarity of the condition.
Although ureteral pseudodiverticulosis is uncommon, it is readily distinguished from ureteral diverticula and other ureteral abnormalities. Pseudodiverticula are smaller than true diverticula averaging approximately 2-3 mm in size. They occur bilaterally but have a somewhat increased incidence in the left ureter. There is also a predilection for the upper and middle thirds of the ureter.
Ureteral pseudodiverticulosis may be diagnosed on any exam in which contrast courses through the ureters. Authors have noted that pseudodiverticula have been demonstrated more readily on retrograde urogram rather than intravenous urogram because the pseudodiverticula appear more prominent with increased hydrostatic pressure in the ureters. Pseudodiverticula are becoming more easily diagnosed on CT urography as both imaging and intravenous contrast quality improves.
No treatment for ureteric pseudodiverticulosis is necessary per se. Long term follow up has been recommended due to the possible association with malignancy.
Differential Diagnosis List