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The radiological and urodynamic significance of large bladder diverticula
Clinical Radiology (1985) 36, 521-524 © 1985 Royal College of Radiologists
0009-9260/85/491521502.00
The Radiological and Urodynamic Significance of Large Bladder Diverticula BRENNAN WILSON* and GEORGE KLUFIOt
Departments of Radiology and ?Urology, Hull Royal Infirmary and Princess Royal Hospital, Hull, Humberside
Large acquired bladder diverticula in adults may cause severe urodynamic disturbance and exacerbate difficulty in micturition. They may accommodate a large proportion of the contents of the bladder during attempted voiding, thus decreasing the effect of the detrusor muscle contraction. The post-micturition radiographs on intravenous urography, after the diverticula have emptied again, may only show a large intravesical post-micturition residue and give little information as to the size of the diverticula during the act of micturition.
Case 2. A 71-year-old man presented in September 1983 with a 1-year history of hesitancy, poor stream and terminal dribbling. Physical examination revealed no abnormality. Rectally, his prostate was small and felt benign Full blood count, biochemical profile, serum acid phosphatase and urinalysis were all normal.
The conditions usually cited as complications of diverticula of the acquired adult type are urinary infection, neoplasm and calculus formation (Fox et al., 1962; Witten et al., 1977; Elkin, 1980; Mundy et al., 1984). It has been realised for many years that the presence of any diverticulum, but especially a large one, alters the urodynamic function of the bladder (Joly, 1923; Miller, 1958), but little prominence has been given in the recent literature to the radiological appearances of these urodynamic abnormalities, their clinical presentation and their behaviour during micturition. We report three cases in which the presence of large diverticula was accompanied by significant vesico-diverticular reflux causing severe disturbances of vesical function with misleading appearances on the intravenous urogram
(IVU). Fig. 1 - Case 1: full-bladder IVU.
CASE REPORTS Case 1. A man aged 69 years presented in October 1982 with a 3-year history of hesitancy, dribbling and a feeling of incomplete emptying after micturition. Physical examination was unremarkable. Rectally, he had a small prostate which felt benign. Full blood count, biochemical profile, acid phosphatase and urinalysis were all normal. Intravenous urography was performed. The upper tracts were normal, but the bladder gave rise to three d~verticula. Assuming that the volumes of these diverticula changed in proportion to the cube of their linear dimensions, they at least doubled their overall volume between the full-bladder radiograph (Fig. 1) and the post-micturitlon radiograph (Fig. 2) and the amount of urine they came to contain was about half of that passed per urethra. The bladder size decreased only slightly after micturition. The patient attended for micturating cystography but was unable to pass urine. However, on attempted micturition a dramatic increase in the size of the diverticula was seen at the expense of the bladder contents, 80% of the original contents of the bladder refluxing into the diverticula, which increased m volume at leasts sevenfold (Fig. 3). He was subsequently treated by suprapubic diverticulectomy and prostatectomy. Histological examination of the diverticula showed carcinoma in situ. He is now voiding very well and has been attending regularly for cystoscopy. His bladder, so far, has remained clear of recurrence of tumour. * Present address for correspondence: Department of Radiology, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW.
Fig. 2 - Case 1: post-mictuntion IVU
522
CLINICAL RADIOLOGY
w2..
¢ v2a~,
Fig. 3 - Case 1: micturating cystogram during attempted micturltlOn The bladder is contracted (closed arrow) and three large diverticula (open arrows) and one small diverticulum are seen.
An IVU showed normal upper tracts. The bladder g~ive rise to three diverticula seen on the full-bladder ra&ograph (Fig. 4). They seemed to contain about half the quantity of urine passed on mlctuntion Three of them had apparently doubled in size on the post-micturitlon film, while the largest of them had halved in size and the total quantity which they contained had not changed signifieantly (Fig. 5). A mlcturating cystogram with cystometry was performed. Once micturitlon had started, it continued until the bladder had completely emptied, during which time the volume of the diverticula increased by about 50% (Fig. 6). The patient then entered a phase of 'squirting' micturltion as the diverticula slowly emptied back into the bladder and urine was passed per urethra in spurts During this phase the detrusor pressure hardly rose at all. The patient subsequently underwent transurethral resection of the prostate and suprapubic divertlculectomies. Case 3. A 71-year-old man was referred in February 1984 with two episodes of E. coh urinary tract infection within the preceding 6 months Over the previous 4 years there had been a significant reduction in his urinary stream Physical examination was unremarkable and his prostate felt small and simple in character. Again, routine blood tests and urinalysis were normal Intravenous urography showed normal upper tracts. There were three diverticula arising from the bladder which were slightly larger on
Fig. 5 - Case 2: post-micturitlon IVU.
Fig. 6 - Case 2: micturating cystogram
;f2:{.
Fig. 4 - Case 2: full-bladder IVU.
Fig. 7 - Case 3: full-bladder IVU.
LARGE BLADDER DIVERTICULA
Fig. 8 - Case 3: post-micturition IVU.
v~
,
2
v
~
v
,
~
v
Fig. 9 - Case 3: micturating cystogram shortly after the start of micturition. The bladder contains an air-fluid level. Two paper clips were taped to the front of the abdomen 10 cm apart for reference (arrows).
the post-micturition IVU (Fig. 8) than on the full-bladder radiograph (Fig. 7). Bladder emptying was very incomplete. A micturating cystogram performed 4 months later prior to surgery showed that the dwerticula nearly doubled in size during the early part of micturition (Fig. 9) and then deflated themselves back into the bladder as micturition was coming to an end. Probably as much urine refluxed into the diverticula during micturition as was voided. Suprapubic diverticulectomies and prostatectomy were subsequently performed.
DISCUSSION It is widely believed that acquired adult-type bladder diverticula arise by pulsion at weak points in the bladder wall when the detrusor pressure is pathologically raised due to outflow obstruction or detrusor instability, and this implies an initial deterioration and change in urodynamic function (Joly, 1923; Mundy et al., 1984). The concept of a diverticulum forming a reservoir of low pressure which progressively expands because of repea-
523
ted micturition under high pressure, gave rise to the 'safety-valve' theory whereby the diverticulum protects the urinary tract from the effects of high detrusor pressure (Hamilton, 1943), although this has been disputed (Smith, 1969). More recently, we have found only isolated reports of clinically significant vesicodiverticular reflux (Redman and Harper, 1979; Kulkarni et al., 1980; Kissinger et al., 1981; Schultz and Hald, 1983). Fox et al. (1962) reported symptoms directly attributable to bladder diverticula in a small proportion of their 115 cases. Blacklock et al. (1983), in their series of 38 patients with bladder diverticula, reported 'no symptoms directly attributable to bladder diverticula', but noted that over half of their patients were improved by diverticulectomy alone, without surgical treatment of bladder outflow obstruction. This implies that the presence of diverticula alone had been contributing to their patients' difficulty in micturition. In our patients, the rise in intravesical pressure at the start of attempted micturition caused marked inflation of moderate-sized or larger bladder diverticula, which then remained inflated until pressure fell at the end of detrusor contraction, when partial refilling of the bladder from the diverticula occurred. This process has three deleterious effects on bladder function. First, the contents of the diverticula form a reservoir of stagnant urine which avoids the expressive action of the detrusor muscle. In this context, it is not uncommon at cystoscopy to find turbid urine or a calculus inside a diverticulum. This suggests that, at times, the contents of a diverticulum become sequestered and the continuity between it and the bladder may be only intermittent. Secondly, flow of urine back and forth between the diverticula and the bladder contributed significantly to our patients' postmicturition residues. Thirdly, in at least two of our patients (Cases 1 and 2), if not all three, vesico-diverticular reflux was considerably exacerbating the difficulty in micturition. It is well established that specialised studies such as micturating cystography or cystometry are required to assess bladder function. Post-micturition IVUs are inevitably taken after an interval when some of the diverticular contents will have returned to the bladder. We wish to emphasise to the surgeon that diverticula alone may cause significant symptoms, and to the radiologist that it is useless to comment on urodynamic function and the significance of post-micturition residues from pre- and post-micturition IVUs in the presence of large diverticula. Acknowledgements.We would like to thank Mr R. Heslop and Mr D. Newling, for allowing us to reproduce the clinical details, and Dr A. S. Early for the radiological material.
REFERENCES Blacklock, A. R. E., Geddes, J. R. & Shaw, R. E. (1983). The treatment of large bladder diverticula. British Journal of Urology, 55, 17-20. Elkin, M. (1980). Ra&ology of the Urinary System. Little, Brown, Boston. Fox, M., Power, R. F. & Bruce, A. W. (1962). Dwerticulum of the bladder - presentation and evaluation of treatment of 115 cases. British Journal of Urology, 34, 286-298. Hamilton, A. J. C. (1943). Divemculum of the urinary bladder - a series of 22 cases. Edinburgh Medical Journal, 50, 513-534. Joly, J. S. (1923). The operative treatment of vesical diverticula.
524
CLINICAL RADIOLOGY
Proceedings of the Royal Society of Medicine (Section of Urology), 16, 55-69. Kissinger, D. J., Beaugard, E. P. & Affuso, P. S. (1981). Unrecognised bladder diverticulum: a cause of persistent urinary tract infection. Journal of the Medical Soctety of New Jersey, 78, 677678. Kulkarni, M. R., Bekirov, H., Tein, A. B. & Newman, H. R. (1980). Giant vesical diverticulum without lower urinary obstruction. New York State Journal of Medicine, 80, 1736-1738. Miller, A. (1958). The aetiology and treatment of diverticulum of the bladder. British Journal of Urology, 30, 43-56. Mundy, A. R., Stephenson, T. P. & Wein, A. J. (eds) (1984).
Urodynamics. Principles, Practice and Application. Churchill Livingstone, Edinburgh. Redman, Y. F. & Harper, D. L. (1979). Case profile: radiographic demonstration of delayed emptying of vesical diverticulum. Urology, 13, 90. Schulze, S. & Hald, T. (1983). Voiding inability after transurethral resection of a bladder diverticulum. Scandinavtan Journal of Urology and Nephrology, 17, 377-378. Smith, J. C. (1969). Studies of vesical diverticula. Proceedings of the Royal Society of Medicine, 62, 1125. Witten, D., Myers, R. & Utz, D. (1977). Emmett's Chnical Urography. W. B. Saunders, Philadelphia.
0009-9260/85/491521502.00
The Radiological and Urodynamic Significance of Large Bladder Diverticula BRENNAN WILSON* and GEORGE KLUFIOt
Departments of Radiology and ?Urology, Hull Royal Infirmary and Princess Royal Hospital, Hull, Humberside
Large acquired bladder diverticula in adults may cause severe urodynamic disturbance and exacerbate difficulty in micturition. They may accommodate a large proportion of the contents of the bladder during attempted voiding, thus decreasing the effect of the detrusor muscle contraction. The post-micturition radiographs on intravenous urography, after the diverticula have emptied again, may only show a large intravesical post-micturition residue and give little information as to the size of the diverticula during the act of micturition.
Case 2. A 71-year-old man presented in September 1983 with a 1-year history of hesitancy, poor stream and terminal dribbling. Physical examination revealed no abnormality. Rectally, his prostate was small and felt benign Full blood count, biochemical profile, serum acid phosphatase and urinalysis were all normal.
The conditions usually cited as complications of diverticula of the acquired adult type are urinary infection, neoplasm and calculus formation (Fox et al., 1962; Witten et al., 1977; Elkin, 1980; Mundy et al., 1984). It has been realised for many years that the presence of any diverticulum, but especially a large one, alters the urodynamic function of the bladder (Joly, 1923; Miller, 1958), but little prominence has been given in the recent literature to the radiological appearances of these urodynamic abnormalities, their clinical presentation and their behaviour during micturition. We report three cases in which the presence of large diverticula was accompanied by significant vesico-diverticular reflux causing severe disturbances of vesical function with misleading appearances on the intravenous urogram
(IVU). Fig. 1 - Case 1: full-bladder IVU.
CASE REPORTS Case 1. A man aged 69 years presented in October 1982 with a 3-year history of hesitancy, dribbling and a feeling of incomplete emptying after micturition. Physical examination was unremarkable. Rectally, he had a small prostate which felt benign. Full blood count, biochemical profile, acid phosphatase and urinalysis were all normal. Intravenous urography was performed. The upper tracts were normal, but the bladder gave rise to three d~verticula. Assuming that the volumes of these diverticula changed in proportion to the cube of their linear dimensions, they at least doubled their overall volume between the full-bladder radiograph (Fig. 1) and the post-micturitlon radiograph (Fig. 2) and the amount of urine they came to contain was about half of that passed per urethra. The bladder size decreased only slightly after micturition. The patient attended for micturating cystography but was unable to pass urine. However, on attempted micturition a dramatic increase in the size of the diverticula was seen at the expense of the bladder contents, 80% of the original contents of the bladder refluxing into the diverticula, which increased m volume at leasts sevenfold (Fig. 3). He was subsequently treated by suprapubic diverticulectomy and prostatectomy. Histological examination of the diverticula showed carcinoma in situ. He is now voiding very well and has been attending regularly for cystoscopy. His bladder, so far, has remained clear of recurrence of tumour. * Present address for correspondence: Department of Radiology, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW.
Fig. 2 - Case 1: post-mictuntion IVU
522
CLINICAL RADIOLOGY
w2..
¢ v2a~,
Fig. 3 - Case 1: micturating cystogram during attempted micturltlOn The bladder is contracted (closed arrow) and three large diverticula (open arrows) and one small diverticulum are seen.
An IVU showed normal upper tracts. The bladder g~ive rise to three diverticula seen on the full-bladder ra&ograph (Fig. 4). They seemed to contain about half the quantity of urine passed on mlctuntion Three of them had apparently doubled in size on the post-micturitlon film, while the largest of them had halved in size and the total quantity which they contained had not changed signifieantly (Fig. 5). A mlcturating cystogram with cystometry was performed. Once micturitlon had started, it continued until the bladder had completely emptied, during which time the volume of the diverticula increased by about 50% (Fig. 6). The patient then entered a phase of 'squirting' micturltion as the diverticula slowly emptied back into the bladder and urine was passed per urethra in spurts During this phase the detrusor pressure hardly rose at all. The patient subsequently underwent transurethral resection of the prostate and suprapubic divertlculectomies. Case 3. A 71-year-old man was referred in February 1984 with two episodes of E. coh urinary tract infection within the preceding 6 months Over the previous 4 years there had been a significant reduction in his urinary stream Physical examination was unremarkable and his prostate felt small and simple in character. Again, routine blood tests and urinalysis were normal Intravenous urography showed normal upper tracts. There were three diverticula arising from the bladder which were slightly larger on
Fig. 5 - Case 2: post-micturitlon IVU.
Fig. 6 - Case 2: micturating cystogram
;f2:{.
Fig. 4 - Case 2: full-bladder IVU.
Fig. 7 - Case 3: full-bladder IVU.
LARGE BLADDER DIVERTICULA
Fig. 8 - Case 3: post-micturition IVU.
v~
,
2
v
~
v
,
~
v
Fig. 9 - Case 3: micturating cystogram shortly after the start of micturition. The bladder contains an air-fluid level. Two paper clips were taped to the front of the abdomen 10 cm apart for reference (arrows).
the post-micturition IVU (Fig. 8) than on the full-bladder radiograph (Fig. 7). Bladder emptying was very incomplete. A micturating cystogram performed 4 months later prior to surgery showed that the dwerticula nearly doubled in size during the early part of micturition (Fig. 9) and then deflated themselves back into the bladder as micturition was coming to an end. Probably as much urine refluxed into the diverticula during micturition as was voided. Suprapubic diverticulectomies and prostatectomy were subsequently performed.
DISCUSSION It is widely believed that acquired adult-type bladder diverticula arise by pulsion at weak points in the bladder wall when the detrusor pressure is pathologically raised due to outflow obstruction or detrusor instability, and this implies an initial deterioration and change in urodynamic function (Joly, 1923; Mundy et al., 1984). The concept of a diverticulum forming a reservoir of low pressure which progressively expands because of repea-
523
ted micturition under high pressure, gave rise to the 'safety-valve' theory whereby the diverticulum protects the urinary tract from the effects of high detrusor pressure (Hamilton, 1943), although this has been disputed (Smith, 1969). More recently, we have found only isolated reports of clinically significant vesicodiverticular reflux (Redman and Harper, 1979; Kulkarni et al., 1980; Kissinger et al., 1981; Schultz and Hald, 1983). Fox et al. (1962) reported symptoms directly attributable to bladder diverticula in a small proportion of their 115 cases. Blacklock et al. (1983), in their series of 38 patients with bladder diverticula, reported 'no symptoms directly attributable to bladder diverticula', but noted that over half of their patients were improved by diverticulectomy alone, without surgical treatment of bladder outflow obstruction. This implies that the presence of diverticula alone had been contributing to their patients' difficulty in micturition. In our patients, the rise in intravesical pressure at the start of attempted micturition caused marked inflation of moderate-sized or larger bladder diverticula, which then remained inflated until pressure fell at the end of detrusor contraction, when partial refilling of the bladder from the diverticula occurred. This process has three deleterious effects on bladder function. First, the contents of the diverticula form a reservoir of stagnant urine which avoids the expressive action of the detrusor muscle. In this context, it is not uncommon at cystoscopy to find turbid urine or a calculus inside a diverticulum. This suggests that, at times, the contents of a diverticulum become sequestered and the continuity between it and the bladder may be only intermittent. Secondly, flow of urine back and forth between the diverticula and the bladder contributed significantly to our patients' postmicturition residues. Thirdly, in at least two of our patients (Cases 1 and 2), if not all three, vesico-diverticular reflux was considerably exacerbating the difficulty in micturition. It is well established that specialised studies such as micturating cystography or cystometry are required to assess bladder function. Post-micturition IVUs are inevitably taken after an interval when some of the diverticular contents will have returned to the bladder. We wish to emphasise to the surgeon that diverticula alone may cause significant symptoms, and to the radiologist that it is useless to comment on urodynamic function and the significance of post-micturition residues from pre- and post-micturition IVUs in the presence of large diverticula. Acknowledgements.We would like to thank Mr R. Heslop and Mr D. Newling, for allowing us to reproduce the clinical details, and Dr A. S. Early for the radiological material.
REFERENCES Blacklock, A. R. E., Geddes, J. R. & Shaw, R. E. (1983). The treatment of large bladder diverticula. British Journal of Urology, 55, 17-20. Elkin, M. (1980). Ra&ology of the Urinary System. Little, Brown, Boston. Fox, M., Power, R. F. & Bruce, A. W. (1962). Dwerticulum of the bladder - presentation and evaluation of treatment of 115 cases. British Journal of Urology, 34, 286-298. Hamilton, A. J. C. (1943). Divemculum of the urinary bladder - a series of 22 cases. Edinburgh Medical Journal, 50, 513-534. Joly, J. S. (1923). The operative treatment of vesical diverticula.
524
CLINICAL RADIOLOGY
Proceedings of the Royal Society of Medicine (Section of Urology), 16, 55-69. Kissinger, D. J., Beaugard, E. P. & Affuso, P. S. (1981). Unrecognised bladder diverticulum: a cause of persistent urinary tract infection. Journal of the Medical Soctety of New Jersey, 78, 677678. Kulkarni, M. R., Bekirov, H., Tein, A. B. & Newman, H. R. (1980). Giant vesical diverticulum without lower urinary obstruction. New York State Journal of Medicine, 80, 1736-1738. Miller, A. (1958). The aetiology and treatment of diverticulum of the bladder. British Journal of Urology, 30, 43-56. Mundy, A. R., Stephenson, T. P. & Wein, A. J. (eds) (1984).
Urodynamics. Principles, Practice and Application. Churchill Livingstone, Edinburgh. Redman, Y. F. & Harper, D. L. (1979). Case profile: radiographic demonstration of delayed emptying of vesical diverticulum. Urology, 13, 90. Schulze, S. & Hald, T. (1983). Voiding inability after transurethral resection of a bladder diverticulum. Scandinavtan Journal of Urology and Nephrology, 17, 377-378. Smith, J. C. (1969). Studies of vesical diverticula. Proceedings of the Royal Society of Medicine, 62, 1125. Witten, D., Myers, R. & Utz, D. (1977). Emmett's Chnical Urography. W. B. Saunders, Philadelphia.