From the Guidelines
The initial management for a patient with a bladder diverticulum is typically conservative observation if the diverticulum is asymptomatic or causing only mild symptoms. This approach is supported by the American Urological Association (AUA) guideline, which states that clinicians should not perform surgery solely for the presence of an asymptomatic bladder diverticulum; however, evaluation for the presence of bladder outlet obstruction (BOO) should be considered 1. The conservative approach includes regular monitoring with periodic ultrasound or cystoscopy to assess for changes in size or complications.
If the patient has recurrent urinary tract infections, prophylactic antibiotics may be prescribed, such as trimethoprim-sulfamethoxazole 80/400 mg daily or nitrofurantoin 50-100 mg daily. For patients with voiding symptoms, treatment of any underlying bladder outlet obstruction is essential, which may involve alpha-blockers like tamsulosin 0.4 mg daily for men with prostatic enlargement or treatment of urethral strictures.
- Key considerations in management include:
- Assessment for BOO and treatment as clinically indicated
- Monitoring for changes in size or complications
- Prophylactic antibiotics for recurrent urinary tract infections
- Treatment of underlying causes of increased bladder pressure Surgical intervention (diverticulectomy) is generally reserved for cases with recurrent infections, large stone formation within the diverticulum, significant urinary retention, or suspected malignancy, as recommended by the AUA guideline 1 and supported by earlier guidelines 1. The conservative approach is justified because many bladder diverticula remain asymptomatic throughout life and don't require intervention, while addressing any underlying causes of increased bladder pressure can prevent progression and complications.
From the Research
Initial Management of Bladder Diverticulum
The initial management of a patient with a bladder diverticulum depends on the symptoms and complications associated with the condition.
- For asymptomatic patients, no treatment may be necessary, but regular follow-up is recommended to monitor for any changes or development of symptoms 2.
- For patients with symptoms such as urinary retention, benign prostatic hyperplasia (BPH) may need to be addressed first, followed by management of the bladder diverticulum 3.
- Endoscopic management, such as transurethral resection of the prostate and endoscopic fulguration of the bladder diverticulum mucosa, may be a viable option for some patients 3.
- Laparoscopic transperitoneal bladder diverticulectomy is another surgical option for patients with large bladder diverticula causing poor emptying 4.
- In cases of spontaneous rupture of bladder diverticula, conservative management with urinary catheterization, antibiotics, and/or percutaneous peritoneal drainage may be considered, especially in patients who are poor candidates for surgery 5, 6.
Considerations for Management
- The patient's overall health and presence of any underlying conditions, such as BPH or Ehlers-Danlos syndrome, should be taken into account when determining the best course of management 2, 5.
- The size and location of the bladder diverticulum, as well as the presence of any complications, such as urinary tract infections or renal damage, should also be considered 3, 4.
- A multidisciplinary approach, involving urologists, surgeons, and other healthcare professionals, may be necessary to ensure optimal management of the patient's condition 6.