Treatment of Bladder Diverticulum
Surgical intervention is the recommended treatment for symptomatic bladder diverticula, particularly when associated with recurrent urinary tract infections, progressive bladder dysfunction, or other complications. 1
Diagnostic Evaluation
Before determining treatment, proper diagnosis is essential:
Imaging studies:
- CT scan with IV contrast (sensitivity 98%, specificity 99%)
- Voiding cystourethrography to confirm diagnosis and assess diverticulum size
- Cystoscopy to evaluate the diverticulum and bladder outlet
Laboratory assessment:
- Urinalysis and urine culture to identify infection
- Renal function tests to assess for complications
Treatment Algorithm
1. Asymptomatic Bladder Diverticula
- Conservative management is appropriate for asymptomatic diverticula
- The presence of a bladder diverticulum alone is not an absolute indication for surgery 1
- Regular follow-up to monitor for development of complications
2. Symptomatic Bladder Diverticula
A. Treat Underlying Cause
- Address bladder outlet obstruction (if present):
- For BPH-related obstruction: surgical intervention such as TURP
- Alpha blockers may be used as adjunctive therapy but not as definitive treatment for significant diverticula
B. Diverticulectomy Indications
Surgical removal of the diverticulum is indicated when associated with:
- Recurrent urinary tract infections
- Progressive bladder dysfunction
- Large diverticula causing symptoms
- Stones within the diverticulum
- Suspected malignancy within the diverticulum 1, 2
C. Surgical Approaches
- Open diverticulectomy - traditional approach with excellent outcomes
- Laparoscopic diverticulectomy - less invasive alternative
- Robotic-assisted diverticulectomy - offers precision for complex cases 2
3. Complicated Cases
Ruptured diverticulum:
- Surgical repair is generally recommended
- Conservative management with catheter drainage may be considered in high-risk surgical patients 3
Large diverticula:
- Typically require surgical intervention even after addressing outlet obstruction 4
- Small diverticula may resolve with relief of bladder outlet obstruction alone
Special Considerations
- Timing of interventions: When both outlet obstruction and significant diverticulum are present, consider addressing both issues, potentially in staged procedures
- Malignancy risk: Bladder diverticula can harbor tumors, requiring careful evaluation and potential biopsy 4
- Critical patients: In high-surgical-risk patients with complications like diverticular rupture, conservative management with catheterization and antibiotics may be attempted under close observation 3
Post-Treatment Follow-up
- Cystoscopy to evaluate healing and rule out recurrence
- Imaging to assess for resolution of complications
- Monitoring of urinary symptoms
Pitfalls to Avoid
- Failing to address underlying bladder outlet obstruction when treating diverticula
- Missing malignancy within diverticula (careful evaluation needed)
- Overlooking bladder diverticula as a cause of recurrent UTIs or pelvic masses 5
The treatment approach should be guided by the patient's symptoms, the size and location of the diverticulum, and the presence of complications, with surgical intervention being the definitive treatment for symptomatic cases that impact quality of life or present with complications.