What is the management and treatment of a trabeculated urinary bladder?

Management and Treatment of a Trabeculated Urinary Bladder

The management of a trabeculated urinary bladder should focus on treating the underlying bladder outlet obstruction, with alpha-blockers being the first-line pharmacological treatment for men with lower urinary tract symptoms due to bladder outlet obstruction. 1

Understanding Trabeculated Bladder

Bladder trabeculation is a morphological change in the bladder wall characterized by thickening and the development of muscular ridges (trabeculae) that can be observed during cystoscopy or imaging studies. It typically develops as a consequence of:

• Chronic bladder outlet obstruction leading to detrusor muscle hypertrophy 1, 2
• Neurogenic bladder dysfunction causing elevated intracystic pressure 2
• Combination of bladder overdistention, outflow obstruction, and uninhibited detrusor contractions 2

Diagnostic Evaluation

A comprehensive urological evaluation is recommended for patients with trabeculated bladder:

• Voiding Cystourethrography (VCUG) is recommended as the initial imaging test for evaluation of urinary dysfunction 3
• CT Urography provides comprehensive evaluation of the genitourinary tract and can identify potential causes of obstruction 3
• Urodynamic testing should be considered to assess bladder contractility, evaluate for detrusor underactivity, and measure post-void residual volumes 3
• Cystoscopy may be performed to directly visualize the trabeculation and rule out other bladder pathologies 4

Treatment Approach

Medical Management

• First-line treatment for men with BOO: α1-adrenergic blocking agents are the treatment of choice for lower urinary tract symptoms due to bladder outlet obstruction 1
• For enlarged prostate: Combination therapy with an α-blocker and 5α-reductase inhibitor has shown the highest efficacy when the prostate is enlarged and/or if serum PSA is greater than 1.5 ng/ml 1
• For coexisting BOO and overactive bladder symptoms: α-blocker and antimuscarinic combination therapy may be considered 1

Interventional Therapy

If medical management fails or is not appropriate, interventional therapy should be considered:

• For men with significant BOO: Transurethral resection of the prostate (TURP) remains the gold standard for interventional treatment 1
• Before proceeding with interventional therapy: Pressure flow studies are indicated if maximum urinary flow rate is greater than 10 ml/second to confirm obstruction 1
• For neurogenic bladder with trabeculation: Augmentation cystoplasty may be considered, especially in cases with severe trabeculation 5

Management of Complications

Patients with trabeculated bladder are at risk for several complications that require specific management:

• Hydronephrosis: Prompt relief of obstruction is necessary 6
• Vesicoureteral reflux: May require surgical correction if conservative measures fail 6, 2
• Urinary tract infections: Appropriate antibiotic therapy and prevention strategies 6
• Bladder diverticula: May require surgical intervention if symptomatic 2

Follow-up Recommendations

Regular follow-up is essential to monitor treatment response and detect complications:

• Reassessment 2-4 weeks after initiation of α-blocker therapy 1
• At least 3 months follow-up for 5α-reductase inhibitors 1
• Annual follow-up to detect any changes in symptoms or complications 1
• Periodic reassessment of renal function 3
• Consider repeat urodynamic studies if symptoms worsen 3

Special Considerations

Neurogenic Bladder

• Management of filling bladder pressures and regular, complete emptying, ideally with clean intermittent catheterization, can prevent or delay many complications 6
• Severe bladder trabeculation in patients with neurogenic bladder might predict an element of intrinsic outlet resistance 5

Pediatric Patients

• In children with posterior urethral valves, trabeculation typically affects the body of the bladder while the base remains smooth due to different innervation patterns 7
• Suprapubic cystostomy is recommended for urinary drainage in pediatric patients with bladder injuries 1

Pitfalls and Caveats

• Repeated attempts at placing a urethral catheter should be avoided in cases of urethral injury as this may increase injury extent 1
• Prolonged and heroic attempts at endoscopic realignment must be avoided as the process may increase injury severity and long-term sequelae 1
• False-positive results on imaging can occur due to benign prostatic hypertrophy mimicking bladder lesions 3