Could intestinal diverticuli or a pedunculated bladder tumor be causing back pain?

Back Pain in a Patient with Intestinal Diverticuli and Pedunculated Bladder Tumor

Both intestinal diverticuli and a pedunculated bladder tumor could potentially cause back pain, though the mechanism and likelihood differ between these conditions.

Intestinal Diverticuli and Back Pain

• Intestinal diverticuli alone typically do not cause back pain unless complications develop such as diverticulitis with inflammation extending to surrounding tissues 1
• When diverticulitis occurs, pain is usually localized to the left lower quadrant, but can radiate to the back in cases of severe inflammation or abscess formation 1
• Complications of diverticulitis that may cause back pain include:
  • Abscess formation, especially if located in the retroperitoneum 1
  • Fistula formation between the colon and adjacent structures 1, 2
  • Perforation with retroperitoneal involvement 1

Bladder Tumor and Back Pain

• A pedunculated cancerous tumor of the bladder can cause back pain through several mechanisms:
  • Direct extension of the tumor beyond the bladder wall into surrounding tissues 3
  • Metastasis to vertebral bodies or paraspinal tissues 4
  • Mass effect from a large tumor, particularly if growing within a bladder diverticulum 5, 6
  • Inflammatory response in surrounding tissues 3

Diagnostic Approach

Imaging Recommendations

• CT scan of abdomen and pelvis with IV and oral contrast is the preferred initial imaging modality:

  • Highly accurate for diagnosing diverticulitis (sensitivity/specificity 95%) 1
  • Can evaluate for potential complications of diverticulitis 1
  • Can assess bladder tumor extension and local invasion 3
  • Can identify alternative causes of back pain 1

• MRI may be considered as a follow-up study:

  • Superior soft tissue resolution for evaluating tumor invasion 1
  • Can better characterize fistula formation 1
  • Useful when there is concern for underlying colonic neoplasm 1

Clinical Considerations

• Back pain associated with diverticulitis typically:

  • Worsens with movement or pressure on the abdomen 1
  • May be accompanied by fever, leukocytosis, or elevated CRP 1
  • Often presents with concurrent abdominal pain 1

• Back pain associated with bladder tumors typically:

  • Is more persistent and progressive 5
  • May be accompanied by hematuria 3
  • Can cause neurological symptoms if there is nerve compression 6

Potential Complications to Consider

• Colovesical fistula formation:

  • Can occur when diverticulitis extends into the bladder 1
  • May present with pneumaturia, fecaluria, or recurrent UTIs 1
  • Can be diagnosed on contrast-enhanced CT by identifying an enhancing tract between colon and bladder 1

• Inflammatory pseudotumor:

  • Diverticulitis can rarely cause inflammatory pseudotumor of the bladder, mimicking a primary bladder tumor 2
  • Presents with urinary symptoms and may be confused with primary bladder cancer 2

Management Implications

• If diverticulitis is causing back pain:

  • Antibiotic treatment should be considered for complicated cases or patients with comorbidities 1
  • Imaging-guided drainage may be needed for abscesses 1
  • Colonoscopy should be performed 6-8 weeks after resolution of acute symptoms to exclude underlying malignancy 1

• If bladder tumor is causing back pain:

  • Staging and treatment planning should proceed urgently 3
  • Special attention should be paid to tumors within bladder diverticula as they have poorer prognosis due to early transmural invasion 3

Conclusion

Back pain in this patient could be caused by either condition, but CT imaging with IV and oral contrast should be performed to determine the exact cause and guide appropriate management. The presence of both conditions requires careful evaluation to determine which is more likely responsible for the back pain, or if there is another underlying cause entirely 4.