Diagnostic and Treatment Approach for 81-Year-Old Woman with Bladder Diverticula, Recurrent UTIs, and Hydronephrosis
This patient requires CT urography (CTU) or MR urography (MRU) as the primary diagnostic imaging, followed by cystoscopy, with treatment directed at relieving bladder outlet obstruction through surgical diverticulectomy to prevent progression to renal failure and reduce recurrent infections.
Diagnostic Workup
Primary Imaging Studies
CTU or MRU are the appropriate first-line imaging modalities for this complicated presentation. 1 Both provide comprehensive evaluation of the entire urinary tract including:
- Assessment of bilateral hydronephrosis severity and etiology 1
- Detailed anatomic depiction of bladder diverticula 1
- Evaluation for vesicoureteral reflux 1
- Detection of urinary tract obstruction 1
CTU has excellent sensitivity and specificity for identifying renal and urothelial lesions, while MRU provides superior functional information about the urinary tract. 1 CTU and MRU are considered equivalent alternatives—only one procedure should be ordered. 1
Additional Diagnostic Studies
Voiding cystourethrography should be considered when bladder diverticula are at or near ureteral orifices to evaluate for vesicoureteral reflux, which may explain the bilateral hydronephrosis. 1
Cystoscopy is indicated for all patients with recurrent complicated UTIs to directly visualize the bladder diverticula, assess their size and location, and exclude malignancy. 1
Essential Laboratory Evaluation
- Urine culture and sensitivity testing before each treatment to guide antimicrobial therapy 2, 3
- Post-void residual measurement to assess for incomplete bladder emptying 3
- Renal function testing given bilateral hydronephrosis
Critical Diagnostic Considerations
Bladder diverticula in elderly women are unusual and typically associated with neurogenic bladder or prior surgery—they are rarely congenital. 1 The combination of:
- High IPSS score (20) with predominant voiding symptoms
- Bilateral hydronephrosis
- Recurrent UTIs
- Bladder diverticula
This constellation strongly suggests bladder outlet obstruction with secondary upper tract deterioration. 4 The bilateral hydronephrosis is particularly concerning as it indicates significant functional impairment that threatens renal function and requires urgent intervention. 4
Treatment Strategy
Acute UTI Management
For acute symptomatic episodes while awaiting definitive management:
- Nitrofurantoin 50-100 mg four times daily for 5 days 2
- Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3-7 days 2, 3
- Fosfomycin trometamol 3 g single dose 2
Treatment should be tailored based on culture results and local antibiogram patterns. 3
Definitive Surgical Management
Surgical diverticulectomy is the reference standard for symptomatic bladder diverticula and should be strongly considered in this patient. 5 The indications for surgery include:
- Recurrent UTIs refractory to medical management 5
- Bilateral hydronephrosis indicating upper tract compromise 4
- High symptom burden (IPSS=20) 6
Robot-assisted surgery has progressively replaced open approaches with favorable outcomes, using either extravesical, transvesical, or transdiverticular techniques. 5 In elderly or frail patients, endoscopic incision of the diverticular neck with fulguration may be considered as an alternative. 5
Medical Management Considerations
While awaiting or as adjunct to surgery:
Alpha-blockers (tamsulosin) may provide symptomatic relief for voiding symptoms, though the underlying anatomical problem requires surgical correction. 7, 6 Tamsulosin 0.4 mg once daily has been shown to improve voiding symptoms with mean IPSS improvements of 8-10 points. 7
Anticholinergics (oxybutynin) for urgency and nocturia should be used with extreme caution given the risk of urinary retention in the setting of bladder outlet obstruction and incomplete emptying. 8, 6
Critical Pitfalls to Avoid
Do not treat this as simple recurrent uncomplicated UTI. This is a complicated UTI with anatomical abnormalities requiring imaging and urological evaluation. 1
Do not delay imaging. The bilateral hydronephrosis indicates upper tract involvement that can progress to irreversible renal damage. 4
Do not start anticholinergic therapy without measuring post-void residual. In the setting of bladder diverticula and high voiding symptom scores, anticholinergics can precipitate acute urinary retention. 8
Pathological evaluation of any resected diverticulum is mandatory as bladder diverticula carry risk of malignancy, and the lack of muscular layer in the diverticular wall may lead to understaging. 5
Prognosis and Follow-up
Following successful diverticulectomy, patients typically experience:
- Resolution of recurrent UTIs 5
- Improvement in voiding symptoms 5
- Resolution or improvement of hydronephrosis 4
Postoperative cystography should be performed before catheter removal to ensure no leakage, typically around day 10-12 post-surgery. 4