What is the best management approach for an asymptomatic male patient with a bladder diverticulum and a history of prostate surgery, with normal bladder emptying and no current urinary symptoms?

Management of Asymptomatic Bladder Diverticulum with Complete Bladder Emptying

Conservative observation with periodic monitoring is the appropriate management for this patient, as surgery is not indicated for an asymptomatic bladder diverticulum when bladder emptying is complete and there are no complications. 1

Guideline-Based Recommendation

The AUA explicitly states that the presence of a bladder diverticulum is not an absolute indication for surgery unless it is associated with recurrent UTI or progressive bladder dysfunction. 1 More recent 2018 AUA guidelines reinforce this by stating that clinicians should not perform surgery solely for the presence of an asymptomatic bladder diverticulum. 1

Key Clinical Features Supporting Conservative Management

Your patient demonstrates several favorable characteristics that support observation:

• Complete bladder emptying - The ultrasound confirms complete emptying with voiding, indicating no significant bladder dysfunction 1
• Absence of symptoms - No urinary retention, recurrent infections, or other complications are present 1
• Prior prostate surgery - The prostate is surgically absent, eliminating bladder outlet obstruction as a causative or perpetuating factor 1
• Moderate diverticulum size - At approximately 3 cm, this is not a "large" diverticulum requiring intervention 1

Evaluation for Bladder Outlet Obstruction

Prior to any consideration of surgery for bladder diverticulum, assessment for bladder outlet obstruction (BOO) should be performed and treated as clinically indicated. 1 However, in this patient with a surgically absent prostate and complete bladder emptying, BOO is unlikely to be present or contributing to the diverticulum.

Absolute Indications for Surgical Intervention

Surgery would be recommended only if the patient develops: 1

• Recurrent urinary tract infections clearly attributable to the diverticulum
• Progressive bladder dysfunction with incomplete emptying or increasing post-void residual
• Bladder stones within the diverticulum
• Recurrent gross hematuria from the diverticulum
• Renal insufficiency secondary to the diverticulum (rare)

Recommended Monitoring Strategy

For patients under conservative management, follow-up should include: 1

• Initial reassessment at 6 months, then annually if stable
• Symptom assessment using validated questionnaires (AUA-SI/IPSS) at each visit 1
• Urinalysis to screen for infection or hematuria 1
• Post-void residual measurement to monitor for development of incomplete emptying 1
• Renal function testing if there are concerns about upper tract involvement 1

Important Clinical Caveats

• The diverticulum likely developed secondary to prior bladder outlet obstruction from BPH before prostate surgery 1
• Diverticula may persist after relief of obstruction but often remain asymptomatic 1
• Do not pursue surgical diverticulectomy based solely on imaging findings in the absence of symptoms or complications 1
• If symptoms develop, ensure they are truly attributable to the diverticulum rather than other causes before proceeding with surgery 1