Editing Bladder Diverticulae (section)

== Diagnosis and Evaluation ==

=== UrologySchool.com Summary ===
*'''<span style="color:#ff0000">History and Physical Exam'''
*'''<span style="color:#ff0000">Labs'''
**'''<span style="color:#ff0000">Urinalysis +/- urine culture'''
**'''<span style="color:#ff0000">Urine cytology'''
**'''<span style="color:#ff0000">PSA, if appropriate'''
*'''<span style="color:#ff0000">Imaging'''
**'''<span style="color:#ff0000">Lower urinary tract: CT scan and/or VCUG'''
**'''<span style="color:#ff0000">Upper urinary tract: CT or Renal US'''
*'''<span style="color:#ff0000">Other'''
**'''<span style="color:#ff0000">Cystoscopy'''
**'''<span style="color:#ff0000">Urodynamics'''

=== History and Physical Exam ===
* '''Most bladder diverticula are found during the investigation of nonspecific lower urinary symptoms, hematuria, or infection.''' The diverticulum may or may not be related to reason for investigation.
*'''History'''
** '''Because large bladder diverticulae empty poorly or incompletely during voiding, symptoms and signs, if present, are usually attributed to urinary stasis within the diverticulum'''
** Characterize LUTS, identify potential occult sources of neurogenic vesicourethral dysfunction (spinal surgery, etc.), and properly characterize any prior lower urinary tract surgery
* '''Physical exam'''
** '''Digital rectal exam'''

=== Labs ===
* '''Urinalysis, urine culture, and urine cytology''' should be considered in most patients with bladder diverticula, especially when nonoperative management is being considered.
** Pyuria and hematuria are often present
* PSA, if appropriate

* '''The finding of a bladder diverticulum in an adult should prompt further evaluation for bladder outlet obstruction, as well as endoscopic examination and imaging (lower and upper urinary tract).'''

=== Imaging ===
* Many bladder diverticula are diagnosed incidentally, sometimes on imaging.
* [[File:Bladder Diverticulum.jpg|alt=Axial CT scan demonstrating a bladder diverticulum|thumb|500x500px|Axial CT scan demonstrating a bladder diverticulum. Source: [[commons:File:Bladder_Diverticulum.jpg|Wikipedia]]]]'''<span style="color:#ff0000">Differential diagnosis of a fluid-filled structure adjacent to the bladder (5):'''
*# '''<span style="color:#ff0000">Müllerian cysts'''
*# '''<span style="color:#ff0000">Uterine, ovarian, and fallopian tube abnormalities'''
*# '''<span style="color:#ff0000">Urachal cysts'''
*# '''<span style="color:#ff0000">Ectopic ureter or ureterocele'''
*# '''<span style="color:#ff0000">Postsurgical changes, including lymphocele'''
* '''Lower urinary tract imaging'''
** '''Can include cross-sectional studies and/or VCUG'''
*** Cross-sectional imaging may provide useful information regarding bladder diverticula (number, location, filling-defect in case of obstructed diverticulum neck) and critical information regarding the surrounding anatomy.
***'''VCUG''' with anterior-posterior, oblique, and lateral images '''provides''' '''information regarding anatomy, location, and size and also associated vesicoureteral reflux and, importantly, emptying of the bladder diverticulum with voiding'''
* '''Consider upper tract imaging'''
** Up to 7% of adults with bladder diverticula have been found to have asymptomatic or silent hydroureteronephrosis related to the diverticulum
** Up to 30% of children with bladder diverticula have been found to have upper tract abnormalities, including renal scarring, dysplasia, and hydronephrosis

=== Other ===

==== Cystoscopy ====
* '''The entire interior of each bladder diverticulum should be thoroughly inspected for stones or abnormal-appearing epithelium.'''
** Any abnormal-appearing epithelium or lesions within the diverticulum are carefully biopsied
*** Biopsy should be performed carefully to prevent perforation because the wall of the diverticulum is very thin owing to the lack of a muscularis propria layer

==== Urodynamics ====
* '''VUDS can be very helpful in patients with bladder diverticula to potentially identify neurogenic voiding dysfunction.'''
** '''Failure to identify and treat an existing underlying urodynamic abnormality prior to or concomitantly with definitive surgical therapy for bladder diverticula may result in a high risk of recurrent diverticula or other problems following surgery'''.
* '''Bladder contractility may appear to be diminished on urodynamics because of the “pressure sink” effect of the bladder diverticulum'''.
** This artifact occurs as the detrusor contracts and the intravesical contents are decompressed through the path of least resistance into the bladder diverticulum as opposed to the urethra. Nevertheless, '''when carefully measured, bladder contractility is not significantly different from that in individuals with benign prostatic hyperplasia without bladder diverticula'''. In addition, elevated postvoid residual urine may be present as a result of retained urine in the diverticulum regardless of the presence or absence of impaired bladder contractility or bladder outlet obstruction.