Bladder diverticula

　　Bladder diverticula are caused by defects in the bladder muscle layer, forming local outward bulges of the bladder, which are more common in the lateral and posterior parts of the bladder and often accompanied by the formation of bladder shelves and small chambers.

　　1. Etiology

　　Congenital lesions such as urethral stricture, posterior urethral valve, and bladder neck stenosis promote the formation and development of diverticula, which are the main factors for the formation of diverticula. In clinical practice, most patients with bladder neck obstruction do not develop diverticula, and some cases of diverticula do not have obstruction, so the formation of bladder diverticula is also related to congenital abnormal arrangement of bladder muscle fibers. Obstruction of the lower urinary tract and high pressure are the main causes of secondary bladder diverticula formation.

　　Clinically, cystoceles located near the ureteral orifice are most common. In terms of embryonic development, the bladder wall is different from the bladder trigone area. It is currently believed that the thin connection between the trigone area and the detrusor muscle is related to the formation of bladder cystoceles.

　　Bladder cystoceles can also occur at the blind end of the ureteral orifice. Oriasa (1990) reported 2 cases of ureteral orifice blind end causing ureteral and bladder cystoceles.

　　Another type of bladder cystocele is located at the neck, which may be related to incomplete disappearance of the umbilical urachus and is often secondary to lower urinary tract obstruction or prune-belly syndrome (Prune-belly syndrome).

　　Second, pathogenesis

　　Congenital cystoceles are often caused by the protrusion of redundant ureteral buds and unobliterated umbilical urachus, or congenital localized thinning of the bladder wall. Cystoceles are mostly solitary and contain the entire bladder wall, most common in children, and there is no obstruction in the lower urinary tract. Cystoceles can also be caused by secondary factors, mostly due to lower urinary tract obstruction, and are formed by the protrusion of detrusor muscle bundles between the split bladder wall secondary to lower urinary tract obstruction. They are often multiple, with mucosal papillae (such as these cystoceles do not contain all layers of the bladder wall, so they are also called pseudocystoceles), most common in adult males, and associated with detrusor hyperplasia.

　　Cystoceles are often located at the bottom and sides of the bladder, with thin walls. They can be infiltrated by inflammatory cells due to infection, and can also be complicated by calculus or tumor. The enlargement of the cystocele can also compress the ureter, causing it to shift and produce obstruction. If the obstruction progresses further, it can cause an increase in intracystic pressure, leading to a decrease in glomerular filtration rate, reduced urine output, and impaired excretion of creatinine and urea nitrogen. In severe cases, renal insufficiency or renal failure may occur.

　　Cystocele usually has no special symptoms if there are no complications. If there is obstruction or infection, symptoms such as difficulty in urination, frequent urination, urgency, and urinary tract infection may occur. Some cystoceles can be as large as 2000ml, compressing the bladder neck and urethra, leading to lower urinary tract obstruction. The lack of muscular contraction in the cystocele may cause poor urine drainage, making it prone to urinary reflux from the ureter to the bladder, which can lead to unilateral or bilateral hydronephrosis and eventually renal insufficiency or failure. However, there are also congenital giant cystoceles that do not have urinary tract obstruction. Due to the lack of muscle fibers in the bladder cystocele wall, urine cannot be expelled from the large cystocele during urination, resulting in secondary urination symptoms. Some patients may have hematuria due to infection or calculus in the cystocele, and a few patients may have urinary retention due to a large cystocele located behind the bladder neck, compressing the bladder outlet, leading to constipation due to compression of the rectum and dystocia due to compression of the uterus.

　　Cystocele is caused by defects in the bladder muscle layer, forming local outward bulges of the bladder, which are often located in the lateral and posterior parts of the bladder and are often accompanied by the formation of bladder shelves and small chambers. Early detection, early diagnosis, and early treatment are of great significance in preventing the disease.

　　During pregnancy, it is important to strengthen nutrition, eat more fruits and vegetables to supplement adequate vitamins, maintain a good mood, and engage in appropriate activities to improve physical fitness, which are all conducive to the correct development of the fetus.

　　If there are no complications, bladder diverticula have no special symptoms, so the diagnosis of this disease requires the help of relevant examinations to be clear. The specific examinations are as follows:

　　1, Urinary tract imaging:It appears as a protruding bladder extraneous spheric shadow, with a neck connected to the bladder.

　　2, Ultrasound manifestations:Show a sac-like or spherical liquid dark area connected to the bladder side or back wall, with enhanced back wall echo.

　　3, CT manifestations:Enhanced scanning shows a protruding bladder extraneous filling contrast agent spheric shadow. If there is a stone or tumor in the diverticulum, there may be a filling defect.

　　If there are no complications, bladder diverticula have no special symptoms, so the diagnosis of this disease requires the help of relevant examinations to be clear. The main treatment for this disease is to relieve lower urinary tract obstruction and control infection. In daily diet, attention should be paid to consume more high-fiber foods and fresh vegetables and fruits, maintain a balanced diet, including proteins, sugars, fats, vitamins, trace elements, and dietary fibers, etc., a variety of food combinations, give full play to the complementary effects of nutrients between foods. It is recommended to eat high-protein and nutritious foods as well as foods rich in vitamins and minerals and high-calorie and easily digestible foods. It is forbidden to eat greasy and difficult-to-digest foods, fried, smoked, grilled, cold, spicy foods, and high-salt and high-fat foods.

　　Most bladder diverticula are solitary and located near the ureteral orifice. Patients with bladder diverticula often die before the age of 10 or between 50 and 60. The main treatment for this disease is to relieve lower urinary tract obstruction and control infection. Commonly used drugs include third-generation cephalosporins, fluoroquinolones, and metronidazole.

　　Currently, it is倾向于首先经尿道行憩室颈口切开术，以引流憩室内尿液。如果效果不好，再考虑开放或腹腔镜下行憩室切除。如果憩室巨大，输尿管口靠近憩室或在憩室内开口，则须做憩室切除行防反流的膀胱输尿管再植术，并注意修复输尿管口膀胱部的肌肉缺损，憩室小者不必切除。