Lower Urinary Tract Anomalies

Fig. 14.1

MR I of the pelvis noting bright periurethral fluid-filled structure representing a midurethral diverticulum

14.3.1.4 UDS

Findings

The urodynamic tracing of this case is shown in Fig. 14.2. The filling cystometrogram shows normal bladder compliance, with scattered uninhibited bladder contractions diagnostic of detrusor overactivity. The patient had normal initial sensations; however, strong desire was at a low volume. Additionally, maximum cystometric capacity (MCC) was lower than the normal limits expected for this age at 160 mL. The voiding phase of the study demonstrated normal contractility, with elevated voiding pressures, with low urine flow.

Fig. 14.2

Urodynamic study in a female with a urethral diverticulum

In summary, it appears that this patient has detrusor overactivity which is likely secondary to a failure to empty based on outlet obstruction from the diverticulum.

14.3.1.5 Treatment Options

The standard of care for urethral diverticula is surgical excision, with multilayered closure. Consideration for tissue interposition must be given in cases where poor tissue quality hinders repair or in recurrent diverticulae.

Whether or not to address the outlet with respect to anti-incontinence surgery at the time of repair remains controversial. This patient has clear stress incontinence due to urethral hypermobility. Some argue that concomitant autologous fascial sling at the time of diverticulectomy can treat stress incontinence at the time of repair [2]. Lee reported rates of stress urinary incontinence after urethral diverticula repair and found that 75 % of women with preoperative stress incontinence continued to have stress incontinence postoperatively. Additionally, of 15 patients who had no prior stress urinary incontinence, 5 (33 %) developed de novo stress urinary incontinence postoperatively [5]. Nevertheless, it is the author’s preference to stage incontinence surgery until after formal repair is performed and confirmed. One reason for this is due to the risk of recurrence of the diverticulum and difficulty in performing secondary repair after anti-incontinence surgery [6]. Urodynamics can be performed several months after repair in order to evaluate any persistent or de novo incontinence. If stress incontinence continues to be a bother, a subsequent synthetic midurethral sling can be performed in an outpatient setting and would be less morbid than an autologous fascial sling.

14.3.1.6 Clinical Course

This patient underwent a vaginal repair, with multilayered closure. No additional adjuvant flap was required, as the patient had a good watertight closure. The patient had a Foley catheter which remained for 2 weeks, at which point, a voiding trial was performed. The patient was seen at 6 months postoperatively, where the symptoms of urinary urgency, frequency, and dysuria were resolved. Some stress urinary incontinence also remained upon Valsalva with a full bladder. While a synthetic suburethral sling was offered, the incontinence was mild in nature, and therefore the patient elected conservative therapy in the form of watchful waiting.

14.4 Bladder Diverticula

Bladder diverticula represent a diagnostic challenge. There are two types of bladder diverticula that are found: congenital and acquired . The former is typically found in boys, at the ureterovesical junction (Hutch diverticulum), and the incidence is approximately 1.7 % [7]. While some are congenital, others develop as a result of obstruction at the bladder outlet over time. For example, in men with benign prostatic hypertrophy, chronic obstruction and high voiding pressure over time may predispose to diverticulum development. Occasionally, these acquired diverticula can become large enough to hold more urine than the native bladder itself [8].

Similarly, women with primary bladder neck obstruction, or increased outlet resistance due to a tight urethral sling, for example, may result in elevated voiding pressures. Initially, high voiding pressures will result in diverticulum development . Over time, with increasing size of the diverticulum, the diverticulum may become the path of least resistance during the voiding phase, resulting in incomplete emptying of the bladder, infrequent voiding, or recurrent urinary tract infections due to urinary stasis.

14.5 Case Study

14.5.1 Patient 2

14.5.1.1 History

A 56-year-old male presented with a history of urinary urgency, frequency, and slow urinary stream for the last 10 years. He had been on alpha blocker therapy throughout the past 5 years with minimal relief; despite medical therapy, he has had several episodes of urinary retention requiring catheterization. Over the past 2 years, however, the urgency and frequency had lessened. However, he stated he had infrequent voiding and feeling of incomplete emptying and urinary hesitancy.

14.5.1.2 Physical Examination

A complete physical examination was performed in this patient. The general examination revealed an obese male in no apparent distress. Cardiac examination demonstrated a normal rate, regular rhythm, with no murmurs or gallups. There was no lymphadenopathy in the neck, groin, or axillae. Neurological examination revealed that he was alert and oriented × 3, with cranial nerves II–XII grossly intact. Psychological evaluation demonstrated a cooperative male, with no agitation, depression or anxiety.

Genitourinary examination that included digital rectal exam was remarkable for a 60-g prostate, with no nodules or tenderness. The patient had a circumcised phallus, with no Peyronie’s plaques. Testes were descended bilaterally without nodules or tenderness.

14.5.1.3 Lab Work/Other Studies

Noninvasive uroflow was poor, with <150 mL voided, despite a catheterized PVR of 950 mL (Fig. 14.3). Cystoscopy was performed in the outpatient setting. Urethroscopy was unremarkable, with no evidence for urethral stricture. The prostatic urethra demonstrated severe bilobar hypertrophy with no obstructing median lobe. The bladder had severe trabeculation throughout, consistent with chronic obstruction. There were several scattered cellules and a small-mouthed, large diverticulum found on the right lateral wall.

Fig. 14.3

Noninvasive uroflow , inadequate to determine proper flow given low voided volume

14.5.1.4 UDS

The cystometrogram phase of this study demonstrated normal bladder compliance, with no uninhibited bladder contractions. There was no evidence for intrinsic sphincter deficiency. The patient’s first sensation was at 70 mL. First desire was at 297 mL, with a strong desire at 584 mL. The patient’s maximum cystometric capacity was 750 mL. After the diverticulum was filled, despite knowing the total maximum capacity was likely over 1 L, he reached maximum cystometric capacity at 750 mL (Fig. 14.4). The voiding phase revealed the inability to void, despite a detrusor maximum pressure reading of 25 cm H₂O.