Download - Bladder Diverticula
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CC: TESTICULAR PAIN
R.S71/M/M
Brgy Balabag, Anilao, Iloilo
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History of Present Illness
1 day pta:
(+) testicular pain, on and off
(+) hypogastric pain (+) blood in the urine
(+) pain upon urination
(-) fever
(-) chills
Immediately brought to this institution
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Past Medical History
3 years pta: the patient was diagnosed tohave BPH and was appraised for surgicaloperation, the patient refused. He wasgiven unrecalled medications.
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Personal/ Social History
(+) smoker 1 pack per day since 25 y.o
(+) occasional alcoholic drinker
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Scout FilmGas & feces-filled non-dilated loops.
The flank stripes areintact. Renal & psoasshadows are partly
obscured by the overlyingbowel loops.
There is an ovoid calcificdensity within the pelvis
meas. 1.9 x 1.8 (LxW).There are osteophytic
spurs in the lumbar area.
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The right kidneymeas. 13.5x 6.1 cm
(LxW) while the leftkidney meas,12.7x7.0 cm. there isprompt opacification
of both pelvocalycealsystems and thesegmentallyvisualized uretersdown to theirrespectiveureteovesicaljunctions.
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The minor calycesare well cupped.The major calycesare not dilated.The ureters are
normal in size andwithin theirnormalanatomical
course.
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Left
ObliqueThere is anoutpouching in theposterolateral portion
of the urinarybladder, meas. 2.4x4.6 cm(LxW), a stalkapp. meas 2.5 cm inlength. There is alsoindentation in theposterior inferiorportion of the urinarybladder.
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Post Void
Shows minimal retention of urine,
there is persistence of the contrastfilled outpouching.
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Case
Discussion
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IVP
Used most widely for detection anddiagnosis of the urinary tract
It demonstrates the gross anatomicfeatures of both the renal parenchymaand the urinary transport system.
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Excretory Urogram
Provides important information about thefunctional capacity of the urinary systemto make, transport and store urine.
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Excretory Urogram
Scout film (AP)
Contrast medium is
injectedUreteral compressionis applied
Film centered andconed to demonstratethe kidneys, areexposed 5 and 10 minsafter injection with thecompression on.
After the 10 mins film,the compression deviceis released and a noncompression film is
exposed
The final film centeredto demonstrate the
bladder is exposedapp. 20 mins afterinjection
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Case Discussion
DIVERTICULA Herniations of the bladder mucosa
between interlacing muscle bundles.
Most are located posterolaterally, near theureterovesical junction
May contain stones, tumor & occasionallydo not fill on cystograms
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Case Discussion
Acquired or congenital
Acquired: are outpouchings through a focal weakness in
bladder muscle associated with chronically raisedintravesical pressure.
Congenital: also arise through muscular defects in the bladder
wall
Majority are located paraureterally (Hutchsdiverticulum) often causes reflux.
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Case Discussion
Most acquired are secondary to eitherobstruction to vesical neck or upper motorneuron type of neurogenic bladder
intravesical pressure causes vesicalmucosa to insinuate itself betweenhypertrophied muscle bundles, so that amucosal extravesical sac develops
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Case Discussion
Are rare in women Congenital: solitary & common among
boys less than 10 years old
Causes: (congenital)1. congenital weakness at the level ofureterovesicular junction
2. aberrant voiding dynamics
3. anatomy
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Case Discussion
Acquired: usually among males >60
Often multiple & commonly in lateralbladder walls
Causes:1. Bladder outlet obstruction
2. Neurogenic vesico-urethraldysfunction
3. Iatrogenic
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Case Discussion
Large ones often displace the ureters &bladder
Narrow neck ones likely urinary stasis,
thus infection may follow Common presenting signs:
1. Recurring UTI
2. Hematuria (due to stone)3. Passing of urine twice
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Case Discussion
Metaplasia & tumor can occur withlikelihood of spread beyond the bladdersince it contains only urothelium without
muscle. Can be evaluated with
1. cytogram
2. ultrasound
3. CT scan
4. cystoscopy
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Case Discussion
Complications:1.Urinary stasis
2.Infection3.Stone formation
4.Vesicoureteral reflux
5.Bladder outlet obstruction
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Case Discussion
Surgical Indications:1. persistent/recurrent UTI2. presence of stones in adiverticulum
3. tumor development in adiverticulum
4. lower urinary tract symptoms
5. voiding dysfunction6. Vesico-ureteral reflux