Pediatr Surg Int (2009) 25:1117–1121
DOI 10.1007/s00383-009-2470-3
ORIGINAL ARTICLE
Lower urinary tract obstruction secondary to congenital bladder
diverticula in infants
Arbinder Kumar Singal Æ V. V. S. S. Chandrasekharam
Accepted: 12 August 2009 / Published online: 2 September 2009
Ó Springer-Verlag 2009
Abstract
Purpose Congenital primary bladder diverticulum is a
rare condition and may present with urinary infection;
other forms of presentation are rare. We present a series of
infants who presented with urinary retention secondary to
large primary bladder diverticulum.
Methods Seven infants were evaluated for symptoms of
lower urinary tract obstruction. All seven were infant boys;
three were neonates. Investigations included ultrasono-
gram, voiding cystourethrogram (VCUG) and cystoscopy.
Results Six infants had single large diverticulum while one
had bilateral diverticula. VCUG was diagnostic in all cases
demonstrating the mechanism of obstruction clearly except
one where bilateral diverticula was diagnosed only on cys-
toscopy prior to definitive surgery. Five children (including
one neonate) underwent successful definitive repair con-
sisting of diverticulectomy and ureteral re-implant while two
neonates were planned for a staged correction. One neonate
later in the series underwent definitive primary repair as
bladder was good sized. All five children have done well
after definitive repair at a follow-up of 6–72 months.
Conclusion Primary bladder diverticulum in infants may
present with lower urinary obstructive symptoms indistin-
guishable from posterior urethral valves. A carefully done
A. K. Singal
MGM’s New Bombay Hospital, Vashi and MGM University
of Health Sciences, Navi Mumbai 400703, India
A. K. Singal (&)
RH-5, O-26, Sector-7, Vashi, Navi Mumbai 400703,
Maharashtra, India
e-mail: arbinders@gmail.com; arbinders@yahoo.com
V. V. S. S. Chandrasekharam
Rainbow Children’s Hospital and Mahavir Hospital & Research
Centre, Hyderabad, AP, India
VCUG can help in diagnosis. Primary definitive repair can be
undertaken even in first few months of life with good results.
Keywords Bladder diverticulum
Urinary retention

Infant
Lower urinary tract obstruction
Introduction
Bladder diverticula in children most often occur secondary
to infravesical obstruction or neurogenic bladder and in
children with connective tissue disorders. In addition,
paraureteric (Hutch) diverticulae may be seen in children
with vesicoureteric reflux. However, true congenital pri-
mary bladder diverticulae are rare in children. Such di-
verticulae occur almost exclusively in boys and usually
present with recurrent urinary tract infection. Presentation
with obstructive symptoms in form of urinary retention or
straining and poor stream is rarer still [1–9]. However, it is
important to entertain this possibility in boys presenting
with urinary retention to avoid misdiagnosis and confusion.
We report a series of infants who presented with urinary
retention secondary to congenital primary bladder diver-
ticulae. To our knowledge, this is the largest series of its
kind in English literature.
Materials and methods
Seven boys (age range 7 days–11 months) presented with
lower urinary tract obstructive symptoms and were evalu-
ated (Table 1). Three (40%) were less than a month old at
presentation. Six of the seven children had a single large
diverticulum in the bladder (4 right sided and 2 left sided)
while one boy had bilateral large diverticulae. None of the
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Table 1 Clinical details of all seven infants

S. no. Age Presenting Catheterization USG Palpable mass VUR Therapy FU (months)
complaints

1 1 year Retention 2 BH, div. Yes Ipsilateral Primary div. excision 72

seen and reimplantation
2 11 months Poor stream 1 UH, div. No Ipsilateral Primary div. excision 30
seen and reimplantation
3a 6 months Poor stream and 2 BH, div. Yes None Primary single-stage 12
retention seen excision of both div.,
bilateral ureteric
reimplantation
4 7 days Retention 1 BH, div. Yes None Vesicostomy Awaiting
seen definitive
surgery
5 5 months Retention 3 UH div. No Ipsilateral Primary div. excision 9
not seen and ureteric
reimplantation
6 10 days Retention 1 BH, div. Yes Ipsilateral Vesicostomy Awaiting
seen definitive
surgery
7 30 days Retention 1 BH, div. seen Yes Ipsilateral Primary div. excision 6
and re-implantation
UH Unilateral hydronephrosis, BH bilateral hydronephrosis, div. diverticulum
a
Bilateral diverticula were initially missed on VCUG as only one was seen due to overlapping on a lateral image. Cystoscopy showed bilateral
involvement

children had received antenatal diagnosis. Clinical exami- Results

nation revealed a large suprapubic cystic mass corre-
sponding to the thick-walled distended bladder in five
infants and in one newborn a separate mass could be pal-
pated corresponding to the distended diverticulum. History
of urinary retention necessitating catheterization could be
elicited in all the patients and some boys had been cathe-
terized more than once. Serum creatinine was within nor-
mal range for all the infants and none had urine infection at
presentation on urine analysis. Ultrasonogram (USG)
revealed varying degrees of hydronephrosis in all seven
and it was bilateral in 5/7. Diverticulum could be seen in 6/
7 as a fluid filled mass behind the bladder. VCUG was done
in all the cases and special emphasis was placed on lateral
and oblique films during filling and voiding phases.
Diverticulum could be well seen in all the patients and
under fluoroscopy; the diverticulum was seen to enlarge
with voiding and compress the bladder outlet from behind,
thus resulting in bladder outlet obstruction (Figs. 1, 2, 3, 4).
Vesicoureteric reflux into the ipsilateral ureter was seen in
5/7 children. There was no contralateral reflux in any child.
In the 7-month-old child with bilateral diverticulae, bilat-
eral involvement was missed out on initial VCUG as on the
lateral film the diverticulae got superimposed (Fig. 2) The
diagnosis of bilateral diverticulae was only made at cys-
toscopy prior to the open surgery.
Five of the seven children (including one 1-month-old
child and the child with bilateral diverticulae) underwent
cystoscopy and primary transvesical excision of the di-
verticulae with reimplantation of ipsilateral ureter (with
ureteric tapering in 4). In the child with bilateral divertic-
ulae, both the ureters had to be reimplanted. All the
diverticula had a constant site of origin from posterolateral
bladder wall close to the ureteric hiatus. At a mean follow-
up of 26 months (range 6–72), all five children are
asymptomatic and follow-up USG demonstrated complete
or near-complete resolution of the hydronephrosis and
insignificant post-void residue. Two neonates underwent
vesicostomy as the initial procedure and are awaiting the
definitive procedure at 1 year of age (Table 1).
Discussion
Bladder diverticula in children may be congenital or
acquired. Acquired diverticula are commonly seen with
obstructive problems such as posterior urethral valves, in
patients suffering from neuropathic bladders or in children
with connective tissue disorders [1–9]. Primary bladder
diverticulum unassociated with above-mentioned disorders

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Pediatr Surg Int (2009) 25:1117–1121
Fig. 1 a VCUG showing large
bladder diverticulum in Case 1.
b Voiding film with retrograde
filling of the anterior urethra
demonstrates compression of
posterior urethra by enlarging
diverticulum at attempts to void
Fig. 2 VCUG of Case 3 showing a large bladder diverticulum in
Case 3. On cystoscopy, the child had bilateral diverticula. On
retrospective review, the other side diverticulum can be faintly seen
through the bladder as denser contrast shadow
is a rare entity and is generally confined to male children
[1, 2, 9]. The etiology of such a primary diverticulum is
inherent weakness in the bladder musculature with the
most common location being the posterolateral bladder
wall just above the ureteric hiatus [1, 3]. The sac wall
consists of bladder mucosa with some muscle fibers only.
1119
Fig. 3 VCUG of Case 4 showing large diverticulum lifting the
bladder out of pelvis as it enlarges behind the bladder. Note the
elevation of bladder neck and stretching of posterior urethra
Primary diverticulum in a girl child has been encountered
only twice [7, 9]. Shukla et al. recently reported a girl with
Ehler–Danlos syndrome who presented with urinary
retention secondary to bladder diverticulum [7].
Congenital bladder diverticula may be asymptomatic or
may present with recurrent urinary tract infection or uri-
nary obstruction. The latter presentation is rare; less than
25 such cases have been reported so far in literature mostly
as individual case reports [2, 4, 5, 9, 10]. Unlike some other
series, all the patients in the present series are infants which
makes this series unique because the diagnosis and surgical
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Fig. 4 VCUG of Case 5 showing giant bladder diverticulum
overlapping the bladder. Note the angulation of bladder neck and
stretching of posterior urethra
management of these lesions is much more challenging at
this young age [8–10]. Retention is secondary to mechan-
ical distortion of the bladder outlet because of angulation
and compression of the bladder neck and posterior urethra
by the large diverticulum. Due to a thin wall and low
pressures, these diverticula enlarge during micturition and
cause retention, which further balloons up the diverticu-
lum, thus worsening the obstruction. In the present series,
such a phenomenon could be clearly demonstrated during
voiding cystography under fluoroscopic guidance (Figs. 1,
2, 3, 4). In fact, in a newborn (Case 4) with acute retention,
the bladder was almost lifted out of the pelvis by the
enlarging diverticulum (Fig. 3).
Incidentally discovered asymptomatic small diverticula
do not require any management, though the ones that retain
contrast post-void should be viewed with concern.
According to Verghese et al., criteria for surgery should
include persistent or recurrent urinary tract infection,
interference with bladder emptying or outlet obstruction
and ureteral obstruction or reflux [6]. In the present series
all the children had huge diverticula which presented with
lower urinary tract obstruction mandating management.
Giant bladder diverticula is the term used when the diam-
eter is more than 1/3 of the bladder diameter [7, 9]. Our
patients had diverticula which were equal to or larger than
the bladder itself (Figs. 1, 2, 3, 4).
In symptomatic children, diverticulectomy is the pro-
cedure of choice. It can be done by extravesical, intraves-
ical or combined approach with good results [2, 5, 6]. In
most cases, there is associated reflux or the ureteric hiatus
is involved by the diverticulum, making ipsilateral ureteric
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Pediatr Surg Int (2009) 25:1117–1121
re-implantation necessary. Thus, transvesical diverticulec-
tomy remains a preferred approach as re-implantation can
be performed concomitantly. The procedure has been well
illustrated by Kelalis [11] and also in a recent paper [9].
For reasons of safety and technical difficulty, in neonates
presenting with large bladder diverticulum a staged
approach including initially a diversion in form of a vesi-
costomy and later reconstruction at 1 year of age is gen-
erally advised [9]. Two of the newborns initially in the
present series with retentive symptoms were also diverted
(vesicostomy) as the bladder was deemed to be too small
for any formal reconstruction (Table 1). As the experience
grew, later in the series we elected to perform a definitive
surgery even in the 30-day-old infant (Case 7). We made
this decision after we observed that even in very large
diverticula the neck is always small and protrudes through
a small detrusor defect. Further, the reflux on VCUG in this
child showed the ureter to be normal sized without the need
for tapering. Thus, we thought it would be worthwhile to
do a single-stage definitive procedure and this was easily
performed in the young baby. The ipsilateral ureter was
placed between the repaired detrusor and the mucosa thus
achieving successful nonrefluxing re-implantation in a
small bladder. The infant has completed 6 months of
uneventful follow-up and is voiding well with good stream.
The hydronephrosis has disappeared and there is minimal
post-void residue on USG.
In the present series, we also report the second case in
English literature of a child with bilateral primary blad-
der diverticulae. As mentioned earlier, the final diagnosis
of bilateral involvement was made on cystoscopy which
we routinely do before any bladder surgery. The excision
of two large diverticulae with reimplantation of large
ureters in an infant bladder is a difficult surgical exer-
cise. We approached this child also intravesically and
avoided extravesical approach because bilateral extrave-
sical dissection around the region of the ureteric hiatus
could have resulted in neurogenic bladder. The basic
principle is to dissect close to the wall of the divertic-
ulum. The child is asymptomatic 6 months after surgery
with USG demonstrating normal kidneys and no post-
void residue.
In conclusion, congenital bladder diverticula may be a
rare cause of lower urinary tract obstructive symptoms in
male infants and needs to be distinguished from more
ubiquitous posterior urethral valves. Our series is the
largest till date and stresses on proper evaluation in form a
carefully done VCUG to establish diagnosis and cystos-
copy prior to surgery to further aid in delineating the
anatomy well. Outcome is excellent after a definitive repair
which includes diverticulectomy and/or ureteric re-
implantation and this can be done with good results even in
first few months of life or in bilateral cases.
Pediatr Surg Int (2009) 25:1117–1121
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