Urology and Nephrology Vol. 1 (4), pp.

323--343 (1969)

Bladder Diverticula
S. GIL VERNET

Department of Urology, University Medical School, Barcelona, Spain

(Received May 10, 1969)

Bladder diverticula are of two different types: 1. Those due to abnormal em-
bryonal evolution giving rise to abnormalities, deviations or arrest in development. To
this group belong the well-known diverticula of the urachus. But apart from these
there exist other, less recognized diverticula probably due to evagination of the em-
bryonal epithelium of the bladder: they are the supratrigonal diverticula, those located
in the centre of the vesical dome, and some varieties of paraureteral diverticula.
A diverticulum is described into which the ureter ends; probably because of excessive
ascension of the embryonal ureter. 2. Those which are not due to abnormalities of
development or so-called acquired diverticula. There are two varieties in this group;
the foetal diverticulum arising in the second half of pregnancy and diverticula formed
after birth, which make up the majority. In the genesis of acquired diverticula, both
predisposing causes (weak spots of the vesical wall) and determinant causes (any
pathology causing prostatism and increase of the intravesical pressure) should be
considered. This mechanism of formation is evident in the acquired diverticula after
birth, and also in the foetal diverticula, since the urine contained in the bladder is
evacuated to the amniotic cavity through actual micturition. It is possible that in this
stage there already exist obstacles to urination. It is, therefore, proper to say that the
same causes produce the same effects in all stages of life.

W e will limit ourselves to the p a t h o g e n e t i c s t u d y o f the vesical diverticula

which will allow us a better u n d e r s t a n d i n g o f their clinical picture a n d especially
o f the best t h e r a p e u t i c a p p r o a c h to each t y p e in p a r t i c u l a r . A n y p r o g r e s s in the
study o f the causes a n d genesis o f lesions is always f a v o u r a b l y reflected in the diag-
nosis a n d t r e a t m e n t o f t h o s e diseases.
S o o n after the s t u d y o f this c o n d i t i o n began, t w o o p p o s i n g theories a p p e a r e d
c o n c e r n i n g their pathogenesis. Several a u t h o r s such as H y m a n , Lex, M a i e r ,
Ferris, W a t s o n a n d Lower, c o n s i d e r these f o r m a t i o n s to be o f c o n g e n i t a l origin.
Others believe t h e y are a c q u i r e d as a result o f m i c t u r i t i o n a l difficulties.
A c t u a l l y there exist b o t h c o n g e n i t a l a n d a c q u i r e d diverticula, b u t it is
necessary to define the m e a n i n g o f these terms. F o r Englisch a n d R a t h b u m ,
c o n g e n i t a l o r true diverticula are those in w h i c h all the layers o f the b l a d d e r can
be seen in their walls, t h a t is to say, the m u c o s a , s u b m u c o s a a n d m u s c u l a r layers.
O n the o t h e r h a n d , they c o n s i d e r a c q u i r e d diverticula as those consisting ex-
clusively o f the vesical m u c o s a .
This criterion, r i g o r o u s l y applied, is n o t acceptable, as s o m e a c q u i r e d diver-
ticula c o n t a i n , at least for s o m e time, m u s c u l a r fibres. A l s o , the congenital dive,.--

Urology and Nephrology 1, 1969

324 Gil Vernet: Bladder diverticula

ticula, containing at their beginning thick muscular walls, often terminate with
no muscular fibres. This is due in part to the progressive distention of the divertic-
ula, but mainly to sclerosis which always follows diverticulitis and peri-divertic-
ulitis.
In my opinion, congenital diverticula are those which result from a deviation
or arrest in the ontogenic development of the urinary bladder. This abnormal
evolution produces a true diverticulum during the first months of the intrauterine
life. Acquired diverticula are those formed in the adult and the elderly, and are
often coincidental with micturitional difficulties. However, we should emphasize
that these diverticula may also appear in the young and even in the last few months
of intrauterine life.
From the above considerations follows that there are three types of divertic-
ula; congenital, due to developmental abnormalities which appear in the first
few months of the intrauterine life; fetal, which are acquired during the last few
months of intrauterine life; and finally acquired, the most common type, which
appear during extrauterine life.

Congenital diverticula
These are the diverticula developing in the vertex of the bladder at the ex-
pense of the urachus which has remained partially patent. They can be compared
to the congenital inguinal hernias due to the persistence of the vagino-peritoneal
process. The existence of a minute lumen in the urachus not always results in this
type of diverticula. There always exists a predisposition to their formation and
development and they can appear late when difficulties in micturition occur. Aside
from this variety, there is no substantial proof as to the existence of any other type
of congenital diverticula, which in the strictest sense of the word, mean abnormal-
ities of development.
As a result of my observations, I described in 1948 a new variety of congenital
diverticula; those developing in the midline of the posterior wall of the bladder
immediately above the interureteral bar. The enclosed micro-photographs of a
few months old foetus show, that in this moment of life there already exists a per-
fectly developed diverticulum (Fig. 1) consisting of a pouch located in the posterior
wall of the bladder (5) and communicating with the vesical cavity (3) through
a narrow portion, called the diverticular orifice (4). The cavity is covered inside by
mucosa, continuous through the orifice with the vesical mucosa. Surrounding it
a thick muscular layer is found with the posterior longitudinal band in the back
and the bundles of the circular muscular layer - at the sides.
Above that level the beginning of the diverticulum is a depression in the
posterior wall of the bladder.
In the sections below the diverticular neck (Fig. 2), made by scraping the
interureteral bar, the perfect separation of the diverticular pouch (5) and the
vesical cavity (3) is observed. This demonstrates that the diverticular orifice seen
in the anterior slide is located above the interureteral bar.

Urology and Nephrology 1, 1969