Answer to the question from page 356.

Prawidłowa odpowiedź: B.

Correct answer: B.

Congenital and acquired diverticula of the urinary bladder may be differentiated by the structure of the wall. The latter do not have a muscle layer and result from intravesical hypertension caused by a subvesical obstacle (most often benign prostatic hyperplasia). This type of a diverticulum was found in this patient. Numerous ultrasonographers focus merely on determining the size of the diverticulum and the width of its connection in accordance with a professional textbook for urologists(. It appears that this approach is not complete since residual (infected) urine and/or blood may collect in the diverticulum, concretions may be formed and even urothelial carcinoma may develop(. In the presented patient, due to the symptoms of urinary tract infection, it was important to assess not only voiding of the urinary bladder, but also elimination of urine from the diverticulum(. In the fig. 1, the bottom of the diverticulum presents a level of echogenic content, probably residual urine. We know that diverticula may react to micturition in three ways: they may reduce their size, enlarge or remain unchanged. Bearing this in mind, such a test was performed in this patient. It revealed that as a result of micturition, the diverticulum increased in size, which is documented in figs. 2 and 3. Moreover, using color Doppler, two other tests were conducted: Valsalva maneuver (fig. 4) and applying compression with the transducer (fig. 5). Both tests showed patency of the diverticulum's neck but the compression test demonstrated greater influence on voiding. Sometimes, a coughing test may also be applied for this purpose. The application of color Doppler in the diagnosis of bladder diverticula was first proposed by Weingardt et al.( Such a manner of examination is particularly significant in determining the connection of the diverticula with the bladder when it is poorly visible or when there are doubts concerning its actual presence. Moreover, it enables to differentiate the bladder diverticula from other fluid lesions in the small pelvis which may imitate such a pathology(. The presented examination technique proved the paradoxical behavior of the diverticulum during micturition (it doubled its size) and showed that color Doppler is useful in determining the connection between a diverticulum and the bladder. It is highly probable that in this case the dysfunctional diverticulum where urine partially collected was responsible for the symptoms of urinary tract infection.

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