Blackwell Science, LtdOxford, UK

IJU
International Journal of Urology
0919-81722002 Blackwell Science Asia Pty Ltd
99September 2002
509
Bladder diverticulum due to bullet injury
K Suzuki
et al.
10.1046/j.0919-8172.2002.00509.x
Case Report517519BEES SGML

International Journal of Urology (2002) 9, 517–519

Case Report

Giant bladder diverticulum due to previous bullet injury:

Findings of gadolinium-enhanced magnetic
resonance imaging
KAZUMI SUZUKI,1,2 OSAMU TANAKA,3 TETSUO SAITO4 AND AKIHIKO TOKUE1
1Department of Urology, Jichi Medical School, Departments of 2Urology and 3Internal

Medicine, Moka Hospital, Tochigi and 4Department of Radiology, Jichi Omiya Medical Center,
Saitama, Japan

Abstract Non-obstructive acquired giant bladder diverticulum is rare. An 84-year-old man presented with dif-
ficulty in urination. Radiological examinations including pelvic magnetic resonance imaging,
urethrocystography and urethrocystoscopy demonstrated a giant bladder diverticulum with normal
infravesical urinary tract. The patient had a past history of gunshot bladder injury and underwent sur-
gical removal of the bullet. The giant bladder diverticulum was thought to be associated with the
injury or the operation.

Key words bladder diverticulum, bullet injury, magnetic resonance imaging.

Introduction was palpable at a high level. Abdominal enhanced com-

Acquired giant bladder diverticula are not uncommon,
but reported causes were infravesical obstruction,
including benign prostatic hyperplasia and urethral
stricture.1,2 Non-obstructive acquired giant bladder
diverticula are rare;3 moreover, in Japan, a bullet injury
is extremely rare. Herein, we report a case of giant blad-
der diverticulum probably associated with a bullet
injury.
Case report
An 84-year-old Japanese man presented with chronic
abdominal distension and severe difficulty in urination.
A physical examination revealed severe distension of
the lower abdomen and an operation scar in the midline
of his lower abdomen. On digital rectal examination, the
prostate was found to be small and a large cystic lesion
Correspondence: Kazumi Suzuki MD, Department of
Urology, Jichi Medical School, Minamikawachi-machi,
Kawachi-gun, Tochigi-ken 329-0498, Japan.
Email: urology@jichi.ac.jp
Received 20 September 2001; accepted 8 April 2002.
puted tomography (CT) scanning revealed left mild
hydronephrosis and a huge cystic mass with a septum-
like structure in the pelvis (Fig. 1). The complete blood
count, serum creatinine and electrolytes were normal.
His catheterization yielded greater than 1500 mL of
urine, and then his abdominal distension was improved.
Duplication of the bladder was suspected by excretory
urography. A subsequent T2-weighted magnetic reso-
nance imaging (MRI) clearly revealed severe bladder
trabeculation with a thickening of the bladder wall
(Fig. 2a), and gadolinium-enhanced imaging demon-
strated a jet flow from the bladder to the left giant cystic
lesion (Fig. 2b). Urethrocystography demonstrated a
giant bladder diverticulum originating from the left lat-
eral bladder wall (Fig. 3). Urethral stricture, prostatic
enlargement and vesicoureteral reflux were not detected.
Urethrocystoscopy also showed no infravesical obstruc-
tion, a tiny orifice of diverticulum at the left lateral blad-
der wall, but neither tumor nor stones were found in the
bladder. Moreover, because he had a past history of mild
cerebral infarction 10 years ago, cystometry was recom-
mended to rule out neurogenic bladder. Regrettably, he
refused the examination. On the other hand, he also had
a past history of bladder injury by a bullet during World
War II and underwent an operation for the bullet
518 K Suzuki et al.
Fig. 1 Abdominal enhanced computed tomography (CT)
scan demonstrating a large cystic lesion with a septum-like
structure in the pelvis.
a
b
Fig. 2 Magnetic resonance imaging (MRI) after 1500 mL
urinary drainage. (a) T2-weighted image showing homoge-
neous intensity in both the bladder (B) and the diverticu-
lum (D). (b) Post-gadolinium image showing a rapid jet
flow from the bladder to the diverticulum (arrow).
Fig. 3 Urethrocystography showing a giant bladder diver-
ticulum and no infravesical obstruction.
removal 61 years ago. At that time, he complained of
acute urinary retention, and his difficulty in urination
still continued after the incident. An abdominal X-ray
well-preserved by him showed the bullet in the bladder
(Fig. 4). The giant bladder diverticulum was thought to
be probably due to the injury or the operation. Unfortu-
nately, he refused to undergo diverticulectomy, and
his micturition was managed by indwelling urethral
catheter.
Discussion
Bladder diverticula are mostly due to congenital anom-
alies or lower urinary tract obstruction.1,2 There are a
few case reports on bladder diverticula due to bladder
injuries associated with pelvic operations.3,4 Because
in our case functional evaluation for bladder outlet
obstruction could not be performed, the etiology of his
difficulty in urination was not obvious. However, the
bullet injury or the operation for the bullet removal was
probably associated with this event to no small extent
because of the very old onset of symptoms, the finding
of the abdominal X-ray at the bladder injury and the
absence of any infravesical obstruction. Unfortunately,
diverticulectomy was not performed and pathological
evaluation of the bladder diverticulum was not obtained.
However, at the operation for the bullet removal, the
suture of the bladder wall might have been insufficient

Fig. 4 Abdominal plain radiograph showing a bullet in
the urinary bladder.
because there would not have been enough sutures and
medical tools during the war.
The useful diagnostic procedures for bladder diver-
ticula are reported to be ultrasonography, urethrocys-
tography, enhanced CT scanning and cystoscopy.1–3 It
was reported that color Doppler ultrasonography and
Bladder diverticulum due to bullet injury 519
renal scintigraphy were incidentally useful for the diag-
nosis of the diverticulum.1,5,6 Furthermore, Gong and
Issa reported that a communicating area between the
bladder and the diverticulum might be well recognized
by coronal MRI.4 Magnetic resonance imaging is gen-
erally a more useful diagnostic modality than CT,
because more section images can be obtained. In our
case, in addition to these examinations, T2-weighted
post-gadolinium MRI was very useful for evaluating
the giant bladder diverticulum. But as the usefulness of
gadolinium-enhanced MRI for bladder diverticulum
was incidental in our case, this examination would not
become a routine examination for bladder diverticulum.
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