Multidetector CT appearance of adhesion-induced small bowel obstructions: matted adhesions versus single adhesive bands

Changing patterns and surgical outcomes of small bowel obstruction in the era of minimally invasive surgery for colorectal cancer

INTRODUCTION

This study aimed to investigate whether the incidence, patterns, and surgical outcomes of small bowel obstruction (SBO) have changed in the era of minimally invasive surgery (MIS) for primary colorectal cancer (CRC).

METHODS

Consecutive patients who underwent laparotomy for SBO were divided into MIS and traditional open surgery (TOS) groups based on the previous colorectal cancer operation technique used. The MIS group was selected from 1544 consecutive patients who underwent MIS as a treatment for primary CRCs between 2014 and 2022, while the TOS group was selected from 1604 consecutive patients who underwent TOS as a treatment for primary CRCs between 2004 and 2013. The demographics, clinicopathological features, and surgical outcomes were compared between the two groups.

RESULTS

The SBO incidence in patients who underwent MIS for primary CRC was significantly lower than that in patients who underwent TOS (4.4%, n =68/1544 vs. 9.7%, n =156/1604, P <0.0001). Compared with the TOS group, the MIS group had significantly different ( P <0.0001) SBO patterns: adhesion (48.5 vs. 91.7%), internal herniation (23.5 vs. 2.6%), external herniation (11.8 vs. 1.9%), twisted bowel limbs (4.4 vs. 0.6%), ileal volvulus with pelvic floor adhesion (5.9 vs. 1.9%), and nonspecific external compression (5.9 vs. 1.3%). A subset analysis of patients with adhesive SBO (ASBO) showed that the MIS group tended to ( P <0.0001) have bands or simple adhesions (75.8%), whereas the TOS group predominantly had matted-type adhesions (59.4%). Furthermore, SBO in the MIS group had an acute (<3 months) or early (3-12 months) onset (64.7%), while that in the TOS group ( P <0.0001) had an intermediate or a late onset. When the surgical outcomes of SBO were evaluated, the TOS group had significantly more ( P <0.0001) blood loss and longer operation time; however, no significant difference was observed in the surgical morbidity/mortality (Clavien-Dindo classification ≧3, 11.8 vs. 14.1%, P =0.6367), hospitalization, and readmission rates between the two groups. Postoperative follow-up showed that the estimated 3-year (11.37 vs. 18.8%) and 6-year (25.54 vs. 67.4%) recurrence rates of SBO were significantly lower ( P =0.016) in the MIS group than in the TOS group.

CONCLUSIONS

The wide adoption of MIS to treat primary CRC has led to a lower incidence, altered patterns, and reduced recurrence rates of SBO. Awareness of this new trend will help develop surgical techniques to prevent incomplete restoration of anatomical defects and bowel malalignments specifically associated with MIS for CRC, as well as facilitate timely and appropriate management of SBO complications whenever they occur.

A multi-analysis of nomogram model for the identification of banded adhesions and matted adhesions in adhesive small bowel obstruction

BACKGROUND

Preoperative diagnosis of the cause of adhesive small bowel obstruction (ASBO) is very challenging for surgeons. We aimed to develop a nomogram model for the identification of banded adhesions (BA) and matted adhesions (MA) of ASBO.

METHODS

This retrospective study enrolled patients with ASBO between January 2012 and December 2020, classified into BA and MA groups according to the intraoperative findings. A nomogram model was developed by using multivariable logistic regression analysis.

RESULTS

A total of 199 patients were included, with 117 (58.8%) cases of BA and 82 (41.2%) cases of MA. There were 150 patients designed for training the model, and the other 49 cases for validation. Multivariate logistic regression analysis showed that prior surgery for once (p = 0.008), white blood cells (WBC) (p = 0.001), beak sign (p < 0.001), fat notch sign (p = 0.013), and mesenteric haziness (p = 0.005) were independently associated with BA. The AREA under the receiver operating characteristic curve (AUC-ROC) of the nomogram model in the training and validation sets were 0.861 (95% CI 0.802-0.921) and 0.884 (95% CI 0.789-0.980), respectively. The calibration plot demonstrated a good agreement. A decision curve analysis demonstrated that the nomogram model was clinically useful.

CONCLUSIONS

The multi-analysis of the nomogram model might have a favorable clinical applicability for the identification of BA and MA in patients with adhesive small bowel obstruction.

Preoperative prediction of inadvertent enterotomy during adhesive small bowel obstruction surgery using combination of CT features

OBJECTIVES

The purpose of this study was to identify the preoperative CT features that are associated with inadvertent enterotomy (IE) during adhesive small bowel obstruction (ASBO) surgery.

METHODS

From January 2015 to December 2019, all patients with ASBO who underwent an abdominal CT were reviewed. Abdominal CT were retrospectively reviewed by two radiologists with a consensus read in case of disagreement. IE during ASBO surgery was retrospectively recorded. Univariate and multivariate analyses of CT features associated with IE were performed and a simple CT score was built to stratify the risk of IE. This score was validated in an independent retrospective cohort. Abdominal CT of the validation cohort was reviewed by a third independent reader.

RESULTS

Among the 368 patients with ASBO during the study period, 169 were surgically treated, including 129 ASBO for single adhesive band and 40 for matted adhesions. Among these, there were 47 IE. By multivariate analysis, angulation of the transitional zone (OR = 4.19, 95% CI [1.10-18.09]), diffuse intestinal adhesions (OR = 4.87, 95% CI [1.37-19.76]), a fat notch sign (OR = 0.32, 95% CI [0.12-0.85]), and mesenteric haziness (OR = 0.13, 95% CI [0.03-0.48]) were independently associated with inadvertent enterotomy occurrence. The simple CT score built to stratify risk of IE displayed an AUC of 0.85 (95% CI [0.80-0.90]) in the study sample and 0.88 (95% CI [0.80-0.96]) in the validation cohort.

CONCLUSION

A simple preoperative CT score is able to inform the surgeon about a high risk of IE and therefore influence the surgical procedure.

KEY POINTS

• In this retrospective study of 169 patients undergoing abdominal surgery for adhesive small bowel obstruction, 47 (28%) inadvertent enterotomy occurred. • A simple preoperative CT score enables accurate stratification of inadvertent enterotomy risk (area under the curve 0.85). • By multivariable analysis, diffuse intestinal adhesions and angulation of the transitional zone were predictive of inadvertent enterotomy occurrence.

Evaluation of ischemia and necrosis in adhesive small bowel obstruction based on CT signs: Subjective visual evaluation and objective measurement

PURPOSE

To investigate the diagnostic performance of CT signs for detecting bowel ischemia and necrosis in adhesive small bowel obstruction(SBO) with subjective and objective methods.

MATERIALS AND METHODS

113 adhesive SBO patients were enrolled and divided into ischemic group (49 cases in necrotic group and 35 cases in reversible ischemic group) and non-ischemic group (29 cases) according to the operation results. Subjective visual assessment of CT signs associated with ischemia and necrosis was performed by two radiologists independently. Elevated unenhanced attenuation and enhancement value of involved bowel wall were objectively measured and compared by single factor analysis of variance. Cut-off value and diagnostic performance were evaluated by receiver operating characteristic curve (ROC).

RESULTS

Closed-loop mechanism, reduced bowel wall enhancement, and mesenteric edema were associated with bowel ischemia, with sensitivity of 81.0%, 65.5%, 75.0%, and specificity of 86.2%, 96.6%, 89.7%, respectively. Increased unenhanced bowel wall attenuation was a specific sign for necrosis with 100.0% specificity and 51.0% sensitivity. The sensitivity and specificity for ischemia were 86.0% and 91.9% with cut-off enhancement value lower than 33.5 HU. The sensitivity and specificity for necrosis were 58.2% and 100.0% with cut-off elevated unenhanced attenuation higher than 16.5 HU, 86.7% and 83.3% with cut-off enhancement value lower than 21.5 HU.

CONCLUSION

Reduced bowel wall enhancement and increased unenhanced bowel wall attenuation were good indicators of bowel ischemia and necrosis. The objective measurement of elevated unenhanced attenuation and enhancement value can predict bowel ischemia and necrosis more accurately.

Adhesive small bowel obstruction: Single band or matted adhesions? A predictive model based on computed tomography scan

BACKGROUND

Preoperative identification of the cause of adhesive small bowel obstruction (ASBO) is crucial for decision making. Some computed tomography (CT) findings can be indicative of single adhesive bands or matted adhesions. Our aim was to build a predictive model based on CT data to discriminate ASBO due to single adhesive band or matted adhesions.

METHODS

A retrospective single center study was conducted, covering all consecutive patients with a preoperative CT scan, undergoing urgent surgery for ASBO between January 1, 2005, and December 31, 2017. Preoperative CT scans were blindly reviewed, and all the CT findings indicative of single adhesive band or matted adhesions described in literature were recorded. According to intraoperative findings, ASBOs were retrospectively classified into single band and matted ASBO. All observed CT findings were compared between the two groups. A predictive model based on logistic regression was developed, and its ability was quantified by discrimination and calibration. Internal cross-validation was conducted by bootstrap resampling.

RESULTS

A total of 116 patients were analyzed (males, 53.5%; median age, 68 years; single band ASBO in 65.5% of cases). The odds of single band ASBO were increased four times in presence of complete obstruction (odds ratios, 4.19; 95% confidence interval, 1.49-12.56) and seven times in presence of fat notch sign (odds ratios, 7.37; 95% confidence interval, 1.83-40.03). The predictive model combining all CT findings had an accuracy of 86% in single band ASBO prediction. Accuracy decreased to 79% in the internal validation. Sensitivity, specificity, and positive and negative predictive values were calculated at different cut-points of the predicted risk: using a 0.70 cut-point, the specificity is 80%, the sensitivity is 68%, and the positive and negative predictive values are 87% and 57%, respectively.

CONCLUSION

The proposed predictive model based on combination of specific CT findings may elucidate whether ASBO is caused by single bands or matted adhesions and, consequently, influence the clinical pathway.

LEVEL OF EVIDENCE

Prognostic study, level IV.

Diagnosis of single adhesive bands versus matted adhesions in small bowel obstructions: a radiological predictive score

PURPOSE

The objective was to develop a radiological score obtained from multi-detector computed tomography (MDCT) to differentiate between single band adhesion (SBA) and matted adhesions (MA) as the etiology of small bowel obstruction (SBO).

METHODS

All consecutive patients who underwent surgery from January 2013 to June 2018 for adhesion-induced SBO were retrospectively included.

RESULTS

Among the 193 patients having surgery for SBO, 119 (61.6%) had SBA and 74 (38.4%) had MA surgically proven. In multivariate analysis, the presence of a beak sign (OR = 3.47, CI [1.26; 9.53], p = 0.02), a closed loop (OR = 11.37, CI [1.84; 70.39], p = 0.009), focal mesenteric haziness (OR = 3.71, CI [1.33; 10.34], p = 0.01) and focal and diffuse peritoneal fluid (OR = 4.30, CI [1.45; 12.73], p = 0.009 and OR = 6.34, CI [1.77; 22.59], p = 0.004, respectively) were significantly associated with SBA. Conversely, the presence of diffuse mesenteric fluid without focal fluid (OR = 0.23, CI [0.06; 0.92], p = 0.04) and an increase of the diameter of the most dilated loop (OR = 0.94, CI [0.90; 0.99], p = 0.02) were inversely associated with SBA. Using the significant predictive factors of SBA, we built a composite score to radiologically predict the etiology of SBO. The area under the receiver operating characteristic (ROC) curve of the score was 0.8274. For a cut-off score of -0.523, sensitivity, specificity and the percentage of patients correctly classified were 78.4%, 84.6% and 80%, respectively. If the score is ≥ 7, the probability that the mechanism of SBO is not SBA was 100%.

CONCLUSIONS

The present score, validated in a different population, could be a significant tool in the decision for surgical management.

Spectrum of CT Findings Related to Bowel Adhesions Without Bowel Obstruction: A Comprehensive Imaging Review

Post-operative adhesions can occur following abdominal or pelvic surgery and are a significant cause of morbidity and mortality. Adhesions are an important cause of abdominal complaints, especially chronic abdominal pain, infertility, and bowel obstruction; responsible for an estimated $2.3 billion annual burden in the United States alone. There is a paucity of literature describing CT findings indicative of the presence of adhesions, however, findings suggestive of this entity may be discovered by a discerning eye. Early recognition and diagnosis may be beneficial for reducing consumption of health-care resources related to abdominal complaints. In addition, these findings may impact surgical planning and facilitate recognition of adhesion-related complications, said to be responsible for a significant number of malpractice claims. The following review discusses various CT findings which may indicate the presence of adhesions. These findings may initially be overlooked, but remain valuable as the clinical presentation evolves to become consistent with adhesive disease. Detection of bowel and peritoneal adhesions can be recognized on imaging modalities based on distortion of bowel loops. This pictorial review illustrates the spectrum of findings related to bowel adhesions encountered on computed tomography imaging.

Adhesive Small Bowel Obstruction: Predictive Radiology to Improve Patient Management

Adhesive small bowel obstruction (SBO) remains one of the leading causes of emergency room visits and is still associated with high morbidity and mortality rates. Because the management of adhesive SBO has shifted from immediate surgery to nonoperative treatment in the absence of ischemia, it is crucial to rapidly detect or predict strangulation, which requires emergent surgery. CT is now established as the best imaging technique for the initial assessment of patients suspected of having adhesive SBO. CT helps confirm the diagnosis of mechanical SBO, locate the site of obstruction, establish the cause, and detect complications. This article is a review of the role of imaging in answering specific questions to help predict the management needs of each individual patient. It includes (a) an update on the best CT signs for predicting ischemia and a need for bowel resection; (b) a discussion of the CT features that help differentiate open-loop from closed-loop obstruction and a single adhesive band from matted adhesions and how these differences can influence the management; and (c) a review of the main CT predictors of the success or failure of nonoperative management in adhesive SBO.

Surgery for adhesive small-bowel obstruction is associated with improved long-term survival mediated through recurrence prevention: A population-based, propensity-matched analysis

BACKGROUND

Adhesive small-bowel obstruction (aSBO) is among the most common reasons for admission to a surgical service. While operative intervention for aSBO is associated with a lower risk of recurrence, current guidelines continue to advocate a trial of nonoperative management. The impact of the increased risk for recurrence on long-term survival is unknown. We sought to explore the potential for improved survival with operative management through the prevention of admissions for recurrence of aSBO and the associated risks.

METHODS

This is a population-based retrospective cohort study using administrative data. We identified patients admitted to hospital for their first episode of aSBO from 2005 to 2014 and created a propensity-matched cohort to compare survival of patients managed operatively with those managed nonoperatively. To test whether survival differences were mediated by recurrence prevention, a competing risk regression was used to model the subdistribution hazard of death when accounting for the risk of recurrence. An instrumental variable approach was used as a secondary analysis to compare survival while accounting for unmeasured confounding.

RESULTS

There were 27,904 patients admitted for their first episode of aSBO between 2005 and 2014. The mean age was 61.2 years (std dev, 13.6), and 51% were female. Operative management was associated with a significantly lower risk of death (hazard ratio, 0.80; 95% confidence interval, 0.75-0.86), which was robust to instrumental variable analyses, and a lower risk of recurrence (hazard ratio, 0.59; 95% confidence interval, 0.54-0.65). When adjusting for the risk of recurrence, operative intervention was not associated with improved survival, suggesting that the survival benefit is mediated through prevention of recurrences of aSBO.

CONCLUSION

In patients admitted for their first episode of aSBO, operative intervention is associated with a significant long-term survival benefit. This survival benefit appears to be mediated through the prevention of recurrences of aSBO.

STUDY TYPE

Retrospective cohort study.

LEVEL OF EVIDENCE

Therapeutic study, Level II.

Multidetector Computed Tomography Findings of Adhesive Internal Hernias

OBJECTIVE

To identify multidetector computed tomography (MDCT) findings of surgically confirmed adhesive internal hernias (IHs).

METHODS

Two gastrointestinal radiologists performed blinded, independent, and retrospective reviews of MDCT findings from a consecutive cohort of 35 adhesive IH and 41 adhesive small-bowel obstruction cases that had undergone surgery within 48 hours after MDCT. Univariate statistical analyses were performed to assess CT signs of adhesive IHs and CT findings of intestinal necrosis in patients presenting with adhesive IHs.

RESULTS

Dislocated cluster of the intestine (P = 0.005), 2 transitional zones (P = 0.002), and presence of fat in the center sign (P = 0.001) were key CT outcomes that were significantly associated with adhesive IHs. Additionally, intramural hemorrhage was found the MDCT feature indicative of intestinal necrosis (P = 0.028).

CONCLUSIONS

This study illustrates specific MDCT findings of IHs, and these observations may help guide early clinical management of the condition.

Adhesive small bowel obstruction - an update

Small bowel obstruction (SBO) accounts for 12-16% of emergency surgical admissions and 20% of emergency surgical procedures. Even with the advent of laparoscopic surgery, intra-abdominal adhesions remain a significant cause of SBO, accounting for 65% of cases. History and physical examination are essential to identify signs of bowel ischemia as this indicates a need for urgent surgical exploration. Another critical aspect of evaluation includes establishing the underlying cause for obstruction and distinguishing between adhesive and non-adhesive etiologies as adhesive SBO (ASBO) can be managed non-operatively in 70-90% of patients. A patient with a history of abdominopelvic surgery along with one or more cardinal features of obstruction should be suspected to have ASBO until proven otherwise. Triad of severe pain, pain out of proportion to the clinical findings, and presence of an abdominal scar suggest possible closed-loop obstruction. Computed tomography has higher sensitivity and specificity compared to plain films and is recommended by the Bologna guidelines. Correcting fluid and electrolyte imbalance is an initial crucial step to mitigate severe hypovolemia. Patients should proceed with surgery if symptoms of bowel compromise are present, or if symptoms do not resolve or have worsened. Surgery is indicated in patients with ischemia, strangulation, perforation, peritonitis, or failure of non-operative treatment. With advances in minimal access technology and increasing experience, laparoscopic adhesiolysis is recommended. Mechanical adhesion barriers are an effective measure to prevent adhesion formation.

Small Bowel Obstruction

Identifying patients with small bowel obstruction who need operative intervention and those who will fail nonoperative management is a challenge. Without indications for urgent intervention, a computed tomography scan with/without intravenous contrast should be obtained to identify location, grade, and etiology of the obstruction. Most small bowel obstructions resolve with nonoperative management. Open and laparoscopic operative management are acceptable approaches. Malnutrition needs to be identified early and managed, especially if the patient is to undergo operative management. Confounding conditions include age greater than 65, post Roux-en-Y gastric bypass, inflammatory bowel disease, malignancy, virgin abdomen, pregnancy, hernia, and early postoperative state.

Adhesive internal hernia: multidetector CT findings and clinical relevance

AIM

To review the clinical and multidetector computed tomography (MDCT) features of adhesive internal hernias (IHs) and to ascertain specific MDCT criteria to assist in the diagnosis of adhesive IHs and the early detection of intestinal strangulation.

MATERIALS AND METHODS

Medical records and preoperative abdominal MDCT findings of 34 patients with surgically confirmed abdominal adhesive IHs were analysed retrospectively.

RESULTS

The specific MDCT features of adhesive IHs included the following: dislocating and clustering of intestinal segments (100%); stretching and crowding of the mesenteric vessels (100%); presence of hernial orifice (88.2%), peritoneal adhesive bands (76.5%); and the fat notch sign (85.3%). In addition, the significant MDCT features indicative of intestinal strangulation compared with those without intestinal strangulation were bowel wall thickening (p=0.009), intramural haemorrhage (p=0.007), and abnormal bowel wall enhancement (p=0.023). Furthermore, bowel obstruction occurred in 17 (50%) patients, and mesenteric whirl was apparent in 8 (23.5%) patients.

CONCLUSION

This article illustrates the specific MDCT criteria of adhesive IHs. Knowledge of MDCT findings in adhesive IHs and their complications is essential for making the correct diagnosis and may help guide early clinical management.

Adhesions small bowel obstruction in emergency setting: conservative or operative treatment?

Adhesions small bowel obstructions (aSBO) are among the leading causes of emergency operative intervention. About the 80% of aSBO cases resolve without a surgical treatment. It's important to identify which patients could undergo a conservative treatment to prevent an useless surgery The aim of this study is to determine findings that can indicate whether patients with aSBO should undergo a conservative or a surgical treatment. 313 patients with diagnosis of submission of aSBO were restudied. Patients were divided into two groups based on the different type of treatment received, 225 patients who underwent surgical treatment within 24 hours after admission, 88 patients which underwent conservative treatment successfully. For each patient, clinical, hematochemical and radiological findings have been analysed. The treatment of aSBO should be, at the beginning, conservative except that cases that presents clinical and/or CT-scan findings predictive for a surgical treatment (free peritoneal fluid, mesenterial edema, transitional point) or a peritonitis (pneumatosis intestinalis, pneumoperitoneum).

Organo-axial volvulus of the small intestine: radiological case report and consideration for its mechanism

Gastrointestinal volvulus is mainly classified into two subtypes, mesentero-axial volvulus and organo-axial volvulus. The detailed imaging findings of organo-axial volvulus of the small intestine have never been reported as far as we know. In this article, we report a case of organo-axial volvulus of the small intestine, focusing on the computed tomography (CT) findings. An 80-year-old man was radiologically diagnosed as having organo-axial volvulus of the terminal ileum and it was confirmed by open surgery without adhesion or any other anatomical abnormalities. CT showed two specific findings, split-bowel sign and rotating-C sign, which we think reflect pathophysiologic features of organo-axial volvulus. We think the pathogenic mechanism of organo-axial volvulus can be explained by the convergence of the reversed-rotational twist following the formation of a twisted but non-obstructive circular loop, even if there is no adhesion. Radiologists should be aware that organo-axial volvulus can occur even in the small intestine, and in the case of small bowel obstruction with single transition point, the two pathophysiologic signs mentioned above must be looked for to diagnose the possibility of organo-axial volvulus.

Laparoscopy for Small Bowel Obstruction Caused by Single Adhesive Band

Background and Objectives:

There are still concerns about the comparative outcomes of operative treatment (OT) and conservative (nonsurgical) treatment (CT) for small bowel obstruction (SBO), especially that caused by single adhesive bands. We performed a retrospective study to compare surgical with nonsurgical outcomes.

Methods:

A total of 62 patients were enrolled. The OT group underwent laparoscopy (n = 16), and the CT group (n = 46) did not. We compared early and late outcomes between the 2 groups.

Results:

Times to first flatus, oral intake, and defecation after treatment were shorter in the OT group (P = .030, .033, and .024), and the recurrence rate was lower in the OT group than in the CT group (6.2% vs 32.6%; P = .038). Time from discharge to first recurrence was longer in the OT group than in the CT group (172 vs 104.6 ± 26.5 days, P = .027).

Conclusions:

SBO related to a single adhesive band is not effectively treated by CT. However, laparoscopic OT provides notable success if the surgery is performed early. Therefore, it should be the preferred treatment.

Spectrum of MDCT Findings in Bowel Obstruction in a Tertiary Care Rural Hospital in Northern India

INTRODUCTION

Multidetector Computed Tomography (MDCT) provides clinically and surgically important information in bowel obstruction. It can depict the severity, level and cause of obstruction.

AIM

To depict the spectrum of MDCT findings in cases of small and large bowel obstruction.

MATERIALS AND METHODS

Contrast enhanced MDCT examination of 50 patients were retrospectively included in the study who had evidence of clinical as well as MDCT evidence of bowel obstruction and in whom surgical/clinical follow-up for final diagnosis was available. CT scan was done in all the patients with Ingenuity CT (128 slice MDCT, Philips Medical Systems). The axial sections were reconstructed in coronal and sagital planes to determine site and cause of bowel obstruction.

RESULTS

There were 34 males and 16 females patients in this study with mean age of 28.4 years. The level of obstruction was in small bowel in 39 patients (76.67%) and large bowel in 11 patients (23.33%). Adhesive bands were the cause of Small Bowel Obstruction (SBO) in 17 patients (43.5% of SBO patients). The most common CT signs in adhesive band SBO were beak sign (seen in 70.6% patients) and fat notch sign (52.9% patients). Five cases of SBO were secondary to benign stricture. Matted adhesions were the cause of obstruction in 3 patients. All these patients showed transition zone in pelvis with positive small bowel faeces sign. Two patients with SBO due to adhesive band had evidence of closed loop obstruction with evidence of gangrenous gut on surgery. Large Bowel Obstruction (LBO) was seen in 11 patients. Most common cause of LBO was primary colonic malignancy, accounting for 7 patients (63.6%). In one patient, the cause was direct invasion of hepatic flexure by carcinoma of gall bladder. Other causes of LBO were pelvic adhesions, faecal impaction and ischaemic stricture.

CONCLUSION

SBO is more common than LBO with adhesive bands being the most common cause of SBO. MDCT is very useful for depicting site and cause of obstruction and any associated complications.

Bladder pseudodiverticulum and debilitating dyspareunia: diagnostic and management dilemmas of a rare case

Dyspareunia in a woman often lacks a well-defined cause with complex etiology. Similarly wide-mouthed nonobstructive bladder diverticula are mostly managed conservatively with no single etiology. Herein a rare case of dyspareunia and urinary symptoms is described, which started following a lower segment cesarean section (LSCS). Ultrasonography, micturating cystogram, and cystoscopy revealed a large wide-mouthed bladder diverticulum. After 3 years of failed and varied conservative therapy and management dilemmas, exploration was done for diverticulectomy which revealed a diagnostic surprise. A post-LSCS thick adhesive band was found between the uterus and anterior abdominal wall as a direct cause for both the bladder diverticulum and dyspareunia. Adhesions after LSCS may cause varied symptoms which may be difficult to diagnose and leave the patient refractory to conservative therapy. Laparoscopy or exploration may be useful in such cases.