Ultrasound Case 027

Presentation

A 68 year old male presents with frank haematuria and urinary retention. A 3 way indwelling urinary catheter (IDC) is inserted to enable a bladder washout. After initially draining some Shiraz coloured urine flow has slowed.

You ultrasound the bladder to see what is going on.


Describe and interpret these scans

IMAGE INTERPRETATION

Image 1: Transverse bladder view fanning from superior to inferior; The most striking abnormality is the heterogeneous solid appearing mass in the base of the bladder. This has the typical appearance of blood clot and is frequently seen in patients with frank haematuria.

Within the blood clot is the inflated balloon of the IDC.

The echogenic small areas within the clot are air introduced with catheter insertion.

There is some bladder wall trabeculation seen at the start of the loop, and a very enlarged but well defined prostate.

When there is clot in the bladder it is very difficult to exclude a bladder wall tumour. The two can appear similar and what is tumour and what is clot is hard to tell. Doppler interrogation can often demonstrate flow within tumour. Clot is not necessarily adherent to the wall and may move with rolling the patient. In this case there is a suggestion that there is hydronephrosis more obvious on the right, and the possibility of a obstructing lesion (in this scenario most likely TCC bladder) must be considered.

The next step would be to see look at the kidneys to see if there is hydronephrosis.


CLINICAL CORRELATION

Blood clot in the bladder with IDC in place. Cannot exclude bladder wall tumour.

When a 3-way urinary catheter and bladder washout fail to clear a large bladder clot manual wash out using a 50ml catheter tipped syringe can be performed. Ultrasound will reveal whether there is improvement.

In the setting of haematuria ultrasound can be used to define:

  1. The bladder volume
  2. Bladder content including blood clot or foreign bodies such as the IDC balloon
  3. The bladder wall for trabeculation, tumour, diverticula or other abnormality
  4. The distal ureters and vesico-ureteric junctions and ureteric jets
  5. Surrounding structures such as prostate, seminal vesicles, free fluid, uterus, ovaries and bowel.
  6. The position of the IDC balloon – occasionally an IDC that is not draining has been inappropriately placed or pulled back into the urethra
  7. To guide procedures including bladder washout, IDC placement or if required suprapubic catheter placement.

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An Emergency physician based in Perth, Western Australia. Professionally my passion lies in integrating advanced diagnostic and procedural ultrasound into clinical assessment and management of the undifferentiated patient. Sharing hard fought knowledge with innovative educational techniques to ensure knowledge translation and dissemination is my goal. Family, wild coastlines, native forests, and tinkering in the shed fills the rest of my contented time. | SonoCPDUltrasound library | Top 100 | @thesonocave |

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