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Suprapubic Pain

1/16/12 - This week's IMAGE of the WEEK is brought to us by Dr. Haviland, Dr. Chesson,  and Dr. Wheatley. 

While evaluating an 83 yo M with abdominal distention and urinary sediment, a bedside US captured the following bladder images – see Images #1, #2, & #3. These images show a significant abnormality in the bladder and kidney requiring prompt consultation and management. 

Image 1

transverse1

Image 2

sagittal2

Probe placement for bladder imaging is shown in images #4 (transverse) & #5 (sagittal). Using the curvilinear probe, the transverse view is obtained with the probe indicator to the right of the patient. The sagittal view is obtained by rotating the probe 90 degrees - the indicator now toward the head of the patient. From both positions, subtle fanning movements permits full visualization of the fluid filled bladder. 

Image 3

kidney3

Image 4

bladdertransverse4

Image 5

bladdersagittal5

Looking back at US images (#1, #2, & #3,) the critical finding is a grossly distended bladder with a large clot of mixed echogenicity – in this case representing pus in the bladder. The patient has a history of BPH with outflow obstruction and uses a chronic Foley catheter. He was sent to the ER with concern for infection given pus/sediment in the Foley bag. On labs, the patient had an acute elevation of his Cr and a WBC >20. The patient arrived tachy but afebrile. See the attached saggital CT image (#6) showing both the enlarged bladder and associated hydronephrosis – both of which were noted on the bedside US.  

Image 6

ctsag6

Thank you for your continued use of bedside US.