Busy as a bee or busy as a beaver, you are feeling north of busy but at least south of overwhelmed. Each questionable request for more Dilaudid is like a sting and each time you feel you are busting through the log jam with your efficient disposition the charge nurse refills all of your beds faster than the last time.
Your next patient is a 5-year-old male with a history of a circumcision three months ago for recurrent UTIs. His mom states he has been having intermittent generalized abdominal pain associated with dysuria and urinary urgency. Despite being potty trained since he was 3, he is now having urinary incontinence as well. There has been no fever or flank or back pain and he is otherwise healthy and not on any medications regularly. Mom states he sometimes starts crying from the pain.
On exam you are surprised to feel what you think is a distended bladder. Not a common exam finding in a five year old. The rest of the exam including a genital exam is normal. A clean catch urine that had been sent from triage is normal. You decide you’d better take a look with the bedside ultrasound to confirm that what you feel is actually the bladder. You obtain the following three images:
What do they show? What should be your next move?
Click here for case conclusion
This patient has severe urinary retention causing bilateral hydronephrosis. Image 1 shows the distended bladder in which the urine is hypoechoic (black) and the bladder wall hyperechoic (white). Posterior enhancement often can be seen behind a fluid filled structure such as the bladder. This causes the area behind the bladder to appear more hyperechoic than it otherwise would. The other images show hydronephrosis (h) of both kidneys, which is mild to moderate in severity. The diaphragm is also labelled (d). Fortunately this child’s BUN and creatinine were both normal.
A urologist at the local children’s hospital was contacted and they recommended placing a Foley catheter and sending him home with a leg bag to follow-up in two days in the office. Since there is no UTI nor evidence of a neurologic disorder and he takes no medication currently the urologist states that he suspects either constipation or severe voiding dysfunction as the most likely cause.
Mom seems happy with the plan, and of course, the 5 year-old now hates hospitals, Foley catheters, and anyone in a white coat. Once the catheter has been successfully placed (under ultrasound guidance), you are thrilled to see how amazed the patient is that he can now watch his urine fill up a bag attached to his leg. Show and tell is going to be awesome on Monday! 
1 Comment
Although the child had normal labs ( BUN,creatinine), why did the provider or urology consultant not recommend additional imaging?
I assume additional imaging was not obtained (XR,or CT) because of close outpatient follow-up.
He has undifferentiated acute urinary retention with bilateral hydro.
how did the case unfold?