“If you are given a second chance in life, don’t blow it,” you advise your eager resident. It has been an overwhelmingly busy day in the department. Interspersed between the motor vehicle collisions, hypoxic and hypotensive CHF exacerbations, and patients with florid sepsis, your team is trying to see and help all of the ankle pains, throat pains, and dysuria that have also walked through the waiting room doors. The neighborhood clinics are completely overbooked, and your department has been dealing with the overflow all week.
Your resident has three charts in her hand and has just finished presenting the two sicker patients to be seen. Her third patient is a 60-year-old, otherwise healthy male, who was just here last week for nausea, dysuria, and “feeling unwell”. He was diagnosed with a UTI at that time, and given a prescription for cephalexin. Per his records, he had reported some unprotected intercourse also, so he was empirically treated with azithromycin and ceftriaxone for gonorrhea and chlamydia. The patient went home and his dysuria did not improve with the antibiotics. He couldn’t afford the co-pay to be seen in our clinic, so he returned to the ED.
On exam, the patient is sitting comfortably in bed, in no acute distress. He has his hospital gown on backwards with the ties and opening in the front—a sure sign that he’s not your typical ED frequent-flier. He’s happy to talk to you about his persistent symptoms, and does not appear angry or disenchanted that this is his second ED visit for the same problem. His vital signs are normal and his chest, abdominal, back, and genitourinary exam is benign. You take a moment to review the patient’s previous urinalysis results with your resident and note that a week ago he had trace leuk esterase, trace ketones, 10 RBC’s, 1 WBC, <1 squamous epi, negative nitrite, and no bacteria. His urine culture from that last visit has not showed any growth to date.
You ask your resident what her plan is for the patient, and she tells you that she wants to give him a stronger antibiotic for his resistant hemorrhagic cystitis and have him follow up with urology as an outpatient. After a deep breath and pause for effect, you remind her that the plan for outpatient follow-up didn’t really pan out the last time the patient was seen in the ED, and you ask her to look at the UA from last week again. “Do you think he has a bladder infection? What else could this be?” She spouts off a differential including trauma, renal stones, nephropathies, glomerulonephritis, cancer, BPH, and even schistosomiasis and renal AVM’s just because you are testing her. You decide to capitalize on this teaching moment and have her wheel in the ultrasound machine to the patient’s bedside.
As you scan through his kidneys bilaterally, you talk some more to your patient and realize that his dysuria is really more of a difficulty starting and maintaining his stream. He has had some nocturia and has noticed some intermittent specks of blood in the toilet after he urinates. His bedside renal ultrasound does not demonstrate any obvious abnormalities other than mild bilateral hydronephrosis, so you turn your attention to the patient’s bladder. What do you see on your bedside bladder scan? (Images 1 & 2) What’s the next step in your treatment plan?
What does the ultrasound show? What is the next step in your treatment plan?
Dx: Prostatic Mass
Upon seeing the images on the screen, you notice a tinge of red in your resident’s cheeks as she begins her spiel about the need to perform a prostate exam as part of the work up today. She eloquently explains to the patient that the ultrasound results and his symptoms are concerning for a prostatic mass that is eroding into the base of his urinary bladder (Image 3). On the transverse view of the bladder a hyperechoic mass can be seen along the posterior wall of the bladder. In the longitudinal view, you can see the hypoechoic lumen of the mass originating from the prostate to the lower left of the bladder wall.
Your resident decides to order blood work, comprehensive imaging, and admit the patient to the hospital for further evaluation and treatment of a suspected prostate malignancy so that he doesn’t get lost to follow up.
Back in the doc box, you remind your resident that this is what residency is all about and we were lucky to have another chance to make the right diagnosis for the patient. Sometimes life is not always about chance, but more so about choice. When provided with a second chance to get it right, try to make the right choice for your patient.
Tips & Tricks for bedside bladder ultrasound
01 Perform a bedside bladder ultrasound if you suspect the patient has urinary retention, to assess for ureteral jets, or to diagnose common causes of hematuria (masses, stones, infection, or foreign bodies).
02 A bladder ultrasound can also be used to help guide a suprapubic catheterization or placement of a transurethral Foley catheter.
03 The urinary bladder is a wonderful acoustic window to utilize in the assessment of the prostate in males and the pelvic organs in females.
04 Have the patient lie supine with the suprapubic area exposed for the scan. Use a low frequency curvilinear or phased array transducer (5-1 MHz).
05 Begin with your probe in a longitudinal fashion and obtain sagittal images of the bladder. Fan left and right and ensure you visualize both lateral margins of the bladder.
06 Next, place your probe in a transverse fashion across the pelvis and obtain axial views of the urinary bladder. Fan from the dome of the bladder down to the base and attempt to visualize any intraluminal abnormalities.
07 If a hyperechoic lesion is visualized in the bladder, determine if it is adherent to the wall or not. The lesion could be a blood clot, abscess, mass, foreign body, or an enlarged prostate pushing against the posterior wall.
08 In males, the hypoechoic prostate can typically be visualized as a distinct structure just posterior to the bladder wall. The normal male prostate is approximately 20 grams (20 mL) and has minor internal irregularities and occasional hyperechoic calcifications with acoustic shadowing.
09 Although it is not within our scope of practice to diagnose prostatic abnormalities on bedside ultrasound, it is important for you to know what an abnormal prostate looks like so you can identify it when you see it. If there is prostatic enlargement noted, or if the gland is visualized abutting or eroding into the wall of the bladder, comprehensive imaging and specialist follow-up should be obtained per your institution’s protocol to determine if the patient has BPH or a malignancy.
10 Stay up to date on how you can use bedside ultrasound to enhance your clinical practice. Check out the ultrasound apps available for smartphones and tablets.