Bladder Scanning in Hematuria

This week's Image of the Week is brought to us Dr. George Leach. While evaluating a 59 year-old man with hematuria and abdominal pain, Dr. Leach performed a bedside US showing the following bladder images. 

 Transverse:

Sagittal:

These images show a significant abnormality in the bladder requiring prompt consultation and management.

Probe placement for bladder imaging is shown below.

Transverse:

Using the curvilinear probe, the transverse view is obtained with the probe indicator to the right of the patient. 

Sagittal:

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 permit full visualization of the fluid filled bladder.

Looking back at the ultrasound images, the critical finding is a distended bladder with a large clot of mixed echogenicity – likely representing acute and subacute bladder hemorrhage. With a history of colorectal cancer, these US findings suggest recurrent disease and likely metastatic spread to the bladder. Bladder irrigation was promptly started in the ER and Urology was consulted. The patient was also found to be anemic, hyperkalemic, and with acute kidney injury secondary to his urinary obstruction. Disease recurrence with metastatic spread was confirmed on admission CT scan.