Friday, April 8, 2016

Big bad bladder?

Little old lady sent in from nursing home. 
She had been noted to be anuric, but also had a distended abdomen. A bladder scan had been done, and was markedly positive, reading about a liter. Placement of a Foley catheter, however, had returned only a minimal amount of urine, and so she was sent to the ED for her "difficult catheterization."

Oddly, placement of the urinary catheter did not seem difficult to the emergency nurses, but even though the Foley flushed well, and the flush could be aspirated, only trivial amounts of urine were obtained, 

A bedside ultrasound easily identified a gigantic "bladder", but the balloon and tip of the Foley could not be located.

Despite numerous tricks of Foley placement, and extensive US investigation, no urine could be obtained, and a CT scan was ordered to check for abnormal anatomy.

Turns out that wasn't a bladder, but instead a giant renal cyst

Repeat bedside ultrasound demonstrated that the clues had been there, but that they were subtle (in the sagittal suprapubic view) or quite difficult to obtain (right coronal view of the kidney).

Renal cysts of this size are fairly rare, and so this scenario, where urinary catheterization is pursued fruitlessly, is unlikely to be encountered often. But the signs of a misplaced balloon, as well as cystic structure in the kidney, could have been appreciated without the aid of CT imaging. 

Open-Access References:
A huge renal cyst mimicking ascites: a case report

An Unusual Cause of Giant Renal Mass