Test Yourself

Case 1

HISTORY

Elderly male presents with increasing confusion, generally unwell.

He is found to be in acute renal failure.

ULTRASOUND FINDINGS

The first image shows a very distended bladder with a large prostate - this is urinary retention.

The trabeculation of the bladder wall means that although this may have acutely worsened there is an element of chronic bladder hypertrophy here.

The next two images show severe hydronephrosis with severe distension of the collecting system, blunting of the calyces and thinning of the renal cortex.

The final image is taken to confirm passage of the urinary catheter prior to drainage of the bladder. The ureteric dilation is seen posterior to the bladder.

DISCUSSION

Acute renal failure - the ultrasound approach is to determine whether this is prerenal, renal or post renal.

Prerenal

Flattened IVC and empty bladder in keeping with intravascular depletion and reduced urine production.

Renal

There may be an abnormal renal appearance ranging from polycystic kidneys, to bulky echogenic kidneys with interstitial disease / acute nephritis or varying aetiology, to small chronically diseased kidneys.

Post renal

Obstructive uropathy is manifest by a distended bladder, ureteric distension (as is seen in this case) and hydronephrosis.

Occasionally there is bilateral ureteric obstruction (as in tumour infiltration or bilateral calculi) and the bladder is not full.  

It is also important to mention that the lack of hydronephrosis does not absolutely exclude ureteric obstruction. With acute obstruction there may not have been time for hydronephrosis to form. Also when there are multiple causes (including prerenal / renal) urine production will be decreased and hydronephrosis may be less evident despite coexistent obstruction.

SUBMITTED BY:

James Rippey


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Distended bladder

Longitudinal view pelvis
Distended bladder Severe right sided hydronephrosis Severe left sided hydronephrosis Bladder with catheter