Case 42

81 yo male smoker with PMH of  CVA, CAD with stents, on ASA 81mg qd, and BPH p/w atraumatic gross hematuria. No f/c/n/v. No other urinary complaints. Family also reports pt has been more SOB recently and pale.  



Eyes: No visual changes, eye pain or discharge.

Cardiac: +SOB; No chest pain with exertion.

Respiratory: No cough or respiratory distress.

GI: No nausea, vomiting, diarrhea or abdominal pain.

GU: +Hematuria



CONSTITUTIONAL: Well-developed; well-nourished; in no acute distress.

SKIN: Remainder of skin exam is warm and dry, no acute rash. +Pallor

EYES: PERRL, EOM intact; conjunctiva and sclera clear.

CARD: S1, S2 normal; no murmurs, gallops, or rubs. Regular rate and rhythm

RESP: No wheezes, rales or rhonchi.

ABD: Normal bowel sounds; soft; non-distended; non-tender; no hepatosplenomegaly.

GU: Blood at meatus

  1. What is this structure? Describe the abnormality of this structure in terms of echogenicity

  2. What is your differential diagnosis?

3. What are the grades of Hydronephrosis. What grade does this patient have?

4. How do you measure bladder volume on ultrasound?


1.In this image we see the bladder in the transverse view, verified by the posterior acoustic enhancement posterior. There is a heterogeneously echoic mass in the  bladder.

2.The ddx for a Heterogeneous bladder mass includes: clotted blood, a malignancy, Pseudosarcoma, Endometriosis, Tuberculosis and Schistosomiasis.

3. Hydronephrosis is identified on ultrasound with a grading system ranging between no hydro to severe (Grades 0-4). Figure 1 demonstrates mild - severe hydronephrosis (A-D). Our patient from the case has mild hydronephrosis

Great Resource for Hydronephrosis :    

4. Bladder volume is calculated by measuring the depth (D1) and width (D2)  in the transverse view and the bladder length (D2) in the sagittal view.                          Volume = WxDxLx(0.75)