A 68 year old male presents with urinary retention and shortness of breath. He states that he has a prostate problem and that “his penis hole is in the wrong place”, but is not on an alpha blocker and has never been offered surgery. Instead he uses a catheter.  He next takes out an old ziplock bag and produces a nasty-looking straight cath. Answers to various other questions confirms that he has had quite fragmented health care. No one ever even suggested that he apply for Medicare!

On exam he is in mild respiratory distress, but vital signs and pulse-ox are normal. He has both rales and peripheral edema.  He also has hypospadia, but his bladder doesn’t really feel that enlarged.

The nurse is unable to pass a Foley or a Coude and asks you if you want to try a straight cath. You answer that you want to do a quick bedside ultrasound of his bladder first. By then his labs have returned. You are not surprised by his raging UTI, elevated creatinine or elevated BNP, though the troponin of 0.2 does raise an eyebrow.

Below is the ultrasound image of the bladder that you obtain.

What does this ultrasound show?

Bonus Question: What EKG finding is pathognomonic for hypospadia

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