Case 32: Straight Cath

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

SCROLL DOWN FOR CASE ANSWER AND TO WRITE COMMENTS

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Get Side-Kick: Emergency Medicine or Quick Essentials: Emergency Medicine

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Answer: Calcified Foley Balloon

The ultrasound shows a large calcified object within the bladder that casts a shadow.  When you mention it, the patient states, ”Oh yeah, about a year ago a catheter broke off in there.  It hasn’t seemed to bother me.”

The urologist says he’ll need a cystotomy in the OR to remove it.

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EXCERPT ON URINARY RETENTION FROM QUICK ESSENTIALS: EMERGENCY MEDICINE

General:    Painless if chronic. Overflow incontinence
Volume:     Post-Void Residual >50ml is abnl.  If >1L get BUN & US, obs 6h, (abx)
Exam:         Can have BPH ĉ nl size gland
Neuro:        cord/cauda, CVA, DM & MS(#1 in women), dementia, parkinson’s, MG, GBS…
Obstruction: BPH(#1 in men), stricture, STD, mass/stone
Pharm:        antichol, benzos, opiates, TCA’s, decongestants, stimulants, NSAIDS.  
Infection:    UTI, abscess, prostatitis, herpes
Women:       MS, DM, UTI > obstruction (urethral abscess, polyp or stricture)
Rx:               Foley, replace 50% fluid lost for post-obstructive diureseis, r/o UTI

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 Bonus Question Answer:  Inverted P-waves (get it?)

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