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Dx: Prostatic Mass
Upon seeing the images on the screen, you notice a tinge of red in your resident’s cheeks as she begins her spiel about the need to perform a prostate exam as part of the work up today. She eloquently explains to the patient that the ultrasound results and his symptoms are concerning for a prostatic mass that is eroding into the base of his urinary bladder (Image 3). On the transverse view of the bladder a hyperechoic mass can be seen along the posterior wall of the bladder. In the longitudinal view, you can see the hypoechoic lumen of the mass originating from the prostate to the lower left of the bladder wall.
Your resident decides to order blood work, comprehensive imaging, and admit the patient to the hospital for further evaluation and treatment of a suspected prostate malignancy so that he doesn’t get lost to follow up.
Back in the doc box, you remind your resident that this is what residency is all about and we were lucky to have another chance to make the right diagnosis for the patient. Sometimes life is not always about chance, but more so about choice. When provided with a second chance to get it right, try to make the right choice for your patient.
Tips & Tricks for bedside bladder ultrasound
01 Perform a bedside bladder ultrasound if you suspect the patient has urinary retention, to assess for ureteral jets, or to diagnose common causes of hematuria (masses, stones, infection, or foreign bodies).
02 A bladder ultrasound can also be used to help guide a suprapubic catheterization or placement of a transurethral Foley catheter.
03 The urinary bladder is a wonderful acoustic window to utilize in the assessment of the prostate in males and the pelvic organs in females.
04 Have the patient lie supine with the suprapubic area exposed for the scan. Use a low frequency curvilinear or phased array transducer (5-1 MHz).
05 Begin with your probe in a longitudinal fashion and obtain sagittal images of the bladder. Fan left and right and ensure you visualize both lateral margins of the bladder.
06 Next, place your probe in a transverse fashion across the pelvis and obtain axial views of the urinary bladder. Fan from the dome of the bladder down to the base and attempt to visualize any intraluminal abnormalities.
07 If a hyperechoic lesion is visualized in the bladder, determine if it is adherent to the wall or not. The lesion could be a blood clot, abscess, mass, foreign body, or an enlarged prostate pushing against the posterior wall.
08 In males, the hypoechoic prostate can typically be visualized as a distinct structure just posterior to the bladder wall. The normal male prostate is approximately 20 grams (20 mL) and has minor internal irregularities and occasional hyperechoic calcifications with acoustic shadowing.
09 Although it is not within our scope of practice to diagnose prostatic abnormalities on bedside ultrasound, it is important for you to know what an abnormal prostate looks like so you can identify it when you see it. If there is prostatic enlargement noted, or if the gland is visualized abutting or eroding into the wall of the bladder, comprehensive imaging and specialist follow-up should be obtained per your institution’s protocol to determine if the patient has BPH or a malignancy.
10 Stay up to date on how you can use bedside ultrasound to enhance your clinical practice. Check out the ultrasound apps available for smartphones and tablets.
Teresa S. Wu (@TeresaWuMD) is the Associate Residency Director, and Director of Ultrasound and Simulation Programs and Fellowships, for the Maricopa EM Program in Phoenix, Arizona. Dr. Wu is the creator of SonoSupport, an ultrasound app for smartphones and tablets.
Brady Pregerson (@TheSafetyDoc) manages a free online EM Ultrasound Image Library and is the editor of the Emergency Medicine Pocketbook series. For more info visit EMresource.ORG.