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Suprapubic pain, frequency, and haematuria—with a twist

BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c6855 (Published 22 December 2010) Cite this as: BMJ 2010;341:c6855
  1. Anika Sud, foundation year 1 doctor,
  2. Jaimin Bhatt, urology specialist registrar,
  3. Adam Jones, urology consultant
  1. 1Harold Hopkins Department of Urology, RBH NHS Foundation Trust, Reading, UK
  1. Correspondence to: A Sud anikasud{at}googlemail.com

A 74 year old woman presented to the emergency department with a two day history of right flank pain, urinary frequency, haematuria, and vomiting. Her medical history included diabetes (treated with gliclazide), myocardial infarction, hypertension, deep vein thrombosis, and autoimmune hepatitis. She had no urological history.

On examination her temperature was 36.4oC, heart rate 110 beats/min, and blood pressure 95/62 mm Hg, and she was tender in the suprapubic region and right flank. The rest of the physical examination was normal.

Laboratory results showed a white cell count of 12×109/l (normal range 4×109/l to 11×109/l), C reactive protein concentration of 40 mg/l (<8 mg/l), glucose concentration of 28 mmol/l (3.0-6.0 mmol/l), urea level of 12 mmol/l (2.5-6.7 mmol/l), and creatinine concentration of 121μmol/l (60-120 μmol/l). Urinalysis was positive for leucocytes, nitrites, protein, and frank blood.

The patient was started on intravenous aztreonam and gentamicin for urosepsis because she was allergic to penicillin. A plain abdominal radiograph was performed, and subsequently a computed tomography scan of the kidney, ureters, and bladder was undertaken to look for renal calculi.

Fig 1 Plain abdominal radiograph

Fig 2 Coronal computed tomography scan of the kidney, ureters, and bladder

Questions

  • 1 What radiological abnormality is present on the scans and what is the differential diagnosis of this abnormality?

  • 2 What is the most likely cause in this case?

  • 3 What is the investigation of choice to diagnose this condition?

  • 4 What is the aetiology and what are the risk factors for this condition?

  • 5 How would you manage this condition?

Answers

1 What radiological abnormality is present on the scans and what is the differential diagnosis of this abnormality?

Short answer

The abdominal radiograph and computed tomography scan of the kidney, ureters, and bladder show …

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