Is Bladder Ultrasound
Alone Effective for
detecting calculi?
A re-audit of Surveillance in a Rehabilitation Service.
Rosie Conlon, Brian McGlone, João Cardoso, Eva Wallace
National Rehabilitation Hospital, Dublin, Ireland.
Dun laoghaire, Dublin, Republic of Ireland
January 2014
Background
Urinary Tract Infections (UTI) are the most frequent medical
complication in patients with Spinal Cord Injuries (SCI) and a
major cause of morbidity
The main purpose of regular urology review (Nurse -led clinic
NLC) is to preserve renal function with the ultimate aim of a non
obstructed urinary system
SCI patients with bladder catheter have a 9-fold risk for bladder
stones, compared to the catheter free patients with spinal cord
injury
Objectives
• Re-audit the findings of ultrasound and X-ray,
• Explore the possibility of reducing exposure to radiation
• Examine the relationship between bladder calculi,
bladder management technique and symptoms
Methods:
28 patients, over a 12 months period, were found to have
urinary bladder calculi at routine urology review.
Results
Bladder Management
Technique Numbers
in patients with bladder stones
Bladder Management
Technique Percentages
in patients with bladder stones
12
12
10
8
8
3%
6
11%
4
3%
43%
3
3
2
1
1
0
29%
11%
Supra Pubic Catheterization (SPC)
Self Intermittent Catheterization (SIC)
Indwelling Urethral Catheterization (IDUC)
Conveen
Pads
Continent
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Results
Bladder ultrasound alone diagnosed 36 % bladder calculi
compared to 18% diagnosed by X-ray alone
Symptoms and Signs
Urinalysis taken on all patients.
Proteus is the microbe commonly
associated with the formation of calculi and
is not a common microbe in SCI patients.
E-coli is a common uro-pathogen, often
recurrent and asymptomatic
Urinalysis
6/28 patients (21.4%) had no growth, colony count < 1000 cfu/ml.
22/28 patients (78.6%) had significant culture.
Of these:
Significant Urine culture results
Number of cases
Percentage
E-coli
12
42,8%
Coli form bacteria
3
10,7%
Proteus
1
2,8%
Enterococcus
1
2,8%
Pseudomonas
1
2,8%
1
2,8%
3
14,3%
Marginella marganil (isolated and multi
resistant ? due to catheter colonisation)
Mixed growth
7
…. Should we change our
current practice??
“An important concern with indwelling catheterization,
whether transurethral or suprapubic, is the long-term risk
of squamous cell bladder neoplasia (SCC). The reported
incidence of SCC associated with chronic indwelling
urinary catheters is 2.3-10%.” [2]
Saline infusion of 100-200mls in a
controlled environment may allow
visualisation of calculi by US and avoid
exposure to radiation in this higher risk
group of patients.
Autonomic Dysreflexia
•
Risk of Autonomic Dysreflexia (AD)
with saline infusion of approx 200mls
to distend the bladder for examination
with ultrasound.
•
Bladder distension below the level of
SCI for those with T6 injury or above
can cause AD
•
If recognised quickly and appropriate
action taken, the symptoms subside
and reduce the risk of complication
•
Risk of introducing infection
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Conclusions
• Our patients have a higher incidence of calculi
than the general population, ultrasound is the
modality of choice for detecting calculi
• Most patients are asymptomatic with calculi
• Routine surveillance is warranted
• Change in practice should reduce the overall
radiation exposure to patients at greatest risk of
bladder stone formation and SCC
• Further audit required
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“Bones can break, muscles can atrophy,
glands can loaf about and even the brain can
sleep without immediate danger to survival.
BUT when the kidneys fail…. neither bone,
muscle gland nor brain could carry on.”
Homer William Smith,
“The Evolution of the Kidney”, Lectures on the Kidney (1943).
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References
•
[1] Chen
•
[2] Kaufman
Y, De Vivo MJ, Lloyd LK. Bladder stone incidence in persons with SCI:
Determinants and trends, 1973-1996. Urology 2001;58(5)665-70.
JM, Fam B, Jacobs SC et al. Bladder cancer and squamous
metaplasia in spinal cord injury patients. J Urol 1977; 118: 967, 1390, 19876.
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