Presentation
Fall down 7 steps. Found to have blood on urinalysis. Trauma CT with particular concern about renal injury.
Patient Data
There is no traumatic vascular, skeletal, pulmonary or solid organ injury.
The skin of the right breast is thickened with ill-defined increased attenuation in the breast tissue. There are no enlarged local nodes.
The left kidney is obstructed with pelvicalyceal and ureteric dilatation and reduced enhancement when compared to the normal right kidney. The cause is a polypoid bladder lesion at the left VU junction. There is no sign of a renal injury.
MRI for staging of the bladder lesion showed no invasion of the muscle layer and no pelvic adenopathy.
Case Discussion
The finding of blood on urine dipstick analysis led to the suspicion of renal injury in this patient who had a fall. The cause was determined to be an incidental bladder lesion. This was causing obstruction but hematuria was not noticed by the patient prior to the trauma and there were no recent blood tests which may have detected an impaired renal function or microcytic anemia.
Up to 75% of patients undergoing whole body trauma imaging have incidental findings detected. Whilst the majority of these will require no further investigation or treatment (such as simple renal or liver cysts), up to 40% will require either immediate or urgent investigation and/or treatment 1. It is important to highlight important incidental findings in trauma CT reports with actionable outcomes for referring clinicians.
On follow up imaging for the breast abnormality, no lesion was detected and on subsequent CTs the findings had resolved. It was assumed that the changes seen on this CT were due to trauma.
Pathology result (abridged):
Microscopic:
The bladder tumor is a papillary transitional cell carcinoma which in most areas is grade 2/low grade. However, there are foci of grade 2/high grade tumor. Most of the tumor is non-invasive, but there are several definite foci of invasion of the lamina propria. Tumor abuts muscularis propria, but is separated from it by stromal reaction. Consequently, the formal pathological stage is pT1. The biopsies also contain fragments of detrusor muscle, which are free from tumor.
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