Ultrasound of the Week: Vaginal Bleeding
Authors: Nina Clark, DO, and Meghna Nagam
Edited by Christopher Parker, DO, and Molly Hartrich, MD.
Here's the story:
83-year-old female with diabetes and hypertension presented to the emergency department (ED) complaining of vaginal bleeding that started the night prior to presentation. She stated that she started to “hemorrhage” while lying in bed and has had continuous bleeding since onset. She used multiple pads during the day and quantifies her bleeding as similar to a menstrual period. This was the first time she has had vaginal bleeding since menopause at age 45. She denied other genitourinary symptoms such as dysuria, hematuria, vaginal discharge, or abdominal pain.
Vitals were 36.4°C, HR 91, BP 201/92, RR 18. On pelvic exam, patient was noted to have slow continuous bleeding from the vaginal introitus. On speculum exam, there was bright red blood visualized in the vaginal vault without a clear source. The vaginal introitus was narrowed, and the speculum was not able to be fully inserted due to a shortened vaginal length. Labs were notable for creatinine of 1.4 mg/dL, elevated from her baseline value of 0.6 mg/dL and hemoglobin of 9.1 g/dL, previously 10.3 g/dL two years prior.
A bedside ultrasound of the kidneys and bladder was performed in the ED, along with a radiology transvaginal ultrasound.
What do you see on ultrasound of the left kidney and bladder?
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Bedside ultrasound of the left kidney showed mild to moderate hydronephrosis (Figure 1). There was also a cystic mass posterior to the bladder and absent ureteral jet on the left (Figure 2) after observation for several minutes, suggesting an obstructed left ureter. Transvaginal ultrasound showed a hypervascular, lobular, hypoechoic cervix which appeared to extend into the urinary bladder wall. This was concerning for cervical neoplasm. Computed tomography (CT) of the abdomen and pelvis (Figure 3) showed asymmetric soft tissue thickening along the left anterior aspect of the cervix extending to the posterior wall of the urinary bladder. There was also moderate left hydroureteronephrosis likely obstructive due to malignancy.
Figure 1. Bedside ultrasound of left kidney demonstrating mild to moderate left hydronephrosis (star), coronal view.
Figure 2. Bedside ultrasound of bladder demonstrating right ureteral jet (arrow) with absent jet on the left, transverse view with color Doppler.
Figure 3. CT imaging of abdomen/pelvis showing asymmetric thickening of left posterior wall of the bladder (arrow), transverse view.
Hydronephrosis, Cervical Cancer, and Ultrasound
Hydronephrosis can be identified on ultrasound as dilatation of the renal pelvis, infundibula, and/or pelvis with anechoic or hypoechoic central areas.  In patients suspected of renal colic, point-of-care ultrasound has a sensitivity of 29% and specificity of 94% for diagnosing moderate to severe hydronephrosis (+LR 5.22; -LR 0.76). 
In a healthy well-hydrated person, the ureteral jet occurs twice or more per minute.  A shortened ureteral jet duration of less than 6 seconds can suggest partial obstruction.  The presence of a ureteral jet during <25% of the total number of ureteral jet ejections over five minutes has a sensitivity as high as 87% and a specificity of 96.4% for ureteral obstruction.  While waiting five minutes is not practical in the ED, these findings can support the final diagnosis.
Cervical cancer can be visible on pelvic ultrasound as a hypoechoic, heterogenous mass involving the cervix and may also show increased vascularity on color Doppler. 
Though cervical cancer is staged clinically, ultrasound can be a useful tool by showing size of the lesion, parametrial invasion, and/or invasion into the vagina/adjacent organs. 
Hydronephrosis in cervical cancer is associated with worse morbidity and trends towards poor outcomes, even if it is diagnosed during cancer treatment. 
In a study from a tertiary referral center in Taiwan, hydronephrosis greater than grade two was independently associated with non-organ-confined ureteric cancer. Non-organ-confined pathology is the most important predictor for local and distant oncological failure. 
The patient was discharged with no urologic intervention and close follow up with gynecology. Pap smear the day following discharge showed high grade squamous intraepithelial lesion, and cervical biopsy was positive for Infiltrating moderately differentiated squamous cell carcinoma, grade two.
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