Blood in the urine, beyond the obvious. How point-of-care ultrasound accelerated diagnosis of bladder diverticulum and chronic cystitis while fast-tracking cancer exclusion
Dr Himanshu Gul Mirani
Case Presentation:
A man in his 70s presented to the emergency department with a 24-hour history of painless gross haematuria and difficulty passing urine. Although he remained able to void, he reported persistent frank haematuria without fever, vomiting, flank pain, or systemic upset.
He had initially expected spontaneous resolution, but ongoing visible haematuria prompted attendance.
Further history revealed chronic lower urinary tract symptoms, including nocturia and a sensation of incomplete bladder emptying, for which community assessment had been pending.
Physical examination demonstrated a soft, non-tender abdomen without palpable bladder distension or signs of sepsis.
Given the severity of visible haematuria and concern for structural urinary tract pathology, point-of-care ultrasound (POCUS) was performed at first contact. Bladder imaging demonstrated marked bladder wall thickening with irregularity, suggestive of chronic inflammatory change. Longitudinal views also identified a probable bladder diverticulum.
In the context of gross haematuria, these findings raised important differential diagnoses including chronic cystitis, bladder outlet obstruction, diverticular disease, and possible bladder malignancy.
While POCUS provided immediate bedside anatomical insight, malignancy could not be excluded, prompting urgent urological discussion and expedited two-week wait referral.
Chronic cystitis changes and UB diverticulum
Management and Outcome:
Initial blood tests were not suggestive of systemic infection, and the patient remained clinically stable. Following urology advice, urine microscopy and culture were obtained, and empirical antibiotic treatment for presumed urinary tract infection was commenced while maintaining urgent cancer pathway follow-up due to visible haematuria. The patient subsequently underwent cystoscopic evaluation under the two-week wait pathway. Cystoscopy confirmed chronic cystitis without evidence of bladder tumour or other malignant lesion. Urine culture later grew Escherichia coli, sensitive to the prescribed antimicrobial therapy, which was completed successfully with symptomatic improvement. The bladder diverticulum was considered a likely contributing structural factor predisposing to urinary stasis and recurrent infection.
This case demonstrated how POCUS can rapidly identify abnormal bladder morphology, guide early diagnostic reasoning, and support appropriate referral decisions, while recognising its limitations in definitively excluding malignancy.
Key Learnings and Points:
Visible haematuria in older adults warrants urgent evaluation for urological malignancy, even when infection appears likely.
POCUS can be a valuable first-line bedside tool to identify bladder wall thickening, irregular inflammatory changes, urinary retention, or diverticula that may suggest chronic cystitis or structural predisposition to recurrent urinary tract infection.
However, POCUS alone CANNOT reliably exclude bladder cancer, particularly when bladder wall irregularity or mass-like appearances are present.
Bladder diverticula may contribute to urinary stasis, incomplete emptying, recurrent infection, and chronic inflammatory bladder changes, especially in older patients with lower urinary tract symptoms.
Key practice points include:
- always investigate gross haematuria through appropriate cancer referral pathways,
- send urine cultures regardless of initial clinical suspicion, treat likely infection promptly, and
- recognise structural abnormalities such as diverticula as potential drivers of recurrent disease.
This case highlights the complementary role of POCUS in accelerating bedside assessment while reinforcing that definitive exclusion of malignancy requires formal urological investigation, including cystoscopy.