ª Springer Science+Business Media, LLC, part of Abdom Radiol (2018)
Abdominal Springer Nature 2018
Radiology
Bladder debris on ultrasound in the emergency
department: correlation with urinalysis
Ghaneh Fananapazir , Behrad Golshani, Ling-Xin Chen, John P. McGahan,
Angelo M. de Mattos, Michael T. Corwin
University of California Davis Medical Center, 4860 Y Street Suite 3100, Sacramento, CA 95817, USA
Abstract
Purpose: To evaluate the correlation between the pres-
ence of bladder debris on ultrasound and urinalysis
results in the emergency department setting.
Methods: Adult patients presenting to the emergency
department with an ultrasound of the bladder and a
urinalysis performed within 24 h of the ultrasound were
included in this retrospective study. Two radiologists in
consensus evaluated for the presence or absence of debris
within the bladder. Urinalysis results were recorded
including continuous variables (specific gravity and pH)
and categorical variables (presence of occult blood,
bilirubin, ketones, glucose, protein, urobilinogen, nitrite,
leukocyte esterase, white blood cells, and red blood cells).
The presence and absence of white and red blood cells
were defined as > 5 cells/high-powered field. To control
the experimentwise type I error rate at 0.05, a Bonfer-
roni-corrected significance level of 0.0042 was used to
determine significant associations.
Results: The presence of bladder debris was associated
with the presence of urobilinogen, nitrite, and white
blood cells (p = < 0.0001, 0.0005, and 0.0004, respec-
tively).
Conclusions: Bladder debris in the emergency department
setting correlates with urinalysis laboratory values sug-
gesting a urinary tract infection. Therefore, the presence
of bladder debris should elicit the recommendation of a
urinalysis in such a setting.
Key words: Bladder—Debris—Ultrasound—Urinalysis
Abdominal ultrasound is commonly performed in pa-
tients presenting to the emergency department with
Correspondence to: Ghaneh Fananapazir; email: fananapazir@uc-
davis.edu
https://doi.org/10.1007/s00261-018-1513-4
abdominal pain, owing to its lack of radiation and rel-
ative low cost. According to the American College of
Radiology practice parameters for ultrasound evaluation
of the urinary tract, assessment of the urinary bladder is
recommended [1]. The bladder contents are normally
anechoic. However, it is not uncommon to observe
floating and layering debris within the bladder.
The clinical implication of such bladder debris is
unclear. While some echoes can be attributed to artifact
[2], the gravity-dependent nature of such ‘‘floaters’’
suggests otherwise and is considered an abnormal finding
[3]. Dehydration (associated with a high specific gravity),
infection, hemorrhage, and inflammation have all been
posited as explanations for bladder debris [4–6]. How-
ever, a recent paper suggested that such debris is not
related to any specific abnormality based on urinalysis
results [7]. However, in that study the patient population
was heterogeneous (not limited to the emergency setting),
and urinalysis could be performed up to a week before or
after the bladder ultrasound.
Therefore, the purpose of our study was to evaluate
the correlation between the presence of bladder debris on
ultrasound and urinalysis results in the emergency
department setting.
Materials and methods
Subjects
This retrospective study was approved by our institu-
tional review board with a waiver of informed consent
and was Health Insurance Portability and Accountability
Act-compliant. Between October 1, 2011 and April 1,
2014, we searched our picture archiving and communi-
cation system for all ultrasound reports of adult patients
that mentioned the term ‘‘bladder debris,’’ ordered by
the emergency department. For a comparison group,
consecutive patients from the emergency department
without bladder debris were included. Patients were ex-
cluded if a complete urinalysis was not performed within
 G. Fananapazir et al.: Bladder debris on ultrasound in the emergency department
the 24 h of the ultrasound. Patients were excluded if the
bladder was decompressed, not allowing a luminal eval-
uation, or in the presence of a bladder catheter or ur-
eteral stenting. A total of 181 patients were thus
identified for inclusion in this study (110 female, 71
male). The average age was 45 years (range:
18–86 years). The primary symptom leading to the
ultrasound was recorded.
Ultrasound
Ultrasound examinations were performed with Logiq E9
(GE Healthcare, Chalfont St. Giles, UK) and Acuson
Sequoia Ultrasound System (Siemens Acuson, Erlangen,
Germany) machines with C6-2, C6-1, and C5-1, and 5-1
and 4-1 MHz vector transducers. Ultrasound examina-
tions were performed by Registered Diagnostic Medical
Sonographer-accredited sonographers under the super-
vision of a board-certified radiologist. The probe was
placed transabdominally anteriorly and angled to visu-
alize the bladder, and gain settings increased to the level
just above which noise could be detected. Both transverse
and longitudinal static grayscale images of the bladder
were acquired in all cases, and occasionally cine clips
were obtained.
Ultrasound interpretation
Two board-certified radiologists with 4- and 38-year
post-abdominal fellowship experience retrospectively re-
evaluated the images of the bladder separately, and
classified those with discrepant interpretations in con-
sensus to evaluate for the absence or presence of ultra-
sound debris (Figs. 1, 2). Bladder debris was defined as
echogenic floating debris that clearly could not be at-
tributed to artifact. Echogenic-dependent mobile mate-
rial that exhibited shadowing (indicative of bladder
calculi) were excluded from the analysis.
Urinalysis
The following urinalysis results were recorded: specific
gravity, pH, the presence of occult blood, bilirubin, ke-
tones, glucose, protein, urobilinogen, nitrite, leukocyte
esterase, white blood cells, and red blood cells. Specific
gravity and pH were recorded as continuous variables,
while the rest of the results were recorded categorically in
a binary fashion as normal or abnormal based on the
laboratory reference ranges. The presence or absence of
white and red blood cells was determined at a cut-off
value of greater than 5 cells/high-powered field.
Statistical analysis
Two-sample t tests were used to compare means of
specific gravity and pH between positive and negative
bladder debris patients. Fisher’s exact tests were used to
test the association between the presence or absence of
bladder debris and binary outcomes (occult blood,
bilirubin, ketones, glucose, protein, urobilinogen, nitrite,
estimated leukocytes, white blood cells counts > 5, red
blood cell counts > 5). To control the experimentwise
Fig. 1. A 27-year-old
female presenting with right
flank pain and underwent an
ultrasound. Grayscale
image of the bladder
demonstrates normal
anechoic contents with no
debris present.
G. Fananapazir et al.: Bladder debris on ultrasound in the emergency department

Fig. 2. A 31-year-old
female presenting with right
flank pain and underwent an
ultrasound. Grayscale
image of the bladder
demonstrates echogenic-
dependent foci within the
bladder consistent with
bladder debris.

type I error rate at 0.05, a Bonferroni-corrected signifi- Table 1. Distribution of positive and negative bladder debris findings
among females and males
cance level of 0.0042 was used to determine significant
associations. US finding Female Male Total

Negative 75 56 131
Results Positive 35 15 50
Total 110 71 181
Of the 181 patients in the study, 50 patients had bladder
debris and 131 patients did not. The sample consisted of
more females than males (61 vs. 39%) (Table 1), but the
presence of bladder debris was not significantly associ-
Table 2. Primary presenting symptom leading to the ultrasound
ated with sex (Chi-square (v2) = 1.96, df = 1, examination
p = 0.161). Subjects with positive bladder debris find-
Presenting symptom Debris present (%) Debris absent (%)
ings tended to be younger than those without bladder
debris (mean ± SD: positive = 40.92 ± 18.85 years, Pain 37 (74) 91 (69)
negative = 46.27 ± 16.94 years), although the differ- Acute kidney injury 6 (12) 21 (16)
Hematuria 5 (10) 5 (4)
ence was not significant (t = 1.75, df = 80.97, Fever 2 (4) 9 (7)
p = 0.08). The symptoms leading to the ultrasound are Decreasing urine output 0 (0) 2 (2)
presented in Table 2. Hypertension 0 (0) 2 (2)
Edema 0 (0) 1 (1)
Of the continuous variables, bladder debris tended to
be associated with a higher pH and higher specific
gravity, although these were not statistically significant
(Table 3). Regarding the binary variables, and after Table 3. Mean ± SD for specific gravity and pH by bladder debris
adjusting for multiple testing, three traits were signifi- finding and results of t test comparing the two groups
cantly associated with bladder debris status (urobilino- Variable Bladder debris finding t test results
gen, nitrite, and WBC). In all cases, the odds of a positive
Negative Positive
finding were higher with patients positive for bladder
debris (Table 4). While the presence of red blood cells Specific gravity 1.013 ± 0.007 1.016 ± 0.008 t = - 2.546, p = 0.128
was higher in patients with positive bladder debris, it did pH 6.103 ± 0.824 6.480 ± 0.880 t = - 2.621, p = 0.010
not meet statistical significance given the adjustment for With adjusting for multiple testing a p value < 0.0042 is necessary for
multiple testing (p = 0.012). statistical significance
 G. Fananapazir et al.: Bladder debris on ultrasound in the emergency department

Table 4. Summary of variables (frequencies and odds ratios) and p values from Fisher’s exact tests for association
Variable p value Odds ratio (Positive)

US Negative Positive

Occult Blood
Negative 67 64 0.188 1.56 (0.808, 3.073)
Positive 20 30
Bilirubin
Negative 128 3 1.00 0.947 (0.032, 8.373)
Positive 49 1
Ketones
Negative 116 15 0.152 1.933 (0.776, 4.651)
Positive 40 10
Glucose
Negative 116 15 1.00 1.069 (0.355, 2.844)
Positive 44 6
Protein
Negative 75 56 0.070 1.840 (0.952, 3.606)
Positive 21 29
Urobilinogen
Negative 115 16 0.0005 4.000 (1.829, 8.867)
Positive 32 18
Nitrite
Negative 115 16 < 0.0001 13.572 (6.310, 30.746)
Positive 17 33
Leuk.Est
Negative 74 57 0.0045 2.732 (1.387, 5.567)
Positive 16 34
WBC
Negative 83 48 0.0004 3.320 (1.689, 6.733)
Positive 17 33
RBC
Negative 73 58 0.012 2.422 (1.2238, 4.883)
Positive 17 33

With adjusting for multiple testing a p value < 0.0042 is necessary for statistical significance

Discussion dance between the presence of bladder debris and uri-

The presence of debris within the lumen of the bladder
identified on ultrasound is associated with laboratory
evidence of a urinary tract infection. Therefore, the
presence of bladder debris should elicit a recommenda-
tion for urinalysis in the emergency setting.
Our findings are in concert with findings related to
pyonephrosis, in which floating debris within the lumen
of the renal pelvis is suggestive of an infectious etiology
[8–10]. In one study, the presence of debris was highly
specific but demonstrated a low sensitivity for
pyonephrosis [10]. This is probably in concert with our
findings, since the absence of bladder debris did not
necessarily mean the absence of a urinary tract infection,
based on urinalysis results. Our results are also in
agreement with a recent study in the pediatric patient
population in which debris is associated with a urinary
tract infection [11].
Our conclusion that bladder debris correlates with
urinalysis results differs from a few published studies [7,
12]. However, in one of these studies by Cheng et al., the
patient population was heterogeneous and a lapse of
7 days was permitted between bladder debris findings
and urinalysis [7]. It is possible that the longer time
period in their study could have contributed to discor-
nalysis findings. It is also possible that our limited setting
of the emergency department with a more homogeneous
population could have brought out the urinalysis dif-
ferences between those that had and did not have debris
on ultrasound. In another study, the particulate echoes
were identified on transvaginal ultrasound [12]. How-
ever, transvaginal ultrasound utilizes overall higher fre-
quency probes, and therefore, this may have increased
artifactual debris. Additionally, their patient population
comprised asymptomatic patients, which was different
from our patient population.
It is unclear the relationship between bladder debris
and urobilinogen. Elevated urobilinogen is associated
with liver damage or increased red blood cell destruction.
There was a trend towards bladder debris being associ-
ated with the presence of red blood cells, although this
did not reach statistical significance. It is possible that a
larger study would allow for significance to be met.
This study has several limitations. Firstly, this is a
retrospective study. Secondly, the presence of debris is
somewhat subjective as there can be some overlap with
artifacts. Thirdly, it would have been useful to correlate
the presence of bacteria on urine culture. However, this
was not obtained in all patients and therefore was not
included in our analysis. It is also possible that our
G. Fananapazir et al.: Bladder debris on ultrasound in the emergency department
search did not include all patients with bladder debris, as
reports may have either not mentioned its presence or
used different terminology. Finally, our patient popula-
tion was narrow: adults in the emergency department
setting with clinical concern leading to an ultrasound
that included bladder imaging and a urinalysis. There-
fore, our results may not be applicable to other settings.
In conclusion, we found that in the emergency setting,
the presence of debris within the bladder is strongly
associated with the presence of an abnormal urinalysis.
Therefore, the presence of debris within the bladder in
such a setting should elicit the recommendation by the
radiologist of the performance of a urinalysis.
Compliance with ethical standards
Funding This study was not funded.
Conflict of interest All authors declared that they have no conflict of
interest.
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the
institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards.
Informed consent Requirement for informed consent was waived by
our institutional review board in this retrospective study.
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