A 43 y.o. K2 user comes in after a fall. The fast of the bladder is shown.

What makes his bladder look like a snow globe?

Our patient had urinary stasis with bilateral hydronephosis.  

Sediment in the urine can be caused by several things: phosphate crystals, white blood cells ,  red blood cells, epithelial cells or oxalate acid crystals. Interestingly,  particulate matter in the bladder only correlates with a urinary tract infection in 48% of the cases.  Our patient did have a urinary tract infection.  He was a homeless alcoholic using K2 who was found down and had a fast scan done to rule out abdominal  injury.  We were surprised to find hydronephrosis .  On further questioning he had trouble urinating for years and had to sit down to urinate. 

The interesting thing about phosphate crystals is that they are commonly seen in the urine when alcoholics are refed. When they are given food, the carbohydrates create a phosphate demand both for ATP to break down sugar and increased demand by hexokinase( an enzyme that attaches phosphate to glucose). Eventually this mobilized phosphate ends up in the urine. 

The role of phosphate in a refeeding syndrome was first described in concentration camp survivors who were refed and died.  It was found that giving them milk replaced their phosphate and allowed them to survive.  

Our patient was homeless and refused a foley.  He said that was incompatible with his lifestyle. His UTi was treated and he was given Flomax.

Wilches C, Gallo A, Moreno A, et al. Particulate echoes within the bladder: does this dfinding correlate with urinary tract infection? Rev Colomb Radio 2011 22(4):3334-40.

Dinkel E, Orth S, Dittrich M , et al. Renal ultrasonography in the differentiation of upper from bower UTI. Am J Roentgenol 1986;146:  775-80.

Ronald A, The etiology of urinary tract infections traditional and emerging pathogens. Am J Med 2002;113(supplA) S 14-19.