IMAGING DIAGNOSIS—A LUMINAL LAMINATED DEBRIS BALL

IN THE URINARY BLADDER OF A DOG

HAKYOUNG YOON, HANJIN KIM, UOOK JUNG , KIDONG EOM

A 5-year-old dog presented with pollakiuria and urinary incontinence. Abdominal radiographs revealed an
oval, multilayered structure with soft tissue opacity and gas lucency in the urinary bladder. Ultrasonography
showed an oval luminal structure with hyper- and hypoechoic layers and internal reverberation artifacts.
Following cystotomy, the hemisected plane showed a layered, pale whitish matrix with a gas layer around the
core. Histopathological examination showed no evidence of cells, bacteria, or fungi. The core and laminae
comprised fibrinous and mineral debris. A final diagnosis of a freely floating, gas-filled laminated debris ball
was made.  C 2016 American College of Veterinary Radiology.

Key words: canine, gas, laminated ball, radiography, ultrasonography, urinary bladder.

Signalment, History, and Clinical Findings

A 5-YEAR-OLD SPAYED FEMALE MINIATURE poodle dog

weighing 3.9 kg presented with depression, pollak-
iuria, and urinary incontinence. Physical examination re-
vealed 5%–7% dehydration. Abnormal laboratory find-
ings included elevated glucose (236 mg/dl; reference range,
74–143 mg/dl) and alkaline phosphatase (773 mg/dl; refer-
ence range, 23–212 mg/dl) levels. A complete blood count
revealed neutrophilia (19,000/µl; reference range, 4000–
12,600/µl) and an increased hematocrit (59%; reference in-
terval, 39%–56%). After radiography and ultrasonography
were performed, a urine sample was collected by cysto-
centesis. The specimen revealed proteinuria and glycosuria.
Abnormalities in urine cytology included a marked num-
ber of bacilli, neutrophils, and urinary bladder transitional
cells. Urine culture was performed, which identified Es-
cherichia coli and Streptococcus spp. exhibiting sensitivity
to enrofloxacin. FIG. 1. An abdominal radiograph shows a right lateral view of a 5-year-old
dog that presented with pollakiuria and urinary incontinence. One large air
bubble (asterisk) and a laminated ball (black arrow) with an outer radiolucent
Imaging, Diagnosis and Outcome area (white arrowhead), inner radiolucent area (white arrow), and radiopaque
layers can be observed.
Abdominal radiographs revealed a fluid-filled stomach
and blunted caudoventral hepatic margins protruding cau- in the urinary bladder (Fig. 1). A large gas bubble around
dal to the costal arch. Notably, an oval, multilayered struc- the ball was identified on a lateral view.
ture with soft tissue opacity and gas lucency was observed Abdominal ultrasonography revealed a fluid-filled stom-
ach and hyperechoic liver with a fine echotexture. In the
urinary bladder, a freely floating, oval structure with multi-
From the Department of Veterinary Medical Imaging, College of
Veterinary Medicine (Eom, Yoon); College of Veterinary Medicine ple hyperechoic and hypoechoic layers was seen (Fig. 2A).
and Veterinary Science Research Institute (Eom), Konkuk University, Multiple hyperechoic foci were present in this laminated
Seoul, 143-701, Korea, and Haedam Animal Hospital, Gwanmyeong-si, object. While some cast an acoustic shadow (Fig. 2B), oth-
Gyeonggi-do, Korea (Kim, Jung).
Address correspondence and reprint requests to Kidong Eom, at the ers created reverberation artifacts (Fig. 2A and B). Color
above address. E-mail: eomkd@konkuk.ac.kr
Received December 29, 2015; accepted for publication May 9, 2016.
doi: 10.1111/vru.12385 Vet Radiol Ultrasound, Vol. 00, No. 00, 2016, pp 1–4.

1
2 YOON ET AL. 2016

FIG. 2. Ultrasonographic images (A and B) and gross appearance (C and D) of a laminated ball found in the urinary bladder of a 5-year-old dog. On
ultrasonography (A and B), a hyperechoic and hypoechoic multilayered (asterisk) laminated ball shows reverberation artifacts within the empty spaces (white
arrow) observed between some layers in gross examination (D). A thick, outer hypoechoic layer (arrowhead) surrounded by a thin, outer hyperechoic layer
can be observed on ultrasonography (B), which appears as a pale, whitish matrix on gross examination (D). The ball demonstrates a yellowish-white color and
smooth surface (C).

Doppler examination revealed no flow within the structure.
Gravity-dependent hyperechoic sediment and free gas with
reverberation artifacts were also identified in the urinary
bladder. On the basis of laboratory, radiographic, ultra-
sonographic, and cytological examinations, tentative diag-
noses of diabetes mellitus, urinary infection, and a luminal
mass in the urinary bladder were made. Differential diag-
noses for the luminal mass included a hematoma, foreign
body, bacterial stone, fungal ball, and laminated fibrinous
ball. Considering that all of these could account for the
clinical presentation, surgical removal was scheduled.
Cystotomy was performed under general anesthesia. The
luminal structure was an oval ball with a yellowish-white
color and smooth surface (Fig. 2C). It was soft to the touch,
but firmer than a marshmallow. The length, height, and
width were 17, 13, and 12.5 mm, respectively. The ball was
hemisected in saline; air bubbles escaped during hemisec-
tion. The hemisected surface showed a concentrically lam-
inated structure, similar to a cut onion (Fig. 2D). Some of
the radiolucent areas observed on the radiographs likely
corresponded to the matrix, which was pale and whitish.
Empty spaces were observed between some inner layers in
the ball.
The core and borders of each layer of the ball showed
positive staining with hematoxylin and eosin, periodic
acid–Schiff, and Masson’s trichrome; however, the thick
outer matrix of the ball did not show definitive staining
(Fig. 3A–C). Sporadic mineral infiltration was identified
VOL. 00, NO. 00 LAMINATED DEBRIS BALL IN A CANINE BLADDER 3

FIG. 3. Histopathological findings after hematoxylin and eosin staining (A, D, G), periodic acid–Schiff staining (B, E, H), and Masson’s trichrome staining
(C, F, I) of a laminated ball found in the urinary bladder of a 5-year-old dog. Microscopic views under 12.5× (A, B, C), 40× (D, E, F), and 400× (G, H, I)
magnifications show the general, core, and layer margin findings, respectively. Empty spaces can be observed between some layers (black arrow).

in each of the layer margins, which were stained with
hematoxylin and eosin (Fig. 3D and G). However, collage-
nous tissue that would show a blue signal with Masson’s
trichrome staining was not observed in any region (Fig.
3C). No cells, bacteria, or fungal hyphae were observed.
Therefore, the structure was diagnosed as a laminated de-
bris ball composed of fibrin and debris without infectious
agents, despite the identification of several bacteria in urine
cytology.
After surgery, the dog exhibited normal urination, and
she did not present any clinical symptom related to cys-
totomy for 7 months since the surgery, as confirmed by
telephone interviews with the owner.
Discussion
Unattached, freely floating, concentrically laminated
balls in the urinary bladder with gas and gas-like radi-
olucent regions are extremely rare and have not been previ-
ously reported in dogs. Laminated fungal1 and fibrinous2–4
balls similar to the one found in the present case have been
reported in humans. In vitro experiments have suggested
that laminated calcium phosphate stones may develop via
a polymer-induced, liquid-like precursor phase in the pres-
ence of abundant organic molecules in urine,5 while lami-
nated fungal and fibrinous balls occur mainly in immuno-
compromised patients such as those with diabetes mellitus
and neoplasia.2,6 Patients with fungal balls can show neg-
ative results for fungal infection in a routine urine culture,
while several fungal hyphae and spores can be identified
in histopathological examination.1,6,7 In a laminated fibri-
nous ball, blood clots and tissue debris may function as a
nucleus for the formation of amorphous fibrin material.3
In the present case, diabetes mellitus was responsible for
an immunocompromised status. Although several bacilli
were identified, no fungal hyphae or spores were observed
in urine cytology. Furthermore, cultures of samples ob-
tained from within the laminated ball showed neither fungi
4 YOON ET AL.
nor bacteria. Although the distinct etiology of the ball was
unclear, the authors consider that the underlying pathogen-
esis was similar to that of fibrinous and fungal balls that de-
velop from the organization of necrotic tissue or fibrinous
or lithiasic debris.2,3,8 In the present case, bacteria were
not observed in the histopathological examination. How-
ever, cell debris and fibrin associated with severe urinary
infection could have agglutinated, rolled, and sequentially
formed a laminated ball. Therefore, we considered this lam-
inated debris ball to be different from previously reported
laminated fibrinous and fungal balls.2,6 All these balls can
grow progressively in size and obstruct the lower urinary
tract; therefore, surgical removal is mandatory.1,8
Interestingly, trapped gas was identified between some
layers on radiography and ultrasonography and during
hemisection of the laminated ball. This indicated the pos-
sibility of the existence of gas-forming bacteria within the
ball at some point in time. In the present case, the ball was
clearly visible on abdominal radiographs because of the ra-
diolucent regions. On the other hand, most fungal and fib-
rinous balls without gas exhibit soft tissue opacity, similar
to urine, and cannot be detected on routine radiographs.1,3
Note that some portion of the radiolucent area was
hypoechoic on ultrasonography and did not stain with
hematoxylin and eosin, periodic acid–Schiff, or Masson’s
trichrome. Loosely organized, dehydrated debris, and de-
bris containing lipids and other radiolucent ingredients
may account for some of the radiolucent areas observed
on radiographs.9
Free luminal gas within the urinary bladder could be due
to gas-forming bacteria. Before radiographic and ultra-
sonographic examinations, no procedure such as urinary
catheterization, cystocentesis, or fine-needle aspiration of
the laminated ball had been performed. From routine urine
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cytology and culture, the presence of anaerobic bacteria
could explain the free gas within the urinary bladder.
In conclusion, to the best of our knowledge, this is the
first report describing an unattached, freely floating lami-
nated debris ball in a canine urinary bladder. A laminated
debris ball should be included as a differential diagnosis
in dogs with a round mass exhibiting multiple radiolucent
and radiopaque layers on radiography and appearing as an
unattached, freely floating, concentric multilayered ball on
ultrasonography in the urinary bladder. However, further
studies are required to determine the etiology and con-
stituents of this phenomenon.
LIST OF AUTHOR CONTRIBUTIONS
Category 1
(a) Conception and Design
Hakyoung Yoon, Kidong Eom
(b) Acquisition of Data
Hakyoung Yoon, Hanjin Kim, Uook Jung
(c) Analysis and Interpretation of Data
Hakyoung Yoon, Uook Jung, Hanjin Kim
Category 2
(a) Drafting the Article
Hakyoung Yoon
(b) Revising Article for Intellectual Content
Hanjin Kim, Uook Jung, Hakyoung Yoon, Kidong Eom
Category 3
(a) Final Approval of the Completed Article
Kidong Eom, Hakyoung Yoon, Hanjin Kim, Uook Jung
ACKNOWLEDGMENT
This study was supported by Veterinary Science Research Institute of
The Konkuk University.
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