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Giant Urethral Calculus: A Case Report
THE JOURNAL OF UROLOGY
Vol. 80, No. 1, July 1958 Printed in U.S.A.
GIANT URETHRAL CALCULUS: A CASE REPORT L. F. VON P. VANDERHORST From the Surgical Service, Winter Veterans Administration Hospital, Topeka, Kansas A 70-year-old Negro stated that22 years earlier, without preceding pain, he suddenly noticed blood in the urine, which lasted one day. He gave no history of venereal disease. About one month later, though there was free urinary passage, he had mild pain in the groin, never in the flank nor in the perineum. The pain lasted about· one week, and has never recurred. Some years later he noticed that he urinated more often, because of what he described as a "feeling of a full bladder." Gradually he acquired a regimen of hourly voiding, with nocturia at intervals of one to two hours. About one month prior to hospitalization, he accidentally palpated a hard lump in his perineum and discovered that by shifting this lump sidewise the urinary current became stronger. Intermittently he noticed blood in the urine but did not seek medical advice or treatment. About one week prior to hospitalization persistent fever with chills developed, and the patient finally sought help. He was emaciated and appeared acutely ill, with fever and tachycardia. A hard mass measuring about 2 by 5 cm. was palpated under the raphe of the perineum. This mass could be shifted to either side. The prostate· was essentially normal. The hemoglobin was 14.7 gm. per cent, the hematocrit 44 per cent. Initial urines were grossly bloody and pyuric. The chest x-ray was essentially normal. On x-ray of the pelvis, a radiopaque density was discovered which was situated between the ischiopubic arches and therefore outside of the urinary bladder and below the prostatic region (fig. 1, A). On passing of a metal sound through the urethra, the tip of the sound made a scraping encounter with the mass in the perineum. Roentgen film after intraurethral injection of thixokon showed a calculus lying in a pouch of the membranous portion of the urethra (fig. 1, B). Abdominal and intravenous pyelographic studies revealed calculi in the left, very poorly functioning kidney with essentially normal right kidney and ureter (fig. 2). Fever and pyuria were controlled with antibiotic therapy, after which an external, 3 cm. Accepted for publication December 19, 1957. 31
long urethrotomy was done. The stone was readily developed with a stone forceps. After a No. 24 sound was easily passed, an indwelling catheter was threaded through the urethra into the bladder. The perinea! wound was closed. Eight days postoperatively, the perinea! wound had healed by primary union. DISCUSSION
A calculus in the male urethra is not rare. Any small concrement passing through the urogenital tract, if not readily passed in the urinary stream, may be caught either in the ureteral or in the urethral structures. A pea-sized calculus lodged in the urethra can cause complete urinary block and therefore bring the patient at an early stage to the physician. Usually the calculus is caught at the posterior entrance of a urethral stricture. During 11 years spent in practice in the tropical Netherlands' East Indies, where I found an unusually high incidence of calculi of the urinary tract, I never encountered a urinary calculus in the urethra of the size of the one which is here presented. Because of its size and presence over many years, without causing too much discomfort to the patient, the question arises how it was possible that such a large calculus could develop over the course of years if it had started with a small concrement passed through the ureter, and halted in the urethra on its passage to the outside world. Neither in the patient's history nor at examination was there found indication of stricture. Presumably in 1935, a small calculus could have lodged in a pre-formed cavity of the urethra and gone unnoticed while it gradually increased in size by layers of sediment deposited from the urinary fluid, as evidenced by x-ray studies of the calculus (fig. 3). In females, sac-like protrusions or pockets of the urethra, also called diverticula, are far from common. It is of little importance to the clinician to determine whether the diverticulum is a true or a false one. The true diverticula have all the structural layers of the urethra, including epithelium; the false ones show absence of one or more urethral layers.
32
L. F. VON P. VANDERHORST
Fm. 1. ~' a~ter?p.ost~rior flat.film of_pelvis with sto11;e between ischiopubic arches. B, oblique flat film of pelvis with m3ect10n of thixokon m urethra, showmg large calculus in membranous portion.
Fm. 2. Intravenous pyelogram after 5 minutes shows calculi in left kidney as previously noted on plain roentgenogram. Dye is seen in upper part of left ureter, in normal right kidney pelvis and calyces, and in right half of bladder. Menville and Mitchell,* at Louisiana Charity Hospital, found in 500,000 female admissions, 13 cases of diverticulum of the urethra ranging between the ages of 26 and 69 years, with an average of 38.8 years, more common among Negroes than whites. Though rare in the female urethra, diverticula are even more rare in the male urethra. I could not find any statistics about their occurrence. In the male, congenital diverticulum is attributed
* Cited in Herbut, P.A.: Urological Pathology. Philadelphia: Lea and Febiger, 1952, p. 47.
FIG. 3. Giant urethral calculus after removal, and roentgenogram of laminated urethral calculus, without foreign body nucleus. to faulty union of the embryonic urethral folds or to an abnormal canalization of the epithelial tissue which forms Cowper's gland, situated at the bulb, the posterior part of the corpus cavernosum urethrae. The bulbar urethral glands of Cowper in the male are homologous with the Bartholin glands in the female, which also arise as diverticula from the epithelial lining of the urogenital sinus. The Cowper's glands, also called bulbourethral glands, are situated above the bulb and placed behind and lateral to the membranous portion of the urethra. Each gland is about the size of a pea. An abscess of one of these glands may rupture into the urethra, and
33
GIANT URETHRAL CALCULUS
if the walls fail to collapse may easily result in a pre-formed cavity resembling a false diverticulum. If in such a pre-formed cavity a small stone were caught, it may have caused hematuria on its descent either through the ureter or through the prostatic and membranous part of the urethra, until its arrival. There it may have lain dormant for many years, without causing any trouble at all to the patient. Only after the stone had grown to considerable size would symptoms of incomplete urinary obstruction develop. On the roentgenogram taken after thixokon was injected in the urethra, one can observe that a normal cavernous urethra is present and that a large pouch, including the stone, had developed at the site where otherwise the Cowper's glands are found, namely, between the terminal site of the membranous part of the urethra and the beginning of the bulbous part of the cavernous urethra, about 2.5 cm. anterior to the urogenital diaphragm. The roentgenogram of the abdomen shows multiple radiopaque shadows in the left kidney.
Intravenous pyelographic studies revealed the same shadows in the left kidney pelvis and calyces. In the 5 minute intravenous pyelogram (fig. 2), a slight trickle of contrast fluid is visualized in the upper portion of the left ureter. Intravenous pyelograms taken after 5, 15 and 30 minutes showed essentially normal right pelvis and right ureter (fig. 2, 5 minute pyelogram). Apparently the early established frequency of urination prevented a damaging increase of back pressure. Because of their probable existence over many years, in this 70-year-olcl man, removal of the left kidney calculi could hardly be expected to restore left renal function. SUMMARY
In a 70-year-olcl Negro a giant urethral calculus was found. Except for one clay of hematuria at the onset, through nearly 22 years it never caused alarming discomfort to the patient. The possibility that this giant calculus could have lodged and grown in size in a pre-formed urethral diverticulum is discussed.
Vol. 80, No. 1, July 1958 Printed in U.S.A.
GIANT URETHRAL CALCULUS: A CASE REPORT L. F. VON P. VANDERHORST From the Surgical Service, Winter Veterans Administration Hospital, Topeka, Kansas A 70-year-old Negro stated that22 years earlier, without preceding pain, he suddenly noticed blood in the urine, which lasted one day. He gave no history of venereal disease. About one month later, though there was free urinary passage, he had mild pain in the groin, never in the flank nor in the perineum. The pain lasted about· one week, and has never recurred. Some years later he noticed that he urinated more often, because of what he described as a "feeling of a full bladder." Gradually he acquired a regimen of hourly voiding, with nocturia at intervals of one to two hours. About one month prior to hospitalization, he accidentally palpated a hard lump in his perineum and discovered that by shifting this lump sidewise the urinary current became stronger. Intermittently he noticed blood in the urine but did not seek medical advice or treatment. About one week prior to hospitalization persistent fever with chills developed, and the patient finally sought help. He was emaciated and appeared acutely ill, with fever and tachycardia. A hard mass measuring about 2 by 5 cm. was palpated under the raphe of the perineum. This mass could be shifted to either side. The prostate· was essentially normal. The hemoglobin was 14.7 gm. per cent, the hematocrit 44 per cent. Initial urines were grossly bloody and pyuric. The chest x-ray was essentially normal. On x-ray of the pelvis, a radiopaque density was discovered which was situated between the ischiopubic arches and therefore outside of the urinary bladder and below the prostatic region (fig. 1, A). On passing of a metal sound through the urethra, the tip of the sound made a scraping encounter with the mass in the perineum. Roentgen film after intraurethral injection of thixokon showed a calculus lying in a pouch of the membranous portion of the urethra (fig. 1, B). Abdominal and intravenous pyelographic studies revealed calculi in the left, very poorly functioning kidney with essentially normal right kidney and ureter (fig. 2). Fever and pyuria were controlled with antibiotic therapy, after which an external, 3 cm. Accepted for publication December 19, 1957. 31
long urethrotomy was done. The stone was readily developed with a stone forceps. After a No. 24 sound was easily passed, an indwelling catheter was threaded through the urethra into the bladder. The perinea! wound was closed. Eight days postoperatively, the perinea! wound had healed by primary union. DISCUSSION
A calculus in the male urethra is not rare. Any small concrement passing through the urogenital tract, if not readily passed in the urinary stream, may be caught either in the ureteral or in the urethral structures. A pea-sized calculus lodged in the urethra can cause complete urinary block and therefore bring the patient at an early stage to the physician. Usually the calculus is caught at the posterior entrance of a urethral stricture. During 11 years spent in practice in the tropical Netherlands' East Indies, where I found an unusually high incidence of calculi of the urinary tract, I never encountered a urinary calculus in the urethra of the size of the one which is here presented. Because of its size and presence over many years, without causing too much discomfort to the patient, the question arises how it was possible that such a large calculus could develop over the course of years if it had started with a small concrement passed through the ureter, and halted in the urethra on its passage to the outside world. Neither in the patient's history nor at examination was there found indication of stricture. Presumably in 1935, a small calculus could have lodged in a pre-formed cavity of the urethra and gone unnoticed while it gradually increased in size by layers of sediment deposited from the urinary fluid, as evidenced by x-ray studies of the calculus (fig. 3). In females, sac-like protrusions or pockets of the urethra, also called diverticula, are far from common. It is of little importance to the clinician to determine whether the diverticulum is a true or a false one. The true diverticula have all the structural layers of the urethra, including epithelium; the false ones show absence of one or more urethral layers.
32
L. F. VON P. VANDERHORST
Fm. 1. ~' a~ter?p.ost~rior flat.film of_pelvis with sto11;e between ischiopubic arches. B, oblique flat film of pelvis with m3ect10n of thixokon m urethra, showmg large calculus in membranous portion.
Fm. 2. Intravenous pyelogram after 5 minutes shows calculi in left kidney as previously noted on plain roentgenogram. Dye is seen in upper part of left ureter, in normal right kidney pelvis and calyces, and in right half of bladder. Menville and Mitchell,* at Louisiana Charity Hospital, found in 500,000 female admissions, 13 cases of diverticulum of the urethra ranging between the ages of 26 and 69 years, with an average of 38.8 years, more common among Negroes than whites. Though rare in the female urethra, diverticula are even more rare in the male urethra. I could not find any statistics about their occurrence. In the male, congenital diverticulum is attributed
* Cited in Herbut, P.A.: Urological Pathology. Philadelphia: Lea and Febiger, 1952, p. 47.
FIG. 3. Giant urethral calculus after removal, and roentgenogram of laminated urethral calculus, without foreign body nucleus. to faulty union of the embryonic urethral folds or to an abnormal canalization of the epithelial tissue which forms Cowper's gland, situated at the bulb, the posterior part of the corpus cavernosum urethrae. The bulbar urethral glands of Cowper in the male are homologous with the Bartholin glands in the female, which also arise as diverticula from the epithelial lining of the urogenital sinus. The Cowper's glands, also called bulbourethral glands, are situated above the bulb and placed behind and lateral to the membranous portion of the urethra. Each gland is about the size of a pea. An abscess of one of these glands may rupture into the urethra, and
33
GIANT URETHRAL CALCULUS
if the walls fail to collapse may easily result in a pre-formed cavity resembling a false diverticulum. If in such a pre-formed cavity a small stone were caught, it may have caused hematuria on its descent either through the ureter or through the prostatic and membranous part of the urethra, until its arrival. There it may have lain dormant for many years, without causing any trouble at all to the patient. Only after the stone had grown to considerable size would symptoms of incomplete urinary obstruction develop. On the roentgenogram taken after thixokon was injected in the urethra, one can observe that a normal cavernous urethra is present and that a large pouch, including the stone, had developed at the site where otherwise the Cowper's glands are found, namely, between the terminal site of the membranous part of the urethra and the beginning of the bulbous part of the cavernous urethra, about 2.5 cm. anterior to the urogenital diaphragm. The roentgenogram of the abdomen shows multiple radiopaque shadows in the left kidney.
Intravenous pyelographic studies revealed the same shadows in the left kidney pelvis and calyces. In the 5 minute intravenous pyelogram (fig. 2), a slight trickle of contrast fluid is visualized in the upper portion of the left ureter. Intravenous pyelograms taken after 5, 15 and 30 minutes showed essentially normal right pelvis and right ureter (fig. 2, 5 minute pyelogram). Apparently the early established frequency of urination prevented a damaging increase of back pressure. Because of their probable existence over many years, in this 70-year-olcl man, removal of the left kidney calculi could hardly be expected to restore left renal function. SUMMARY
In a 70-year-olcl Negro a giant urethral calculus was found. Except for one clay of hematuria at the onset, through nearly 22 years it never caused alarming discomfort to the patient. The possibility that this giant calculus could have lodged and grown in size in a pre-formed urethral diverticulum is discussed.