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Urethral calculi in children
Urethral
Calculi
in Children
By A. Bedii Salman Erzurum, Turkey l Sixty patients diagnosed to have urethral calculi in Diyarbakir State Hospital Department of Pediatric S,urgery were evaluated retrospectively to determine factors influencing the clinical picture and treatment. All the patients were boys. Pain in the penis and retracting of the penis by the patient himself were most common symptoms. The patients with posterior urethral calculi had continuous urinary dribbling, and those with anterior urethral calculi had acute urinary retention. At the time of initial admittance, the calculi were posterior urethral in 10 cases, bulbous in 13, penile in 20, and external urethral meatal in 17. The 10 calculi located in the posterior urethra and four located in the bulbous urethra were manipulated retrogradely into the bladder. Forty-two calculi were extracted through the external urethral meatus. However, a calculus required urethrotomy, and other calculi required extraction trough a urethracutaneous fistula. The mode of clinical presentation and treatment in children with urinary calculi depends on localization. Localization is determined by the shape and diameter of the calculi. Copyright o 1996 by W.B. Saunders Company
INDEX
WORDS:
Urethral
calculi.
LTHOUGH the incidence of pediatric urethral stone disease is particularly low in well-developed countries, the results of many epidemiological studies have shown the existence of well-defined areas of the world in which either upper or lower urinary tract stones predominate.‘.* Urinary calculi is still a common pediatric surgical problem in Turkey.3-5 It has been suggested that urinary calculi may be related to hygiene, diet, habit of water drinking, and long-lasting diarrhea.‘13 Although urethral calculus is an important surgical problem in the same parts of the world among children, it has not been thoroughly evaluated in the literature. Therefore, a retrospective clinical analysis was performed to determine the factors that influence clinical presentation and treatment among children diagnosed as having urethral calculi.
A
MATERIALS
AND METHODS
During a j-year period (1989 and 1994), 60 children diagnosed to have urethral calculi in the Department of Pediatric Surgery, Diyarbakir State Hospital, were evaluated retrospectively. The diagnosis of urethral calculi was based on palpation and radiological examination. Posterior urethral calculi initially were manipulated into the bladder, preceded by suprapubic emptying of the bladder. For retrograde manipulation, the urethra was forcedly irrigated by liquid Vaseline. Calculi with bulbous and penile locations underwent observation. Observation included hospitalization with intravenous fluids. Additionally, a urethral catheter was used to dislodge the calculi by gentle manipulation and to lubricate the urethral surface with liquid Vaseline. The urethral catheter was JournalofPediatric
Surgery,
Vol31,
No 10 (October),
1996: pp 1379-1382
not passed into the bladder, and suprapubic aspiration was not performed. The duration of observation was 4 hours. Age, gender, signs and symptoms, diagnostic and therapeutic approaches, and outcome were evaluated from the hospital records.
RESULTS
All 60 children were boys. Four children were younger than 1 year of age (7, 8, 9, and 10 months old). Forty-three were younger than 5 years of age (72%) (Fig 1). The most common symptoms, which were encountered in all cases, were penile pain and retracting of the penis by the patient himself. Other associated symptoms were acute urinary retention (47 cases; 78%) and continuous dribbling of urine (12 cases; 22%).
The physical examination showed globe vesicalis in 54 patients (90%). The presence of calculi in the external urethral meatus was visible in 17 patients. A patient with penile urethral calculi also had a complicating urethracutaneous fistula. All 32 penile and bulbous calculi were palpable. Two of the 10 calculi located in the posterior urethra were not palpable via either the perineal or the rectal route. Initial direct radiographs demonstrated the calculi in 52 patients. Because of the density of calculi, the location behind the image of glans penis failed to show the calculi in six patients. However, the oblique radiographs demonstrated the calculi. Only two calculi were radiolucent. The location of calculi at the time of initial diagnosis was posterior urethral in 10 cases (17%), bulbous urethral in 13 (22%), penile urethral in 20 (33%), and external urethral meatal in 17 (28%) (Figs 2 and 3). Acute retention was observed in children who had anterior urethral calculi. However, the calcuii located in the posterior urethra resulted in continuous dribbling of urine. The dribbling was encountered among 10 posterior, one bulbous, and one penile urethral calculi. The diameters of the calculi differed according to the location at the time of initial admittance. While
From the Department of Pediatric Surgery, Ataturk University, Faculty of Medicine, Erzurum, Turkey. Address reprint requests to A. Bedii Salman, A?D, Cocuk Cerrahi A.B.D., Ataturk Universitesi Tip Fakultesi, Erzurum 25240, Turkey, Copyright o 1996 by JKB. Saunders Company 0022-3468196/3110-0011$03.00/O 1379
1380
A. BEDII SALMAN
Number
of patients
11 10 9 8 7 6 5 4 3 2 1 0
1
2
Fig 1.
3
4
5
Age distribution
6
7
8
of children
9
with
10
11
urethral
12
13 14 15 Age (years)
calculi.
the posterior urethral calculi were larger than 6 mm in diameter (8.5 k 2.1 mm), the bulbous (6.5 -+ 1.2 mm), penile (5 k 0.8 mm), and external urethral meatal (4 + 0.6 mm) calculi usually were smaller than 6 mm in diameter. However, the diameters and the shape of the calculi varied greatly. Retrograde manipulation has been successful in nine patients with posterior urethral calculi. The remaining patient in this group underwent open cystotomy with retrograde manipulation, using a metal sound combined with digital rectal manipulation. Among the 13 bulbous urethral calculi, nine moved
Fig 2.
Calculus
located
in posterior
urethra.
Fig 3.
Calculus
located
in penile
urethra.
distally. Three of them were extracted spontaneously, and six moved distally but lodged in the external urethral meatus. The remaining four calculi required the same regimen used for posterior urethral calculi. After the 4-hour observation period, seven of penile calculi extracted spontaneously. Nine calculi moved distally and lodged in the external meatus. One calculus was removed from the urethrocutaneous fistula, which subsequently necessitated surgical treatment. Another patient with impacted penile urethral calculi required urethrotomy. Two patients refused treatment. The external urethral meatal calculi were removed in accordance with their diameter and shape. It was possible to grasp and extract 12 calculi that were in this location at the time of initial admittance and 10 of those that moved to this location during the observation period. However, five patients with external meatus as the initial location and 5 with this as the secondary location required meatotomy for extraction. Biochemical analyses of stones were available for 12 patients. All the calculi were composed of magnesium ammonium phosphate and calcium phosphate (triple phosphate). Urinary tract infection was detected in all patients. Although no patient had an anomaly of the urinary tract, any metabolic disorder, or previous urethral trauma, five patients (8%) had additional calculi with renal pelvic (1) or vesical locations (4).
URETHRAL
CALCULI
1381
DISCUSSION
Lower urinary tract calculi, which was common throughout the world in the nineteenth century, is still a common problem in some developing countries. Although the exact cause is not known, the presence of varying degrees of malnutrition or undernutrition, especially lack of protein and of sulfur-containing amino acids, resulting from low economic status among rural people suggests some dietary and hygienic factors.1s6%7Additionally, restriction of fluid intake, sweating, and diarrhea1 disease may play a part in the ethiopathogenesis.3 Most calculi encountered in developing countries are composed of triple phosphate. Although dietary and hygienic factors are commonly proposed, triple-phosphate calculi have been suggested to be a separate entity of stone disease that might be a complication of urinary tract infection with urea-splitting bacteria.8 All urethral calculi in the present series were encountered in boys. 9~0Because water drinking, diet, and hygiene do not differ according to gender and because no urinary tract abnormality, metabolic disorder, or previous trauma” was detected and urinary tract infection was common, some other factor(s) must be responsible for this gender preponderance. Toilets in this part of Turkey are different than in Western countries. They are at the base level, without any place to sit. Females micturate in a squatting position, and males stand. This difference in position may be related to the development of bladder stones and subsequent urethral location. Because urinary tract infection is encountered more frequently among boys under 5 years of age, the triple-phosphate calculus is suggested to be more common among boys.*J2 Additionally, the anatomic differences between the male and female urethra also may influence the urethral impaction of calculi. The most common symptoms of urethral calculi among the patients in the present series were penile pain and retracting of the penis by the patient. Acute urinary retention and urinary dribbling differ according to the location of the calculi. The incidence of acute retention in children is reportedly higher than in adults.13J4
The location of the calculus depends largely on its diameter and shape. Larger calculi tend to be located in the posterior and bulbous urethra, and smaller calculi impact distally. The larger calculus in the proximal urethra does not cause acute retention, and some urine passes around it, causing continuous dribbling. However, the smaller calculus tends to impact the distal urethra totally and results in acute urinary retention. In the presence of this classical clinical presentation, the diagnosis of urethral calculus should be suspected. Examination of the external urethral meatus and palpation of the entire urethra (including digital rectal route) usually reveal the location of the calculi. Plain radiographs are necessary to confirm the diagnosis and to evaluate the presence of additional radio-opaque calculi. Oblique radiographs are more valuable.9J4J5 Treatment varies according to location. Because the posterior urethral calculi are larger, they should be manipulated retrogradely into the bladder. For retrograde manipulation, emptying the bladder is essential. Bulbous and penile urethral calculi may move distally, with increasing retrograde pressure owing to urine, and lubricating the distal urethra may be helpful. Therefore, a period of observation is necessary. If the impacted calculus does not move distally or maneuvers of retrograde manipulation do not help, urethrotomy might be necessary. However, once the calculus moves distally to the bulbous urethra, the need for urethrotomy usually will be minimal. If the extraction of external urethral meatal calculi carries a risk of damage, meatotomy should be performed. The clinical symptoms and treatment of urethral calculi in children depend largely on the location, the diameter, and the shape.
ACKNOWLEDGMENT’ The author
thanks
F. Cahit
Tanyel
for reviewing
the manuscript.
REFERENCES 1. Koga S, Arakaki Ural 65:288-289,199O
Y, Matsuoka
M, et al: Urethral
calculi.
Br J
2. Sutor DJ, Wooley SE, Illingworth JJ: A geographical and historical survey of the composition of urinary stones. Br J Ural 46:393-407,1974
3. Tellaloglu 26:51-60.
1984
S, Ander
H: Stones
in children.
Turk
J Pediatr
4. Gursel AE: Une etude sur les lithiasis urinaires en Turquie. J Urologique 42:447, 1936 5. Eckstein HB: Endemic urinary lithiasis in Turkish children. Arch Dis Child 36:137, 1961 6. Valyasevi A, Van Reen R: Pediatric bladder stone disease; current status of research. J Pediatr 72:546-553, 1968 7. Churchill DN, Maloney CM, Nolan R, et al: Pediatric urolithiasis in the 1970s. J Ural 123:237-2381980
1382
8. Scholten HG, Bakker NJ, Cornil C: Urolithiasis in childhood. J Urol109:744-745,1973 9. Amin HA: Urethral calculi. Br J Urol45:192-199,1973 10. Sharfi AR: Presentation and management of urethral calculi. Br J Urol68:271-272,199l 11. Giindogdu H, Tanyel FC, Btiyiikpamukcu N, et al: Primary realignment of posterior urethral ruptures in children. Br J Urol 65:650-652,199O
A. BEDII SALMAN
12. Hodgkinson A: Composition of urinary tract calculi in children of different ages. Br J Urol49:453-455, 1977 13. Selli C, Barbagli G, Carini M, et al: Treatment of male urethral calculi. J Urol132:37-39, 1984 14. Paulk SC, Khan AU, Malek RS, et al: Urethral calculi. J Urol116:436-439,1976 1.5. Bridges CH, Belville WD, Buck AS, et al: Urethral calculi. J Urol128:1036-1037, 1982
Calculi
in Children
By A. Bedii Salman Erzurum, Turkey l Sixty patients diagnosed to have urethral calculi in Diyarbakir State Hospital Department of Pediatric S,urgery were evaluated retrospectively to determine factors influencing the clinical picture and treatment. All the patients were boys. Pain in the penis and retracting of the penis by the patient himself were most common symptoms. The patients with posterior urethral calculi had continuous urinary dribbling, and those with anterior urethral calculi had acute urinary retention. At the time of initial admittance, the calculi were posterior urethral in 10 cases, bulbous in 13, penile in 20, and external urethral meatal in 17. The 10 calculi located in the posterior urethra and four located in the bulbous urethra were manipulated retrogradely into the bladder. Forty-two calculi were extracted through the external urethral meatus. However, a calculus required urethrotomy, and other calculi required extraction trough a urethracutaneous fistula. The mode of clinical presentation and treatment in children with urinary calculi depends on localization. Localization is determined by the shape and diameter of the calculi. Copyright o 1996 by W.B. Saunders Company
INDEX
WORDS:
Urethral
calculi.
LTHOUGH the incidence of pediatric urethral stone disease is particularly low in well-developed countries, the results of many epidemiological studies have shown the existence of well-defined areas of the world in which either upper or lower urinary tract stones predominate.‘.* Urinary calculi is still a common pediatric surgical problem in Turkey.3-5 It has been suggested that urinary calculi may be related to hygiene, diet, habit of water drinking, and long-lasting diarrhea.‘13 Although urethral calculus is an important surgical problem in the same parts of the world among children, it has not been thoroughly evaluated in the literature. Therefore, a retrospective clinical analysis was performed to determine the factors that influence clinical presentation and treatment among children diagnosed as having urethral calculi.
A
MATERIALS
AND METHODS
During a j-year period (1989 and 1994), 60 children diagnosed to have urethral calculi in the Department of Pediatric Surgery, Diyarbakir State Hospital, were evaluated retrospectively. The diagnosis of urethral calculi was based on palpation and radiological examination. Posterior urethral calculi initially were manipulated into the bladder, preceded by suprapubic emptying of the bladder. For retrograde manipulation, the urethra was forcedly irrigated by liquid Vaseline. Calculi with bulbous and penile locations underwent observation. Observation included hospitalization with intravenous fluids. Additionally, a urethral catheter was used to dislodge the calculi by gentle manipulation and to lubricate the urethral surface with liquid Vaseline. The urethral catheter was JournalofPediatric
Surgery,
Vol31,
No 10 (October),
1996: pp 1379-1382
not passed into the bladder, and suprapubic aspiration was not performed. The duration of observation was 4 hours. Age, gender, signs and symptoms, diagnostic and therapeutic approaches, and outcome were evaluated from the hospital records.
RESULTS
All 60 children were boys. Four children were younger than 1 year of age (7, 8, 9, and 10 months old). Forty-three were younger than 5 years of age (72%) (Fig 1). The most common symptoms, which were encountered in all cases, were penile pain and retracting of the penis by the patient himself. Other associated symptoms were acute urinary retention (47 cases; 78%) and continuous dribbling of urine (12 cases; 22%).
The physical examination showed globe vesicalis in 54 patients (90%). The presence of calculi in the external urethral meatus was visible in 17 patients. A patient with penile urethral calculi also had a complicating urethracutaneous fistula. All 32 penile and bulbous calculi were palpable. Two of the 10 calculi located in the posterior urethra were not palpable via either the perineal or the rectal route. Initial direct radiographs demonstrated the calculi in 52 patients. Because of the density of calculi, the location behind the image of glans penis failed to show the calculi in six patients. However, the oblique radiographs demonstrated the calculi. Only two calculi were radiolucent. The location of calculi at the time of initial diagnosis was posterior urethral in 10 cases (17%), bulbous urethral in 13 (22%), penile urethral in 20 (33%), and external urethral meatal in 17 (28%) (Figs 2 and 3). Acute retention was observed in children who had anterior urethral calculi. However, the calcuii located in the posterior urethra resulted in continuous dribbling of urine. The dribbling was encountered among 10 posterior, one bulbous, and one penile urethral calculi. The diameters of the calculi differed according to the location at the time of initial admittance. While
From the Department of Pediatric Surgery, Ataturk University, Faculty of Medicine, Erzurum, Turkey. Address reprint requests to A. Bedii Salman, A?D, Cocuk Cerrahi A.B.D., Ataturk Universitesi Tip Fakultesi, Erzurum 25240, Turkey, Copyright o 1996 by JKB. Saunders Company 0022-3468196/3110-0011$03.00/O 1379
1380
A. BEDII SALMAN
Number
of patients
11 10 9 8 7 6 5 4 3 2 1 0
1
2
Fig 1.
3
4
5
Age distribution
6
7
8
of children
9
with
10
11
urethral
12
13 14 15 Age (years)
calculi.
the posterior urethral calculi were larger than 6 mm in diameter (8.5 k 2.1 mm), the bulbous (6.5 -+ 1.2 mm), penile (5 k 0.8 mm), and external urethral meatal (4 + 0.6 mm) calculi usually were smaller than 6 mm in diameter. However, the diameters and the shape of the calculi varied greatly. Retrograde manipulation has been successful in nine patients with posterior urethral calculi. The remaining patient in this group underwent open cystotomy with retrograde manipulation, using a metal sound combined with digital rectal manipulation. Among the 13 bulbous urethral calculi, nine moved
Fig 2.
Calculus
located
in posterior
urethra.
Fig 3.
Calculus
located
in penile
urethra.
distally. Three of them were extracted spontaneously, and six moved distally but lodged in the external urethral meatus. The remaining four calculi required the same regimen used for posterior urethral calculi. After the 4-hour observation period, seven of penile calculi extracted spontaneously. Nine calculi moved distally and lodged in the external meatus. One calculus was removed from the urethrocutaneous fistula, which subsequently necessitated surgical treatment. Another patient with impacted penile urethral calculi required urethrotomy. Two patients refused treatment. The external urethral meatal calculi were removed in accordance with their diameter and shape. It was possible to grasp and extract 12 calculi that were in this location at the time of initial admittance and 10 of those that moved to this location during the observation period. However, five patients with external meatus as the initial location and 5 with this as the secondary location required meatotomy for extraction. Biochemical analyses of stones were available for 12 patients. All the calculi were composed of magnesium ammonium phosphate and calcium phosphate (triple phosphate). Urinary tract infection was detected in all patients. Although no patient had an anomaly of the urinary tract, any metabolic disorder, or previous urethral trauma, five patients (8%) had additional calculi with renal pelvic (1) or vesical locations (4).
URETHRAL
CALCULI
1381
DISCUSSION
Lower urinary tract calculi, which was common throughout the world in the nineteenth century, is still a common problem in some developing countries. Although the exact cause is not known, the presence of varying degrees of malnutrition or undernutrition, especially lack of protein and of sulfur-containing amino acids, resulting from low economic status among rural people suggests some dietary and hygienic factors.1s6%7Additionally, restriction of fluid intake, sweating, and diarrhea1 disease may play a part in the ethiopathogenesis.3 Most calculi encountered in developing countries are composed of triple phosphate. Although dietary and hygienic factors are commonly proposed, triple-phosphate calculi have been suggested to be a separate entity of stone disease that might be a complication of urinary tract infection with urea-splitting bacteria.8 All urethral calculi in the present series were encountered in boys. 9~0Because water drinking, diet, and hygiene do not differ according to gender and because no urinary tract abnormality, metabolic disorder, or previous trauma” was detected and urinary tract infection was common, some other factor(s) must be responsible for this gender preponderance. Toilets in this part of Turkey are different than in Western countries. They are at the base level, without any place to sit. Females micturate in a squatting position, and males stand. This difference in position may be related to the development of bladder stones and subsequent urethral location. Because urinary tract infection is encountered more frequently among boys under 5 years of age, the triple-phosphate calculus is suggested to be more common among boys.*J2 Additionally, the anatomic differences between the male and female urethra also may influence the urethral impaction of calculi. The most common symptoms of urethral calculi among the patients in the present series were penile pain and retracting of the penis by the patient. Acute urinary retention and urinary dribbling differ according to the location of the calculi. The incidence of acute retention in children is reportedly higher than in adults.13J4
The location of the calculus depends largely on its diameter and shape. Larger calculi tend to be located in the posterior and bulbous urethra, and smaller calculi impact distally. The larger calculus in the proximal urethra does not cause acute retention, and some urine passes around it, causing continuous dribbling. However, the smaller calculus tends to impact the distal urethra totally and results in acute urinary retention. In the presence of this classical clinical presentation, the diagnosis of urethral calculus should be suspected. Examination of the external urethral meatus and palpation of the entire urethra (including digital rectal route) usually reveal the location of the calculi. Plain radiographs are necessary to confirm the diagnosis and to evaluate the presence of additional radio-opaque calculi. Oblique radiographs are more valuable.9J4J5 Treatment varies according to location. Because the posterior urethral calculi are larger, they should be manipulated retrogradely into the bladder. For retrograde manipulation, emptying the bladder is essential. Bulbous and penile urethral calculi may move distally, with increasing retrograde pressure owing to urine, and lubricating the distal urethra may be helpful. Therefore, a period of observation is necessary. If the impacted calculus does not move distally or maneuvers of retrograde manipulation do not help, urethrotomy might be necessary. However, once the calculus moves distally to the bulbous urethra, the need for urethrotomy usually will be minimal. If the extraction of external urethral meatal calculi carries a risk of damage, meatotomy should be performed. The clinical symptoms and treatment of urethral calculi in children depend largely on the location, the diameter, and the shape.
ACKNOWLEDGMENT’ The author
thanks
F. Cahit
Tanyel
for reviewing
the manuscript.
REFERENCES 1. Koga S, Arakaki Ural 65:288-289,199O
Y, Matsuoka
M, et al: Urethral
calculi.
Br J
2. Sutor DJ, Wooley SE, Illingworth JJ: A geographical and historical survey of the composition of urinary stones. Br J Ural 46:393-407,1974
3. Tellaloglu 26:51-60.
1984
S, Ander
H: Stones
in children.
Turk
J Pediatr
4. Gursel AE: Une etude sur les lithiasis urinaires en Turquie. J Urologique 42:447, 1936 5. Eckstein HB: Endemic urinary lithiasis in Turkish children. Arch Dis Child 36:137, 1961 6. Valyasevi A, Van Reen R: Pediatric bladder stone disease; current status of research. J Pediatr 72:546-553, 1968 7. Churchill DN, Maloney CM, Nolan R, et al: Pediatric urolithiasis in the 1970s. J Ural 123:237-2381980
1382
8. Scholten HG, Bakker NJ, Cornil C: Urolithiasis in childhood. J Urol109:744-745,1973 9. Amin HA: Urethral calculi. Br J Urol45:192-199,1973 10. Sharfi AR: Presentation and management of urethral calculi. Br J Urol68:271-272,199l 11. Giindogdu H, Tanyel FC, Btiyiikpamukcu N, et al: Primary realignment of posterior urethral ruptures in children. Br J Urol 65:650-652,199O
A. BEDII SALMAN
12. Hodgkinson A: Composition of urinary tract calculi in children of different ages. Br J Urol49:453-455, 1977 13. Selli C, Barbagli G, Carini M, et al: Treatment of male urethral calculi. J Urol132:37-39, 1984 14. Paulk SC, Khan AU, Malek RS, et al: Urethral calculi. J Urol116:436-439,1976 1.5. Bridges CH, Belville WD, Buck AS, et al: Urethral calculi. J Urol128:1036-1037, 1982