Giant urethral calculus: A rare cause of acute urinary retention

Giant urethral calculus: A rare cause of acute urinary retention

The Journal of Emergency Medicine, Vol 14, No 6, pp 707 -709, 1996 Copyright 0 1996 Elsewer Science Inc. Printed in the USA. All tights resewed 0716.4...

1MB Sizes 0 Downloads 63 Views

The Journal of Emergency Medicine, Vol 14, No 6, pp 707 -709, 1996 Copyright 0 1996 Elsewer Science Inc. Printed in the USA. All tights resewed 0716.46791%


* .a0

PI1 SO736-4679(96) 00180-l



and Jim Edward Weber, Dot

*Department of Emergency Medicine, Mercy Hospital of Pittsburgh, Center for Emergency Medicine of Western Pennsylvania, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and tSection of Emergency Medicine, Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan Reprint Address: G. Luke Larkin, MD, MS, MSPH, FACEP, Department of Emergency Medicine, Mercy Hospital of Pittsburgh, 1400 Locust Street, Pittsburgh, PA 15219

0 Abstract-We present a caseof a 9%yr-old woman with acute &nary retention secondary to a large urethral calculus. This is a unique cause of obstructive uropathy for several rctasom First, urethral calculi are extremely rare in AmericaR-born Caucasian females. second, urethral stones in females are nearly always associated with underlying ge14tom%ary pathoIogy; however, subsequent work up failed to reveal any strictures, diverticul~ or related proceplpesthat may have prediiposed this patient to urethral 6zaldus form&m. The epidemiology, pathogenesis,clhdcal pand emergency management of large urethral cakxdi are reviewed. 0 1996 Elsevier Science Inc. El Keywords-urethral

CASE REPORT A 9%yr-old female nursing home resident presentedto the emergencydepartment(ED) complaining of perineal and lower abdominal pain, with inability to void for the previous 36 h. Pasthistory was remarkablefor genitourinary tuberculosis, ureterolithiasis, endometrial carcinoma, and a radical hysterectomy. On arrival to the ED, the vital signs were blood pressure of 132/76 mmHg, pulse of 102 beats/min, respiratory rate of 18 breaths/mm, and temperature of 38°C. Physical examination revealedan elderly but alert woman in moderate distress. Abdominal examination revealed suprapubictendernessand a palpable bladder 5 cm above the pubic symphysis. Pelvic examination demonstrateda large white stone impacted at the external urethral meatus.The vaginal and rectal examinationswere unremarkable, as was the remainder of the physical examination. The patient had an IV started and was given meperidine 50 mg intravenously. An abdominal flat p&e radiograph confirmed the pxresenmof an opaque mass at the bladder outlet (Figure 1) . Suprapubicpressuremsukedin expulsion of small amountsof blood-tinged foul-smelling urine, followed by delivery of the intact calculus (Figure 2). A complete blood count, blood urea nitrogen, cm&inine, and intravenous pyelogram were al1within normal limits. The urinalysis was positive for numerous white and red blood cells, protein, leukocyte estemee,and mixed flora on Gram’s stain. A urine culture was sent,

calculi; acute urinary retention

INTRODUCTION Patients with acute urinary retention routinely seek emergency care becauseof suprapubic discomfort, urinary dribbling, severe urinary frequency, or inability to void. Common causes of obstructive uropathy are numerous (Table 1) and are dependent on the age, sex, and underlying health of the patient. Although rare, acute urinary retention from a urethral calculus may occur. If mismanaged, severe bladder outlet obstruction may ensue, resulting in urethral stricture formation and long-term urinary dysfunction. RECEIVED: ACCEPTED

30 June 1995; 1 May 1996




12 April 1996; 707


G. L. Larkin and J. E. Weber

Table 1. Differential Urinary Retention


of Acute

Gross examination of the stone revealed a coarse, irregularly shapedcalculus weighing 45 g and measuring 46 X 37 X 32 mm. Complete dissection and pathologic evaluation confirmed the absenceof any foreign material. Crystallographic analysis (SmithKline BioScience Laboratories, Norristown, PA) revealed that the stone was comprised of 59% magnesium phosphate hexahydrate (struvite) and 37% calcium carbonate. Urine culture grew mixed flora including Stuphylococcus saprophyticus and Escherichia coli, both of which were sensitive to ciprofloxacin.

Obstructive lesions Prostatic or bladder carcinoma Strictures of the urethra Phimosis Paraphimosis Intentional foreign bodies Clot with hematuria Urethral calculi Neurogenic Cerebrovascular accident Multiple sclerosis Spinal cord trauma Spinal cord tumor Psychiatric Psychological stress Hysterical retention Medications Sympathomimetics Antidepressants Antidysrhythmics Anticholinergics Antiparkinsonian Antipsychotics Antihistamines Antihypettensives Muscle relaxants


and the patient was started on ciprofloxacin, 400 mg intravenously, prior to discharge. The patient was returned to the nursing home with intermittent catheterizationperformed every 8 h. In addition, shewas treatedwith ciprofloxacin 500 mg p.o. BID. Subsequent urologic and cystoscopic evaluation at 10 days after discharge revealed sterile urine and no cystoscopic anatomical or structural abnormalities. The previously dilated urethra returned to neat-normal size within 10 days of her ED presentation.Intermittent catheterization was discontinued after 2 weeks and the patient recovered without complications.

Figure 1.~.Abdominal . ._ mass at the bladder

flat . _plate outlet.



The urethra is probably the rarest site of calculi formation, accounting for fewer than 1% of all urinary calculi ( 1). Of 50,000 urinary stones reported in the largest retrospective series to date, only 0.9% and 0.4% were isolated from the urethra in men and women, respectively ( 1). An analysis of the world literature reveals only five reviews on the subject between 1973 and the present. Of 246 reported cases over the past 20 yrs, only 18 (7.3%) were in women. Globally, the most common causeof urethral calculi is Schistosoma haematobium, accounting for 30% of all reported cases(2). Correspondingly, the incidence of urethral calculi is highest in the Orient and Middle East and is lowest in the United States (3-5). The overall incidence of urethral calculi appears to be on the decline due to improved hygiene and dietary habits. Urethral calculi are generally classified as native (those formed de novo in the urethra) or migratory (those formed in the bladder or kidney with secondarydescent). Most native calculi form in associationwith chronic stasis and urinary infection, either within a urethral diverticu-

radiopaque Figure 2. Calculus


46 x 37 x 32 mm.


Giant Urethral Calculus

lum or proximal to a urethral obstruction ( 1) . In addition, there appearsto be a strong relationship betweende novo stone formation and surgical instrumentation, urethral foreign bodies. and urinary tract pathology (e.g., hypospadias, meatal stenosis, prostate lesions, carcinoma of the bladder, abscesscavities, fistulous tracts, diverticuli, etc.) (4.6-8). The present case is remarkable because neither foreign bodies nor anatomic anomalies were evident after complete pathologic and urologic evaluations. Our patient’s remote history of ureterolithiasis and genitourinary tuberculosis (GU TB ) may have predisposed her to urethral calculi: however, GU TB has not been identified previously as a risk factor for urethral stone formation. De novo urethral calculi are generally composed of magnesium ammonium phosphate (struvite) (3,4). In contrast, migratory stonestypically begin as vesical calculi and are often composed of calcium phosphate or calcium carbonate.Migrant calculi are reported to be at least IO times more common than native calculi (4). Interestingly, the composition of our stone was 57% struvite, making the underlying etiology unclear. The clinical presentationof urethral calculi is variable. Specific signs and symptomsusually dependon the anatomic location of the stone.Anterior urethral stonescause dysuria and may be confirmed by palpation. Posterior urethral calculi may produce pain referred to the rectum or perineum. Calculi in either location may cause acute urinary retention and must be included in the differential diagnosisalong with benign prostatic hypertrophy, tumor, foreign body, stricture, and meatal stenosis. Becauseof the rare nature of urethral calculi, appropriate treatment is not clearly defined. Management varies dependingon the stonesize, anatomiclocation, associated urethral pathology, and underlying patient substrate ( 3,4.9) . Favorableresults havebeenreportedwith noninvasive measuresand surgical intervention. The normal adult urethral caliber of 30F theoretically should allow for free passageof stones10 mm or smaller ( 10). Smaller stones that do not spontaneouslypass may be extracted through the urethral meatus. Proximal calculi may be

amenableto cystoscopicretrogrademanipulation into the bladder. Large calculi may be best removed by operative meatotomy (9). However, surgical managementof large urethral calculi in females is limited to case reports. The overall morbidity for meatotomyis 10% i 11 1.Therefore, urologic consultation is necessarywhen considering this procedure. Potential complications include bleeding, incontinence, impotence, and stricture formation. Attempting to . ‘milk ’ the stoneout of the urethra is inadvisable becauseit may irreparably damagethe delicate urethral epithelium, causing continued pain and long-term stenosis (2-4,8 ). The abrasive surface cbf this stone would have likely traumatized the urethra had it been forcibly removed. If urinary obstruction cannot be relieved promptly, suprapubic bladder drainage should be considered (8). This procedure will permit the clinician to do a more thorough evaluation while promptly alleviating the patient’s pain and anxiety. Indications for admission in patients with a renal or extrarenal calculus include the following: signs of systemic illness such as fever, intractable pain or vomiting, inability to void, or a calculus that is infected or unlikely to pass.In this particular case,once the obstruction was relieved. the patient was treated for a simple, uncomplicated urinary tract infection with parenteral antibiotics. Becauseour patient had none of thesecriteria, admission was not considerednecessary.If dischargeis a consideration, close follow up is necessary,particularly in elderly patients. CONCLUSION Urethral calculi are a rare causeof obstructive uropathy. Clinical symptoms are variable and depend on the anatomical location of the stone. Managementcan be surgical or non-surgical, depending on the size and location of the calculus. If mismanaged,long-term urinary dysfunction can occur; therefore, urethral calculi should be considered in the differential diagnosis of acute urinary retention.

REFERENCES I. Schreyet- H. Treatment of urethra1 stones. In: Schnieder H-J, ed. Urolithiasis: therapy-prevention, vol 17/B, 1st ed. Berlin, Springer-Verlag; 1986:293-6. 2. Shah PJR. Urethral calculi. Arch Ital Urol. 1988;LX:259-64. 3. Paulk S. Khan AU, Malek RS, Green LF. Urethra1 calculi. J Urol. 1975; 116:436-9. 4. Bridges CH, Belville WD, Buck AS, Dresner ML. Urethra1 calculi. Br J Urol. 1982; 12X:1036-7. 5. Koga S, Arakaki Y, Matsuka M, Chyama C. Urethral calculi. Br J Ural. 1990;65:288-9. 6. Dalens B, Vanneuville G, Vincent L, Fabre JL. Congenital polyp

7. 8. 9. IO. I I.

of the posterior urethra and vesical calculus in :i boy. J Ural. 1982:128:1034-5. Ginsberg P, Finkelstein LH. Urethral diverticulum with calculi: report of a case. J Am Osteopath Assoc. 1983;82:588-90. Amin HA. Urethral calculi. Br J Urol. l973:45: 192-9. Sharfi AR. Presentration and management of urethral calculi. Br J Urol. 1991;68:271-2. El-Sheril AE, El-Hafi R. Proposed new method for nonoperative treatment of urethral stones. J Urol. 1991; 346:1546-7. Nesbitt JA. Techniques in urethrotomy. In: Glenn JF. ed. Urologic surgery, 4th ed. Philadelphia: J.B. Lippincott: I991 :702- I I,