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Giant urinary bladder calculi
Clinical Radiology (1985) 36, 313-314 © 1985 Royal College of Radiologists
0009-9260/85/356313502.00
Giant Urinary Bladder Calculi M. H. D A H N I Y A * and L. G O R D O N - H A R R I S
Department of Radiology, Connaught Hospital, Freetown, Sierra Leone
Four patients with giant urinary bladder calculi are presented. All were males with bladder outflow obstruction. The literature on the subject is reviewed.
Grant urinary bladder calculi are rare. Four cases seen over a 10-year period are reported. All were in males and were associated with bladder outlet obstruction. In one case, there was a coexisting bladder carcinoma with skeletal metastases.
CASE REPORTS Case 1. A 70-year-old retired railway worker presented with a 3-year history of dysuria, hesitancy, suprapubic pain and intermittent haematuria. The important physical findings were a moderately. enlarged prostate and a large, stony, hard palpable lower abdominal mass. Haemoglobin was 9g/dl and blood urea 13.2mmol/litre (80 mg/100 ml). The serum calcium was normal. The urine showed numerous pus and red blood cells. A plain radiograph of the abdomen revealed an enormous bladder calculus occupying the pelvis and extending to the lower abdomen (Fig. 1). Thcre was no evidence of excretion of contrast medium on intravenous urography. Considerable difficulty was encountered at surgery, but the calculus was successfully removed with the aid of obstetric forceps. Prostatectomy was performed. The calculus measured 16 cmx9 cm and weighed 1410 g. Case 2. A fisherman aged about 50 years was admitted because of acute retention of urine. He complained of suprapubic discomfort
*Present address: Department of Radiology, University of Maiduguri, Borno State, Nigeria.
and a bulge in the right inguinal region. Physical examination revealed a hard mass in the lower abdomen and an enlarged prostate. His haemoglobin was 12 g/dl and serum urea 8.2 retool/ litre (50 mg/100 ml). Plain abdominal radiography showed two giant bladder calculi, one of which was thought to be in a bladder diverticulum (Fig. 2). This was confirmed at surgery. Intravenous urography showed mild bilateral hydronephrosis and hydroureters. Cystolithotomy and prostatectomy were performed and the bladder diverticulum excised. Recovery was uneventful. The combined weight of the calculi was 1350 g. Case 3. A farmer aged about 60 years presented with severe backache, suprapubic pain and two episodes of frank haematuria. He was ill-looking and showed evidence of recent weight loss. His blood pressure was 180/120mmHg. He had required repeated bouginage in a provincial hospital for urethral stricture. A hard, mobile mass was felt in the suprapubic region. A plain radiograph of the abdomen showed a large bladder calculus (Fig. 3) and osteolytic destruction of the left ischium. An intravenous urogram was abandoned because of a severe hypotensive reaction. The patient died suddenly of a cerebrovascular accident and autopsy showed extensive infiltration of the bladder by carcinoma and a large calculus which weighed 510g. Histological examination showed squamous-cell carcinoma. Case 4. A male, aged 49 ycars, gave a long history of difficulty in passing urine, poor stream and intermittent urethral discharge. Physical examination was normal apart fi-om a slightly distended bladder. Radiography of the pelvis showed a large, segmented bladder calculus, the smaller lower segment forming a cast of the prostatic urethra (Fig. 4). An ascending urethrogram revealed a stricture in the bulbous urethra. He had a successful cystolithotomy, The stricture was treated by bouginage. The calculus weighed 384 g.
DISCUSSION Vesical calculi are usually secondary to obstruction in the lower urinary tract. A few are of renal and ureteric origin, from where they pass into the bladder
Fig. 1 - Case 1. Giant bladder calculus shown on plain abdominal radiograph,
Fig. 2 - Case 2. Plain radiograph of pelvis showing two giant bladder calculi.
314
CLINICAL RADIOLOGY
Fig. 3 - Case 3. Large calculus shown in the pelvis.
lum. One of the two giant calculi in Case 2 was in a diverticulum. The calculus reported by Randall (1921) weighed 1814 g, that ofPowers and Matflerd (1952), 1410g, that of Dorsey (1952), 455g and that of Wenger and Berry (1952), 154 g. The largest calculus in our report (Case 1) weighed 1410 g and the smallest (Case 4), 384 g_ Giant bladder calculi in association with neoplasm of the bladder is extremely rare (Powers and Matflerd, 1952). In the case reported by these authors, the giant calculus was associated with an extensive squamouscell carcinoma of the bladder_ Our third case was also associated with an extensive squamous-cell carcinoma of the bladder and osteolytic metastasis in the pelvis. It is possible that the prolonged irritation caused by the calculus initiated the development of the neoplasm. The importance of lower urinary tract obstruction in the formation of bladder calculi has been emphasised (McKay et al., 1948). The fact that all four of our cases had bladder outlet obstruction, from either an enlarged prostate or a urethral stricture, supports this. Giant bladder calculi are less common in women (Wenger and Berry, 1952). This is probably because outlet obstruction is much less commonly seen in females. Our patients were all males. Bladder calculi can reach enormous sizes before causing symptoms leading to discovery. The associated disease of the urinary tract, present in a high percentage of patients, leads to early diagnosis and removal. In tropical Africa, where bladder outlet obstruction and delay in seeking medical advice are very common, we find it surprising that giant bladder calculi have not been reported more often. Acknowledgements. We thank Mr J. Roxy-Harris and Mr A. B. Kargbo, Senior Consultant Surgeons, for permission to publish Cases 1 and 2, and Miss Harrieth N. Nwalozie for typing the script. REFERENCES
Fig. 4 - C a s e 4. Large segmented calculus shown in lateral view of the pelvis.
(McKay et al., 1948). Giant bladder calculi are rare and, although there are single case reports in the literature, only one case has, as far as we know, been reported from tropical Africa (Owoseni et al., 1978). The largest recorded calculus weighing 6294 g was reported by Arthure in 1953 and this calculus was thought to have been formed in a bladder diverticu-
Arthure, H. (1953). Large abdominal calculus. Journal of Obstetrics and Gynaecology of the British Empire, 60, 416. Dorsey, J. W. (1952). Giant vesical calculus bilateral hydronephrosis. Journal of Urology, 68, 201-205. McKay, H. W., Baird, H. H. & Lynch, K., Jr (1948). Analysis of 200 cases of urinary calculi with particular reference to methods of management of ureteral stones. Journal of the American Medical Association, 137, 225-230. Owoseni, A. A., Osegbe, D. N. & Amaku, E. O. (1978). Giant vesical s t o n e - a surprise operative finding. Nigerian Medical Journal, 8, 64-65. Powers, J. H. & Matflerd, R. G. (1952). Giant vesical calculus and carcinoma of the bladder. Journal of Urology, 67, 184-191. Randall, A. (1921). Giant vesical calculus. Journal of Urology, 5, 119-125. Wenger, D. S. & Berry, C. D. (1952). Giant bladder calculus. United States Armed Forces Medical Journal, 3, 1515-1518.
0009-9260/85/356313502.00
Giant Urinary Bladder Calculi M. H. D A H N I Y A * and L. G O R D O N - H A R R I S
Department of Radiology, Connaught Hospital, Freetown, Sierra Leone
Four patients with giant urinary bladder calculi are presented. All were males with bladder outflow obstruction. The literature on the subject is reviewed.
Grant urinary bladder calculi are rare. Four cases seen over a 10-year period are reported. All were in males and were associated with bladder outlet obstruction. In one case, there was a coexisting bladder carcinoma with skeletal metastases.
CASE REPORTS Case 1. A 70-year-old retired railway worker presented with a 3-year history of dysuria, hesitancy, suprapubic pain and intermittent haematuria. The important physical findings were a moderately. enlarged prostate and a large, stony, hard palpable lower abdominal mass. Haemoglobin was 9g/dl and blood urea 13.2mmol/litre (80 mg/100 ml). The serum calcium was normal. The urine showed numerous pus and red blood cells. A plain radiograph of the abdomen revealed an enormous bladder calculus occupying the pelvis and extending to the lower abdomen (Fig. 1). Thcre was no evidence of excretion of contrast medium on intravenous urography. Considerable difficulty was encountered at surgery, but the calculus was successfully removed with the aid of obstetric forceps. Prostatectomy was performed. The calculus measured 16 cmx9 cm and weighed 1410 g. Case 2. A fisherman aged about 50 years was admitted because of acute retention of urine. He complained of suprapubic discomfort
*Present address: Department of Radiology, University of Maiduguri, Borno State, Nigeria.
and a bulge in the right inguinal region. Physical examination revealed a hard mass in the lower abdomen and an enlarged prostate. His haemoglobin was 12 g/dl and serum urea 8.2 retool/ litre (50 mg/100 ml). Plain abdominal radiography showed two giant bladder calculi, one of which was thought to be in a bladder diverticulum (Fig. 2). This was confirmed at surgery. Intravenous urography showed mild bilateral hydronephrosis and hydroureters. Cystolithotomy and prostatectomy were performed and the bladder diverticulum excised. Recovery was uneventful. The combined weight of the calculi was 1350 g. Case 3. A farmer aged about 60 years presented with severe backache, suprapubic pain and two episodes of frank haematuria. He was ill-looking and showed evidence of recent weight loss. His blood pressure was 180/120mmHg. He had required repeated bouginage in a provincial hospital for urethral stricture. A hard, mobile mass was felt in the suprapubic region. A plain radiograph of the abdomen showed a large bladder calculus (Fig. 3) and osteolytic destruction of the left ischium. An intravenous urogram was abandoned because of a severe hypotensive reaction. The patient died suddenly of a cerebrovascular accident and autopsy showed extensive infiltration of the bladder by carcinoma and a large calculus which weighed 510g. Histological examination showed squamous-cell carcinoma. Case 4. A male, aged 49 ycars, gave a long history of difficulty in passing urine, poor stream and intermittent urethral discharge. Physical examination was normal apart fi-om a slightly distended bladder. Radiography of the pelvis showed a large, segmented bladder calculus, the smaller lower segment forming a cast of the prostatic urethra (Fig. 4). An ascending urethrogram revealed a stricture in the bulbous urethra. He had a successful cystolithotomy, The stricture was treated by bouginage. The calculus weighed 384 g.
DISCUSSION Vesical calculi are usually secondary to obstruction in the lower urinary tract. A few are of renal and ureteric origin, from where they pass into the bladder
Fig. 1 - Case 1. Giant bladder calculus shown on plain abdominal radiograph,
Fig. 2 - Case 2. Plain radiograph of pelvis showing two giant bladder calculi.
314
CLINICAL RADIOLOGY
Fig. 3 - Case 3. Large calculus shown in the pelvis.
lum. One of the two giant calculi in Case 2 was in a diverticulum. The calculus reported by Randall (1921) weighed 1814 g, that ofPowers and Matflerd (1952), 1410g, that of Dorsey (1952), 455g and that of Wenger and Berry (1952), 154 g. The largest calculus in our report (Case 1) weighed 1410 g and the smallest (Case 4), 384 g_ Giant bladder calculi in association with neoplasm of the bladder is extremely rare (Powers and Matflerd, 1952). In the case reported by these authors, the giant calculus was associated with an extensive squamouscell carcinoma of the bladder_ Our third case was also associated with an extensive squamous-cell carcinoma of the bladder and osteolytic metastasis in the pelvis. It is possible that the prolonged irritation caused by the calculus initiated the development of the neoplasm. The importance of lower urinary tract obstruction in the formation of bladder calculi has been emphasised (McKay et al., 1948). The fact that all four of our cases had bladder outlet obstruction, from either an enlarged prostate or a urethral stricture, supports this. Giant bladder calculi are less common in women (Wenger and Berry, 1952). This is probably because outlet obstruction is much less commonly seen in females. Our patients were all males. Bladder calculi can reach enormous sizes before causing symptoms leading to discovery. The associated disease of the urinary tract, present in a high percentage of patients, leads to early diagnosis and removal. In tropical Africa, where bladder outlet obstruction and delay in seeking medical advice are very common, we find it surprising that giant bladder calculi have not been reported more often. Acknowledgements. We thank Mr J. Roxy-Harris and Mr A. B. Kargbo, Senior Consultant Surgeons, for permission to publish Cases 1 and 2, and Miss Harrieth N. Nwalozie for typing the script. REFERENCES
Fig. 4 - C a s e 4. Large segmented calculus shown in lateral view of the pelvis.
(McKay et al., 1948). Giant bladder calculi are rare and, although there are single case reports in the literature, only one case has, as far as we know, been reported from tropical Africa (Owoseni et al., 1978). The largest recorded calculus weighing 6294 g was reported by Arthure in 1953 and this calculus was thought to have been formed in a bladder diverticu-
Arthure, H. (1953). Large abdominal calculus. Journal of Obstetrics and Gynaecology of the British Empire, 60, 416. Dorsey, J. W. (1952). Giant vesical calculus bilateral hydronephrosis. Journal of Urology, 68, 201-205. McKay, H. W., Baird, H. H. & Lynch, K., Jr (1948). Analysis of 200 cases of urinary calculi with particular reference to methods of management of ureteral stones. Journal of the American Medical Association, 137, 225-230. Owoseni, A. A., Osegbe, D. N. & Amaku, E. O. (1978). Giant vesical s t o n e - a surprise operative finding. Nigerian Medical Journal, 8, 64-65. Powers, J. H. & Matflerd, R. G. (1952). Giant vesical calculus and carcinoma of the bladder. Journal of Urology, 67, 184-191. Randall, A. (1921). Giant vesical calculus. Journal of Urology, 5, 119-125. Wenger, D. S. & Berry, C. D. (1952). Giant bladder calculus. United States Armed Forces Medical Journal, 3, 1515-1518.