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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 2  |  Issue : 1  |  Page : 21-23

A female patient with urethral calculus presenting with bladder distention: A case report


1 Department of Radiology, Samsun Gazi State Hospital, Samsun, Turkey
2 Department of Urology, Samsun Gazi State Hospital, Samsun, Turkey
3 Department of Radiology, Ankara Ataturk Education and Research Hospital, Ankara, Turkey
4 Department of Radiology, Ondokuz Mayis University School of Medicine, Samsun, Turkey

Date of Web Publication29-Nov-2014

Correspondence Address:
Tanrivermis Sayit Asli
Department of Radiology, Samsun Gazi State Hospital, Samsun
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2148-7731.145818

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  Abstract 

Urethral calculi are extremely rare, especially in female patients, and usually associated with genitourinary tract abnormalities such as urethral stricture or diverticulum. Primary calculus of the urethra is very rare and usually associated with congenital diverticulum. Secondary urethral calculus, often originate from the kidney or bladder. However, primary calculus of the urethra is very rare and is usually associated with congenital diverticulum. Diagnosis of urethral calculus is difficult due to location, and failure of the diagnosis may cause urethral injury, incontinence or renal insufficiency. Herein, we report the computed tomography, clinical and surgical findings of a urethral calculus in a female patient without any urogenital anomaly.

Keywords: Computed tomography, female, lithotripsy, urethral calculus, urinary retention


How to cite this article:
Asli TS, Bahattin UM, Ilkay IS, Pinar GH. A female patient with urethral calculus presenting with bladder distention: A case report . Sifa Med J 2015;2:21-3

How to cite this URL:
Asli TS, Bahattin UM, Ilkay IS, Pinar GH. A female patient with urethral calculus presenting with bladder distention: A case report . Sifa Med J [serial online] 2015 [cited 2019 Mar 23];2:21-3. Available from: http://www.imjsu.org/text.asp?2015/2/1/21/145818


  Introduction Top


Urethral calculus, is a rare cause of obstructive uropathy that accounts for less than 2% of all urinary tract stones. It is extremely rare, less often in women compared with men. [1] It usually originates from the upper urinary tract or bladder, but can be formed in situ. [2] The presenting symptoms of the urethral calculus are acute retention of urine, perineal and rectal pain, external meatus pain, urethral pain, interrupted stream, weak stream with dribbling and palpable urethral mass. [3],[4] Diagnosis is very difficult due to the location of the calculus. Failure of the diagnosis may cause urethral injury, incontinence or renal insufficiency. [2] Herein, we report the computed tomography (CT), clinical and surgical findings of an urethral calculus in a female patient without any urogenital anomaly.


  Case Report Top


A 56-year-old female patient admitted to urology department, with complaints of dysuria and interrupted urination, which started few days ago. On physical examination, the vital signs were normal but suprapubic tenderness was noticed. Urinalysis showed 4-5 red blood cells and 3-4 white blood cells per high-powered field. Cystitis was primarily considered for the differential diagnosis in the patient without a history of renal colic. So, the patient was referred to our clinic for evaluation of the bladder with urinary tract ultrasonography (US). Under sonographic examination, bladder distention and right mild hydronephrosis were detected. The thickness of bladder wall was normal and there was no pathology in the lumen of the bladder. Subsequently, non-contrast CT was performed and a 14 mm sized calculus was detected in the proximal urethra [Figure 1] and [Figure 2]. A 16 F urethral catheter, was gently inserted into the urethra and pushed the stone back to the urinary bladder without any complications. The urinary culture was negative. On the following day, the calculus was broken with laser lithotripsy under local anesthesia with intravenous sedation and all pieces of the calculus were removed from bladder by cystoscopy. During cystoscopic examination, edema with 5 mm hyperemic area on the left ureteral orifice was identified. The patient was discharged after the cystoscopy procedure without any complication. Fifteen days later, the patient was called for second examination. Transurethral excisional biopsy was taken around the left ureteral orifice due to the persistence of hyperemic areas with papillary projections. The biopsy findings were compatible with inverted papilloma. All symptoms were completely resolved and the laboratory findings were normalized. Three months later, follow-up ultrasound scan showed normal wall thickness of the bladder. Also, annual follow-up cystoscopy is recommended to the patient for the possibility of malignancy.
Figure 1: Axial non-contrast abdomino-pelvic computed tomography showed a well defined, dens calcification in the proximal urethra at the level of the symphysis pubis

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Figure 2: Coronal non-contrast abdomino-pelvic computed tomography revealed 14 mm dense calculi in the proximal urethra

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  Discussion Top


The incidence of a urethral calculus is 0.3% and accounts for approximately 2% of all urinary tract calculi. [2] It is more commonly seen in man due to longer and tortuous urethra and less common in women and children. [5],[6],[7],[8] There are approximately 25 published reports of female patients presenting with urethral calculi in the literature, but most of them are associated with urethral diverticulum. [9] Primary urethral (native) calculus is a rare form of urolithiasis, and often associated with urethral diverticulum, stricture or previous surgery. Secondary (migrating) calculi often originate from kidney or bladder, and were reported to be at least 10 times more common in occurrence than the primary stones. [10],[11] Symptoms of urethral calculus depend on the anatomic location of it. Anterior urethral calculus usually presents with dysuria. However, posterior urethral calculus causes a pain referred to rectum and perineum. [10] Impacted urethral calculus often causes acute urinary retention and hydronephrosis. Physical examination may reveal costovertebral angle tenderness and palpable bladder. [2],[12] Our patient complained about painful and difficult urination, which started a few days ago. The US examination showed bladder distention and grade 1 hydronephrosis of the right kidney. Non-contrast CT showed a 14 mm calculus in the proximal urethra with no associated diverticulum. The absence of urethral anomalies considered a secondary calculus, which might be originated from the kidney or bladder. Although CT is the gold standard, due to its high sensitivity and specificity, for the diagnoses of upper and lower urogenital tract calculi, [2] the initial examinations are plain kidneys, ureters, and bladder x-rays. In addition, US may help in diagnosis for the non-opaque calculi.

Our patient applied to our clinic with interrupted urination and dysuria. The initial clinical diagnosis was cystitis. However, we detected the urethral calculus on the CT examination. The clinical differential diagnoses of urethral calculus include cystitis, pyelonephritis, renal colic, and genitourinary malignancies. In addition, benign prostatic hypertrophy, prostatitis, hemorrhage and genitourinary malignancies should be considered in differential diagnosis in male patients. [2] Routine blood tests, urinalysis and urine culture should be performed in the patients with the symptoms of renal colic. Complications of the urethral obstruction due to calculi are obstructive renal failure, long-term urethral damage, urethrocutaneous fistula and incontinence.

Inverted papilloma is an uncommon tumor of the urinary tract, accounting for about 2.2% of tumors of the urinary system and mostly occur in the lower urinary tract. In general, it is considered to be a benign lesion and has a low recurrence rate; however, malignant changes or concomitant transitiocellular tumor may be ocur. [13],[14] They are typically solitary and rarely may be multiple. Although there are many hypotheses about the pathogenesis of the inverted papilloma, generally chronic irritation and inflammation have been suggested to play a role in the etiology. Urinary cytology, cystoscopy and intravenous pyelogram (IVP) have a low sensitivity and specificity in the definitive diagnosis, whereas histopathologic interpretation is the best for definitive diagnosis. The most common method of treatment is transurethral resection. [15] In our case, the lesion was solitary and approximately 5 mm in diameter and histopathologic diagnosis was benign inverted papilloma. Although the most of the lesions are benign, annual follow-up cystoscopy is recommended for the possibility of malignancy.

The aim of the treatment of urethral calculus is to remove the calculus without any complication and to resolve the obstruction of the urinary tract. Treatment options include pushing the calculus back into the bladder for subsequent electrohydraulic, ultrasonic or laser lithotripsy, in situ lithotripsy and open surgery. [2],[4] Endoscopic push back into the bladder for subsequent lithotripsy is feasible just for posterior urethral calculus, as they tend to be large and close to the bladder. Also success rate for this procedure is 86%. [4] In our case, the calculus was pushed back into the bladder and broken with laser lithotripsy without complication, as it was too close to the bladder. In conclusion, urethral calculi are extremely rare in female patients with no associated genitourinary abnormality. Symptoms like dysuria, hematuria, burning urination and urinary frequency should be considered for lower genitourinary tract pathologies. CT urography is gold standard for early diagnosis of the urethral pathologies. Urethral calculi must be kept in mind in case of female patients, with cystitis like symptoms. Especially, in patients with bladder distention, CT urography should be added for evaluation of urethral calculi to prevent serious long-term urologic complications.

 
  References Top

1.
Maloney ME, Springhart WP, Ekeruo WO, Young MD, Enemchukwu CU, Preminger GM. Ethnic background has minimal impact on the etiology of nephrolithiasis. J Urol 2005;173:2001-4.  Back to cited text no. 1
    
2.
Bielawska H, Epstein NL. A stone down below: A urethral stone causing acute urinary retention and renal failure. CJEM 2010;12:377-80.  Back to cited text no. 2
    
3.
Mihmanli I, Kantarci F. Transrectal voiding sonourethrography for diagnosis of a prostatic urethral calculus. J Ultrasound Med 2006;25:1455-7.  Back to cited text no. 3
    
4.
Kamal BA, Anikwe RM, Darawani H, Hashish M, Taha SA. Urethral calculi: Presentation and management. BJU Int 2004;93:549-52.  Back to cited text no. 4
    
5.
Hemal AK, Sharma SK. Male urethral calculi. Urol Int 1991;6:334-7.  Back to cited text no. 5
    
6.
Durazi MH, Samiei MR. Ultrasonic fragmentation in the treatment of male urethral calculi. Br J Urol 1988;62:443-4.  Back to cited text no. 6
    
7.
Thompson B, Hardwood-Nuss AL. Urolithiasis in a child: An uncommon presentation of an uncommon disease. Ann Emerg Med 1995;25:837-40.  Back to cited text no. 7
    
8.
Suziki Y, Ishigooka M, Hayami S, Nakada T, Mitobe K. A case of primary giant calculus in felame urethra. Int Urol Nephrol 1997;29:237-9.  Back to cited text no. 8
    
9.
Larkin GL, Weber JE. Giant urethral calculus: A rare cause of urinary retention. J Emerg Med 1996;14:707-9.  Back to cited text no. 9
    
10.
Shim JS, Oh MM, Kang JI, Ahn ST, Moon du G, Lee JG. Calculi in a female urethral diverticulum. Int Neurourol J 2011;15:55-7.  Back to cited text no. 10
    
11.
Thomas JS, Crew J. Obstructing urethral calculus in a woman revealed to be the cause of chronic pelvic pain. Int Urogynecol J 2012;23:1473-4.  Back to cited text no. 11
    
12.
Koga S, Shiraishi K, Saito Y, Arakaki Y, Matsuoka M. Sonography of urethral calculi. Urol Int 1993;50:203-4.  Back to cited text no. 12
    
13.
Picozzi S, Casellato S, Bozzini G, Ratti D, Macchi A, Rubino B, et al. Inverted papilloma of the bladder: A review and an analysis of the recent literature of 365 patients. Urol Oncol 2013;31:1584-90.  Back to cited text no. 13
    
14.
Cheon J, Kim HK, Kim JJ, Yoon DK, Koh SK, Kim IS. Malignant inverted papilloma of the urinary bladder: The histopathologic aspect of malignant potential of inverted papilloma. J Korean Med Sci 1995;10:103-10.  Back to cited text no. 14
    
15.
Huang WJ, Huang WJ, Chen KK. Large inverted papilloma of the urinary bladder acting as a check-value mechanism to the bladder outlet. JTUA 2005;16:13-6.  Back to cited text no. 15
    


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