A case report: giant urethral calculus

A case report: giant urethral calculus

I Gusti Agung Thede Surya Putra¹, Paksi Satyagraha^1,&

¹Department of Urology, Medical Faculty, Brawijaya University-Saiful Anwar General Hospital, Malang 65145, East Java, Indonesia

^&Corresponding author
Paksi Satyagraha, Department of Urology, Medical Faculty, Brawijaya University-Saiful Anwar General Hospital, Malang 65145, East Java, Indonesia

Introduction    

Urethral calculus is an uncommon condition (the incidence is less than 1%) [1]. Males have a higher incidence of urethral calculus than women [2]. Static urine flow, infection, and other conditions such as urethral stricture, urethral diverticulum, recurrent urinary tract infection, foreign bodies within the urinary tract, schistosomiasis, and a history of lower urinary tract operation are the most common predisposition factors for urethral calculus. Urethral calculus is generally composed of struvite, calcium phosphate, or calcium carbonate components. Most urethral calculi originate from the upper urinary tract or the bladder; the calculus migrates and eventually obstructs the posterior and anterior urethra [3, 4]. Urethral calculus obstruction manifests clinically as urine retention, frequent urination, dysuria, suprapubic pain, weak urinal stream, urethra mucosal damage, urethra-cutaneous fistula, and even kidney failure. Urethroscopy lithotripsy is the first choice in urethral calculus management [5, 6]. Nevertheless, if the calculus is large, obstructs the anterior urethra, and is also accompanied by urethral stricture and diverticulum, external urethrotomy could be the therapeutic choice [7].

Patient and observation     

This is a report of a 54-year-old male who came to the emergency room with suprapubic pain that radiated to the left and right thigh and also across the edge of the penis. The patient also complained of straining when urinating. The symptoms had started 5 years before, and had increased in intensity in the previous month. The patient had a significant history of pain in the lower back region which radiated towards the edge of the penis, accompanied by calculus expulsion when urinating. These two symptoms had started 4 years before, but the patient had not sought routine medical assistance. The patient also had a significant history of vesicolithotomy and a cystotomy procedure 2 weeks before, due to bladder calculus. From physical examination, there was a significant suprapubic scar with an inserted cystostomy catheter. From penis palpation, a solid mass with dimensions 6 * 3cm was identified. The mass was located within the ventral region of the penis (Figure 1). Routine laboratory examination and kidney function were within normal limits. Urine culture did not show any bacterial/fungal growth. KUB and pelvic radiographic images before the vesicolithotomy and cystostomy procedures (Figure 2A) depicted a bladder calculus and a large urethral calculus within the pars pendularis of the urethra. A pelvic radiographic image after the operation is shown in Figure 2B. Urethral calculus extraction was conducted by following cystoscopy procedure steps and urethrolithotomy. The calculus was found to obstruct the pendular part of the urethra. It was then extracted carefully and was found to have dimensions of 6 * 3.5cm (Figure 3). A silicone catheter was introduced as a guide, and the urethra was then stitched layer by layer. The catheter was maintained for approximately 1 month. One year after the operation, the patient was re-evaluated. No complications (urethral stricture or recurrent calculus) were found.

Discussion     

Urethral calculus is a rare manifestation of lower urinary tract calculus. Incidence is less than 1% of all urolithiasis, but nevertheless has a high prevalence in developing countries [1]. Urethral calculus is more commonly found in men, and there have only been a few cases in children and women [2]. Predisposition factors for urethral calculus include urethral diverticulum, urethral stricture, hypospadias, and meatal stenosis [3]. Most urethral calculi consist of uric acid and struvite, which are the same components as those originating from the bladder (nutritional and socio-economic factors might have a role) [3]. Urethral calculi are usually located within the pars prostatica of the urethra; only 30% are located within the anterior urethra. A calculus larger than 1 cm can cause obstruction. Urethral calculus obstruction leads to urine retention, urethral mucosal damage, urethra-cutaneous fistulas, and even kidney failure. Based on their origin, urethral calculi can be divided into primary (in situ) and secondary calculi (migration) [3]. Primary urethral calculi are associated with abnormalities within the urethra such as urethral stricture, diverticula, or a foreign body within the urethra [3], while secondary urethral calculi have migrated from the upper urinary tract. Primary urethral calculi seldom cause acute symptoms, while urethral calculi migrating from the upper urinary tract can cause urine retention, dysuria, straining while urinating, or even sepsis due to possible infection. Management of a urethral calculus depends on its location, size, and the presence of other abnormalities within the urethra. In cases of small posterior urethral calculi, a retrograde manipulation into the bladder could be feasible. The procedure is then followed by lithotripsy, litholapaxy, or open surgery [6]. A small anterior urethral calculus can be extracted by installing 2% lidocaine jelly, dorsal meatotomy, or urethroscopy [5]. Large urethral calculi must be treated with open surgery. In urethral calculi caused by urethral stricture, calculus extraction and urethroplasty is the method of choice [5].

Conclusion     

Large urethral calculus is a rare condition of lower urinary tract calculus. A urethral calculus can come from a migrating upper urinary tract calculus or migrating bladder calculus, or it could be related to anatomical abnormalities such as urethral stricture, urethral diverticulum, and the presence of a foreign body within the urethra. A diagnosis of urethral calculus should be considered in patients with difficulty in urinating or urine retention, in addition to a history of persistent lower back pain and calculus expulsion. Accurate and precise diagnosis is paramount in preventing long-term complications caused by urethral calculus.

Competing interests     

The authors declare no competing interests.

Authors´ contributions     

I Gusti Agung Thede Surya Putra performed the study design and drafting the article and Paksi Satyagraha contributed to the editing and final approval of the article. All authors have read and given final approval of the version to be published.

Figures     

Figure 1: clinical appearance of a large calculus obstructing the anterior urethra

Figure 2: A) KUB and pelvic radiograph before the vesicolithotomy and cystostomy procedures; B) pelvic radiographic image of the pelvis after operation

Figure 3: clinical images during the operation and after extraction

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