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BLADDER STONES
2
‫عبدالرزاق السلمان‬.‫د‬
A primary bladder stone is one that develops in sterile urine; it
often originates in the kidney.
A secondary stone occurs in the presence of infection, outflow
obstruction, impaired bladder emptying or a foreign body.
Composition and cystoscopic appearance
Most vesical calculi are mixed.
1-An oxalate calculus is a primary calculus that grows slowly;
usually, it is of moderate size and solitary, and its surface is
uneven.
2- calcium oxalate: Although is white, the stone is usually dark
brown or black because of the incorporation of blood pigment.
3-Uric acid calculi are round or oval, smooth and vary in colour
from yellow to brown . They occur in patients with gout but are
also found in patients with ileostomies or with bladder outflow
obstruction.
4- A cystine calculus occurs only in the presence of cystinuria and
is radio-opaque because of its high sulphur content.
5-A triple phosphate calculus is composed of ammonium,
magnesium and calcium phosphates and occurs in urine infected
with urea-splitting organisms. It tends to grow rapidly. In some
instances it occurs on a nucleus of one of the other types of
calculus; more rarely it occurs on a foreign body.
It is dirty white in colour and of chalky consistency. A bladder
stone is usually free to move in the bladder and it gravitates to the
lowest part of the bladder. Less commonly, the stone is wholly or
partially in a diverticulum, where it may be hidden from view.
Clinical features
Men are affected eight times more frequently than women. Stones
may be asymptomatic and found incidentally.
1-Frequency, may be a sensation of incomplete bladder emptying.
2-Pain (strangury) is most often found in patients with a spiculated
oxalate calculus. It occurs at the end of micturition and is referred
to the tip of the penis or to the labia majora; more rarely it is
referred to the perineum or suprapubic region. The pain is
worsened by movement. In young boys, screaming and pulling at
the penis with the hand at the end of micturition are indicative of
bladder stone.
3-Haematuria is characterised by the passage of a few drops of
bright-red blood at the end of micturition.
4-Interruption of the urinary stream is due to the stone blocking
the internal meatus.
5-Urinary infection is a common presenting symptom.
Examination
Rectal or vaginal examination is normal; occasionally, a large
calculus is palpable in the female
GUE/ microscopic haematuria, pus or crystals
KUB/visible in most pt.
US/ is visible on ultrasound.
Imaging of the whole of the urinary tract should be undertaken to
exclude an upper tract stone.
Treatment: Nearly all stones can be dealt with endoscopically. In
men with bladder outflow obstruction, endoscopic resection of the
prostate should be performed at the same time as the stone is
dealt with.The cause of the stone should be sought and treated;
this may include bladder outflow obstruction or incomplete bladder
emptying in patients with neurogenic bladder dysfunction.
Litholapaxy
The blind lithotrite was an early type of minimally invasive
technique. Standard management now includes the optical
lithotrite, electrohydraulic lithotrite, Holmium laser or ultrasound
probe. Other devices include the stone punch, which is useful to
crush small fragments further so that they can be evacuated with
an Ellik evacuator.
Contraindications to perurethral litholapaxy are extremely rare:
• urethral: a urethral stricture that cannot be dilated
sufficiently;when a patient is aged below 10 years;
• bladder: a contracted bladder;
• stone characteristics: a very large stone.
Ultrasound lithotripsy is extremely safe but appropriate only for
small stones. Laser lithotripsy with the holmium laser can deal with
most large stones.
Percutaneous suprapubic litholapaxy
As in percutaneous nephrolithotomy. This is the best method to
use if it is not possible to carry out litholapaxy per urethram
because of a narrow urethra.
Removal of a retained Foley catheter
A retained Foley catheter is usually caused by the channel that
connects the balloon to the side arm becoming blocked, usually at
the end near the balloon. The best way of dealing with this
problem is to
1- further inflate the balloon with 20 ml of water and then burst
the balloon percutaneously using a needle under ultrasound
screening. it is important to subsequently cystoscope the patient
to ensure that any fragments are removed before they can form a
foreign body calculus.
2- Cutting off the side arm and attempting to clear the channel
with a wire is only occasionally successful.
FOREIGN BODIES IN THE BLADDER
The most common foreign body in the bladder is a fragment of
catheter balloon. Occasionally, a foreign body enters through the
wall of the bladder, for example non-absorbable sutures used in an
extravesical pelvic operation. Complications include:
• lower UTI.
• perforation of the bladder wall.
• bladder stone.
Treatment
A small foreign body can usually be removed per urethram by
means of an operating cystoscope. Occasionally, a suprapubic
approach using the percutaneous insertion of a cystoscope is
needed.
DIVERTICULAE OF THE BLADDER
Definition
The normal intravesical pressure during voiding is about 35–50
cmH2O; however, pressures as great as 150cmH2O may be
reached by a hypertrophied bladder endeavouring to force urine
past an obstruction. This pressure causes the lining between the
inner layer of hypertrophied muscle to protrude, forming multiple
saccules.If one or more, but usually one, saccule is forced through
the bladder wall, it becomes a diverticulum.Congenital diverticula
are the result of a developmental defect.
Aetiology of diverticulae
Congenital diverticulae
These are situated in the midline anterosuperiorly and represent
the unobliterated vesical end of the urachus.
Pulsion diverticula
The usual cause is bladder outflow obstruction.
Complications
Recurrent urinary infection a stagnant pool of urine within it.
Peridiverticulitis can cause dense adhesions
diverticulum and surrounding structures.
between
the
Bladder stone This develops as a result of stagnation and
infection. The stone often protrudes into the bladder.
Hydronephrosis and hydroureter This is extremely rare and is
a consequence of peridiverticular inflammation and fibrosis.
Neoplasm Neoplasm arising in a diverticulum is an uncommon
complication (< 5%).
Clinical features
Usually causes no symptoms. The patient is nearly always male
(95%) and over 50 years of age. Symptoms are those of
associated urinary tract obstruction, recurrent infection and
pyelonephritis. Haematuria (due to infection, stone or tumour) is a
symptom in about 30%. In a few patients micturition occurs twice
in rapid succession (the second act may follow a change of
posture).
Diagnosis/
Usually discovered incidentally on cystoscopy or ultrasound.
Indications for operation
Operation is necessary only for the treatment of complications.
Provided the diverticulum is small and associated outflow
obstruction has been dealt with by prostate resection, there is no
reason to resect the diverticulum. Even a large diverticulum may
not require treatment in the absence of infection or other
complications.
Traction diverticulum (synonym: hernia of the bladder)
A portion of the bladder protruding through the inguinal or femoral
hernial orifice occurs in l.5% of such herniae treated by operation.
URINARY FISTULAE
1-Congenital urinary fistulae:The causes include:
• Ectopia vesicae.
• A patent urachus – the presence of a urinary leak from the
umbilicus, present at birth or commencing soon after, suggests
this diagnosis. In adult life, infection in a urachal cyst may produce
a fistula and adenocarcinoma may occur.
Treatment is by means of excision of the urachal tract and closure
of the bladder once distal obstruction has been excluded.
• In association with imperforate anus.
2-Traumatic urinary fistulae:Perforating wounds, damage not
recognised during surgery or poor healing and avascular necrosis
following radiotherapy and surgery may lead to fistula formation.
3-Vesicovaginal fistulae
Aetiology
• Obstetric. The usual cause is protracted or neglected labour.
•Gynaecological.as complication of total hysterectomy and anterior
colporrhaphy.
• Radiotherapy.
• Direct neoplastic infiltration. Exceptionally, carcinoma of the
cervix ulcerates to implicate the bladder.
Clinical features
There is leakage of urine from the vagina and excoriation of the
vulva. Vaginal examination may reveal a localised thickening on its
anterior wall or in the vault. On inserting a vaginal speculum, urine
will be seen escaping from an opening in the anterior vaginal wall.
The ‘three-swab test’
The differential diagnosis between a ureterovaginal and
vesicovaginal fistula can be made by placing a swab in the vagina
and injecting a solution of methylene blue through the urethra; the
vaginal swab becomes coloured blue if a vesicovaginal fistula is
present. Cystoscopy and bilateral retrograde ureterography
provide a more reliable demonstration. An IVU should be
performed to exclude a coincidental ureterovaginal fistula. Usually,
the IVU shows some upper tract dilatation resulting from partial
obstruction.
Treatment
Just occasionally, conservative management of a vesicovaginal
fistula following hysterectomy, by urethral bladder drainage, is
successful; however, the majority of fistulae will require definitive
surgical repair. A low fistula (subtrigonal) is best repaired per
vaginam. Cystoscopy before the repair procedure and bilateral
ureterograms performed. For high fistulae a suprapubic approach.
Reimplantation into the bladder is often required. Depending on
the amount of ureter lost, it may be possible to achieve
reimplantation with a psoas hitch procedure. If the gap is too large
a Boari flap of anterior bladder wall should be cut and brought
over to meet the ureter and a reimplant performed. The most
important principle of ureteric reimplantation is that there should
be no tension on the repair.