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Department of  Urology, Presbyterian Doctor Gordon Hospital of Rio Verde, Rio Verde, GO, Brazil.

Background: Primary urethral calculi are rare in the West. Development is often associated with previous changes in urine flow, such  as diverticula, urethral stenosis and foreign bodies. The authors report a case of a 50-year-old who complained of hardened mass in the anterior penis. Urethrolithiasis diagnosis was made by radiographic imaging studies and a foreign rubber was found inside the giant stone after surgery.

To report a rare case of giant urethrolithiasis by the introduction of a foreign body.

The case of a 50-year-old man suffering from mental development delay, negative history for diverticula and urethral stenosis is presented. Imaging tests revealed the presence of a giant urethral stone. A one-stage urethro-lithotomy approach was indicated.

Postoperative follow up was satisfactory. The patient was discharged from the hospital two days after the surgery. Follow-up of 12 months showed no evidence of urethral stricture or recurrent stones.

Conclusion: To the best of our knowledge there are few published cases of urethral stones of the size we report. Management of urethral calculi varies according to their localization, their size and any associated urethral pathology. The treatment for an impacted, large calculus in urethra is urethro-lithotomy. An appropriate follow up is necessary for these cases.

The prevalence of primary urethral calculi varies according to the population studied, and the urethrolithiasis rates vary according to the region. This prevalence is uncommon in western countries and relatively frequent in Eastern countries, particularly in the Middle East and India. The urological literature about this subject is sparse, perhaps due to the rarity of cases, and in some cases the diagnosis is based solely on clinical findings. The urologist should be aware of the major risk factors associated with prior urethral changes, such as diverticula, stenosis areas and atypical findings which are often correlated with stone formation in urethral tube [1-5].

           The evaluation of these cases should take into account the patient´s age, clinical history, symptoms, urinalysis, urine culture, biochemical and haematological analysis and radiological imaging studies such as direct urinary system radiology and urinary ultrasonography. All this information will provide additional data for a better and more comprehensive approach to the patient [2-4]. Patients may occasionally be diagnosed with urethrolithiasis when a radiologic imaging study of the pelvis is performed. [6-9].

         In the case reported below, the aetiological factor of stone formation – a foreign body – was discovered only after surgery, although the clinical history and radiologic studies suggested the possibility of a foreign body in the urethral tube. Urinary calculus formation in the urethral tube is seldom seen and is usually found in men with urethral stricture or diverticulum [10,11,12]. Most of calculi of the urinary system are located in the upper region of the  urinary system and stone formation usually occurs when  soluble material (e.g., calcium) supersaturates the urine and begins the process of crystal formation. Urethrolithiasis  represents less than 1% of all lithiasis [1,3,10]. The calculi are usually formed elsewhere and get stuck in the proximal urethra, but they may rarely be formed primarily in the urethra [1,2,3,10].

          Urethral stones are seldom encountered  in urological practice and the  published studies  consist of small series and several case reports. Giant urethral calculi are even rarer and to the best of our knowledge there are few published cases about urethral stones of the size we report.  Most urethral calculi are originated from bladder migration. Calculi in the urethra can be mainly formed in the proximal urethra and are primarily related to stenosis or urethral diverticulum. Most calculi occur in male urethral tube and they are extremely rare in females [3,12,13,14,15].

A 50-year-old man was admitted at the emergency service of Presbyterian Doctor Gordon Hospital of Rio Verde in January 2010 with clinical findings of oedema and sharp pain in the penis and scrotum, for the past 2 months. He also complained about a hardened mass in the anterior penis. The patient’s past medical history was positive for hepatitis type B and for mental development delay by birth. He did not show any other significant medical problems and past medical history was also negative for urethral diverticulum and for urethral stenosis. The patient showed a history of dysuria with no associated fever. He had no episodes of haematuria.

         The physical examination revealed an increase of penis volume with inflammatory signs and a small leakage (fistula) of urine at the peno-scrotal junction. There was only mild discomfort. He had also report normal urinary flow. He had no fever or any other relevant systemic diseases. However, the scrotum revealed marked oedema with no purulent lesions, and a crackle around the penis on the ventral surface near the glans was noted. He was previously treated with ciprofloxacin for urinary tract infection.

            Plain radiographs of the pelvis showed the image of a giant urethral calculus (Figure 1).

 

Plain X-ray and ultrasound scans of the kidney, ureter and bladder area were all normal. General physical examination did not reveal any abnormality. The possibility of a foreign body in the urethra was considered. Routine metabolic work-up and renal function tests were normal. Urine culture did not show any growth. Levels of serum parathyroid hormone and serum calcium were within normal range. Digital rectal examination did not detect any abnormality. A one-stage urethro-lithotomy approach was indicated and the patient underwent an open surgery.

            The following steps were performed during the surgery: 1- Circular incision of the foreskin around one cm below the glans. 2- Foreskin degloving release down to the base of the penis 3- Incision at three longitudinal urethral points corresponding to locations of the urethral stones. 4- Urethro-lithotomy  (Figures 2 and 3).

 

5- uretheral closure using Vycril® 4.0 with running suture dual layer was performed. 6- Excess of preputial skin was resected and cutaneous sutures were placed across the mucosa circumference of penis. 7- Urethral catheterization was performed with a foley catheter number 18 and a suprapubic cystostomy was finished by a trocar and a foley catheter number 16 was left. After the surgery, a rectangular rubber fragment was found inside the urethral stones, which represented  the source of  calculus development (Figures 4 and 5).

           Postoperative follow up was satisfactory. The patient was discharged from the hospital two days after surgery. The duration of catheterization was 15 days for urethral catheter and 21 days for cystostomy. The patient had no complications in this period. On the 30th day, he returned to the ambulatory clinic with no urinary complaint. On the 90th day after the surgery, he was submitted to  urethrocystography, which was normal ( Figures 6, 7 and 8).

 

 

Follow-up at 12 months showed no evidence of urethral stricture or recurrent stones.

Urethral calculi are rarely found in urological practice and published studies  consist of small series and several case reports. Most urinary stones are located in the upper urinary tract so calculi in the urethra are especially rare (around 1%) [1,3,10]. In most cases, the   stones formed in the high urinary tract  are migrated to the urethra and get  stuck in this area. Theoretically, the caliber of the urethra of the adult (30 F) allows the passage of stones with a diameter less than or equal to 10 mm. However, when there is stenosis or a large stone, the anatomic conditions become uncertain to allow their free progression [2]. There is also well established association between the diagnosis of calculi of the urethra with local diverticula, chronic urinary infection, obstruction of variable etiology and foreign bodies [1,6,7], and there are indications that the dietary habits and hygienic conditions are involved in the pathogenesis of the disease [4].

 Depending on the origin, urethral calculi are classified as primary or secondary (due to migration) [5,6,7]. Secondary stones are more common than primary ones and the stones migrate from the upper urinary tract [5,6,7,8]. Urethral calculi are usually small [5,6].  Giant calculi in the urethra are rare, but in some specific groups of patients they could be developed around foreign bodies inserted in the urethral tube. As the urinary symptoms are early, which often follow the foreign body´s insertion, the diagnosis is generally early as well [3]. However in this case this patient looked for medical help tardily, perhaps due to mental development delay.

              The progression of urethral lithiasis depends on the patient´s reaction to the foreign element and this is determined by the type of the inserted material, its duration in the patient´s body, associated infection and the individual´s immunological response [7].

               Most urethral calculi occur in the male [4]. Urethrolithiasis prevalence is much higher in men, due to the increased length of the urethral canal, and the age varies from 3- to 81- year- old individuals [4,5,22]. The group most affected by the  insertion of foreign bodies in the urinary tract are the  young adults, probably caused by the exercise of masturbatory practices [5], the psychiatric patients [3,5,6], patients  with cognitive impairment and  alcoholic patients [6].

                 Urethral calculus can be completely asymptomatic or may be accompanied by one of the following symptoms: perineal or penile pain, increased urinary frequency, urgency, decreased urinary stream, haematuria and / or urethral discharge due to infection. The patient can show signs of acute urinary retention or insignificant history. The diagnosis is based on clinical history and relevant investigations [5-10]. The appropriate management in the presence of urethral calculus will vary depending on the location and size of the stones and the presence or absence of associated diseases in the urethral canal. Retrograde manipulation for the urinary bladder followed by litholapaxy or lithotripsy is an appropriate procedure for posterior urethral calculus [14-20].

Stones in the anterior urethra can be treated with instillation of lidocaine jelly 2% or ventral meatotomy according to their location. Giant urethral calculus should be treated with open surgery. In addition, if the urethra has a stenosis or has been damaged by previous attempts to extract a stone, urethroplasty is preferred [3,23,24]. In the immediate postoperative period the patient can develop an urinary tract infection, pain, fistula and urinary retention. In the late postoperative, patients can develop urethral stenosis [7,10,14,21,22,25).

There are few published cases about urethral stones the size we report. Urethral primary stones are rare and correspond to less than 1% of urinary tract calculus. Management of urethral calculi varied according to the site, size and associated urethral pathology. The diagnosis can be done by radiologic imaging studies. The choice of treatment for an impacted, large calculus in urethra is urethro-lithotomy with stone removal. One stage procedure (urethro-lithotomy) was indicated.

Retrograde manipulation for the urinary bladder followed by litholapaxy or lithotripsy is an appropriate procedure for a posterior urethral calculus. For the anterior urethra, meatotomy or urethrotomy is generally used. Endoscopic treatment can be performed as well, but sometimes the urothelium may obscure the foreign body.

In this case report, the patient showed dysuria only. Urethral stricture and  diverticulum were not detected. Follow-up of 12 months showed no evidence of urethral stricture or recurrent stones. An appropriate follow up is necessary for these cases.

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