Urolithiasis is the formation of stones (calculi) in the kidney, bladder, and/or urethra with a prevalence rate of approximately 12% worldwide [1]. The fundamental cause for all stones is supersaturation of urine [2]. Urolithiasis is a more common disease in men rather than women with 3:1 male to female ratio although this ratio is narrowing recently [3]. Approximately 5% of all bladder stones occur in women and are usually associated with foreign bodies (sutures, synthetic tapes, or meshes) or urinary stasis [4]. Vesical calculi have developed after vesicourethral suspension performed using a mesh [5]. It also developed in a woman in whom an intrauterine contraceptive device migrated from the uterus to the bladder [6]. Bladder stone can develop following fistula repair [7]. A vesical calculus weighing more than 100g is categorized as a giant urinary bladder stone [8]. There is a report of a woman with bladder stone weighing 565 g and its size 10 cm x 9.8 cm x 7.6 cm [9]. There was a case report of giant bladder stone in a man weighing 465gms [10]. Bladder stones can be asymptomatic but may result in hematuria, recurrent infections, and irritable symptoms [4], dysuria, positional voiding, hematuria, and incontinence [11]. Stones can be detected by x-ray, ultrasound, or computed tomography scan and cystourethroscopy [4]. Bladder stones can be treated with different methods of different cure rate, extracorporeal shock wave lithotripsy (75-100%), transurethral cistolithotripsy (63-100%), percutaneous cistolithotripsy (89-100%) and open surgery (100 %) [12]. When stone burden is large, percutaneous endoscopic disintegration or open suprapubic cystolithotomy is preferable.

History

55 years old para II woman presented with suprapubic pain of 10 years duration which was progressive and increasing in severity from time to time. She had undergone fistula repair 28 years back in Hamlin fistula center, Ethiopia. After the repair she had leakage of urine during coughing, laughing and lifting weight for which she has undergone additional surgery 20 years back. The leakage has decreased but didn’t completely stop for which she was restricting herself from taking enough water. 10 years back she started to have suprapubic pain which was increasing in intensity from time to time. The leakage of urine also worsened and started to be continuous. She noticed that her urine is having whitish discharge mixed with it. She didn’t notice any reddish discoloration of the urine. She didn’t have fever, flank pain. She has no bowel related complaints. She is divorced and not sexually active for 15 years.

Physical Examination

She has suprapubic severe tenderness with ill-defined mass. She has wet perineum with whitish discharge on the vulva, the urethral meatus is patulous and retracted inside. During digital vaginal examination there was a hard mass on the anterior vaginal wall, the vaginal mucosa and cervix are normal, No fistula was seen on speculum examination. Urine was seen leaking from the ureteral meatus with whitish discharge. Metallic catheter was inserted through the urethral meatus and “scraping sound” was heard when the metallic catheter came in contact and scrapes it by the side and possibility of bladder stone was suspected and pelvic x-ray done.

Figure 1: Metallic catheter inserted in the urethra (Note: picture was taken for demonstration after the patient was treated).

Figure 2: X-Ray appearance of the stones (two overlapping stones seen in the pelvis).

Treatment

Abdomen was opened through previous midline scar.. Bladder was found indurated, thickened and edematous. Cystolithotomy was done at the dome to remove two huge stones, together measuring a size of 9x7x5cms and separately 6x5x4cm and 6x4x3.5 cms and weighing 118.78 grams. There was no abnormality in the bladder mucosa or any other foreign body. After surgery the pain has completely subsided and patient discharged.

Figure 3: Making cystotomy after opening the abdomen.

Figure 4: The stone seen inside after opening the bladder.

Figure 5: The two stones seen together (Compared with the scrub nurses hand).

Figure 6: The two stones seen separately.

Figure 7: Digital weight scale displaying the weight of the stones.

Bladder stones are much less common in women as compared with men because of the lower incidence of urinary obstruction in women. The largest ever recorded bladder stone size occurred in men. Bladder stones usually occur in the background of foreign body and urinary concentration. Bladder stone can develop in patients with vesicovaginal fistula due to restricted fluid intake and concentrated urine. But after closure of vesicovaginal fistula, development of bladder stone is rare. Because they take adequate fluid. This woman has developed the stone after fistula repair, may be, because she had residual urinary incontinence for which she has restricted herself from adequate fluid intake, or she may have urethral stricture that occurred due to the stress surgery (likely urethral tightening or bladder neck support).

Bladder stone can develop following fistula repair with additional bladder neck procedures that may result in urethral stricture. Patients who present with suprapubic pain after fistula surgery should be evaluated for the presence of stone.

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