Bladder Stones 2 د.عبدالرزاق السلمان

د.عبدالرزاق السلمان BLADDER STONES 2 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 between the diverticulum and surrounding structures. 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.