British Journal of Urology (1991), 68,211-212
01991 British Journal of Urology
Presentation and Management of Urethral Calculi A. R . SHARFI Department of Surgery, Faculty of Medicine, University of Khartoum, Khartoum, Sudan
Summary-A total of 36 patients with urethral calculi are presented; 34 were males, aged 2 to 6 5 years (mean 43). Eight patients were [underthe age of 6 years and presented with retention of urine. Calculi were in the posterior urethra in 56% of the patients, 33%had associated urinary tract calculi, and 47% had other diseases of the lower urinary tract, the commonest being posterior urethral stricture (42%). Of these calculi, 58%could be manipulated endoscopically into the urinary bladder, then crushed. Associated urethral strictures were dealt with by visual internal urethrotomy before manipulating the calculi. Other methods of treatment and their complications are discussed.
Although urethral calculi occur fairly commonly in developing countries (Koga et al., 1990), reports are scanty. We report the pattern of urethral calculi in 36 patients treated over 5 years in the genitourinary unit at Soba University Hospital, Khartoum.
Patients and Methods All patients diagnosed as having urethral calculi between 1985 and January 1990 were included in the study. A detailed urological history was taken; physical examination included palpation of the urethra and rectal examination and a ;plain X-ray of the urethra and bladder region was obtained. A retrograde urethrogram was performed if associated urethral pathology was suspected. Urethral calculi were analysed with regard to symptoms, anatomical site, associated diseases and management. Follow-up ranged between 6 andL33 months (mean 9).
urine. Other presenting symptoms are shown in Table 1. Twenty of the calculi in the male patients were in the posterior urethra, 10 were in the penile urethra and 4 in the fossa navicularis. Seventeen patients (47%) had associated diseases of the lower urinary tract, the commonest being urethral stricture (15 patients) (Table 2). The 2 female patients had had previous pharaonic circumcision and both had calculi in associated urethral diverticula. Twelve patients (33%) had associated urinary calculi; these were renal or ureteric in 8 and vesical in 4. Management of the urethral calculi is summarised in Table 3. The 8 patients presenting with acute retention of urine received urgent treatment. The urethral calculi were manipulated endoscopically into the urinary bladder; this was followed by vesicolithotomy in 5 children but in the Table 1 Presenting Symptoms and Signs in 36 Patients with Urethral Calculi
Results A total of 36 patients with urethral calculi were analysed (34 male and 2 female). Their mean age was 43 years (range 2-65). All 8 patients under the age of 6 years presented with acute retention of Accepted for publication 8 January 1991
Symptoms and signs
Dysuria Interruption of urinary stream Retention of urine Urethral fistulas and sinuses Palpable urethral mass Total
27 1
No. of patients 12 10 8 3
3 36
272
BRITISH JOURNAL OF UROLOGY
Table 2
Associated Diseases of the Lower Urinary Tract in 17 Patients with Urethral Calculi
Associated disease
No. of patients
Urethral stricture Urinary bilharziasis Urethral diverticulum Multiple urethral fistulas and sinuses Total
15 4 4
3 26
Nine patients had more than one associated disease.
Table 3
Management of urethral calculi in 36 Patients
Management
No. of patients
Visual internal urethrotomy and Push-back, then litholapaxy Retrograde manipulation, then Litholapaxy Retrograde manipulation, then Vesicolithotomy Removal through external urethrotomy Extraction through the meatus Total
12 9
5 1
3 36
remaining 3 cases the calculi could be extracted from the external urethral meatus. The 15 patients with urethral calculi and associated urethral strictures underwent visual and internal urethrotomy initially; the stones were then pushed into the bladder and crushed in 12 cases, while in 3 patients the stones were removed through a perineal urethrotomy either because the stricture was too tight or the stone too big. In the remaining 13 patients, 9 had retrograde manipulation of the calculus into the bladder followed by litholapaxy, while 4 also required external urethrotomy to deal with an associated diverticulum. There were 7 postoperative complications : Gram-negative septicaemia in 3, the tip of the Sache urethrotome knife broke in the urethral lumen in 2, 1 patient had urethral bleeding and another developed a urethral fistula 3 weeks after removal of the calculus.
Discussion Urethral calculi in children were commoner in this study (22%) than in that reported by Koga et al. (1990). All of the children in this study presented with acute retention of urine. Amin (1973) reported a high incidence of retention (89%) but Paulk et al. (1976) and Selli et al. (1984) found it to be an uncommon occurrence. Calculi were in the poste-
rior urethra in 56% of patients; this is in agreement with the findings reported by Paulk et al. (1976) and Koga et al. (1990). The higher incidence of posterior urethral calculi in the present series is possibly related to the high incidence of postinflammatory urethral strictures in the region of the posterior urethra (Sharfi, 1989). Associated urinary calculi occurred in 33% of the patients; this is similar to the incidence reported by Koga et al. (1990) and emphasises the importance of evaluating the upper urinary tract in patients with urethral calculi. Management of the urethral calculi varied according to the site, size and associated urethral pathology. Retrograde manipulation into the urinary bladder, then litholapaxy, can be a safe procedure for posterior urethral calculi provided that the manipulation is done endoscopically under direct vision. A distal urethral stricture can be dealt with by visual internal urethrotomy before manipulating the calculus into the urinary bladder (Sharfi, 1989). Impacted, large irregular calculi or those in a urethral diverticulum are best removed through an external urethrotomy followed by excision and repair of the diverticulum. Extraction through the external meatus is suitable only for small, smooth calculi in the region of or distal to the fossa navicularis. Suarez (1985) reported that a urethral calculus could be engaged in a basket and pulled inside the urethroscope sheath, so that the stone, basket and sheath could be removed under direct vision. Durazi and Samiei (1988) reported successful ultrasonic fragmentation of impacted urethral calculi in 7 patients.
References Amin, H. A. (1973). Urethralcalculi. Br. J. Urol.,45, 192-199. Durazi, M. H. and Samiei, M. R. (1988). Ultrasonic fragmentation in the treatment of male urethral calculi. Br. J . Urol.,62, 443-444. Koga, S., Arakaki, Y., Matsuoka, M. et d. (1990). Urethral calculi. Br. J . Urol., 65, 288-289. Paulk, S. C., Khan, A. U., Makek, R. S. et al. (1976). Urethral calculi. J . Urol., 166,436439. Selli, C., Barbagli, G., Carini, M. e l al. (1984). Treatment of male urethral calculi. J . Urol., 132, 37-39. S h a h , A. R. (1989). Complicated male urethral strictures: Presentation and management. Int. Urol. Nephrol., 21, 491491. Suarez,G. M. (1985). Letter to the Editor. J . Urol., 133,292.
The Author A. R. Sharfi, MCS, Consultant Urologist, Department of Surgery, Facultyof Medicine P.O. Box 102, Khartoum, Sudan.
01991 British Journal of Urology
Presentation and Management of Urethral Calculi A. R . SHARFI Department of Surgery, Faculty of Medicine, University of Khartoum, Khartoum, Sudan
Summary-A total of 36 patients with urethral calculi are presented; 34 were males, aged 2 to 6 5 years (mean 43). Eight patients were [underthe age of 6 years and presented with retention of urine. Calculi were in the posterior urethra in 56% of the patients, 33%had associated urinary tract calculi, and 47% had other diseases of the lower urinary tract, the commonest being posterior urethral stricture (42%). Of these calculi, 58%could be manipulated endoscopically into the urinary bladder, then crushed. Associated urethral strictures were dealt with by visual internal urethrotomy before manipulating the calculi. Other methods of treatment and their complications are discussed.
Although urethral calculi occur fairly commonly in developing countries (Koga et al., 1990), reports are scanty. We report the pattern of urethral calculi in 36 patients treated over 5 years in the genitourinary unit at Soba University Hospital, Khartoum.
Patients and Methods All patients diagnosed as having urethral calculi between 1985 and January 1990 were included in the study. A detailed urological history was taken; physical examination included palpation of the urethra and rectal examination and a ;plain X-ray of the urethra and bladder region was obtained. A retrograde urethrogram was performed if associated urethral pathology was suspected. Urethral calculi were analysed with regard to symptoms, anatomical site, associated diseases and management. Follow-up ranged between 6 andL33 months (mean 9).
urine. Other presenting symptoms are shown in Table 1. Twenty of the calculi in the male patients were in the posterior urethra, 10 were in the penile urethra and 4 in the fossa navicularis. Seventeen patients (47%) had associated diseases of the lower urinary tract, the commonest being urethral stricture (15 patients) (Table 2). The 2 female patients had had previous pharaonic circumcision and both had calculi in associated urethral diverticula. Twelve patients (33%) had associated urinary calculi; these were renal or ureteric in 8 and vesical in 4. Management of the urethral calculi is summarised in Table 3. The 8 patients presenting with acute retention of urine received urgent treatment. The urethral calculi were manipulated endoscopically into the urinary bladder; this was followed by vesicolithotomy in 5 children but in the Table 1 Presenting Symptoms and Signs in 36 Patients with Urethral Calculi
Results A total of 36 patients with urethral calculi were analysed (34 male and 2 female). Their mean age was 43 years (range 2-65). All 8 patients under the age of 6 years presented with acute retention of Accepted for publication 8 January 1991
Symptoms and signs
Dysuria Interruption of urinary stream Retention of urine Urethral fistulas and sinuses Palpable urethral mass Total
27 1
No. of patients 12 10 8 3
3 36
272
BRITISH JOURNAL OF UROLOGY
Table 2
Associated Diseases of the Lower Urinary Tract in 17 Patients with Urethral Calculi
Associated disease
No. of patients
Urethral stricture Urinary bilharziasis Urethral diverticulum Multiple urethral fistulas and sinuses Total
15 4 4
3 26
Nine patients had more than one associated disease.
Table 3
Management of urethral calculi in 36 Patients
Management
No. of patients
Visual internal urethrotomy and Push-back, then litholapaxy Retrograde manipulation, then Litholapaxy Retrograde manipulation, then Vesicolithotomy Removal through external urethrotomy Extraction through the meatus Total
12 9
5 1
3 36
remaining 3 cases the calculi could be extracted from the external urethral meatus. The 15 patients with urethral calculi and associated urethral strictures underwent visual and internal urethrotomy initially; the stones were then pushed into the bladder and crushed in 12 cases, while in 3 patients the stones were removed through a perineal urethrotomy either because the stricture was too tight or the stone too big. In the remaining 13 patients, 9 had retrograde manipulation of the calculus into the bladder followed by litholapaxy, while 4 also required external urethrotomy to deal with an associated diverticulum. There were 7 postoperative complications : Gram-negative septicaemia in 3, the tip of the Sache urethrotome knife broke in the urethral lumen in 2, 1 patient had urethral bleeding and another developed a urethral fistula 3 weeks after removal of the calculus.
Discussion Urethral calculi in children were commoner in this study (22%) than in that reported by Koga et al. (1990). All of the children in this study presented with acute retention of urine. Amin (1973) reported a high incidence of retention (89%) but Paulk et al. (1976) and Selli et al. (1984) found it to be an uncommon occurrence. Calculi were in the poste-
rior urethra in 56% of patients; this is in agreement with the findings reported by Paulk et al. (1976) and Koga et al. (1990). The higher incidence of posterior urethral calculi in the present series is possibly related to the high incidence of postinflammatory urethral strictures in the region of the posterior urethra (Sharfi, 1989). Associated urinary calculi occurred in 33% of the patients; this is similar to the incidence reported by Koga et al. (1990) and emphasises the importance of evaluating the upper urinary tract in patients with urethral calculi. Management of the urethral calculi varied according to the site, size and associated urethral pathology. Retrograde manipulation into the urinary bladder, then litholapaxy, can be a safe procedure for posterior urethral calculi provided that the manipulation is done endoscopically under direct vision. A distal urethral stricture can be dealt with by visual internal urethrotomy before manipulating the calculus into the urinary bladder (Sharfi, 1989). Impacted, large irregular calculi or those in a urethral diverticulum are best removed through an external urethrotomy followed by excision and repair of the diverticulum. Extraction through the external meatus is suitable only for small, smooth calculi in the region of or distal to the fossa navicularis. Suarez (1985) reported that a urethral calculus could be engaged in a basket and pulled inside the urethroscope sheath, so that the stone, basket and sheath could be removed under direct vision. Durazi and Samiei (1988) reported successful ultrasonic fragmentation of impacted urethral calculi in 7 patients.
References Amin, H. A. (1973). Urethralcalculi. Br. J. Urol.,45, 192-199. Durazi, M. H. and Samiei, M. R. (1988). Ultrasonic fragmentation in the treatment of male urethral calculi. Br. J . Urol.,62, 443-444. Koga, S., Arakaki, Y., Matsuoka, M. et d. (1990). Urethral calculi. Br. J . Urol., 65, 288-289. Paulk, S. C., Khan, A. U., Makek, R. S. et al. (1976). Urethral calculi. J . Urol., 166,436439. Selli, C., Barbagli, G., Carini, M. e l al. (1984). Treatment of male urethral calculi. J . Urol., 132, 37-39. S h a h , A. R. (1989). Complicated male urethral strictures: Presentation and management. Int. Urol. Nephrol., 21, 491491. Suarez,G. M. (1985). Letter to the Editor. J . Urol., 133,292.
The Author A. R. Sharfi, MCS, Consultant Urologist, Department of Surgery, Facultyof Medicine P.O. Box 102, Khartoum, Sudan.
