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Case report

Impacted bladder stone a cause of renal failure


Mukosai S, Silumbe M, Kalo K, Labib M, Kachimba J
Department of Surgery, Urology Unit II
Abstract
We present a case of 10 year old child from Kafue district who presented with features of renal
failure, bilateral hydronephrosis secondary to impacted bladder stone of size 4.5x4cm. Bladder
stones though a common urological condition rarely cause obstruction[1]. In this case report
Patient was managed by early renal support through peritoneal dialysis, blood transfusion and
removal of bladder stone by open method after which satisfactory results were achieved. The case
illustrates the importance of early radiological intervention in any patient who presents with
recurrent urinary tract infections, especially in male patients.
Introduction
Bladder stones commonly manifest with clinical presentation of irrigative urinary symptoms and few
obstructive symptoms. Bladder stone is a common urological disease, but it is rare for such a
calculus to be so large as to cause bilateral hydronephrosis [2]. Impacted bladder stone can result in
obstructive uropathy and renal failure [3]. The aetiology and pathogenesis of bladder stones remain
obscure [4]. Bladder stones can be easily diagnosed with simple radiological investigations such
plain x ray KUB and ultrasonography to enable early diagnosis and prompt interventions. We are
reporting a case presented to our hospital of impacted bladder stone presenting with renal failure.
Case report
A 10 year old male child presented to urology clinic with a 3 year history of voiding dysfunction
characterised by difficulty in voiding and constant tapping at the phallus with recurrent febrile illness
caused by recurrent urinary tract infections. The child has had history of loin pain for similar
durations. He had been treated for UTI at a local hospital. He denies history of hematuria. Plain KUB
revealed radiopaque shadows in the area of the bladder [figure3]. Urinalysis showed plenty of pus
cells with epithelial cells 3-5 HPF. There was no red bloodcells. Urine culture yielded Escherichia Coli
which was sensitive to nitrofurantoin. Renal function test revealed blood urea (BUN) 43.72mmol and
serum creatinine 635.8umol/l.
On physical examination, the child was ill health dyspnoeic wasted moderately pale afebrile to
touch. On systemic examination respiratory system was clear, cardiovascular system revealed
tachycardia with heart rate 100 b/m. Other systems were un remarkable.
Subsequent management involved strict input and and output, intravenous fluids, renal support with
peritoneal dialysis and received 3units of packed red blood cells. On day 5 post admission, the child
developed generalised convulsions controlled with diazepam and phenobarbitone episodes. He had
4 episodes in 2 days. Full septic screen done revealed negative for blood culture x 3 samples. Chest x
ray was not revealing. No growth in the urine. Lumbar puncture was not done because of un stable
child condition. He was covered on broad spectrum cefotaxime.

On day 20 of admission the child developed self-limiting paralytic ileus which was managed
conservatively with nasal gastric tube and intravenous fluids {Ringers lactate}. Upon the child
condition stabilising he was taken for Transvesical Cystolithotomy in which two bladder stones were
extracted, one impacted in the bladder neck size 4x4cm.

Figure 1

Figure2

Figure 3

Outcome
At post operative period the child developed post obstructive diuresis up to 4200ml/day. There was
subsequent dramatic improvement in renal function. Serum creatinine dropped to 109umol/l. He
was discharged to be followed up in the clinic on 20th postoperative day with good urinary stream
out put and mild occasional urinary incontinence.

Figure 4

Literature review/ Discussion


Bladder calculi are uncommon cause of illness in most western countries, but result in specific
symptoms and are a significant discomfort [5]. These stones are usually associated with urinary
stasis but can form in health individuals without evidence of anatomic defects, strictures, infections
or foreign bodies [6]. Malnutrition has been attributed to formation of primary bladder stones which
is still common in developing countries where malnourishment is common especially in growing
children [7].
A few international articles have reported bladder stone causing renal failure.
Wuran W. et al, from Harvard Medical School, reported a 62 year old man presented with large
bladder calculus causing bilateral obstruction and renal failure. Diagnosis was delayed despite the
patients history of recurrent urinary y tract infection [8].
Borg Z. et al, from Poland, reported a case of severe exacerbation of chronic renal failure with
bilateral hydronephrosis and urosepsis caused by asymptomatic large bladder stone. Managed by
temporally haemodialysis, removal of stone and controlling of severe urinary tract infection.
Kamal F, et al reported a case of 30 year old man who presented with obstructive renal failure and
urosepsis. Due to bladder outlet obstructing bladder calculi that formed around three copper wires
that were self inserted into urinary bladder 15 years previously [9].
Most bladder stones are mobile within the bladder due large space and thus continuous flow of
urine [10]. If untreated bladder stones can grow big in size causing mechanical obstruction by
impinging pressure on the Ureteric orifice within the bladder and also by being impacted on the
bladder neck leading to infravesical obstructive uropathy. Management of such cases is focused on
patient stabilisation with temporal peritoneal or haemodialysis , early removal of stone ,continue

renal support treatment, correct acidosis and look out for post obstructive diuresis in the postoperative period. Surgical intervention by open Cyst lithotomy or endoscopic Cystolithotomy can
achieve satisfactory results [9]. It is advisable to manage patients in cooperation with nephrologists.
Efforts must made to investigate the primary cause of repeated urinary tract infections through
radiological investigations like plain x-ray KUB and ultrasonography in patients with voiding
problems[ 10].
Conclusion
Bladder stone if large enough or if impacted in the bladder neck can cause obstructive uropathy
leading to renal failure. Recurrent urinary tract infections should be adequately evaluated with
radiological investigations for early and prompt diagnosis of the cause.
References
1. Daeschner C.W, Single J.C.C [1960], Urinary Tract Calculi and Nephrocalcinosis in infants and
Children .Vol.57 Issues pages 721-732
2. Sundaram CP, Houshiar AM, Reddy PK. [1997], Bladder stone causing renal failure. Minn Med.
Sep; 80(9): 25-6.
3. Dorairajan L.N, Talmer & Hemal A.K [2001), Stone Neclace of Urinary tract presenting as renal
Failure.
4. Aurora A.L, Taneja O.P, Gupta D>N [2008] Bladder Stone Disease of Childhood; An
Epidemiological Study.
*
*

5. Fadi Kamal, MD, Aaron T.D. Clark, MD, Luke Thomas Lavalle, BSc, Matthew

Roberts, MD,* and James Watterson, MD* Intravesical foreign bodyinduced bladder calculi
resulting in obstructive renal failure
6. Wuran Wei1 and Jia Wang [2009] A huge bladder calculus causing acute renal failure, urological
research.
7
S. Madjar1, B. Moskovitz1, A. Kastin1, M. Stein1 and O. Nativ [1996], Anuria and acute renal
failure caused by multiple bladder calculi
8. Wuhan W. Harvard Medical School, Large bladder causing hydronephrosis.
9

Kamal Bladder outlet obstruction due renal calculi

10. Joshi B R, Shrestha PM Can Urinary Bladder Stones Cause Renal Failure?