Bladder Stones

Bladder calculi are an uncommon cause of illness in most Western countries, but they result in specific
symptoms and are a significant source of discomfort. This article discusses the diagnosis and current
management techniques for vesical calculus disease.

History of the Procedure

Bladder stones have been treated both medically and surgically for many centuries. The oldest bladder
stone discovered dates back to 4800 BC and was found by archeologists in Egypt around the turn of the
20th century.1 The first literary references to bladder stones date back to a time as early as, or earlier than,
the time of Hippocrates.2More than 23 centuries ago, Hippocrates warned that, "To cut through the
bladder is lethal," and part of the Hippocratic oath includes, "I will not cut for stone, even for the patients in
whom the disease is manifest; I will leave this operation to be performed by practitioners." His admonition
to young physicians was to leave this highly risky and complicated procedure to the purveyors (ie, the
lithotomists) of what could only be described as an art. 1
Famous historical figures who developed vesical calculi include King Leopold I of Belgium, Napoleon
Bonaparte, Emperor Napoleon III, Peter the Great, Louis XIV, George IV, Oliver Cromwell, Benjamin
Franklin, the philosopher Bacon, the scientist Newton, the physicians Harvey and Boerhaave, and the
anatomist Scarpa.1
Operations to remove bladder stones via the perineum were performed by Hindus, Greeks, Romans, and
Arabs. Ammonius (200 BC), Celsus (first century), and the Hindu surgeon Susruta were among the first to
write about perineal lithotomy to treat bladder calculi. 1 They wrote excellent and sometimes detailed
descriptions of the surgery, including preoperative and postoperative care and management. 2 In the
1500s, Pierre Franco introduced suprapubic lithotomy.3 Frre Jacques Beaulieu developed the lateral
approach to perineal vesicolithotomy in the late 1600s. An itinerant lithotomist with little anatomic
understanding but impeccable character, Beaulieu performed the often-lethal procedure in France through
the early 1700s. He is remembered by the urologic community as the subject of an old French nursery
rhyme, although some have suggested that it was really written as a satirical mockery of the Jacobinic
monks whose order was popular in France at the time. 4
In an attempt to avoid incisions, another form of surgical treatment, transurethral lithotrity, became more
common in the early 1800s. Lithotrity was developed through creative applications of everyday tools. The
Egyptian physicians were known to pass large wooden or cartilage cannulas through the urethra, followed
by manual aspiration of the stones from the bladder. A popular technique of the 1700s involved passage
of a long nail via the urethra; the nail was then struck with a blacksmiths hammer, fracturing the stone.
Although many other creative and colorful transurethral instruments were developed, technological
advancement in the modern era came in the form of the fenestrated lithotrite. This device allowed stones
to be grasped and crushed so their fragments could be evacuated from the bladder via glass or metal
suction bottles. Sir Philip Crampton was the first to introduce the manual crushing concept in Dublin (circa
1834). However, litholapaxy was not firmly established until Henry J. Bigelow, the famous professor of
surgery at Harvard, performed (1876) and popularized (1878) the procedure. 1 The mechanical crushing of
stones remained popular through the 1960s and 1970s, although it was fraught with complications when
performed by inexperienced urologists.5

In the 1950s, endoscopic electrohydraulic lithotripsy (EHL) was first performed in the Soviet Union. Over
the next 4 decades, multiple other modalities have been developed and allow safe transurethral or
percutaneous stone ablation.6

Problem
Vesical calculi refer to the presence of stones or calcified materials in the bladder (or bladder substitute
that functions as a urinary reservoir). These stones are usually associated with urinary stasis, but they
can form in healthy individuals without evidence of anatomic defects, strictures, infections, or foreign
bodies. The presence of upper urinary tract calculi is not necessarily a predisposition to the formation of
bladder stones.

Frequency
The incidence of primary bladder calculi in the United States and Western Europe has been steadily and
significantly declining since the 19th century because of improved diet, nutrition, and infection control. In
these countries, vesical calculi affect adults, with a steadily declining frequency in children. In the Western
hemisphere, vesical calculi primarily affect men who are usually older than 50 years and have associated
bladder outlet obstruction. However, bladder calculi remain common in less-developed countries and
areas such as Thailand, Burma, Indonesia, the Middle East, and North Africa. Although the prevalence of
bladder calculi is declining in these populations, it remains a disease that affects children, among whom
the disease is far more common in boys than in girls.6
In 1977, Van Reen published a symposium on idiopathic urinary bladder stone disease. 7 Unfortunately, no
definitive worldwide data accurately reflect the frequency of bladder calculi. This is mostly because of
poor hospital records in developing regions of the world. Despite several studies in countries with a high
incidence of the disease, the reporting is not uniform.

Etiology
Bladder outlet obstruction remains the most common cause of bladder calculi in adults. Prostatic
enlargement, elevation of the bladder neck, and high postvoid residual urine volume cause stasis, which
leads to crystal nucleation and accretion. This ultimately results in overt calculi. In addition, patients who
have static urine and develop urinary tract infections are more likely to form bladder calculi. In a study of
patients with spinal cord injuries (newly acquired neurogenic bladders) who were monitored for more than
8 years, 36% developed bladder calculi. More recent reports indicate that, because of better care of
patients with injured spinal cords, this rate has dropped to less than 10%.
Bladder inflammation secondary to external beam radiation or schistosomiasis can also predispose to
vesical calculi.8 The dystrophic calcifications that develop radiotherapy-related bladder and prostate
damage might serve as a nidus for stone formation. Congenital or acquired vesical diverticula may serve
a reservoir of urinary stasis, leading to stone formation. Other rare anatomic abnormalities that have been
implicated as contributors to stasis and stone formation include sliding inguinal hernias containing the
urinary bladder.9
Multiple underlying risk factors predispose to bladder stones in pediatric patients who undergo bladder
augmentation. Mathoera et al (2000) described risk factors for stone formation in 89 pediatric patients
who had undergone bladder augmentation and presented with bladder calculi. Cloacal malformations,
vaginal reconstructions, ureteral reimplantations, and bladder neck surgery were all associated with

higher risk for stone formation. Preventive antibiotic therapy for recurrent infections decreased the amount
of struvite stone formation but yielded no statistically significant reduction in overall stone formation. 10
Other etiologic factors for bladder stone formation include foreign bodies in the bladder that act as a nidus
for stone formation. These are subclassified into iatrogenic and noniatrogenic bodies. The first group
includes suture material, shattered Foley catheter balloons, eggshell calcifications that form on a catheter
balloon, staples, ureteral stents, migrating contraceptive devices, erosions of surgical implants, and
prostatic urethral stents.11,12,13,14,15 Stones on suture material may have an early presentation if sutures were
originally placed within the bladder lumen or may have a delayed presentation if they are caused by
erosion through the bladder wall.16 Noniatrogenic causes include objects placed into the bladder by the
patients for recreational and various other reasons.17
Metabolic abnormalities are not a significant cause of stone formation in patients with urinary diversions.
In this group of patients, the stones are primarily composed of calcium and struvite. In rare cases,
medications (eg, viral protease inhibitors) may be the source for bladder calculus formation. 18
In general, if an otherwise healthy person in the United States or Europe is found to have a bladder stone,
a complete urological evaluation must be undertaken to find a cause for urinary stasis. Examples
include benign prostatic hyperplasia, urethral stricture, neurogenic bladder, diverticula, and congenital
anomalies such asureterocele and bladder neck contracture. In females, examples include an
incontinence repair that is too tight, cystoceles, and bladder diverticula. 19

Pathophysiology
Most vesical calculi are formed de novo within the bladder, but some may initially have formed within the
kidneys as a dissociated Randall plaque or on a sloughed papilla and subsequently passed into the
bladder, where additional deposition of crystals cause the stone to grow. However, most renal stones that
are small enough to pass through the ureters are also small enough to pass through a normally
functioning bladder and unobstructed urethra. In older men with bladder stones composed of uric acid,
the stone most likely formed in the bladder. Stones composed of calcium oxalate are usually initially
formed in the kidney.
The most common type of vesical stone in adults is composed of uric acid (>50%). Less frequently,
bladder calculi are composed of calcium oxalate, calcium phosphate, ammonium urate, cysteine, or
magnesium ammonium phosphate (when associated with infection). 20,21 Interestingly, patients with uric
acid bladder calculi rarely ever have a documented history of gout or hyperuricemia. In many cases, the
core is composed of one chemical, while layers of different chemicals form around it.
Pediatric stones are composed mainly of ammonium acid urate, calcium oxalate, or an impure mixture of
ammonium acid urate and calcium oxalate with calcium phosphate. 22 The common link among endemic
areas relates to feeding infants human breast milk and polished rice. These foods are low in phosphorus,
ultimately leading to high ammonia excretion. These children also usually have a high intake of oxalaterich vegetables (increased oxalate crystalluria) and animal protein (low dietary citrate). 23,7,22 Bladder stones
in patients with spinal cord injuries are often composed of struvite or calcium phosphate.
Vesical calculi may be single or multiple, especially in the presence of bladder diverticula. Vesical calculi
can be small or large enough to occupy the entire bladder. Their physical features range from soft to
extremely hard and from having smooth-faceted surfaces to jagged spiculated surfaces, the latter termed
"jack" stones based on their resemblance to the metal objects in the children's game Jacks (see image

below). In general, most vesical calculi are mobile within the bladder, although some stones are fixed
when they form on a suture, on the intravesical portion of a papillary tumor, or on retained stents.

Two delicate jack stones removed prior to open prostatectomy.

In regions where vesical lithiasis is endemic among children, stone formation is more common among
boys younger than 11 years, more common among people from low socioeconomic backgrounds, not
usually associated with renal calculi, and relatively less likely to reoccur after treatment (when compared
with upper tract calculi).24

Presentation
The presentation of vesical calculi varies from completely asymptomatic to symptoms of suprapubic pain,
dysuria, intermittency, frequency, hesitancy, nocturia, and urinary retention. 21 Parents of children with
vesical calculi may notice priapism and occasional enuresis.8
Other common signs include terminal gross hematuria and sudden termination of voiding with some
degree of associated pain referred to the tip of the penis, scrotum, perineum, back, or hip. The discomfort
may be dull or sharp and is often aggravated by sudden movements and exercise. Assuming a supine,
prone, or lateral head-down position may alleviate the pain initiated by the stone impacting the bladder
neck by causing it to roll back into the bladder. Less specific signs of vesical calculi include microscopic or
gross hematuria, pyuria, bacteriuria, crystalluria, and urine cultures that demonstrate urea-splitting
organisms.
A history of prior pelvic surgery should be sought in all patients, especially when synthetic materials were
implanted.25
Common physical examination findings include suprapubic tenderness, fullness, and, occasionally, a
palpable distended bladder if the patient is in acute urinary retention. Associated findings include
cystoceles in women, stomal stenosis (if the patient had undergone prior urinary diversion), and
neurological deficits in patients with neurogenic bladder.
Historically, bladder calculi were diagnosed based on transurethral passage of van Buren sounds. The
contact of the van Buren sounds with the stones causes transmission of a clicking noise or vibration,
which confirms the presence of the stone. Because of advancements in cystoscopy, this maneuver is
rarely used today. Currently, abdominopelvic planar radiography is used to easily identify radio-opaque

stones. However, adult calculi, which are composed predominantly of uric acid, are radiolucent and,
unless coated with calcium, are more difficult to visualize on radiographs. Cystoscopy, noncontrast CT
scanning, and ultrasonography are common diagnostic methods used to confirm the presence of bladder
calculi.8

Indications
Because a bladder stone is in itself a sign of an underlying problem, removal of the stone and treatment
of the underlying abnormality are nearly always indicated. Management of the underlying cause of stone
formation (eg, bladder outlet obstruction, infections, foreign body, diet) has been integral to preventing
recurrence. Recent literature describes treatment of bladder calculi without relieving outlet obstruction, but
the follow-up period was not long enough to warrant this as general practice. 26

Relevant Anatomy
In men, the main anatomical problem that leads to vesical obstruction is prostatic enlargement. The
prostate forms a ringlike growth around the vesical neck and, when hypertrophic, can significantly impede
the flow of urine. Stasis due to this blockage is responsible for the deposition of layer upon layer of new
stone material.
In women, voiding dysfunction and urinary stasis can occur but are less commonly associated with
calculi. Typical anatomic findings include cystoceles, enteroceles, or findings of prior urethral surgery, all
of which contribute to elevated residuals. With rare exceptions, any foreign body that cannot escape the
bladder is calcified and eventually forms a stone.

Contraindications
The only contraindication to bladder stone removal would be existence of the stone in a medically
unstable or near-terminal asymptomatic patient.
In general, most vesical calculi procedures are performed via endoscopy. However, when the stone is too
large or too hard or if the patient's urethra is too small (eg, in children) or surgically altered, complicating
access to the bladder, the open or percutaneous suprapubic surgical approach is preferable.
Relative contraindications exist to certain types of bladder stone ablative techniques. Electrohydraulic
lithotripsy (EHL) should be used with great caution in patients with small-capacity bladders and those with
cardiac-pacing or defibrillation devices. Percutaneous lithotripsy may be more hazardous in patients who
have undergone prior lower abdominal surgery or prior pelvic surgery or who have small-capacity
noncompliant bladders.
Pregnancy is a relative contraindication to some forms of lithotripsy (eg, extracorporeal shock-wave
lithotripsy [ESWL], EHL, mechanical lithotrity), but the benefits of eliminating a source of infection,
retention, or pain with other modalities (eg, holmium laser, lithoclast), as well as a potential complicator of
vaginal delivery if stones are large, may outweigh the risk of intervention. 27
Otherwise, the usual contraindications to any type of surgery also apply here.