CASE REPORT: Bladder Calculi

I. ABSTRACT

Bladder stones account for approximately 5% of all urinary system stones and are prevalent
among children living in poor or rural regions due to low socioeconomic status, a diet with low protein,
animal milk, and dehydration. The symptoms in children with bladder stones are usually urgency,
frequency, incontinence, dysuria, pyuria, difficulty voiding, and fever, small caliber of urinary stream,
lower abdominal pain and urinary intermittency. Herein, we report an 8-year-old child who presented
with dysuria and was diagnosed with a large urinary bladder stone weighing 52 grams, measuring 45cm x
30cm x 25cm in dimension successfully managed with open cystolithotomy. Early diagnosis and
management of bladder stones in the pediatric age group are crucial to prevent subsequent complications
including recurrent urinary tract infections, excessive antimicrobial use and dissemination of antimicrobial
resistance, and consequent renal insufficiency.

II. INTRODUCTION

A bladder stone is a rare condition that affects 5% of all urinary calculi. In the Philippines,
according to the Philippine Pediatric Society disease registry program, there are only 186 cases reported,
and 38 of which are from Central Visayas. Bladder stones are usually affecting males older than 60 years
old. However, in cases of endemic regions, it could affect children due to dietary intake, especially
prevalent among children living in poor or rural regions.[1] The giant bladder stone is not very common
and it is usually associated with nutritional factors.

The etiology of bladder stone is classified as primary and secondary related to association with
other diseases respectively. Primary or endemic bladder stone occurs in the absence of other urinary tract
pathologies, typically seen in children in areas with a diet lacking animal protein, poor hydration, and
recurrent diarrhea.[2] Secondary bladder stone occurs in the presence of other urinary tract abnormalities,
including bladder outlet obstruction, neurogenic bladder dysfunction, chronic bacteriuria, foreign bodies
including catheters, bladder diverticula, and bladder augmentation or urinary diversion.[3]

The symptoms and findings in children with bladder stones are usually urgency, frequency,
incontinence, dysuria, pyuria, difficulty voiding, small caliber of urinary stream, lower abdominal pain and
urinary intermittency, with fever reported in about 20–50% of these children.[4] Additionally, microscopic
or macroscopic hematuria in children with bladder stones has been noted in 33–90% of patients.[5] Most
bladder stones are composed of calcium oxalate (45–65%), followed by calcium phosphate (14–30%).[6]
Bladder stones tend to be larger in younger children and therefore have a lower rate of spontaneous
passage. Stones in children are usually bigger than 2.5 cm in diameter and are radiologically dense, and
open cystolithotomy is therefore the preferred treatment for their removal.[7] Prognosis is favorable after
open surgery. The recurrence of bladder stones after removal is extremely rare.[8] In this case report, we
present a case of a large bladder stone in a child weighing 52 grams, measuring 45cm x 30cm x 25cm in
dimension successfully managed with open cystolithotomy.
 III. PATIENT CASE PRESENTATION

An 8-year-old male child presented to our medical institution with 1-month history of dysuria
associated with abdominal pain with a pain score of 8/10. During the 1-month period before admission,
patient’s mother noted that for the patient to be able to urinate, he squeezes the tip of his penis with one
hand, and with the other hand, he inserts one fingertip to his anus. His symptoms worsened which
prompted consult at our institution.

Patient was born to an 18-year-old G6P5(5005) mother. He was born term, delivered via normal
spontaneous delivery at a birthing center. Newborn screening and hearing screening tests were done and
were noted to be normal. Patient was exclusively breastfed until 6 months of age. Semi-solid foods
introduced at 6mos of age. Developmental and behavioral milestones are at par with age. Patient was
noted to have previous history of bladder stones at 1 year old. Medical management was done during
that time with an unrecalled antibiotic which prompted relief of the condition. Patient has no food or drug
allergies, nor previous hospitalizations or past surgeries. Immunization is noted to be complete as claimed
by the mother done at their local health center. No noted family history of kidney or bladder stones. The
patient’s parents are both garbage collectors. He usually accompanies them during their work. They live
in a made-up house at the side of the street. And he often plays in a river polluted with garbage. His diet
consisted of starchy foods and foods with high fiber content. His water intake and total protein intake
(especially animal protein) were not sufficient.

On physical examination, the patient’s weight was 15kg

(<5 percentile) and height was 107cm (<5th percentile). Vital signs
th

were within normal limits but the patient was noted to be in pain.
Pertinent physical exam findings include dry gingival hemorrhages,
dry lips, distention and tenderness on hypogastric area, and noted
with multiple lesions on the dorsal and ventral aspect of his penis.
Other physical findings were normal. On laboratory investigation,
leukocyte count was 49.5 x 10^9/L with neutrophilic predominance
of 93%, and platelet of 577 x 10^9/L. Urinalysis revealed pH 7.0,
20-50 erythrocytes/high-powerfield (HPF), and more than 100
leukocytes/HPF with leukocyte clumps noted on microscopic
examination. On biochemical analysis, sodium, potassium, calcium
were all normal. Serum creatinine was noted to be elevated at 3.64
and also Procalcitonin of 50. Serum albumin was low at 2.0 g/dL,
with appropriate correction using Human albumin, his level
increased to normal. Blood culture and sensitivity had no growth
after 5 days of incubation. Urine culture and sensitivity isolated
organism was Pseudomonas aeruginosa about 50,000 colonies per
mL of urine sample and Piperacillin-Tazobactam were
administered. The levels of 24-hour urine collections for creatinine
clearance, calcium oxalate, phosphate, uric acid and cystine were
not processed due to financial constraints. An abdominal X-ray in
flat plate and upright position showed a large radiopaque bladder
stone, which was 3.0 cm in size (Figure 1). Figure 1. Abdominal Xray,
flat plate and upright
Patient was referred to Pediatric Urologist and underwent open
cystolithotomy under general anesthesia for bladder stone extraction
(Figure 2). Biochemical analysis of the stone showed positive for
calcium, ammonium, phosphate, and magnesium. A suprapubic Foley
catheter was inserted. Surgery proceeded smoothly and there were no
complications such as wound infection, suprapubic urinary leakage,
postoperative bleeding or catheter blockage. The Foley catheter was
retained for 2 weeks. Nutrition build up was started post operation
with F75 and F100 milk combined with feeding with computed
calories. On Hospital Day 20, patient had febrile episodes. Repeat
urinalysis and urine culture and sensitivity was done, still showed
infection but now with intermediate sensitivity with Piperacillin-
Tazobactam thus shifted to Levofloxacin taken for 7days. Suprapubic
catheter was also removed due to suspicion of catheter-related Figure 2. A 52kg bladder stone
infection and febrile episodes eventually resolved. Patient was measuring was extracted by
discharged with home medication of Levofloxacin. He was also referred open cystolithotomy
to their local health center for continuation and monitoring of his
nutrition build up. Upon follow up 1 week after discharged, post op site was noted to be infection due to
poor compliance of daily wound dressing. Patient was prescribed with Co-Amoxiclav to be taken for 7 days
and an antibacterial ointment to be placed every after dressing. Patient failed to follow up thereafter.

IV. DISCUSSION

Pediatric urolithiasis, especially of the bladder, is a rare occurrence. There are marked geographic
variations in the incidence of urinary tract stones in children. Although epidemiological data from some
parts of the world are unclear, it is estimated that the incidence of pediatric urolithiasis may range
between 1:10,000 and 1:7000 pediatric admissions. [9] The male:female ratio for bladder stones is 15:1,
and the peak age for occurrence is 2−5 years.[10]

The etiology of bladder stone is classified as primary and secondary related to association with
other diseases respectively. Primary or endemic bladder stone occurs in the absence of other urinary tract
pathologies, typically seen in children in areas with a diet lacking animal protein, poor hydration, and
recurrent diarrhea.[2] Secondary bladder stone occurs in the presence of other urinary tract abnormalities,
including bladder outlet obstruction, neurogenic bladder dysfunction, chronic bacteriuria, foreign bodies
including catheters, bladder diverticula, and bladder augmentation or urinary diversion.[3] Primary bladder
stones (endemic stones) have almost disappeared in developed countries, probably as a result of a more
balanced diet.[11] In some underdeveloped or developing countries, however, primary bladder stones still
constitute a significant problem, such as seen in this case who presented with the aforementioned risk
factors.

Symptoms of bladder stones in children vary with age. Renal colic and flank pain associated with
stone passage is uncommon in children. Hematuria, either microscopic or macroscopic, has been reported
in 33−90% of children with stones,[5] while lower abdominal pain or pelvic pain occurs in approximately
50% of childhood cases.[4] Urinary incontinence and urinary frequency, caused either by the stone itself
or by associated urinary infections, are also common manifestations of bladder stones. In infants, pain
from stones can mimic colic.[11] In preschool children, most commonly associated with stones are urinary
tract infections. [11] Our patient suffered from dysuria, lower abdominal pain, urinary incontinence and
microscopic hematuria, as reported in the literature.

Abdominal radiography, ultrasonography, intravenous pyelography (IVP) and computed

tomography (CT) are the most useful tools for the evaluation of children with stones.[10,11] Many clinicians
use plain abdominal radiography and ultrasonography for initial studies. Ultrasonography reveals many
types of stones, including some radiolucent stones, and may yield other clinically important findings such
as urinary obstruction or nephrocalcinosis. Many pediatric nephrologists use an abdominal flat plate and
ultrasound for routine surveillance in asymptomatic children, reserving the non-enhanced thin-cut helical
CT for patients who are symptomatic.[12] Open surgery is the preferred treatment of choice for removing
bladder stones[7] because the stones in children are usually > 2.5 cm in diameter and are radiologically
dense. In the present case, the bladder stone was 45cm x 30cm x 25cm and open cystolithotomy was
chosen by the pediatric surgeon.

The prognosis of bladder stones depends on the primary diagnosis and adherence to therapy.
Recurrence after surgical removal of the stone is unusual.[8] The patient was able to urinate normally. The
dysuria and abdominal pain were eradicated in our patient by surgical removal of the stone.

V. CONCLUSION

Bladder stones in children are still a major problem, especially in developing countries. Risk factors
and thorough examination should be considered in diagnosing patients with bladder stone signs and
symptoms. Additionally, adequate daily fluid intake, prevention of dehydration, and nutritional support
are essential strategies to minimize the rising incidence of bladder stones in children living in endemic
areas.
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