A rare case of acute urinary retention: Anterior urethra stones
Anterior urethra stones are extremely rare causes of acute urinary retention. The data of 34 adult patients who presented with acute urinary retention between August 2011 and September 2017 and treated with anterior urethra were evaluated retrospectively. Their ages, sizes of stones, locations, etiological factors, physical examination findings, treatment modalities, operation period and complications were analyzed. All the patients were male and the mean age was 46.9 ± 17.88 years. All of the stones evaluated in the study were single and the mean stone size was 12.17 ± 3.23 (6-19) mm. Location of the urethral calculi was fossa navicularis in 12 (35.3%) patients, bulber urethra in 7 (20.6%) patients and penil urethra in 15 (44.1%) patients. A total of 20 patients had urinary calculi located in the other parts of the urinary system at the time of presentation. Stone of the 7 patients with fossa navicularis localized had been treated by intraurethral instillation of 2% lidocaine gel, the other 5 patients had been treated with ventral meatotomy. Urethra stone of the 7 patients with penile and bulbar urethra located were taken by the help of direct forceps without requiring any fragmentation operation. Other stones were treated with endoscopic holmium laser lithotripsy. As a result of surgery operations, urinary tract infection in 3 patients, urethrorrhagia in 2 patients and hematuria in 5 patients were observed. We consider that it is very important to to (to) keep anterior urethra stones in mind among differential diagnosis especially in male patients admitted with acute urinary retention
Keywords: acut urinary retention, urethra stones, penil pain
Urinary system stone disease constitute an important part of the administrations to the emergency clinics. Although there is not enough statistical data in our region, it is known than in the USA more than one million administrations related to urolithiasis to the emergency clinics per year.Findings in urinary system stone disease show changes depending on age and the general status of the patient, the location, the size and formation time of the stone.However, a large part of the cases are presented emergency units with complaints of renal colic[2-5].
Urethra stones disease is the least frequently seen urinary system stone disease. Its incidence is less than 1% and it has a quite different symptom from the upper urinary tract stone disease. Patients with urethral stone may administer with very different findings such as acute urinary retention, hematuria, difficulty in urination, dysuria, penile or perineal pain. Although urethra stones emerge in small sizes, yet they are rarely observed in stone structures reaching large dimensions resulting in very difficult treatment processes[6, 7]. There are two essential factors determining the clinical status of the cases in urethral stones.These are the urethra lumen structure and the size of the stone. In a natural urethral lumen, a stone that reaches large dimensions can make acute urinary retention, and it should be kept in mind that natural structure of a small stone may deteriorate and may cause the same effect in a narrowing of the urethra.In addition to all these, researches made in past years it is known that the most frequent complaints of patients who administered to clinics with urethral stones is acute urinary retention[8, 9].
Acute urinary retention is a urological emergency which is characterized by a sudden loss of urine output and a distended bladder. Mostly, there is a strong pain in the lower abdomen.However, rare cases of pain may not be observed in cases accompanied by neurological disorders. This case should not be confused with anuria observed in acute renal failure. While there is pathology in the urine production in patients with renal failure, there is a problem in the urinary excretion of urine from the bladder in acute urinary retention. Acute urinary retention may appear depending upon disorders that occur on detrusor muscle such as spinal cord injury, diabetic neuropathy, central nervous system tumors. But is often secondary to the pathologies of urinary flow. To these pathologies many clinical cases such as benign prostatic hyperplasia, urethral stenosis, pelvic organ prolapses, pelvic traumas, prostate, bladder neoplasms may be given as examples[12-15].The main aim of the treatment is to provide drainage of the urinary tract with proper catheterization and to protect the patient from pathologies that may arise secondary to urinary retention such as upper urinary tract damage, renal failure and urinary tract infections[14, 15].
Urethral stones have been rarely observed, when the articles in the past years literature have been examined, that most of the cases are case reports or small series.There is no detailed information about risk factors, diagnosis, treatment and follow-up approaches compared to other patients with acute urinary retention.In this retrospective study, 34 patients who administered to our clinic with acute urinary retention and whose anterior urethral stones were treated and followed-up were discussed by our results.
Materials and Methods
The files of 34 adult patients who presented with acute urinary retention between August 2011 and September 2017 and treated with the diagnosis of anterior urethral stone were evaluated retrospectively. Preoperative evaluation was performed with a medical history form recorded by the physician, urine analysis, routine hematological, biochemical examinations, direct urinary system graphy and non-contrast abdominal tomography. Age, presentation complaints, stone size, location, physical examination findings, etiologic factors, treatment modalities, duration and complications of the patients were analyzed retrospectively. Patients whose data were not complete were excluded from the study.
Percutaneous suprapubic cystostomy catheter was applied to all patients after the first clinical evaluation.Urinary ultrasonography was performed to all patients before catheterization.No pathology was observed in any patient to prevent suprapubic catheterization such as bladder cancer and inadequate bladder fullness.Aurine (A urine) culture was taken from each patient and a wide spectrumantibiotic (a broad-spectrum antibiotic) was started.Performed treatment procedures were shaped according to the size and location of the stone. All procedures were performed under sterile conditions.Stones smaller than 1 cm and with smooth surfaces that could be observed by fossa navicularis localized inspection were aimed to be taken out with physical manipulations under local anesthesia applied with 2% lidocaine gel. On the other hand, ventral meatotomy was performed on the stones which did not have a smooth surface or had more than 1 cm and fossa navicularis localized.Endourologic interventions were preferred in the treatment of all penile and bulbar urethral stones.When the procedures of application of endourological interventions are examined, lidocaine 2% gel was applied into the urethra in the lithotomy position. Cystourethroscopywas performed using a 0-degree lens passed into a 19. 5 Fr or 22 Fr endoscope.In addition to the patients who had urethral stenosis during cystourethroscopy, urethral pathologies were treated by surgical intervention.After the urethra stones were reached, and stones with the smooth surface smaller than 1 cm were taken out with the help of forceps. Other urethra stones were planned to advance to the bladder to perform holmium laser lithotripsy. In-situ holmium laser lithotripsy was applied to thestones that could not be advanced to the bladder.Holmium: Yttrium-Aluminum-Garnet laser device (Lisa Laser Spihinx 60, Germany) was used as lithotripter. During lithotripsy, differentprobes (different probes) 272μ and 550μ were preferred depending on the size ofthe (of the) stone. In all endourological interventions, sterile 0.9% NaCl solution was used for fluid irrigation. All applied meatotomy or endourologic procedures were performed under general or spinal anesthesia.
Patients data were expressed as mean ± standard deviation(minimum maximum). SPSS (Statistical Package for the SocialSciences in PASW Statistics) version 18.0 software was usedfor (used for) data analysis.
34 patients with acute urinary retention and those who were diagnosed by anterior urethral stones were included in the study. All the patients were male and the mean age was 46.9 ± 17.88(18-78) years.All the stones were radiopaque and as a result of the genitourinary system examination it was revealed that 15 (44.1%) of the stones were palpated in the urethra.In 34 patients whose main complaint were acute urinary retention and in addition to this complaint, high fever at 4 of these 34 patients and renal failure at 3 of them were observed.Urinary tract infection was detected in 15 (44.1%) cases. The most common detected microorganism was Escherichia coli (66.7%) (Table 1).
All of the stones evaluated in the study were single and the mean stone size was 12.17 ± 3.23 (6-19) mm.Location of the urethral calculi was fossa navicularis in 12 (35.3%) patients, bulber urethra in 7 (20.6%) patients and penil urethra in 15 (44.1%) patients(Table 2).A total of 20 patients had urinary calculi located in the other parts of the urinary system at the time of presentation. Of these 20 patients; 12 had renal calculi, 5 had bladder stones, 2 had distal ureteral stones, and 1 patient had both kidney stones and bladder stone.When the anamnesis forms were evaluated in details, 2 patients had endoscopic systolicatomy (cystolithotomy?), 3 patients underwent ureterorenoscopy, 1 patient had percutaneous nephrolithitis, 4 patients had transurethral resection of the prostate and 2 patients had frequent urethral infection.
Considering our treatment approaches, stones of the 8 patients without urethral mea stenosis and whose fossa navicaria localized were smaller than 1 cm in size and the surface area was evaluated as smooth were decided to taken out by physical manipulations following lidocadine gel application. While the stones of the 7 patients were successfully removed, 1 patient underwent ventral meatotomy. In addition, fossa navicularis localized stones of the 4 patients whose size was larger than 1 cm or had no smooth surface were also removed by ventral meatotomy.Cystourethroscopy was performed in all patients and urethra lumens were evaluated in detail. No pathological findings were recorded in the other parts of the urethra in these 12 patients treated without endourologic methods. On the other hand, the penil and bulber urethra stone of 7 patients, whose size was less than 1 cm in size, and the surface area was observed properly, was taken by the help of forceps. Urethral stones of the remaining 15 patients with penile and bulbar were planned to be advanced into the urethral stone bladder for fragmentation. In a total of 9 patients the urethral stone was successfully advanced into the bladder. Using holmium laser lithotripsy, the stones in the bladder were successfully fragmented and taken out with the help of forceps or evacuator.A total of 6 patients underwent in-situ holmium laser lithotripsy since the urethral stones could not be advanced into the bladder. All stones were successfully fragmented and taken out with the help of forceps.
When all procedures were evaluated, urethral stenosis was detected in 19 (55.9%) patients. During the preoperative evaluation, 2 patients were found to have ureteral stones, and these patients additionally received ureterorenoscopy.Similarly, 6 patients had bladder stones. Endoscopic systolithotomy was performed in these patients. The fragmentation of the stones was performed by holmium laser lithotripsy.The operation time was determined by subtracting the time used for these specified endourologic procedures from the recorded time for the total surgical procedure.The mean operative time was recorded as 18.67 ± 5.40 minutes. When the complications of the procedure were examined, urinary tract infection was detected in 3 patients, urethrorrhagia in 2 patients, and hematuria was observed in 5 patients lasting less than 24 hours and did not require blood transfusions.
Acute urinary retention, which is defined as the inability to make a sudden urination, is much more observed in the male population and the risk of encounter increases with age. Approximately while 10% of males in the 70s report acute urinary retention at least once, this rate reaches up to 33% in 80s.Acute urinary retention, mostly known as the disease of advanced elderly men, is rarely seen in children and women[15-18]. Previous studies have reported that the overall incidence of acute urinary obstruction in men with USA citizens is 4.5 to 6.8 per 1000 men. The publications made in the female population are quite limited and it is estimated that it is observed in 3 out of 100,000 women annually.
The most common cause of acute urinary retention is prostate disease, which is observed in an increasing prevalence in the aging population.However, etiologic factors show differences between sex and age groups. The development of acute urinary retention is mainly focused on two mechanisms. The first one is the resistance that increases the urine flow by mechanical or dynamic means, and the other is the deteriorations of the detrusor muscle[13, 15]. In this context, although urethra stones were extremely seen, they may cause obstruction in the urethra lumen due to mechanical causes.
Urinary stone diseases are among the oldest known diseases in human history. Its incidence varies in relation to many factors such as geographical region, dietary habits, gender, genetic and socio-cultural status. In our country, in the study by Akıncı et al. the prevalence of urinary stone disease was reported to be 14.8% and the incidence was 2.2%.In routine clinical practices, urethral stones are among the most rare group of urinary tract stone diseases. Epidemiological studies in the past years indicate that urethra stones are more common in the Middle and Far Eastern countries rather than in the Western world[6, 8, 22]. Urethral stones can be seen as primary, urinary tract stones can also be seen as secondary urethral stones by migrating stones at different localizations. In relation to this study, when Koga et al. examined the patients with 56 urethral stones, the incidence of stone in the upper urinary tract with urethra stone was reported to be 32%. In another study, Kiciler et al. had found this rate as 47.1%. In a retrospective multicentre study done by Jung et al. it was reported that upper urinary tract stones and/or hydronephrosis had increased the urethral stone risk 3-fold.In our study 58.8% of patients were found to have stone in another localization of the urinary system along with urethral stone.In addition to this information, it has been known that in urethra stone formation, many etiological factors such as urinary tract infections, urethral strictures, urinary schistosomiasis, history of endourologic intervention, pelvic trauma, forgotten foreign bodies, urethral diverticulum and fistulas play a role[6, 8, 24-28].Urethra stone diseases are predominantly seen in the male population. This is directly related to the anatomy of the urethra.Normal adult male urethra diameter is 30 Fr and it allows natural stones that are smaller than 10 mm to be expelled from the body naturally. Any pathology that may occur in the urethra lumen is a predisposing factor for the formation of stones in the urethra. In a study of 36 patients with urethral stones, urethral pathology was detected in 47% of patients .In another study by Kiciler et al. it was found that 35.3% of urethral pathology was found in patients with urethral stones.In our study, urethral pathology was observed in 55.9% of patients.
The first step in the treatment of urethral stones causing acute urinary retention is the placement of suprapubic cystostomy catheter. It should always be kept in mind that persistence of urethral catheter application in these patients may lead to pathologies that are extremely difficult to treat in the urethra. Treatment procedures of anterior urethral stones must be evaluated according to the stone size, localization, anatomical structure of urethra, age and sex of the patient.Many different methods such as milking, ventral meatotomy, forceps extraction, extracorporeal shockwave lithotripsy, transurethral lithotripsy have been used in the treatment[22, 23, 30-35].In a clinical study conducted on 18 patients with urethral stones smaller than 10 mm, and without urethral stricture, it was decided to take out urethral stones as conservatively with the help of physical manipulation with 2% lidocaine gel application into the urethra.In their study, they reported that 14 patients were completely treated of urethral stones and their success rate was 77.8% .In our study, similar procedure had been applied to 8 patients with fossa navicularis stone and the success rate had been observed as 87.5%.Meatotomy was among the preferable treatments for large size or lumen implanted fossa navicularis stones.In our study, a total of 5 patients with similar features underwent ventral meatotomy and the success rate was recorded as 100%.The use of endoscopic treatment methods that provide direct vision in the treatment of all the stones in the other parts of the urethra is very important in terms of the least damage to the treatment procedures of the urethral mucosa. During the transurethral lithotripsy process, very different lithotriptors can be used. However, the use of holmium laser in the endourology in parallel with technological innovations appears to be prominent. According to previous studies, Maheshwari and Shah reported that they achieved 100% success in in-stu holmium laser lithothipses with dimensions ranging from 7 to 22 mm in 18 urethral stones and they did not follow major intraoperative complications.In our study, holmium laser lithotripsy was applied successfully in all patients with low complication rates in the fragmentation of urethral stones.
There are some limitations exist with this study such as retrospective nature, limited numbers of subjects and absence of biochemical analysis of stones that were managed.
When the past year studies were examined, there was a limited number of publications on anterior urethral stones and no detailed information about clinical approaches was found as in other urinary stone diseases.In the patients with acute urinary retention, we think that the application of correct treatment algorithms among the differential diagnosis of urethral stones is extremely important in protecting the cases against the damage to the difficult urethra diseases.
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