THE URINARY BLADDER STONES ,FISTULA DIVERTICULUMDr. Ali Kamal M. SamiM.B.Ch.B. M.A.U.A.F.I.B.M.S. M.I.U.A.
DefinitionA primary bladder stone is one that develops in sterile urine;it often originates in a kidney and passes down the ureter to thebladder, where it enlarges.A secondary bladder stone occurs in the presence ofinfection, bladder outflow obstruction, impaired bladderemptying or a foreign body such as nonabsorbablesutures, metal staples or catheter fragments.
Composition :Oxalate calculusUric acid and urate calculiCystine calculusTriple phosphate calculus A bladder stone is usually free to move in the bladder. It gravitates to the lowestpart of the bladder which is the outflow when the patient is erect or sitting. Inthe recumbent position (and at cystoscopy) the stone occupies a positionbehind the interureteric ridge..
Males are eight times more often affectedthan femalesSymptoms 1-asymptomatic 2-Frequency.3- sensation of incomplete bladderemptying.4- Pain (Strangury) is most often foundin patients with a spiculated oxalatecalculus. It usually occurs at the end ofmicturition and is referred to the tip ofthe penis or to the labia majora, morerarely to the perineum or suprapubicregion. 5-Haematuria 6-Interruption of the urinary stream7-Symptoms of urinary infection
Examination•Rectal or vaginal examination is usually normal; occasionally alarge calculus is palpable in the female.•Examination of the urine usually reveals microscopic haematuria,pus or crystals typical of the calculus.•Radiography — in most patients, the stone is visible on a plain X-ray .If the stone is radiolucent, a filling defect may be visualised onIVU.•Cystoscopy is essential and most stones nowadays can be dealtwith endoscopically.•ULTRASOUND examinationTreatment•vesicolitholapaxy•vesicolithotomy•Percutaneous suprapubic litholapaxy•Extracorporeal shock wave lithotripsy (ESWL)
Removal of a retained Foley catheterThis is not an uncommon problem and is usually causedby the channel which connects the balloon to the side armbecoming blocked, usually at the very distant end. Thebest way of dealing with this problem is to further inflatethe balloon with 20 ml of water and then burst the balloonpercutaneously using a spinal needle under ultrasoundscreening. The instillation of fluid such as ether to dissolvethe balloon is not recommended because fragments ofballoon may be left behind. However the balloon isburst, it is important to subsequently cystoscope thepatient to ensure that any fragments are removed beforethey can form a foreign body calculus.
Foreignbodies in the bladderThe commonestforeign body is a fragment ofcatheter balloonComplications Lower Perforation of a foreign Bladder urinary tract of the body in the stone infection bladder wall bladder Treatment A small foreign body can usually be removed per urethra by cystoscope.Occasionally, a suprapubic approach using thePercutaneous insertion of a cystoscope is needed.
Diverticulum of the bladderThe normal intravesical pressure during voiding is about35—50 cmH2O. Pressures as great as 150 cmH2O may bereached by a hypertrophied bladder endeavouring to forceurine past an obstruction. This pressure causes themucous lining between the inner layer of hypertrophiedmuscle bundles to protrude, so forming multiple saccules.If one or more, but usually one, saccule is forced throughthe whole thickness of the bladder wall, it becomes adiverticulum. Congenital diverticula are due todevelopmental defect.
Etiology ofdiverticulumCongenital diverticulum — This is rare. It may be situated in themid line anterosuperiorly and represent the unobliterated vesical end of theurachus. It empties with the bladder and is symptomless. Others in the usualsituation on the base of the bladder can occur without obstruction, and may require excision because of the risk ofchronic infection or stone formation in a young adultPulsion diverticulum —the usual causative obstructive lesion is bladder outflow obstruction.
ComplicationsRecurrent urinary infection; Squamouscell metaplasia and leucoplakia areinfrequent complications.Bladder stoneHydronephrosis and hydroureterNeoplasm
Clinical featuresAn uninfected diverticulum of the bladder usuallycauses no symptoms. The patient is nearly alwaysmale (95 per cent) and over 50 years of age.There are no pathognomonic symptoms; they arethose of lower urinary tract obstruction, recurrenturinary infection and pyelonephritis. Haematuria(due to infection, stone or tumor).
Diagnosis;CystoscopyIntravenous urographyRetrograde cystographyUltrasonographyIndications for operationOperation is only necessary for the treatment ofcomplicationsTraction diverticulum ( hernia of the bladder)A portion of the bladder protruding through theinguinal or femoral hernial orifice occurs in 1.5 percent of such herniae treated by operation.
Urinary fistulaeCongenital urinary fistula Ectopia vesicae; in association with imperforate anusTraumatic urinary fistulaVesicovaginal fistulaEtiology Obstetrics — the usual cause is protracted or neglected labour; Gynaecological — the operations chiefly causing this complication are total hysterectomy and anterior colporrhaphy; Radiotherapy Direct neoplastic infiltration.
Clinical featuresThere is leakage of urine from the vagina and as a consequence excoriation ofthe vulva occurs. Digital examination of the vagina may reveal a localisedthickening on its anterior wall, or in the vault in the case of post hysterectomyfistula. On inserting a vaginal speculum, urine will be seen escaping from anopening in the anterior vaginal wall.Differential diagnosis between a ureterovaginal and vesicovaginal fistula can bemade if a swab is placed in the vagina and a solution of methylene blue isinjected through the urethra; the vaginal swab becomes coloured blue if avesico-vaginal fistula is present.Treatment Usually, operative treatment is required. A urethral andsuprapubic catheter should be left in situ for 10—14 days.
Fistula arising as a result of infectionThe commonest cause is diverticulitis of the colon. They may also follow Crohn’sdisease, appendix abscess or pelvis sepsis in association with acute salpingitis, ormay be the result of surgery and radiotherapy within the pelvis.Fistula due to carcinomaPrimary bladder tumors very rarely fungate through the abdominal wall unless anopen cystotomy has been performed .involvement of the bladder by tumours ofcervix, uterus, colon and rectum can produce fistulae, as may lymphosarcoma ofthe small gut. Carcinoma of the prostate rarely produces a rectal fistula.Treatment is palliative