Bladder Stones Clinical Presentation: History and Physical Examination

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Presentation

History and Physical Examination

The presentation of vesical calculi ranges from a complete absence of symptoms to the presence of suprapubic pain, dysuria, intermittency, frequency, hesitancy, nocturia, and urinary retention.^[3]Parents of children with vesical calculi may notice priapism and occasional enuresis.^[10]

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 when the stone contacts the bladder neck by causing the stone to roll back into the bladder.

A history of prior pelvic surgery should be sought in all patients, especially when synthetic materials were implanted.^[26]

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 neurologic deficits in patients with neurogenic bladder.

Historically, bladder calculi were diagnosed on the basis of transurethral passage of van Buren sounds. Contact between a van Buren sound and a stone causes transmission of a clicking noise or vibration, which confirms the presence of the stone. Because of advances in cystoscopy, this maneuver is not used today. Currently, imaging studies are used to identify bladder stones (see Workup).

Differential Diagnoses

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Media Gallery

Multiple laminated bladder calculi in patient with neurogenic bladder.
Endoscopic view of spiculated "jack" stone with erythematous bladder mucosa in background.
Large calculus visible on plain film of intravenous pyelogram performed for hematuria.
Ex vivo photograph of bladder stone.
Two delicate "jack" stones removed before open prostatectomy.
Bladder stone accretion on matrix. Patient had history of urinary tract infections and presented with irritative voiding symptoms and microscopic hematuria. Upper-tract evaluation findings were normal, but cystoscopy demonstrated calculus. Upon laser treatment of stone, soft matrix core was encountered beneath glistening outer core. Exposed matrix core is visible in crevices.
Bladder stone accretion on matrix. Patient had history of urinary tract infections and presented with irritative voiding symptoms and microscopic hematuria. Upper-tract evaluation findings were normal, but cystoscopy demonstrated calculus. Upon laser treatment of stone, soft matrix core was encountered beneath glistening outer core. Exposed matrix core is visible in crevices.
Laser destruction of stone. Note small lacuna generated in stone as result of laser energy. At lower power settings, stone can be quickly reduced to dust.
Layered nature of bladder calculus exposed as laser strips away surface.

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Author

Joseph Basler, MD, PhD Thomas P Ball Residency Education Professor, Urology Residency Program Director, Department of Urology, University of Texas Health Science Center at San Antonio; Chief, Section of Urology, Audie Murphy Veterans Affairs Hospital

Joseph Basler, MD, PhD is a member of the following medical societies: American Urological Association, Society of University Urologists, SWOG, Texas Medical Association, Society for Basic Urologic Research, Society of Urologic Oncology

Disclosure: Nothing to disclose.

Coauthor(s)

Joel A Leon-Becerril, MD

Joel A Leon-Becerril, MD is a member of the following medical societies: American Medical Association, Pan-American Trauma Society

Disclosure: Nothing to disclose.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, Society of University Urologists

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: AUA Journal of Urology<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical; Olympus, .

Acknowledgements

Christopher H Cantrill, MD Resident Physician, Department of Urology, University of Texas Health Sciences Center at San Antonio

Christopher H Cantrill, MD is a member of the following medical societies: American Association of Clinical Urologists, American Urological Association, and Endourological Society

Disclosure: Nothing to disclose.

Aldo Ghobriel, MD Staff Physician, Department of Surgery, Division of Urology, University of Texas Health Sciences Center at San Antonio

Aldo Ghobriel, MD is a member of the following medical societies: American Medical Association and American Urological Association

Disclosure: Nothing to disclose.

Leonard Gabriel Gomella, MD, FACS The Bernard W Godwin Professor of Prostate Cancer Chairman, Department of Urology, Associate Director of Clinical Affairs, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University

Leonard Gabriel Gomella, MD, FACS is a member of the following medical societies: American Association for Cancer Research, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Urological Association, Sigma Xi, Society for Basic Urologic Research, Society of University Urologists, and Society of Urologic Oncology

Disclosure: GSK Consulting fee Consulting; Astra Zeneca Honoraria Speaking and teaching; Watson Pharmaceuticals Consulting fee Consulting

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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