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. [2] 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 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. [23]
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).
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Multiple laminated bladder calculi in patient with neurogenic bladder.
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Endoscopic view of spiculated "jack" stone with erythematous bladder mucosa in background.
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Large calculus visible on plain film of intravenous pyelogram performed for hematuria.
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Ex vivo photograph of bladder stone.
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Two delicate "jack" stones removed before open prostatectomy.
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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.
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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.
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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.
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Layered nature of bladder calculus exposed as laser strips away surface.
