Sexually Transmitted Diseases - I. I. Mavrov 2005

Diseases of the Genital Organs of Various Etiologies
Urethral Calculi

Urethral stones occur predominantly in men, considerably less frequently in women, and quite often in children. They are classified into Primary and secondary urethral stones. Primary stones are those that originate directly within the Urethra itself, forming in cases of urethral fistulas, strictures, diverticula, or prolonged retention of small Foreign bodies in the urethra. Secondary stones or their fragments originate in the upper Urinary Tract and become lodged in the urethra as they pass, where they continue to grow. Primary stones are observed less frequently than secondary ones.

Urethral stones in men. These are categorized into stones of the anterior and posterior urethra. Secondary stones typically occur in the anterior urethra. Having formed in the upper urinary tract, they descend and become lodged in the pendulous urethra. Small, rounded stones do not remain there for long and are usually passed spontaneously during urination. Larger stones may linger in the urethra for a longer period, particularly in the navicular fossa or the bulbar portion.

Based on their Location, they are classified as stones in the urethra proper; stones in a urethral diverticulum; and mixed forms (urethrovesical, urethroprostatic, urethroscrotal). Prostatic stones that protrude with their free edges into the urethral lumen, as well as stones in perineal fistulas in patients with urethral strictures, are also classified as urethral stones.

Urethral stones in men are most often solitary, though multiple stones may also occur. The size of the stones is inversely proportional to their number and depends on their location: the largest are found in urethral diverticula, while smaller ones occur within the urethra itself.

The shape of the stones is highly variable and generally corresponds to the section of the urethra they occupy as they grow.

The composition of urethral stones includes uric acid, urates, and phosphates. Mixed stones also occur, featuring a core of uric acid salts and a surface layer of phosphates. The surface of a stone is smooth if it consists of uric acid salts, and rough or granular if composed of phosphate salts. A groove is frequently present On the surface of the stone, allowing urine to flow past and thereby preventing urinary retention.

Clinical presentation. A stone in the urethra causes pain and impairs urination (manifesting as difficulty in urinating and a weakened urinary stream). Obstruction of the canal leads to Acute Urinary Retention. These changes may appear suddenly or develop gradually. Stones in the posterior urethra cause perineal pain, along with frequent and painful urges to urinate. The urinary stream is irregular in shape.

In some cases, a stone may remain in the urethra for a prolonged period without causing any symptoms. As a result, There is a slow development of urethral dilation proximal to the site of stone impaction, accompanied by inflammation of the affected urethral segment that may spread as suppuration toward the Urinary Bladder. Urine in such cases is alkaline, and gross Hematuria is observed. In some patients, urethritis leads to purulent urethral discharge. Frequently, a stone can provoke an inflammatory process in the urethra, resulting in periurethral abscess formation and fistulas. Sufficient stretching of the urethra may lead to The formation of a urethral diverticulum. If mucosal stretching does not occur, urinary extravasation and fistulas may develop, with infiltration of the Tissues surrounding the urethra.

Diagnosis. Stones in the pendulous and scrotal portions of the urethra can be palpated through the external integument. If the stone is located in the navicular fossa, it can be visualized upon inspection. To diagnose a stone in the posterior urethra, the Perineum and Prostate Gland are palpated. If the stone cannot be palpated, a metal sound is introduced into the urethra, which encounters an obstruction and produces a frictional sensation. More precise diagnostic Methods include urethrography or ultrasound. Urethroscopy is occasionally utilized for so-called invisible stones. In the presence of fistulas, the stone can be felt by introducing a thin probe into the fistulous tract.

Treatment. Stones in the anterior urethra are removed through the external urethral meatus. If the stone is located in the navicular fossa, the margins of the external meatus are spread apart, and the stone is extracted with forceps. Meatotomy is indicated if the external meatus is narrow. When a small stone is lodged in the pendulous urethra, massage movements can be applied to advance it toward the external meatus and grasp it with forceps. If this is not feasible, an attempt should be made to extract it using specialized urethral forceps under the guidance of Palpation or a urethroscope. Should this manipulation fail, the stone can be pushed back into the urinary bladder and crushed there. Urethrolithotomy is performed in certain cases. Most often, this necessitates urinary diversion via the creation of an suprapubic cystostomy.

Stones in the prostatic urethra are removed via the urinary bladder. A small stone in the posterior urethra is pushed into the bladder with a sound and crushed there. In cases of a fixed stone in the posterior urethra, a urethroprostatic stone, or concurrent urinary infection, perineal lithotomy is performed by incision of the urethra over the stone. For a urethrovesical stone, it is extracted via the urinary bladder.

Urethral stones in women. Primary stones in the urethra arise in the presence of a urethral diverticulum, where they are most commonly localized. Secondary stones are observed very rarely, which is attributable to the short length of the female urethra, its significant distensibility, and its nearly straight course.

Urethral stones in women may be solitary or multiple. Solitary stones are ovoid or spherical and can attain large sizes. Multiple stones are small in size and irregular in shape. The stones may consist of urates, phosphates, and oxalates.

Clinical presentation. When a stone becomes lodged in the urethra, acute pain occurs, and the act of urination is disrupted. If the stone remains in place for some time, the female patient experiences a sensation of heaviness behind the pubic bone and in the region of the external genitalia. Pain arises in the sitting position and during walking. Urination is difficult, frequent, and painful; Urinary Incontinence is noted. Urinary retention typically does not occur. The urine is cloudy and contains Blood and pus. An inflammatory infiltrate sometimes develops at the site of the stone, which, in the event of suppuration, leads to perforation of the urethrovaginal wall and elimination of the stone through the resulting opening.

Diagnosis is established without difficulty. Upon inspection and palpation of the vaginal introitus, a stone is readily detected, and its nature is recognized by its density. To refine the diagnosis, examination with a metal sound, radiography, and ultrasound are performed.

Treatment. In women, urethral stones are removed with forceps or pushed into the urinary bladder and crushed there. If the stone is located in a urethral diverticulum, an attempt should be made to extract it through the urethra. If the neck of the diverticulum is narrow, a longitudinal incision of the diverticulum is performed, the stone is extracted, and the diverticulum is resected.

Urethral stones in children occur most frequently between the ages of 2 and 7 years. Secondary stones originating in the Kidneys are typically observed. They are found in all PARTS OF THE urethra, but most commonly in its narrowest segments (the membranous portion, the navicular fossa). Urinary stasis, strictures, and congenital urethral diverticula contribute to the formation of stones.

Compared to solitary stones, multiple stones form less frequently. The diameter of the stones usually does not exceed 1–2 cm, but stones the size of a pigeon's egg or larger are occasionally observed (especially in the prostatic urethra). These stones may enlarge toward the bulbar portion of the urethra and the cavity of the urinary bladder (vesicourethral stones). In such cases, the stones have an hourglass (pyriform or mushroom-like) shape.

The Clinical presentation of urethral stones in children is characterized by diverse manifestations. Pain may be variable (acute, dull, intermittent, or constant). It frequently becomes severe, is localized in the urethral region, and intensifies during urination. In such instances, the child frequently grasps the Penis with their hands in an effort to alleviate the acute pain. Pain often radiates to the perineum and the glans penis.

Urinary retention is observed, after which urine begins to pass involuntarily in drops, bypassing the obstruction. In cases of vesicourethral stones, urinary incontinence is noted, caused by sphincter paresis resulting from inflammatory infiltration or mechanical factors that prevent complete closure of the sphincter.

Primary urethral stones in children often remain asymptomatic for months or even several years. In some cases, patients learn to pass urine by manually displacing the stone. However, once inflammatory Changes in the urethral mucosa develop, pain, difficulty in urination, and urethral discharge appear. The formation of periurethral abscesses, urinary fistulas, etc., is possible.

Diagnosis. Detecting stones in a boy's urethra generally presents no difficulty. The Nature of the Complaints (acute, severe pain in the genital region, impaired urination, etc.) and the child's behavior (frequently grasping the penis to alleviate pain) indicate the presence of a urethral stone. Thorough palpation of the penis along its entire length, particularly on its inferior surface, convinces the physician of the presence of a foreign body. In A number of cases, by spreading the margins of the external urethral meatus, a lodged stone can be visualized. Passing a metal sound through the urethra generally provides a tactile sensation of touching the stone. Detection of a stone in the posterior urethra is achieved by rectal examination. Radiographic imaging and ultrasound are of decisive importance for establishing the diagnosis.

Treatment. Urethral stones in children are frequently passed spontaneously. If the stone bypasses the narrowest (membranous) part of the urethra, there is every reason to expect its spontaneous passage. In some instances, upon detecting a stone in the urethra, attempts are made to gently advance it toward the external urethral meatus using the fingers. Subsequently, it is extracted using a grooved probe or a Volkmann's spoon. For a narrow external urethral meatus, a meatotomy is performed.

The advancement of the stone toward the external urethral meatus and its expulsion outwardly typically require a certain amount of time (sometimes several days). Therefore, to accelerate the passage of the stone, the consumption of large quantities of fluid is prescribed, and 3–5 ml of a 0.5–1% novocaine solution is instilled into the urethra, followed after a few minutes by an equal amount of sterile glycerin or liquid petrolatum. The Procedure is repeated several times.

If removal of the stone is impossible (due to large volume or diverticular stones), surgical removal of the calculus via external urethrotomy is indicated.