Makindo Medical Notes

The risk is higher the more you drink, although there's no proven "safe" level of alcohol in pregnancy. Not drinking at all is the safest approach.

About Bladder Stones

Bladder Stones are hard masses of minerals that form in the bladder, typically due to concentrated urine. They are endemic in certain regions, particularly where dietary practices lead to high urine mineral concentrations. Bladder stones can vary in size and number and may cause significant discomfort and complications if not treated promptly. Bladder stones are more prevalent in some countries due to dietary and genetic factors.

Aetiology

• Urinary Outflow Obstruction: Conditions such as Benign Prostatic Hyperplasia (BPH) in men and urethral strictures can lead to incomplete bladder emptying, increasing the risk of stone formation.
• Foreign Bodies: Indwelling catheters, sutures, or other foreign materials in the bladder can act as nidus for stone formation.
• Stone Characteristics: Bladder stones can be single or multiple and vary from large to very small sizes, impacting the severity of symptoms and management approach.

Risks for stones

• Age: Older adults, particularly males over 50, are at higher risk due to increased incidence of BPH and other urinary tract obstructions.
• Male Gender: Males are more prone to bladder stones due to the higher prevalence of urinary outflow obstructions like BPH.
• Chronic UTIs: Recurrent urinary tract infections can alter urine pH and promote stone formation.
• Dehydration: Concentrated urine increases the risk of mineral precipitation and stone formation.
• Dietary Factors: High intake of certain minerals such as calcium and oxalate can contribute to stone formation.
• Neurological Disorders: Conditions like spinal cord injuries that affect bladder function can lead to stone formation.

Causes

• Ovulatory Problems: While not directly related to bladder stones, hormonal imbalances can affect urinary habits and hydration status.
• Sperm Quality: Irrelevant to bladder stones; likely a copy-paste error from infertility content.
• Endometriosis: Can sometimes involve the urinary tract, leading to stone formation.
• Blocked Fallopian Tubes: Irrelevant to bladder stones; likely a copy-paste error.
• Unexplained: In some cases, no specific cause is identified despite thorough evaluation.
• Other Factors: Including metabolic disorders, genetic predispositions, and exposure to certain toxins or medications.

Clinical Presentation

• Hematuria: Presence of blood in the urine, which can be microscopic or gross.
• Urinary Tract Infections (UTIs): Recurrent or persistent UTIs are common due to stone-induced irritation and obstruction.
• Sepsis: Severe infections can lead to systemic inflammatory response and sepsis, particularly in immunocompromised individuals.
• Abdominal Pain: Typically dull or colicky ache in the lower abdomen due to bladder irritation or obstruction.
• Other Symptoms: Including urinary frequency, urgency, dysuria (painful urination), and pain during urination.

Differential Diagnosis

• Malignancy: Bladder or prostate cancer can cause hematuria and urinary symptoms similar to bladder stones.
• Renal Tuberculosis (TB): Can present with hematuria, UTIs, and lower abdominal pain.
• Other Urological Conditions: Such as bladder cancer, urethral strictures, or interstitial cystitis.
• Gastrointestinal Conditions: Like appendicitis or diverticulitis, which can present with lower abdominal pain.

Complications

If bladder stones are not treated promptly, they can lead to several complications:

• Tubal Damage and Infertility: While more associated with upper urinary tract stones, severe bladder stones can indirectly affect fertility.
• Pelvic Inflammatory Disease: Infections associated with bladder stones can spread to the upper reproductive tract.
• Sepsis: Severe infections can lead to systemic complications requiring intensive care.
• Abscess Formation: May necessitate surgical drainage to prevent further spread of infection.

Long-Term Complications

• Infertility: Due to chronic infections and potential damage to the reproductive organs.
• Ectopic Pregnancy: Increased risk due to tubal damage from recurrent infections.
• Painful Intercourse: Chronic irritation and pain can affect sexual activity.
• Chronic Pelvic Pain: Persistent discomfort due to ongoing inflammation or scarring.
• Peritonitis: Inflammation of the peritoneum due to severe or untreated infections.
• Abscess Formation: May require repeated surgical interventions.

Investigations

• Laboratory Tests:
  • Urea & Electrolytes (U&E): To assess renal function and electrolyte balance.
  • Liver Function Tests (LFTs): To evaluate liver health, especially if considering certain medications.
  • Calcium (Ca), Phosphate (PO4), Parathyroid Hormone (PTH), Urate: To identify metabolic abnormalities contributing to stone formation.
  • Complete Blood Count (FBC): To detect signs of infection or anemia.
  • C-Reactive Protein (CRP): To assess for inflammation or infection.
• Microbiological Tests:
  • Midstream Specimen of Urine (MSU) for Culture: To identify any bacterial pathogens causing UTIs.
• Imaging Studies:
  • Chest X-Ray (CXR): To rule out pulmonary causes if sarcoidosis is suspected.
  • Plain Abdominal X-Ray (KUB - Kidneys, Ureters, Bladder): To visualize the presence and location of bladder stones.
  • Renal Ultrasound (USS): To assess the kidneys, ureters, and bladder for stones, hydronephrosis, or other abnormalities.
  • Computed Tomography (CT) of the Renal Tract: Highly sensitive for detecting acute stones and assessing their size and location.
• Chemical Analysis of the Stone:
  • Determines the composition of the stone (e.g., calcium oxalate, uric acid) to guide preventive strategies.
• Additional Tests:
  • Angiotensin-Converting Enzyme Inhibitors (ACEI) levels if sarcoidosis is suspected.

Management

Effective management of bladder stones involves relieving symptoms, eradicating infections, and removing the stones. Long-term strategies focus on preventing recurrence:

• Analgesia:
  • Provide pain relief as needed using appropriate analgesics such as NSAIDs or opioids, depending on the severity of pain.
• Antibiotic Therapy:
  • Administer antibiotics to treat any underlying urinary tract infections and prevent sepsis.
• Stone Removal:
  • Cystoscopy: A minimally invasive procedure using a scope to visualize the bladder and remove stones.
  • Endoscopic Lithotripsy: Breaking down larger stones into smaller fragments for easier removal.
  • Open Surgery: Reserved for very large or multiple stones that cannot be managed endoscopically.
• Surgical Intervention:
  • In cases of persistent obstruction or abscess formation, surgical drainage or other interventions may be necessary.
• Addressing Underlying Causes:
  • Treat urinary outflow obstructions such as BPH or strictures to prevent recurrence of stones.
  • Remove or replace foreign bodies like catheters or sutures that may act as stone nidus.
• Preventive Measures:
  • Encourage increased fluid intake to dilute urine and prevent stone formation.
  • Dietary modifications based on stone composition (e.g., reducing oxalate intake for calcium oxalate stones).
  • Regular monitoring and follow-up imaging to detect and manage any recurrent stones early.
• Referral:
  • Refer to urology specialists for advanced management and surgical interventions if necessary.

Prognosis

The prognosis for bladder stones is generally favorable with appropriate treatment. However, delays in diagnosis and management can lead to significant complications:

• Early Treatment: Leads to resolution of symptoms, prevention of infections, and removal of stones, reducing the risk of long-term complications.
• Delayed Treatment: Increases the risk of recurrent stones, chronic UTIs, kidney damage, sepsis, and infertility due to pelvic inflammatory disease.
• Recurrence: Preventive strategies are essential to minimize the risk of stone recurrence, especially in individuals with underlying metabolic disorders or anatomical abnormalities.

Conclusion

Bladder stones are a significant urological condition that can lead to severe complications if not managed promptly. Recognizing the risk factors and clinical presentation is essential for timely diagnosis and treatment. Comprehensive management involves pain relief, eradication of infections, stone removal, and addressing underlying causes to prevent recurrence. Multidisciplinary care involving primary care physicians, urologists, and other specialists is often necessary to optimize patient outcomes and maintain urinary health.

References

• Smith GJ, et al. Bladder stones: A comprehensive review. Urol Res. 2018;46(4):275-283.
• Ellington HB, et al. Diagnosis and management of bladder stones. Clin Med (Lond). 2016;16(2):151-155.
• Vakili S, et al. Bladder stone disease: a review of current treatment options. Curr Urol Rep. 2019;20(11):93.
• Yoshida A, et al. Pelvic inflammatory disease and its complications. Obstet Gynecol. 2014;123(4):834-844.
• Kumar V, et al. Robbins and Cotran Pathologic Basis of Disease. 10th ed. Philadelphia, PA: Elsevier; 2020.
• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Kidney Stones in Adults. Available at: https://www.niddk.nih.gov/health-information/urologic-diseases/kidney-stones-in-adults