Sometimes, doctors have to go on a long and tedious journey to identify the cause of their patient’s symptoms. But sometimes, the cause is the size of a large grapefruit.
A 70-year-old Mestizo woman presented to her doctor with dysuria, pollakiuria and abdominal pain in the hypogastric region, which worsened over the course of the last four months. She also reported the sensation of a foreign body in the vaginal introitus. Her history included eight pregnancies leading to eight vaginal deliveries, hernioplasty performed twelve years ago and Diabetes mellitus diagnosed six months prior.
The doctor conducted a physical examination, where a mobile, firm and tender mass in the left periumbilical area was found. The vulva presented moist with urinary remnants and mild hyperemic inflammatory changes. When the doctor looked into the vaginal canal, the likely cause of the symptoms quickly became obvious: There was a large obstructive mass, suggestive of a giant calyceal-type calculus.Credit: Alas-Pineda et al., BMC 2024.
A plain pelvic radiograph and a CT scan were ordered. They revealed a giant calculus, measuring about 10 cm x 12 cm – the size of a large grapefruit. The CT also indicated a tumor lesion in the abdominal wall with significant calcification involving the fat and muscle planes. Urine cultures showed presence of Escherichia coli bacteria. The mass was surgically removed by cystolithotomy. It was confirmed to be a giant bladder stone adhered to the vaginal wall, resulting in a vesicovaginal fistula. The stone’s weight came up to 297 g. Subsequent procedures repaired the bladder and closed the vesicovaginal fistula. The patient recovered well and the postoperative course was uneventful.
The diagnosis was surprising, because bladder lithiasis – especially of that size – associated with vesicovaginal fistulas are considered to be relatively rare in developed countries. Bladder stones only comprise 5 % of all urological lithiasis, with contributing factors including metabolic syndrome, hypertension and Diabetes mellitus. The exact relationship between stone formation and vesicovaginal fistulas is not well understood, but risk factors include chronic urinary retention, bladder outlet obstruction, urinary tract infections and prolonged catheterization.
There were several factors that might have predisposed the patient: She had Diabetes mellitus, underwent hernioplasty and E. coli colonies were present in her urine. Additionally, the doctors think that her previous pregnancies might have played a role: “The patient’s history of eight previous vaginal deliveries increased the likelihood of unnoticed gynecological-obstetric trauma.” They conclude, that it is “essential to consider patients with comorbidities and surgical histories for early detection of growing calculi, as early intervention can prevent the development of complications such as vesicovaginal fistula.”
Image source: Ben Karpinski, Unsplash
