Bladder calculi usually are a manifestation of an underlying pathologic condition, including voiding dysfunction or a foreign body. Voiding dysfunction may be due to a urethral stricture, benign prostatic hyperplasia, bladder neck contracture, or flaccid or spastic neurogenic bladder, all of which result in static urine. Foreign bodies such as Foley catheters and forgotten double-J ureteral catheters can serve as nidi for stones (Figure 16–-22).
Most bladder calculi are seen in men. In developing countries, they are frequently found in prepubescent boys. Stone analysis frequently reveals ammonium urate, uric acid, or calcium oxalate stones. A solitary bladder stone is the rule, but there are numerous stones in 25% of patients (Figure 16–-23). Patients present with irritative voiding symptoms, intermittent urinary stream, urinary tract infections, hematuria, or pelvic pain. Physical examination is unrevealing. A large percentage of bladder stones are radiolucent (uric acid). Ultrasound of the bladder identifies the stone with its characteristic shadowing.
The stone moves with changing body position. Stones within a ureterocele do not move with body position (Figure 16–-24) as seen on ultrasound examination. They frequently are nonobstructive. Endoscopic incision and stone removal rarely result in vesicoureteral reflux.
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The mode of stone removal for other bladder stones should be directed by the underlying cause.
Early instruments used to remove bladder calculi were both clever and bizarre. Simple mechanical crushing devices are still used today. Mechanical lithotrites should be used with caution to prevent bladder injury when the jaws are closed.
Ensuring partially full bladder and endoscopic visualization of unrestricted lateral movement before forceful crushing of the stones helps reduce this troublesome complication. Cystolitholapaxy allows most stones to be broken and subsequently removed through a cystoscope. Electrohydraulic, ultrasonic, laser, and pneumatic lithotrites similar to those used through a nephroscope are effective. Cystolithotomy can be performed through a small abdominal incision.
Figure 16–22. Genesis and symptoms and signs of vesical calculus.
Figure 16–23. A: Plain abdominal radiograph demonstrating 2 bladder calculi. B: Gross picture of removed bladder calculi. Note the characteristic shape of jack-stones typically composed of uric acid.
Figure 16–24. A: Scout abdominal radiograph demonstrating extraosseous calcification in the region of the bladder. B: Intravenous pyelogram demonstrates stone to be within a ureterocele.
Tramadol Indications and Dosage
For the treatment of moderate pain or moderately severe pain including arthralgia, headache, myalgia, dental pain following oral surgery such as extraction of impacted molars or chronic conditions such as low-back pain, bone pain and cancer-related pain.
Tramadol Maximum Dosage Limits:
- Adults: 100 mg/dose PO or 400 mg/day PO.
- Elderly >= 75 years: 100 mg/dose PO or 300 mg/day PO.
- Elderly 65 – 74 years: 100 mg/dose PO or 400 mg/day PO.
- Adolescents >= 16 years: 100 mg/dose PO or 400 mg/day PO.
- Adolescents 13 – 15 years: Maximum dosage has not been determined.
- Children: Maximum dosage has not been determined.
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Marshall L. Stoller, MD
