ORIGINAL ARTICLE

Management of Impacted Urethral Stones in Children

Jamshed Akhtar, Soofia Ahmed and Naima Zamir

ABSTRACT
Objective: To find out the clinical presentation, site of impaction, management and outcome of children presenting with
urinary retention due to urethral stone.
Study Design: Case series.
Place and Duration of Study: Surgical Unit B of National Institute of Child Health (NICH), Karachi, from April 2009 to
January 2010.
Methodology: All the patients under the age of 12 years, who presented with urinary retention due to impacted urethral
stones were included. Urinary retention due to other causes like trauma, stricture, pelvic masses etc. were excluded.
Diagnosis was made on clinical examination (palpable stone in penile urethra) and with the help of radiology. Surgical
procedure was tailored according to the site of impaction in urethra. All stones were sent for chemical analysis and patients
were followed in Nephrology OPD (stone clinic) for further work-up.
Results: There were a total of 19 patients with mean age of 3.94 2.27 years. All were males. Twelve patients (63.1%)
had stones impacted in anterior urethra while 7 (36.9%) were found in posterior urethra. Stones in penile urethra were
removed in emergency either by meatotomy (when impacted at urethral meatus, n = 3) or following initial supra-pubic
decompression of urinary bladder (using wide bore cannula) by urethrolithotomy (n = 6). Stones in bulbous (n = 3) and
posterior urethral (n = 7) locations were pushed back into bladder and later removed on elective list by supra-pubic
vesicolithotomy. No patient had proximal urinary tract calculi on further work-up. All patients remained well except one who
developed retention of urine after a week of discharge. He had urinary tract infection and was treated with antibiotics. All
the stones were of calcium oxalate type.
Conclusion: Urethral stones must be kept in differential diagnosis in a child who presents with acute urinary retention.
Clinical examination can identify causes in significant number of cases. Simple procedures like meatotomy, supra-pubic
bladder decompression and urethrolithotomy can relieve the misery in these children.
Key words:

Urethral stones. Acute urinary retention. Child. Urethrolithotomy.

INTRODUCTION
Paediatric urolithiasis is prevalent in some geographical
regions popularly known as the stone belt. This belt
runs from Philippines, Thailand, Myanmar in the Far
East through Pakistan into Iran, Middle East and
extends up-to Turkey.1 Many factors are responsible for
this endemic nature, namely nutritional deficiencies in
vitamin A, magnesium, phosphates and vitamin B6, lowprotein and high-carbohydrate diet, dehydration, urinary
tract infection etc.2 The pattern of urinary tract
involvement is quite distinct. In developed countries, it
is mostly the upper urinary tract where calculi are
found while reverse is noted in children from developing
countries where poverty prevails. A century ago, lower
urinary tracts were also reported frequently from
developed countries but as the socioeconomic
conditions improved, change occurred in the pattern of
stone disease.3,4
Department of Paediatric Surgery, National Institute of Child
Health, Karachi.
Correspondence: Dr. Jamshed Akhtar, Department of
Paediatric Surgery, National Institute of Child Health, Rafiquee
Shaheed Road, Karachi-75510, Pakistan.
E-mail: jamjim88@yahoo.com
Received November 14, 2011; accepted May 16, 2012.
510

Research in the field of stone disease identified many

preventive measures so as to reduce burden of the
disease. This is done to prevent renal loss due to
obstruction and infection. There is also a parallel
development of minimally invasive surgical techniques
to deal with urinary tract calculi. The paediatric population
is usually less fortunate as advancement in technology
aims more at adults and as a trickle down effect children
also receive benefit out of it. Though equipments are
present at many centres for minimally invasive surgical
approach for adults urolithiasis, but not for paediatric
population.5
Acute urinary retention due to impacted urethral calculus
is not an uncommon condition.6 This is extremely painful
situation and demands urgent relief. If remain unattended,
can lead to disastrous consequences of urinary extravasation and infection.7 The diagnosis is usually clinical
and simple measures can help in relieving emergency
situation. There is paucity of data on urethral stones in
paediatric age group.8
This study aimed at determining the management of this
condition so as to provide an algorithm to facilitate the
children with acute retention of urine, due to impacted
urethral stone.

Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (8): 510-513

Management of impacted urethral stones in children

METHODOLOGY

RESULTS

This case series was conducted from March 2009 to

January 2010 at one of the two Surgical Units of
Department of Paediatric Surgery, NICH, Karachi. The
data of all the patients admitted with the diagnosis of
acute retention of urine due to impacted urethral stone
were analyzed. Patients aged less than 12 years were
included. All those with retention of urine due to other
causes like urethral injury, stricture, pelvic mass etc.
were excluded.
Patients were admitted and detailed history and diligent
clinical examination were done specially palpating penile
urethra and also feeling for presence of any firm
structure in the line of urethra through scrotum and at
perineal region. All patients had complete blood count,
blood urea, serum creatinine and electrolytes done.
Urine analysis and culture of sample of urine obtained,
were also performed. All patients had X-ray KUB and
ultrasound for evaluation of urinary tract.

In a duration of 10 months, 19 patients presented with

acute retention of urine due to impacted urethral stone
(Figure 1). All were males. Age ranged from one year to
10 years with the mean age of 3.94 years 2.27 years.
None of (63.1%) the patients had any anatomical lesion.
In 12 patients (63.1%) stones were impacted in anterior
urethra while 7 patients (36.9%) were located at posterior
part. Stones impacted at external urethral meatus were
removed in emergency in 3 patients (15.7%) by meatotomy. In 6 patients (31.5%) with stone impacted in penile
shaft, initially supra-pubic catheterization was done to
relieve the acute symptom of urinary retention. Urethrolithotomy was then performed under general anaesthesia. During surgery an attempt was made to milk the
stone distally by instilling lubricant jelly. When procedure
remained unsuccessful, urethrolithotomy was done.

In cases where stone was clinically palpable, an urgent

examination under anaesthesia was planned. Where
urinary bladder was grossly palpable, size 16 cannula
was passed supra-pubically for decompression of urine
to relieve pain. The choice of further procedure was
dictated by location of stone and its gentle maneuvering
(milking) through urethra distally, after instilling xylocaine
jelly through urinary meatus facilitated by meatotomy. If
the procedure was unsuccessful, surgical exploration
(urethrolithotomy) was performed. In this procedure,
after taking proximal control of stone by fixing it between
index finger and thumb, an incision was made over the
calculus and stone was retrieved. Closure of periurethral
tissues was done over size 8 urethral tube with
polyglycolic 5/0 sutures applied in interrupted fashion,
taking care not to penetrate urethral mucosa. Urethral
tube remained in place for 7 days. After passage of urine
following removal of urethral tube, patients were discharged home, to be followed in outpatient department.

Calculi in bulbous (n = 3) and posterior urethral locations

(n = 7) were pushed back into the bladder. All patients

Figure 1: Stone impacted at external urinary meatus.

For stones located in bulbous and posterior urethra as

revealed by X-ray, gentle push back was done using size
8 Fr. urethral tube and stone was removed suprapubically by transvesical approach on elective list,
usually within 48 hours. Minimally invasive surgery was
not available in NICH. In cases where push back was
not successful a supra-pubic size 16 French cannula
was placed in palpable urinary bladder to drain urine and
vesicolithotomy was then scheduled at the earliest.
Bladder was drained for 48 hours after open procedure.
All stones were sent for chemical analysis.
Data were entered on a proforma and analyzed with
Statistical Package for Social Sciences (SPSS)
version 16. Descriptive analysis was performed. Mean
and standard deviation were calculated for variable like
age. Frequency and percentages were calculated for
parameters like gender, anatomical site, type of
procedure and complications.

Figure 2: Algorithm for management of impacted urethral stones.

Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (8): 510-513

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Jamshed Akhtar, Soofia Ahmed and Naima Zamir

did well except for one who developed retention of urine

after a week. This patient had urinary tract infection and
antibiotics were given. None of the patients had difficulty
in urination, urethrocutaneous fistula or development of
urethral stricture at follow-up. The chemical analysis of
stone showed all to be of calcium oxalate type. An
algorithm for the management of impacted urethral
stones based upon the results is shown in Figure 2.

DISCUSSION
The urinary tract calculi are prevalent in many regions of
the world. Extensive literature is found on both adult and
paediatric population, but surprisingly data on urethral
calculi is sparse. Few studies are available on the
subject from the stone belt region in children.9,10
Occasional case reports were also retrieved from
internet search, but no study can be found with a large
number of patients with any well-defined protocol for the
management of stones impacted in urethra without any
obstructive pathology.11,12 It thus becomes important to
contribute the data related to this infrequently addressed
condition which is extremely painful both for the children
and their families. Pain due to inability to pass urine is
described as one of the worst pain in humans. In this
study, 19 patients were managed in a span of 10
months. This number is quite high when compared with
overall frequency of stone disease in hospital based
studies from western countries.13 Even from the regional
countries like Turkey, Verit et al. reported only 8 patients
with urethral stone in a 6 years period.14 In 8 studies on
a large cohort of urinary tract calculi from pediatric
urological department in Pakistan, not a single case of
urethral calculus has been reported.15,16 The authors of
those studies concluded that upper urinary tract stones
are now increasingly reported in comparison with lower
urinary tract stone in Pakistan. These observations thus
may not be reflective of true picture from Pakistan. It
may be possible that patients with lower urinary tract
stones seek treatment in nearby facilities rather than
tertiary care hospitals.
Urethral calculi are divided into two types namely
primary (when formed within urethra due to some
anatomical defect) or secondary when stones from
upper urinary tract or bladder gets lodged into urethra.
These are called migratory stones. In a study on urethral
calculi from London in year 1930, 37 cases of secondary
urethral calculi were reported in a span of 20 years.17
While reporting on urinary calculi not much stress is
made on urethral calculi thus it is not clear as to the true
incidence and age distribution of this type of calculi. In
one study, it is reported that urethral calculi constitute
0.3% of all the urinary tract calculi.14
In the era of minimally invasive surgery, equipment has
been developed for treating urinary calculi at various
anatomical regions. For urethral calculi, use of Holmium
laser lithotripsy is reported in paediatric age group with
512

success.18 For those stones that can be pushed back

into bladder, minimally invasive surgery is another
option.19 The availability of the advanced equipment and
expertise remains an issue. The children are referred
from far flung areas and a more practical approach thus
would be an open surgical procedure, that can be used
by surgeons even at district level hospital. Simple pushback, meatotomy and urethrolithotomy procedures
suffice in this emergency situation. If surgical facilities
are not available supra-pubic decompression of urinary
bladder with large bore cannula is another option
before referring the child to a nearby facility where
operative procedure can be undertaken. Supra-pubic
decompression can be performed with commercially
available kit though it is difficult to obtain this even in an
urban region. This technique can be used if surgeon has
to buy time while waiting for availability of operation
suite and anaesthesia facility. In this study, bladder
decompression was employed as a bridging step by
using cannula to relieve the child from the agonizing
pain.
Urethrolithotomy needs attention to meticulous details of
closure of urethrotomy. Use of fine suture material,
urethral stent, and obtaining a water tight seal without
compromising blood supply of urethra are mainstay of
surgical approach. With observations of these surgical
principles chances of stricture and urethrocutaneous
fistula are negligible. In this series, no such complication
occurred. Interrupted sutures are equally effective in
achieving goals as noted in this study. In an oedematous
tissue at the site of impaction of stone, continuous
sutures may cut through easily.
The chemical analysis of the calculi revealed calcium
oxalate as a constituent in this series. Calcium oxalate
stones are commonly reported as most common type of
stones in many series though a change in pattern has
been observed, where similarities are reported with
developed countries both in terms of location and
chemical composition of calculi.20-22 Oxalates rich food
like dark green leafy vegetables should be avoided.
Vitamin C is another source of oxalate.23 Increase fluid
intake works in all types of stones. The data on role of
calcium intake is also controversial but it must be
remembered that calcium binds with oxalate in diet and
prevents its absorption from gastrointestinal tract. A
balanced diet is thus recommended with plenty of water
intake for prevention of recurrence of stones.24

CONCLUSION
Urethral stone is an important cause of acute retention
of urine in children. Anterior urethra is more frequent site
of obstruction. Variety of procedures can be employed to
relieve obstruction that does not require costly
equipment and surgery can be undertaken at peripheral
hospitals where operation theatre facility is available.

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Management of impacted urethral stones in children

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