Multiple Vesical Calculi

This is a start case for post-graduates

40 year old man. 
Presented with episodic dysuria and hematuria for last one year
How would you evaluate this patient?

Multiple Vesical Calculi


  • Utsav Shah
    Utsav Shah
    20 May 2020 08:42:24 PM

    Respected Sir,

    40y M with episodic dysuria and hematuria found to have multiple, smooth vesical calculi. 

    I would like to get:
    - urine routine and microscopy
    -RFT, Sr calcium, Sr uric acid and PTH. 
    -USG KUB and prostate.

    Will review these and then proceed.  

    I’m suspecting these to be secondary bladder stones probably due to ?infection/obstruction. 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    20 May 2020 10:06:33 PM

    @ Utsav,

    Why not uroflowmetry and PVR?
    What about physical status of patient, as I have seen such type of stones in non ambulant patients with spinal injury and severe bone demineralization. There are other reasons also, you have to ask relevant history.
    Whoud you like to ask neurological history and focal neurological examination?
    I suggest before you ask for further history please ask relevant history and examination findings...

  • Utsav Shah
    Utsav Shah
    20 May 2020 10:16:10 PM

    Yes I agree Anil sir. 

    From the given details, I considered that the Male is healthy with dysuria and hematuria as the only positive history. 

    I would like to know whether patient is suffering from any neurological condition, spinal disorders, any surgeries in past(eg meningocoele, etc) and also abt his habitus(whether he is malnourished) 

  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    20 May 2020 10:30:20 PM

    Sir,in this case scenario.. along with urine test n blood test n usg..I want to do rgu n mcug of this case...if finding r normal or suggestive of any neurological  problem .. would like to add urodynami test too for investigation..

    20 May 2020 11:44:23 PM

    A proper history is a must. 

    Then USG  of KUB -PVR, renal function and urine culture.
    Urodynamics and uroflowmetry with so many large calculi may not be informative.

  • Nitesh Jain
    Nitesh Jain
    21 May 2020 12:29:50 AM

    Spine doesnot look normal ? Spins Bifida 

  • Pankaj N Maheshwari
    Pankaj N Maheshwari
    21 May 2020 07:20:47 AM

    Thanks friends for a good discussion.

    I had taken this image from twitter just for this discussion
    My thoughts:
    1. These appear to be secondary calculi. The calculi in a X-ray KUB should be in midline near the pubic symphysis. Why are they elevated? It nearly looks like a prostatic impression but 40 is no age for large BPH.
    2. Such calculi suggests post-void residue with recurrent infections
    3. Clinical neurologic assessment is very important
    4. USG for prostate, upper tracts & PVR. This would help look at why there is such a large prostatic impression. Are we dealing with some prostatic mass? May be prostatic sarcoma
    5. Uroflowmetry is a simple test that would give lot of important information.
    6. UDS if high PVR and poor flow rates
    7. MR Spine if suspicion of neurogenic bladder
    8. MR Pelvis if some mass lesion suspected.
    Management is not an issue. Surely a open cystolithotomy would be the treatment of choice. Post-op look for complete bladder emptying and document sterile urine. Regular follow-up is vital.

    Any more thoughts welcome

  • Nitesh Jain
    Nitesh Jain
    21 May 2020 10:18:34 PM

    See the marked area ... I feel he needs a neurological examination and a MRI spine 

  • Nitesh Jain
    Nitesh Jain
    21 May 2020 10:19:53 PM


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