Case report Impacted bladder stone a cause of renal failure Mukosai S, Silumbe M, Kalo, Nenad, Prof Labib Mohammed,

Kachimba J Department of Surgery, Division of Urology Abstract We present a case of 10 year old child from Kafue district who presented with features of renal failure, bilateral hydronephrosis secondary to impacted bladder stone of size 4.5x4cm. Bladder stones though a common urological condition rarely cause obstruction[1]. In this case report Patient was managed by early renal support through peritoneal dialysis, blood transfusion and removal of bladder stone by open method after which satisfactory results were achieved. The case illustrates the importance of early radiological intervention in any patient who presents with recurrent urinary tract infections, especially in male patients. Introduction Bladder stones commonly manifest with clinical presentation of irrigative urinary symptoms and few obstructive symptoms. Bladder stone is a common urological disease, but it is rare for such a calculus to be so large as to cause bilateral hydronephrosis [2]. Impacted bladder stone can result in obstructive uropathy and renal failure [3]. The aetiology and pathogenesis of bladder stones remain obscure [4]. Bladder stones can be easily diagnosed with simple radiological investigations such plain x ray KUB and ultrasonography to enable early diagnosis and prompt interventions. We are reporting a case presented to our hospital of impacted bladder stone presenting with renal failure. Case report A 10 year old male child presented to urology clinic with a 3 year history of voiding dysfunction characterised by difficulty in voiding and constant tapping at the phallus with recurrent febrile illness caused by recurrent urinary tract infections. The child has had history of loin pain for similar durations. He had been treated for UTI at a local hospital. He denies history of hematuria. Plain KUB revealed radiopaque shadows in the area of the bladder [figure3]. Urinalysis showed plenty of pus cells with epithelial cells 3-5 HPF. There was no RBCc. Urine culture yielded Escherichia Coli which was sensitive to nitrofurantoin. Renal function test revealed blood urea (BUN) 43.72mmol and serum creatinine 635.8umol/l. On physical examination, the child was ill health dyspnoeic wasted moderately pale afebrile to touch. On systemic examination respiratory system was clear, cardiovascular system revealed tachycardia with heart rate 100 b/m. Other systems were un remarkable. Subsequent management involved strict in and and output, intravenous fluids, renal support with peritoneal dialysis and received 3units of packed red blood cells. On day 5 post admission, the child developed generalised convulsions controlled with diazepam and phenobarbitone episodes. He had 4 episodes in 2 days. Full septic screen done revealed negative for blood culture x 3 samples. Chest x ray was not revealing. No growth in the urine. Lumbar puncture was not done because of un stable child condition. He was covered on broad spectrum cefotaxime. On day 20 of admission the child developed self limiting paralytic ileus which was managed conservatively with nasal gastric tube and intravenous fluids {Ringers lactate}. Upon the child

condition stabilising he was taken for Transvesical Cystolithotomy in which two bladder stones were extracted, one impacted in the bladder neck size 4x4cm.

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Outcome At post operative period the child developed post obstructive diuresis up to 4200ml/day. There was subsequent dramatic improvement in renal function. Serum creatinine dropped to 109umol/l. He was discharged to be followed up in the clinic on 20th postoperative day with good urinary stream out put and mild occasional urinary incontinence.

Figure 4

Literature review/ Discussion Bladder calculi are uncommon cause of illness in most western countries, but result in specific symptoms and are a significant discomfort [5]. These stones are usually associated with urinary stasis but can form in health individuals without evidence of anatomic defects, strictures, infections or foreign bodies [6]. Malnutrition has been attributed to formation of primary bladder stones which is still common in developing countries where malnourishment is common especially in growing children [7]. A few international articles have reported bladder stone causing renal failure. Wuran W. et al, from Harvard Medical School, reported a 62 year old man presented with large bladder calculus causing bilateral obstruction and renal failure. Diagnosis was delayed despite the patient s history of recurrent urinary y tract infection [8]. Borg Z. et al , from Poland, reported a case of severe exacerbation of chronic renal failure with bilateral hydronephrosis and urosepsis caused by asymptomatic large bladder stone. Managed by temporally haemodialysis, removal of stone and controlling of severe urinary tract infection. Kamal F, et al reported a case of 30 year old man who presented with obstructive renal failure and urosepsis. Due to bladder outlet obstructing bladder calculi that formed around three copper wires that were self inserted into urinary bladder 15 years previously [9]. Most bladder stones are mobile within the bladder due large space and thus continuous flow of urine [10]. If untreated bladder stones can grow big in size causing mechanical obstruction by impinging pressure on the Ureteric orifice within the bladder and also by being impacted on the bladder neck leading to infravesical obstructive uropathy. Management of such cases is focused on

patient stabilisation with temporal peritoneal or haemodialysis , early removal of stone ,continue renal support treatment, correct acidosis and look out for post obstructive diuresis in the post operative period. Surgical intervention by open Cystolithotomy or endoscopic Cystolithotomy can achieve satisfactory results [9]. It is advisable to manage patients in cooperation with nephrologists. Efforts must made to investigate the primary cause of repeated urinary tract infections through radiological investigations like plain x-ray KUB and ultrasonography in patients with voiding problems[ 10]. Conclusion Bladder stone if large enough or if impacted in the bladder neck can cause obstructive uropathy leading to renal failure. Recurrent urinary tract infections should be adequately evaluated with radiological investigations for early and prompt diagnosis of the cause. References .Daeschner C.W, Single J.C.C [1960], Urinary Tract Calculi and Nephrocalcinosis in infants and Children .Vol.57 Issues pages 721-732 2. Sundaram CP, Houshiar AM, Reddy PK. [1997], Bladder stone causing renal failure. Minn Med. Sep; 80(9): 25-6. 3. Dorairajan L.N, Talmer & Hemal A.K [2001), Stone Neclace of Urinary tract presenting as renal Failure. 4. Aurora A.L, Taneja O.P, Gupta D>N [2008] Bladder Stone Disease of Childhood; An Epidemiological Study. * * 5. Fadi Kamal, MD, Aaron T.D. Clark, MD, Luke Thomas Lavalle, BSc, Matthew 1

Roberts, MD,* and James Watterson, MD* Intravesical foreign bodyinduced bladder calculi resulting in obstructive renal failure
6. Wuran Wei1 and Jia Wang [2009] A huge bladder calculus causing acute renal failure, urological research. 7 S. Madjar1, B. Moskovitz1, A. Kastin1, M. Stein1 and O. Nativ [1996], Anuria and acute renal failure caused by multiple bladder calculi 8 9 Wuran W. Harvard Medical School, Large bladder causing hydronephrosis. Kamal F,bladder outlet obstruction due renal calculi

10. Joshi B R*,Shrestha PM Can Urinary Bladder Stones Cause Renal Failure?