Bladder Stone (Vesical calculi)

Bladder Stones (calculus) is a composed of mineral masses formed in the bladder as a result of Concentrated, stagnant urinary, dehydrated causes of crystallization. Small bladder stones in most cases, pass on their own in the flow of urine.

A. Symptoms
The symptoms are as results of irritation of bladder wall or the stones have blocked the flow of the urine causes of infection and complications. In most cases, Bladder stone large and small do not cause any symptoms at all.
1. Inability to walk, constipation and urinary incontinence
There is a report of a case of massive irreducible procidentia with a hard palpable mass in the anterior vaginal wall mimicking an impacted faecal mass in a 57-year-old multiparous, post-menopausal woman with symptoms of Inability to walk, constipation and urinary incontinence as her primary complaints. targeted plain X-ray and ultrasound of the prolapsed mass disclosed the existence of multiple vesical calculi(1).

2. Lower abdominal pain, pain during micturation and pollakuria
There is a report of a  48-year-old man hospitalized with the chief complaints of lower abdominal pain, pain during micturation and pollakuria, plain radiography showed 2 giant bladder stone shadows: one as 6.0 × 5.0 cm and the other one 5.0 × 5.0 cm in size(2).


3. Voiding symptoms (Poor stream, Hesitancy, Terminal dribbling, Incomplete voiding, Overflow incontinence) and hematuria (Blood in your urine)
There is a report of a case of 43 year old man with the diagnosis of giant bladder stone (more than 10 cm diameter) with symptoms of voiding symptoms and hematuria(3).

4. Others symptoms
a. Repeated cloudy or abnormally dark-colored urine as a result of infection of the urinary track.
b. In men, pain or discomfort in the penis due to blockage or infection
c. Etc.

B. Causes and Risk factors
B.1. Causes
1.  Primary neurologic deficit
In the study of Medical management of urinary calculi in a stallion with breeding dysfunction, researchers at the University of Pennsylvania, showed that the stallion may have had a primary neurologic deficit affecting bladder control and function that was causing calculi to form secondarily because of delay in movement of urine through the urinary tract(4).

2. Urinary tract calculi and infections
Urinary tract calculi and infections are common causes of presentation to the emergency department. Computed tomography kidney-ureter-bladder is the initial imaging study of choice in patients presenting with symptoms of urinary tract calculi. As clinical evidence of superimposed infection can be atypical or absent, it is crucial to identify subtle imaging findings that suggest this complication(5).

3. The use of urinary catheters 
Prolonged period of using  urinary catheters can cause infection. There is strong experimental and epidemiological evidence that infection by Proteus mirabilis is the main cause of the crystalline biofilms that encrust and block Foley catheters. The ability of P. mirabilis to generate alkaline urine and to colonize all available types of indwelling catheters allows it to take up stable residence in the catheterized tract in bladder stones and cause recurrent catheter blockage(6).

4. Bladder cancer
There is a report of case of ileovesical fistula caused by a bladder carcinoma is presented. A 66-year-old male was referred with complaints of urinary pain. On admission, fecaluria and urinary tract infection with bladder stone were detected(7).

5. Schistosomiasis 
Schistosomiasis is a parasitic infection that affects 200 million people and is directly responsible for an annual death of 20,000 patients. Three species are responsible for most of the morbidity in humans: Schistosoma hematobium in Africa, S. mansoni in Africa and South America, and S. Japonicum in the Far East. Renal involvement occurs mostly with S. hematobium infection as a consequence of fibrosis and calcification of tissue-trapped ova in the lower urinary tract, leading to obstruction, reflux, infection, and stone formation(8).

6. Prostatic hyperplasia (BPH)
Benign prostatic hyperplasia (BPH) is one of the most common diseases to affect older men. Histological disease is present in more than 60% of men beyond their sixties, and more than 40% of men in this age group have lower urinary tract symptoms (LUTS)(9).

7. Kidney stones
As a result of small kidney stones travel down the ureters into the bladder that are not passed through urination

8. Etc.

B.2. Risk factors
1. Cystinuria
Cystinuria is an inherited autosomal recessive disease. There is a report of an unusual cystine stone presented in 24-year-old man. Radiographs showed a giant bladder stone shadow, 8.0 x 10.0 x 5.0 cm in size(10).

2. Age and gender
If you are male and over 30 years of age, you are at increased risk of bladder stone. In the study of a series of 1,354 stones derived from urology departments in Western Algeria was studied by IRTF spectroscopy. Analysis of the results concerned the crystalline composition and anatomical site of the stones and the age and gender of the patients.found that the male/female ratio has remained almost constant at 2.23. The anatomical site has changed with a predominance in the upper tract (77.4% of stones). The nucleus showed that phosphates are predominant in 48.6% of cases versus 35.6% for oxalates. Carbapatite and struvite are more frequent in women, found in 50.8% and 6.7% of cases, respectively, than in man, found in 44.6% and 3.7% of cases, respectively. Calcium oxalate is predominantly found in the upper urinary tract (70.9%) rather than in the bladder (48.3%), regardless of gender. Calcium phosphate is more abundant in the upper tract of females with 23.7% of cases versus 10.7% in the bladder. It is equally distributed between the bladder and the upper tract in males (13.7% and 13.2%, respectively). Examination of the side affected by stones showed a predominance of the left side in both sexes.

4. Bladder outlet obstruction(11)
There is a report of a 48-year-old man was hospitalized with the chief complaints of lower abdominal pain, pain during micturation and pollakuria. Plain radiography showed 2 giant bladder stone shadows: one as 6.0 × 5.0 cm and the other one 5.0 × 5.0 cm in size. That were completely obstructing the bladder outlet and observed several years following pelvic traumahe(12). There are many causes of bladder outlet obstruction but enlarged prostate is one of  primary risk factors.

6. Frequent bladder infections
Chronic bladder infections can lead to the formation of bladder stones.

7. Urinary track infection
Urinary tract infection can cause obstruction of the urinany flow that can lead to formation of bladder stone. Urinary tract bacterial infections are common in women. Moreover, they tend to recur throughout life and in the same relatively small group of women. In most cases, bladder and renal infections are asymptomatic and manifest by demonstrating coincidental bacteriuria. In some instances, however, especially with frequent sexual activity, pregnancy, stone disease, or diabetes, symptomatic cystitis or pyelonephritis develops and antimicrobial therapy is indicated(13)

8. Nutritional factors
In teh study to describe clinical cases of childhood bladder stones and associated risk factors. Forty children (9 girls), aged 1-14-years old, (means 4.7 +/- 0.5 years), who underwent surgical stone removal in the Saravane Provincial Hospital during a 13-month period, researchers at the Institut de la Francophonie pour la Médecine Tropicale, showed that  the morbidity and social cost of childhood bladder stones may be high. A larger scale prospective and comparative study assessing their incidence and associated nutritional factors is warranted and feasible, and may lead to preventive measures(14).

9. Etc.

C. Complications and Diseases associated with Bladder stone
1. Bladder pain syndrome/interstitial cystitis
In the study of included 9,269 cases who had received their first-time diagnosis of bladder pain syndrome/interstitial cystitis (BPS/IC) between 2006 and 2007 and 46,345 randomly selected controls, BPS/IC was found to be significantly associated with prior urinary calculi (UC) regardless of stone location; the adjusted ORs of kidney calculus, ureter calculus, bladder calculus, and unspecified calculus when compared to controls were 1.58 (95 % CI = 1.38-1.81), 1.73 (95 % CI = 1.45-2.05), 3.80 (95 % CI = 2.18-6.62), and 1.83 (95 % CI = 1.59-2.11), respectively(15).

2. Irreducible uterine prolapse
A vesical calculus in a prolapsed cystocele is rare. There is a report of case of irreducible total uterine prolapse caused by multiple vesical calculi. Bladder stones were removed through vaginal cystolithotomy followed by vaginal hysterectomy(16).

3. Acute renal failure
There is a report of a 39-year-old man with repeated urinary tract infection and lower abdominal pain, kidney-ureter-bladder (KUB) and IVU film showed a huge 450-g elliptical pelvic calculus that was surgically removed with excellent results(17).

4. Enterovesical fistula
Enterovesical fistula is a very rare complication of primary urological malignancies. A case of ileovesical fistula caused by a bladder carcinoma is presented. A 66-year-old male was referred with complaints of urinary pain. On admission, fecaluria and urinary tract infection with bladder stone were detected. Cystography revealed the passage of contrast medium into the small bowel. Under the diagnosis ofileovesical fistula due to suspected inflammatory disease, sigmoidectomy and segmental small bowel resection with partial cystectomy were performed. Histological evaluation revealed a poorly differentiated urothelial carcinoma(18).

5. Spontaneous rupture of the urinary bladder
Spontaneous rupture of the urinary bladder is an uncommon occurrence. There is a report of a 36-year-old man with complaints of pain and progressive distension of abdomen and anuria for 2 days. His abdomen was tense, tender and distended with free fluid. Blood urea was 340 mg% and ascitic fluid urea was 337 mg%. An USG showed massive ascitis, a large vesical calculus and a left renal calculus, according to the study by University College of Medical Sciences and Guru Teg Bahadur Hospita(19).

6. Etc.

D. Diagnosis
After a complete physical examination (incluning rectal examination) and family history are recorded, if you are suspected to have developed bladder stones, the test which your doctor orders, may include
1. Bladder or pelvic x-ray
The aim of the test is to let your doctoe visualize  the bladder, urethra (the tube connecting the bladder with the outside of the body), and the ureters (the tubes connecting the kidneys to the bladder) of the patient, for  the bladder's stones and abnormalities in the pelvic, including the a blockage in the urinary path.

2. Cystoscopy
Cystoscopy is the examination of the bladder and urethra with use of cystoscope. In the examination, smaller bladder stone can be removed if found. It is hekpful as smaller bladder stones sometime can not be detected by the X ray.

3. Urinalysis
The aim of the test is to rule out the infectious and other causes of urinary tract symptoms

4. CT scans
CT scans are the better test to identify very small stones not seen by other tests

5. Etc.

E. Prevention
E.1. The do's and do not's list
1. Avoid dehydration
Dehydration can cause increased urine concentration which can lead to crystallization.

2. Drinking 6 - 8 glasses of water or more per day
In most case smaller bladder stones can  pass on their own in the flow of urine

3. Avoid eating too much foods contain high amount of axalates which can increase the risk of the risk of bladder stone.

4. Quit smoking
Smoking increased the risk of the accumulation of cadmium on the bladder wall

5. Enlarged prostate
Enlarged prostate is the primary cause of bladder stone in men.

6. Etc.

E.2. Diet to prevent bladder stone
1. Cranberry
Cranberries have long been the focus of interest for their beneficial effects in preventing urinary tract infections (UTIs). Cranberries contain 2 compounds with antiadherence properties that prevent fimbriated Escherichia coli from adhering to uroepithelial cells in the urinary tract(20).

2. Low calcium diet, low sodium diet or low calcium diet plus hydrochlorthiazide
Researchers showed that low calcium diet, low sodium diet or low calcium diet plus hydrochlorthiazide reduced hypercalciuria significantly (P less than 0.01).  Low calcium diet combined with hydrochlorthiazide was the most effective treatment for hypercalciuria(21).

3. Balance diet with enough nutrient
In the study to evaluate Reduction of urinary stone in children from north-eastern Thailand, Dr. at the showed that bladder stones in children have decreased now compared with the previous decade. If we promote good nutrition for children, bladder stones will decrease and might be eradicated in the future. A seminar of doctors and health personnel from 19 hospitals in the north-eastern provinces of Thailand was conducted to survey bladder stones in children by weighting and interviewing bladder stone symptoms then giving supplementary diet milk and vitamins and teaching health education about nutrition and urinary stones through referring children with bladder stones to hospitals in north-eastern(22).

4. Water
Drink enough water daily. If you are exercising, drink more water to prevent dehydration as it is the main cause of bladder stone in athletics.

5. Pumpkin seeds
in  the study of the effect of pumpkin-seed supplementation on oxalcrystalluria and urinary composition in 20 boys age 2-7 yr from a hyperendemic area of Ubol province in Thailand, found that  Pumpkin seeds lowered calcium-oxalate crystal occurrence and calcium level but increased phosphorus, pyrophosphate, glycosaminoglycans, and potassium values in urine as compared with orthophosphate supplementation. Pumpkin seeds provide high phosphorus levels and can be used as a potential agent in lowering the risk of bladder-stone disease(23).

6. Lemon juice 
In the study of Can lemon juice be an alternative to potassium citrate in the treatment of urinary calcium stones in patients with hypocitraturia? A prospective randomized study, researchers at the Bakirkoy Research and Training Hospital, showed that lemon juice can be an alternative in the treatment of urinary calcium stones in patients with hypocitraturia. Additionally, dietary recommendations can increase effectiveness of the treatment(24).

7. Etc.


F. Treatment
F.1. In conventional perspective
1. Drinking  at least 6 - 8 glasses of water per day to increase urination to help small stones to pass on their own in the flow of urine.

2. If  bladder stones are confirmed
2.1. Medication
Medication such as Potassium citrate can help to dissolve uric acid stones. In the study to evaluate by a prospective randomized controlled study the efficacy of the association of potassium citrate and dry extract of couch grass (Agropyrum repens) (CalcoMEV) in renal stone treatment, showed that potassium citrate and couch grass showed a significant reduction in the total number of stones (-1.0 +/- 0.2 vs. 0.0 +/- 0.2 stones) and in the larger diameter of the stones (-3.6 +/- 0.9 mm vs. 0.0 +/- 0.8 mm), as well as a statistically significant reduction of uric acid urinary excretion (-164.7 +/- 45.3 vs -38 +/- 42 mg/24 h). No significant differences in the two groups were observed with respect to urinary citrate, oxalate and calcium urinary excretions and urinary pH(25).

2.2. If possible, laser energy may be used to break up the stones
2.3. Surgery
a. Cystoscope
Smaller stones which can not be passed on their own in urination but discovered by Cystoscopy can be removed with local anesthesia
b. Open surgery
Other larger stone may need open surgery to remove them

F.2. In Herbal medicine perspective
1. Asparagus racemosus Willd
In the study of the ethanolic extract of Asparagus racemosus Willd. for its inhibitory potential on lithiasis (stone formation), induced by oral administration of 0.75% ethylene glycolated water to adult male albino Wistar rats for 28 days, showed that the histopathological findings also showed signs of improvement after treatment with the extract. All these observations provided the basis for the conclusion that this plant extract inhibits stone formation induced by ethylene glycol treatment(26).

2. Goldenrod
Investigations in molecular pharmacology could show new mechanisms responsible for the biological effect of natural product from goldenrod extracts. The use of such herbal preparations with a rather complex action spectrum (anti-inflammatory, antimicrobial, diuretic, antispasmodic, analgesic) is especially recommended for treatment of infections and inflammations, to prevent formation of kidney stones and to help remove urinary gravel. This therapy is safe at a reasonable price and does not show drug-related side-effects, according to the study of the Institut für Pharmazie der Freien Universität Berlin, Berlin(27).

3. Couch grass (Agropyrum repens)
Couch grass showed a significant reduction in the total number of stones (-1.0 +/- 0.2 vs. 0.0 +/- 0.2 stones) and in the larger diameter of the stones (-3.6 +/- 0.9 mm vs. 0.0 +/- 0.8 mm), as well as a statistically significant reduction of uric acid urinary excretion (-164.7 +/- 45.3 vs -38 +/- 42 mg/24 h)(25).

4. Etc.

F.3. In TCM perspective
C.1. According to the article of Chinese medicine Hospital for Chronic and Difficult diseases(25), traditional Chinese medicine defined formation of stones is a condition caused by
1. Qi stagnation
a. The aim of the herbal treatment is to Promotethe circulation of qi, inducing diuresis, relieving strangury and removing the stones.
b. Herbal formula: Modified Pyrrosia Decoction 
Lysimachia, Pyrrosia leaf, Plantago seed, Cluster mallow fruit, Oriental water plantain rhizome, Citron fruit, Vaccaria seed, Radish seed and Rhubarb.
 
2. Damp-Heat Pattern
a. The aim of the herbal formula is to clear heat and dampness, relieve strangury and remove the stones.
b. Herbal formula: Modified Eight Health Restoring Powder
Lysimachia, Prostrate knotweed, Chinese pink herb, Talc, Phellodendron bark, Capejasmine fruit and Plantago seed , Rhubarb and Licorice root tip
3. Kidney deficiency
a. The aim of the herb used to treat kidney stones as a result of kidney deficiency is to tonify qi, reinforce the kidney, relieve stranguria and remove the stones.  
b. Herbal formula: Modified Kidney-Reinforcing Decoction
Prepared rehmannia root, Wolfberry fruit, Dogwood fruit, Achyranthes root,  Bighead atractylodes. Rhizome eucommia bark, Cinnamon bark, Pilose asiabell root, Lysimachia and Climbing fern spore
 
C.2. Chinese herbal formula Wu Ling San (Poria, Rhizoma Alismatis, Polyporus, Cortex Cinnamomi, Rhizoma Atractylodis Macrocephalae (stir-baked))
In  the study to determine the effects of a traditional Chinese herbal formula, Wulingsan (WLS), on renal stone prevention using an ethylene glycol-induced nephrocalcinosis rat model. Forty-one male Sprague-Dawley (SD) rats were divided into four groups. Group 1 (n=8) was the normal control; group 2 (n=11) served as the placebo group, and received a gastric gavage of starch and 0.75% ethylene glycol (EG) as a stone inducer; group 3 received EG and a low dose of WLS (375 mg/kg); and group 4 received EG and a high dose of WLS (1,125 mg/kg), found that the rats of placebo group gained the least significant body weight; in contrast, the rats of WLS-fed groups could effectively reverse it. The placebo group exhibited lower levels of free calcium (p=0.059) and significantly lower serum phosphorus (p=0.015) in urine than WLS-fed rats. Histological findings of kidneys revealed tubular destruction, damage and inflammatory reactions in the EG-water rats. The crystal deposit scores dropped significantly in the WLS groups, from 1.40 to 0.46 in the low-dose group and from 1.40 to 0.45 in the high-dose group. Overall, WLS effectively inhibited the deposition of calcium oxalate (CaOx) crystal and lowered the incidence of stones in rats (p=0.035). In conclusion, WLS significantly reduced the severity of calcium oxalate crystal deposits in rat kidneys, indicating that Wulingsan may be an effective antilithic herbal formula(28).

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