Most stones in the bladder are passed spontaneously in the urine. Occasionally, one impacts in the urethra, especially in boys in areas where bladder stones are common. The patient is usually able to pass urine around it, but pain, strangury, and dribbling are severe. Suspect that he has a urethral stone, if he has severe pain and dribbling, a distended bladder, and you can feel a hard mass somewhere along the course of his urethra.
URETHRAL STONES [s8]IN CHILDREN Feel along the child's urethra for a calculus. He may be able to show you where it has stuck.
Removal by manipulation under general anaesthesia may succeed.
If an X-ray suggests that it might be wedged in the neck of his bladder, try to feel it rectally. You may be able to push it back up into his bladder. If you fail, insert a well- lubricated Lister's sound into his urethra, until it strikes the stone. You may be able to push it back into his bladder.
If this fails, ask your assistant to exert upward pressure on the stone, with his finger in the child's rectum, while you manipulate it with the sound. If you can move the stone back into his bladder, proceed to remove it suprapubically, as above.
If it impacts between his bulbous urethra, and his fossa navicularis, remove it by external urethrolithotomy.
If it impacts at his external meatus or his fossa navicularis, you may be able to ''milk' it free.
If it has developed in a diverticulum (rare), you may have to cut down on this.
URETHROLITHOTOMY. Give him a general anaesthetic (A 18.3), or ketamine (A 8.5), and place him in the lithotomy position.
Clean and prepare his genitalia, the medial surface of his thighs, and his perineum. Feel for the stone in his urethra, and steady it between the thumb and index finger of your left hand.
Make a 3 cm midline incision over the stone, on the ventral surface of his penis. Cauterize or tie off the bleeding points. This is a very vascular area. If you don't control bleeding, everything will be obscured. Ask an assistant to retract the skin flaps with rake retractors.
Incise the part of his urethra containing the stone. Make the incision just big enough to deliver it. Lift it out with stone forceps or a haemostat. Try not to break it.
Insert a small (10 or 12 Ch) Foley catheter into his urethral meatus, and up past the incision into his bladder. Inflate the balloon. Don't try to close his urethra, its edges will fall together and heal naturally. Close his skin.
Connect the Foley catheter to a bedside drainage bottle, and remove it after a week.
Fig. 23-22 URETHRAL STONES. A, the sites where stones can impact in the urethra. B, removing a stone by bouginage. C, the suprapubic approach. D, the perineal approach.
1, the prostatic urethra. 2, the bulb of the urethra. 3, the perineal urethra. 4, the fossa navicularis. 5, the external meatus.