—Discomforts and symptoms produced by bladder stone depend upon their size, number, roughness, movability, and location. The larger and rougher stones, which are more or less easily moved inside a tender and irritable bladder, will cause a large amount of discomfort and actual pain, while a small calculus, which may be formed within a pocket or become encysted at some distance from the urethral opening may remain unnoticed. The indications of calculi are essentially those of cystitis, pain, frequency of urination, and pyuria, sometimes with hematuria. The pain is local and referred, especially along the urethra, to the glans in the male, and is often aggravated by the final expulsive movements of the bladder at the termination of urination. Local discomfort is aggravated by active exercise. Reflex pains have been known in distant parts of the body. The frequency of urination is increased by exposure to cold or by activity. Pyuria and hematuria do not differ from those of non-calculous cystitis. A most significant feature is sudden stoppage of the urinary stream, with more or less pain. Statements to this effect, especially if accompanied by a history of renal calculi in time past, are most suggestive.
Unless, however, particles of calcareous material have been passed the positive diagnosis of calculus rests upon its detection by examination, either with a stone searcher or with the cystoscope. The former is essentially a short-beaked, light sound, which may be more easily manipulated after introduction within the bladder. In using it the same precautions are taken as for catheterization or sounding, while the deep urethra may be made less sensitive by a cocaine solution. The instrument is introduced exactly as is a sound, and its beak is carried completely into the bladder. Sometimes even before this has been accomplished will be noted the rough, grating sensation which indicates contact with a stone. At other times it is only after considerable search that a small stone is “touched.” A stone easily found is within the possibilities of unskilled manipulation, but to accurately examine a bladder, especially behind a large prostate, is a fine art. For this purpose the bladder should be partially distended with fluid, the patient should be in the horizontal position, and the stone searcher so manipulated that its beak may be made to traverse every portion of the lower part of the bladder and to come into contact with its wall, for only in this way can an encysted calculus be discovered. The beak must, moreover, be rotated so as to be carried down into the pocket behind an enlarged prostate, as in such pockets many calculi nestle. Some stones are felt even in introducing a soft catheter; others are discovered only after such manipulation as the above. Nothing but necrosed bone or a foreign body can convey to the metal instrument, and through it to the finger, the peculiar sensation produced by contact with a stone. By attaching an auscultatory tube to the instrument a characteristic sound may also be heard.
With the cystoscope in the hands of an expert it is possible to orient one’s self definitely concerning the size and location of a calculus, but much information can also be obtained by the use of the ordinary searcher.
It has occasionally happened that calculi have been discovered by accident, either during a suprapubic or some other pelvic operation.
Treatment.
—The presence of vesical calculus being established, there is but one rational treatment, i. e., its removal. It remains, then, only to select the method of operation and to perform it. Vesical calculi are removed by two general kinds of operations: by crushing and evacuation of fragments through the natural passages, or by a cutting operation and extraction entire. The former is known as lithotrity, or, as now performed in one sitting, litholapaxy, and the other as lithotomy, which may be performed either above the pubis, through the perineum, through the vagina, or through the rectum. Each method has certain obvious advantages. Thus in favor of crushing there is freedom from an open wound, with its dangers of infection and of hemorrhage, while it appeals to the sentiment of those patients who “dread the knife.” One objection to it is that even when performed with skill assurance cannot be given that the bladder shall be freed from all calcareous particles, one of which may, by remaining, serve as a nidus for another calculus. In favor of the cutting operations are their brevity, i. e., the celerity with which they may be performed, the relief afforded by drainage, which can be carried out through the lithotomy wound, and which is often indicated in bladders that have been long tortured by the presence of calculi; while, finally, their simplicity, at least in most instances, makes lithotomy attractive to the operator of limited ability. It may be added that certain calculi, especially of the oxalic type, are so dense and resistant that even when secured in the grasp of an instrument they can scarcely be crushed. It may be urged also that septic urine is just as harmful in a bladder whose mucous membrane has been slightly injured here and there in the process of crushing as in one which has been more or less opened by a lithotomy.
Between cutting methods choice varies also according to the taste and views of various operators, as well as the nature of the case. When the prostate is large a suprapubic operation was held the simpler for the removal of calculus, and this earlier teaching is not abandoned. In the young the urethra is small and the bladder lies high in the pelvis, and both these conditions favor the suprapubic method. Again it enjoys repute because there is no danger of injury to the prostatic urethra or the seminal ducts or vesicles, and because it leaves the genital apparatus absolutely untouched. It is also free of possibility of harm to the rectum, which was by no means unknown in the hands of the older operators who resorted to the perineal route. But the removal of a large stone by the suprapubic route entails an opening of considerable size, and it is not unlikely that a large calculus may need to be fragmented and removed in pieces rather than leave a large opening at a point where urinary fistulas would likely ensue. It will be seen, then, that even lithotomy is not always to be performed without crushing of the calculus.
Of the perineal routes only two are in vogue today, the median and the lateral. The median is resorted to for stones of moderate dimensions, while the lateral will be required for large calculi. The vaginal route is often selected in women, although, rather than make an extensive opening between the bladder and the vagina, it will probably be easier and better to dilate the urethra, and, through it, crush a calculus which, in the female, could thus be made more accessible than in the male. Therefore in the female the suprapubic route or a litholapaxy is usually adopted. The operation through the rectum has been long since abandoned.
After a calculus has been removed by crushing a self-retaining catheter should be inserted, for at least a day or two, and the bladder washed, while at the same time treatment for the cystitis, which is still present, should not be discontinued. After opening the bladder the wound is drained for at least a day or two. Drainage has this disadvantage, that if long continued it leaves a urinary fistula, often slow to close, but a metal, glass, or hard or soft rubber tube may be placed in a median perineal opening, around which should be packed gauze to check oozing, and left in this condition for two or three days. Usually within a week after its removal the deep sphincters have recovered their retentive power, and the patient can retain urine for some time, while generally within two weeks the entire wound is closed. In all these cases a sound or bougie should be passed at suitable intervals for the purpose of preventing stricture formation in the deep urethra at the site of the operation.
Litholapaxy is performed by first crushing the stone between the beaks of an instrument known as the lithotrite, which is constructed in various forms, yet all conforming to one type, which is introduced into the bladder through the urethra, after which its blades are separated and manipulated until the stone is felt to be entangled or secured between them. By a device at the handle the blades are then locked, and screw power exerted, also from the handle, by which the blades are forced together and the stone between them more or less broken ([Figs. 652] and [653]). By repetition of this process each fragment is seized separately and crushed until the bladder contains more or less debris resulting from the manipulation. The lithotrite is then removed and a washing tube or catheter of large dimension inserted, and connected with a so-called washing bottle, which is compressible and permits a stream of water to be violently thrown into the bladder, thus stirring up the fragments and particles, and which is an instant later withdrawn by suction in such a way as to carry them with it. Escaping into the washing bottle they drop by gravity into a glass receptacle at its base, where they become at once visible. This process is repeated until everything has been washed out of the bladder which will come. The lithotrite is then substituted and the maneuver repeated, and as many times as may seem desirable. In this way calculi, especially soft ones of large size, may be disintegrated and removed in small fragments. The final test of success is failure to aspirate any more particles or to discover them with the cystoscope ([Fig. 654]). The time consumed in the operation will depend on the operator’s skill and the size or hardness of the stone. It is frequently performed under local anesthesia, the bladder being injected with a weak cocaine solution, or under spinal anesthesia.