What is the management approach for penile stones?

Management of Penile Stones

Ureteroscopy (URS) with laser lithotripsy is the recommended first-line treatment for penile stones, as it offers the highest stone-free rates with minimal invasiveness and complications. 1

Diagnosis and Initial Assessment

• Imaging: Non-contrast CT scan is the gold standard for diagnosis and preoperative planning 1
• Laboratory tests:
  • Urinalysis (mandatory)
  • Urine culture if signs of infection are present
  • CBC and platelet count to assess for bleeding risk
  • Serum electrolytes and creatinine if renal dysfunction is suspected 1

Treatment Algorithm

1. Small Penile Urethral Stones (≤10 mm)

• First-line: Ureteroscopy (URS) with laser lithotripsy

  • Offers highest stone-free rates (85-95%)
  • Lower likelihood of requiring repeat procedures compared to other modalities 1, 2
  • Can be performed in patients with bleeding disorders or on anticoagulation therapy 1

• Alternative: Meatotomy or direct extraction if stone is visible at meatus

2. Large Penile Urethral Stones (>10 mm)

• First-line: Ureteroscopy with laser lithotripsy
• Alternative: Open urethrolithotomy if:
  • Stone is too large for endoscopic management
  • Multiple large stones are present
  • Associated with severe urethral stricture 3

3. Complicated Cases

For patients with large impacted stones causing urethral obstruction or tissue damage:

• Step 1: Urinary drainage (suprapubic cystostomy)
• Step 2: Urethrolithotomy
• Step 3: Reconstructive urethroplasty if urethral damage is extensive 3, 4

Special Considerations

Infection Management

• If infection is suspected with obstruction, urgent drainage of the collecting system is mandatory before stone removal 1
• Appropriate antibiotic therapy should be administered until clinical resolution 2

Technical Considerations

• Avoid electrohydraulic lithotripsy (EHL) as it has a high risk of damaging urethral mucosa and causing perforation 1
• Consider using α-blockers to reduce discomfort associated with stent placement after the procedure 1

Complications to Monitor

• Urethral stricture formation
• Infection
• Penile gangrene (rare but serious complication of impacted stones) 4
• Erectile dysfunction

Follow-up Care

• Post-procedure imaging to confirm stone clearance
• Metabolic evaluation to identify risk factors for recurrence
• Increased fluid intake (>2L/day) to maintain dilute urine
• Dietary modifications based on stone composition to prevent future stone formation 2

Pitfalls to Avoid

1. Delayed treatment: Impacted penile urethral stones can lead to severe complications including urethral stricture, infection, and in extreme cases, penile gangrene 4

2. Inadequate drainage: When infection is present with obstruction, failure to establish immediate drainage can lead to sepsis and increased morbidity 1

3. Inappropriate technique selection: Using electrohydraulic lithotripsy in the urethra increases risk of mucosal damage and should be avoided 1

4. Overlooking underlying causes: Failure to identify and address predisposing factors (strictures, diverticula, etc.) may lead to recurrence 4