What is the recommended workup and treatment for bladder stones, and when is observation appropriate?

Diagnostic Workup and Management of Bladder Stones

Surgery is recommended for patients with bladder stones clearly due to BPH and refractory to other therapies, as these stones can lead to significant morbidity including recurrent UTIs, hematuria, and renal insufficiency. 1

Diagnostic Evaluation

• Non-contrast CT scan is the gold standard imaging modality for diagnosing bladder stones, providing detailed information about stone location, size, density, and surrounding anatomy 2
• Ultrasound is recommended as the first-line imaging tool with 88% sensitivity for bladder stones, offering the advantage of no radiation exposure 2
• KUB (kidney-ureter-bladder) radiography helps differentiate between radiopaque and radiolucent stones and is useful for follow-up imaging 2
• Basic laboratory evaluation should include:
  • Serum electrolytes, calcium, creatinine, and uric acid to identify underlying medical conditions 2
  • Urinalysis with dipstick and microscopic evaluation to assess for infection, pH, and crystals that may indicate stone type 2
  • Urine culture to rule out infection, especially if intervention is planned 1

Treatment Algorithm

Step 1: Determine if immediate intervention is needed

• Urgent intervention required if:
  • Signs of infection or sepsis with obstructing stone (immediate drainage via catheter) 1
  • Renal insufficiency clearly due to bladder outlet obstruction 1
  • Intractable pain or hematuria 2

Step 2: For non-urgent cases, assess stone characteristics and patient factors

• Stone size and number:
  • Small solitary stones (<1 cm): May consider observation if asymptomatic 3
  • Multiple or large stones (>1 cm): Active intervention recommended 3, 4
• Underlying conditions:
  • Presence of bladder outlet obstruction (e.g., BPH): Address underlying cause 1
  • Neurogenic bladder or recurrent UTIs: Active intervention recommended 1

Step 3: Select appropriate intervention based on assessment

• Transurethral cystolithotripsy (TUCL): First-line therapy for most bladder stones in adults 3
  • Higher stone-free rates compared to SWL
  • Shorter hospital stay compared to open surgery
  • Can be performed with laser, pneumatic, or ultrasonic lithotripters
• Percutaneous cystolithotripsy (PCCL): Consider for very large stones or when urethral access is difficult 3
  • Similar stone-free rates to TUCL
  • Slightly longer hospital stay than TUCL
• Open cystolithotomy: Reserved for very large stone burden or when endoscopic options are not feasible 3, 4
  • 100% stone-free rate but higher morbidity
  • Longer recovery time and hospital stay
• Extracorporeal shock wave lithotripsy (SWL): Limited role, lower success rates (75-100%) 5, 3
  • Consider only for high-risk surgical patients with small stones

Management of Underlying Conditions

• For bladder stones due to BPH:
  • Surgical management of BPH (e.g., TURP) should be considered concurrently with stone removal 1
  • Recent studies question the necessity of prostate surgery in all cases, but lack long-term follow-up data 4
• For bladder stones due to neurogenic bladder:
  • Implement appropriate bladder management strategies (intermittent catheterization, indwelling catheter) 1
  • Address any urinary tract infection before definitive stone treatment 1

Special Considerations

• Antimicrobial prophylaxis:
  • Should be administered prior to all endoscopic stone procedures 1
  • Base selection on prior urine culture results and local antibiogram
• Stone analysis:
  • All retrieved stone material should be sent for analysis to guide prevention strategies 1
  • Exception: patients with multiple recurrent stones of previously documented composition 1
• Intraoperative findings:
  • If purulent urine is encountered during intervention, abort procedure, establish drainage, continue antibiotics, and obtain culture 1

Prevention Strategies

• Increased fluid intake:
  • Target urine output >2.5 L/day to prevent recurrent stone formation 2
• Treatment of underlying conditions:
  • Management of bladder outlet obstruction 1
  • Appropriate bladder drainage in neurogenic bladder 1
• Follow-up:
  • Regular imaging to monitor for recurrence 2
  • Address metabolic abnormalities if identified 2

When is Observation Appropriate?

Observation without active intervention may be appropriate in very limited circumstances:

• Small (<5mm), asymptomatic stones 3
• Patients with prohibitive surgical risk 5, 3
• Absence of:
  • Infection or history of recurrent UTIs 1
  • Significant symptoms (pain, hematuria) 2
  • Renal insufficiency 1
  • Large stone burden 3

However, most bladder stones will eventually become symptomatic and require intervention, making observation a temporary strategy in most cases 3, 4.