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Penile urethral calculus
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Author(s) :
Ravi Kadasne, MD
Presentation A young man presents with vague discomfort in the penis of a few hours duration. There was no history of trauma or any other significant medical history. A penile ultrasound was performed.
Caption: Images of the tip of the penis using a water-bath
Description: The penile urethra demonstrates the presence of an elongated echogenic calculus.
Caption: Sagittal image of the tip of the penis
Description: The calculus is again noted and demonstrates posterior acoustic shadowing. Based on the history and the shape of the calculus, it seems likely that this calculus is ureteric in origin.
Caption: Transverse image of the penis
Description: This image also demonstrates the calculus in another plane. Significant posterior shadowing is cast by the stone.
Differential Diagnosis Penile urethral calculus
Final Diagnosis A calculus in the penile urethra that has possibly migrated from the ureter
Discussion Urethral calculus may be either primary or secondary in nature. Primary stones are the ones that may occur as a sequel to a primary urethral pathology such as a stricture or urethral diverticulum. Secondary urethral calculi are stones that may have migrated from either the kidney, ureter or bladder. Very small calculi may be asymptomatic and larger ones tend to produce symptoms of dysuria, gradual reduction in the stream of urine, dribbling of urine and bladder outlet obstruction. Giant urethral calculi in the posterior urethra have also been reported.

The normal anatomy of the male urethra consists of the posterior urethra [prostatic urethra and membranous urethra] and the anterior urethra [incorportaing the bulbous urethra and penile urethra]. Stones may occur in either the anterior or posterior urethra. Ultrasound enables the visualization of these calculi and simultaneously can image the entire urinary tract for the presence of other calculi. The posterior urethra is better imaged by transrectal ultrasound and the anterior urethra can be imaged by placing the transducer probe directly over the penis.

Management of these stones involves removal by either electrohyraulic lithotripsy or, in an anatomically normal urethra, by retrograde manipulation of the stones back into the urinary bladder using various techniques such as irrigation. The stones can then be easily removed from the bladder. Unless obviously visible at the urethral meatus, forced extraction of these stones via the urethral meatus may damage the urethral mucosa resulting in strictures and should not be done.

Case References 1. Win T. Giant urethral calculus. Singapore Med J. 1994 Aug;35(4):414-5.
2. Case of the month # 16.

Technical Details A water-bath has been used [demonstrated in image 1], to obtain better images of the penile urethra, as the latter is a very superficial structure.
Follow Up This patient was sent to a surgeon who used artery forceps to extract a calculus that was impacted at the urethral meatus.