Diagnostic delay of a urethral stone

A urethral stone hidden from usual view could be the cause of chronic pelvic pain and clinical examination of the genitalia and perineum is recommended, according to authors of a case report published in the Lancet (2018;392:1246).

They report a 50-year old man who had been suffering chronic perineal pain for five years. There were no bothersome urinary tract symptoms and he had a reasonable urine flow. He had been treated for chronic pelvic pain syndrome.

Clinical examination revealed a hard swelling 4cm above the anal verge in the midline. A plain x-ray of the pelvis showed a radio-opaque shadow inferior to the pubic symphysis and a retrograde urethrogram showed the obstruction in the bulbar urethra, suggesting a 2cm stone.

The stone was retrieved by ventral urethrotomy with a perineal approach. Following the operation the patient reported complete relief from his pain.

According to the authors, stones in the bulbar urethra are likely to be missed by routine trans-abdominal ultrasound and thorough clinical examination is advised in cases where the causes of pain are not obvious.

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