An 83-year-old man presented with frank haematuria. An abdominal x-ray showed an appearance suggestive of at least four bladder calculi with spiculated margins (fig 1). A flexible cystoscopy and subsequent open cystolithotomy was performed with removal of a dark, mobile, spiculated, 4×4×4 cm single calculus (fig 2).
Bladder calculi vary in size, shape and colour. They can be single or multiple. Most are circular, but they can be almost any shape. An unusual type is the jack stone variety, which classically have a characteristic radiographic appearance and resemble toy jacks.1
Bladder calculi are usually associated with urinary stasis, which may arise from benign prostatic hypertrophy, urethral stricture, neurogenic bladder, recurrent urinary tract infections or chronic catheterisation. Presentations include abdominal pain, urinary retention and other lower urinary tract symptoms. Conversely, bladder calculi can form in a normal bladder and be asymptomatic.
The cause of frank haematuria in our patient was a bladder calculus, but it can arise from local bleeding anywhere along the urinary tract and less commonly from general causes such as bleeding diatheses. Most importantly, urological malignancies such as renal cell carcinoma and transitional cell carcinoma are common causes of frank haematuria. They need to be suspected even if another cause is found. All patients with frank haematuria require a urology referral.2 Initial investigations include blood tests and excluding transient causes, including a urinary tract infection. Further assessment includes an ultrasound scan of the urinary tract and a flexible cystoscopy.