Large primary vaginal stone in a woman with multiple sclerosis

Background

The occurrence of a primary vaginal stone is extremely rare and, in many cases, initially misdiagnosed. Primary vaginal stones are believed to be formed by stasis of urine in the vagina, leading to the deposition of urinary salts. Even though most primary stones are detected in association with vesicovaginal or urethrovaginal fistulae, various other aetiologic factors are described—for example, neuropathic dysfunction of the bladder, ectopic ureters or anatomical abnormalities causing vaginal outlet obstructions.1 Secondary stones are the result of deposition of urinary salts around foreign bodies such as contraceptive devices, forgotten surgical tools or gauzes or secondary to vaginal mesh exposure.

We present a case of a neurologically disabled woman with a large vaginal stone in absence of a vesicovaginal fistula, representing delay in the accurate diagnosis that allowed the stone to enlarge.

Case presentation

The patient was a 54-year-old woman, known with multiple sclerosis (MS)-related paraparesis and urinary incontinence as a result of neurogenic bladder dysfunction. Her Expanded Disability Status Scale (EDDS) score was 8.5. She presented to the urologist with recurring urinary tract infections (UTI) and suspected macroscopic haematuria, which had been presented for the past 6 months, causing blood loss in her incontinence sanitary pad every 3–5 weeks. Urinalysis showed red blood cells and bacteriuria. A flexible cystoscopy was performed, while the patient was sitting in her wheelchair, showing no abnormalities. The urologist decided to treat the UTI and advised to differentiate between haematuria and vaginal bleeding through the use of a vaginal tampon. Delay occurred due to a no-show and several unsuccessful attempts of the tampon test at home. Five months later, during a telephone consultation, the bleeding turned out to be persistent and the patient was referred to the gynaecologist to determine whether the bleeding had a genital source. Furthermore, her wish was to remove her intrauterine device (IUD), which was placed 9 years ago because of heavy menstrual bleeding. On request of the patient, the IUD had not been removed earlier, since the menstrual bleeding had stopped completely and she had no reports. She kept postponing the removal of her IUD because she dreaded the difficult transfer to a gynaecological examination chair with her physical disability.

In our outpatient clinic, on gynaecological examination, a large, hard and white vaginal stone that could not be removed was discovered (figure 1). The stone filled up ¾ of the vagina, so we were not able to see the cervix and therefore not able to perform cervical cytology or remove the IUD.

Investigations

An attempt was made to perform a transvaginal ultrasonography, results of which were inconclusive. The vaginal stone could not be outlined and blocked the image of the uterus, cervix and adnexa. Based on these findings, the patient was listed to undergo operative removal of the vaginal stone and for further investigation to be performed under general anaesthesia. No additional imaging was performed.

Treatment

Under general anaesthesia, the stone was extracted with the use of several sharp instruments. The museux tenaculum forceps (6 mm jaws, 24 cm) provided the best grip on the stone and were strong and sharp enough to crush it into smaller pieces, spreading a foul odour. The instrument features double-pronged jaws that ensure fixation onto tissues. Their principal use is to stabilise and hold the uterus and cervix during hysterectomy, oophorectomy or tubal ligation. The stone was entirely removed without complications in 109 min. A small laceration of the vaginal wall was sutured. The stone measured approximately 10×6×5 cm and the threads of the IUD were trapped inside the stone. It appeared as though the growing stone had pulled the IUD out of the uterus sometime before. Inspection of vulva and vagina showed no anatomical abnormalities. Several decubitus ulcerations were seen, on which estriol (Synapause-E3) was applied. A cervix cytology test was performed. Transvaginal ultrasound showed a normal uterus and adnexa. A methylene blue solution was instilled into the bladder to exclude the presence of a vesicovaginal fistula.

Outcome and follow-up

On chemical analysis, the stone was found to be composed of 70% magnesium phosphate (struvite) and 30% calcium phosphate (apatite). Furthermore, culture of the urine showed a UTI with Proteus mirabilis. The UTI was treated with ciprofloxacin and, on consultation with the urologist, a long-term urinary catheter was left in situ. The patient continued applying topical estriol (Synapause-E3) for 2 weeks. Cervix cytology appeared inconclusive (Pap 0), which led to the advice to repeat the test at a later stage. Follow-up after 4 weeks was uneventful, and the patient was symptom free after this period. The decubitus ulcerations were believed to be the cause of the vaginal bleeding.