Diagnosis and Removal of Urethral Calculi Using Bedside Ultrasound in the Emergency Department

A 38-year-old male presented to the emergency department (ED) with 3 weeks of sensing a palpable mass in the distal aspect of his penis, associated with decreased urinary flow. He had been evaluated in the ED 2 weeks prior with similar symptoms and was diagnosed with renal calculi based on clinical history and presence of microscopic hematuria and had been taking Flomax and ibuprofen. On physical exam, the patient was a well-appearing male in no apparent distress, with a benign abdominal exam and no costovertebral angle tenderness to percussion. He was noted to have two palpable, mobile masses along the distal volar surface of the penis, with the largest approximately 0.5 · 0.5 cm. Ultrasound was performed revealing two shadowing echogenic foreign bodies (Figure 1), which were confirmed by noncontrast computed tomography (CT) imaging to be consistent with renal calculi. Urology was consulted and attempted blind removal of the stones was performed unsuccessfully, primarily because of inability to grasp the stone with forceps; the patient was prepared for operative intervention. Using procedural sedation, the emergency physicians utilized dynamic ultrasound imaging with a high-frequency probe to localize the stones and facilitate removal while being actively visualized with clamp and Katz extractor (Figure 2 and Video Clips S1–S3, available as supporting information in the online version of this paper). Following the procedure, the patient was discharged with Foley catheter placement and a course of ciprofloxacin. The stones were sent for analysis, revealing primary calcium oxalate composition. He had an unremarkable urology follow-up and has not had recurrence of stones to date. In cases of distal urethral stones, ultrasound imaging is both diagnostic and effective in facilitating procedural removal of the stones in the ED.