590 Published by Intisari Sains Medis | Intisari Sains Medis 2023; 14(2): 590-594 | doi: 10.15562/ism.v14i2.1756CASE REPORT
Intisari Sains Medis 2023, Volume 14, Number 2: 590-594
P-ISSN: 2503-3638, E-ISSN: 2089-9084
ABSTRACT
Bladder stone in a 1-year infant with recurrent
urinary tract infections: a rare case report
I Dewa Gede Reza Sanjaya
1
, Agustin Junior Nanda De Niro
2*
,
Anak Agung Putri Nadia Paramitha
2
Background: Bladder stone is a rare disease accounting
for 5% of all urinary calculi. It is more common in
middle- and low-income countries due to nutritional
obstacles, water sanitation, and warm climates.
Primary bladder calculi are most common in children
younger than 10 years old, with a peak incidence at 2
to 4 years. There have been no reports of bladder stones
in children under 2 years of age. This case study aims
to evaluate the bladder stone in a 1-year infant with
recurrent urinary tract infections.
Case Presentation: An infant boy 1 year and 2 months
presented with a 6-month history of complaints of pain
on micturition presented with pulling the penis, cloudy
urine, and recurrent fever in our clinic. During the 6
months before admission, he visited several pediatric
clinics and was diagnosed with and treated for UTI. On
ultrasonography, we found a bladder stone 1,9 x 1,3 cm
in size. Then we performed open cystolithotomy under
general anesthesia. One day after surgery, the patient
was discharged from the hospital.
Conclusion: Children who live in endemic areas are
more likely to develop bladder stones due to dietary
issues. Preventing dehydration, treating urinary
tract infections effectively, and securing metabolic
abnormalities are the methods for reducing the
prevalence of pediatric bladder stones. Pediatric
bladder stones must be diagnosed and treated to avoid
the stones’ recurrence and improve quality of life.
Keywords: Pediatric, Bladder stone, Endemic bladder stone, Open cystolithotomy.
Cite This Article: Sanjaya, I.D.G.R., Niro, A.J.N.D., Paramitha, A.A.P.N. 2023. Bladder stone in a 1-year infant
with recurrent urinary tract infections: a rare case report. Intisari Sains Medis 14(2): 590-594. DOI: 10.15562/ism.
v14i2.1756
1
Urology Doctor at Balimed Buleleng Hospital,
Buleleng, Bali, Indonesia
2
Balimed Buleleng Hospital, Buleleng, Bali, Indonesia
*Corresponding to:
Agustin Junior Nanda De Niro; Balimed Buleleng
Hospital, Buleleng, Bali, Indonesia;
deniro_nanda @yahoo.co.id
Received: 2023-04-28
Accepted: 2023-06-06
Published: 2023-07-10
Published by Intisari Sains Medis
Open access: http://isainsmedis.id/
INTRODUCTION
Bladder stones are the most common
manifestation of lower urinary tract
lithiasis, accounting for 5% of all urinary
stone diseases and approximately 1.5%
of urologic hospital admissions in the
Western world.
1
There has been a paradigm
shift in the size and location of stones
in the lower urinary tract. In the past 50
years, the incidence of vesical calculus has
steadily declined in the Western world.
The underdeveloped nations continue to
see vesical calculi, particularly in children.
2

Bladder calculi in nonendemic areas are
common in adults and secondary to other
disease processes. In endemic areas, the
calculi are seen frequently in children
and do not exist with other anomalies.
1,2

Traditionally, bladder stones are classified
as migrant, primary idiopathic, or
secondary. Primary bladder stones
usually are described as those that form
without any predisposing cause, whereas a
secondary reason is found in most patients
with certain predisposing causes.
1
Primary
bladder stones are historically associated
with nutritional deficiency.
2
Children in
endemic areas consume a cereal-based diet
that is poor in animal protein and low
in phosphate. Low dietary intake of
phosphates leads to hypophosphaturia,
promoting the precipitation of calcium
oxalate and ammonium acid urate.
In addition to the earlier-mentioned
factors, it has been proposed in endemic
areas that a diet rife with oxalates leads to
hyperoxaluria, leading to calcium oxalate
stones.
The primary bladder stones are known
to form within the first 5 years of life and
have a male preponderance. Primary
bladder calculi are most common in
children younger than 10, with a peak
incidence at 2 to 4 years. The disease is
much more common in boys than in
girls, with ratios ranging from 9:1 to as
high as 33:1.
3
The composition of primary
bladder stone is commonly ammonium
acid urate, calcium oxalate, uric acid, and
calcium phosphate.
2
Children suffering
from bladder stones rarely seek medical
attention acutely. There are often preceding
symptoms, such as the passage of cloudy
and sandy urine. Children often experience
abdominal discomfort, dysuria, frequency,
and haematuria. Pulling the penis, in
children, is considered pathognomonic of
bladder stone. In adults, the presentation
can be acute urinary retention; however,
this is rare in children with primary
bladder stones.
4
The options for treating bladder stones
are medical management, extracorporeal
shock wave lithotripsy, transurethral
lithotripsy, suprapubic cystolithotomy,

591Published by Intisari Sains Medis | Intisari Sains Medis 2023; 14(2): 590-594 | doi: 10.15562/ism.v14i2.1756CASE REPORT
suprapubic cystolithotripsy, and open
surgery.
4,5
The factors that decide the
line of management are the size of the
stone, stone composition, age of the
patient, build of the patient, coexistent
location of urolithiasis elsewhere,
concomitant bladder outlet obstruction,
and available expertise or equipment.
Open cystolithotomy has been considered
the gold standard surgical procedure in
pediatric bladder stones. Workers have
also reported the feasibility of catheterless
and drainless cystolithotomy in children
with two layered closures. However, recent
advances in minimally invasive technology
and endoscopic techniques have improved
the urological armamentarium to treat
bladder stones in pediatrics definitively.
4–7

In this report, we present a case of a
bladder stone in an infant with recurrent
urinary tract infection with the complaint
of irritative voiding symptoms successfully
managed with open cystolithotomy.
CASE REPORT
An infant boy, 1 year and 2 months,
presented with a 6-month history
of complaints of pain on micturition
presented, with pulling the penis, cloudy
urine, and recurrent fever in our clinic.
During the 6 months before admission, he
visited several pediatric clinics and was
diagnosed with and treated for UTI. His
symptoms did not improve, and he was
referred to Balimed Buleleng Hospital
Urology Clinic for further evaluation and
management.
The boy’s parents was a farmer; he
had one brother and they lived together
in a poor, rural seaside area. There was
no family history of bladder stones.
From birth until 1 year of age, he was fed
formula milk. His diet consisted of starchy
foods and foods with high fiber content.
His water and total protein intake were
insufficient, especially animal protein.
On physical examination, we found the
patient’s weight was 8 kg and height was
72,5 cm (Z score < -1). Vital signs were
within normal limits. There was no flank
knocking pain, abdominal tenderness, or
palpable mass. Other physical findings
were normal. On laboratory investigation,
hemoglobin was 10,2 g/dL, leukocyte
count was 11930/uL, and platelet count
was 409 x 10
3
/uL. Urinalysis revealed
Figure 1. Urology ultrasound confirmed the bladder stone (blue arrow)
about 1,9 x 1,3 cm in size.
Figure 2. Urology ultrasound of the right (a) dan left (b) kidneys were normal.
pH 6.0, albumin +1, ketone +1, leukocyte
+3 on macroscopic examination and
2 -3 erythrocytes / high power field,
15 – 17 leukocyte / high power field on
microscopic examination. Blood urea
nitrogen, creatinine, sodium, potassium,
calcium, and chloride were all normal on
biochemical analysis. Bleeding time and
clotting time checks were
normal. On urology ultrasound, we
found a bladder stone 1,9 x 1,3 cm in size.
Another abdominal organ, including both
kidneys, was normal (Figure 1 and Figure
2).
Then, we performed cystolithotomy
under general anesthesia (Figure 3).
A Foley catheter was inserted and
ceftriaxone 150 mg intravenous was
administered for prophylaxis. We made
a Pfannenstiel incision on the suprapubic
region, deepened to the rectus fascia
(Figure 4). Fascia opened, and the muscle
then split. The bladder was incised, but
before that, we instilled 200 ml saline
liquid into it and the stone was removed
with a stone tang. After that, we wash the
wound and bladder with saline liquid until
there are no more stone flakes and dirt. Then
we removed the catheter and closed the
bladder with one layer locking continuing
suture using absorbable thread. We close
the surgical wound without leaving a
drain on it. We continued intravenous
antibiotics and intravenous paracetamol
for analgetic. One day after surgery, the
patient’s condition was good, and the urine

592 Published by Intisari Sains Medis | Intisari Sains Medis 2023; 14(2): 590-594 | doi: 10.15562/ism.v14i2.1756CASE REPORT
color was clear, so we let him be discharged
from the hospital.
Six days after surgery, the patient went
to the urology outpatient clinic, and the
stone composition analysis was 90 % of
uric acid and 10 % of the matrix. He just
complained of mild pain in his penis,
no fever, and no hematuria. The post-
operative surgical wound was in good
condition, with no sign of infection.
DISCUSSION
Bladder stones in children are evident
from archeological discoveries, and
historical reports show that 2-3 % of
children can develop urinary calculi.
8

Nonetheless, in nations where the stone
disease is endemic, urolithiasis remains
a serious problem, accounting for 4-8%
of cases of end-stage renal disease
during childhood.
9
The prevalence of
bladder stones was reported in Europe
and North America in the 18th and 19th
centuries.
10
This trend later shifted to the
East, stretching in a broad stone belt from
Egypt through Iran, Pakistan, India and
Thailand to Indonesia.
11
Urinary bladder
stone contributes about 50% of pediatric
urolithiasis.
12
Endemic bladder stones are
higher in developing nations and more
common in males, with male-female ratios
between 10:1 and 4:1 reported. Bladder
stones were widespread in children in
Indonesia, particularly in West Sumatra,
with a yearly prevalence of 8.3 per 100,000
people, peaking at ages 2-4, and usually
occurring in low-income families that
consumed little protein and phosphate. A
pediatric bladder stone is a rare disease;
in the last five years, there have been few
reports about this condition. Maulana
et al., reported a large bladder stone in
Sasak young teens with 4 cm in diameter.
13

Rizkyansyah H et al., reported bladder
stones in a six-year-old boy with 2,4 x 1,8
cm in size.
14
Sharma G et al. reported
bladder and urethral stones 12-year-old
child.
11
Our patient complains of pain
on micturition, presented with pulling
the penis, cloudy urine, and recurrent
fever in the last 6 months. Based on our
findings, there’s no obstruction to the flow
of urine and no evidence of pathological
abnormalities in the organs. Therefore,
the etiology in this patient is a primary or
endemic bladder stone.
Primary bladder stones are historically
associated with nutritional deficiency.
The cause for the formation of these
calculi is believed to be a combination
of decreased urine output, alteration
in the urine PH, and other metabolic
abnormalities. Vitamin deficiency
and dietary compromise in the form of
deficient animal proteins are responsible
for the genesis of these stones. Children
in endemic areas consume a cereal-based
diet that is poor in animal protein and
low in phosphate. Low dietary intake of
phosphates leads to hypophosphaturia,
promoting the precipitation of calcium
oxalate and ammonium acid urate. In
addition to the earlier mentioned factors, it
has been proposed in endemic areas that a diet
rife with oxalates leads to hyperoxaluria,
leading to calcium oxalate stones. The
composition of primary bladder stones is
commonly ammonium acid urate, calcium
oxalate, uric acid, and calcium phosphate.
4

Girls’ urethras are less convoluted and
shorter than those of boys, and they may
pass the majority of calculus debris
without holding nuclei in the bladder. A
stone core forms and is retained in some
males. The overall result of storage and
resorptive mechanisms functioning over
months or years determines subsequent
stone development.
3
Bladder stones are rarely asymptomatic
at the time of presentation. The most
common manifestation of bladder calculi
is terminal haematuria. In addition, the
patients have various lower urinary tract
symptoms, including intermittency,
frequency, urgency, decreased flow,
urge incontinence, and abdominal pain.
Children suffering from bladder stones
rarely seek medical attention acutely. There
are often preceding symptoms, such as
the passage of cloudy and sandy urine.
Children often experience abdominal
discomfort, dysuria, frequency, and
haematuria. Pulling the penis, in children,
is considered pathognomonic of bladder
stone. In adults, the presentation can be
acute urinary retention; however, this is
rare in children with primary bladder
stones.
4
Rarely, bladder stones can lead
to kidney damage.
15
In general, they are
mobile within the intravesical space. As a
Figure 3. An elliptical bladder stone was extracted by open
cystolithotomy.
Figure 4. Pfannenstiel incision and post-
operative wound closure.

593Published by Intisari Sains Medis | Intisari Sains Medis 2023; 14(2): 590-594 | doi: 10.15562/ism.v14i2.1756CASE REPORT
result, they hardly restrict the bladder exit
and do not reduce urine flow. Large stones
may remain for a very long time without
showing any symptoms.
3
However,
larger stones can damage the bladder
neck and put a mechanical strain on the
ureteral orifice if left untreated, leading to
intravesical obstructive uropathy.
15
Abdominal radiography,
ultrasonography, intravenous pyelography,
and computed tomography are the most
useful tools for diagnosing children with
stones. Clinicians use plain abdominal
radiography and ultrasonography for
initial assessment. Ultrasonography can
diagnose and reveals many types of stones,
including some radiolucent stones.
2

Our patient underwent a cystolithotomy
(open bladder stone surgery) with a
1,9 x 1,3 cm stone size. The options for
treating bladder stones are medical
management, extracorporeal shock wave
lithotripsy, transurethral lithotripsy,
suprapubic cystolithotomy, suprapubic
cystolithotripsy, and open surgery. The
factors that decide the line of control are the
size of the stone, stone composition, age of
the patient, build of the patient, coexistent
location of urolithiasis elsewhere,
concomitant bladder outlet obstruction,
and available expertise or equipment.
4

According to the Association of Indonesian
Urologists’ 2018 guidelines for urinary
tract stones, endoscopic lithotripsy is the
main treatment option for stones smaller
than 20 mm. The main treatment option
for stones larger than 20 mm or in children
is open surgery (open cystolithotomy), but
endoscopic lithotripsy is also an option.
16

Due to the excellent stone-free rate and
accessibility of published long-term
data, traditional open cystolithotomy is
the gold standard surgical method for
treating children’s bladder stones.
17,18

Transurethral cystolithotripsy has recently
gained popularity as an alternative to open
cystolithotomy. However, because urethral
diameters are tiny and there are issues
with iatrogenic urethral constriction, the
usefulness of this method is restricted,
particularly in boys.
19,20
Many modern
techniques and equipment are still
unavailable in some underdeveloped
nations, and many patients cannot afford
the prices of less invasive operations.
Under these circumstances, open surgery
is risk-free, productive, has a manageable
hospital stay, is very well received by
the patient, is inexpensive, causes little
morbidity, and has a high stone-free rate.
19
Our patient was discharged one day
after surgery without the urethral catheter.
Workers have reported the feasibility of
catheterless and drainless cystolithotomy
in children with two-layered closure.
4

Six days after surgery, the patient went
to the urology outpatient clinic. He just
complained of mild pain in his penis,
no fever, no haematuria, and he could
void spontaneously without any sign of
inflammation. A catheter in the bladder
following surgery is advised in some
publications, as is the placement of a
drain in the retropubic area for a few
days to allow for the drainage of urine or
hematoma in the event of postoperative
leakage. However, some negative effects
of catheter use, including infection and
stricture, need to be watched carefully.
21

In order to reduce catheter-associated
urinary tract infections, the length of
the catheterization should not exceed 8
days.
22-25
This case report described the patient’s
disease and treatment in detail, which
can be helpful to physicians dealing with
similar cases. But it just reflects one
case, it is limited in that it cannot prove
causation or generalize results to a larger
population.
CONCLUSION
Children who live in endemic areas are
more likely to develop bladder stones due
to dietary issues. Preventing dehydration,
treating urinary tract infections effectively,
and securing metabolic abnormalities are
the methods for reducing the prevalence of
pediatric bladder stones. Pediatric bladder
stones must be diagnosed and treated to
avoid the stones’ recurrence and improve
quality of life.
CONFLICT OF INTEREST
The author declares no personal or
financial conflict of interest in writing the
case report.
ETHICS APPROVAL
Permission or informed consent has been
approved by the patient and urology
doctor of Balimed Buleleng Hospital for
using the patient information and medical
record in this case report.
FUNDING
This case report did not receive a specific
grant from any funding agency, whether
public or commercial.
AUTHOR CONTRIBUTIONS
All authors contributed equally in
writing and revising the case report from
the conceptual framework until draft
manuscript preparation before being
published.
REFERENCES
1. Hughes T, Ho HC, Pietropaolo A, Somani
BK. Guideline of guidelines for kidney and
bladder stones.  Turk J Urol. 2020;46(Supp.
1):S104-S112.
2. Önal B, Kırlı EA. Pediatric stone disease:
Current management and future concepts.
Turkish Archives of Pediatrics. 2021;56(2):99–
107.
3. Halstead SB. Epidemiology of bladder stone
of children: precipitating events. Urolithiasis.
2016;44(2):101–108.
4. Cicione A, DE Nunzio C, Manno S, Damiano
R, Posti A, Lima E, et al. Bladder stone
management: an update. Minerva Urol Nefrol.
2018;70(1):53-65.
5. Mohamed AH, Yasar A, Mohamud HA. Giant
bladder stone of 152g in an 11-year child with
recurrent urinary tract infections: A rare case
report and review of the literature.  Urol Case
Rep. 2021;38:101676.
6. Softness KA, Kurtz MP. Pediatric Stone Surgery:
What Is Hot and What Is Not. Curr Urol Rep.
2022;23(4):57–65.
7. Okada T, Taguchi K, Kato T, Sakamoto S,
Ichikawa T, Yasui T. Efficacy of transurethral
cystolithotripsy assisted by percutaneous
evacuation and the benefit of genetic analysis
in a pediatric cystinuria patient with a large
bladder stone. Urol Case Rep. 2020;34:101473.
8. López M, Hoppe B. History, epidemiology
and regional diversities of urolithiasis. Pediatr
Nephrol. 2010;25(1):49–59.
9. Clayton DB, Pope JC. The increasing pediatric
stone disease problem. Ther Adv Urol
2011;3(1):3-12.
10. VanDervoort K, Wiesen J, Frank R, Vento S,
Crosby V, Chandra M, et al. Urolithiasis in
Pediatric Patients: A Single Center Study of
Incidence, Clinical Presentation and Outcome.
J Urol. 2007;177(6):2300– 2305.
11. Sharma AP, Filler G. Epidemiology of pediatric
urolithiasis. Indian J Urol. 2010;26(4):516-522.
12. Brisson P, Woll M, Parker D, Durbin R.
Bladder Stones in Afghan Children. Mil Med
2012;177(11):1403–1405.

594 Published by Intisari Sains Medis | Intisari Sains Medis 2023; 14(2): 590-594 | doi: 10.15562/ism.v14i2.1756CASE REPORT
13. Maulana A, Suryalathifani S. Large Bladder
Stone in Sasak Young Teen Boy. Lombok
Journal of Urology. 2022;1(2):72-76.
14. Rizkyansyah HF, Ambeng YY. Pediatric Bladder
Stone in Secondary Hospital Care Setting: A
Case Report. JRSSEM. 2021;1(5):486-491.
15. Husein A, Sigumonrong Y. Pediatric’s giant
bladder stone: A proposed new terminology.
International Journal of Surgery Open.
2021;37:1-5.
16. Al-Marhoon MS, Sarhan OM, Awad BA,
Helmy T, Ghali A, Dawaba MS. Comparison
of endourological and open cystolithotomy in
the management of bladder stones in children. J
Urol. 2009;181(6):2684-2688.
17. Davis NF, Donaldson JF, Shepherd R, et al.
Treatment outcomes of bladder stones in
children with intact bladders in developing
countries: A systematic review of >1000 cases on
behalf of the European Association of Urology
Bladder Stones Guideline panel. J Pediatr Urol.
2022;18(2):132–140.
18. Zafar GM, Javed N, Humayun F, Iqbal A.
Transurethral fragmentation of bladder stone in
children: Our experience. Journal of Pediatric
and Adolescent Surgery. 2020;1(1):32–36.
19. Esposito C, Autorino G, Masieri L, Castagnetti
M, Del Conte F, Coppola V, et al. Minimally
Invasive Management of Bladder Stones in
Children. Front Pediatr. 2020;8:618756.
20. Dahril, Ismy J, Asnafi A, Pratama R.
Percutaneous cystolithotripsy of bladder stones
in children: A case series, an experience from a
tertiary hospital. Urol Ann 2022;14(1):85-88.
21. Araujo da Silva AR, Marques AF, Biscaia di
Biase C, et al. Interventions to prevent urinary
catheter–associated infections in children and
neonates: a systematic review. J Pediatr Urol
2018;14(6):556.e1-556.e9.
22. Al-Hazmi H. Role of duration of catheterization
and length of hospital stay on the rate of
catheter-related hospital-acquired urinary tract
infections. Res Rep Urol. 2015;7:41.
23. Dahril, Ismy J, Hasibuan IA, Andreas. Bladder
stone in children: literature review. Bali Medical
Journal. 2021;10(2):763-767.
24. Ismy J, Pratama ME, Dahril, Ridha M, Mauny
MP. The correlation between demographic
factors and urolithiasis composition in a tertiary
hospital. Bali Medical Journal. 2021;10(2):780-
784.
25. Kusbaryanto, Diana. The relationship between
catheter placement and the incidence of
urinary tract infections in Condong Catur
Hospital, Yogyakarta. Bali Medical Journal.
2022;11(1):256-258.