From Prostate Enlargement to Bladder Stone: Large Bladder Stone as a Complication of Long‐Standing BPH: A Case Study

ABSTRACT

Vesicular calculi, or bladder stones, are a common occurrence in males of older age. Although there is a variety of different etiologies reported, one of the less common ones includes a background of benign prostatic hyperplasia (BPH). This case report describes a rare presentation of a large vesicular calculus in an old male patient that was diagnosed along with BPH. The patient, with a history of alcohol abuse and hypertension, previously had a percutaneous nephrolithotomy. Diagnosis was confirmed through transrectal ultrasound, x‐ray Kidney–Ureter‐Bladder, and cystourethroscopy. He underwent transurethral resection of prostate and open vesicolithotomy, with a smooth recovery. This case highlights the pathophysiological and urodynamical relationship between bladder stones formation and BPH, and explores other factors in stone formation.

Summary.

• Long‐standing benign prostatic hyperplasia can lead to bladder stone formation due to urinary stasis.

• Early urological evaluation may prevent complications.

1. Introduction

Benign prostatic hyperplasia (BPH) affects up to 50% of men aged 50–60 years and often causes symptoms like reduced urinary flow and incomplete bladder emptying due to bladder outlet obstruction (BOO). Although urinary retention and infections are common complications of BPH, its precise role in the pathogenesis of lower urinary tract stones remains unclear and warrants further investigation, and how altered urodynamics can increase the chances of developing stones needs to be explored.

Surgery remains the primary treatment modality for BPH patients with bladder stones, especially in the case of recurring symptoms and when conservative treatments fail.

Despite clinical recommendations, studies examining the risk of bladder stone formation in BPH patients remain limited, highlighting a significant knowledge gap. This case report aims to identify these risk factors and to understand BPH's role in stone formation, discussing an effective treatment plan [1, 2, 3].

2. Case History and Examination

A 55‐year‐old textile mill worker presented with complaints of flank pain and exacerbated lower urinary tract symptoms (LUTS) like frequency, urgency, straining, nocturia, dysuria, hesitancy, intermittent stream, dribbling, hematuria, and strangury (painful, frequent urination of small volumes that are expelled slowly only by straining) for 2 years. The patient's IPSS (International Prostate Symptom Score) was 16, indicating moderate severity. The patient had a history of alcohol abuse and hypertension and a previous kidney stone removal procedure 5 years prior. No family history of prostate or other cancers was reported.

On physical examination, suprapubic tenderness was noted and a smooth, firm, and symmetrically enlarged prostate was found upon digital rectal examination; the rest of the examination and other full systemic examination from head to toe were not significant. The patient's vitals were within normal range as well.

3. Diagnosis and Investigations

Baseline findings included Hemoglobin 12 mg/dL (normal: 13–18 mg/dL), White Blood Cell count 15 (normal: 4.5 to 11.0 × 10⁹/L) indicating ongoing inflammation or urinary tract infection (UTIs) correlating with the complaint of dysuria. Serum Creatinine 0.57 (normal: 0.6–1.1 mg/dL) and normal levels of electrolytes indicate that renal function was not compromised. Prostate‐specific antigen (PSA) 2.19 (normal: Up to 3 ng/mL in age 50–59) is a screening test for ruling out prostate cancer but not definitively. Uroflowmetry showed a maximum flow rate (Q _max) of 10 mL/s (normal: above 15 mL/s) with a voided volume of 190 mL (normal: 200–500 mL). Urinalysis revealed red blood cells, nitrites, crystals, and leukocytes, with urine cultures positive for Enterobacter species. A low Q _max indicates obstruction in the lower urinary tract, a finding consistent with the history of LUTS, and the urine detailed report and culture support the diagnosis of a urinary tract infection. Preoperative imaging included transabdominal ultrasound and X‐ray of the kidney, ureter, and bladder (KUB) that confirmed a large 5 cm bladder stone (Figures 1 and 2). Transrectal ultrasound revealed an enlarged prostate measuring 60 mL, consistent with grade C/III, large prostate. Hence, the patient was diagnosed with a large bladder stone along with BPH and an ongoing UTI.

FIGURE 1.

Preoperative kidney, ureter, and bladder (KUB) X‐ray. This anteroposterior radiograph of the pelvis demonstrates a large, ovoid, radio‐opaque density in the region of the urinary bladder, consistent with a vesical calculus. This imaging was a key part of the diagnostic workup that confirmed the presence of the five‐centimeter bladder stone in the 55‐year‐old male patient presenting with exacerbated lower urinary tract symptoms.

FIGURE 2.

Transabdominal ultrasound of the urinary bladder. The sonogram reveals a large, hyperechoic structure within the bladder lumen, which produces a distinct posterior acoustic shadow (a common artifact for calculi). This finding, along with the KUB X‐ray, corroborated the diagnosis of a large bladder stone. The same patient's transrectal ultrasound also revealed an enlarged prostate of 60 mL, consistent with Grade C/III Benign Prostatic Hyperplasia (BPH).

4. Treatment and Follow‐Up

The patient was started on oral medication: Dutasteride (0.5 mg) + Tamsulosin HCL (0.4 mg) once daily and intravenous medication: Ceftriaxone (1 g) twice daily and Amikacin (250 mg/mL) once daily. Procedure Transurethral resection of the prostate (TURP) + open vesicolithotomy was planned.

With the informed consent and preoperative preparations, the team proceeded with the surgery. First, diagnostic cystourethroscopy was performed in the lithotomy position, and then transurethral resection of the prostate was done using the Barnes' technique. The middle lobe was resected from 6 o'clock to the verumontanum, the right lateral lobe from 6 to 11 o'clock, and the left lateral lobe from 6 to 1 o'clock, and the anterior lobe was left intact. A three‐way urethral catheter was then placed, and irrigation with saline was done. For vesicolithotomy, a Pfannenstiel incision was made in the lower abdomen, and the bladder was accessed through a vertical incision. A large, dark brown, 5 cm stone was removed as a whole and sent for stone analysis that revealed a 100% calcium oxalate stone composition (Figure 3). Absorbable sutures secured the incision site, and the surgical wound was closed. Urinary catheters were removed on the fifth postoperative day, and the patient was mobilized. Skin stitches were removed on the seventh postoperative day, and the patient was discharged the same day with over‐the‐counter analgesics and adequate counseling on avoiding strenuous activity and drinking enough water. After a six‐week follow‐up, the patient had improved urodynamics with respect to decreased complaints of nocturia, urgency, straining, and frequency. The complaints of dysuria and hematuria were completely resolved, and no new urinary complications or residual symptoms were reported.

FIGURE 3.

Gross specimen of the surgically removed vesical calculus. Pictured is the vesical stone after its complete removal via open vesicolithotomy. The specimen was a single, dark brown stone measuring five centimeters in diameter. Subsequent laboratory analysis confirmed its composition was 100% calcium oxalate, highlighting a potential link to the patient's urinary chemistry and history of renal stones.

5. Discussion

Prostatic diseases are the leading cause of LUTS in elderly men globally. Over the past 30 years, the incidence of BPH has risen, causing lower urinary tract symptoms (LUTS) in around 25% of men over the age of 40 [4, 5]. BPH refers to a non‐malignant increase in the size of the prostate gland as a result of hormonal imbalance. This hormonal dysregulation refers to a decrease in the level of testosterone and high levels of estrogen and dihydrotestosterone.

Bladder stones are a major cause of these LUTS. This case report highlights an unusual overlap of BPH and bladder stones, emphasizing the relationship between the two conditions and exploring the underlying pathogenesis.

Bladder stones are said to be linked with incomplete bladder evacuation, often related to BOO and BPH, needing surgical intervention, with 3%–8% of bladder stones being a direct result of BPH [6, 7].

Other conditions like urinary tract infections (UTI), diverticula, neurogenic bladder, foreign bodies as well as gout and other metabolic abnormalities can also contribute to urinary calculi formation [8, 9].

In this case report, the patient had a long two‐year past medical history of LUTS resulting in complications causing BOO, which accounts for 45%–79% of urinary tract stones according to medical literature [6, 10]. Our patient has an International Prostatic Symptom Score of 16. High IPSS scores indicate the presence of BOO, which can lead to urinary stasis causing complications such as UTI and bladder stone [11]. Lim et al. explored the relation between BPH and bladder stone, finding that a high intravesical prostatic protrusion (IPP) and acute urinary retention (AUR) were key risk factors for bladder stone formation [12]. A high IPP significantly co‐relates with the severity of BOO, which in turn relates to the severity of BPH. BPH severity can be determined through IPSS and as well as grading done through transrectal ultrasound. In this case, the patient had grade C/III BPH as the volume was between 50 and 85 mL [13].

The patient's urinalysis indicates a UTI from Enterobacter species which alters urine chemistry by producing urease, breaking down urea into ammonia, increasing urine pH and precipitating salts like calcium, magnesium, ammonium, and phosphate, leading to struvite stones [14].

While metabolic abnormalities might influence stone formation, other unmeasured lithogenic factors could be significant. Lower urinary pH and elevated uric acid levels suggest uric acid stones [15].

According to a study, heavy alcohol consumption is associated with an increased likelihood of moderate–severe LUTS in a dose‐dependent manner [16] and our patient has a significant history of alcohol abuse.

The formation of bladder stones often involves alterations in urinary chemistry. Our patient is a known case of hypertension, and the use of antihypertensive medications, particularly thiazide diuretics, can increase calcium levels in urine, predisposing individuals to calcium‐based stone formation.

The patient has a history of renal stones, which can migrate into the bladder, causing obstruction and back‐pressure, leading to changes in bladder function. This pressure can result in bladder stones, as stagnant and concentrated urine increases crystallization [17]. This table highlights the complex interplay of risk factors for BPH and vesical stones, with some shared and distinct factors contributing to each condition (Table 1).

TABLE 1.

Risk factors and their relevance in BPH and vesical stone.

Risk factors	BPH	Vesical stones
Age	Increases with age > 50	More common in older adults
Family history	Genetic predisposition	Not well‐established
Hormonal factors	Androgen horemones	No clear link
Lifestyle factors	Obesity, sedentary lifestyle, high‐fat diet	High animal protein, low fluid intake
Metabolic factors	Diabetes, metabolic syndrome	Diabetes, obesity
Urinary factors	Urinary retention, obstruction	Urinary stasis, infection
Other factors	Heart disease, hypertension	Neurogenic bladder, obstruction
Drugs	Certain drugs (e.g., testosterone)	Certain drugs (e.g., thiazides)

6. Conclusion

According to our case report, the incidence of bladder calculi in patients with BPH tended to be closely associated with preoperative positive urine culture, high IPSS, and grade of BPH. This case highlights intravesical prostatic protrusion (IPP) as a potential risk factor for bladder calculi formation, underscoring the importance of early intervention in patients with significant BPH‐related obstruction. Besides, the prevention of UTI is also important for the prevention of bladder calculi; the consideration of other risk factors such as previous history of renal stones, anti‐hypertensive drugs, alcohol consumption, and metabolic abnormalities is equally important.

Author Contributions

Fazeela Bibi: conceptualization. Barkah Ali: supervision. Umama Alam: writing – original draft. Vohra Maham Hassan: writing – review and editing. Usama Khan: investigation. Sufia Ahmed: visualization. Qurat‐ul‐Ain Akram: investigation. Gupta Devi: writing – review and editing. Mohammad Mansoor Hassan: project administration.

Ethics Statement

The authors have nothing to report.

Consent

Written consent was taken from the patient. The patient is in contact with the authors.

Conflicts of Interest

The authors declare no conflicts of interest.

Bibi F., Ali B., Alam U., et al., “From Prostate Enlargement to Bladder Stone: Large Bladder Stone as a Complication of Long‐Standing BPH: A Case Study,” Clinical Case Reports 13, no. 10 (2025): e71264, 10.1002/ccr3.71264.

Data Availability Statement

The data was taken from a patient who presented to our hospital, all data and references are publicly available on databases such as Pub‐med and Google Scholar.