Patients often describe a bladder stone in deceptively mild terms, ‘a bit of pain when I pass urine’, ‘I keep wanting to go but nothing comes out’,’my stream keeps stopping and starting’. Such mild descriptions can mask a condition that, if left untreated, can lead to increasing amounts of pain, recurring infections, and progressive bladder damage. Bladder stones form and grow directly inside the bladder itself, usually where urine is not being completely emptied with each void, as opposed to kidney stones which form inside the kidney and may migrate.
Bladder stones occur less frequently than kidney stones in most populations but are nevertheless an important cause of lower urinary tract symptoms, particularly in men with bladder outlet obstruction due to BPH, in patients with neurogenic bladder, and in children in some regions where dietary and nutritional factors contribute to a distinctive pattern of paediatric bladder stone disease . Whatever the cause, the underlying cause for incomplete bladder emptying or urinary stasis must be identified and treated along with removal of the stone itself, otherwise recurrence is likely.
A bladder stone (vesical calculus) is a hard mass of crystallised minerals that forms inside the urinary bladder. Bladder stones are generally classified as primary (forming de novo in the bladder, usually without any prior history of kidney stones) or secondary (a kidney stone that has travelled down the ureter into the bladder and continued to grow, or stones forming around a foreign body such as a long-term catheter, suture material or mesh from a surgical procedure).
Urinary stasis, urine that stays in the bladder for long periods because the bladder is not emptying completely, is the basic mechanism for most primary bladder stones. Stagnant urine can lead to concentration of minerals in the urine and formation of crystals which may aggregate and grow over time to form a stone. The most common underlying cause of urinary stasis in adult men is bladder outlet obstruction from BPH, the enlarged prostate prevents complete bladder emptying, leaving residual urine in which stones can form and grow, sometimes reaching several centimetres in diameter and taking on the shape of the bladder cavity itself. Bladder stones can be single or multiple, and vary in size from a few millimetres to several centimetres, the largest reported bladder stones have weighed several hundred grams.
The most common cause of bladder stones in adult men is bladder outlet obstruction. Incomplete bladder emptying caused by BPH results in the urinary stasis in which stones form. The size of the stones is often proportional to the length and severity of the untreated obstruction. Another important risk factor is neurogenic bladder secondary to spinal cord injury, multiple sclerosis, spina bifida or other neurological conditions affecting bladder emptying. This is particularly relevant in patients managed with long term catheterisation, which can itself act as a nidus for stone formation through encrustation. Bladder diverticula are outpouchings of the bladder wall where urine can become trapped and stagnant and are a recognised site of stone formation. Foreign bodies within the bladder, including long-term indwelling catheters, surgical sutures or mesh from previous pelvic surgery and (rarely) self-inserted objects, provide a surface for mineral deposition and stone growth . Recurrent urinary tract infections with urease producing bacteria (the same mechanism as struvite kidney stones) can also promote bladder stone formation especially in patients with chronic catheterisation. Dietary and nutritional factors, particularly low fluid intake, low protein intake in childhood and high oxalate or phosphate diets, are important in the unique pattern of paediatric bladder stones seen in some areas. Men are affected far more often than women, in line with the much higher prevalence of bladder outlet obstruction (BPH) in men.
Bladder stones have symptoms that overlap considerably with other lower urinary tract disorders, UTI, BPH, and overactive bladder, which may delay diagnosis . The main feature that should alert you to the possibility of a bladder stone is pain or symptoms that change with body position or physical activity. This is because the stone moves in the bladder.
Pain in Lower Abdomen or Pelvis (Suprapubic Pain)
Diagnosis of bladder stone is based on imaging to confirm presence, size and number of the stone, combined with assessment of the underlying cause, especially bladder outlet function, that led to formation of the stone. The main investigations are summarised in the table below:
Investigation | What It Shows | Role in Bladder Stone Diagnosis |
Ultrasound KUB | Echogenic mass with acoustic shadow in bladder; post-void residual | First-line; identifies stone, size, and any obstruction causing stasis |
Urine Routine & Culture | Blood, leucocytes, bacteria, crystals | Detects associated infection and haematuria; guides antibiotic choice |
X-ray KUB (Plain Film) | Radio-opaque stones visible (calcium-based) | Useful for calcium stones; uric acid stones often not visible |
CT KUB (Non-Contrast) | Precise stone size, number, density, and any associated pathology | Gold standard; detects all stone types including radiolucent ones |
Cystoscopy | Direct visualisation of stone(s) and bladder wall condition | Confirms diagnosis; assesses bladder wall (trabeculation, tumour, diverticula) |
Uroflowmetry & PVR | Flow rate and post-void residual volume | Identifies bladder outlet obstruction as underlying cause |
In most cases, ultrasound is the first diagnostic modality; bladder stones are highly echogenic and produce a characteristic acoustic shadow that is easily recognised. CT KUB is most useful in cases with inconclusive ultrasound findings or in planning treatment for large or multiple stones. Cystoscopy, whether as a diagnostic outpatient procedure or combined with the treatment procedure itself, provides direct visual confirmation and allows simultaneous assessment of the bladder wall for any associated pathology (trabeculation suggesting chronic outlet obstruction, diverticula or, importantly, any suspicious lesions that might suggest bladder tumour coexisting with the stone).
Treatment of bladder stones varies according to size and number of stones present, and whether there is any underlying condition that needs to be treated at the same time. The main approaches are summarised in the below table:
Treatment | Stone Size | Approach | Hospital Stay |
Cystolitholapaxy (Laser/Pneumatic) | Most stones up to ~4 cm | Endoscopic , cystoscope passed via urethra; stone fragmented and removed | Day care / overnight |
Cystolitholapaxy (Large Stones) | > 4 cm or multiple stones | Endoscopic fragmentation, may require longer procedure time | 1 night |
Open / Laparoscopic Cystolithotomy | Very large stones; multiple/staghorn bladder stones | Direct surgical removal through small bladder incision | 1–2 nights |
Concurrent BPH/Obstruction Surgery | Any size with outlet obstruction | Combined stone removal + TURP or bladder neck procedure | 1–2 nights |
Paediatric bladder stone disease has a distinct epidemiology which is markedly different from that of adult bladder stones, and from that of kidney stone disease in children which is increasingly related to metabolic factors. Dietary and nutritional factors unique to certain regions and socioeconomic settings are most frequently implicated in the aetiology of bladder stones in children.
Why Bladder Stones Occur in Children in Certain Regions
Stone removal alone, without addressing the cause, often leads to recurrence. To prevent recurrence of bladder stone, the underlying cause that allowed the stone to form in the first place must be addressed. Definitive treatment of the BPH, whether with medication, UroLift, laser surgery, or other appropriate procedure, is essential in men with BPH-related bladder outlet obstruction to restore complete bladder emptying and eliminate the urinary stasis that drives stone formation. Bladder stones tend to recur unless the obstruction is removed.
Patients with neurogenic bladder managed by long-term catheterisation should have the catheter changed regularly (generally every two to four weeks in case of indwelling catheters), drink enough fluid to produce dilute urine, and change to intermittent catheterisation (which is associated with lower stone formation rates than indwelling catheters) where appropriate—all of which diminish recurrence risk. In patients with bladder diverticula, surgical excision of the diverticulum can be considered if the stones recur repeatedly in the diverticulum. This is a good general preventive measure for all patients irrespective of cause. Adequate hydration is necessary to dilute the urine and reduce the concentration of stone forming minerals. The urine should be pale and dilute throughout the day. Prompt and complete treatment of each infection is advantageous in patients with recurrent stone-associated UTIs, as chronic bacteriuria with urease-producing organisms directly favours stone formation.
A kidney stone is formed inside the kidney and may stay there or travel down the ureter, causing the severe colicky pain of renal colic during travel. A bladder stone is formed (or, less frequently, completed) within the bladder, usually due to urinary stasis resulting from incomplete emptying of the bladder. Symptoms vary accordingly; classically, kidney stones cause flank pain radiating to the groin, while bladder stones cause suprapubic pain, urinary frequency, interrupted stream, and symptoms that change with body position. There are also differences in the treatment methods. Kidney stones are treated by RIRS , PCNL or ESWL depending on size and location. Bladder stones are most commonly treated by endoscopic cystolitholapaxy through the urethra.
A kidney stone is formed inside the kidney and may stay there or travel down the ureter, causing the severe colicky pain of renal colic during travel. A bladder stone is formed (or, less frequently, completed) within the bladder, usually due to urinary stasis resulting from incomplete emptying of the bladder. Symptoms vary accordingly; classically, kidney stones cause flank pain radiating to the groin, while bladder stones cause suprapubic pain, urinary frequency, interrupted stream, and symptoms that change with body position. There are also differences in the treatment methods. Kidney stones are treated by RIRS , PCNL or ESWL depending on size and location. Bladder stones are most commonly treated by endoscopic cystolitholapaxy through the urethra.
The usual treatment for most bladder stones is endoscopic cystolitholapaxy and is done with the patient under general or spinal anaesthesia, so the actual procedure is painless. After the procedure mild burning on urination and occasional blood stained urine are normal for a few days and are managed with simple analgesics and increased fluid intake. Most patients are discharged the same day or after one night in hospital. In simple cases, people usually go back to their normal activities within two or three days. If the procedure is done at the same time as surgery for BPH (for men with bladder outlet obstruction), then recovery is on the same schedule as that combined procedure, which is often one to two weeks for full recovery.
Bladder stone recurrence is nearly always caused by an untreated underlying condition, most commonly persistent bladder outlet obstruction (untreated or undertreated BPH), neurogenic bladder with incomplete emptying, an indwelling catheter acting as a nidus for new stone formation, or a bladder diverticulum where urine continues to stagnate. If stone is removed but cause of urinary stasis is not addressed, the same conditions that allowed the first stone to form are still in place and a new stone will typically form over months to years . That’s why it is important to do a complete work-up to find out what is causing it and develop a treatment plan that deals with the cause and not just the stone itself to prevent recurrence.
Yes, bladder stones are much less common in women than in men but that’s mostly because the most common cause (bladder outlet obstruction due to BPH) only occurs in men. In women, bladder stones are more commonly associated with neurogenic bladder, long-term catheterisation, bladder diverticula, foreign bodies (including surgical mesh or sutures from previous pelvic surgery) or , rarely , significant pelvic organ prolapse leading to incomplete bladder emptying. It is particularly important to find out the underlying reason for a bladder stone in a woman, because the usual male cause (BPH) does not apply and another explanation must be sought.
If left untreated a bladder stone will in most cases continue to grow over time as the conditions that allowed it to form (urinary stasis) continue. As the stone enlarges, urinary symptoms worsen, pain increases, interruptions of urine flow become more frequent and severe, and recurrent infections become more troublesome. Large longstanding bladder stones can cause chronic bladder wall irritation and inflammation . In rare cases bladder stones have been associated with an increased risk of squamous cell carcinoma of the bladder , a rare but recognised long-term complication of chronic bladder stone irritation . If bladder stones are left untreated they can also exacerbate any underlying obstruction and in severe long standing cases this can lead to changes to the upper urinary tract (hydronephrosis). If treated early, this progressive deterioration can be prevented.
Small-to-moderate-sized bladder calculi (up to about four centimetres) are generally managed by endoscopic cystolitholapaxy . Laser or pneumatic energy is delivered via a cystoscope to fragment the stone, with fragments either being retrieved or irrigated away. Larger stones, multiple stones or stones with very hard composition can require longer endoscopic procedure times or in some cases open or laparoscopic cystolithotomy, a small incision into the bladder through which the stone is removed directly. The selection is dependent on the stone size, number, composition (assessed by CT density) and the surgeon’s assessment of what can be safely achieved endoscopically in a reasonable procedure time . Dr. Vikas Singh is very experienced in endoscopy and even large stones can often be treated without open surgery.
Bladder stones are primarily located in the bladder but may have implications in the upper urinary tract in some cases. Sometimes a large bladder stone or a stone near the ureteric orifices may partially block one or both ureters and cause hydronephrosis (swelling of the kidney). Chronic bladder outlet obstruction, the etiologic factor in many bladder stones, can cause bilateral hydronephrosis and progressive impairment of kidney function if longstanding and severe, regardless of the stone itself. Assessment of kidney function and upper tract imaging is part of the standard evaluation of any patient with a significant bladder stone, especially if it is large or has been present for a long time.
Bladder stones themselves are not, in most cases, a cause of bladder cancer. A chronic bladder stone, however, may cause chronic irritation and has been associated with an increased risk for squamous cell carcinoma of the bladder, a less common type of bladder cancer that is different from the more common urothelial (transitional cell) carcinoma. This association is more relevant for very long-standing, untreated stones. In addition, as some of the symptoms of bladder stone (haematuria, irritative voiding symptoms) overlap with the symptoms of bladder cancer, cystoscopy for the diagnosis or treatment of stones also serves the important role of examining the bladder wall for any separate or coexisting tumour, particularly important in patients with risk factors for bladder cancer such as smoking history.
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