Stone deals tough guy a low blow
Sam Wong, 39, is a tough man with a tough life. He makes a living as a labourer, relying on his strength and hardy attitude to get by.
When Wong (whose name has been changed for patient confidentiality reasons) started having pain when urinating and developed a swelling in his scrotum, he saw a family doctor. He was treated for a urinary tract infection with antibiotics, even though scrotal swelling is not a typical UTI symptom.
The medication failed to reduce the swelling, which grew larger and more tender by the day. Wong also noticed that his underwear was frequently stained with a yellowish, pus-like substance. Every time he passed urine, it was agony.
Despite the grievous pain and disturbing symptoms, the tough-minded Wong tried to soldier on. When the pain in his groin was finally too much for him to bear, Wong showed up at the emergency room of Kwong Wah Hospital, where doctors were shocked to see that his scrotum had ballooned to the size of a large orange, about 8cm in diameter.
A urology team headed by consultant Dr Law In-chak was quickly assembled to tackle this unusual case. Dr Ringo Chu Wing-hong, an associate consultant, and Dr Wayne Chan Kwun-wai, a urology resident, were also called in.
Meanwhile, Wong felt the urge to urinate but was unable to. Nurses tried to insert a urethral catheter to drain the urine but found that the catheter simply could not pass up Wong's urethra.
Chan then performed a cystoscopy, where a thin, lighted viewing tool was inserted into Wong's urethra. He found that the passage was completely obstructed by a massive stone.
The urgency now was to drain Wong's bladder to relieve his growing discomfort. Since the urethral catheter failed, Chan had to use a suprapubic catheter where the drainage tube was inserted into Wong's bladder via his abdomen.
Then the focus turned to the stone in Wong's urethra. An urgent computed tomography scan of Wong's pelvis showed that an enormous 4cm-wide stone was lodged in the urethra near the prostate, at the base of the penis. The average urethra is less than 1cm at its widest point.
The scan also showed that fluid collection around the stone was what swelled the scrotum to such proportions.
Wong was immediately prepped for an emergency operation. The standard treatment for a lodged stone was to push it back into the bladder.
But the stone tere was much too large to be moved up the urethra.
Using a special rod inside the cystoscope called a Lithoclast, Chan had to break the stone into pieces using a jackhammer effect. The fragments were removed using miniature forceps inside the cystoscope. Both had to be taken out of the urethra with each fragment as the extended claws gripping the stones were too wide to be withdrawn back into the cystoscope. The cystoscope and forceps had to then be reinserted into the urethra to collect the next fragment.
This laborious task took the surgical team three hours.
After the stone fragments were finally removed, the team saw that Wong's urethra had a pouch on the side of its wall called a diverticulum. Urethral diverticula are very rare, and when they do occur, they tend to develop in women.
Diverticula can also develop as a result of trauma, such as childbirth or injury. As Wong says he has never had a groin injury, his situation was extremely unusual, and it is possible that he might have been born with this defect, says Chan.
He explains that a diverticulum presents a problem because urine can collect in the pouch and stagnate. Minerals in the urine start to crystallise in the concentrated waste fluid, and the crystals collect to form the stone. The stagnant solution is also prone to breeding infection, which also promotes formation of the stone.
After surgery, Wong had a urethral catheter inserted besides the suprapubic catheter already in place. The fluid, pus and urine in the pouch also needed to be milked daily. After two days, Wong was able to pass urine himself and the urethral catheter was removed.
Its removal also helped the pus to pass out naturally along the urethra, and the swelling in his scrotum gradually diminished.
One week later, Wong was discharged. Chan advised him to return for surgery to remove the diverticulum to prevent another episode of fluid retention and calculus formation. On the day of the surgery, Wong failed to show. Chan does not know why Wong decided to skip surgery.