GIANT VAGINOLITH

Amir Fauzi, Yanuarman

Moch. Hoesin Hospital Departement of Obstetric and Ginecologic
Medical Faculty University of Sriwijaya Palembang, Indonesia

Abstract
Background: Primary vaginal stones (vaginolith) are extremely rare but important because they
are often mistaken for bladder calculi on plain film. They are known to occur in association with
urinary fistulae: vesicovaginal fistulae or uretherovaginal fistulae (primary vaginal stone), or in
association with self introduced foreign bodies by the mentally deranged or for sexual
gratification (secondary vaginal stone).
Case: The patient, a 50 years old women, developed vesicovaginale fistula was 15 years ago
after deliver the last baby with prolonged labor in the rural area. She was referred to our hospital
complaining of lower abdominal pain and presence stone introitus vagina.
From the examination, vaginal stone showed yellowness in the vagina and by using sondage
ostium urethera externum was found vesicovaginal fistula at trigonum area. BNO-IVP showed
that present stone back of bladder as big as baby head, and by ultrasound showed mass
hiperechoed with shadow posterior mass appearance. The vaginal stone was strongly fixated in
the vagina, so management of stone by abdominal evacuation.
Intraoperative: Uterine normal (8 weeks), tube and ovarii, bladder was normally, and decided to
TAH-BSO and extraction of the stone. The size of stone was 11 x 10 x 11 cm and 900 gram of
weight. And from stone biochemitry analisis the stone composed uric acid, phosphate and
oxalate. The stone also have in uterine attached to IUD with diameter stone 2 cm. Post operative
examination, vesicovaginale fistula located at trigonum with diameter about 0,5 cm, we plan to
repair the fistula 3 months later.
Keyword: Primary vaginal stone, giant vaginolith, vesicovaginale fistula

PREFACE
Vaginal stones is a very rare cases, especially one with such a big size.some cases has been
reported that vaginal stone is related with the pathological of urinary tract or last surgery. Mqst
are related with vesicovaginal vistule (primary vaginal stone) or the insertion corpus alienum
inside the vagina, like mentally deranged patients or sexual gratification or the secondary vagina
stones. Primary vagina stones without urinary tract disorder haven,t been reported.123
1. Primary vaginal stone (related to urinary tract phatological example: vesco vaginal
fistule).
2. Secondary vaginal stone ( related to the inserrtioncorpus alienum into vagina
Vaginal stones commonly related with the pathological of the urinary tract or result of the last
surgery. In this case vesicovagina fistule can be found and haven,t fixed for such a long time. So
the vagina contact to the urine every time, called primary vaginal stone.
Primary vagina stone former mechanism almost similar with the vesical stone,s oue.1234
The most common came of vesical stone is the obstruction of urethrae , elevision of the
vesicalsneck and the elevation of the uric cause stam of uric provoked crystal former, to the
sedimentation process from the stone. Patient with vesicovaginal fistule have the similar process
with vesical stone formation,wich stam of urine and the collecting in vagina can form crystal, so
the sedimentation process form the stoner. Besides the urine in vagina can provoked the growth
of normal flora in vagina so that can ferformed the infection which can induced the stone
formation with urea friction by the microorganism. Other etiology of vesical stone are corpus
alienumin vesica as the centre of the stone formation.1,2,9,10,13,14
Pathogenetic of stone formation .Theorytically there are 5 theory of urinary tract stone,s
formation : 9,10,11
1. Supersaturasi theory / crystalization
Mixture of the active ions inside the urine came interection so inpheech the saturation of the
urine,s element.If the consentration of unsoluble elements in the urines is increase (
calcium,oxalate,phosfat ),so the crystallization of the elemens can be performed.
2. Nucleal theory / nidus formation
Nidus or nucleal is the centre of the stoma.Nidus were came from the ulceration of the
mucous layer,blood coagulation,epithelialcellor pus,even the bacteria,necrotic ischemic layer
which comes from the neoplasma or infection and corpus alienum.
3. Non inhibitor theory
 Supersaturation of the calcium oxalate,and uric acidin the uterus inpheech the inhibitor
crystallization,magnecium,cytrat,sama glicoraminoglicans.such at chondroitine sulphat can
inhibit the calcium crystal formation which performed before.
4. Epictation theory
Epictation is a sedimentation of crystal over the others crystal so thatsnot common finding
the urinary tract stone with uric acid on the centre of the stone which is over layered by the
oxalate calcium
5. Combination theory
The last theory is urinans tracts take formation is the combination of more than one
Theory above.
CASE
Female patient, 50 year old, husband has been died 13 year ago, came with chief complain was
lower abdominal pain and hard undulation in vagina. 14 year ago, the patient also complained
that her vagina always wet and smelly.3 year ago the patient felt theres an undulatioan at the
lower abdomen, hard and sometime painfull she havent search for the medication support
because of financial problems becaused of the patients complains of lower abdominal pain and
wet vagina, the patient went to midwife to pick up her IUD. After the examination by the
midwife there werw stone inside the introitus vagina ,than the patient was reffered to RSMH
Palembang.
Patient has been menopaused for 5 years, has 4 children,the fourth kid was 15 year old, had
been a hard and neglected labor,by the traditional attendant.The patient had been used the IUD
for 15 years.
General condition was good from gifnecology examination we found hard solid mais like
stone at above of the symphisis, 10 x 10 cm, sure mobile. There were hard solid mais like stone,
greenish, size 8 x 8 cm sunide the vagina. The wall of vagina was thichened and urine smell
partion could not be debermined from OUE sondage we found vesikovagina fistule. Palpabled
hard, solid mass,size 10 x 10 x 8 cm inside the vagina, sencouvagina fistule size 0,5 cm OUEs
hard to determined, corpus uteri and parametrial adneda were hard to defined.
Based on anamnertic, phytical examination and gynecology examination to this patient,
diagnosed with vaginal stone ( vaginolith) and venicovagina fistule.
Laboratorium gived normal performance,ultrasound was normal size of the uterus,betug pushed
to the right side, and the vesica urinaria was pushed to the left side and there were hiperechodc
mais under the vesica urinaria with shadour appearance with diameter 60.7 mm,parametrial
adnexa in normal condition.Diagnosed with stone which came from undetermined tisrue. BNO
found opaque shadow in big size like the head of a at suprapubic area and IUD. IUP, found an
indentation at the poiterior wall of the opaque shadaw like the the head of baby with IUD above
it.
Diagnozed with intra uterin calcification size like the head of baby with indentation of the
porterior wall of nenica urinaria and normal renal / ureter.
Intraoperatif with spiral anesthetia and lithotomif poution, big stone and firun fixation, then
then operator decided to do the abdominal opration from exploration :
8 weeks uteruss size, hard cousistantion bath of tuba and ovarian were in normal condition.
Normal vesica urinaria, mais inside the uterus which exsended to the tutroitus vagina, hard
cousistantion and fimily fixation. The operator decided to do the total hysterectomy & bilateral
salphingooforektomi and evacuation of the stone.& because of hard to identificate the
portio,uterius being cut at the level of the neek mass, IUD lipes loop surrounded by yellows
mass, hard, size 3 x 3 x 4 cm its stieks at the vagina ta release the mass in vagina. The vagina
was mass with yellows, hard, and strongly fixation. To evacuation stoke in vagina with to push
from introitus vagina. There were yellows stone, hard, size, 11 x 10 x 11 cm. the weight of mass
900 gr.to examination the vagina on the fistula vesico vagina 0,5 cm. Repair planned there ( 3 )
month post operation the patient was hospitalize.
The analytic of biochemist that stone in laboratony with the weight of stone was 900 gr with
size 11 x 9 x 10 and 2 x 3 x 4 cm. the stone surface was rough, yellow and here from uwalitatif
analytic was the layer stone with containt : urie, phosfat and oxalat. Diagnose : stone with
containt urie, fosfat and oxalate.
Picture 1. The examition inspekulo there were the yellows mass in the introitus vagina,
Hard, fixatie.
BNO can be opaque shadow size like a head of baby on the supra public and
IUD. IUF the vesica shower indentension on the posterior wal of the opaque
Shadow size head of a baby with upper IUD

Picture 2. Vaginal stone as like had of a baby, size 11 x 10 x 11 cm with stone weight
900 grams.
 In his study,kolte and friends hard six vaginolith, 3 cases fistula vasileo vagina posca
histerektomi, 2 cases with visika urinaria history before and one years women with konfinital
stenosis hymen.
In Belgia bar moshe friend report for the giant batu vagina 100 gr weight in family 26 th in
this case there is a stenosis out side the vigina in her childhrood and in this case surgeny therapy
is simple evolution.
In the develop country like Indonesia fistula after find, generally this is complication for
obstetric fistula often find like vesicovagina, vesiko uretrovagina, vesiko servikovagina, and
fistula rekto vagina in the ( maju ) country, fistula cause trauma obstetric is rase to find but
increase histrehoni abdominal operation or vagina. Indication mioma uteri, PUD, and carcinoma
in situ, complication fistula vesicovagina are often find generally the cause of fistula are trauma
obstetric, ginecology of urologi prosedur and another trauma like radiation for karsinoma
ginekologi.
Fistula vesico vagina cause obstetric oction, ginecology and other cause are become a
serius deflet in a patient life. Many patient divorce by his husband, separate from her social life
and they cant make sexsual intercause with her husband like usually, SPOG must can solve this
fistula pasient kebeiharsilan for repair this fistula, cant depud only for they slinel but also their
konsistensi, location, how to repair from this fistula,also after operation treatment.
For this case fistula vesikovagina happen cause by obstetric factor which is from the last
delivery and long dan difficult and who help the delivery is traditional attendant. This delivery
happen because of push the passage by fetus head if to long can cause ischemia and the death of
tissue in passage.
For the diagnosis disuprapubik stone, beside amansis yang deep and phisicycal
examination and the ginecoly examination and also another examination like urinalisa, study
imaging, ultrasonografi, sistogram and pyelogram interavena, CT scan, pelvic MRI and
sistoscopi.
Urinalisi
Examination prosedur easy and cheap, also can give the use information, Diagnostic examition
can have a pastitif result for nitrit, esterase, leukosit, and blood urine BJ increase because of
minimum lilixuid PH yang asam for asam urat stone.
Studi Imaging
Urografi examination for ren, ureter,visika for the first devisi is radiografi polos for ren,ureter
and visika, because easy and cheap best for self or continue pyclogram intravena (IUP ).
Sistogram and pyclogram interavena.
This exanention do only if at the first cant fnd the stone,but the clinical suspect is high slow
the stone wis defect appearance full the vesica,especially if change with exchange posisition (
Diferenial Diageral is kongulation, bola jamur, karsinoma ureterial papiler ) this method also can
find another defert like vagina stone, batu saluran kemih yang lebih atas ureterolel, sistokel,
pembesaran prostate, anddivertikal vesica in this case BNO examination find a big with shadow
like fetus head at supropulis and IUD. IUP find fungsion exkresi rend extra suristra
good,refrogram dextra sirustra good,pelvicocolycis dextra sinistra normal ureter dextra sinistra
normal buli buli look indentasi at posterior wall by the whise shadow will a big fetus head and
IUD above.
Fine the suspect calsification intrauterine with a big fetus head with indentasi posterior buli
buli both of ren/ ureter normal,this show that stone not in tractus urinarius.
Ultrasonography ( USG )
Show hyperekhoik klasic object with shawdow posterior, effectif for identification radiolusen or
radio pak.
Computed Tomography Scan ( CT Scan )
This examanition is so sensitive and specific for diagnostic stone in stractus urinarius even can
detection pure urat stone.
Pelvic MRI
Black bole affearance in full bladder, shown a stone in bladder.
Sistoskopi
Test which is generally use to conformate a stone and plan the therapy is sistaskopi this test gives
a picture of stone and meaturarent of amount size and position meaturewent of uretra,vesica wall
and ureter hole can identificate strictur divertikulum and of vesica.
Biochemistry Analisis of the Stone
Biochemyty structure of the stone could be urid and else like aksolat carbonate cystin calcium,
magregum and ammonium structure this stone shown there are uric,fosfate and oksalate.
In this case the stone contist of uric alid fosfate and oklate which is a combination stone as
mocroscopic the uric acid stone usually multiple in size from a millimeter to 0,5 cm in other way
the fosfate stone usually reach a huge size till a centimeter in size ltr colour like karit and the
shape rarely like the place which the stone from susfece of otolate stone usually blinking and
small horrs.
To knowing the chemyty structure of the stone, we have to cut the stone and each of piece
being mash till smooth before check eack of layer could shown thedifferent structure of the
stone.
Therapy
If the vagina stone is small and abestit strogly fixated in vagina so simple approseh with simple
evolution in other way the vagina stone which fixated stronghy and the hard structur stone with
large superior part, evacuated of the stone still in debated but generally surgical approrch of
vaginal stone exactly like vertical stone which are :
1. Transurethrol cystoktholapaty
2. Percutaneous suprapabic cystolitholapaty
3. Sistostomi
Planning of management vesicovaginal fistula
Surgical approach can through vaginal,supropubic or both kombination operation through
vaginal early todo by obstretrician and ginecolog and gives better result generally vesicovaginal
fistula can fixed through vaginal like the report by lee from 303 fistula cases 80 % fixed by
operation through vaginal in the case of fistula which has large fikrote sicatric tissue and fixated
on simphisis or public,the kombination operation through vaginal and aldominal should be the
shoice it means to release vesica and uretrika by sispropublic incision though fistula its felf
coussed though vaginal.
In this case cause of large fixated stone and the reproduction fuction is no need any more so the
abdominal approach is the choice first action are total histesectomi and soefirgooferetolomi
bilateral and then evaluatod of the stone through introitus vaginal from superion in exploration
founded vesico vaginal fistula with hisperenis at the end of fistula and planed for repair at 3
month later.
Preoperation infection of troct urinarius must be therapied which make the acid
environment in urin antibiotic and antiseptic included.
When possible infection shoul cured before operation when the atropi genetalia and sterosis
vagina occurred it wise to use oral estrogen on topical as long as two weeks before operation.
 The fistula operation best do after 3 6 month after this therapy this condition is purposed
to reviae the inflation and infection process coused by the vaginal stone.

CONCLUTION
It have been reported the case of a women with glant vaginal stone with vesicoroginal fistula and
its therapy.
Repair of vesico vaginal fistula after 3 month from evacuated the stone this case is rate and
have no reparted before.

REFERENCES
1. Kolte SP, Choube S, Phulare S, Joharapurkar SR. Primary vaginoliths. Ind J Radiol Imag
2002 12;4:511-512
2. Satija L, Dhagat P, Sharman A, Satija N. Vesical calculi formation on a perforating
vaginal foreign body. Ind J Radiol 200;10:45-46
3. Bar-Moshe O, Oboy G, Assi J. Vaginal calculi in a young women. European Urology
200;37:505-507.
4. Wittich AC, Murray JE. Intravagina foreign body of long duration: a case report. Am J
Obstet Gynecol 1993;169:211-2
5. Santoso BI. Fistula uroginetal. Dalam: Junizaf, Josoprawiro, Santoso BI, Djusad S,
Syafiudin NM. Buku ajar: Uroginekologi. Subbagian uroginekologi-rekonstruksi. Bagian
Obstetri dan ginekologi FKUI/RSUPN-CM. 2002:6-13
6. Junizaf. Fistula vesikovagina. Dalam: Junizaf, Josoprawiro, Santoso BI, Djusad S,
Syafiudin NM. Buku ajar: Uroginekologi. Subbagian uroginekologi-rekonstruksi. Bagian
Obstetri dan ginekologi FKUI/RSUPN-CM. 2002:14-19
7. Wiknjosastro H. Beberapa aspek urologi pada wanita. Dalam: Wiknjosastro H, Saifuddin
AB, Rachimhadhi T. Ilmu kandungan. Edisi kedua. Jakarta; Yayasan Bina Pustaka
Sarwono Prawirohardjo, 1999:467-471
8. Keettel WC.Vesicovaginal and urethrovaginal fislulas. In: Buchsbaun HJ, Schmidt JD.
Gynecologic and obstetric urology. Philadelphia; WB Saunders, 1978:267-274
9. Menon M, Resnick M. Urinarylithiasis: etiology, diagnosis and medical management. In:
Campbells urology CD-rom version. 8th Edition. Philadelphia; WB Saunders,
2003:96;1-78
10. Stoller ML, Bolton DM. Urinary stone disease.In: Tanagho EA, McAniach JW. Smiths
general urology. 14th Edition. Prentice Hall International, 291-316
11. Meeks GR, Roth TM. Vesicovaginal and urethrovaginal fistulas. In: Rock JA, Jones HW.
Te Lindes operative gynecology. 9th edition. Philadelphia; Lippincott Wlilliams &
Wilkins, 2003:1099-1120
12. Widjajaputera B. Sonografi ginjal dan saluran kemih. Dalam: Mose JC, Sabarudin U.
Effendi J. Ultrasonografi kedokteran. Perhimpunan Ultrasonografi Kedokteran Indonesia
cabang Jawa Barat. 2002:155
13. Oswari LD.Upaya pencegahan batu saluran kencing berdasarkan hasil analisa batu
saluran kencing. Bagian Biokimia FK UNSRI Palembang. MKS. 2001;33(2):79-82
14. Purnomo BB. Dasar-dasar urologi. Edisi kedua. Jakarta; Sagung Seto, 2003:13-67