Two patients with stones yesterday. One was a 60 year old farmer who had classic symptoms of ureteric colic leading to the passage of a small stone from his penis, but a larger stone had clogged up the works and he was unwilling to drink because nothing much was getting past the stone. He came to the clinic to ask for help. Examining him, I could see the white surface of the stone just before the navicular fossa ( about half an inch in, for you lay people). My plan was to anaesthetise the urethra with xylocaine jelly, squirted into a syringe then gently introduced down his penis. Not only did this numb his pain, but the stone was dislodged and retreated towards the bladder.
I couldn’t squeeze the stone out, so I tried a trick I’d learned in Africa, using a sterile needle with the sharp tip snapped off, the the end curled around to form a hook. The plan was to slide the needle flat past the stone, then twist it through 90 degrees to pull the stone out. But I couldn’t get the needle past the stone at all. There seemed to be a stricture and a stone a centimetre across just wasn’t going to come. I asked a Burmese colleague for some help and he tried valiantly with some sinus forceps, but he could not get any purchase on the smooth stone. We had to admit defeat and ask him to attend the Thai hospital.
I discussed this man with Duncan Summerfield, consultant urologist in Leicester via email. He just happened to be doing some admin work and answered immediately. We now know how to handle this in the future (I’ll spare you the details, but it involves producing a surgical hypospadias). So a big thanks to Duncan, and any other medical colleagues who help me out with clinical conundrums.
The next patient also had two stones, but they weren’t causing him much bother. He had a patch of impetigo on his chin and at first I thought the small lumps under his jaw were reactive lymph nodes. But they were smaller, round and hard. Almost certainly, they were calculi in his submandibular salivary glands. We usually check this by asking the patient to think of their favourite food, which triggers the salivary glands into action with pain if the stones are stopping the flow. It didn’t work with him because his favourite food was sweets, and he had just eaten a packet. So, I sorted out his impetigo, and hopefully, the stones will pass or not cause him any further trouble.