Vaginal caculi, or vaginal lits, are rare and mostly found in case reports. The first case was described by Halban in 1900 of a stone formed in a vaginal cysticeal. Since then, there have been several dozen case reports of vaginal caculi. The stones usually consist of urinary salt deposits. These include ammonium magnesium phosphate, or struvite, and carbon apatite, or dalite. Vaginal flavoliths have also been reported. Because of their location and rare occurrence, vaginal caculi are highly susceptible to misdiagnosis. There are two types of vaginal caculi, primary and secondary. Primary vaginal caculi are formed due to stasis of urine in the vagina, typically in the setting of vaginal outlet obstruction, vesicovaginal or urethrovaginal fistula, incontinence, or ectopic vaginal ureters. This is the more commonly described form, with one study showing that it comprises 82% of reported cases. Often, patients with primary vaginal caculi have mental and or physical disability, are in prolonged recumbent position, wheelchair-bound, or bedridden. These stones were found in a 24-year-old female with a partial transverse vaginal septum and hypospadias, and are examples of primary vaginal caculi. Secondary vaginal caculi arise from salt deposits formed around a foreign body, such as a pessary, surgical equipment, or displaced intrauterine contraceptive devices. These are thought to be less common, comprising of 18% of reported cases. On the right is a picture of a vaginal caculus formed over an exposed vaginal mesh. This is an example of a secondary caculus. Because vaginal caculi are rare, they can often be mistaken for bladder caculi. Radiographs can also be misleading. In the case below, the patient was thought to have a large bladder stone based on her KUB and was taken to the operating room for a cystoscopy with laser litholipaxy. Alternatively, she was found to have a normal cystoscopy with no visible bladder caculus. Pelvic examination then revealed a large vaginal stone, about 4 cm proximal to the entroitis. This highlights the importance of a physical exam, especially the pelvic exam. Other imaging techniques, such as CT and MRI, can be used to obtain the correct diagnosis. In the images below, the radiograph on the left shows a caculus in the pelvis, but it wasn't until the CT was performed. It was clear that the stone is in the vagina. Vaginal caculi can be difficult to remove. Cystoscopy is recommended to help assess urethral or bladder involvement. Often blunt and sharp dissection are needed to remove the vaginal stone with or without an episiotomy. Novel methods have also been described, such as using a nephroscope with an ultrasonic device to disintegrate the stone. Laparotomy is also an option of last resort. In this video, we describe and demonstrate the removal of a vaginal caculus with a surgical drill. This is a novel, minimally invasive method using a drill normally used for orthopedic surgery. It is especially useful for vaginal caculi that are not complicated by vesicovaginal fistula and when the caculus is larger than the vaginal entroitis, as seen in the image on the right. This method also avoids the use of an episiotomy for vaginal stone removal. The procedure was performed under sedation in dorsal lithotomy position. On physical exam, the vaginal stone was visible approximately 4 cm proximal to the entroitis. On radiology, the stone was noted to be 8 by 10 cm in size. Cystoscopy had revealed a normal urethra and bladder. Vaginoscopy revealed that this is a secondary vaginal stone most likely formed over a neglected pessary. The electric surgical drill used for this procedure is normally used for orthopedic surgery and typically available at all surgical centers. While assembly is required, the setup for the drill is minimal as seen here. We use a 2 to 3 mm drill bit for our procedure which is also shown here. This is an animated video of the procedure. The drill was used to perforate sequential holes across a corner of the vaginal caculus breaking the stone apart. However, if the stone remained in place, ronguer forceps were then used to help fragment the caculus between the perforated holes. This process is repeated until the vaginal caculus can be safely removed from the vaginal entroitis. This is a video from the actual procedure. Initially, only the surgical drill was used to perforate and fragment the stone. Ronguer forceps such as these were later used to facilitate fragmentation of the vaginal caculus as demonstrated in the video of the actual procedure. At the end of the case, the 8 x 10 cm vaginal caculus was extracted safely from the vagina without any pseudotomy after much of the stone was fragmented and removed using the drill and forceps. In summary, vaginal caculi are rare but should be in the differential to avoid misdiagnoses. Pelvic exams should also be performed on all patients with a suspected pelvic stone. We demonstrated the novel use of the surgical drill to safely remove a large secondary vaginal caculus. This surgical method allowed for a safe and minimally invasive removal without an episiotomy. This method can be used in future cases of vaginal caculi.

vaginal caculi

urinary salt deposits

primary vaginal caculi

secondary vaginal caculi

surgical drill