Long-term migration of a bullet to the bladder after 47 years of trauma: A literature review

Abstract

Foreign bodies in the urinary tract are uncommon and can arise from self-insertion or migration from other organs. Documented cases include various objects such as intrauterine devices, fragments of Foley catheters, toothpicks, and fish bones. However, the migration of bullet fragments into the urinary tract from another location is extremely rare with only a few cases reported in the current literature. Here, we present a case of a urinary tract stone formed around a foreign body—a bullet fragment—discovered 47 years after the patient experienced trauma.

Highlights

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Urinary tract foreign bodies, like bullets, are rare and linked to gunshot trauma.
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Bullets in the urinary tract can cause stone formation if not removed properly.
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Surgeons must choose between transurethral and cystostomy to avoid urinary injuries.

1 Introduction

Foreign bodies in the bladder are commonly self-insertion, trauma, or iatrogenic injuries. Among these etiologies, the migration from other locations to the bladder is particularly rare. The exact mechanism of migration is not well understood; however, it is proposed that gradual erosion of the bladder wall, caused by prolonged irritation and combined with the bladder’s muscular contractions, may facilitate the migration process. This phenomenon enables the foreign body to act as a nidus for stone formation, eventually resulting in lower urinary tract symptoms (LUTS).

2 Case presentation

A 64-year-old woman presented with a two-month history of dysuria, painful urination, and occasional hematuria. Her medical history was notable for recurrent urinary tract infections and a gunshot wound to the hypogastric region sustained at age 17, 47 years prior, which was managed with exploratory surgery, but no bullet was recovered at that time. Physical examination revealed a 10 cm midline surgical scar extending from below the umbilicus to just above the pubic symphysis. Laboratory findings were mostly unremarkable except for leukocyturia on urinalysis, and her urine culture was negative for bacterial growth. Imaging studies, including a non-contrast X-ray of the kidneys, ureters, and bladder, showed a 2 × 3 cm bladder stone with a radiopaque center, strongly suggestive of a retained bullet ( Fig. 1 ). Abdominal ultrasound further confirmed the stone’s presence, demonstrating that it was mobile within the bladder without causing ureteral obstruction.

A cystoscopy was subsequently performed, during which the stone around the bullet was successfully fragmented using a Holmium laser. The bullet was then removed through the resectoscope, completing the procedure effectively ( Fig. 2 A–B). The patient had an uneventful postoperative recovery and was discharged on the following day. At one-week follow-up, she reported complete resolution of lower urinary tract symptoms, with no recurrence.

3 Discussion

Urinary tract foreign bodies are uncommon, with only a few reported cases involving bullets in the urinary tract as a result of gunshot trauma. These cases typically occur due to penetrating bladder injuries from gunshots or because of bullet migration through from other organs, such as the gastrointestinal tract. Reports of bullet migration and residence within the bladder are especially uncommon, with 12 documented cases identified in PubMed, Web of Science, and Google Scholar using the keywords “Bullet” and “Bladder” ( Table 1 ). All cases involved penetrating gunshot injuries, where bullets initially entered the body through regions such as the lumbar area, pelvis, thigh, abdomen, or buttocks. Many patients underwent diagnostic procedures during initial hospitalization, including laparoscopy, cystogram, or cystoscopy, to evaluate bladder injuries. In several cases, these evaluations delivered negative results, indicating that bullets can remain undetected in the body for years. Detection times varied widely, ranging from 2 days to as long as 47 years. Symptoms leading to later detection commonly included hematuria (53 %), urinary retention (46 %), dysuria (15 %), and penile pain (15 %). These symptoms are often underestimated and are commonly mistaken for a simple urinary tract infection. However, they typically persist or worsen, prompting further investigation. Interestingly, one case involved an asymptomatic patient with a normal urinalysis. Currently, treatment approaches for such cases remain unclearly, as studies are predominantly case reports. Depending on the specifics of each case, various approaches have been described. In nearly half the cases, the use of a Foley catheter was documented, and 67 % of these resulted in bullet expulsion within 2 hours to 2 days following catheter removal. The remaining cases were treated successfully using endoscopic techniques, resulting in no or only minor complications. Historically, open cystolithotomy was the standard treatment for foreign bodies. However, with advances in minimally invasive techniques, procedures such as transurethral or percutaneous endoscopic approaches now provide safer access with reduced surgical risk.

Table 1

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