Giant vaginal lithiasis in spinal cord injury related neurogenic lower urinary tract dysfunction: diagnostic pitfall with upper urinary tract deterioration.

INTRODUCTION: Vaginal lithiasis is exceptionally rare and may mimic vesical lithiasis on imaging, particularly in women with spinal cord injury (SCI) and neurogenic lower urinary tract dysfunction (nLUTD). Delayed recognition may cause recurrent infection, obstructive uropathy and upper urinary tract deterioration.

CASE PRESENTATION: A 38-year-old woman with a T6 ASIA Impairment Scale (AIS) grade A SCI and nLUTD after epidural abscess drainage presented with continuous urinary leakage, recurrent febrile urinary tract infections and progressive renal impairment. Urine culture grew Pseudomonas aeruginosa. Non-contrast-enhanced computed tomography showed a 10 × 5.7 cm midline pelvic calculus with bilateral grade II-III ureterohydronephrosis, initially read as a giant intravesical stone. Persistent incontinence was inconsistent with presumed detrusor-sphincter dyssynergia, prompting clinical reassessment. Cystoscopy revealed an empty bladder and a midline vesico-vaginal fistula; colposcopy confirmed a giant vaginal calculus occupying the vaginal vault. The calculus was removed transvaginally using Kielland obstetric forceps. Hydronephrosis resolved and renal function improved; fistula repair was deferred per patient preference.

DISCUSSION: A focused review identified fewer than 20 reported cases of primary vaginal lithiasis, most associated with nLUTD, neurological impairment, anatomical abnormalities, urinary fistulas or chronic urinary stasis. This case emphasizes that imaging alone may mislocalize pelvic calculi. In SCI patients with nLUTD, clinical and pelvic examination are essential and may establish the diagnosis while assessing for fistula. After risk stratification, structured long-term surveillance of the upper urinary tract and awareness among spinal cord-injured individuals and physicians are crucial to prevent complications and recurrence.