( 1 ) patients may report dysuria , intermittency , haematuria , frequency , hesitancy , nocturia or sudden termination of voiding .
a 62 year old lady presented to the hospital with a swelling in her right thigh .
she had a past history of myelomeningocele spina bifida which had been closed at birth .
she suffered from urinary incontinence and had been managed with long term suprapubic catheters for 20 years .
she had required a vesicolithotomy via a midline incision and a vaginal hysterectomy 13 years previously .
initial examination revealed a swollen right thigh and a calcified mass protruding through the skin in the right groin .
a strong smell of urine was noted although it was thought that this was secondary to a leakage from around the site of her supra pubic catheter .
laboratory data demonstrated normal renal function , a raised c - reactive protein and normal white cell count .
due to her swollen right leg a deep vein thrombosis was excluded with an ultrasound scan and negative d dimer and plain radiographs of her right hip and pelvis were requested .
a urology opinion was sought , initially , with regard to management of the suprapubic catheter . on closer examination ,
urine was noted to be leaking not from the suprapubic site but around the calcified mass in the right groin and a diagnosis of vesicocutaneous fistula was made .
her radiographs demonstrated two urinary calculi ( fig 1 ) and she went on to have an abdominal computed topography scan ( fig 2 ) which confirmed the diagnosis of a vesicocutaneous fistula .
plain radiographs demonstrating two bladder calculi ct demonstrating the two bladder calculi pointing towards the right groin vesicolithotomy was performed removing the calculi by enlarging the fistulous opening .
( fig 3 ) two calculi measuring 40 mm  43 mm  30 mm and 43 mm  50 mm  33 mm were extracted .
4 ) the suprapubic catheter was changed and the fistula was left open and urine leakage continued to decrease in quantity until the fistula tract closed .
intraoperative view of the bladder calculi emerging through the vesicocutaneous fistula into the right groin the two bladder calculi following extraction
urological complications are often a major source of morbidity for these patients . ( 5 ) abnormal bladder sensation and function combined with sphincter dysnergia predispose the spina bifida patient to urinary stasis , recurrent urinary tract infections , stone formation and renal function impairment .
( 5 ) management of the problem can be difficult and may include the use of anti - cholinergics , intermittent self catheterisation ( isc ) , supra pubic catheterisation or surgical intervention to allow urinary diversion .
( 6 ) increased fluid intake , weekly changes of indwelling catheters if isc is not possible and regular ultrasonic screening , to pick up stone formation at an early stage , may help reduce the burden of these problems .
( 2 - 4 ) predisposing factors to bladder stone formation include urinary stasis , bladder outflow obstruction urinary stasis , recurrent urinary tract infections and foreign bodies within the bladder ( 1 ) , all of which can be seen in spina bifida patients . in our case
the added sensory abnormalities secondary to spina bifida left the bladder calculus undiagnosed until it had formed the vesicocutaneous fistula .
good control of the predisposing factors can dramatically reduce the risk of developing bladder calculi , but especially in cases where this is difficult , a high index of suspicion , regular urological review and timely uss can prevent the development of both the bladder calculus and its complications .
 we present a rare case of a vesicocutaneous fistula secondary to two large bladder calculi in a patient with spina bifida . 
 a 62 year old lady presented with swelling of her right thigh and a calcified mass protruding through the subcutaneous tissues of her right groin . 
 urine was seen to be draining from around the area and plain radiographs and a computed topography ( ct ) scan confirmed the presence of two bladder calculi with a vesicocutaneous fistula . 
 vesicolithotomy was performed and the fistula tract left to close spontaneously . 
 worldwide this is only the fourth case of a bladder calculus causing a vesicocutaneous fistula . 
INTRODUCTION
CASE REPORT
DISCUSSION