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Senior - Urology > 1 - Urinary Stone Disease > Flashcards

1 - Urinary Stone Disease Flashcards

1
Q

Urinary stone disease factoids

A

3rd MC urinary tract d/o

Male > female 2.5:1

Age 30-50’s

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2
Q

Urolithiasis?

A

Stone formation anywhere in urinary tract

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3
Q

Nephroloithiasis

A

Stones in the kidneys

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4
Q

Ureterolithiasis

A

Stones in the ureters

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5
Q

Urinary calculi

A

Polycrystalline aggregates of crystalloid and organic matrix

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6
Q

Stone formation is a result of?

A

Uninary supersaturation of solute

  • low fluid intake -> low urine volume -> high concentrations of stone forming solutes in urine
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7
Q

Most stones are?

A

Calcium (85%)

- radiopaque

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8
Q

Factors that affect urinary stone formation

A
  • high protein intake
  • high salt intake
  • inadequate hydration
  • Sedentary lifestyle
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9
Q

Stones of our fathers?

A

A clint eastwood movie
- wait, maybe not

They are genetic though

  • calcium based - 50% heritable
  • cystinuria - (autosomal dominant d/o) leads to cysteine stones
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10
Q

Urine pH effects on stones?

A

Acidic

  • uric acid stones
  • cystine stones

Alkaline

  • UTI (urease producing organisms)
  • > struvite stones
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11
Q

5 types of urinary stones?

A
  1. Calcium oxalate
  2. Calcium phosphate
  3. Struvite (mg, ammonium phosphate)
  4. Cystine
  5. Uric acid
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12
Q

Staghorn stones are

A

Struvite

- magnesium ammonium phosphate

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13
Q

MC type of stone?

A

Calcium oxalate (by far MC)

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14
Q

Risk factors for calcium oxalate stones?

A

Urinary pH 5.5-6.8

High sodium
High protein
Dehydration
Hypercalciuria
Low urine citrate
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15
Q

Oxalate stones result from?

A

Digestion: oxalate is metabolic end product

Excess ascorbic acid (>2g/day)
- H urinary oxalate levels

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16
Q

Strongest promoter of oxalate stone formation?

A

Urinary oxalate

- it has a high affinity for calcium so calcium follows it into the urine

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17
Q

How does citrate promote calcium phosphate and oxalate stones?

A

Urinary citrate binds w calcium making it unavailable to bind with phosphate and oxalate

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18
Q

PH effect on citrate?

A

Acidosis -> L urinary citrate

Alkalosis -> H urinary citrate

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19
Q

Risk for calcium phosphate stones?

A
  • alkaline urine
  • high sodium
  • high protein
  • dehydration
  • hyepercalciuria
  • low urine citrate

(Pretty similary to calcium oxalate)

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20
Q

MC struvite stone presentation?

A

Women w recurrent UTI w urease-producing baceria

  • proteus
  • pseudomonoas
  • providencia
  • klebsiella
  • staph
  • mycoplama

High urine pH (>7.2)

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21
Q

Struvite stones are made of?

A

Magnesium-ammonium-phosphate stones

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22
Q

Struvite stones on radiograph?

A

Radiopaque

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23
Q

Staghorn calculi?

A

Upper Urinary tract stones that involve:

  • renal pelvis (extend to 2+ calyces)
  • composed of struvite
24
Q

Cystine stones pH?

A

Acidic urine (<5.5)

25
Q

Cystine in urine?

A

The only amino-acid that is insoluble in urine

26
Q

Risk factors for uric acid stones?

A
  • hyperuricemia
  • myeloproliferative d/o
  • malignancy w H uric acid production
  • abrupt and dramatic wt loss
27
Q

Uric acid urine pH?

A

Acidic <5.5

28
Q

Uric acid stones radiograph?

A

Radiolucent

29
Q

Clinical findings for stones?

Obstruction

A

Obstruction - cholic pain

Hematuria

30
Q

Describe the obstructing stones presentation

A
  • sudden onset (awaken from sleep)
  • severe, unremitting flank pain
  • n/v
  • constant movement of pt
31
Q

Where is the pain with stones?

A

Initial Episodic
- can radiate anterior over abd

As progresses down ureter
- refers to ipsilateral groin

May have CVA tenderness

32
Q

If the stone gets lodged at ureterovesicular junction?

A

Marked urinary urgency and freq

Males get pain at tip of penis

33
Q

Stone size and pain?

A

Doesnt correlate w symptoms severity

34
Q

Ddx for stones?

A 
Bleeding in kidney
Pyelonephritis
GYN
AAA
Mesenteric ischemia
Herpes zoster
Drug-seeking

More info on each on slide 25

35
Q

labs for stones?

A

UA

  • hematuria
  • urine pH

Serum studies - chem 17

Stone analysis - urine strainer

36
Q

Gold standard of imaging for stones?

A

Non-contrast CT

- will show all stones radiopaque or radiolucent

37
Q

Other imaging for stones

A

Plain film (KUB)

  • gets most stones
  • cannot r/o stones

Renal US

  • preggo
  • er use
38
Q

Acute tx for stones?

A

Asymptomatic and no infection
- nothing

= 5-6 mm pass spontaneously

Hydration is key to stone passing

Meds

  • analgesics
  • antiemetic
  • alpha-blocker
39
Q

Indications for referral w stones?

A 
Indicated for:
– Infection
– Obstruction
– Intractable pain (admit &amp; control pain)
– Persistent nausea/vomiting
– Stone size ≥6 mm
– Fails to pass w/in 4 weeks
– Anatomic abnormalities or single kidney
– Patient is pregnant
– Patient is immunocompromised
– PMH of severe renal disease
40
Q

A pt with obstructive urinary calculi w fever and infected urine?

A

Emergent urologic eval and drainage

“Pus under pressure”

41
Q

What is extracorporeal shock wave lithotripsy (ESWL)?

A

TOC - in 75% requiring tx

  • works well in renal pelvis
  • upper 2/3 of ureter
  • size >1.5cm
42
Q

When using ESWL you need to make sure the pt?

A

D/c NSAIDS x 3 days prior to lower bleeding risk

43
Q

What may be required following ESWL to facilitate passage of fragmented stones?

A

Ureteral stent

44
Q

Stones in lower 1/3 of ureter may need?

A

Ureteroscopic stone extraction

45
Q

Who needs percutaneous nephrolithotomy?

A
  • Stone in renal collecting system
  • upper 2/3 of ureter
  • size >2 cm may need?
46
Q

Open stone surgery is reserved for?

A

Pt w

  • complex anatomy
  • obstruction
  • large infected struvite stones

(<5% of cases that need intervention)

47
Q

Bottom line for acute stone tx?

A 
Push fluids
Pain control
Confirm stone
Admit (if tx/pain failure)
Refer (large, infection, comorbids)
48
Q

Recurrent stone formers need?

A

Lab workup

  • 24hr urine
  • serum PTH
  • Uric acid -> r/o primary hyperparathyroidism or gout
49
Q

With recurrent stone formers you should not restrict?

A

Calcium - low calcium diets lead to higher risk of stones

- complex process, explained on 43

50
Q

Fiber effect in stones?

A

Fiber -> H fecal extraction of calcium -> lower urinary calcium

51
Q

Why do soda’s effect stones?

A

High in phosphate -> H calcium phosphate stones

52
Q

Dont take more than ___ vitamin c if you want to avoid stones?

A

> 2g/day

53
Q

Foods high in oxalate?

A

Grits and ovaltine

Much much more on slide 45

54
Q

Recurrent stone formers w high/low urinary calcium need? (Med)

A

High - Thiazide diuretics

  • HCTZ
  • chlorthalidone

Low - potassium citrate therapy

  • raise citrate in calcium stone formers
  • raise pH in uric acid/cystine stone formers
55
Q

Prevent stones w

A

Water

1.5-2L/day

56
Q

Follow up for chronic stone formers?

A

24hr urine q 6 mo

Repeate stone analysis if interventions are failing

Yearly CT

57
Q

Iguana tap it

A

But i have reptile dysfunction

Senior - Urology (7 decks)

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