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A - MSRA Renal and Urinary [17] > [2] Urinary Tract Stones > Flashcards

[2] Urinary Tract Stones Flashcards

1
Q

What are urinary tract stones also known as?

A

Urolithiasis

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2
Q

What is urolithiasis?

A

When a solid piece of material occurs in the kidney tract

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3
Q

Where do urinary tract stones form?

A

Typically in the kidney

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4
Q

How to urinary tract stones typically leave the body?

A

In the urine stream

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5
Q

When can kidney stones pass in the urine stream without causing symptoms?

A

When it is small (under 5mm)

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6
Q

What may happen when a stone is bigger than 5mm?

A

It can cause blockage of the ureter resulting in severe pain and other symptoms

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7
Q

When are renal calculi formed?

A

When the urine is supersaturated with salt and minerals.

The other factor that leads to stone production is the formation of Randall’s plaque

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8
Q

What salt and minerals might the urine become supersaturated with?

A
  • Calcium oxalate
  • Struvite
  • Uric acid
  • Cysteine
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9
Q

What causes Randall’s plaques?

A

The precipitation of calcium oxalate in the basement membrane of the thin loops of Henle, which eventually accumulate in the subepithelial space on renal papillae

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10
Q

What does the formation of Randall’s plaques eventually lead to?

A

The formation of a calculus

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11
Q

What % of urinary tract stones are bladder stones?

A

Around 5%

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12
Q

What do bladder stones usually occur due to?

A
  • Foreign bodies
  • Obstruction
  • Infection
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13
Q

What is the most common cause of bladder stones?

A

Urinary stasis due to failure of emptying the bladder completely on urination

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14
Q

Which gender do bladder stones occur most commonly in?

A

Men (95% of cases)

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15
Q

What are bladder stones in women usually associated with?

A
  • Sutures
  • Synthetic tapes or meshes
  • Urinary stasis
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16
Q

What are the risk factors for urinary tract stones?

A
  • Anatomical anomalities in kidneys and/or urinary tract
  • Family history of stones
  • Hypertension
  • Gout
  • Hyperparathyroidism
  • Immobilisation
  • Relative dehydration
  • Metabolic disorders that cause an increased excretion of solute
  • Deficiency of citrate in urine
  • Cystinuria
  • Drugs
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17
Q

What anatomical abnormalities in the kidneys and/or urinary tract increase the risk of urinary tract stones?

A
  • Horseshoe kidney
  • Urethral stricture
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18
Q

What metabolic disorders cause an increased excretion of solute?

A
  • Chronic metabolic acidosis
  • Hypercalciuria
  • Hyperuricosuria
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19
Q

What drugs can increase the risk of urinary tract stones?

A
  • Diuretics such as triamterene
  • Calcium/vitamin D supplements
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20
Q

How are most urinary tract stones discovered?

A

During investigations for other conditions, as many are asymptomatic

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21
Q

What is the classic symptom of urinary colic?

A

Sudden severe pain

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22
Q

What causes the pain in urinary tract stones?

A

Stones in the kidney, renal pelvis, or ureter, which causes dilation, stretching, and spasm of the ureter

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23
Q

Other than pain, what symptoms may be present with urinary tract stones?

A
  • Rigors and fever
  • Dysuria
  • Haematuria
  • Urinary retention
  • Nausea and vomiting
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24
Q

Where does the pain in renal colic start?

A

In the loin, at about the level of the costovertebral angle

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25
Q

Where does the pain in renal colic move too?

A

Moves to the groin, with tenderness of the loin or renal angle

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26
Q

When do urinary tract stones cause pain in the loin?

A

When the stone is high and distends the renal capsule

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27
Q

When do urinary stones cause pain in the flank?

A

As it moves anteriorly and down the urinary system

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28
Q

What is more painful, a stone that is moving or a stone that is static?

A

A stone that is moving

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29
Q

Where might renal colic pain radiate?

A
  • Testis
  • Scrotum
  • Labia
  • Anterior thigh
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30
Q

Describe the pattern of pain in renal colic?

A

It is fairly constant, but there are often periods of relief, or just a dull ache before it returns

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31
Q

How will a patient with renal colic appear from the end of the bed?

A

They will be writing around in agony, in contrast to a patient with peritoneal irritation who lies still

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32
Q

When will a renal colic patient be apyrexical?

A

When it is uncomplicated

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33
Q

What might abdominal examination reveal with renal colic?

A

Sometimes reveals tenderness over affected loin, and bowel sounds may be reduced

34
Q

Why is full and thorough abdominal examination required in renal colic?

A

To check for other possible diagnoses

35
Q

What do the differential diagnoses of urinary tract stones depend on?

A

The position of the pain, and the presence or absence of pyrexia

36
Q

What are the differential diagnoses of urinary tract stones?

A
  • Biliary colic
  • Dissected aortic aneurysm
  • Pyelonephritis
  • Acute pancreatitis
  • Acute appendicitis
  • Perforated peptic ulcer
  • Epididymo-orchitis or testicular torsion
37
Q

What investigations are done into urinary tract stones?

A
  • Urine testing
  • Blood tests
  • CT scanning
  • Ultrasound scanning
  • Plain x-rays of the kidney, ureter, and bladder
  • Stone analysis
38
Q

What is the imaging modality of choice for urinary tract stones?

A

CT scanning

39
Q

Why may ultrasound scanning be useful in urinary tract stones?

A

It may be helpful to differentiate radio-opaque from radiolucent stones, and in detecting evidence of obstruction

40
Q

What can plain x-rays of kidney, ureter, and bladder be useful for in urinary tract stones?

A

Watching the passage of radio-opaque stones

41
Q

What should urine testing involve in urinary tract stoens?

A
  • Stick testing
  • Midstream specimen of urine for MCS
42
Q

What are red cells suggestive of when urine testing for suspected urinary tract stones?

A

Urolithiasis

43
Q

What are white cells and nitrates suggestive of on urine stick testing?

A

Infection

44
Q

What does a pH above 7 suggest on urine stick testing?

A

Urea-splitting organisms such as Proteus

45
Q

What does a pH below 5 suggest on urine stick testing?

A

Uric acid stones

46
Q

What blood tests should be done in urinary tract stones?

A
  • FBC
  • CRP
  • Renal function
  • Electrolytes
  • Calcium
  • Phosphate and urate
  • Creatinine
47
Q

What are the indications for stone analysis?

A
  • All first-line stone formers
  • All patients with recurrent stones who are on pharmacological preventing therapy
  • Late recurrence after long stone-free period
48
Q

Where can the initial management of urinary tract stones take place?

A

As an inpatient or urgent outpatient basis, depending on how easily the pain can be controlled

49
Q

What are the indications for hospital admission with urinary tract stones?

A
  • Fever
  • Solitary kidney or known non-functioning kidney
  • Inadequate pain relief or persistent pain
  • Inability to take fluids due to nausea and vomiting
  • Anuria
  • Pregnancy
  • Poor social support
  • People over the age of 60 years, if there are concerns on clinical condition or diagnostic uncertainty
50
Q

What are the indications for urgent outpatient appointment with urinary tract stones?

A
  • Pain has been relieved
  • Patient able to drink large volumes of fluid
  • Adequate social circumstances
  • No complications evident
51
Q

What should be offered first line for the relief of renal colic pain?

A

NSAIDs, usually in the form of diclofenac IM or PR

52
Q

Why are NSAIDs first line in managing renal colic pain?

A

Because they are more effective than opioids for this indication, and have less tendency to cause nausea

53
Q

What is the use of parenteral morphine in the management of renal colic pain?

A

Parenteral morphine is required in severe renal colic pain, as it works quickly and provides pain relief in the time taken for an NSAID to work

54
Q

What opioid should not be used in the management of urinary tract stones?

A

Pethidine

55
Q

What therapies should be used in addition to pain relief when required?

A
  • Anti-emetics
  • Rehydration
56
Q

What happens to the majority of stones?

A

They pass spontaneously

57
Q

How long do stones take to pass spontaneously?

A

1-3 weeks

58
Q

How often should the progress of a urinary tract stone be monitored?

A

At a minimum of weekly intervals

59
Q

Which patients should have monitoring of their stone progress?

A

Those who have not passed the stone, or have continuing symptoms

60
Q

How long can conservative management of urinary tract stones be continued for?

A

Up to 3 weeks, unless the patient is unable to manage the pain, or if they develop signs of infection or obstruction

61
Q

What is medical expulsive therapy?

A

A therapy used to facilitate the passage of a stone, using calcium-channel blockers or alpha-blockers

62
Q

When is medical expulsive therapy useful in urinary tract stones?

A

In cases where there are no obvious reasons for immediate surgical removal

63
Q

How should patients with urinary tract stones be managed at home?

A

Should drink lots of fluids, and if possible void urine into a container or through a strainer to catch any identifiable calculus

Paracetamol can be used for mild to moderate pain. Codeine can be added if more pain relief is required

64
Q

What % of kidney stones will not pass spontaneously?

A

1/5

65
Q

How are urinary tract stones managed surgicall when the ureter is blocked, or could potentially become blocked?

A

A stent is inserted using a cystoscope

66
Q

Describe a urinary tract stent

A

It is a thin, hollow tube with both ends coiled

67
Q

What is the purpose of a urinary tract stent?

A

It is used as a temporary holding measure, as it prevents the ureter from contracting and thus reduces pain, buying time until a more definitive measure can be taken

68
Q

What surgical procedures can be used to remove stones?

A
  • Extracorporeal shock wave lithotripsy (ESWL)
  • Percutaneous nephrolithotomy
  • Ureteroscopy
  • Open surgery
69
Q

What happens in extracorporeal shock wave lithotripsy?

A

Shock waves are directed over the stone to break it apart, and the stone particles will then pass spontaneously

70
Q

What is percutaneous nephrolithotomy used for?

A
  • Larger stones (>2cm)
  • Staghorn calculi
  • Cysteine stones
71
Q

What happens in a percutaneous nephrolithotomy?

A

Stones are removed using a nephroscope

72
Q

What is a ureteroscopy?

A

Using a laser to break up the stone

73
Q

When is open surgery used in urinary tract stones?

A

Rarely necessary, usually reserved for complicated cases or those in whom all the other surgical options have failed, e.g. multiple stones

74
Q

What is the advantage of a percutaneous surgical approach in the management of bladder stones?

A

It has a lower morbidity, with similar results to transurethral surgery

75
Q

Who is ESWL reserved for in the management of bladder stones?

A

Patients with high surgical risks

76
Q

Why is ESWL reserved for patients with high surgical risks in the management of bladder stones?

A

Because it has a lower rate of elimination of stones

77
Q

What are the complications of urinary tract stones?

A
  • Complete blockage of urinary flow from kidney
  • Infection and sepsis
  • Pyelonephritis
78
Q

What can happen if a complete blockage of urinary flow from the kidney persists for more than 48 hours?

A

May cause irreversible renal damage

79
Q

Is recurrence of renal stones common?

A

Yes

80
Q

What is the result of the recurrence of urinary stones being common?

A

Patietns who have had a renal stone should be advised to adopt several lifestyle measures to prevent or delay recurrence

81
Q

What lifestyle changes should be advised to prevent the recurrence of urinary stones?

A
  • Increase fluid intake
  • Reduce salt intake
  • Reduce amount of meat and animal protein eaten
  • Reduce oxalate intake, e.g. chocolate, nuts
  • Drink regular cranberry juice
  • Maintain calcium intake at normal levels
  • Medications can sometimes be given to prevent further stone formation
82
Q

What medications can be given to prevent further stone formation?

A
  • Thiazide diuretics
  • Allopurinol
  • Calcium citrate

A - MSRA Renal and Urinary [17] (17 decks)

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