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Urology > Renal Colic > Flashcards

Renal Colic Flashcards

1
Q

Renal … classically refers to acute severe loin pain that occurs secondary to a urinary stone.

A

Renal colic classically refers to acute severe loin pain that occurs secondary to a urinary stone.

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2
Q

Urinary stones, also termed urolithiasis, refer to stone formation anywhere within the urinary tract. They may be asymptomatic or cause acute … to … pain due to ureteric obstruction.

A

Urinary stones, also termed urolithiasis, refer to stone formation anywhere within the urinary tract. They may be asymptomatic or cause acute loin-to-groin pain due to ureteric obstruction.

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3
Q

Urinary stones are extremely common, …. are affected up to three times more than …. The peak incidence of symptomatic urinary stones is between 40-60 years in males and late 20’s in females.

A

Urinary stones are extremely common, men are affected up to three times more than women. The peak incidence of symptomatic urinary stones is between 40-60 years in males and late 20’s in females.

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4
Q

Renal colic is caused by …. to urinary … within the ureter that occurs secondary to urinary ….

A

Renal colic is caused by obstruction to urinary flow within the ureter that occurs secondary to urinary stones.

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5
Q

The majority of renal stones, approximately 80%, are composed of ….

A

The majority of renal stones, approximately 80%, are composed of calcium. The most common being calcium oxalate, but calcium phosphate stones are also seen. Other types of stones include struvite (2-15%), uric acid (10%) and cystine (1-2%).

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6
Q

The majority of renal stones, approximately 80%, are composed of calcium. The most common being calcium …., but calcium … stones are also seen. Other types of stones include struvite (2-15%), uric acid (10%) and cystine (1-2%).

A

The majority of renal stones, approximately 80%, are composed of calcium. The most common being calcium oxalate, but calcium phosphate stones are also seen. Other types of stones include struvite (2-15%), uric acid (10%) and cystine (1-2%).

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7
Q

Calcium oxalate renal stones

A

Calcium oxalate is the most common type of stone and is thought to develop from the precipitation of calcium crystals within the interstitium. Accumulation of these crystals leads to the formation of ‘Randall’s plaques’, which are subepithelial calcification of renal papillae. They are thought to act as a nidus for stone formation.

The development of calcium oxalate stones is associated with a number of factors. These include high concentrations of oxalate in the urine, loss of natural stone inhibitors (e.g. citrate, magnesium) and high urinary pH.

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8
Q

Struvite stones

A

V Struvite stones are composed of magnesium, ammonium and phosphate. They may grow rapidly and can lead to the development of staghorn calculi - these are large stones that fill the entire intrarenal collecting system and cause renal dysfunction.

Struvite stones are associated with urease-producing microorganisms including Proteus and Klebsiella. These microorganisms are able to convert urea into ammonia which reacts with water increasing the pH of the urine. Collectively, the increased ammonia and alkaline urine promote stone formation.

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9
Q

Uric acid stones

A

The development of uric acid stones is strongly associated with a low urinary pH and a high urinary concentration of uric acid. The proportion of uric acid stones is higher in hot, dry climates because of the tendency to produce more acidic and low-volume urine.

Circumstances that increase the levels of uric acid predispose patients to the formation of uric acid stones. Classically, uric acid stones are seen in patients with gout who have hyperuricaemia and, therefore, hyperuricosuria. However, the likelihood of stone formation is still strongly related to urinary pH.

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10
Q

Cystine stones

A

Cystine is a homodimer of the amino acid cysteine. The development of cystine stones is usually secondary to the genetic disorder cystinuria in which there is impairment in the normal renal handling of cystine. This leads to failed reabsorption of cystine and precipitation within the renal tubules. Patients with cystinuria typically present with stones at a younger age.

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11
Q

Modifiable risk factors for renal stone formation:

A

Modifiable risk factors are those that patients can change to help reduce the risk of calculi forming. Understanding these helps to form advice that can be given following the occurrence of a stone.

Certain medications may also be related to the development of renal calculi. These include protease inhibitors and diuretics - whether these can or cannot be adjusted depends on numerous factors.

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12
Q

Non-modifiable risk factors for renal stone formation:

A
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13
Q

Urinary stones classically obstruct at one of three sites: the …-ureteric junction (PUJ), the …. brim and the …-ureteric junction (….

A

Urinary stones classically obstruct at one of three sites: the pelvi-ureteric junction (PUJ), the pelvic brim and the vesico-ureteric junction (VUJ).

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14
Q

Label the circles

A
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15
Q

The obstruction to flow within the ureter leads to the release of ….

A

The obstruction to flow within the ureter leads to the release of prostaglandins. Prostaglandins cause vasodilatation of surrounding vessels and stimulate ureteric smooth muscle spasm.

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16
Q

Prostaglandins cause vasodilatation of surrounding vessels and stimulate ureteric smooth muscle spasm.

A

… cause vasodilatation of surrounding vessels and stimulate ureteric smooth muscle spasm.

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17
Q

Blood vessel … promotes a natural diuresis, which further places pressure on the kidney and can lead to distention of the renal capsule. Distention of this capsule causes the intense pain of renal …, which is further exacerbated by ureteric smooth muscle spasm.

A

Blood vessel vasodilatation promotes a natural diuresis, which further places pressure on the kidney and can lead to distention of the renal capsule. Distention of this capsule causes the intense pain of renal colic, which is further exacerbated by ureteric smooth muscle spasm.

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18
Q

Renal colic occurs in …, 20-60 minutes long, that can be extremely intense. Renal colic pain usually settles quickly following relief of the obstruction (e.g. by a stent) or passage of the stone.

A

Renal colic occurs in paroxysms, 20-60 minutes long, that can be extremely intense. Renal colic pain usually settles quickly following relief of the obstruction (e.g. by a stent) or passage of the stone.

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19
Q

The classical presentation of renal colic is …-to… pain.

A

The classical presentation of renal colic is loin-to-groin pain.

20
Q

Symptoms of renal colic (5)

A 
Loin-to-groin pain
N&V
Haematuria
Dysuria
Urgency
21
Q

Signs of renal colic (4)

A

Flank tenderness
Haematuria (typically microscopic)
Fever
Rigors

22
Q

All symptoms and signs of…

A

Renal colic

23
Q

The imaging of choice in the diagnosis of acute renal colic in non-pregnant adults is a …

A

The imaging of choice in the diagnosis of acute renal colic in non-pregnant adults is a non-contrast computed tomography (CT) scan.

24
Q

A CT KUB (kidneys-ureters-bladder) is a …-… scan that can be used to help identify both stones and urinary tract obstruction. It has a sensitivity in the high 90’s and has the benefit of being readily available and easily interpreted in a short space of time.

A

A CT KUB (kidneys-ureters-bladder) is a non-contrast scan that can be used to help identify both stones and urinary tract obstruction. It has a sensitivity in the high 90’s and has the benefit of being readily available and easily interpreted in a short space of time.

25
Q

Importantly, non-contrast CT does not expose the patient to IV contrast which can be …

A

Importantly, non-contrast CT does not expose the patient to IV contrast which can be nephrotoxic. It is the first-line investigation in adult, non-pregnant, patients.

26
Q

Importantly, non-contrast CT does not expose the patient to IV contrast which can be nephrotoxic. It is the first-line investigation in …

A

Importantly, non-contrast CT does not expose the patient to IV contrast which can be nephrotoxic. It is the first-line investigation in adult, non patients.

27
Q

Ultrasonography tends to be reserved for patients where there is an increased risk of using ionising radiation. It is useful for the identification of hydronephrosis and may be used to look for stones and other gross abnormalities. It is the first-line investigation in:

….
…. + …

A

Ultrasonography tends to be reserved for patients where there is an increased risk of using ionising radiation. It is useful for the identification of hydronephrosis and may be used to look for stones and other gross abnormalities. It is the first-line investigation in:

Pregnant women
Children and young adults (i.e. people under 16 years)

28
Q

… is best suited for picking up large, proximal stones (e.g. > 5mm at the PUJ). It can be more difficult to visualise small, distal stones.

A

Ultrasound is best suited for picking up large, proximal stones (e.g. > 5mm at the PUJ). It can be more difficult to visualise small, distal stones.

29
Q

Most urinary stones are composed of … which makes them radiopaque to plain radiograph. X-rays are inexpensive and typically quick to obtain. They are poor at picking up small stones and lack the sensitivity of CT KUB.

A

Most urinary stones are composed of calcium which makes them radiopaque to plain radiograph. X-rays are inexpensive and typically quick to obtain. They are poor at picking up small stones and lack the sensitivity of CT KUB.

30
Q

Bedside investigations for renal colic

A

Observations
ECG
Urinalysis (urine dipstick)
Urine culture

31
Q

Bloods for renal colic

A 
FBC
U&Es
CRP
LFTs
Amylase
Bone profile
Uric acid
32
Q

A metabolic stone workup can be completed in patients with significant stone disease. This involves: (2)

A

Stone analysis
Serum calcium

Other tests may include uric acid levels and parathyroid hormone. Urinary collections may be arranged to look at oxalate, calcium, uric acid and citrate levels.

33
Q

In the majority of patients, renal colic can be managed conservatively with the use of … and adequate …

A

In the majority of patients, renal colic can be managed conservatively with the use of analgesia and adequate hydration.

34
Q

In general, the management of renal colic is dependent on the size and location of the stone. The larger (e.g. > …mm) and more … (e.g. PUJ) the stone, the more likely intervention will be needed.

A

In general, the management of renal colic is dependent on the size and location of the stone. The larger (e.g. > 10mm) and more proximal (e.g. PUJ) the stone, the more likely intervention will be needed.

35
Q

A stone that is < … mm in size will have an 80% chance of spontaneous passage whereas a stone > … mm in size only has a 20% chance of spontaneous passage.

A

A stone that is < 4 mm in size will have an 80% chance of spontaneous passage whereas a stone > 8 mm in size only has a 20% chance of spontaneous passage.

36
Q

In all patients, appropriate analgesia and hydration are important in the ongoing management. Urgent urological assessment should be considered in the following circumstances:

U..
Acute … …/a…
… functioning kidney
… pain

A

In all patients, appropriate analgesia and hydration are important in the ongoing management. Urgent urological assessment should be considered in the following circumstances:

Urosepsis
Acute kidney injury/anuria
Solitary functioning kidney
Unresponsive pain

37
Q

NSAIDs are considered excellent for pain relief in renal colic as they help to reduce the ureteral spasm - particularly when given via the rectal route. They should be used with caution in patients with an … or with a history of g… or .. … disease.

A

NSAIDs are considered excellent for pain relief in renal colic as they help to reduce the ureteral spasm - particularly when given via the rectal route. They should be used with caution in patients with an AKI or with a history of gastritis or peptic ulcer disease.

38
Q

Anti-emetics (e.g. …. or …) can be used to help control nausea and vomiting in renal colic

A

Anti-emetics (e.g. ondansetron or cyclizine) can be used to help control nausea and vomiting in renal colic

39
Q

In renal colic, medical expulsive therapy involves the use of medications, most commonly … (an alpha-blocker) to help induce spontaneous passage

A

Medical expulsive therapy involves the use of medications, most commonly tamsulosin (an alpha-blocker) to help induce spontaneous passage of the stone.

40
Q

Shockwave lithotripsy (SWL) - what is it? When is it used?

A

Shockwave lithotripsy (SWL): a non-invasive procedure that uses shockwaves to break up stones. Normally indicated in those with stones less than 20mm in size.

41
Q

Ureteroscopy (URS) with laser lithotripsy: when is it used?

A

Ureteroscopy (URS) with laser lithotripsy: a urological procedure where energy devices are used to break up the stones, normally indicated in stones 10-20mm in size or less than 10mm where SWL fails or is contraindicated.

42
Q

Percutaneous nephrolithotomy (PCNL): when is it used?

A

Percutaneous nephrolithotomy (PCNL): a nephroscope is passed into the collecting system and used to break up stones. Tends to be reserved for larger stones (> 20mm) or in smaller stones where other measures have failed.

43
Q

The two main options for relieving obstruction before doing anything more definite include radiologically-guided insertion of a … tube into the renal pelvis under local anaesthetic or insertion of a … … stent under general anaesthetic.

A

The two main options for relieving obstruction before doing anything more definite include radiologically-guided insertion of a nephrostomy tube into the renal pelvis under local anaesthetic or insertion of a ureteric JJ stent under general anaesthetic.

44
Q

Address modifiable risk factors for reducing risk of recurrence of renal calculi (5)

A 
Avoiding excess salt
Good oral hydration (and adding lemon juice to drinking water)
Avoiding carbonated drinks
A balanced diet
Healthy weight loss
45
Q

In addition to the above advice potassium citrate may be given to: adults with recurrent stones that are …
And children and young people with stones that are…

A

Adults: with recurrent stones that are > 50% calcium oxalate.
Children and young people: with recurrent stones that are > 50% calcium oxalate with either hypercalciuria or hypocitraturia.

46
Q

… acts as an inhibitor of crystallisation of calcium salts - … has been shown to be a risk factor for the development of calcium oxalate stones.

A

Citrate acts as an inhibitor of crystallisation of calcium salts - hypocitraturia has been shown to be a risk factor for the development of calcium oxalate stones.

47
Q

In addition to the advice regarding modifiable risk factors for renal colic, thiazide diuretics may be given to adults with:

A

Recurrence and stones that are > 50% calcium oxalate and
Hypercalciuria after - Restricting salt intake to 6g / day
Thiazides are relatively inexpensive and reduce urinary calcium, reducing the risk of calcium-based stones.

Urology (13 decks)

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