Renal Stones & Urological Haematuria

Question 1

A man presents with

• Loin pain
• Moderate intensity nausea
• Urinary frequency

What further history and examination would you take? what do you need to exclude?

Answer 1

• Determine pain characteristics
• Rule out DDx: AAA, testicular/ ovarian torsion, appendicitis, sepsis
• Any complicating factors such as - pregnancy, renal
• Fhx

Physical Exam

• Temperature
• Rule out other causes of the pain
• Usually no peritonism

Question 2

What are the risk factors for renal stones?

Answer 2

• Dehydration

- Diet (animal protein, sodium)

Question 3

What investigations would be involved in an acute work up for renal stones? Do renal stones present in an acute manner?

Answer 3

Investigations

1. FBE, UNE, creatinine
2. Serum calcium and uric acid
3. MSU
4. CT KUB ( or CT-IVP) and plain KUB

Renal stones do not usually present in such an acute manner, it would more likely be a ureteric stone.

Question 4

what are some indications for intervention, when there is presentation like this? What are some methods acute management?

Answer 4

Infection/ Sepsis
Renal impairment
Bilateral obstructing calculi
Solitary kidney (anatomical or functional)
Inability to control Symptoms
- Refractory pain (repeat presentations)
Prolonged obstruction
- Unlikely to pass spontaneously

Some acute management

• NSAIDS
• Opioids
• Paracetamol
• Hydration, admission, surveillance

Question 5

What is obstructive pyelonephrosis? What is it usually caused by? Complications? What is the management?

Answer 5

It is the inflammation of the kidney renal tissue, pelvis and calayces. It is commonly caused by bacterial infection which has ascended. Usually Gram Neg Bacilli such as E.coli.

Complications: High rate of SIRS/ Sepsis

What is the management?

• IV antibiotics for gram neg bacilli & Entercoccus coverage
• Urgent decompression, nephrostomy or stent
• Supportive care: Fluids, monitoring ICU

Question 6

What is a medically expulsive therapy you can use to treat a stone?

Answer 6

Something you can use is an alpha adrenergic receptor blocker, which relaxes the ureteric wall and allows stone passage better, decreasing time of passage and pain. This is called tamsulosin

Question 7

For radiolucent stones

Answer 7

Radiolucent stones -Usually uric acid ( or cysteine)

• Form in acridic urine (pH 6.5
• Potassium citrate/ sodium bicarb
• Allopurinol if serum uric acid levels elevated
• monitory efficacy with urinary pH strips
• High fluid intake

Question 8

What are some surgical options to get rid of the stone?

Answer 8

JJ Stent - Keeps ureter open

Lithotripsy - laser, pneumatic: Using ultrasound shockwaves to break down the stone and its cleared

Question 9

What to do for follow up?

Answer 9

Home with PO analgesia ( paracetamol and nsaids, with opiod for breakthrough pain)

• Arrange a follow up KUB
• Early follow up: See how stone is progressing, evidence of obstruction, return to ED if pain

Question 10

How do we prevent recurrence of renal stones?

Answer 10

• intake of adequate fluid
• Dietary modifications
• Urinary alkylisation
• Medical therapy: Allopurinol, thiazide diuretics
• Cystinuria

Question 11

What are some urological causes of haematuria?

Answer 11

Period, prostate( prostatitis, CaP, BPH), obstructive uropathy, Nephritis ( IgA, interstitial), Trauma, Tumour (renal, urothelial, CaP, Urethral), TB, Thrombosis ( renal infarct, renal vein thrombosis), haematological (anti- coagulation, bleeding diathesis, sick cell), Infection/ inflammation ( radiation cystitis, cyclophosphamide, interistitial cystitis, stones)

Question 12

What are some medications causing red urine

Answer 12

Pyridium, Nitrofurantoin, Ripampin, Ibuprofen, Phenytoin, L-DOPA, Chloroquine, Beetroot

Question 13

Common causes of haematuria”

Answer 13

10-20 percent are urological malignancy
Post op trauma
Radiation due to chemical cystitis
Anticoagulation

Question 14

What is the investigation workup?

Answer 14

Bloods: Hb, Clotting, Creatinine
MSU/ CSU: M/C/S - confirm haematuria, check for intection, glomerular vs non glomerular

Upper tract imaging
CT - IVP ( gold standard)
US - For a lower risk group

Cystoscopy
Other

• urine cytology
• PSA
• Analysis for active urine ( red/ white cell casts, proteinuria)

Question 15

Management?

Answer 15

Significant bleeding with clots or retention - 3 way IDC
Manual bladder washout 2-3 L
Continuous bladder irrigation ( stops new clots forming, NOT to washout pre formed clots)
Stop anticoag if safe to
Does the person need transfusion
Refer to urology