Stone Disease Flashcards
Nephrolithiasis
general term for renal calculi
Predominant symptom of nephrolithiasis
flank pain due to renal colic. (dilation, stretching, spasm)
Physical Exam findings for nephrolithiasis
severe CVA tenderness pain can migrate to upper/lower ab quadrant (migration of ureteral stone) abdominal exam unremarkable (hypoactive bowel sounds, absent peritoneal signs) painful testicles constant body positional movements tachycardia hypertension microscopic hematuria
Lab Testing for stones
urinary sediment/dipstick test CBC with diff (febrile pts) serum electrolytes (vomiting pts) serum and urinary pH level microscopic UA 24 hr urine profile
Imaging for stones
noncontrast abdominopelvic CT scan renal ultrasound kidney/ureter/bladder xray IVP Retrograde pyelography nuclear renal scanning plain renal tomography
management goals for stones
medical therapy: encourage spontaneous passage of stone. supportive care (pain control/antibiotics)
surgical therapy: completely relieve the obstruction
Medical management for stones
IV hydration antiemetics antibiotics pain control NSAIDS uricosuric agents (allopurinol) antidiuretics alkalinizing agents corticosteroids CCBs alpha blockers
Surgical management
stones greater or equal to 7 mm to pass spontaneously and require some type of surgical procedure: stent placement, percutaneous nephrostomy tube (PNT), extracororeal shockwave lithotripsy, uretoscopy, percutaneous nephrostolithotomy, open nephrostomy
Pathophys of stones
supersaturation mechanism: supersaturation of the urine by stone-forming constituents
majority of renal canculi contain calcium
uric acid calculi and crystals of uric acid, with or without other contaminating lens, comprise the bulk of the remaining minority
calcium oxalate, calcium phosphate, and calcium urate are associated with the following disorders
hyperparathyroidism
increased gut absorption of calcium
renal calcium leak
renal phosphate leak
etiology of stones
low fluid intake
hypercalciuria (most common metabolic abnormality)
magnesium (especially citrate) are important inhibitors of stone formation
4 main chemical types of stones (calcium, struvite, uric acid, cystine)
the most potentially dangerous aspect of stone disease
urinary tract obstruction & upper UTI
pyelonephritis, pyonephresis, and urosepsis
necessitates early recognition and immediate surgical drainage
patients at risk of stone development are counseled to seek immediate medical attention if
he or she experiences flank or abdominal pain
visible bleed in the urine
regularly visiting a HCP who advises preventative treatment plans can
- improve the situation in most patients with stones
- strongly motivated to follow a program for maximum kidney stone prophylaxis
- merely increasing fluid intake and can cut the stone recurrence rate by 60%
- phenomenon known as the stone clinic effect
- optimal use of metabolic testing with proper eval and compliance with therapy can completely eliminate new stones in many pts
- significantly reduces new stone formation in most patients
urologic emergency
- complete urinary tract obstruction
- obstruction in a solitary kidney
- obstruction with fever, infection, or both
- renal failure
- pain that is uncontrolled with oral meds
- n/v that causes dehydration
obstructive uropathy can result in
- pain
- uti
- loss of renal function
- urosepsis
- death
urinary obstruction causes/signs/symptoms
- gross or microscopic hematuria
- altered patterns of micturition
- acute or chronic renal failure
- recurrent urinary tract infection
- new onset or poorly controlled HTN secondary to obstruction and increased renin-angiotensin
- polycythemia secondary to increased EPO production in the hydronephrotic kidney
- history of recent gynecologic or ab surgery
upper urinary tract
kidney and ureter to the hiatus with the bladder
lower urinary tract
bladder and urethra to the urethral meatus
uretopelvic junction
ureter connects to kidney
ureterovesical junction
ureter connects to bladder
acute upper urinary tract obstruction symptoms
- flank pain
- ipsilateral back pain
- ipsilateral groin pain
- n/v
- fever, chills, and dysuria
- hematuria
chronic upper urinary tract obstruction symptoms
- asymptomatic
- fever, chills, and dysuria,
- bilateral obstruction or unilateral obstruction in a solitary kidney is sever and renal failure is present, uremia can be present
- uremia symptoms include weakness, peripheral edema, mental status changes, and pallor
lower urinary tract obstruction symptoms
- urgency
- frequency
- nocturia
- incontinence
- decreased stream
- hesitancy
- postvoid dribbling
- inadequate emptying
- suprapubic pain or a palpable bladder (urinary retention)
- dysuria
- hematuria
- urethral stricture
- uterine or bladder prolapse
- urethral diverticulum
- prostatic enlargement
lab studies for obstruction
UA: look for wbcs (infection/inflammation), nitrite, LE
RBCS: microscopic or gross hematuria
Urine pH: stones
Basic Metabolic Panel: Renal insufficiency increased BUN/creatinine, bilateral renal obstruction in a solitary kidney.
hyperkalemia and acidosis may be present
CBC: leukocytosis or anemia
imaging studies for obstruction
US high resolution CT IVP MRI retrograde pyelography nephrostography
treatment: medical therapy for obstruction
partial urinary tract obstruction (absence of infection) ca be initially managed with analgesics and prophylactic antibiotics. Antibiotics should cover common urinary tract pathogens. Manage Pain
treatment: surgical therapy for obstruction
goal is to completely relieve the obstruction. urethral catheter. suprapubic tube/catheter. urethral stent. percutaneous nephrostomy tube
Percutaneous nephrostomy tube (PNT)
a flexible tube placed through the back directly into the renal pelvis. when ureteral stent cannot be placed cystoscopically in a retrograde fashion.
complications of surgical therapy for obstruction
cystitis, pyelo, abscess formation, urosepsis, urinary extravasation, urinary fistula formation, renal insufficiency or failure, bladder dysfunction, pain
follow up for obstruction
after definitive treatment is achieved, final imaging study is obtained to verify complete relief of the obstruction. the type of study performed, as well as the timing of the study, is left to the discretion of the urologist
outcome and prognosis of obstruction
depend on cause, location, degree, duration, and presence of UTI. worse prognosis the longer the duration, the greater the severity, the presence of concomitant infection.
