Stone Disease

Question 1

Nephrolithiasis

Answer 1

general term for renal calculi

Question 2

Predominant symptom of nephrolithiasis

Answer 2

flank pain due to renal colic. (dilation, stretching, spasm)

Question 3

Physical Exam findings for nephrolithiasis

Answer 3

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

Question 4

Lab Testing for stones

Answer 4

urinary sediment/dipstick test
CBC with diff (febrile pts)
serum electrolytes (vomiting pts)
serum and urinary pH level
microscopic UA
24 hr urine profile

Question 5

Imaging for stones

Answer 5

noncontrast abdominopelvic CT scan
renal ultrasound
kidney/ureter/bladder xray
IVP
Retrograde pyelography
nuclear renal scanning
plain renal tomography

Question 6

management goals for stones

Answer 6

medical therapy: encourage spontaneous passage of stone. supportive care (pain control/antibiotics)
surgical therapy: completely relieve the obstruction

Question 7

Medical management for stones

Answer 7

IV hydration
antiemetics
antibiotics
pain control
NSAIDS
uricosuric agents (allopurinol)
antidiuretics
alkalinizing agents
corticosteroids
CCBs
alpha blockers

Question 8

Surgical management

Answer 8

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

Question 9

Pathophys of stones

Answer 9

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

Question 10

calcium oxalate, calcium phosphate, and calcium urate are associated with the following disorders

Answer 10

hyperparathyroidism
increased gut absorption of calcium
renal calcium leak
renal phosphate leak

Question 11

etiology of stones

Answer 11

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)

Question 12

the most potentially dangerous aspect of stone disease

Answer 12

urinary tract obstruction & upper UTI
pyelonephritis, pyonephresis, and urosepsis
necessitates early recognition and immediate surgical drainage

Question 13

patients at risk of stone development are counseled to seek immediate medical attention if

Answer 13

he or she experiences flank or abdominal pain

visible bleed in the urine

Question 14

regularly visiting a HCP who advises preventative treatment plans can

Answer 14

• 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

Question 15

urologic emergency

Answer 15

• 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

Question 16

obstructive uropathy can result in

Answer 16

• pain
• uti
• loss of renal function
• urosepsis
• death

Question 17

urinary obstruction causes/signs/symptoms

Answer 17

• 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

Question 18

upper urinary tract

Answer 18

kidney and ureter to the hiatus with the bladder

Question 19

lower urinary tract

Answer 19

bladder and urethra to the urethral meatus

Question 20

uretopelvic junction

Answer 20

ureter connects to kidney

Question 21

ureterovesical junction

Answer 21

ureter connects to bladder

Question 22

acute upper urinary tract obstruction symptoms

Answer 22

• flank pain
• ipsilateral back pain
• ipsilateral groin pain
• n/v
• fever, chills, and dysuria
• hematuria

Question 23

chronic upper urinary tract obstruction symptoms

Answer 23

• 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

Question 24

lower urinary tract obstruction symptoms

Answer 24

• 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

Question 25

lab studies for obstruction

Answer 25

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

Question 26

imaging studies for obstruction

Answer 26

``` US high resolution CT IVP MRI retrograde pyelography nephrostography ```

Question 27

treatment: medical therapy for obstruction

Answer 27

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

Question 28

treatment: surgical therapy for obstruction

Answer 28

goal is to completely relieve the obstruction. urethral catheter. suprapubic tube/catheter. urethral stent. percutaneous nephrostomy tube

Question 29

Percutaneous nephrostomy tube (PNT)

Answer 29

a flexible tube placed through the back directly into the renal pelvis. when ureteral stent cannot be placed cystoscopically in a retrograde fashion.

Question 30

complications of surgical therapy for obstruction

Answer 30

cystitis, pyelo, abscess formation, urosepsis, urinary extravasation, urinary fistula formation, renal insufficiency or failure, bladder dysfunction, pain

Question 31

follow up for obstruction

Answer 31

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

Question 32

outcome and prognosis of obstruction

Answer 32

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.