Urolithiasis Flashcards
Risk factors
Points of constriction of the ureter
▪ Pelvic-ureteric junction (PUJ)
▪ Pelvic brim (near bifurcation of the common iliac arteries)
▪ Veisco-ureteric junction (VUJ) – entry to the bladder
Types of calculi: X-Ray appearance, acidic/alkaline urine, clinical features
Pathogenesis
1) Supersaturation wrt stone forming salts
2) Infection
3) Drugs
Clinical Presentation
- Pain
- Obstruction
- Ulceration leading to hematuria
- Chronic infection –> pyelonephritis, pyonephrosis, urosepsis, kidney failure
Differences in clinical presentation in location of stone?
- Renal Stones - asymptomatic often unless lodged in PUJ causing hydronephrosis and pyonephrosis
- Ureteric stones - ureteric groin pain (loin to groin), hematuria, cause Upper UTI, stone at VUJ can cause frequency, urgencym dysuria
- Bladder stones asymptomatic, frequency, urgency , hematuria, infection
History
- Chronology of stone events
- age of 1st presenration
- number/size
- spontaneous passage vs need for intervention
- symptoms during past episodes - Systemic Disease Hx
- Crohns
- Gout
- RTA
- HyperPT
- HyperT - Stone Formation
- FMH
- Meds (antacids, salicyclic acid, anti viral
- Occupational Hx
- Diet
PE
Renal punch
Ix
Management
- Pain control
- Abx for UTI
- Allow for spontaneous passage or active stone removal
▪ Kidney Stones – often asymptomatic – treatment pre-emptive in anticipation of potential complications (observe if <5mm and monitor for growth, treat if >7mm)
▪ Ureteric Stones – symptomatic – trial of passage if <7mm, otherwise treat - Treat etiology of occurrence
-Conservative-
Stones < 5mm can be treated conservatively as 70% will be passed out; only treat if they do not pass out after 4 to 6 weeks,
and/or cause symptoms
- Spontaneous stone passage aided with prescription of narcotic pain medications as well as daily alpha-blocker therapy
(tamsulosin) → improve stone passage by up to 20% (check for postural hypotension when patient is on alpha-blockers)
- High fluid intake
▪ Drink about 2-3L of water/day or till urine clear (a glass of water before sleep is good practice)
- Diet modifications
▪ ↓intake of protein-rich food red meat, animal internal organs – i.e. intestines, liver (for uric acid stones)
▪ ↓ intake of oxalate-rich food – i.e. peanut, spinach, beetroot, strawberries
▪ Coffee and Tea in moderation (for calcium stones)
▪ ↓ intake of sugars (fructose) – i.e. soft drinks, sweets, chocolate
▪ ↑intake of fibre – i.e. fruits, veg, high fibre diet (wholemeal bread, wheat & corn)
▪ ↓ Salt Intake
▪ Normal Calcium Diet
- Medical Therapy – limited, slow process
▪ Calcium stones – thiazide (increase urinary calcium excretion), citrate, low sodium diet
▪ Struvite stones – eradication of underlying infection
▪ Uric acid stones – alkalinizing urine with baking soda or potassium citrate, allopurinol
- Urine should be strained with each void and radio-opaque stones tracked with KUB X-Ray
-Surgery-
Indications - size, site, symptoms, stasis, stuck, sepsis, social
Complications
- Hematoma / Significant Bleeding
- Urinary tract infection
- Ureteric Injury – perforation / ureteric avulsion
- Failure of procedure –i.e. unable to assess stone with URS
