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Urology > UROLITHIASIS > Flashcards

UROLITHIASIS Flashcards

1
Q
  1. What is nephrolithiasis?
  2. Stones can be found where? 3
  3. What is probably the most excruciating painful event a person can endure?
A
  1. Nephrolithiasis refers to stones in the kidney
  2. Stone can be found in the kidney, ureter or bladder of the urinary tract
  3. Acute renal colic
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2
Q

Nephrolithiasis
Pathophysiology
Stones are thought to be caused by 2 basic phenomena

1st phenomena? 2

A
  1. Supersaturation of urine by stone-forming constituents, including calcium, oxalate, and uric acid
  2. Crystals or foreign bodies can act as a nidus which ions from supersaturated urine form microscopic crystalline structures
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3
Q

Nephrolithiasis
Pathophysiology
Stones are thought to be caused by 2 basic phenomena

2nd phenomena? 4

More likely responsible for what kind of stones?

A

2nd phenomena

  1. Deposition of stone material on a renal papillary calcium phosphate nidus (Randall plaque)
  2. Calcium phosphate precipitates the basement membrane of the thin loops of Henle, and erodes into the interstitium and then accumulates in subepithelial space of the renal papilla
  3. Subendothial deposits (Randall plaque) eventually erode through the papillary urothilium
  4. Stone matrix, calcium phosphate, and calcium oxalate gradually deposit on the nidus to create a urinary stone

More likely responsible for calcium oxalate stones

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4
Q

Nephrolithiasis
Etiology?
2

A
  1. Low fluid intake with low volume of urine production produces high concentrations of stone forming solutes
  2. Hypercalcuria is a common metabolic abnormality
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5
Q

Nephrolithiasis:
Hypercalcuria is a common metabolic abnormality.

How does this happen? 3

A
  1. Some cases are related to increase in intestinal absorption of calcium
  2. Some are related to excess reabsorption of calcium from bone
  3. An inability of renal tubules to properly reclaim calcium in glomerular filtrate
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6
Q

Nephrolithiasis

Types of Stones seen? 5

A
  1. Calcium
  2. Uric acid
  3. Cystine
  4. Struvite
  5. Xanthine
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7
Q

Nephrolithiasis

African Americans have ________ incident of stones than Caucasian

A

lower

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8
Q

Nephrolithiasis: Risk factors?

3

A
  1. Family history
  2. Gout
  3. Primary hyperparathyroidism
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9
Q
  1. Most stones develop in _____ years old
  2. Peak incident is at age ______
  3. Stone in children are ____?
  4. What practices can cut stone recurrence by 60%? 3

Known as the “stone clinic” effect

A
  1. 20-49
  2. 35-45
  3. rare
    • Increase fluid intake,
    • regular visits to a provider who advises increase fluids, and
    • dietary modifications
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10
Q

Nephrolithiasis: Clinical practice
1. Patients report what kind of symptoms? 3

  1. Stones where usually cause the most pain?
  2. Symptoms? 4
A
  1. Patients report
    - pain,
    - infection, or
    - hematuria
  2. Stone in the kidney usually do not cause pain, stones in the ureter usually cause pain from obstruction (hydronephrosis)
  3. Symptoms
    - Acute onset sever flank pain radiating into the groin
    - Gross/microscopic hematuria
    - Nausea/Vomiting
    - Fever/Chills (only with infection)
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11
Q

Nephrolithiasis
Work up?
7

A
  1. UA
  2. CBC
  3. CMP/BMP
  4. 24 hour urine
  5. KUB
  6. Renal US
  7. CT scan
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12
Q

Work up for Nephrolithiasis. What are we looking for in the following:

  1. UA? 3
  2. CBC? 1
  3. CMP/BMP? 3
A
  1. UA
    - Can have hematuria (gross/microscopic) No hematuria does not reduce chance of stone
    - Always look for bacteria (nitrites)
    - or leukocytes (Infection more serious)
  2. CBC
    Looking for elevated WBC
    -Usually >15,000/μL
    • Electrolytes
    • BUN/Cr levels
    • Parathyroid hormone level with ionized calcium level
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13
Q

What is happening with the following Calcium and PTH levels:

  1. Normal and Normal?
  2. Low and High?
  3. Low and Normal or Low?
  4. High and High?
  5. High and Low?
  6. Normal and High?
A

Interpretation
1. Calcium regulation system functioning OK

  1. PTH is responding correctly; may run other tests to check for other causes of hypocalcemia
  2. PTH not responding correctly; probably have hypoparathyroidism
  3. Parathyroid gland producing too much PTH; may do imaging studies to check for hyperparathyroidism
  4. PTH is responding correctly; may run other tests to check for non-parathyroid-related causes of elevated calcium
  5. Mild hyperparathyroidism
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14
Q

Nephrolithiasis

Work-Up
1. 24 hour urine is used to identify what?

  1. Most common findings? 4
A
  1. Used to identify urinary risk factors
  2. Most common findings
    - Hypercalcuria
    - Hyperoxaluria
    - Hyperuricosuria
    - hypocitraturia
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15
Q

Nephrolithiasis
24 hour urine
Evaluates for:

10

A
  1. Volume
  2. pH
  3. Calcium
  4. Sodium
  5. Phosphate
  6. Citrate
  7. Uric acid
  8. Cystine
  9. Oxalate
  10. Magnesium
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16
Q

Nephrolithiasis Imaging
1. KUB: Good for? 3

  1. Advantages? 2
A
  1. Good for:
    - Monitoring stones
    - Large stones, may miss small stones
    - Radiopaque stones
    • Less radiation
    • inexpensive
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17
Q

Nephrolithiasis

  1. Renal US good for what?
  2. Difficult to see what?
  3. Advantage?
  4. Test of choice for what?
  5. What is the Gold Standard for stones?
A
  1. Renal Ultrasound-Good for diagnosing hydronephrosis
  2. Difficult to see ureteral stones
  3. -No radiation
  4. Test of choice for pregnancy
  5. CT scan (without contrast)
    Gold standard for stones
    95-99% specificity compared to IVP
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18
Q

Treatment of Nephrolithiasis
Depends on several factors such as?
6

A
  1. Stone size
  2. Infection with obstructing stone
  3. Solitary kidney
  4. Pregnancy
  5. Patient preference
  6. Surgical
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19
Q

Nephrolithiasis: Stone size

  1. less than 4mm __% passage on own
  2. 5-7mm___%
  3. > 8mm ____%
A
  1. 80
  2. 50
  3. 0-10
20
Q

Nephrolithiasis: Infection with obstructing stone

  1. First thing to do?
  2. What do they need?
  3. Worry for what?
A
  1. Consult Urologist
  2. Needs ureteral stent placement same day
  3. Worry for sepsis
21
Q

Nephrolithiasis: Factors cont.
1. Solitary kidney management? 2

  1. Pregnancy options? 2
  2. Patient preference Try to pass on own, given that you educate on chances of passage. What are the options if they want to pass it?
    2
A
    • Consult Urologist
    • Stent placement same day or stone removal
  2. Stent placement vs. pain medication
    • Alpha-blocker (Flomax, Doxazozin)
    • NSAIDS and pain medication
22
Q

Nephrolithiasis: Treatment
Surgical Options?
5

A
  1. Stent placement vs. Percutaneous nephrostomy
  2. ESWL (Extracorporeal ShockWave Lithotripsy)
  3. Ureteroscopy
  4. Percutaneous Nephrostolithotomy (PNL)
  5. Open nephrostomy
23
Q

Nephrolithiasis: Treatment
Medicines
5

A
  1. Flomax 0.4mg one PO qday
  2. Ketorolac 30mg IM/IV single dose
  3. Hydrocodone or Oxycodone
  4. Metoclopramide 10mg IM/IV q4-6 hours prn
  5. Morphine 1-2mg IV q2-4 hours prn
24
Q

Nephrolithiasis
Treatment
Diet Considerations?
5

A
  1. Increase fluids above 2 liters in 24 hours
  2. Avoid excess salt and protein intake
  3. Moderation in foods high in oxilate
  4. Do not limit calcium d/t hyperoxaluria
  5. Restricted to 600-800 mg/d
25
Q

Nephrolithiasis
Treatment
Diet Considerations: Moderation in foods high in oxilate such as? 3

A
  1. Green leafy vegetables
  2. Chocolates
  3. Tea
26
Q

Nephrolithiasis
Types of stones
5

A
  1. Calcium oxalate
  2. Uric acid
  3. Cystine
  4. Struvite
  5. xanthine
27
Q

Nephrolithiasis
1. Whats the most common stone?

  1. What is the most common radiolucent stone?
A
  1. Calcium oxalate stones

2. Uric acid stones

28
Q

Nephrolithiasis

  1. Calcium oxalate stones: formation is caused by what?
  2. Uric acid stones: What causes the formation of this?
A
  1. Calcium oxalate stones
    - Formation is caused by high calcium and high oxalate excretion
  2. Uric acid stones
    - Low urine volume and acidic urine pH promote precipitation of uric acid
29
Q

Nephrolithiasis: Cystine stones
1. Caused by what?

  1. Describe the process?
A
  1. A genetic cause of kidney stones (1-7000 births)
  2. Patients with cystinuria have impairment of renal cystine transport with decreased proximal tubular reabsorbtion of filtered cystine resulting in increased urinary cystine excretion and stone formation
30
Q 
Nephrolithiasis
Struvite stones
1. Grow how quickly?
2. Can grow into what?
3. Caused by what?

Xanthine stones

  1. How common?
  2. Caused by what?
  3. Cannot be oxidized into what?
A

Struvite stones

  1. Can grow rapidly over weeks or months
  2. Can grow into staghorn calculus
  3. Caused by UTI
    - Urease-producing organism (Proteus & Klebsiella)

Xanthine stones

  1. Are rare
  2. Caused by inborn defect of xanthine oxidase
  3. Xanthine cannot be oxidized to uric acid
31
Q 
Nephrolithiasis:
Hypercalciuria
1. Most common cause?
2. Decrease intake of what?
3. What can lower calcium excretion by as much as 50%?

Hyperoxaluria
1. Caused by what? 2

A

Hypercalciuria

  1. Most common cause is idiopathic
  2. Decrease sodium intake
  3. Thiazide therapy

Hyperoxaluria

    • Intestinal hyperabsorption
    • Increase consumption
32
Q

Nephrolithiasis: Hyperuricosuria

  1. What is it?
  2. Low urinary ____?
  3. What is used to reduce calcium stones?
  4. Daily dose of what?
A
  1. Elevated urinary excretion of uric acid, thought to promote calcium oxalate stone formation
  2. Low urinary pH
  3. Allopurinol used to reduce calcium stones
  4. Potassium citrate 30-80 meq daily (raise pH)
33
Q

Nephrolithiasis:
1. When to refer to Urology. . .
Outpatient? 2

  1. Treatment includes? 5
A
    • Stone >5 mm
    • Failure to pass symptomatic stone after conservative management
    • Stent placement
    • Extracorporeal Shock wave lithotripsy ESWL
    • Ureteroscopic lithotripsy
    • Percutaneous nephrolithotomy
    • Laparascopic stone removal
34
Q

Nephrolithiasis:
When to refer to Urology. . .
Urgent inpatient? 5

A
  1. Urosepsis (severe infection originating in urinary tract then spreads into bloodstream)
  2. Intractable pain
  3. Bilateral obstructing stones
  4. Acute renal failure
  5. Anuria (no urinary output)
35
Q

Nephrolithiasis:

  1. What are the most common type?
  2. ___ is test of choice for diagnosis
  3. Increase ________ for acute treatment and prevention

Only limited evaluation necessary after the first episode

A
  1. Calcium oxalate stones
  2. CT
  3. fluid intake
36
Q
  1. Kidney stones are classified on their what?
  2. The majority are_______ containing
  3. What is the most important inhibitor of stone formation?
  4. What factors can be predisposing? 4
A
  1. composition
  2. calcium
  3. Urine volume
    • Environment,
    • lifestyle,
    • dietary and
    • anatomical
37
Q
  1. Two most common presentations are what?
  2. Basic workup:
    7
A
  1. pain and hematuria
    • UA,
    • lytes,
    • bun, serum creatinine
    • PTH if serum calcium is elevated
    • Stone analysis if possible
    • KUB
    • Helical/spiral CT
38
Q

Medical management for kidney stones ?

4

A
  1. Alpha 1 Blocker
  2. NSAIDs
  3. Antibiotics if concurrent infection
  4. Anti-emetics
39
Q

Kidney stones: General Measures? 5

A

1 Increase fluid intake

  1. Decrease intake of animal protein
  2. Restrict salt intake
  3. Normal calcium intake
  4. Decrease dietary oxalate
40
Q

Bladder Stones

  1. What are they?
  2. Almost all occur in who?
  3. Less common that what?
  4. Stones occur here how?
  5. Most common type?
A
  1. Hard buildups of minerals that form in the urinary bladder
  2. Almost all occur in men
  3. Less common than kidney stone
  4. Stones may occur when the urine is concentrated and materials crystalize
  5. Most common stone is uric acid stone
41
Q

Bladder Stones

Risk factors? 5

A
  1. Bladder diverticulum
  2. Bladder outlet obstruction (most common)
  3. Neurogenic bladder
  4. UTIs
  5. Catheters
42
Q

Bladder Stones

Presentation? 7

A
  1. Abdominal pain/pressure
  2. Hematuria or dark colored urine
  3. Difficulty urinating
  4. Urgency/frequency
  5. Interruption of stream
  6. Penile discomfort
  7. UTI
43
Q

Bladder Stones
DX?
4

A
  1. Rectal exam
    - Reveals an enlarged prostate usually
  2. Bladder or Pelvic x-ray
  3. Cystoscopy
  4. Labs -UA with Culture
44
Q

Bladder Stones

Treatment?

A
  1. Cystoscopy in office for small stones
  2. Surgery
  3. Medical
45
Q

Bladder Stones
Treatment:
1. What surgeries are options? 4

  1. What medication?
A
  1. Surgery
    - Cystolithalopaxy
    - Cystolithotomy
    - TURP
    - Simple Prostatectomy
  2. Medical
    - Potassium citrate (Urocit K) 60 mEq/day

Urology (12 decks)

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