Urology - Urolithiasis: Ix And Mx

Question 1

Ix: Urine and blood

Answer 1

• Urine: dip for haematuria and MC+S, may need a 24h collection to try and assess how to avoid recurrence
• Blood: FBC, U+E, Ca, PO4, urate

Question 2

Ix: imaging (not including IVU)

Answer 2

• KUB XR: 90% of stones are radio opaque (urate radiolucent and cysteine faint)
• USS: look for hydronephrosis
• Spiral non contract CT KUB: gold standard, 99% of stones visible

Question 3

Ix: imaging - IVU (and contra indications)

Answer 3

• Intravenous urogram: IV contrast injected and immediate serial films taken until contrast reaches level of obstruction (much more radiation than KUB XR)
• CIs: contrast allergy, renal failure, severe asthma, metforming, pregnancy

Question 4

Urolithiasis: initial Rx

Answer 4

• Analgesia (NSAIDs allowed): diclofenac or opioids (pethidine)
• Fluids: IV if unable to tolerate PO
• ABX if infection: contact micro/local trust policy

Question 5

Urolithiasis: Rx - conservative (<5mm in lower 1/3 of ureter)

Answer 5

• 90-95% pass spontaneously
• can discharge pt with analgesia
• sieve urine to collect stone for OPD analysis

Question 6

Urolithiasis: Rx - Medical expulsion therapy (MET)

Answer 6

• Indications: stone 5-10mm and expected to pass

- Drugs: Nifedipine or tamsulosin +/- prednisolone

Question 7

Rx: active stone removal - indications

Answer 7

• Low likelihood of spontaneous passage (>10mm)
• Persistent obstruction
• Renal insufficiency
• infection

Question 8

Rx: active stone removal - Extracorporeal shockwave lithotripsy (SWL)

Answer 8

• Stones <20mm in kidney or proximal ureter
• SE: may cause renal injury and raise BP
• CI: pregnancy, AAA, bleeding diathermy

Question 9

Rx: active stone removal - other options

Answer 9

• Ureterorenoscopy
• Percutaenous nephrolithotomy (PNL)
• lap or open surgery: rare

Question 10

Rx: active stone removal - surgical emergency

Answer 10

• When pt is febrile with renal obstruction
• needs percutaneous nephrostomy or stent
• IV ABX

Question 11

Rx: active stone removal - summary

Answer 11

• Conservative if stone <5mm in distal ureter
• MET if stone 5-10mm and expected to pass
• Active if stones >10mm, persistent pain and renal insufficiency