Urolithiasis

Question 1

Risk factors

Answer 1

Question 2

Points of constriction of the ureter

Answer 2

▪ Pelvic-ureteric junction (PUJ)
▪ Pelvic brim (near bifurcation of the common iliac arteries)
▪ Veisco-ureteric junction (VUJ) – entry to the bladder

Question 3

Types of calculi: X-Ray appearance, acidic/alkaline urine, clinical features

Answer 3

Question 4

Pathogenesis

Answer 4

1) Supersaturation wrt stone forming salts
2) Infection
3) Drugs

Question 5

Clinical Presentation

Answer 5

1. Pain
2. Obstruction
3. Ulceration leading to hematuria
4. Chronic infection –> pyelonephritis, pyonephrosis, urosepsis, kidney failure

Question 6

Differences in clinical presentation in location of stone?

Answer 6

1. Renal Stones - asymptomatic often unless lodged in PUJ causing hydronephrosis and pyonephrosis
2. Ureteric stones - ureteric groin pain (loin to groin), hematuria, cause Upper UTI, stone at VUJ can cause frequency, urgencym dysuria
3. Bladder stones asymptomatic, frequency, urgency , hematuria, infection

Question 7

History

Answer 7

1. Chronology of stone events
   - age of 1st presenration
   - number/size
   - spontaneous passage vs need for intervention
   - symptoms during past episodes
2. Systemic Disease Hx
   - Crohns
   - Gout
   - RTA
   - HyperPT
   - HyperT
3. Stone Formation
   - FMH
   - Meds (antacids, salicyclic acid, anti viral
   - Occupational Hx
   - Diet

Question 8

PE

Answer 8

Renal punch

Question 9

Ix

Answer 9

Question 10

Management

Answer 10

1. Pain control
2. Abx for UTI
3. 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
4. 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

Question 11

Complications

Answer 11

• Hematoma / Significant Bleeding
• Urinary tract infection
• Ureteric Injury – perforation / ureteric avulsion
• Failure of procedure –i.e. unable to assess stone with URS