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Urologic Stone Disease

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Urologic Stone Disease

  1. 1. Urologic Stone Disease Tintinalli Chapters 96-97 Randall Adolph
  2. 2. Epidemiology <ul><li>3:1 M:F (~7% men/ 3% women) </li></ul><ul><li>3 rd -5 th decade most common (70%) </li></ul><ul><li>Hereditary predisposition (RTA type 1, Hyper-parathyroidism, cysteinuria, milk-alkali syndrome, sarcoidosis, Crohn's disease) </li></ul><ul><li>Climate (mountainous, desert, or tropical) </li></ul><ul><li>Time of year (warmest three months) </li></ul><ul><li>Lifestyle (sedentary) </li></ul><ul><li>Medications: protease inhibitors, carbonic anhydrase inhibitors, laxatives, triamterene </li></ul>
  3. 3. Patient Characteristics <ul><li><16 year old comprise 7% of cases </li></ul><ul><li>1:1 M:F </li></ul><ul><li>Causes: metabolic abnormalities 50%, urological abnormalities 20%, infection 15%, immobilization 5% </li></ul><ul><li>1/3 have recurrence within 1 year </li></ul><ul><li>50% within 5 years </li></ul>
  4. 4. Pathophysiology <ul><li>Formation requires three key elements </li></ul><ul><ul><ul><li>Supersaturation of urine with solutes </li></ul></ul></ul><ul><ul><ul><li>Relative lack of the inhibitors citrate & pyrophosphate </li></ul></ul></ul><ul><ul><ul><li>Stasis or lack of urine flow </li></ul></ul></ul><ul><li>Composition : </li></ul><ul><ul><ul><li>75% calcium oxalate </li></ul></ul></ul><ul><ul><ul><li>10% staghorn calculi (struvite): associated with urease-splitting bacteria, poor Ab. penetration and usually require surgery </li></ul></ul></ul><ul><ul><ul><li>Uric acid stones 10% </li></ul></ul></ul>
  5. 5. Composition Continued <ul><li>Calcium oxolate  Hyperoxaluria occurs in the presence of small bowel disease--Crohn's disease, ulcerative colitis, and radiation enteritis. </li></ul><ul><li>Uric Acid  10% of all stones </li></ul><ul><ul><li>excessive excretion of uric acid in the urine </li></ul></ul><ul><ul><li>increases with uricosuric agents </li></ul></ul><ul><ul><li>Radiolucent!!! </li></ul></ul>
  6. 6. Obstruction leads to: <ul><li>Rapid redistribution of renal blood flow  , ↓ glomerular filtration rate  renal excretion shifts to unaffected kidney </li></ul><ul><li>Causes rapid decrease in ureteral peristaltic activity </li></ul><ul><li>Complete obstruction may lead to loss of renal function </li></ul><ul><li>Increased occurrence of irreversible damage after 1 to 2 weeks of obstruction </li></ul><ul><li>Partial obstruction lower likelihood of renal injury, may still result in irreversible damage. </li></ul>
  7. 7. Critical size <ul><li>5 mm~ 90% < 5 mm and located in the lower ureter pass spontaneously </li></ul><ul><li>15% pass if between 5 and 8 mm </li></ul><ul><li>95% >8 mm become impacted generally requiring lithotripsy or surgical removal </li></ul><ul><li>75% of stones are located in the distal third of the ureter </li></ul>
  8. 8. Area of impaction <ul><li>Renal calyx </li></ul><ul><li>UPJ, where ureter passes over pelvic brim and iliac vessels </li></ul><ul><li>UVJ: smallest diameter of the urinary tract </li></ul><ul><li>In FM the posterior pelvis: ureter is crossed anteriorly by the pelvic blood vessels and broad ligament </li></ul>
  9. 9. Places for obstruction
  10. 10. Causes of pain <ul><li>Colicky, severe flank pain: hyperperistalsis of smooth muscle of the calyces, pelvis, and ureter </li></ul><ul><li>Dull ache: attributed to acute obstruction and renal capsular tension </li></ul>
  11. 11. Clinically <ul><li>Usually asymptomatic until obstructs </li></ul><ul><li>acute onset severe pain, typically at rest </li></ul><ul><li>little if any POP </li></ul><ul><li>Typically flank, abdomen with referral to ipsilateral labia or testicle </li></ul><ul><li>May be writhing in pain, reluctant to lie still </li></ul><ul><li>Episodic as passes, pain free until obstructs more distally </li></ul>
  12. 12. Urinary pH  <ul><li>pH> 7.6 suspicious for urea-splitting organisms because the kidney will not, under normal conditions, produce urine in this alkaline range. </li></ul><ul><li>pH < 5 often associated with the formation of uric acid calculi. </li></ul>
  13. 13. LABORATORY <ul><li>UA  hematuria supports diagnosis, absent in 15% ;crystals seen w/wo stones </li></ul><ul><li>Dipstick detects heme, myoglobin and porphyrins, need micro (see RBCs) </li></ul><ul><li>Urine C&S, </li></ul><ul><li>BUN & Creatinine especially if imaging with RCM, higher rates of complications in DM >1.5, CRF >2.5 </li></ul>
  14. 14. Imaging <ul><li>performed with a first episode of renal colic. </li></ul><ul><li>Other indications: </li></ul><ul><ul><li>Diagnosis is unclear </li></ul></ul><ul><ul><li>Those in whom a proximal UTI, in addition to a calculus, is suspected. </li></ul></ul><ul><li>A KUB is the standard, initial radiograph done before injecting contrast media during IVP. </li></ul>
  15. 15. Imaging <ul><li>Helical CT preferred modality </li></ul><ul><li>US if pregnant </li></ul><ul><li>Others IV urography, Radionuclide renal scan, plain abd. Film </li></ul><ul><li>Shows stone, location, IDs complications </li></ul><ul><li>Unilateral ureteral dilatation and perinephritic stranding together: PPV 96% </li></ul><ul><li>Both absent NPV 93-97% </li></ul>
  16. 16. Noncontrast CT <ul><li>Advantages: fast, avoids RCM, </li></ul><ul><li>Disadvantages: specificity/sensitivity low for other pathologies (AAA, appendicitis) </li></ul><ul><li>Does not evaluate renal function or degree of obstruction </li></ul><ul><li>If negative may need RCM to look for other cause of pain </li></ul>
  17. 17. IV Urography <ul><li>Indicators of obstructing stone: </li></ul><ul><ul><li>1 st and most reliable indicator of obstruction is a delayed nephrogram in the 5-minute film </li></ul></ul><ul><ul><li>Visualization of the entire ureter is suggestive of obstruction </li></ul></ul><ul><ul><li>Ureteral contrast column cutoff, prolonged nephrogram, renal enlargement, dilatation of the collecting system, contrast extravastation </li></ul></ul>
  18. 18. Helical CT <ul><li>Advantages: provides info on function </li></ul><ul><li>Disadvantages: uses RCM (allergy,nephrotoxic) </li></ul><ul><li>Nephrotoxicity: 9% in pts. with RI or DM </li></ul><ul><li>BUN, Creatinine before RCM </li></ul><ul><li>Metformin & RCM  severe Lactic acidosis, nephrotoxicity </li></ul><ul><li>False negative if stone small, radiolucent, partially obstructing, or passes into bladder before contrast passed by kidneys </li></ul>
  19. 19. US <ul><li>During pregnancy, children </li></ul><ul><li>May misses stones < 5mm </li></ul><ul><li>Less sensitive in middle ureter </li></ul><ul><li>Overall low sensitivity/specificity for stones </li></ul><ul><li>98% sensitive for hydronephrosis, however 22% of cases not associated with obstruction </li></ul>
  20. 20. US <ul><li>Advantages: </li></ul><ul><ul><li>noninvasive, no dyes or radiation, no known side effects </li></ul></ul><ul><ul><li>Superior to IVU for UVJ stones </li></ul></ul><ul><li>Disadvantages: </li></ul><ul><ul><li>excretion function not evaluated operator and equipment dependant </li></ul></ul><ul><ul><li>obesity may hinder ability to perform </li></ul></ul>
  21. 21. Plain Films <ul><li>90% stones radiopaque (Ca > Struvite > Cystine) </li></ul><ul><li>Uric acid and stones associated with medications radiolucent </li></ul><ul><li>Overall poor Sensitivity & Specificity </li></ul><ul><li>Greatest utility is excluding other pathologies </li></ul>
  22. 22. Stone gone wild <ul><li>infection occasionally occurs in the presence of an obstructive stone. </li></ul><ul><li>A history of fever and chills strongly suggests superimposed infection and is a urologic emergency. It is imperative to do an IVP or an ultrasound study in these cases </li></ul><ul><li>Sterile pyuria strongly suggests renal tuberculosis; confirmation acid-fast bacilli </li></ul>
  23. 23. Differential Diagnosis <ul><li>Aortic dissection , AAA </li></ul><ul><li>Appendicitis: usually don’t see rebound, guarding, distention with stone </li></ul><ul><li>Infectious: fever with CVA, consider pyelonephritis </li></ul><ul><li>Papillary necrosis: DM, SCD, NSAID abuse; see Hematuria and pyuria </li></ul><ul><li>Vascular:Renal vein thrombosis, Mesenteric ischemia </li></ul><ul><li>Gynecological </li></ul>
  24. 24. vascular etiology <ul><li>If suspected, a contrast CT or angiogram done. </li></ul><ul><li>Relatively rare: m/c renal artery embolism, most often of cardiac origin (atrial fibrillation, subacute bacterial endocarditis, mural thrombus) </li></ul><ul><li>IVP should demonstrate decreased or absent excretion of contrast material. Immediate angiogram indicated  early diagnosis allows possible salvage of the ischemic kidney Predisposing factors for renal vein thrombosis include the nephrotic syndrome, malignancies, and pregnancy </li></ul>
  25. 25. TREATMENT <ul><li>Pain control: Opiods and nsaids </li></ul><ul><li>NSAIDs: analgesic, decrease ureterospasm and renal capsular pressure by diminishing GFR in the obstructed kidney. </li></ul><ul><li>Obstruction with Infection: Urology emergency </li></ul><ul><li>Consult if: RI, Severe underlying disease, extravasation or complete obstruction, Multiple ED visits, large stone, sloughed renal papillae </li></ul>
  26. 26. Management <ul><li>Average time to pass stone varies (7-20 days) </li></ul><ul><li>Long acting CCB (Nifedipine) and steroids may enhance passage </li></ul><ul><li>F/U Urology in 7 days </li></ul><ul><li>Stone saved/submitted to urologist for analysis. </li></ul><ul><li>Dispo: return immediately if intractable, severe pain, persistent nausea and vomiting, fever and chills </li></ul>
  27. 27. Indications for Admission <ul><li>Obstruction with infection </li></ul><ul><li>Persistent pain </li></ul><ul><li>Persistent nausea and vomiting </li></ul><ul><li>Urinary extravasation </li></ul><ul><li>Hypercalcemic crisis </li></ul><ul><li>Relative Indications for Admission </li></ul><ul><li>High-grade obstruction </li></ul><ul><li>Solitary kidney </li></ul><ul><li>Intrinsic renal disease </li></ul><ul><li>Size of obstructing stone </li></ul><ul><li>Duration of symptoms </li></ul><ul><li>Social situation </li></ul>
  28. 28. Admit <ul><li>severely dehydrated </li></ul><ul><li>unrelenting pain or vomiting </li></ul><ul><li>underlying infection with hydronephrosis </li></ul>
  29. 29. Bladder stones <ul><li>different from renal stones </li></ul><ul><li>almost exclusively elderly men </li></ul><ul><li>most often complication of other urologic disease (Proteus). </li></ul><ul><li>The other common indwelling catheter </li></ul><ul><li>May complain of sudden interruption of the urinary stream. This strongly suggests a vesical stone that intermittently obstructs the bladder outlet </li></ul>
  30. 30. Hematuria and Hematospermia <ul><li>Tintinalli Chapter 97 </li></ul>
  31. 31. Hematuria <ul><li>Definition: </li></ul><ul><ul><li>>5 RBCs/hpf warrants an attempt at definitive diagnosis </li></ul></ul><ul><li>Timing: </li></ul><ul><ul><li>Initial suggests urethral disease </li></ul></ul><ul><ul><li>B/n voiding and only staining undergarments, with clear urine  distal urethral or meatus </li></ul></ul><ul><ul><li>Total  disease of kidneys, ureters, or bladder </li></ul></ul><ul><ul><li>Terminal  bladder neck or prostatic urethra </li></ul></ul><ul><li>Amount </li></ul><ul><ul><li>Gross hematuria  lower tract cause while microscopic tends to be kidney disease </li></ul></ul><ul><li>Color: </li></ul><ul><ul><li>Brown/Smokey colored with casts and proteinuria suggests glomerular </li></ul></ul><ul><ul><li>Red clotted blood indicates source below kidney </li></ul></ul>
  32. 32. HEMATURIA <ul><li>a harbinger of serious urologic disease </li></ul><ul><li>Gross hematuria  5X more likely to have life-threatening conditions when compared to those with microhematuria . </li></ul><ul><li>Lower and middle urinary tract ~60% </li></ul><ul><li>Urologic malignancies 2.2% to 12.5% with microscopic hematuria, up to 20% if > 50 years with gross hematuria. </li></ul><ul><li>Gross hematuria (>3 red blood cells/hpf on two of three urinalyses found a potentially life-threatening lesion in 9.1% of these patients. </li></ul>
  33. 33. Hematuria <ul><li>Young Pts. most often urolithiasis or UTI </li></ul><ul><li>Consider glomerulonephritis, goodpasture, HSP, Wilms Tumor, SCD/trait </li></ul><ul><li>PSGN  7-14 days following pharyngitis, Abs do not prevent this </li></ul><ul><li>IgA nephropathy following viral URI </li></ul><ul><li>Elderly: infection, Nephroolithiasis, bladder, prostate, renal CA </li></ul>
  34. 34. Other sources of bleeding <ul><li>infection of the bladder (hemorrhagic cystitis) </li></ul><ul><li>varices of the bladder </li></ul><ul><li>Diverticula </li></ul><ul><li>bladder stones </li></ul><ul><li>postradiation changes </li></ul><ul><li>Anticoagulation at currently recommended levels does not predispose patients to hematuria </li></ul>
  35. 35. Risk factors for Uroepithelial CA <ul><li>Age >40 </li></ul><ul><li>Excessive analgesic use </li></ul><ul><li>Smoking </li></ul><ul><li>Exposure to dyes, benzenes, aromatic amines </li></ul><ul><li>Pelvic irradiation </li></ul><ul><li>Cyclophosphamide </li></ul><ul><li>Hematuria in patients on blood thinners, have underlying disease 80% of the time </li></ul>
  36. 36. glomerular and nonglomerular <ul><li>glomerular origin : frequently associated with dysmorphic erythrocytes, RBC casts, and significant proteinuria (2+ to 3+) </li></ul><ul><li>IgA nephropathy (Berger's disease) m/c, cause </li></ul><ul><li>nonglomerular hematuria : uniformly round erythrocytes and absence of erythrocyte casts and proteinuria. </li></ul>
  37. 37. glomerular disease <ul><li>Typically young males  have hematuria, erythematous skin rash, and fevers suggesting immunoglobulin nephropathy, or Berger's disease </li></ul><ul><li>Family history of deafness, renal disease, and hematuria is linked to Alport nephritis . </li></ul><ul><li>A rash, arthritis, and hematuria are seen with systemic lupus erythematosus. </li></ul><ul><li>Hematuria, hemoptysis, and microscopic anemia are common presentations of Goodpasture's syndrome . </li></ul><ul><li>A preceding upper respiratory infection, pharyngitis, skin infection, or rash with associated hematuria suggests poststreptococcal glomerulonephritis. </li></ul>
  38. 38. nonglomerular disease <ul><li>A family history of bleeding disorders or renal cystic disease suggest hemophilia and polycystic kidney disease, respectively. </li></ul><ul><li>Suspect papillary necrosis in diabetics, sickle cell patients, and analgesic abusers (Classic urolithiasis, sudden flank pain and hematuria) </li></ul>
  39. 39. Diagnosing <ul><li>Clarify symptoms and source: </li></ul><ul><li>traumatic/atraumatic </li></ul><ul><li>Gross/micro </li></ul><ul><li>Initial/total/terminal </li></ul><ul><li>Associated symptoms: flank pain, menstruation, dysuria, etc. </li></ul><ul><li>Travel (schistosomiasis) </li></ul><ul><li>Abnormal RBC morphology, casts, protein suggest glomerular source </li></ul><ul><li>Strenuous exercise frequently cause, but deserves investigation even if spontaneously resolves </li></ul>
  40. 40. Exercise-Induced <ul><li>Exercise-induced hematuria that does not resolve after 48 hours commonly results from punctate hemorrhagic lesions suggesting bladder cancer </li></ul><ul><li>Diagnosed by cystoscopy </li></ul>
  41. 41. dipstick <ul><li>positive only if there has been lysis of RBCs or with myoglobinuria. </li></ul><ul><li>[Hemoglobin] greater than 0.003 mg/L (10,000 red blood cells/mm3 or 1 to 2 RBCs/hpf) </li></ul><ul><li>Current recommendations: urinalysis and cytology for 3 consecutive years if resolution of hematuria or persistent asymptomatic microhematuria </li></ul><ul><li>ross hematuria should be reevaluated in all instances </li></ul>
  42. 42. Renal Imaging <ul><li>IVP  clearly delineates most renal tumors, obstruction, or stones and their precise location </li></ul><ul><ul><li>Disadvantage: RCM, does not assess aorta, retroperitenium and pelvis </li></ul></ul><ul><li>Helical CT  fast highly sensitive and specific for stone, RCM used for other pathologies </li></ul><ul><li>Renal US to screen for AAA, Hydro, obstruction. Study of choice in Pregnant and children </li></ul><ul><ul><li>Disadvantages: rarely identifies small stones, no idea of functioning, </li></ul></ul>
  43. 43. Treatment <ul><li>Abs. for infection </li></ul><ul><li>Pain meds. & hydration for nephrolithiasis </li></ul><ul><li>D/C only if asymptomatic, tolerating PO, Abs. & analgesics & no sig. comorbidities </li></ul><ul><li><40 to PCP for repeat UA 1-2 weeks, if persists or >40 and risk for CA, Urology for cystoscope </li></ul><ul><li>Asymptomatic microscopic hematuria associated with a 2 fold increase of future RF </li></ul><ul><li>Proteinuria: a sign of prognostically significant glomerular disease & needs further workup </li></ul>
  44. 44. Complications <ul><li>Gross hematuria may lead to intravesical clot and subsequent outflow obstruction </li></ul><ul><li>New glomerulonephritis: at risk for Pulmonary edema, volume overload, azotemia or HTN emergency  need admission </li></ul><ul><li>Pregnant: May be preeclampsia, pyelonephritis, obstructing stone  call OB and possibly admit </li></ul>
  45. 45. Hematospermia <ul><li>Trauma, injury (tumor with erosion), inflammation, infection of ejaculatory system </li></ul><ul><li>M/C iatrogenic from instrumentation, radiation. </li></ul><ul><li>>40 prostate CA, BPH considerations </li></ul><ul><li><40 prostatitis, seminal vesiculitis, urethritis, STD, epididymo-orchitis, calculi, TB </li></ul><ul><li>UA warranted </li></ul><ul><li>Usually benign, but urology referral indicated </li></ul>
  46. 46. Questions?
  47. 47. Question 1 <ul><li>What season is associated with an increased incidence of stones? </li></ul><ul><ul><li>Winter </li></ul></ul><ul><ul><li>Spring </li></ul></ul><ul><ul><li>Summer </li></ul></ul><ul><ul><li>Fall </li></ul></ul><ul><ul><li>Answer C </li></ul></ul>
  48. 48. Question 2 <ul><li>True or false: Hematuria seen in a patient on therapeutic levels of blood thinners is usually microscopic and benign? </li></ul><ul><li>False: underlying pathology 80% of time </li></ul>
  49. 49. Question 3 <ul><li>In the ED what is a value fror defining hematuria? </li></ul><ul><ul><ul><li>Any RBCs/hpf </li></ul></ul></ul><ul><ul><ul><li>2 RBCs/hpf </li></ul></ul></ul><ul><ul><ul><li>4 RBCs/hpf </li></ul></ul></ul><ul><ul><ul><li>5 RBCs/hpf </li></ul></ul></ul><ul><li>Answer: D </li></ul>
  50. 50. Question 4 <ul><li>The most common cause of stone formation is? </li></ul><ul><ul><ul><li>metabolic abnormalities </li></ul></ul></ul><ul><ul><ul><li>urological abnormalities </li></ul></ul></ul><ul><ul><ul><li>infection </li></ul></ul></ul><ul><ul><ul><li>Immobilization </li></ul></ul></ul><ul><li>Answer: A 50% </li></ul>
  51. 51. Question 5 <ul><li>What is the most common composition of renal stones? </li></ul><ul><ul><ul><li>Uric acid stones </li></ul></ul></ul><ul><ul><ul><li>struvite </li></ul></ul></ul><ul><ul><ul><li>calcium oxalate </li></ul></ul></ul><ul><ul><ul><li>Magnesium </li></ul></ul></ul><ul><ul><ul><li>Answer: C </li></ul></ul></ul>

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