Urolithiasis, or the formation of urinary stones, is a common condition impacting millions and costing the U.S. healthcare system over $2 billion annually. Factors influencing stone formation include age, sex, diet, and familial history, with symptoms varying from severe pain to asymptomatic presentations. Diagnosis involves physical examination, imaging, and laboratory tests, followed by management strategies that include pain relief, medical expulsive therapy, and surgical options when necessary.

1. Urolithiasis
Prepared by
1.Yter chamrane
2.Teang chaanmakara
3.Korng pharat
4.Tea titiya
Lectured by Yok
Ratana MD

2. contents
• Urolithiasis
• Background
• Epidemiology
• Chemical type of stone
• Pathophysiology of stone formation
• Risk factors
• Clinical feature
• Location and characteristic of pain
• Phase of an attack
• Physical examination
• Diagnosis
• Emergency
• Management

3. Urolithiasis
• Urolithiasis (from Greek oûron-urine and lithos-stone) is
the condition where urinary stones are formed or located
anywhere in the urinary system.

4. Background
 Urolithiasis is a common disease that is estimated to
produce medical costs of $2.1 billion per year in the United
States alone.

5. Background
 Renal colic affects approximately 1.2 million people
each year in USA and accounts for approximately 1% of
all hospital admissions.
 Most active emergency departments (EDs) manage
patients with acute renal colic every day.

6. Epidemiology
• The lower the economic status, the lower the likelihood
of renal stones
• Most at 20-49 years
• Peak incidence at 35-45 years
• Male-to-female ratio of 3:1

7. Urolithiasis
Kidney
Stone
Bladder
Stone
Ureteral
Stone
Uretheral
stone

8. Chemical types of stone
Four main chemical types :
1st Calcium stone
2nd Struvite stone
3rd Uric Acid stone
4th Cystine stone

9. Chemical types of stone
Kidney stone
type
Occurrence in
population
when do they
form
Calcium( oxalate,
phosphate)
75-80% when urine is acidic or
alkaline
Uric acid 5-10% When urine is
persistently acidic
Struvite 10-15% Infections in the kidney
Cystine 1-2% Rare genetic disoder

10. Chemical types of stone
• (Use this space to discuss procedures to follow in the
event of a lab accident.)

11. Pathophysiology
The formation of renal calculi is a complex
process and depends on the interaction of
several factors, including:
 Urinary concentration of stone forming
ions
 Urinary pH
 Urinary flow rate
 The balance between promoter and
inhibitory factors of crystallisation,
 Anatomic factors that encourage urinary
stasis,

12. Remember…

13. Pathophysiology

14. Risk factors for stone Disease
• Age (younger age group, peak at 40)
• Sex (male)
• Strong family history of stone formation
• Race (Caucasian > black > Asian)
• Positive family history
• Diet: obesity
– High animal protein (high ca, uric & oxalate, low
pH, low citrate)
– High salt (hypercalciuria)
– High Calcium intake is protective
– Vit D (increase instestinal Ca absorption)
– Vit C (cause hyperoxaluria)
• Occupation: sedentary lifestyle
• Gout
• Low fluid intake (urine output <1L)

15. Risk factors for stone Disease

16. Urinary risk factor stone formation

17. Clinical manifestation
The presentation is variable.
Patients with urinary calculi may report:
 Pain
infection
Hematuria
Asymptomatic

18. Clinical manifestation
Classic Renal Colic
• Acute onset of severe flank
pain radiating to the groin,
scrotal, or labia areas
• Gross or microscopic
hematuria
• Nausea, and vomiting not
associated with an acute
abdomen in 50%
 Acute renal colic is probably the most excruciatingly painful event a
person can endure

19. Clinical manifestation
• Staghorn calculi are often
relatively asymptomatic.
• Branched kidney stone
occupying the renal pelvis
and at least one calyceal
system.
• Manifest as infection and
hematuria.

20. Clinical manifestation
• Acute obstruction of ureter-
• severe colic
• Flank pain referred to
genitalia
• Nausea, vomiting
• Microhematuria
• can be little or no pain
• Chronic stone distends to
be associated with large or
multiple stones
• may have impaired renal
function,anemia, weight
loss etc.
• concomitant infection more
likely

21. Location and Characteristics
of pain
Depends on the level of
obstruction and its degree:
• ureteropelvic junction
• pelvic brim
• ureterovesical junction

22. Location and Characteristics
of pain
UPJ stone
• Stones obstructing the
ureteropelvic junction may
present with mild-to-severe
deep flank pain without
radiation to the groin

23. Location and Characteristics
of pain
Ureteral stone
Cause abrupt, severe, colicky pain in the flank and ipsilateral
lower abdomen(lower abdomen)
 with radiation to the testicles or the vulvar area.
 Intense nausea, with or without vomiting, usually is
present.

24. Location and Characteristics
of pain
Upper ureter
Tends to radiate to the
flank and lumbar areas
Mid Ureter
• Cause pain that radiates
anteriorly and caudally.
• Can easily mimic appendicitis
on the right or acute
• diverticulitis on the left

25. Location and Characteristics
of pain
• Distal Ureter and UVJ
stones
• Cause pain that tends to radiate
into the groin or testicle in the
male or labia majora in the female
• At the ureterovesical junction also
may cause irritative
voiding symptoms mimicking
cystitis, such as:
urinary frequency
dysuria

26. Pain distribution

27. Location and Characteristics
of pain
Bladder stone
Usually asymptomatic and are passed relatively easily during
urination.
• Rarely, a patient reports positional urinary retention
(obstruction precipitated by standing, relieved by
recumbency).

28. Phases of an attack
• The entire process typical lasts 3-18 hours
• Acute phase: peak in most patients within 2 hours
of onset (30 min to 6
• hours)
• Constant Phase 1- 4 hours maximum 12 hours
• Relief phase 1.5-3 hours

29. Physical examination
Dramatic costovertebral angle
tenderness
unremarkable abdominal evaluation
painful testicles but normal-appearing
constant body positional movements
(eg, writhing, pacing)
Tachycardia
Hypertension
Microscopic hematuria

30. Diagnosis
Hx, PE, Clinic
Imaging
Lab Test

31. Diagnosis
Diagnosis Clinic:
• symptoms or incidentally
Presenting symptoms include pain or
haematuria (microscopic or occasionally macroscopic).
*Struvite staghorn calculi classically present
with recurrent UTIs. Malaise, weakness, and
loss of appetite can also occur.

32. Diagnosis
Diagnosis Imagining:
 Ultrasound (US) :its sensitivity about 95%,
can identify stones located in the calices, pelvis, and
pyeloureteric and vesico-ureteric junctions, upper
urinary tract dilatation.
 KUB radiography
 Intravenous radiography
 Intravenous pyelogram(IVP)
 CT scan

33. Diagnosis

34. Laboratory test
The recommended based on EUA recommendations:
 Urinary sediment/dipstick test: To demonstrate blood cells
 Serum creatinine level: To measure renal function
Additional lab test
May be helpful:
 CBC in febrile patients
 Serum electrolyte assessment in vomiting patients
 24-Hour urine profile on outpatient basis

35. Emergency renal colic
IV access to allow :
 Fluid
 Analgesics:
Paracetamol
NSAID
Opiod
 Antiemetic
 In case of infection:
 Urine culture
 Blood culture accordingly e.g. febrile
 Antibiotics

36. Medical option
Renal colic:
Pain relief should be initiated immediately.
• NSAIDs are effective in patients with acute stone colic
• Opioids, particularly pethidine, are associated with a high
rate of vomiting compared to NSAIDs
Prevention of recurrent renal colic
• First choice: NSAIDs. (diclofenac*, indomethacin or
ibuprofen**).
• Second choice: hydromorphine, pentazocine or tramadol.
• Alpha-blockers as medical expulsive therapy for ureteral
stone.

37. Surgical option
Obstruction relief:
 Ureteral stent insertion
 Percutaneous nephrostomy
Definitive surgical treatment:
 ESWL
 Ureteroscopy
 PCNL
 Open, laparoscopic and robotic
pyelo-lithotomy, ureterolithotomy,
cystolithotomy

38. References
• Medscape article nephrolithiasis by J Stuart
Wolf Jr, MD, FACS updated
feb 11, 2013
• Campbell-Walsh Urology 10th edition
• Smith and Tanagho's General Urology,
Eighteenth Edition

39. Thank you for
your attention