Clinical Presentation Of Urolithiasis

1. Urolithiasis
Dr Massam

2. Learning objectives
By the end of this session, students are expected to be able to:
• Define urolithiasis
• Describe type of stone and their chemical content.
• List risk factors for urolithiasis
• Describe the clinical features of urolithiasis
• Describe the management and complication of urolithiasis

3. Definition
• Urolithiasis is a condition where urinary stones are formed or
located anywhere in the urinary system.
• Urinary tract stones are a common cause of visits to the
emergency department.
• Most stones are formed by minerals or stone-forming salts
and begin to crystallize when their concentration becomes
supersaturated in the urine

4. Epidemiology
• The lower the economic status, the lower the likelihood of
renal stones.
• Most at 30 – 49 years
• Peak incidence at 4th to 6th decades
• Male to female ratio 3:1

5. Urolithiasis

6. Type of stone
There four main type of stone.
• Calcium stone formed when urine is acidic or alkaline
o75-80% occurrence in population
• Struvite stone formed when there infection in the kidney
o10-15% occurrence in population
• Uric Acid stone formed when urine is persistently acidic
o5-10% occurrence in population
• Cystine stone;- Rare genetic disorder
o1-2% occurrence in population

7. Chemical content cont…
• Calcium stones are composed of calcium compounds mostly
calcium oxalate, sometimes calcium phosphate.
oThe may be caused by high calcium level such as in;
Hyperparathyroidism.
oHigh oxalate levels can also increase the risk for calcium
stone
• Uric Acid Stone are formed due to low urine output, excessive
intake of proteins especially meat, alcohol intake, inflammatory
bowel disease and gout. Not visible in plain x-ray.

8. Chemical content cont…
• Struvite are usually associated with urinary infection.
oThey can grow very rapidly forming cast in the urinary
tract (staghorn calculus) if left untreated they may cause
chronic infection and permanent kidney damage.
• Crystine stone, occur due to an inherited defect in amino acid
transport, manifests as recurrent stones in young patient.

9. Risk factors for stone disease
• Age (younger age group, peak at 40 years)
• Sex (Male)
• Strong family history of stone formation/positive family
history
• Race (Caucasian>black>Asian)
• Diet: Obesity
• Occupation: sedentary life style
• Gout
• Low fluid intake (urine out< 1L)

10. Clinical features
Patient with urinary calculi may have variable presentation;
• Pain
• Infection
• Hematuria
• Asymptomatic

11. Pain distribution

12. Clinical features cont…
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 acute abdomen
in 50%
• Tenderness in renal angle

13. Clinical features cont…
Ureteral stone
• Causes sudden onset of severe, colicky pain in the flank and
ipsilateral lower abdomen
• Pain radiating to the testicles or the vulvar area
• Intense nausea, with or without vomiting, usually is present
• May have impaired renal function, anemia, weight loss

14. Clinical features cont…
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)
• May present with cystitis, UTI

15. Activity: Brainstorming
• Mention the investigations you will order for the patient
presenting with sign and symptom of urolithiasis.

16. Investigations
• Abdominal pelvic ultrasound is sensitive about 95%, can
identify stones located in the calces, pelvis and pyeloureteric
and vesco-ureteric junction, upper urinary tract dilation
• KUB radiography; To see kidney shadow, stones (90%—
radio-opaque).
• Intravenous radiography
• Intravenous pyelogram
• CT scan
• Other investigation will depend to the clinical presentation of
a patient.

17. Treatments
In case of renal colic
• Open an IV line
• Give fluid, Analgesia, antiemetic
• Refer a patient for further evaluation and treatment
In case of infection
• Urine for culture
• Blood culture
• Broad spectrum antibiotic
• Refer for further evaluation and treatment

18. Complication of urolithiasis
• Ureteral scaring and stenosis
• Serious infection of the kidney that diminishes renal function
• Urinary fistula formation
• Ureteral perforation
• Urine extravasation
• Urine outflow obstruction-hydronephrosis - CRF

19. Key points
• Urolithiasis is a condition where urinary stones are formed or
located anywhere in the urinary system.
• Most stones are formed by minerals or stone-forming salts
and begin to crystallize when their concentration becomes
supersaturated in the urine
• Calcium stone is the most encountered in the general
population.

20. Evaluation
• Define urolithiasis
• Mention three (3) clinical features of urolithiasis
• Mention the complication of urolithiasis

21. Reference
• Alan J. Wein, Louis R. Kavoussi, Alan W. Partin, Graig A.
Peter (2011) Campbell-Walsh urology (10th edition). BJU
international.
• E. Tanagho, J. McAninch, Donald R. Smith (2013) Smith and
Tanagho’s General Urology (18th edition).Lange
• Courteney M. Townsend, B. Mark Evers, R. D. Beauchamp,
Kenneth L. Mattox (2012) Sabiston textbook of surgery (20th
edition). Elsevier