Urolithiasis Disease

DESCRIPTION

The state describing the presence of calculi within the urinary system. Commonly known as kidney stones.

System(s) affected: Renal/Urologic
Genetics: Familial tendency
Incidence/Prevalence in USA: 70-210 in 100,000 population. 2%-5% of population in lifetime.
Predominant age: Peak 20-30. Range 20-60.
Predominant sex: Male > Female (4:1)

SIGNS AND SYMPTOMS

Usually sudden onset
Severe agonizing pain, costovertebral angle to groin depending on stone location
Patient in constant motion, no comfort
Nausea with or without vomiting
Diaphoresis
Tachycardia
Intestinal ileus
Abdominal guarding and rebound (rare)
Tenderness to deep abdominal palpation, usually at CVA
Lower tract stone with frequency, urgency, dysuria
Fever, with infection
Hematuria
Pyuria, with infection
May be asymptomatic if stone stays within kidney

CAUSES

Calcium oxalate/calcium phosphate 65%-85%
- Supersaturation from any cause
- Dehydration
- Increased absorption
- Increased calcium excretion - familial
- Renal tubular acidosis
- Hyperparathyroidism
- Chronic bowel disease with absorptive disorders
- Poor GI citrate absorption
- Excessive oral vitamin D or C
- Alkaline urinary pH
- Chronic use of calcium antacids
- Diet high in calcium or oxalate
- Malignancy
- Hyperthyroidism
- Chronic steroid therapy
- Thiazide diuretics
Struvite (staghorn calculus) 15%-20%
- Infection
- Alkaline urine
Uric acid 5%
- Hereditary
- Gout
- Chronic bowel disease
- High purine diet
- Acidic urine, very low pH
- Malignancy with chemotherapy
Cystine 1%-3%
- Hereditary homocystinuria

RISK FACTORS

Family history
Climate, hot
Work in hot environment
Poor fluid consumption
Diet high in oxalate, purine, calcium
Excessive vitamins
Malignancy
Sarcoidosis
Gout
Thiazide diuretics
Bowel or kidney disease

LABORATORY

Urinalysis: Hematuria nearly 100%; if pH < 5.5 means uric acid, if pH > 7.5 means struvite
Chemistries: Calcium, phosphorus, electrolytes, uric acid, creatinine, magnesium
Parathyroid hormone: If serum calcium high
Urine cystine: If stone not visible on plain x-ray
Urine culture: If pyuria or fever

Drugs that may alter lab results: Pyridium may alter urinalysis
Disorders that may alter lab results: See Causes and Risk Factors

PATHOLOGICAL FINDINGS

Stone analysis: 60-80% calcium base, 15-20% struvite, 5% uric acid, 1-3% cystine

SPECIAL TESTS

Stone analysis

IMAGING

Plain kidney, ureter and bladder (KUB) x-ray: 80%-90% visible with some calcium
Intravenous pyelogram (IVP): Primary study for urolithiasis
Ultrasound: Technique varies, if good has equal sensitivity and specificity to IVP
Spiral CT scan (growing use); can still miss a small stone

DIAGNOSTIC PROCEDURES

Retrograde pyelogram, if necessary for high grade obstruction or poor visualization on IVP

APPROPRIATE HEALTH CARE

80% outpatient only, most pass in 48 hrs
20% hospitalization and urology referral
Stone size and likelihood of passing spontaneously
- < 4 mm - 80%
- 4–6 mm - 59%
- > 6 mm - 21%

GENERAL MEASURES

Reassurance
Strain urine
Hydration
Pain control
Refer to urologist for: Intractable pain, obstruction, size > 6 mm, infection, dehydration, failure to progress, stone growth, single kidney, persistent gross hematuria, pregnancy, severe renal disease
Hospitalize for:
- Pain - intractable - parenteral medications
- Persistent vomiting
- High grade fever
- Obstruction with infection
- Solitary kidney with obstruction

SURGICAL MEASURES

Extracorporeal shock wave lithotripsy: Stone in renal pelvis or upper 2/3 ureter, size < 2 cm, noninfected, no coagulopathy
Urethroscopy: Lower 1/3 ureter, normal anatomy present. Newer graspers available for upper ureter.
Percutaneous nephrolithotomy: Renal collecting system or upper 2/3 ureter, size > 2 cm, ureter stricture, cystine or uric acid stones, struvite, infection, obesity - may be used with intracorporeal lithotripsy
Open surgery: Less than 5% of patients, complex anatomy, obstruction, large infected struvite stone
Urethroscopy with lithotripsy available for lower 1/3 ureter
Stenting for upper 1/3 or lower 1/3 ureter

ACTIVITY

Bedrest, if necessary during acute phase. No restrictions after stone passes.

DIET

Normal diet, 8 oz. water every 1 hour while awake, and if possible every 2 hours during sleep hours
If uric acid stones, less protein in diet and take sodium bicarbonate to alkalinize urine

PATIENT EDUCATION

Instructions on urine straining, dietary advice
See Patient Care, August 15, 1990, p.42

PREVENTION/AVOIDANCE

Hydration with urine > 2 liters a day (including nocturia once nightly). Dietary calcium < 1 g/d.

POSSIBLE COMPLICATIONS

Hydronephrosis or kidney damage
Infection and sepsis

EXPECTED COURSE AND PROGNOSIS

80% will pass in 48-72 hours with outpatient therapy
Recurrence - 10% at 1 year, 35% at 5 years, 50% at 10 years

ASSOCIATED CONDITIONS

See Causes section

AGE-RELATED FACTORS

Pediatric: Homocystinuria or other hereditary disorder
Geriatric: N/A
Others: N/A

PREGNANCY

Urology referral

OTHER NOTES

N/A

ABBREVIATIONS

KUB = kidney, ureter and bladder
IVP = intravenous pyelogram
HCTZ = hydrochlorothiazide

Clinical Investigations

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