Urinary Calculi

Occurrence - Males > Female

Developed world- upper tract stones more common
Developing world- bladder stones more common

Occcurs when the balance between
Factors keeping solutes in solution and
Factors promoting precipitation of solutes are lost.

Mechanism

1. Supersaturationproduction of concentrated urine
Metabolic abnormalities (Ca, Mg, Phophate, Vit D, PTH, Oxalate metabolism)
Due to dehydration, hot climate

2. Crystal Formation reduction in inhibitors (citrate, Mg nephrocalcin, glycosaminoglycans)

3. Nucleation crystals aggregate around organic matrix or nidus
Ex- epithelial cell debris, foreign bodies, microrganisms, red cells, other
crystals

4. Stasis

Types of Stones

1. Calcium Oxalate 70%
2. Calcium Phosphate cause stag horn calculi, seen in infected, alkaline urine,
Occurs specially in the presence of Proteus organisms
3. Uric acid/Urate stones 5% (in idiopathic gout)
4. Cystine stones- 1% (in cystinuria)
These stones are radio-opaque because they contain sulphur
5. Xanthine stones rare





































Aetiology

1. Idiopathic majority
2. Dietary deficiency of vit A causes desquamation of the epithelium. This provides a nidus for
calculi formation in the bladder.
3. Hypercalcaemia due to primary hyperparathyroidism, vit. D ingestion
4. Hypercalciuria due to hypercalcaemia, excessive dietary intake of calcium, excessive
resorption of calcium from the skeleton in prolonged immobilization
5. Hyperoxaluria ingestion of food high in oxalate such as spinach, tea, dietary calcium
restriction with compensatory increased absorption of oxalate, dehydration
6. Inherited error of metabolism
7. Secondary causes
Infection in UTi due to Proteus
Stasis
Medullary Sponge kidney
Foreign bodies
8. Drugs loop diuretics, vit D, antacids
9. Bladder stones may be the result of bladder outflow obstruction and presence pf a foreign
body (catheter, suture material)
10. Primary renal disease
11. Renal tubular acidosis












Note
enteric hyperoxaluria-by 2 mechanisms
The intestinal mucosa may become more permeable to oxalate from the direct action of
nonabsorbed bile salts and fatty acids
The nonabsorbed bile salts and fatty acids may complex divalent cations, reducing the
amount of free calcium and magnesium in the intestinal lumen.
Clinical Presentation

Asymptomatic
Symptoms Abdominal pain renal / Ureteric colics
Due to stone entering ureter and obstructing it or causing
spasm
Pattern of severe exacerbation on a background of
continuing pain
Loin to groin radiation
Lasting a few hours

- Haematuria (Macroscopic/ Microscopic)
- Pyuria
- Lump
- Infection (Pyelonephritis /Pyonephrosis )
- Anuria
- Retention

Bladder Stones - Stangury pain
-Frequency
-Interruption of Urine stream
Systemic features vomiting/nausea
Fever if superadded infection present

Examination - Tenderness +/- guarding in the iliac fossa, lumbar or hypochondrial region
Renal angle tendeness
Ballotable mass in lumbar region
Stone may be palpable in the urethra/visible at the meatus on genital
examination

Principles of Management

Diagnosis
1. Confirmation
2. Search for cause
3. Assess renal function
4. Assess complications of stones such as

- Obstruction
- Infection
- Dehydration











Investigation

























UFR
- Red cells- seen in 85% of those with urinary tract stones
- Pus cells- may be present

- Crystals- presence indicates urine with high susceptibility to form
calculi
Urine Culture if UTi is suspected
Radiography
- X-ray KUB-helpful in differentiating between radiolucent and
radiopaque stones
- USS -should be used as the primary procedure, safe (no risk of
radiation), Visualise stone and hydroureter and hydronephrosis if
present
- -IVU previously the gold standard
- Non contrast Spiral CT scan most sensitive and specific modality to
diagnose ureteric calculi, become the standard method for
diagnosing acute flank pain
Cystoscopy (Bladder stones)
Renal Function Test
- S. Creatinine
- BU
- DTPA Scan


Recommended basic analysis in emergency stone patient

Treatment

Conservative management stones <5mm pass spontaneously
- Pain relief (diclofenac Na/pethidine)
- Hydration
- Follow up
Medical Management
Emergency Management
- PCN
- J stenting
- IV antibiotics for infection
Intervention
- ESWL stone with size up to 1cm, for upper tract stones
- Cystoscopic or ureteroscopic stone Extraction after crushing /
retrievalusingdormia basket or balloon
- PCNL
- Open surgery (Pyelolithotomy/ureterolithotomy/ vesicolithotomy)
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For decompression of obstructed system and
preservation of renal function
Contraindications of ESWL
There are several contraindications to the use of ESWL, including:
Pregnancy, due to the potential effects of the shock wave energy on the foetus
bleeding diatheses, which should be compensated at least 24 hours before and
48 hour after treatment
Uncontrolled urinary tract infections ( especially acute pyelonephritis)
Severe skeletal malformations and severe obesity, which will not allow targeting
of the stone
Some indications for open surgery
Complex stone burden (partial and complete staghorn stones)
Intrarenal anatomical abnormalities: infundibular stenosis, stone in the calyceal
diverticulum (particularly in an anterior calyx), obstruction of the ureteropelvic
junction, stricture
Non-functioning lower pole (partial nephrectomy), non-functioning kidney
(nephrectomy)
Treatment failure of ESWL and/or PNL, or failed ureteroscopic procedure
Co-morbid medical disease
Stone in an ectopic kidney where percutaneous access and ESWL may be difficult
or impossible
Complications

1. Obstructive uropathy& chronic renal failure esp in bilateral stone disease
Silent stones first presentation may be renal failure
2. Infection Chronic pyelonephritis, Pyonephrosis
3. Stricture
4. Malignancy- in the bladder
6. Recurrence of stones

Patients with recurrent stones and bilateral/ multiple stones need to be investigated further for a
cause. Metabolic screening serum Ca, K, BUN, creatinineetc

Prevention by adequate hydration to ensure UOP of 2L/day at least 3L of fluids/day needed.