LWW/AENJ LWWJ331-03 April 25, 2007 22:57 Char Count= 0

Advanced Emergency Nursing Journal

Vol. 29, No. 2, pp. 98–110
Copyright 
c 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins

Radiology
R O U N D S
Column Editor: Jonathan Lee, MD

Diagnosis and Treatment of

Urolithiasis
Emily D. Eads, MD ;
Karen A. Herbst, MD ;
Jonathan Lee, MD

M ORE THAN 600,000 patients are

seen in the emergency department
in the United States each year due to
urolithiasis and the complications of this dis-
EPIDEMIOLOGY
The annual incidence of urolithiasis ranges
from about 0.5% to 1% (Moe, 2006). The
prevalence has been noted to be markedly dif-
ease (Stamatelous, Francis, Jones, Nyberg, &
ferent among third world countries and de-
Curhan, 2006). A recent U.S. study indi-
veloped nations, likely relating to lack of ac-
cated that up to $2 billion is being spent
cess to radiographic diagnoses, which may
on the diagnosis and treatment of urolithiasis
lower the number of diagnoses. The preva-
(Stamatelous et al., 2006). Urolithiasis is the
lence in the United States in the last decade
formation of solid depositions due to pre-
has been around 5% (Pak, 1998). A lifetime
cipitated solute in the renal system, includ-
risk for urolithiasis has been reported in mul-
ing the renal pelvis, ureters, bladder, or
tiple studies as 10% to 15% (Pak, 1998). Those
urethra. The signs and symptoms of urolithi-
who have been diagnosed with a prior kidney
asis are widely variable, making it one of
or urethral stone have a 50% chance of devel-
those possible differential diagnoses on many
oping an additional stone with symptoms in
patients presenting with vague signs and
the next 5 to 10 years (Moe, 2006).
symptoms.
This article reviews the epidemiology and
etiology of urolithiasis, risk factors, recent ad- RISK FACTORS
vances in imaging, and several treatment op-
Factors such as age and the type of soda
tions for patients with urolithiasis.
drink ingested by patients have been associ-
ated with increased risks of nephrolithiasis
(Moe, 2006). Men develop stones in the re-
From the Transitional Medicine Program (Dr Eads), nal system three times more often than do
and the Departments of Internal Medicine (Dr Herbst) women (Portis & Sundaram, 2001).
and Emergency Medicine (Dr Lee), Scripps Mercy Hos-
pital, San Diego, CA. Other risk factors include diabetes, a his-
tory of renal stone, a history of vasectomy, hy-
Corresponding author: Emily D. Eads, MD, Transitional
Medicine Program, Scripps Mercy Hospital, San Diego, pertension, marathon running, and a strong
CA 92103 (e-mail: eads.emily@scrippshealth.org). family history of renal stone (Smith, Levine,

98
LWW/AENJ LWWJ331-03 April 25, 2007 22:57
April–June 2007 r Vol. 29, No. 2
& Rosenfeld, 1999). Patients who have had
a recent increased risk of hypercalcemia
are also at risk. These include patients
with resorptive processes, including hyper-
parathyroidism, immobilization, or metastatic
disease.
Individuals with higher serum levels of uric
acid are also at an increased risk of uric acid
stones. These individuals include those with
inflammatory bowel disease, ileostomies, and
chronic diarrhea. These conditions can result
in metabolic acidosis.
TYPES OF STONES
Urinary tract stones vary in nature and lo-
cation. The types of stones that can form
include calcium oxalate or calcium phos-
phate stones, phosphate-containing stones,
uric acid stones, cystine stones, or combina-
tions of the former. Generally, 75% of stones
are composed of calcium oxalate or calcium
phosphate stones, mainly due to increases
in urine calcium concentration via calcium
oxalate or phosphate precipitates (Daudon
et al., 2005). Phosphate-containing stones
make up about 15% of urinary tract stones.
The stones are generally composed of mag-
nesium ammonium phosphate precipitates.
Urea-splitting organisms found in common
urinary tract infections (UTIs) are often asso-
ciated with such stones, which are then called
struvite. These organisms produce urease, a
protein that splits urea, which results in an in-
crease in pH. Klebsiella, Proteus, and Staphy-
lococcus saprophyticus are organisms that are
often associated with urease. Uric acid stones,
making up about 5% to 10% of urinary tract
stones, are associated with urine with acidic
pH and high levels of uric acid. Cystine stones
are very rare and make up only about 1%
of urinary tract stones. These stones are as-
sociated with an autosomal recessive disease
called cystinuria.
PATHOPHYSIOLOGY
Very little is known about the exact mech-
anism of urinary tract stone formation, but
most of the literature support the notion that
Char Count= 0
Urolithiasis 99
higher concentrations of substrate in the poor
urinary flow setting due to low urinary vol-
ume can lead to precipitation of that sub-
strate. Different types of stones and their re-
lated illnesses or disease states that can lead
to a higher urinary concentration of its sub-
strate are described in the previous section.
Because the majority of renal stones are com-
posed of either calcium oxalate or calcium
phosphate stones, most of the literature has
focused on the pathophysiology of calcium
stones.
Randall plaque lesions were first described
in the 1930s, and were found in individu-
als with renal calcium calculi. These plaques
have been thought to be a nidus for calcium
stone formation. It is thought that apatite for-
mation can occur due to sheer forces in partic-
ular areas of the urinary system. It arises from
the basement membrane of the thin limbs
of the loops of Henle, protruding into the
uroepithelium and encasing the interstitium.
It was initially thought that calcium stones are
formed on these plaques, but of late it has
been determined that these plaques are of-
ten free from and do not correlate with stone
formation.
Uric acid stones are generally formed in a
low urine pH (usually pH <5.5). It has been
observed in patients with metabolic acidosis
(such as diabetic ketoacidosis, chronic diar-
rhea, or secondary to using medications such
as acetazolamide, hydrochlorothiazide, etc).
Indinavir has also been associated with stone
formation secondary to the drug precipitating
in the urine, forming crystals.
SIGNS AND SYMPTOMS
Renal colic, though a common presentation
for urolithiasis, is only one of the many com-
plaints patients may have when presenting
with a stone. It is thought that at least one
third of the urinary system must be occluded
before pain or symptoms begin. Most com-
monly, patients present with waxing and wan-
ing pain, classically in the mid-back and flank,
radiating into the abdomen, and later in the
groin (Table 1).
LWW/AENJ LWWJ331-03 April 25, 2007 22:57 Char Count= 0

100 Advanced Emergency Nursing Journal

Table 1. Signs and symptoms for patients

with stones

Stone location Common symptoms

Kidney Vague flank pain,

hematuria, nausea,
and vomiting
Proximal ureter Renal colic, flank pain,
upper abdominal pain
Middle section Renal colic, anterior
of ureter abdominal pain, flank
pain
Distal ureter Renal colic, dysuria,
urinary frequency,
anterior lower
abdominal pain, flank
pain, hematuria
Figure 1. 3-mm ureteral stone located over the
psoas muscle lateral to the L3 vertebral body.
Note. From “Diagnosis and Initial Management of Kidney
Stones,” by A. J. Portis and C. P. Sundaram, 2001, Ameri-
should also prompt a clinician to seek for
can Academy of Family Physicians, 63, pp. 1329–1338.
Adapted with permission of the authors. another cause of the presentation such as
leaking abdominal aortic aneurysm, aortic
Some patients present with nausea and dissection, renal infarction, renal artery dis-
vomiting. This nausea and vomiting and the section, incarcerated hernia, retroperitoneal
sensation of “upset stomach” are thought to hematoma, mesenteric ischemia, epidural ab-
relate to the idea that the celiac plexus inner- scess, or perforated viscus.
vating the kidneys and ureters also innervates
the stomach and proximal small intestine. RADIOGRAPHIC TECHNIQUES FOR DETECTION
Men with renal stones frequently complain AND DIAGNOSIS
of testicular pain or penile pain, which is of-
There are several radiologic techniques used
ten mistaken for testicular torsion. Groin pain
in the detection and diagnosis of renal stones.
is a symptom that is often attributed to a small
These include the plain radiograph, the intra-
hernia, but is later found to be due to stones
venous pyelogram (IVP), and computed to-
in the distal urethra.
mography (CT).
Some patients without any symptoms can
present with microscopic hematuria, though
Plain Radiograph
this rarely leads to a work up for renal sys-
tem stones. Patients with symptoms of re- The plain radiograph is capable of detect-
nal stones without hematuria should also ing only radio-opaque stones (Fig 1). Cal-
undergo evaluation for stones because hema- cium phosphate and calcium oxalate stones
turia is not always present. Occasionally, pa- comprise 90% of renal stones and are radio
tients will present with recurrent urinary tract opaque (Herring, 1962). Intermediate density
infections (UTIs) or pyelonephritis, and are stones including struvite (i.e., magnesium am-
later found to have renal calculi preventing monium phosphate) and cystine stones are
clearance of the urinary system. also typically visible in plain radiographs. The
The classic presentation of a patient with lower density stones are composed of uric
severe flank pain radiating into inguinal area acid, and are radiolucent, or undetectable,
and inability to find a position of comfort on plain radiographs (Table 2). Since 90% of
LWW/AENJ LWWJ331-03 April 25, 2007 22:57 Char Count= 0

April–June 2007 r Vol. 29, No. 2 Urolithiasis 101

Table 2. Stone composition and detection on plain radiographs versus CT

Radio opaque High

% of renal (seen on plain attenuation
Stone composition stones radiograph) (seen on CT)

Calcium phosphate or calcium oxalate 80 Yes Yes, 800–1000 H

Magnesium ammonium phosphate (struvite) 15 Yes Yes, 330–900 H
Cystine 1–2 Yes Yes, 200–880 H
Uric acid or xanthine 3–4 No Yes, 150–500 H
Matrix <1 No No, <50 H
Indinavir <1 No No, <50 H

Note. H = Hounsfield units. From “Pelvicaliceal System, Ureters, Bladder, and Urethra,” by W. E. Brant, 2006, in W. E.
Brant and C. A. Helms (Eds.), Fundamentals of Diagnostic Radiology (pp. 887–908), Philadelphia: Lippincott Williams
& Wilkins. Adapted with permission.

stones contain calcium, and therefore are ra- obstruction with the presence of a kidney
dio opaque, one might expect the sensitivity stone. Although the IVP does give physio-
of plain radiographs to approach 90%. How- logic information as to the excretory func-
ever, plain radiographs have a sensitivity of tion of the kidney and the flow of contrast
only 45% and a specificity of 77% (Levine, within the ureter, it is typically the presence
Neitlich, Verga, Dalrymple, & Smith, 1997). or absence of obstruction that determines
This low sensitivity may be due, in part, to dif- the management of renal stones, rather than
ficulty detecting smaller stones, stones overly- the degree of obstruction (Smith et al., 1999).
ing bone, and secondary signs of obstruction
on plain radiographs. The low specificity may
be due to the fact that the calcification cannot
be directly localized within the ureter, mak-
ing it easier to mistake phleboliths for renal
stones.

Intravenous Pyelogram
The IVP, or excretory urogram, has been the
criterion standard for imaging the urinary
tract (Fig 2). With the development of the he-
lical CT, however, the noncontrast CT has re-
placed IVP as the primary diagnostic imaging
technique. The IVP requires injection of IV
contrast, which is concentrated by the kid-
neys into the collecting system and then ex-
creted into the ureter, thus allowing visualiza-
tion of the urinary tract. The IVP measures
an indirect sign of obstruction: a delayed ex-
cretion of contrast and dilatation of the renal
collecting system. The IVP does not directly
visualize renal stones, and a plain radiograph Figure 2. Intravenous pyelogram (IVP) with dye
is required to correlate the indirect signs of tracing the urinary tract.
LWW/AENJ LWWJ331-03 April 25, 2007 22:57 Char Count= 0
102
Figure 3. Radiodense (bright white spot) 5-mm
stone located outside the medial border of the right
kidney.
In addition, the use of IV contrast carries the
risks of nephrotoxicity and anaphylaxis. In
high-grade obstructions, the contrast is not
well concentrated in the urinary tract, and
hence the IVP is of little diagnostic utility.
Computed Tomography
Since the first use of CT for detecting renal
stones was published in 1995 (Smith et al.,
1995), it has quickly replaced the IVP as the
imaging modality of choice for urolithiasis
(Fig 3). CT images can be acquired rapidly
and have a higher sensitivity and specificity
for the detection of urinary tract stones. More-
over, CT allows for a more accurate descrip-
tion of stone size and location, both of which
determine management. Finally, CT also al-
lows simultaneous evaluation for alternative
diagnoses, which are found in 10% to 32% of
cases. CT images are obtained in a mean time
of 4 min versus 63 min for IVP (Niall, Russell,
MacGregor, Duncan, & Mullins, 1999). The
sensitivity and specificity of CT for urolithiasis
ranges from 97% to 100% and 92% to 100%,
respectively (Chen & Zagoria, 1999; Field-
ing, Steele, Fox, Heller, & Loughlin, 1997;
Niall et al., 1999; Smith, Verga, MacCarthy, &
Rosenfield, 1996).
Advanced Emergency Nursing Journal
Figure 4. 2-mm ureterovesical junction (UVJ)
stone located on the left side within the bladder.
Technique
Optimal CT imaging is dependent on the
proper positioning of the patient and the pres-
ence of a distended bladder. The renal stone
noncontrast CT protocol is performed in the
prone position so that stones impacted in
the ureterovesicular junction (in the poste-
rior bladder wall) may be distinguished from
stones in the bladder, which rest on the an-
terior bladder wall with the patient in the
prone position (Fig 4). With a distended blad-
der, the uterus is displaced, allowing better vi-
sualization of the distal ureters and easier dif-
ferentiation of phleboliths from distal ureter
stones.
Stone Detection
Virtually all renal stones are visible on CT
scan, because almost all are highly attenu-
ated (see Table 2). The only exceptions are
two types of low-attenuation stones: non-
crystalline matrix stones composed of pro-
tein, cellular debris, and organic materials and
indinavir stones composed of the HIV pro-
tease inhibitor, indinavir (Blake, McNicholas,
& Raptopoulos, 1998). The high attenuation
(>150 H) of renal stones on CT scan
makes it possible to distinguish from low-
attenuation (<50 H) structures such as
LWW/AENJ LWWJ331-03 April 25, 2007 22:57
April–June 2007 r Vol. 29, No. 2
Table 3. Stone width and likelihood of spon-
taneous passage
Spontaneous
Stone width (mm) passage (%)
1 87
2 72
3 83
4 72
5 60
6 72
7 47
8 56
9 33
Note. From “Relationship of Spontaneous Passage of
Ureteral Calculi to Stone Size and Location as Revealed by
Unenhanced Helical CT,” by D. M. Coll, M. J. Varanelli, and
R. C. Smith, 2002, AJR American Journal of Roentgenol-
ogy, 178(1), pp. 101–103.
tumors, hematomas, infectious material, and
cellular debris (i.e., sloughed papilla).
Stone Size
The major limitation of CT is that smaller
stones may not be detected, depending on the
slice size of the images gathered. Multidetec-
tor CTs utilize thin slices, thus making smaller
stones more visible. The size of the stone, in
particular the width, is the most important
predictor of the rate of spontaneous passage.
According to one study, the rate of sponta-
neous passage was 87% for 1-mm stones, 76%
for 2- to 4-mm stones, 60% for 5- to 7-mm
stones, 48% for 7- to 9-mm stones, and 25% for
stones exceeding 9-mm size (Coll, Varanelli, &
Smith, 2002; Table 3). The spontaneous pas-
sage rate is also affected by stone length, with
2- to 4-mm stones having a rate of 95% and 11-
mm stones having a rate of 20% (Ueno, Kawa-
mura, Ogawa, & Takayasu, 1977).
Stone Localization
CT, unlike the plain radiograph and the IVP,
allows the localization of the ureteral stone
within the ureter. The tissue rim sign is a halo
of soft tissue surrounding the stone that rep-
resents edema of the ureteral wall. The rim
Char Count= 0
Urolithiasis 103
sign appears between 4 and 24 hours after
impaction of a stone (Smith et al., 1995). In
one study, 92% of ureters with less than 4-
mm stones revealed a rim sign, whereas larger
stones were less likely to show a rim sign
(Heneghan, Dalrymple, Verga, Rosenfield, &
Smith, 1997). Only 8% of phleboliths revealed
a rim sign. Therefore, the presence of the
rim sign is helpful in differentiating ureteral
stones from phleboliths.
The ability to directly localize the site of
the stone within the ureter is an important
advantage of CT, as the location of the stone,
in addition to its size helps predict the
likelihood of spontaneous passage. Common
sites of stone impaction within the ureter
are at the anatomic sites of narrowing: for
example, (1) the ureteropelvic junction, (2)
the site where the ureter crosses the pelvic
brim, and (3) the ureterovesicular junction.
According to a CT study by Dalrymple et al.
(1998), 35% of stones are localized in the
proximal ureter, 7% in the midureter, 33% in
the distal ureter, 18% at the ureterovesicular
junction, and 8% within the bladder (Table 4).
Table 4. Stone location and likelihood of
spontaneous passage
% of Likelihood of
Stone renal spontaneous
location stonesa passage (%)b
Proximal ureter 35 48
Mid ureter 7 60
Distal ureter 33 75
Ureterovesicular 18
junction
Bladder 8
a From “The Value of Unenhanced Helical Computerized
Tomography in the Management of Acute Flank Pain,” by
N. C. Dalrymple, M. Verga, K. R. Anderson, P. Bove, A. M.
Covey, A. T. Rosenfield, et al., 1998, Journal of Urology,
159(3), pp. 735–740.
b From “Relationship of Spontaneous Passage of Ureteral
Calculi to Stone Size and Location as Revealed by Unen-
hanced Helical CT,” by D. M. Coll, M. J. Varanelli, and R. C.
Smith, 2002, AJR American Journal of Roentgenology,
178(1), pp. 101–103.
LWW/AENJ LWWJ331-03 April 25, 2007 22:57 Char Count= 0

104 Advanced Emergency Nursing Journal

The rate of spontaneous passage is 48% for

proximal ureteral stones, 60% for midureteral
stones, and 75% for distal ureteral stones (Coll
et al., 2002). Stone location also helps guide
interventional therapy, because proximal
stones are treated with extracorporeal shock
wave lithotripsy (SWL) and distal stones are
treated with ureteroscopy with extraction or
intracorporeal lithotripsy.

Signs of Secondary Obstruction

Indirect signs of stone impaction are also visi-
ble on CT scan, including signs of obstruction.
These signs include (1) more than 3-mm di-
latation of the pelvicaliceal system and ureter
proximal to the stone, (2) perinephric soft
tissue stranding, (3) perinephric fluid collec-
tions, and (4) decreased attenuation of the af-
fected kidney due to edema. The two most im-
portant signs are ureteral dilatation and per-
inephric stranding, both of which vary with
the severity of obstruction and duration of
symptoms (Fig 5).
In a study of patients with acute
ureterolithiasis, ureteral dilatation was
seen in 84% and 97% of patients at 2 and 8 hr,
respectively (Varanelli, Coll, Levine, Rosen-
field, & Smith, 2001). Perinephric stranding
was seen in 5% and 51% of patients at 2 and
8 hr, respectively. Most studies, however,
have failed to correlate these secondary
signs of obstruction with the likelihood
of spontaneous stone passage. In general,
secondary signs of obstruction do not change
management. It is primarily the stone size and
symptom severity that dictate management
(Preminger, Vieweg, Leder, & Nelson, 1998). Figure 5. (a) Two intrarenal stones (one near the
For detecting ureteral obstruction, ureteral superior pole and a smaller one near the infe-
dilatation has a sensitivity of 90%, a specificity rior pole with pererenal edema and fat stranding.)
(b) Dilated hydroureter (a round cystic structure
of 93%, a positive predictive value of 92%,
located medial to the left kidney).
and a negative predictive value of 90% (Smith,
Verga, Dalrymple, McCarthy, & Rosenfield,
1996). Other causes of ureteral dilatation in- struction has a sensitivity of 82%, a speci-
clude a UTI, which impairs peristalsis, extrau- ficity of 93%, a positive predictive value of
reteral inflammation secondary to appendici- 92%, and a negative predictive value of 84%
tis or diverticulitis, prior stone with residual (Smith, Verga, Dalrymple, et al., 1996). The
dilatation, extrinsic compression by a mass decreased specificity is due to the fact that
(typically the ovary), and megaureter. Per- this finding is also associated with numerous
inephric stranding for detecting ureteral ob- conditions other than renal stone obstruction,
LWW/AENJ LWWJ331-03 April 25, 2007 22:57
April–June 2007 r Vol. 29, No. 2
Table 5. Common alternative diagnoses on
noncontrast CT ordered to evaluate for
urolithiasis
• Ovarian mass with torsion or hemorrhage
• Appendicitis
• Diverticulitis
• Choledocholithiasis
• Crohn’s disease
• Pancreatitis
Note. From “The Value of Unenhanced Helical Comput-
erized Tomography in the Management of Acute Flank
Pain,” by N. C. Dalrymple, M. Verga, K. R. Anderson, P.
Bove, A. M. Covey, A. T. Rosenfield, et al., 1998, Journal
of Urology, 159(3), pp. 735–740.
including pyelonephritis, renal vein throm-
bosis, renal infarction, trauma, hemorrhage,
and tumor. When used in combination, the
presence of both ureteral dilation and per-
inephric stranding has a positive predictive
value of 99%, whereas their absence has a neg-
ative predictive value of 95% (Smith, Verga,
Dalrymple, et al., 1996).
Detection of Alternative Diagnoses
An additional benefit of using CT for diag-
nosing renal stones is its ability to detect
other causes of flank pain, which in or-
der of frequency include ovarian mass with
torsion or hemorrhage, appendicitis, diverti-
culitis, choledocholithiasis, Crohn’s disease,
and pancreatitis (Dalrymple et al., 1998;
Table 5). Other findings documented include
among others pyelonephritis, leaking abdom-
inal aortic aneurysms, incarcerated hernias,
splenic rupture, and renal artery aneurysm.
In one study, 33% of patients had alter-
nate diagnoses by noncontrast CT that were
not suspected by clinical presentation, half
of whom had significant disease (Ha &
MacDonald, 2004).
Limitations of CT
Potential pitfalls of diagnosis of nephrolithia-
sis by CT include detection of indirect signs
of obstruction without detection of a renal
stone impacted in the ureter. Findings of a di-
Char Count= 0
Urolithiasis 105
Figure 6. Pheleboliths: Two located medial to the
right hip bone; one medial to the left hip bone.
lated ureter without a stone may represent re-
cent stone passage or impaired peristalsis sec-
ondary to a UTI. Perinephric fat stranding may
represent residual inflammation from a prior
insult. An extrarenal pelvis or peripelvic cysts
may mimic hydronephrosis. In addition, high-
attenuation lesions such as atherosclerotic
calcifications or phleboliths, which are calcifi-
cations within thrombosed veins, may be con-
fused with urinary tract stones (Fig 6). Four
key features distinguish phleboliths from re-
nal stones: (1) the lesion is not localized along
the course of the ureter, (2) the absence of the
tissue rim sign, (3) the presence of a “comet
tail sign,” which represents the thrombosed
vein extending from the calcification, and
(4) lower attenuation of phleboliths (∼160 H)
(Table 6). In a study by Bell et al., a comet
sign was present in 0% of ureteral stones and
21% of phleboliths; therefore, the presence
of a comet tail can exclude the diagnosis of
a ureteral stone, but the absence of a comet
tail is not helpful (Bell, Fenlon, Davison,
Ahari, & Hussain, 1998). Phleboliths are com-
monly found in the pelvic veins, known
as the periprostatic and perivesical veins in
men and the perivaginal, pericervical, and
perivesical veins in women. They may demon-
strate a central lucency due to the presence
LWW/AENJ LWWJ331-03 April 25, 2007 22:57 Char Count= 0
106
Table 6. Four key features distinguishing
ureteral stones from phleboliths
Ureteral
stone Phlebolith
Localization along + −
the course of
the ureter
Tissue rim sign + −
Comet tail sign − +
Attenuation High Low
of a thrombi within the calcified exterior;
however, this is seen only on plain ra-
diographs, and not on CT scans (Traubici,
Neitlich, & Smith, 1999). The attenuation of
the calcification on CT can distinguish stones
from phleboliths, as the latter tend to have
lower attenuation.
Suggested Imaging Algorithm
In patients presenting with acute flank pain
and a history of urinary tract stones, either
no imaging or a plain radiograph may be
obtained. In some institutions, repeat renal
stone CT scan is done with a reduced dose of
radiation. If complicating factors such a fever,
elevated white blood cell count, or urinalysis
indicative of infection are present, then a non-
contrast CT should be obtained. In addition, if
symptoms persist in patients managed conser-
vatively with hydration and analgesia, a non-
contrast CT should be obtained. In patients
without a history of renal stones, a noncon-
trast CT is a must (Fig 7). The exception to
the above is pregnant patients, in whom the
need for a rapid diagnosis must be balanced
with the risks of radiation exposure. Some
providers advocate the use of ultrasound, al-
though its sensitivity is much lower even
when combined with plain radiographs (24%,
44%, 61%, and 77% in findings of Catalano,
Nunziata, Altei, & Siani, 2002; Fowler, Locken,
Duchesne, & Williamson, 2002; Sheafor et al.,
2000; Tublin, Dodd, & Verdile, 1994, respec-
tively). Others advocate use of noncontrast
Advanced Emergency Nursing Journal
Figure 7. Imaging algorithm.
CT with low-dose radiation and a single pass
for image acquisition.
After obtaining a noncontrast CT, manage-
ment and further imaging is dependent on the
CT findings. The following algorithm is modi-
fied from Smith et al. (1999) (Fig 8):
1. If a stone is located in the ureter on the
symptomatic side, ureterolithiasis can be
diagnosed. The CT scout image should
be used as a baseline radiograph for com-
parison with future plain radiographs to
document stone passage. Only 17% to
47% of stones are visible on CT scout, al-
though 48% to 60% are visible on plain
radiograph (Jackman, Potter, Regan, &
Jarrett, 2000). Therefore, if the stone is
not visible on the scout image, a plain
radiograph should be obtained. If the
stone is more than 1 cm in size and not
visible on the CT scout image, it is most
likely a radiolucent stone and a plain ra-
diograph is of little utility.
2. If no stone is detected, and there
is neither ureteral dilatation nor evi-
dence of perinephric fat stranding, then
the diagnosis of ureterolithiasis can be
excluded.
3. If there is no stone, but unilateral
ureteral dilatation and perinephric fat
LWW/AENJ LWWJ331-03 April 25, 2007 22:57
April–June 2007 r Vol. 29, No. 2
Figure 8. Algorithm for interpretation of CT images. From “Helical CT of Urinary Tract Stones: Epidemiol-
ogy, Origin, Pathophysiology, Diagnosis, and Management,” by R. C. Smith, J. Levine, and A. T. Rosenfeld,
1999, Radiology Clinics of North America, 37(5), pp. 911–952. Adapted with permission of the authors.
stranding are present on the symp-
tomatic side, then symptoms must be
taken into account.
a. If the patient has no fever, elevated
white blood cell count, or evidence
of a UTI on urinalysis, then the pa-
tient may have either a tiny stone or
may have recently passed a stone.
b. If the patient has a fever, elevated
white blood cell count, and evidence
of UTI, then one must exclude the
diagnosis of pyelonephritis or py-
onephrosis.
4. If there is no stone, moderate to se-
vere unilateral perinephric fat strand-
ing, and nephromegaly without ureteral
dilatation, then one must rule out
pyelonephritis, renal vein thrombosis,
renal infarct, and renal tumor with hem-
orrhage. One may obtain a CT scan
with IV contrast to evaluate the pres-
ence of renal parenchymal disease. If
there is no stone but there is a calcifi-
cation along the ureter, one can reana-
lyze the reformatted CT images to locate
Char Count= 0
Urolithiasis 107
the stone directly within or outside the
ureter. One can also look for a tissue rim
sign.
PATIENT CARE MANAGEMENT
The management of renal calculi depends
largely on the radiographic findings of the
calculi, and the signs and symptoms and the
severity of the primary disease leading to the
calculi, and whether or not the calculi will
be amendable to minimally invasive proce-
dures. Other determinants are size, location,
and composition of the stone. The probability
of spontaneous passage of the stone is related
to the stone size and location. The American
Urological Association has published guide-
lines on management of ureteral stones on the
basis of size and location of stones (Segura
et al., 1997c). Approximately 98% of stones
less than 0.5-cm size, especially in the dis-
tal ureter, will pass spontaneously and can be
managed with hydration and analgesia. Stones
with a low probability of passage more fre-
quently require intervention by a urologist on
LWW/AENJ LWWJ331-03 April 25, 2007 22:57 Char Count= 0

108 Advanced Emergency Nursing Journal

the basis of size and shape of the stone, inter-
nal anatomy, or history of nonpassage.
Documentation of stone passage is impor-
tant, as relief from symptoms is not an ac-
curate indicator of stone passage. Weekly or
biweekly plain radiographs are obtained to
document stone passage, and are compared
with a baseline CT scout image or plain radio-
graph. In addition, patients are instructed to
strain their urine for stone fragments. Chemi-
cal analysis of the stone composition is impor-
tant in guiding prevention and therapy.
Medical management of urolithiasis in-
cludes not only aggressive hydration but also
diet modification. Thiazide diuretics have
been shown to decrease the incidence of new
stone formation, presumably by causing intra-
cellular acidosis at the level of the nephron.
This reduces calciuria, that is, preventing cal-
cium stone formation. This does not treat cur-
rent renal calculi.
Stones that fail conservative management
(i.e., the stone remained impacted, symptoms
worsen, or signs of infection such as fever,
elevated white blood cell count, urinalysis
indicative of infection develop) may require
urologic intervention. The type of interven-
tion depends on the location (i.e., proximal or
distal ureter) and size (i.e., >1 cm or <1 cm)
of the stone. For stones located in the prox-
imal ureter, small stones less than 1 cm
in size can be treated with extracorporeal
shock wave lithotripsy (SWL) (Table 7; Segura
et al., 1997a). Stones exceeding 1-cm size may
require extracorporeal SWL, percutaneous
nephrolithotomy, or ureteroscopy. For stones
located in the distal ureter, stones less than
or more than 1 cm in size can be treated with

Table 7. Treatment outcomes for ureteral stones

Extracorporeal Percutaneous Open

Location shock wave Ureteroscopy nephrolithotomy surgery
Outcomes in ureter lithotripsy (%) (%) (%) (%)

Chances of being Upper 84 56 76 99

stone free with Lower 85 89 No data 90
stones <1-cm
wide
Chances of being Upper 72 44 74 71
stone free with Lower 74 73 No data 84
stones >1-cm
wide
Chances of Upper 4 11 9 8
significant acute Lower 4 9 No data No data
complications
Chances of Upper 15 27 15 11
unplanned Lower 10 7 No data 18
secondary
interventions
Chances of Upper No data 2 8 1
long-term Lower No data 1 No data No data
complications:
Ureteral stricture

Note. From “Ureteral Stones Clinical Guidelines Panel: The management of ureteral stones: A doctor’s guide for pa-
tients,” by J. W. Segura, G. M. Preminger, D. G. Assimos, S. P. Dretler, R. I. Kahn, J. E. Lingeman, et al., 1997b, retrieved
January 9, 2007, from www.auanet.org/guidelines/patient guides/Ureteral Stones ptguide.pdf. Adapted with permis-
sion of the authors.
LWW/AENJ LWWJ331-03 April 25, 2007 22:57 Char Count= 0
April–June 2007 r Vol. 29, No. 2
ureteroscopy and intracorporeal SWL. Certain
stone types, that is, calcium oxalate monohy-
drate, calcium phosphate, and cystine stones,
are not well fragmented with SWL and may
require percutaneous removal (McCullough,
1992).
Additional imaging modalities include
the CT-IVP and the MR-IVP, which provide
the added benefit of imaging the renal
parenchyma in addition to dynamic imag-
ing of the ureter (Blandino et al., 2002;
Kawashima et al., 2004).
SUMMARY AND CONCLUSION
Ureteral stones are a common cause of
emergency department presentations of pa-
tient with abdominal pain. In the diagnosis
and management of ureteral stones, CT has
become the imaging modality of choice.
CT provides critical information for manage-
ment, including the size of the stone and
its location within the ureter. CT also pro-
vides additional information about surround-
ing abdominal structures that may lead to in-
clusion or exclusion of alternative diagnoses.
In patients with a history of ureteral stones
and without complicating factors, plain radio-
graphs may be obtained; however, for most
other patients, noncontrast CT is the imag-
ing of choice. Stones less than 0.5-cm size
have approximately a 98% chance of sponta-
neous passage and may be managed with hy-
dration and analgesia; serial plain radiographs
may be obtained to document stone passage.
Most other patients require noncontrast CT
for accurate diagnosis and treatment. Treat-
ment choices include SWL, uteroscopy, and
percutaneous nephrolithotomy, and their suc-
cess depends on the stone size and location
within the proximal or distal ureter.
REFERENCES
Bell, T. V., Fenlon, H. M., Davison, B. D., Ahari, H. K.,
& Hussain, S. (1998). Unenhanced helical CT criteria
to differentiate distal ureteral calculi from pelvic phle-
boliths. Radiology, 207(2), 363–367.
Blake, S. P., McNicholas, M. M., & Raptopoulos, V. (1998).
Urolithiasis 109
Nonopaque crystal deposition causing ureteric ob-
struction in patients with HIV undergoing indinavir
therapy. AJR American Journal of Roentgenology,
171(3), 717–720.
Blandino, A., Gaeta, M., Minutoli, F., Salamone, I., Magno,
C., Scribano, E., et al. (2002). MR urography of the
ureter. AJR American Journal of Roentgenology,
179(5), 1307–1314.
Brant, W. E. (2006). Pelvicaliceal system, ureters, bladder,
and urethra. In W. E. Brant & C. A. Helms (Eds.), Fun-
damentals of diagnostic radiology (pp. 887–908).
Philadelphia: Lippincott Williams & Wilkins.
Catalano, O., Nunziata, A., Altei, F., & Siani, A. (2002).
Suspected ureteral colic: Primary helical CT versus se-
lective helical CT after unenhanced radiography and
sonography. AJR American Journal of Roentgenol-
ogy, 178(2), 379–387.
Chen, M. Y., & Zagoria, R. J. (1999). Can noncontrast heli-
cal computed tomography replace intravenous urogra-
phy for evaluation of patients with acute urinary tract
colic? Journal of Emergency Medicine, 17(2), 299–
303.
Coll, D. M., Varanelli, M. J., & Smith, R. C. (2002). Re-
lationship of spontaneous passage of ureteral calculi
to stone size and location as revealed by unenhanced
helical CT. AJR American Journal of Roentgenology,
178(1), 101–103.
Dalrymple, N. C., Verga, M., Anderson, K. R., Bove, P.,
Covey, A. M., Rosenfield, A. T., et al. (1998). The value
of unenhanced helical computerized tomography in
the management of acute flank pain. Journal of Urol-
ogy, 159(3), 735–740.
Daudon, M., Donsimoni, R., Hennequin, C., Le Moel, G.,
Donsimoni, R., Fellahi, S., et al. (2005). Sex- and age-
related composition of 10617 calculi analyzed by in-
frared spectroscopy. Urology Research, 23, 319–326.
Fielding, J. R., Steele, G., Fox, L. A., Heller, H., & Loughlin,
K. R. (1997). Spiral computerized tomography in the
evaluation of acute flank pain: A replacement for ex-
cretory urography. Journal of Urology, 157(6), 2071–
2073.
Fowler, K. A., Locken, J. A., Duchesne, J. H., &
Williamson, M. R. (2002). US for detecting renal calculi
with nonenhanced CT as a reference standard. Radi-
ology, 222(1), 109–113.
Ha, M., & MacDonald, R. D. (2004). Impact of CT scan in
patients with first episode of suspected nephrolithi-
asis. Journal of Emergency Medicine, 27(3), 225–
231.
Heneghan, J. P., Dalrymple, N. C., Verga, M., Rosenfield,
A. T., & Smith, R. C. (1997). Soft-tissue “rim”sign in the
diagnosis of ureteral calculi with use of unenhanced
helical CT. Radiology, 202(3), 709–711.
Herring, L. C. (1962). Observations on the analysis of ten
thousand urinary calculi. Journal of Urology, 88, 545–
562.
Jackman, S. V., Potter, S. R., Regan, F., & Jarrett, T. W.
(2000). Plain abdominal x-ray versus computerized
LWW/AENJ LWWJ331-03 April 25, 2007 22:57 Char Count= 0
110
tomography screening: Sensitivity for stone localiza-
tion after nonenhanced spiral computerized tomogra-
phy. Journal of Urology, 164(2), 308–310.
Kawashima, A., Vrtiska, T. J., LeRoy, A. J., Hartman, R. P.,
McCollough, C. H., & King, B. F., Jr. (2004). CT urogra-
phy. Radiographics, 24(Suppl. 1), S35–S54; discussion
S55–S38.
Levine, J. A., Neitlich, J., Verga, M., Dalrymple, N., &
Smith, R. C. (1997). Ureteral calculi in patients with
flank pain: Correlation of plain radiography with un-
enhanced helical CT. Radiology, 2004, 27–31.
McCullough, D. L. (1992). Extracorporeal shock wave
lithotripsy. In P. C. Walsch, A. B. Retik, T. A. Stamey, &
E. D. Vaughan Jr. (Eds.), Campbell’s urology (6th ed.,
pp. 2157–2182). Philadelphia: WB Saunders.
Moe, O. W. (2006). Kidney stones: Pathophysiology and
medical management. Lancet, 367(9507), 333–344.
Niall, O., Russell, J., MacGregor, R., Duncan, H., & Mullins,
J. (1999). A comparison of noncontrast computer-
ized tomography with excretory urography in the
assessment of acute flank pain. Journal of Urology,
161(2), 534–537.
Pak, C. Y. (1998). Kidney stones. Lancet, 351, 1797–1801.
Portis, A. J., & Sundaram, C. P. (2001). Diagnosis and initial
management of kidney stones. American Academy of
Family Physicians, 63, 1329–1338.
Preminger, G. M., Vieweg, J., Leder, R. A., & Nelson, R. C.
(1998). Urolithiasis: Detection and management with
unenhanced spiral CT—A urologic perspective. Radi-
ology, 207(2), 308–309.
Segura, J. W., Preminger, G. M., Assimos, D. G., Dretler, S.
P., Kahn, R. I., Lingeman, J. E., et al. (1997a). Ureteral
Stones Clinical Guidelines Panel: Report on the man-
agement of ureteral calculi. Retrieved January, 9,
2007, from http://www.auanet.org/guidelines/main
reports/UreStnMain8 16.pdf
Segura, J. W., Preminger, G. M., Assimos, D. G., Dretler, S.
P., Kahn, R. I., Lingeman, J. E., et al. (1997b). Ureteral
Stones Clinical Guidelines Panel: The management
of ureteral stones: A doctor’s guide for patients.
Retrieved January 9, 2007, from www.auanet.org/
guidelines/patient guides/Ureteral Stones ptguide.pdf
Segura, J. W., Preminger, G. M., Assimos, D. G., Dretler,
S. P., Kahn, R. I., Lingeman, J. E., et al. (1997c). Ureteral
Stones Clinical Guidelines Panel summary report on
the management of ureteral calculi. The American
Advanced Emergency Nursing Journal
Urological Association. Journal of Urology, 158(5),
1915–1921.
Sheafor, D. H., Hertzberg, B. S., Freed, K. S., Carroll, B. A.,
Keogan, M. T., Paulson, E. K., et al. (2000). Nonen-
hanced helical CT and US in the emergency evaluation
of patients with renal colic: Prospective comparison.
Radiology, 217(3), 792–797.
Smith, R. C., Levine, J., & Rosenfeld, A. T. (1999). Heli-
cal CT of urinary tract stones: Epidemiology, origin,
pathophysiology, diagnosis, and management. Radiol-
ogy Clinics of North America, 37(5), 911–952, v.
Smith, R. C., Rosenfield, A. T., Choe, K. A., Essenmacher,
K. R., Verga, M., Glickman, M. G., et al. (1995). Acute
flank pain: Comparison of non-contrast-enhanced CT
and intravenous urography. Radiology, 194(3), 789–
794.
Smith, R. C., Verga, M., Dalrymple, N., McCarthy, S.,
& Rosenfield, A. T. (1996). Acute ureteral obstruc-
tion: Value of secondary signs of helical unenhanced
CT. AJR American Journal of Roentgenology, 167(5),
1109–1113.
Smith, R. C., Verga, M., McCarthy, S., & Rosenfield,
A. T. (1996). Diagnosis of acute flank pain: Value of
unenhanced helical CT. AJR American Journal of
Roentgenology, 166(1), 97–101.
Stamatelous, K. K., Francis, M. E., Jones, C. A., Nyberg,
L. M., & Curhan, G. C. (2006). Time trends in re-
ported prevalence of kidney stones in the United
States: 1976–2004. Kidney International, 63, 1817–
1823.
Traubici, J., Neitlich, J. D., & Smith, R. C. (1999). Distin-
guishing pelvic phleboliths from distal ureteral stones
on routine unenhanced helical CT: Is there a radiolu-
cent center? AJR American Journal of Roentgenol-
ogy, 172(1), 13–17.
Tublin, M. E., Dodd, G. D., III, & Verdile, V. P. (1994).
Acute renal colic: Diagnosis with duplex Doppler US.
Radiology, 193(3), 697–701.
Ueno, A., Kawamura, T., Ogawa, A., & Takayasu, H.
(1977). Relation of spontaneous passage of ureteral
calculi to size. Urology, 10(6), 544–546.
Varanelli, M. J., Coll, D. M., Levine, J. A., Rosenfield, A. T.,
& Smith, R. C. (2001). Relationship between duration
of pain and secondary signs of obstruction of the uri-
nary tract on unenhanced helical CT. AJR American
Journal of Roentgenology, 177(2), 325–330.