BLOCK OF KIDNEY AND URINARY TRACT SYSTEM

SCENARIO 2

TUTOR : Satriyo Dwi Suryantoro, dr., Sp.PD

GROUP 2A1 MEMBERS :

Garuda Nusantara P. U. 011911133009

Bendix Samarta Witarto 011911133010
Ahila Meliana 011911133011
Cahyani Tiara Safitri 011911133012
Ameilia Anastasya R.A. 011911133013
Bagus Dwi Nugraha 011911133014
A. Insyirah Khaerana 011911133015
Aprilia Mazikhatul Faizah 011911133016
Hana Salsabila 011911133017
Hafidz Alfarobi 011911133018

MEDICINE PROGRAMME
FACULTY OF MEDICINE UNIVERSITAS AIRLANGGA
SURABAYA
2021
SCENARIO

A 58-year-old woman came to the clinic complaining of left flank pain

OBJECTIVE
Students are expected to be able to implement knowledge of the kidney and urinary tract
system, the etiology and pathogenesis of diseases included in the kidney and urinary tract
system system in simulated cases. Students are expected to be able to understand cases of left
flank pain guidance from a facilitator.
 CHAPTER I

A. MAIN PROBLEM
Left flank pain
B. KEYWORDS
Female, 58 years old, clinic, left flank pain
C. EARLY HYPOTHESIS
The patient has low flank pain due to organ disorders of the urinary system
● Kidney :
○ Infection: pyelonephritis,
○ Tumors: Renal Carcinoma,
○ Other causes: Nephrolithiasis, Urolithiasis, Glomerulonephritis, Kidney
failure, Hydronephrosis
● Ureter
○ Infection: Ureteritis
○ Tumors:
○ Other causes: Ureteral Obstruction
● Bladder
○ Infection: Cystitis
○ Tumor
○ Other causes
● Urethra
○ Infection: Urethritis
○ Tumor
○ Other causes
The patient has low flank pain due to organ disorders from non-urinary system
● Muscle disorders
● Nervous disorders
● Injury/trauma
● Spinal disorders

D. ADDITIONAL QUESTIONS AND INFORMATIONS

Additional Questions
1. What is the patient's current address?
 Reason: to complete patient identification data
2. What type of pain does the patient currently feel? Is the pain dull or sharp?
Reason: to complete the history of the present illness and to know the exact
description of the pain experienced by the patient at this time
3. Does the patient experience pain during urination?
Reason: pain symptoms when urinating can help to refer to certain diseases, such
as kidney stones etc
4. How is the patient's urinary frequency and volume in a day?
Reason: To help confirm the diagnosis, e.g. kidney stones. Symptoms of kidney
stones can include increased frequency of urination and urination in small amounts.
5. What are the factors that exacerbate left back pain that the patient feels?
Reason: To complete the history of current illness
6. What are the factors that relieve left back pain that the patient feels?
Reason: to complete history of current illness
7. What is the patient's daily drinking habit?
Reason: lack of water consumption is a risk factor for kidney disease
8. Does the patient have a habit of holding urine?
Reason: is a risk factor for several diseases of the urinary system
9. What are the patient's daily eating habits?
Reason: To complete the psychosocial history and eliminate causative factors
10. What are the patient's daily exercise habits?
Reason: To complete the psychosocial history
11. Is there any radiating back pain?
Reason: to estimate low back pain originating from organs based on the
characteristics of the pain propagation

Additional Informations
1. Patient identity
- Name : Mrs. N
- Age : 58 years old
- Address: Gubeng, Surabaya
- Occupation: Retired Midwife
- Education : S1
- Marital Status : Widow, with 2 children
2. Current Medical History
- Chief complaint: left flank pain
- Duration : 2 weeks
- Pain quantity : Pain scale 2/10 (Disappearing)
- Type of pain felt (sharp/dull pain): no data
- Time : Since last 1 week
- Pee becomes reddish color
- Patients experiencing pain when urinating: no data
- Patient's urinary frequency: no data
- Other complaints: no fever
- Difficult BAK: no data
- Patient's daily urine volume: no data
- Aggravating factors: no data
- Mitigating factors: no data
3. Past Medical and Obstetric History
- Birth history: spontaneous
- No history of surgery
- No diabetes and high blood
- The patient had experienced passing stones during urination 10 years ago that
never been treated and had surgery
- No previous history of urinary tract infection
4. Medication History
- No medication history
5. Family Disease History
- Her father had urolithiasis (urinary stones)
6. Psychosocial History
- Smoking habit: none
- Habit of drinking coffee/tea: none
- Drinking habits per day: no data
- Habit of drinking alcohol: none
- Habit of holding urine: no data
- Eating habits: no data
- Exercise habits: no data
- Daily habits: no data
7. Review of System
Within normal limits
8. Physical Examinations
- General condition looks good
- BP : 116/80 mmhG
- Pulse: 72 x/minute
- Temperature: 36.3 C
- RR : 16x
- Weight/TB : 55kg/165cm
- Head and neck examination: normal
- Cardiopulmonary: normal
- Abdomen extremities: normal
- Left costovertebral tap pain
9. Supporting Investigations
- Urinalysis examination: Urinary sediment: many erythrocytes, leukocytes
2-4
- Blood Count: Hb : 12; Leukocytes: 6800; Platelet : 180,000
- Plain Abdomen
 ● A radiopaque shadow is seen at the level of the paravertebral 1 2 left
● Size 10 x 7 mm
● Conclusion: suspicion of left kidney stone
- Kidney functions check:
- Creatinine : 0.9
- BUN : 10
- IVP
- Left kidney inferior calyx stone
- Size : 10 x 7 mm
- Local calyectasis

E. EARLY CONCEPT MAPPING

F. LEARNING ISSUE I
1. What are the complaints related to flank pain?
2. What are the complaints related to red/bloody urine?
3. What is the anatomy and physiology of the lower urinary tract in women?
4. What are the pathophysiology, symptoms, and risk factors for the formation of
urolithiasis (urinary tract stones)?
5. What is the differential diagnosis of low flank pain with bloody urine?
6. What are the physical examinations and investigations needed for low flank pain
with bloody urine?
 CHAPTER II

A. COGNITIVE STRATEGY
1. Gaining crucial information by asking additional questions
2. Seeking references through journals, textbooks, and many more other credible
resources
3. Thinking critically to solve the problem using information gained by the answers
of the additional questions and literature

B. ANSWER OF LEARNING ISSUE I

1. What are the complaints related to flank pain?
Low flank pain is usually defined as pain, muscle tension, or stiffness localized
below the costal margins and above the inferior gluteal folds, with or without leg
pain (sciatica). The following are complaints related to low flank pain (Purnomo,
2003):
a. Urethral stones
Urethral stones usually come from kidney stones / ureter stones that go down
the bladder, then enter the urethra. The complaint submitted by the patient is
that micturition suddenly stops causing urinary retention, which may have
been preceded by low flank pain. If the stone comes from the ureter that
descends into the bladder and then into the urethra, the patient usually
complains of low flank pain before complaining of difficulty in micturition.
b. Renal Hamartoma
Renal hamartoma or angiomyolipoma is a benign kidney tumor consisting of
fat, blood vessels, and smooth muscle components. This tumor affects more
women than men with a ratio of 4: 1. Clinical symptoms that may be
complained of are: low flank pain, hematuria, symptoms of upper urinary tract
obstruction and sometimes there are symptoms of retroperitoneal cavity
bleeding.
c. Renal adenocarcinoma
Renal adenocarcinoma is a malignant tumor of the renal parenchyma
originating from the proximal tubule of the kidney. These tumors constitute
3% of all malignancies in adults. The clinical picture of this disease is that
there are three classic triad signs, namely: low flank pain, hematuria, and a
 mass in the waist which is a sign of a tumor in an advanced stage. Pain occurs
due to tumor invasion into other organs, obstruction to urine flow, or tumor
mass causing stretching of the fibrous capsule of the kidney.
d. Ureteral colic or renal colic
Ureteral colic or renal colic is severe low flank pain that comes on suddenly,
intermittently, which occurs as a result of smooth muscle spasm against an
obstacle. The feeling of pain begins in the lumbar region and can radiate
throughout the abdomen, to the inguinal area, testicles, or labium. The cause of
blockage in general is a stone, blood clot, or debris that comes from the kidney
and descends into the ureter. The clinical picture is usually found that the
patient looks restless, has low flank pain, always wants to change positions
from sitting, sleeping then standing in order to get a position that is considered
painless.
e. Acute cystitis
Acute cystitis is an acute inflammation of the bladder mucosa which is often
caused by infection by bacteria. Unlike the symptoms of an upper urinary tract
infection, cystitis is rarely accompanied by fever, nausea, vomiting, weakness,
and general deterioration. If accompanied by fever and low flank pain, it is
necessary to think about the spread of infection to the upper urinary tract.

2. What are the complaints related to red/bloody urine?

Urinating blood in medical terms is also known as hematuria. Usually, blood
mixed with urine will appear reddish, pink, or dark brown, similar to tea.
Urinating blood is not always dangerous, for example in women who are
menstruating. Complaints related to red/bloody urine are as follows:
a. Urinary tract infection
Urinary tract infection or UTI is one of the main causes of bloody urine
complaints. This disease occurs when bacteria multiply in the urinary tract or
bladder. The entry of bacteria into the urinary tract can be triggered by many
things, such as the installation of a urinary catheter, the habit of holding pee,
the flow of urine is not smooth, or how to clean the vagina that is not correct.
In addition, UTIs are usually more at risk for pregnant women or people who
frequently change sexual partners. In addition to urinating blood, urinary
tract infections can cause various other symptoms, such as a burning
 sensation or pain when urinating, ‘anyang-anyangan’, frequent urination,
strong urine odor, and pain in the abdomen or flank pain.
b. Kidney disorders
There are several kidney disorders that can cause symptoms in the form of
blood urine, namely kidney infections, kidney stones, kidney failure,
glomerulonephritis, and kidney cancer. In addition, nephritic syndrome and
nephrotic syndrome can also cause blood to pass through the urine. In
addition to urinating blood, kidney disorders can cause various other
symptoms, such as pain in the lower back or waist, swelling in the body, legs,
hands, and face, shortness of breath, nausea, vomiting, reduced appetite,
itching. , to chest pain.
c. Enlarged prostate
In men, enlargement or abnormalities in the prostate is one of the most
common causes of bloody urine. This condition generally occurs in men over
the age of 50. Some diseases of the prostate that can cause bloody urine
include benign prostate enlargement (BPH), prostate inflammation, and
prostate cancer. In addition to blood in the urine, an enlarged prostate can
also cause difficulty urinating, frequent urges to urinate, more urination at
night, and a feeling of less completeness after urination.
d. Bladder cancer
Blood in the urine can also be caused by bladder cancer. In addition to
causing bloody urine, bladder cancer can cause pain when urinating and flank
pain. Unfortunately, most of these symptoms are only felt when the condition
is severe or when the cancer has reached an advanced stage. Bladder cancer
can be caused by many factors, including smoking, chronic urinary tract
infections, chemical exposure, radiation exposure, or having a family history
of bladder cancer. As explained above, urinating blood can be a sign of a
serious condition. Therefore, if you notice blood in your urine, both in large
and small amounts, you should not ignore it and immediately consult a
doctor so that the cause can be identified

3. What is the anatomy and physiology of the lower urinary tract in women?

Anatomy of the lower urinary tract in women

The lower urinary tract consists of the urinary bladder and urethra.

a. Urinary Bladder

The empty bladder is shaped like a pyramid with three sides with one end at
one end. The urinary bladder has an apex, a base, and a superior surface, and
two inferolateral surfaces.

- The apex vesicae faces the top of the symphysis pubica; a structure known
as the median umbilical ligament (a remnant of the chorda urachus/chorda
umbilicalis embryonic that contributes to the formation of the urinary
bladder) continues superiorly up the anterior abdominal wall towards the
umbilicus.

- The base of the bladder is shaped like an inverted triangle and faces
posteroinferior. The two ureters enter the bladder at each upper corner of
the bladder base, and the urethra passes inferiorly from the lower corner of
the bladder base. Internally, the mucosal layer at the base of the bladder is
smooth and firmly adheres to the smooth muscle layer of the underlying
wall—unlike elsewhere in the bladder where the mucosa is folded and
loosely attached to the wall. The smooth triangular area between the
ureteral os and the urethra on the inside of the urinary bladder is known as
the trigone vesicae.
- The inferolateral surface of the bladder is supported between the levator
ani muscle of the pelvic diaphragm and the adjacent obturator internus
muscle, above the attachment of the pelvic diaphragm. The superior
surface is almost dome-shaped when the bladder is empty; The superior
surface expands upward as the bladder fills.

b. Cervix/collum vesicae

The cervix vesicae surrounds the beginning of the urethra at the point where
the two inferolateral surfaces and the base of the bladder cross. Cervix
vesicae is the most inferior part of the urinary bladder and is also the most
"fixed" part. The cervix vesicae is anchored into position by a pair of strong
fibromuscular bands, which connect the cervix vesicae and the pelvic part of
the urethra to the posteroinferior aspect of each pubic bone. In women, this
 fibromuscular band is called the pubovesical ligament. Together with the
perineal membrane and associated muscles, the levator ani muscle, and the
pubic bone, these ligaments help support the bladder.

c. Urethra

The urethra begins at the base of the bladder and ends with an opening
(ostium urethrae externum) in the perineum. The pathways taken by the
urethra differ significantly in women and men. In women, the urethra is
short, about 4 cm long. The urethra passes with a slight curvature as it passes
inferiorly across the pelvic floor into the perineum, where it passes through
the deep perineal space and perineal membrane before opening into the
vestibule vaginale which lies between the two labium minus pudendi. The
external urethral os is located anterior to the vaginal ostium in the vaginal
vestibule. The inferior aspect of the urethra is attached to the anterior surface
of the vagina. Two small paraurethral mucous glands (Skenes' glands)
communicate with the lower end of the urethra.

Physiology

Once formed in the kidneys, urine is channeled through smooth muscle-lined

ureters to the bladder. Urine does not flow through the ureters simply due to the
pull of gravity. Peristaltic contractions of smooth muscles in the walls of the
ureters push urine forward from the kidneys to the bladder. The ureters penetrate
the bladder wall obliquely, traveling along the bladder wall for several
centimeters before opening into the bladder cavity. This anatomic arrangement
prevents backflow of urine from the bladder to the kidneys when pressure in the
bladder increases. As the bladder fills, the ends of the ureters within the bladder
wall are compressed until they close. However, urine can still enter because
contraction of the ureter produces sufficient pressure to overcome the resistance
and push the urine through the closed end.

a. The role of the bladder

The bladder can accommodate large fluctuations in urine volume. The bladder
wall is composed of smooth muscle which is lined by a special type of
 epithelium. Both epithelium and smooth muscle are actively involved in the
bladder's ability to accommodate large changes in urine volume. The surface
area of ​the epithelium can be increased and decreased through a gradual
process of repeated cycles of membranes as the bladder fills and empties
alternately. During bladder filling, cytoplasmic vesicles enclosed by a
membrane are inserted through the process of exocytosis to the surface area,
then the vesicles are pulled in by endocytosis to reduce the surface area during
bladder emptying. Bladder smooth muscle can be stretched greatly without
causing an increase in bladder wall tension. In addition, the highly folded
bladder wall folds flat during bladder filling to increase storage capacity.
Bladder smooth muscle is rich in parasympathetic fibers, the stimulation of
which causes bladder contractions. If the channel through the urethra is open,
the bladder contracts to empty the urine from the bladder. However, the exit
from the bladder is guarded by two sphincters, the internal urethral sphincter
and the external urethral sphincter. The contraction of the bladder will empty
the urine from the bladder. However, the exit from the bladder is guarded by
two sphincters, the internal urethral sphincter and the external urethral
sphincter. The contraction of the bladder will empty the urine from the bladder.
However, the exit from the bladder is guarded by two sphincters, the internal
urethral sphincter and the external urethral sphincter.

b. The role of the urethral sphincter

A sphincter is a ring of muscle that closes or allows passage when it is open.

The internal urethral sphincter is a polis muscle and hence its control is
involuntary. When the bladder relaxes, the anatomical arrangement of the
internal urethral sphincter region closes the bladder outlet. In the lower part of
the outlet, the urethra is surrounded by a layer of skeletal muscle, the external
urethral sphincter. This sphincter is strengthened by the entire pelvic
diaphragm. The motor neurons that innervate the external sphincter and pelvic
diaphragm continue to signal at a moderate rate unless inhibited so that these
muscles continue to contract tonically to prevent the passage of urine from the
urethra. Under normal circumstances, when the bladder relaxes and fills, both
the internal and external sphincters are closed to prevent dripping of urine.
4. What are the pathophysiology, symptoms, and risk factors for the formation
of urolithiasis (urinary tract stones)?
Urolithiasis is the process of formation of stones (calculi) in the urinary tract that
can exit the renal pelvis and move to the rest of the urinary collecting organs,
including the ureters, bladder and urethra.
a. Pathophysiology
Urolithiasis occurs when the high consistency of urine causes precipitation and
crystallization to form stones (calculi) in the kidney parenchyma which is
known as nephrolithiasis. These crystals will aggregate together and continue
to grow, potentially migrating to the ureter and causing symptomatic
symptoms. If the stone is obstructed, one of which is urinary stasis and
decreased urine volume due to dehydration and inadequate fluid intake, this
can increase the risk of urolithiasis. Difficulty expelling urine through the
ureters, dilatation of the ureters and renal pelvis may occur, causing pain due
to increased luminal tension and hydronephrosis will cause the release of
prostaglandins, resulting in the colic pain associated with this condition. The
location of stones that most often clogs is around the ureteropelvic junction
(UPJ) because in that area the diameter of the ureter is very narrow. There are
two areas of narrowing in the ureter, the first is the area where the ureter
crosses the iliac vessels and the second is at the ureterovesical junction (UVJ).
In addition, various conditions that trigger the occurrence of urolithiasis such
as diverse stone compositions are the main factors for identifying the cause of
urolithiasis (Thakore and Liang, 2021).
b. Symptom
In most cases, patients with urinary tract stones are asymptomatic and only
discovered after a physical examination and investigations have been carried
out. The classic feature of renal colic is sudden, severe pain. It is usually
caused by the presence of colic in the kidneys, renal pelvis or ureters, causing
dilatation, stretching and spasm of the ureters. Pain begins in the loin around
the costovertebral angle (but sometimes lower) and moves to the groin, with
tenderness in the loin or renal angle, sometimes with haematuria. If the stone is
high and the renal capsule is distended then the pain will be in the waist but as
it moves down the pain will move anteriorly and down towards the groin.
 Stones that move are often more painful than stones that are static. Whereas
biliary or bowel colic pain is intermittent, renal colic pain is more constant but
there is often a period of relief or just a dull ache before it returns. The pain
may change as the stone moves. Patients can often pinpoint the site of maximal
pain and this correlates well with the current location of the stone. Other
symptoms that may be present include: Stiffness and fever. dysuria. Hematuria.
Urinary retention. Nausea and vomiting (Knott, 2021).
c. Risk Factor
The formation of urinary tract stones is associated with the onset of previous
recurrence which occurs in about 50% of patients who can relapse at least 1
time in a lifetime. Risk factors for the formation of urolithiasis include, having
experienced urolithiasis at a young age, heredity with a history of urolithiasis,
stones containing brushite (CaHPO4.2H2O), uric acid and stones containing
uric acid, stones due to infection, hyperparathyroidism, metabolic syndrome,
and drug factors. -medicine.

5. What are the differential diagnoses for low flank pain and bloody urine?
a. Kidney stones
Symptoms that can occur:

- Flank pain: Symptoms or complaints of flank pain can be colic or

non-colic pain.
- Colic pain: Occurs because peristaltic activity of the smooth muscles of
the calyces system increases in an effort to expel stones from the urinary
tract.
- Tenderness or knock: This symptom of tenderness or tenderness
(costovertebral angle/CVA) usually occurs in the area of ​the costal arch on
the side of the affected kidney.
- Symptoms of urinary tract infection: Kidney organs that function as
filters for toxins that enter the body and dispose of them with urine,
making kidney stones even large can interfere with the urinary tract.
Complaints that can be felt are almost the same as symptoms of a urinary
tract infection such as flank pain, fever, dysuria, and increased frequency
of urination. If it is advanced due to infection (urinary tract), fever and
pain can occur when urinating.
 - Hematuria: Hematuria is a condition of bloody urine. Blood that comes
out when urinating can be caused by various diseases, ranging from
urinary tract infections, kidney disease, to prostate cancer. Associated with
large kidney stones such as kidney stones cause trauma to the urinary tract
mucosa. This happens, especially after exercising or carrying out
strenuous activities because the stones rub against each other and erode
the urinary tract mucosa. In addition to bloody urine, another symptom of
kidney stones to watch out for is cloudy, sandy urine or small stones.
b. Kidney Cancer
Kidney cancer is often associated with a person's advanced age, obesity,
smoking, and high blood pressure. The kidneys are part of the urinary system,
which function to filter toxins and excess fluids and electrolytes from the
blood. These organs also produce hormones that aid in the production of red
blood cells and help regulate blood pressure.
- Symptom
Symptoms usually do not appear in the early stages of kidney cancer. Some
people start to experience it especially when the cancer spreads more widely.
This causes the following symptoms:
● There is blood in the urine
● Feeling a lump on the side or waist.
● Fever and night sweats
● High blood pressure
● Loss of appetite.
Several factors are associated with the risk of developing kidney cancer,
including smoking, obesity, high blood pressure, family history, herbicides
(agricultural chemicals to treat weeds), and metals such as cadmium (heavy
metal contamination). More often found in men.

c. Endometriosis

Endometriosis can be one of the causes of hematuria in women. This disease

occurs when the tissue that lines the uterus grows outside the uterus. Although
it can affect any part of the body, endometriosis usually occurs in the outer
lining of the uterus, ovaries and fallopian tubes. If left untreated,
 endometriosis can affect a woman's fertility. Symptoms of endometriosis can
vary. Some women may experience mild symptoms, but some may experience
moderate to severe symptoms. Some of the symptoms that generally arise are:
● Severe pain in the lower abdomen and around the pelvis, especially during
menstruation
● Stomach cramps for a few days before and during menstruation
● Excessive blood volume during menstruation
● Pain in the flank pain during menstruation
● Bleeding outside the menstrual cycle
● Dyspareunia or pain during or after sexual intercourse
● Pain when defecating or urinating
● Diarrhea, bloating, nausea, constipation, and easily tired during
menstruation
● Difficult to get pregnant
d. Urinary Tract Infection

A urinary tract infection, often abbreviated as UTI, is a condition where an

infection occurs in one or more parts of the urinary system. This urinary
system includes the kidneys, ureters (tubes from the kidneys to the bladder),
bladder, and urethra (tubes that release urine). Symptoms of a urinary tract
infection can be characterized by complaints such as pressure in the lower
abdomen, discomfort in the lower abdomen, and blood in the urine. Lower
urinary tract infections involving the bladder and urethra are usually
characterized by:

● Strong and persistent urge to urinate suddenly

● Pain or discomfort when urinating
● Feeling incomplete or feeling that something is left behind when urinating
● ‘anyang-anyang’
● Turbidity in urine
● Changes in the color of urine to red, light pink, or brown
● The pungent smell of urine
● Pain in the lower abdomen, especially experienced in women
● Feeling sore and tired easily
 Meanwhile, the signs and symptoms of a UTI that generally occur in upper
urinary tract infections involving the kidneys and ureters are:

● Fever with a temperature above 38oC

● Pain in the waist
● Shivering
● Agitation and discomfort in the body
6. What are the physical examinations and investigations needed for low flank pain
with bloody urine?
a. Physical examination

Physical examination of the patient with complaints of low flank pain and
bloody urine (hematuria) that can be found among others:

● Hypertension (blood pressure)

● Fever: increase in body temperature associated with an inflammatory
reaction.
● Anemia: can occur due to blood being wasted with urine so that the
number of red blood cells in the body is reduced, this can be identified
through conjunctival examination.
● Shock (general condition of the patient)
● Kidney palpation: some possibilities that can be found from kidney
palpation can be palpable enlargement of the kidneys.
● Knock examination of the kidneys: at the costovertebral angle in abnormal
circumstances will feel tenderness, tenderness of the tap.
● Supra symphysis: Tenderness, palpable stone, bladder full impression
● External Genitalia Palpation: Palpable stones in the urethra
● Digital rectal (rectal tussae): Palpable stones in the bladder (bimanual
palpation)
b. Supporting investigation
● Urinalysis
A urinalysis is the initial and most useful test to perform. Although urine
dipsticks are widely available and can be performed quickly, they can give
a false positive or false negative result and require urinalysis and a urine
microscope to confirm the diagnosis. The presence of 3 or more RBCs per
 High Power Field in the urine sediment was defined as microscopic
hematuria even though there was no "safe" lower limit of hematuria.
Appearance of urine, pH, presence of protein, leukocytes, nitrite,
leukocyte esterase, crystals, and casts are very helpful. A dirty urine
specimen with significant leukocytes, positive nitrite, and leukocyte
esterase indicates a urinary tract infection (UTI) and a possible cause of
hematuria. Meanwhile, the presence of proteinuria with hematuria
indicates the possibility of glomerulonephritis.
● Blood Check
In addition to a complete urinalysis, a complete blood count, serum
electrolytes, blood urea nitrogen, and serum creatinine may also be
performed. If a coagulation disorder is suspected, the prothrombin time,
partial thromboplastin time, and bleeding time should be checked
(prothrombin time, partial thromboplastin time, and bleeding time).
● Urine Microscopic Examination
Microscopic examination of urine is used to examine urine sediment for
erythrocytes and the erythrocyte cast is the single most significant test that
can differentiate between glomerular and non-glomerular hemorrhage.
Dysmorphic erythrocytes >25% per High Power Field were highly
specific (>96%) with a high positive predictive value (94.6%) but not very
sensitive (20%) for Glomerulonephritis. Erythrocyte casts are rare but
almost diagnose glomerular pathology.
● Imaging
CT scan of the abdomen with or without contrast is the modality of choice
for detecting kidney stones and other renal morphological abnormalities.
Other imaging may include IVP, ultrasound of the kidneys, ureters, and
bladder. Both tests can help in diagnosing anatomic causes of hematuria
such as kidney/bladder stones or kidney masses. In addition, it can also
detect kidney cysts. MRI of the abdomen and pelvis is another useful
modality if CT scanning is contraindicated or unhelpful.
● Cystoscopy
After ruling out a urinary tract infection and having negative imaging of
the kidneys and ureters to detect any abnormalities, cystoscopy by a
urologist is the next step in the evaluation of hematuria. This examination
 can detect urothelial carcinoma, bladder wall inflammation, or thickening
of the mucosa.
● Urine cytology
Urine cytology may be performed to detect malignant cells or to detect
urothelial carcinoma, but it is not a substitute for cystoscopy.
● Kidney biopsy
Renal biopsy is the gold standard for diagnosing the cause of glomerular
haematuria. The presence of dysmorphic erythrocytes and an erythrocyte
cast should be followed by a renal biopsy. Because it is an invasive test, it
can cause complications such as life-threatening bleeding, but the
frequency of occurrence is low. An adequate kidney sample is 2-3 biopsy
nuclei with a sufficient number of glomeruli. Light microscopy, electron
microscopy, and immunofluorescence are performed to view the structure
of the glomerulus to diagnose glomerulonephritis.

C. LOGICAL AND CRITICAL ANALYSIS OF PROBLEMS IN SCENARIO

A 58-year-old woman came to the clinic because of pain in the left hip. From
the anamnesis, it was found that the patient's complaints had been going on for the last
2 weeks with the quality of dull pain that came and went without propagation and the
quantity of pain was 2 out of 10. Pain was reduced by the use of analgesic drugs. In
addition, we found the presence of red urine in the patient. The patient's frequency of
urination is 5-6 times per day which is normal. The patient did not feel pain when
urinating and the habit of holding urine was denied. Based on previous medical
history, the patient did not have other diseases such as diabetes mellitus, high blood
pressure, and had never had a urinary tract infection before. However, about 10 years
ago the patient had experienced a stone that came out during urination. The patient
had never previously received treatment or underwent surgery. History of the patient's
delivery is spontaneous delivery. The patient's father had previously suffered from
urinary tract stones (urolithiasis). The patient never drank alcohol or smoked.

Complaints of low flank pain related to the urinary system and complaints of
hematuria can be caused by urinary tract infections, urinary tract stones, and kidney
cancer. In these patients, upper urinary tract infections could be excluded because
there were no complaints of fever. Lower urinary tract infections were also excluded
 because there was no dysuria and urinary frequency in normal patients. Intermittent
pain in the patient is in accordance with the pain caused by the presence of urinary
tract stones. This intermittent pain occurs due to peristaltic activity of the smooth
muscles of the urinary tract in an attempt to expel stones. In addition, the patient was
found to have risk factors for urinary tract stones in the form of a previous history of
urolithiasis and heredity from his father. In kidney cancer, the course of disease tends
to be chronic and generally in patients with kidney cancer usually found a mass on
the side or bottom of the back, so it is necessary to do further examination to
determine the presence of a mass. For now, the patient's diagnosis is likely to lead to
urinary tract stones and other possibilities such as kidney cancer. Therefore, to
confirm the diagnosis, further examination is needed, namely physical examination
and supporting examinations such as urinalysis, urine microscopy, urine culture,
radiological examination, and kidney biopsy if there are indications.

OBSTACLES

One of the obstacles is technical problems. All the members have to ensure that they
have adequate signals and well-worked devices during the online class. All of the
group members did not experience any problems in searching for data and
information.

D. LEARNING ISSUES II
1. What is the etiology and pathophysiology of nephrolithiasis (kidney stones)?
2. What are the complications and prognosis of nephrolithiasis (kidney stones)?
3. How is the management and medical management of nephrolithiasis (kidney
stones)?
4. How is education and prevention in nephrolithiasis (kidney stones)?
 CHAPTER III

A. METHOD AND STEPS IN FINDING INFORMATION

To find the information needed for our scenario, we conducted a tutorial three times,
guided by a doctor as a tutor.
In the first tutorial, we discuss the main problems and keywords. After that we
determined some early hypotheses. We then asked the tutor about additional data,
each question for additional data must be accompanied by a reason. After getting
additional data, we compiled the first learning issue to discuss the answers in the
second tutorial on e-learning. We search for the answer for the learning issue based on
valid journals and books with the longest period in the last 10 years.We also discuss
making an early concept mapping.
In the second tutorial, we discussed the answers of the first learning issue.
Furthermore, we can ask tutors additional questions and reasons for additional data.
Additional questions that cannot be answered by the tutor can be asked to the scenario
maker on e-learning. Then, we made learning issue 2 to be discussed in the third
tutorial. We answer the learning issue based on books and journals that we have
learned.
In the third tutorial, we discussed learning issue 2 which was compiled at the previous
meeting. Next, we discussed making the final concept mapping and concluded the
final hypothesis.

B. ANSWER OF LEARNING ISSUES II

1. What is the etiology and pathophysiology of nephrolithiasis (kidney stones)?
a. Etiology
The etiology of urinary tract stones (urolithiasis) includes kidney stones
(nephrolithiasis) depending on the type of stone formed. The etiology of stones
that form can come from non-infection, infection, genetic disorders, and drugs.
The most common types of stones are calcium oxalate or phosphate stones (up to
80%). Other types of stones include uric acid (9%), struvite (10%), and cystine
stones (1%). Different types of stones occur due to various risk factors such as
diet, previous personal and family history of stones, environmental factors,
medications, and the patient's medical history.
The following is the etiology of kidney stones based on the type of stone formed:
- Calcium Stone
a. Hypercalciuria (presence of > 4 mg Ca/kg/day in urine) without
hypercalcemia: Idiopathic, renal tubular acidosis, medullary sponge
kidney, nephrotoxicity of cadmium and beryllium.
b. Hypercalciuria with hypercalcemia:
● Primary hyperparathyroidism
● Secondary hyperparathyroidism
c. Hyperoxaluria:
● Primary hyperoxaluria: 3 types due to a gene mutation that causes a
unique enzymatic defect in the hepatic glyoxylate pathway.
● Secondary hyperoxaluria: Malabsorption or excess intake (celiac
disease, Crohn's disease, chronic pancreatitis, short bowel syndrome,
after bariatric surgery); ethylene glycol poisoning.
d. Hypocitraturia: metabolic acidosis, hypokalemia, hypomagnesemia,
starvation, infection, androgens, and exercise.
e. Medications: Loop diuretics, vitamin D, corticosteroids, calcium
supplements, antacids (both calcium and non-calcium), theophylline, and
topiramate.

- Uric Acid Stones

a. Hyperuricosuria: excessive purine or protein intake, disorders related to
cell damage (tumor lysis syndrome, myeloproliferative disorders,
hemolytic anemia), gout, shift of uric acid from intracellular to
extracellular, uricosuric drugs, certain inherited metabolic errors
(Lesch-Nyhan syndrome and Glucose-6-phosphatase deficiency), and
possibly excessive fructose intake.
b. Urine pH < 5.5: The increasing incidence of obesity and insulin resistance
in the United States leads to a parallel increase in uric acid lithiasis.
Urinary acidosis is probably the result of impaired ammoniagenesis, which
results in excessive excretion of (unbuffered) acid and a very low urine
pH.
c. Drugs: Salicylates, probenecid, and melamine (contamination in baby milk
products)
- Struvite Stone
Struvite stones are composed of magnesium ammonium phosphate and calcium
carbonate apatite.
a. Infection by organisms that produce urease: Proteus, Haemophilus,
Yersinia spp., Staphylococcus epidermidis, Pseudomonas, Klebsiella,
Serratia, Citrobacter, and Ureaplasma.
Women are more susceptible to struvite nephrolithiasis than men because
women tend to be more susceptible to UTIs. Other risk factors for struvite
nephrolithiasis include patients with urinary catheters, neurogenic bladder,
genitourinary tract anomalies, and spinal cord lesions. Alkaline urine (pH
7.0), urine cultures of urease-producing bacteria, and large kidney stones
suggest the diagnosis of struvite nephrolithiasis.
b. Increased urine pH

- Cystine Stone

Hereditary disorder of tubular transport with mutations in the solute-linked

carriers genes 3A1 and 7A9.

- Xanthine stone

Associated with inherited metabolic disorders such as hereditary xanthinuria or

Lesch-Nyhan syndrome.

- Drugs

Here's a table of drugs that can cause kidney stones:

 Table source: (Dobrek, 2020)

b. Pathophysiology

Stone formation

Nephrolithiasis is probably caused by two basic phenomena. The first

phenomenon is hypersaturation of urine by stone-forming constituents, including
calcium, oxalate, and uric acid. Ions from saturated urine form microscopic
crystal structures. The resulting deposits cause symptoms when they collide in the
ureters as they pass through the bladder.

Most kidney stones contain calcium. Uric acid stones and uric acid crystals, with
or without other polluting ions, make up the majority of the remaining minority
material. Other, less common types of stones include cystine, ammonium uric
acid, xanthine, dihydroxyadenin, and various rare stones associated with
deposition of drugs in the urinary tract. Urinary supersaturation is likely the
underlying cause of urate and cystine stones, but calcium-based stones (especially
calcium oxalate stones) may have a more complex etiology.

The second phenomenon, most likely responsible for calcium oxalate stones, is
the deposition of stone material in the renal papillary calcium phosphate nidus,
usually Randall's plaques (which are always composed of calcium phosphate).
Evan et al proposed this model based on evidence gathered from several
laboratories.

Calcium phosphate precipitates on the basement membrane of the thin loop of

Henle, is eroded into the interstitium, and then accumulates in the subepithelial
space of the renal papilla. The subepithelial deposits, long known as Randall
plaques, are eventually eroded through the papillary urothelium. The stone
matrix, calcium phosphate, and calcium oxalate gradually settle on the substrate
to make urinary calculus.

Development of renal colic pain and kidney damage

The type of colic pain known as renal colic usually begins in the upper lateral mid
back above the costovertebral angle and sometimes subcostals. It spreads
inferiorly and anteriorly towards the groin. Pain produced by renal colic is
primarily due to the dilatation, stretching, and spasm caused by acute ureteral
obstruction. (When a severe but chronic obstruction develops, as in some types of
cancer, it is usually painless.)

In the ureter, increased proximal peristalsis via activation of the intrinsic ureteral
pacemaker may contribute to pain perception. Muscle spasm, increased proximal
peristalsis, local inflammation, irritation, and edema at the site of obstruction may
contribute to the development of pain through activation of chemoreceptors and
stretching of submucosal free nerve endings.

The term "renal colic" is actually a misnomer, as this pain tends to be persistent,
whereas intestinal or biliary colic is usually rather intermittent and often comes in
waves. The pattern of pain depends on the individual's pain threshold and
perception and on the speed and degree of change in hydrostatic pressure in the
proximal ureter and renal pelvis. Ureteral peristalsis, stone migration, and tilting
or twisting of the stone with subsequent intermittent obstruction can cause
exacerbation or renewal of renal colic pain.

The severity of the pain depends on the degree and location of the obstruction,
not on the size of the stone. A patient can often point to the site of maximum
tenderness, which is most likely the site of ureteral obstruction (see image
below).

Nephrolithiasis: acute renal colic. Distribution of renal and ureteral pain.

Stones that move down the ureter and cause only intermittent obstruction may
actually be more painful than stones that don't move. Constant obstruction, even
if high grade, allows multiple autoregulatory mechanisms and reflexes, renal
interstitial edema, and pyelolymphatic and pyelovenous backflow to help reduce
renal pelvic hydrostatic pressure, which gradually helps reduce pain.

The resulting renal interstitial edema stretches the renal capsule, enlarges the
kidney (ie, nephromegaly), and increases renal lymphatic drainage. (Increased
capillary permeability facilitates this edema.) It may also reduce the radiographic
density of the affected renal parenchyma when viewed on a non-contrast CT scan.

Renal pelvic distention initially stimulates ureteral hyperperistalsis, but this

diminishes after 24 hours, as does renal blood flow. Peak renal pelvic hydrostatic
pressure is reached within 2-5 hours after complete obstruction. Within the first
90 minutes of total ureteral obstruction, there is vasodilation of the preglomerular
afferent arterioles, which temporarily increases renal blood flow. Between 90
minutes and 5 hours after obstruction, renal blood flow begins to decrease while
intraureteral pressure continues to rise. At 5 hours after complete obstruction,
renal blood flow and intraluminal ureteral pressure decreased on the affected side.

Renal blood flow decreases to about 50% of normal levels after 72 hours, 30%
after 1 week, 20% after 2 weeks, and 12% after 8 weeks. At this point,
intraureteral pressure has returned to normal, but proximal ureteral dilation
remains and ureteral peristalsis is minimal.

Interstitial edema in the affected kidney actually increases fluid reabsorption,

which helps increase renal lymphatic drainage to establish a new, relatively stable
balance. At the same time, renal blood flow is increased in the contralateral
kidney because renal function is decreased in the obstructed unit.

In summary, within 24 hours of complete ureteral obstruction, the hydrostatic

pressure of the renal pelvis has decreased because of:

1) Decreased ureteral peristalsis.

2) Decreased renal arterial vascular flow, leading to a corresponding

decrease in urine production on the affected side; and

3) Renal interstitial edema, which causes a marked increase in renal

lymphatic drainage.

In addition, as the ureter proximal to the stone is distended, some urine may
occasionally flow around the obstruction, relieving proximal hydrostatic pressure
and establishing a stable and relatively painless balance. These factors explain
why severe renal colic pain usually lasts less than 24 hours in the absence of
infection or movement of the stone.

Whether calix stones cause pain is controversial. In general, in the absence of

infection, how kidney stones cause pain remains unclear, unless they also cause
obstruction. Arguably, proving that calices cause obstruction can be difficult.
However, a stone trapped in the lid can block the passageway from that lid,
causing blockage and subsequent pain.
 If there is only partial obstruction, the same changes occur, but to a lesser extent
and over a longer period of time. The hydrostatic pressure of the renal pelvis and
proximal ureter tends to remain elevated for longer, and ureteral peristalsis does
not decrease rapidly. If the increased pressure is sufficient to establish reasonable
flow beyond the obstructing stone, glomerular filtration and renal blood flow
approach the baseline reference range, although pain may persist.

2. How is the management and medical management of nephrolithiasis (kidney stones)?

a. According to Guyton, 1993 complications of nephrolithiasis are:
● Kidney failure: Occurs due to further damage to the nephrons and blood
vessels called compression stones on the kidney membrane due to obstructed
oxygen supply. This leads to renal ischemia and if left untreated can lead to
kidney failure.
● Infection: In a static urine stream is a good place for the proliferation of
microorganisms. This will cause peritoneal infection.
● Hydronephrosis: Because the flow of urine is blocked, it causes urine to be
retained and accumulate in the kidneys and over time the kidneys will enlarge
due to the accumulation of urine.
● Avascular ischemia: Occurs because blood flow to the tissue is reduced,
resulting in tissue death.
b. Prognosis

Nephrolithiasis is a lifelong disease process. The recurrence rate of

nephrolithiasis is 50% in 5 years (Khan et al., 2016). Patients at the highest risk
for relapse are often those who do not comply with medical therapy and
dietary/lifestyle modifications, or if there is an underlying metabolic disorder.
Residual stone fragments from surgery will usually pass spontaneously as long as
they are <4 mm in size. The Return of Kidney Stones (ROKS) can be used to
help predict the risk of a second kidney stone (Rule et al., 2014).

Kidney stones that cannot pass through the urinary tract are potentially
obstructive and can cause acute kidney failure, or they can become a nidus of
infection that can be fatal. If the patient undergoes a nephrostomy tube or
catheter, there is a possibility of bleeding, renal collecting system injury, visceral
 organ injury, pulmonary complications, thromboembolic complications, and
extrarenal stone migration (Nojaba & Guzman, 2020).

3. How is education and prevention in nephrolithiasis (kidney stones)?

The decision to treat upper urinary tract stones can be based on stone composition,
stone size, and patient symptoms. The general therapy to treat the symptoms of
urinary tract stones is the administration of analgesics should be given immediately in
patients with acute colic pain. Non-Steroid Anti Inflammation Drugs (NSAID) and
paracetamol with regard to the dose and side effects of the drug are the drugs of first
choice in patients with acute colic pain and have better efficacy than opioids. NSAIDs
that can be given include diclofenac, indomethacin, or ibuprofen.

The specific treatment options for kidney stones are as follows.

1. Conservative (Observation)

Observation of kidney stones, especially in the calyx, depends on the history of

the disease course. Recommendations for observation of kidney stones are
currently not supported by good literature. Currently, a prospective study
recommends annual observation for asymptomatic inferior calyx stones 10
mm. If there is an increase in the size of the stone, the interval follow-up need
to be shortened. Intervention is recommended if the stone increases in size >5
mm.

2. Pharmacologist

Dissolution of stones by pharmacological treatment is the only treatment

option for uric acid stones, but information about stone composition is
necessary in determining the choice of therapy.

3. Indications for Active Removal of Kidney Stones

Indications for the removal of stones in kidney stones include:

● Stone size increase

 ● Patients at high risk of stone formation
● Obstruction caused by stones
● Urinary tract infection
● Stones that cause symptoms such as pain or hematuria
● Stone size >15 mm
● Stone size <15 mm if observation is not a treatment option
● Patient preferences
● Comorbidity
● Patient's social circumstances (e.g., profession and travel)

4. Choice of Procedures for Active Removal of Kidney Stones

● Superior/Media Pelvic Kidney or Calix Stones

Treatment modalities in cases of kidney stones are Shock Wave Lithotripsy

(SWL), Percutaneous Nephrolithotripsy (PNL), and Retrograde Intra Renal
Surgery (RIRS). The effectiveness of PNL is not very dependent on the size of
the stone, while the effectiveness of the Stone Free Rate (SFR) of SWL or
RIRS is highly dependent on the size of the stone. The SWL procedure has a
fairly good SFR rate in stones <20 mm in size, except for the inferior calyces.
Endourological procedures such as PNL are considered as alternatives because
they require fewer repetitions of the procedure and shorter time to achieve
stone-free conditions. Stones >20 mm in diameter should be treated primarily
with PNL, because SWL often requires multiple procedures and is associated
with an increased risk of ureteral obstruction requiring additional therapy.

● Inferior Calyx Stone

The stone-free rate after the SWL procedure was seen to be lower in inferior
calyx stones compared to intra-renal stones in other locations. One study
reported that the SFR after SWL in inferior calyx stones was 25-95%. Action
RIRS compared to SWL in inferior calyx stones has a higher SFR efficacy, but
with a higher invasive rate. Depending on the operator's ability, stones up to 3
cm in size can be treated by RIRS, although repetition of the procedure is
often required.20 In the case of complex stones, an open or laparoscopic
approach is an alternative treatment option.
Kidney Stone Management
1. Evaluation

Perform an evaluation that includes a history of disease and a history of

diet, laboratory, and urinalysis in patients who have just been diagnosed
with kidney or ureteral stones

The patient's nutritional history related to stones, depending on the type of

stone and risk factors, including calcium intake below or above the nutritional
adequacy rate, low fluid intake, high sodium intake, low intake of fruits and
vegetables, and high intake of animal purines. Dietary history needs to be
asked including the amount of fluid intake, protein, calcium, sodium, foods
high in oxalate, fruits, vegetables, and supplements. Laboratory tests that need
to be checked include electrolytes, calcium, creatinine, and uric acid.
Urinalysis examinations can use a dipstick or microscopically to evaluate urine
pH, indicators of infection, and to identify the type of stone crystals. Urine
culture can be performed in patients with suspected urinary tract infection or in
patients with recurrent urinary tract infections.

Check parathyroid hormone levels as part of the evaluation if primary

hyperparathyroidism is suspected.

Primary hyperparathyroidism should be suspected if the serum calcium level is

high.

When a rock sample is available, it is necessary to perform a rock analysis

at least once.

Stone composition consisting of uric acid, cystine, or struvite can have

implications for specific metabolic disorders or genetic disorders and
information about stone composition can be helpful for preventive measures.

Perform imaging to determine the size of the stone burden.

Multiple or bilateral kidney stones at the time of initial examination can have a
high risk of recurrence of stone formation. Nephrocalcinosis has implications
for metabolic disorders (such as type 1 renal tubular acidosis, primary
 hyperparathyroidism, primary hyperoxaluria) or anatomical conditions
(medullary sponge kidney) that are at risk for stone formation.

Perform additional metabolic testing in patients at high risk or first-time

stone formation and in patients with recurrent stones.

A 24-hour urine test can be used to identify and monitor treatment.

Identification of metabolic risk factors can assist in providing
dietary/nutritional and medical therapy.

Metabolic examination (urine 24 hours) is taken 1 or 2 times on a free diet

and minimal examination includes total volume, pH, calcium, oxalate, uric
acid, citrate, sodium, potassium, and creatinine.

2. Diet Therapy
● Recommends all stone patients to consume fluid intake with a target urine
volume of at least 2.5 liters per day.
● Provide education to patients with calcium stones and high urinary
calcium levels to limit sodium and calcium intake to 1000-1200 mg per
day.
● Provide education to patients with calcium oxalate stones and relatively
high urinary oxalate stones to limit the intake of oxalate-rich foods and
maintain a normal amount of calcium intake.
● Provide education to patients with relatively low urinary calcium and
citrate stones to increase fruit and vegetable intake and limit animal
protein.
● Provide education to patients with uric acid stones or calcium stones and
relatively high urinary uric acid to limit animal protein intake.
● Provide education to patients with cystine stones to limit sodium and
protein intake.
3. Pharmacological Therapy
● Administer thiazide diuretic therapy to patients with high or relatively
high urinary calcium and recurrent calcium stones. Thiazide doses
associated with hypocalciuric effects include hydrochlorothiazide (25 mg
orally, twice daily; 50 mg orally, once daily), chlorthalidone (25 mg orally,
 once daily), and indapamide (2.5 mg orally, once daily). Potassium
supplementation (either potassium citrate or chloride) may be considered
when thiazide therapy is given.
● Provide potassium citrate therapy to patients with recurrent calcium stones
and low or relatively low urinary citrate.
● Administer allopurinol therapy in patients with recurrent calcium oxalate
stones with a history of hyperuricosuria and urinary calcium. Febuxostat
therapy can be given as second-line therapy.
● May give cystine-binding thiol drugs, such as thiopronine, for patients
with cystine stones who do not respond to dietary modifications and urine
alkalinization, or who have recurrent large stones.
4. Follow Up
● Perform a 24-hour urine analysis to see risk factors for stones in the first 6
months since the initiation of therapy, to assess response to dietary
modifications and medical therapy.
● After initial follow-up, perform a 24-hour urine analysis annually or more
frequently, depending on stone activity, to assess patient compliance and
metabolic response.
● Perform routine blood tests to assess side effects of medical therapy.
● If the means are possible, it is advisable to repeat the urinary tract stone
analysis if a new stone sample is available, especially if the patient does
not respond to therapy.
● Monitor patients with struvite stones for possible reinfection of
urease-producing bacteria and develop preventive strategies. Monitor
patients with struvite stones for possible reinfection of urease-producing
bacteria and develop preventive strategies.

4. How is education and prevention in nephrolithiasis (kidney stones)?

Kidney stone patients, regardless of individual risk, should follow the preventive
measures listed in the following table. The main focus is the normalization of dietary
habits and lifestyle risks. High-risk patients require specific prophylaxis to prevent
recurrence, which is usually pharmacological therapy based on stone analysis.
 General precautions to prevent recurrence:

Fluid intake (drinking advice) Fluid amount : 2.5 – 3.0 L/day

Circadian drinking

Neutral pH beverages

Diuresis : 2.0 – 2.5 L/day

Specific weight of urine < 1010 g/day

Nutritional advice for a balanced diet Balanced diet*

Rich in vegetables and fiber

Normal calcium content: 1 – 1.2 g/day

Limited NaCL content: 4-5 g/day

Limited animal protein content: 0.8 – 1.0

g/kg/day

Lifestyle advice to normalize common risk BMI: retain normal BMI

factors
Adequate physical activity

Balancing excessive fluid loss

* Protein requirements are age dependent; therefore, protein restriction in childhood should
be handled with care. * Avoid excessive consumption of vitamin supplements.

(EAU Guidelines 2020)

Education and prevention on nephrolithiasis (kidney stones) is carried out according to the
type of stone that appears, including:
Abnormality Education

Governance 1. Fluids (urine output >2.5L/day)

general 2. Restricted sodium intake (< 2,300 mg or <
100 meq per day or 1 teaspoon)
3. Increase citrate consumption
4. Avoid drinks like black tea, dark soda
5. Adequate protein diet (fish or other meat.
Fist-sized proportions or protein 0.8-1 g/kg/day
or 6-8 oz/day or <150 g/day)

Hypercalciuria 1. Restriction of sodium intake

2. Adequate calcium intake (1,000-1,200
mg/day)
3. Fish oil (Omega 3, 1,200mg/day)

Hypocitraturia 1. Increase intake of citrate (lemon, lime,

melon, orange)
2. Adequate protein diet
3. Increase fruit and vegetable intake

Hyperuricosuria 1. Adequate protein diet

2. Maintain body BMI

Hypernatriuria Limit sodium intake

Hyperoxaluria 1. Restrict high oxalate foods (spinach, nuts,

berries, etc.)
2. Adequate calcium intake

low urine pH 1. Adequate protein intake

2. Increase fruit and vegetable intake
Uric acid stones 1. Diabetes control
2. Lifestyle improvement
3. BMI control
4. If there is hyperuricosuria, limit protein and
purine intake

cystine stone 1. Hyper Diuresis (target urine output >3L/day,

drinking education >4L/day, urine cystine
target <200 mg cystine/L, education to wake up
at least 1 time to urinate and drink water)
2. Restriction of sodium intake
3. Adequate protein intake

struvite stone 1. The main therapy is surgery

2. There is no role of diet therapy

(Handbook for the Clinical Management of Urinary Tract Stones 2018)

C. ANALYSIS II

From the physical examination, the general condition of the patient appeared to be
good, BP: 116/80 mmHg, Pulse: 72 x/min, Temperature: 36.3 C, RR: 16x. The
patient's vital signs are normal. The patient's weight/height is 55 kg/165 cm, the
patient's BMI is normal. Examination of the head-neck, thorax, abdomen and
extremities in the patient was normal. The patient had left costovertebral tenderness.
Costovertebral tenderness can be a symptom of nephrolithiasis (kidney stones).

In addition to physical examination, there were results of supporting examinations

which include urinalysis, complete blood count, plain abdominal radiograph, renal
function examination, and IVP (intravenous pyelography). From the results of the
patient's urinalysis, there were many erythrocytes and 2-4 leukocytes. The results of
the urinalysis showed that the occurrence of red urine in the patient was caused by the
large number of erythrocytes in the urine, so that the patient experienced
macrohematuria. Hematuria itself can be a symptom of kidney stones
(nephrolithiasis). From a complete blood count, it was found that Hb: 12 mg/dl,
Leukocytes: 6800, and Platelets: 180000. The results of the patient's blood laboratory
examination were normal. In addition, plain abdominal radiographs were also
obtained as follows:

On plain abdominal radiographs, a radiopaque shadow appears as high as the left

paravertebral 1 2 with a size of 10 X 7 cm. From the results of plain abdominal
radiographs, it was suspected that the patient had left kidney stones (nephrolithiasis).
On examination of the patient's kidney function, creatinine: 0.9 and BUN: 10. Normal
values ​for serum creatinine in women are 0.5 to 1.1 mg/dl and BUN are 5 to 20 mg/dl,
so the patient's kidney function is still normal. And from the results of IVP
(intravenous pyelography), obtained inferior calyx stones of the left kidney with a size
of 10 X 7 cm and local calyectasis. In addition, as previously discussed, the patient
has risk factors for suffering from kidney stones, in the form of a history of passing
stones during urination 10 years ago and the patient's father has urolithiasis (urinary
tract stones). Therefore, from the results of the history, physical examination, and
supporting examinations, the patient's diagnosis can be concluded as left kidney stone
(nephrolithiasis).
Nephrolithiasis is a lifelong disease process. The recurrence rate of nephrolithiasis is
50% in 5 years. Complications of nephrolithiasis can include renal failure, infection,
hydronephrosis, and avascular ischemia. General therapy for painful symptoms of
nephrolithiasis is analgesics, can be given NSAIDs or paracetamol. Specific therapy
for nephrolithiasis can be conservative therapy in the form of observation of kidney
stones, especially in the calyces, depending on the history of the disease course.
Currently, a prospective study recommends annual observation for asymptomatic
inferior calyx stones 10 mm. If there is an increase in stone size, the follow-up
interval should be shortened. Intervention is recommended if the stone increases in
size >5 mm. There is also a pharmacological treatment which is the only treatment
option for uric acid stones, however, information about the composition of the stone is
necessary in determining the choice of therapy. In addition, active kidney stone
removal can be carried out with several indications such as increasing stone size,
urinary tract infection, stone size > 15 mm, stones causing symptoms such as pain or
hematuria, and others. Stone removal procedures can be: Shock Wave
Lithotripsy(SWL), Percutaneous Nephrolithotripsy (PNL), and Retrograde Intra
Renal Surgery (RIRS). The patient has acute pain, so the patient can be given
analgesics in the form of NSAIDs or paracetamol. Specific treatment for patients can
be active stone removal with indications that the stone in the patient causes symptoms
of pain and hematuria. Specific management of inferior calyx kidney stones in
patients can be in the form of an SWL procedure with a stone free rate (SFR) of 25% -
95% based on a study or an RIRS procedure with a higher SFR efficacy, but also with
a higher risk.

In addition, as previously discussed, nephrolithiasis has a risk of recurrence, so that

patients need to be educated to prevent recurrence. General precautions to prevent
recurrence can be in the form of drinking advice (fluid intake) in the form of
consuming a fluid amount of 2.5 – 3.0 L/day, drinking with a circadian rhythm,
drinking drinks with neutral pH, and others. Nutritional advice for a balanced diet can
be in the form of a balanced diet, rich in vegetables and fiber, limiting the content of
several substances such as calcium, NaCl, and animal protein. In addition, lifestyle
advice can be given to normalize common risk factors such as maintaining a normal
BMI, adequate physical activity, and balancing excessive fluid loss.
D. FINAL HYPOTHESIS
The patient experienced left flank pain due to left kidney stone (nephrolithiasis).

E. GROUP OPINION
Our group opinion regarding this scenario is that this scenario is good enough. The
scenario given was able to trigger us to think critically and be more curious about
human kidney and urinary tract system problems. This scenario allows us to learn new
things about neuropsychiatry from journals, books, and from other relevant sources
that we may not have gotten in college. Through this scenario, we learned more about
kidney stone including its etiology, pathophysiology, therapy, and others. In addition,
with this scenario we also know more about clinical cases that we might get in later
clinical lectures. However, the additional information given to us was a bit lacking so
we had a hard time solving the problem in that scenario.
F. FINAL CONCEPT MAPPING
 REFERENCES

Colvin, RB, Chang, A, Farris, AB, Kambham, NK, Cornell, LD, Meehan, SM, Liapis, H,
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 SOURCE CITED IN SEARCHING METHOD INFORMATI VALIDITY IMPORTANCE APPLICABILITY
ON TYPE

FOUNDATION RESULT FOUNDATION RESULT FOUNDATI RESULT

ON

LI 1 No. Search about Article Ideas Valid, trusted Content of The Is it Yes, the
Colvin, RB,
1 etiology and resource from Information information applicable? information
Chang, A, SAMJ looked for was
pathophysiology
Farris, AB, was found applicable
in nephrolithiasis
Kambham,
(kidney stones)
NK, Cornell,
LD, Meehan,
SM, Liapis, H,
Gaut, JP,
Bonsib, SM,
Seshan, SV,
Jain, S &
Larsen, CP,
2016,
Diagnostic
Pathology
Kidney
Diseases, 2nd
ed,
Philadelphia,
Elsevier, pp.
924-931.

LI 1 No. Search about Article Ideas Valid, trusted Content of The Is it Yes, the
Dobrek Ł.
1 etiology and resource from Information information applicable? information
‘Kidney stone SAMJ looked for was
pathophysiology
disease with was found applicable
in nephrolithiasis
special regard
(kidney stones)
to
drug-induced
kidney stones
– a
contemporary
synopsis’.
Wiad Lek.
2020;73(9 cz.
2):2031-2039.
PMID:
33148855.

Feehally, J, LI 1 No. Search about Article Ideas Valid, trusted Content of The Is it Yes, the

Floege, J, 1 etiology and resource from Information information applicable? information

pathophysiology SAMJ looked for was

Tonelli, M, &
was found applicable
in nephrolithiasis
Johnson, RJ,
(kidney stones)
2019,
Comprehensiv
e Clinical
Nephrology,
6th ed,
Edinburgh,
Elsevier,
pp.689-716.
Pais, VM, LI 1 No. Search about Article Ideas Valid, trusted Content of The Is it Yes, the

Lowe, G, 1 etiology and resource from Information information applicable? information

pathophysiology SAMJ looked for was

Lallas, CD,
was found applicable
in nephrolithiasis
Preminger,
(kidney stones)
GM, &
Assimos, DG,
2006,
'Xanthine
urolithiasis',
Urology, vol.
67, issue 5,
pp.1084.e10-1
084.e11.
Saleem, M & LI 1 No. Search about Article Ideas Valid, trusted Content of The Is it Yes, the
resource from Information information applicable? information
Hamawy, K, 5 physical
examination and SAMJ looked for was
2021,
was found applicable
necessary
‘Hematuria’,
investigations in
StatPearls flank pain with
[Internet], bloody urine

retrieved from

https://www.n

cbi.nlm.nih.go

v/books/NBK

534213/ on

5th January

2022.
Thakore, P. LI 1 No. Search about Article Ideas Valid, trusted Content of The Is it Yes, the
and Liang, 1 resource from Information information applicable? information
etiology and
T.H, 2021, SAMJ looked for was
pathophysiology
Urolithiasis. was found applicable
[online] in nephrolithiasis
Nih.gov. (kidney stones)
Available at:
https://www.n
cbi.nlm.nih.go
v/books/NBK
559101/

Khan, S. R., LI II No. Search about the Article Ideas Valid, trusted Content of The Is it Yes, the
Pearle, M. S., 2 resource from Information information applicable? information
prognosis of
Robertson, W. SAMJ looked for was
nephrolithiasis
was found applicable
G., Gambaro,
G., Canales, B.
K., Doizi, S.,
Traxer, O., &
Tiselius, H. G.
(2016). Kidney
stones. Nature
reviews.
Disease
primers, 2,
16008.
https://doi.org/1
0.1038/nrdp.20
16.8.

Rule, A. D., LI II No. Search about the Article Ideas Valid, trusted Content of The Is it Yes, the
Lieske, J. C., 2 resource from Information information applicable? information
prognosis of
Li, X., Melton, SAMJ looked for was
nephrolithiasis
was found applicable
L. J.,
Krambeck, A.
E., &
Bergstralh, E. J,
2014, The
ROKS
nomogram for
predicting a
second
symptomatic
stone episode.
Journal of the
American
Society of
Nephrology,
25(12),
2878-2886.