UROLITHIASIS

Diagnos2c Tests
- Urolithiasis should always be considered in the differen4al diagnosis of abdominal
pain.
o The classic presenta/on of renal colic is excrucia/ng unilateral flank or lower
abdominal pain of sudden onset that is not related to any precipita/ng event and
is not relieved by postural changes or nonnarco/c medica/ons.
o With the excep/on of nausea and vomi/ng secondary to s/mula/on of the celiac
plexus, gastrointes/nal symptoms are usually absent.
- O;en begins as vague flank pain
o Pa/ents frequently dismiss this pain un/l it evolves into waves of severe pain. It
is generally believed that a stone must at least par/ally obstruct the ureter to
cause pain.
o The pain is commonly referred to the lower abdomen and to the ipsilateral groin.
As the stone progresses down the ureter, the pain tends to migrate caudally and
medially
- The diagnosis of urinary tract calculi begins with a focused history.
o Key elements include past or family history of calculi, dura/on and evolu/on of
symptoms, and signs or symptoms of sepsis. The physical examina/on is oEen
more valuable for ruling out nonurologic disease.

A. URINALYSIS
- Microhematuria
- Urine pH
o Acidic urine = uric acid stones
o Alkaline urine = stone forma/on resul/ng from infec/on
- Presence of crystals

B. Diagnos2c Imaging
1. Ultrasonography- Good for diagnosing hydronephrosis and renal stones
2. Plain radiography- accessible and inexpensive; document the size and loca/on of
radiopaque urinary calculi.
3. Intravenous pyelography- contrast injec/on; provides informa/on on anatomy and
func/oning of both kidneys
4. Non-contrast helical computed tomography- most sensi/ve and specific radiologic
test; Indirect signs of the degree of obstruc/on; Provides informa/on on
nongenitourinary condi/ons
Medical and Surgical Management
1. Extracorporeal Shock Wave Lithotripsy (ESWL)- This non-invasive procedure uses shock
waves to break kidney stones into smaller pieces, making them easier to pass through
the urinary tract.
o is a technique in which an x-ray is used to target stone loca/on, and shockwaves
from an energy source are used to fragment the stone into smaller pieces that
can be passed into the urine. This technique may require follow-up ureteral stent
placement to facilitate fragment passage. This technique typically requires IV
seda/on or general anesthesia but can be performed on an outpa/ent basis.
Cys/ne stones may be resistant to treatment.
2. Ureteroscopy (URS): A thin, flexible scope is passed through the urethra and bladder to
reach the stone in the ureter or kidney. The stone is then broken into smaller pieces
with a laser or removed intact.
o is the most common method used and involves an endoscopic approach passed
through the lower urinary tract system into the ureters and calyces. This
technique allows for the visualization of the urinary tract and the retrieval of an
obstructing stone.[24] Flexible ureteroscopy is a good option for lower pole
stones between 1.5 and 2 cm in size.[25] Additionally, it is an ideal choice of
treatment for patients taking anticoagulant/antiplatelet medications.
3. Percutaneous Nephrolithotomy (PCNL): This procedure is used for larger stones or
when ESWL or URS is not feasible. A small incision is made in the back, and a
nephroscope is inserted into the kidney to remove or break up the stones.
o is often reserved for patients that fail or have contraindications to URS or ESWL.
This method is preferred for stones greater than 20 mm in size, staghorn calculi,
and stones in patients with a history of chronic kidney disease. Large stones
located in the kidney and proximal ureter are often treated using this technique.
General or spinal anesthesia is used, and a small puncture wound is placed in the
flank skin overlying the stone, followed by a ureteroscope to retrieve the stone.
Contraindications to PCNL include current pregnancy, bleeding disorders, and
active urinary tract infections.
Medica2ons
1. NSAIDs or an2-inflammatory medica2ons- first line tx for pain
2. Opiods- reserved for refractory pain
3. IV lidocaine- effec/ve pain control op/on
4. Medical expulsive therapy (MET) - includes alpha-blockers, such as doxazosin
and tamsulosin, which is a useful adjunct to facilitate passage of larger (5-10 mm) stones
but has not shown to be beneficial in the passage of smaller ones.
5. IV crystalloid fluids- can be given to pa/ents who appear dehydrated due to persistent
vomi/ng, but have not been shown to facilitate stone passage.
1. Allopurinol- used to lower uric acid levels in the blood and urine, which can help
prevent the forma/on of uric acid stones (for uric acid stones and calcium stones)
2. Potassium citrate- oEen prescribed to alkalinize urine, which can help dissolve certain
types of stones, par/cularly those made of uric acid (for calcium stones)
3. An2bio2cs- (acetohyroxamic acid) for struvite stones; bacteria-causing
4. Diure2cs- Diure/cs may be used to increase urine output, which can help prevent the
buildup of minerals that contribute to stone forma/on (for calcium stones)