? ? ? Urolithiasis

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? ? ?Urolithiasis

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Components of stones

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Etiology Aspects

• Extrinsic Factors
• Intrinsic Factors
• Heredity
• Age and Sex
• Abnormal metaboly
• Local factors

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Extrinsic Factors

• Climatic and seasonal factors
• Water intake
• Diet
• Medication

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Water intake

• the volume of water ingested as opposed to that
  lost by perspiration and respiration
• the mineral or trace element content of the water
  supply of the region

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Diet

• Protein
• Increasing the acid in urine
• Hyperuricosuria
• Calcium
• Hypercalciuria
• Hyperoxaluria

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Diet

• Sodium
• Hypercalciuria
• Magnesium
• Inhibit crystallization of Calcium Phosphate
• reduce calcium oxalate crystalloiduria
• Vitamins

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Medications

• Steroids
• Vitamins
• Sulfanilamide

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Abnormal metaboly

• Calcium Oxalate Stone
• Calcium Phosphate Stone
• Uric Acid Stone
• Cystine Stone

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Calcium Oxalate Stone

• Hypercalciuria (excessive calcium in the urine
  and kidneys)
• Absorptive Hypercalciuria
• Resorptive Hypercaiciuria
• Renal Hypercalciuria

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Calcium Oxalate Stone

• Hyperoxaluria
• Hyperuricosuria
• Citrate

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Calcium Phosphate Stone

• Pure calcium phosphate stone is quite rare
• More common in women and are often associated
  with tubular acidification defects
• Showing pure calcium phosphate
• Distal renal tubular acidosis
• Primary hyperparathyroidism
• sarcoidosis

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Uric Acid Stones

• By-product of purine
• Typically radiolucent in nature and may not be
  identified on plain abdominal films
• Visible on noncontrast CT images
• Associated calcium deposits, may be partially
  radiopaque

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Cystine Stones

• Cystine can be found in nerves, muscles, and
  other body tissues
• Cystinuria cause excessive cystine build up in
  the urine, lead to cystine stones
• Occurs in about 1 to 2 of patients with kidney
  stone disease
• The condition often runs in families

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Local Factors

• Urinary Infection
• Urinary Obstruction
• Urinary Eyewinker

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Local Factors

• Urinary Tract Infection
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• pH7.2
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Local Factors

• Urinary Obstruction
• Anatomic
  Abnormalities
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Local Factors

• Urinary Tract Eyewinker
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• The influencing Factors of Stone Forming

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• Anatomic Abnormalities
• Urinary Tract Infection
• Nutrition Status
• Others

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Pathogenesis
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Some Theories

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Process

• Nucleation (????)
• Crystal Growth (????)
• Crystal Aggregation (????)
• Crystal Retention (????)

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Pathogenesis

• struvite (infection stones)
• Made of crystallized magnesium and ammonia
  phosphate
• common acidic by-products of the bacterial
  breakdown of urea

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Pathophysiology

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Pathophysiology

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Pathophysiology

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ureterpelvic junction
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over the iliac vessels
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ureterovesical junction
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Pathophysiology

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  (Staghorn)

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Pathophysiology

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• (obstruction)
  (infection)

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Suspense

• If urinary constituents are similar from each
  kidney and if there is no evidence of
  obstruction,
• Why do most stones present in a unilateral
  fashion?
• Why don't small stones pass uneventfully down the
  ureter early in their development?
• Why do some people form one large stone and
  others form multiple small calculi?

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Question OR Comment?
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?????
Upper Urinary Tract Calculi
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Nephrolithiasis
Including

• (Kidney Stones)

and
Ureteral Calculi
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Types of Stones

• calcium salts
• struvite (infection stones)
• uric acid
• cystine

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Struvite Stones

• Accounts for up 20 of kidney stones
• Often occurs in patients who develop urinary
  tract infections
• More common in women
• Typically develops as a "staghorn"

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Types of Stones - Clinical

• Renal Calyx Calculi
• Renal Pelvis Calculi
• Staghorn Calculi
• Upper Mid Ureter Calculi
• Distal Ureter Calculi

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Clinical Presentation

• Pain Hematuria associated with activity
• The character of the pain depends on the stone
  location, size, movement and complication
• Renal Colic and noncolicky renal pain are two
  types of pain originating from kidney
• Noncolicky renal pain is caused by distention of
  the renal capsule

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Symptoms Signs

• Renal Colic (???) usually is caused by stretching
  of the collecting system or ureter
• Urinary obstruction is the main mechanism
  responsible for renal colic
• Local mechanism such as inflammation, edema,
  hyperperistalsis may contribute to the perception
  of pain

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Renal (Ureteral) Colic

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• Comes on suddenly and acutely
• Wax and Wane, may be relatively constant
• Usually starts in the back, at waist or in the
  flank, stomach or groin
• Nausea, vomiting, chills, fever
• Frequently move constantly into unusual position
  in an attempt to relieve the pain

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Renal (Ureteral) Colic

• Radiation of pain
• PUJ or upper ureteral tract obstruction
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• Midureteral obstruction
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• Distal ureter entering vesical, ureteral orifice
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Radiation of pain with various types of ureteral
stone
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Radiation of pain with various types of ureteral
stone
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Radiation of pain with various types of ureteral
stone
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Hematuria

• Blood in the urine - another classic symptom
• The blood may be clearly visible, or may be
  microhematuria
• Often, patients urine is usually tea-colored
  and/or cloudy
• Microhematuria after movement may be the only one
  symptom

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Symptoms Signs

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Diagnosis

• History
• Evaluate the nature of the pain, including its
  onset character potential radiation activities
  that exacerbate or ease the pain
• Associate nausea, vomiting
• Gross hematuria
• History of similar pain

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History

• Typical renal, ureteral colic with hematuria
• Risk factors
• Crystalluria
• Diet
• Occupation and climate
• Family history
• Medications

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Physical Examination

• Attempting to find relief in multiple,
  frequently, bizarre, positions
• Tachycardia, sweating and nausea
• An abdominal mass may be palpable in patients
  with long-standing obstructive urinary calculi
  severe hydronephrosis

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Physical Examination

• Abdominal Examination should exclude other causes
  of abdominal pain
• Examination of abdomen reveals moderate deep
  tenderness on palpation over the location of the
  calculus and the area of the loin

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Diagnosis

• Stone diagnosis
• including location, size, number, shape, type
• Complication diagnosis
• Urinary infection
• Degree of obstruction
• Renal failure
• Etiological evaluation

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Laboratory Test

• Urinalysis (????)
• Microscopic or gross hematuria
• Moderate pyuria or pus cells
• Gross hematuria may be the only complaint
• Crystalluria
• Urine germiculture (?????)

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Laboratory Test

• Serum biochemistry examination
• Ca, P, Cr, AKP, Uric acid, Albumen, K, Na, Cl,
  PTH, etc
• Analysis of urinary metabolites in 24-hour urine
  collections
• Acidified sample - Calcium, Oxalate, Magnesium,
  Phosphorus
• Alkaline sample Uric acid
• Untreated aliquots - Creatinine

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Laboratory Test

• Analysis of Uroliths
• Chemical analysis qualitative
  semiquantitative
• Infrared Spectroscopy
• Binocular Stereoscopic microscope
• X-ray Diffraction, Electron Microscopy
• A combination of morphologic and structural
  examination of stone has shown to provide a
  cost-effective, precise, and reliable analysis of
  stone

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1. Apatite (??? )
2. Struvite (??? )
3. Calcium oxalate Dihydrate (???)

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• D. Calcium oxalate monohydrate
• E. Cystine
• F. Ammonium acid urate

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Diagnostic Uroradiology

• Ultrasonography (Type B)
• Noninvasive method for screening urinary stone
• Sensitive in detecting radiolucent calculi
  particularly those measuring 23mm in largest
  dimension small stones

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Diagnostic Uroradiology

• Ultrasonography (Type B)
• Presenting anatomic structure changes and
  hydronephrosis
• An echogenic focus with posterior acoustic
  shadowing
• False-postive

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Uretervesical Junction Calculus
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Radiographic Examination

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Radiographic Examination

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Radiographic Examination

• Computerized Tomography (CT)
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Differential Diagnosis

• Acute abdomen ( peritoneal signs! )
• Acute appendicitis
• Ectopic and unrecognized pregnancies
• Ovarian pathologic conditions
• Biliary stones with without obstruction
• Peptic ulcer disease
• Acute renal artery embolism, etc

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Differential Diagnosis

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treatment

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• Prevention

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Vesical Calculi
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Urolithiasis
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Urethral Calculi
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Conspectus

• Majority stones expelled from the kidney
  bladder
• Rarely may form primarily when stricture, pouch
  or diverticulum presented
• Usually only a single stone is encountered in
  anterior urethra
• Females rarely develop urethral calculi

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Diagnosis

• Clinical Presenting
• Typical symptom
• Acute urinary retention associated with severe
  perineum/rectum pain
• Pain may radiate to the tip of the penis
• Intermittent urinary stream
• Terminal hematuria infection

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Diagnosis

• Confirmed diagnosis
• palpation, endoscopic visualization
  radiographic study
• A hard mass could be touched via Digital Rectal
  Examination in the path of urethra

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