Urolithiasis

Calculi are crystalline aggregates of one or more components,

most commonly calcium oxalate. They also may contain
calcium phosphate, magnesium
ammonium phosphate
(struvite), uric acid, or cystine.

Calcium- and struvite-containing stones often are visible

on plain radiographs, but CT scans will demonstrate all
calculi except those composed of crystalline-excreted
indinavir, an antiretroviral medication. For this reason,
noncontrast CT scans have become the study of choice
to evaluate for urolithiasis.

Patients often will develop calculi after gastric bypass, which

has been attributed to increased oxalate excretion in the urine.
After bypass, dietary calcium is bound by
unabsorbed dietary fats (saponification), preventing
it from binding dietary oxalate, thereby making oxalate more
available for intestinal absorption.

α-Blockers, which relax the distal ureter, may

be given to reduce renal colic.

Renal pain
Dull aching to pricking type of pain posteriorly
in the renal angle formed by the sacrospinalis
and 12th rib.

Murphy's kidney punch test demonstrates

tenderness at renal angle. The same pain may some times be felt
anteriorly in the costal margin. Hence, it is described as
costovertebral pain.

Nausea and vomiting is due to intense

sympathetic stimulation caused by stretching
of renal capsule mediated by coeliac plexus.

Ureteric colic
When the stone is impacted in the
pelviureteric junction or anywhere in the
ureter, it results in severe colicky pain
originating at the loin and radiating to the
groin, testicles, vulva and medial side of the
thigh.

This may be associated with

strangury.
The referred pain is due to irritation of the
genitofemoral nerve.
Recurrent UTI: Fever with chills
and rigors, burning micturition, pyuria may
occur, along with increased frequency of
micturition.

Complications
• Calculous hydronephrosis
Occurs due to back pressure producing renal enlargement.
Stretching of the renal capsule results in pain. In such cases, an
associated palpable kidney mass suggests hydronephrosis.

• Calculous pyonephrosis
Infected hydronephrosis where in the kidney is converted into a
bag of pus.
 • Renal failure
Bilateral staghorn stones may not be symptomatic until they
present with uraemia and renal failure.

• Squamous cell carcinoma

Long-standing stones increase the risk of carcinoma.

Urine for culture and sensitivity.

Stones come down from pelvis of the kidney and
may get impacted at any site of anatomical
narrowing of ureter, namely:

• Pelviureteric junction
• Crossing of the iliac artery
• Crossing of the vas deferens or
broad ligament.
• Site of entry into the bladder wall
• Ureteric orifice
This may lead to hydroureteronephrosis, renal parenchymal
atrophy, infection and pyonephrosis.

When stone descends into lower ureter, pain radiates to

the testicles, labia majora and to the upper portion of
thigh due to irritation of genitofemoral nerve. Colic lasts
for about 4-6 hours and is relieved by antispasmodics,
narcotics and NSAID.

Attack of haematuria or pyuria

Guarding and rigidity of the abdominal wall if present on

the right side, is confused with acute appendicitis

Pain
Pain occurs in 75 per cent of people with urinary stones. Fixed
renal pain occurs in the renal angle (Figure 75.23), the
hypochondrium, or in both. It may be worse on movement.

Ureteric colic
Severe exacerbations on a background of continuing pain
Radiates to the groin, penis, scrotum or labium as the stone
progresses down the ureter
Severity of pain is not related to stone size
Haematuria is very
common
There may be few physical signs