as sound energy as described by
and the Royal London School of Medicine
Chungcharoen.4 Esnest and colleagues also
thought that turbulent blood flow produced
sound but attributed it to the murmur-like
tones rather than the tapping tones.8 Their
evidence was that blood flow at the time the
tapping sound was emitted was negligible or
just beginning to accelerate.
Conversely Bruns thought that turbu-
lence could not be responsible for the
sounds9: “If turbulence caused murmurs, all
murmurs would have the same frequency.”
Other possibilities
Other suggestions for the origin of
Korotkoff sounds are the water hammer and
transmission of heart sounds theories. These
theories have been consistently disproved by
various studies.
Other authors, such as Ur and Gordon,
think that Korotkoff sounds are due to a
combination of the concepts mentioned
above.11 They believe that the oscillation in
the arterial wall and the turbulence theory
cause the tapping tones and murmur-like
tones respectively.
Which is right?
The cavitation theory, the arterial wall
theory and the turbulence theory are the
three most popular theories that have been
Picture Quiz:
Renal impairment
A 68 year old man with renal impairment
was referred to a urology department. He
had traces of blood and protein in his urine.
He was clinically well and the examination
was unremarkable.
The radiographs in figs 1, 2, and 3 were
taken.
Questions
(1) What are the investigations shown in figs
1 and 2?
(2) What abnormality is seen in figs 1 and 2?
(3) Fig 3 is an oblique view of the above
investigation. What can you see?
Answers
(1) Fig 1 shows kidneys, ureters, and bladder
film (KUB); fig 2 shows an intravenous
urogram (IVU).
(2) Fig 1 shows a radio-opaque mass at the
level of the left proximal ureter. Whether
STUDENT BMJ VOLUME 11 JULY 2003 studentbmj.com
put forward to explain the origin of
Korotkoff sounds. There is evidence to sup-
port elements of each of these theories, but
further investigations would have to be com-
pleted to formally establish the cause of the
sounds. The experiments I evaluated used
collapsible tubes or non-living arteries,
which limited the reliability of the results.
Subsequent experiments would therefore
have to be carried out on willing patients.
Any volunteers?
Fig 3 Turbulence theory. Blood proximal to
the cuff has a considerable amount of
potential energy. When the cuff deflates, the
blood enters the artery under the cuff (a
system of low energy). This system of low
energy absorbs the energy of the blood
slowing the blood down and causing
turbulent blood flow
the mass is in the ureter or overlying it is
not clear. Fig 2 shows the same radio-
opaque mass in addition to the outline
of the renal tract. The left renal tract
proximal to the mass appears to be
dilated.
(3) The oblique view shows an mass 8 mm
across in the left ureter causing partial
obstruction. The calcified mass seen
above is a mesenteric lymph node over-
lying the ureter.
Discussion
Renal stone disease has been affecting
human beings for as long as records exist,
and, in fact, much of the early history of sur-
gery deals with stone disease and its disas-
trous consequences. The Hippocratic oath
reflects this: “I will not cut, and certainly not
those suffering from stone, but I will cede
this to men who are practitioners of this art.”
Many factors have been suggested to
Tom Cunningham fourth year medical student, Barts
ha9270@qml.ac.uk
With thanks to Ben Benjamin for giving me the
idea for the article and overseeing it.
1 Korotkoff MS. On the subject of methods of determin-
ing blood pressure. Bull Imperial Mil Med Acad
1905;11:365.
2 O’Sullivan J, Allen, J, Murry A. The forgotten Korotoff
phases: how often are phases II and III present and
how do they relate to the other Korotkoff phases? Am J
Hypertens 2002;15:264.
3 Venet R, Miric D, Pavie A, Lacheheb D. Korotkoff
sound: the cavitation hypothesis. Med Hypotheses
2000;55:141.
4 Chungcharoen D. Genesis of Korotkoff sounds. Am J
Physiol 1964;207:190.
5 Korotkoff NS. On the subject of methods of determin-
ing blood pressure Bull Imp MI Med Acad (St
Petersburg) 1905;11:365.
6 Erlanger J. Studies in blood pressure estimation by
indirect methods. II. The mechanism of the compres-
sion sounds of Korotkoff. Am J Physiol 1916;40:82.
7 Malcolm JE. Blood pressure sounds and their meanings.
London: Heinemann, 1957.
8 Ernest P, McCutheon MD, Rushmer RF. Korotkoff
sounds an experiment technique. Circ Res 1967;20:149.
9 Bruns DL. A general theory of the causes of murmurs
in the cardiovascular system. Am J Med 1970;207:360.
10 Rouanet JR. Analysedes bruits du Coeur. These Paris
1832;252:1.
11 Ur A, Gordon M. Origin of Korotkoff sounds. Am J
Physiol 1970;218:524-9.
12 Lange RL, Heght HH. Genesis of pistol-shot and
Korotkoff sounds. Circulation 1958;8:975.
affect the incidence of stones including gen-
der, race, geography, occupation, and the
hardness of water. Overall the chance of a
white man developing a renal stone by the
age of 70 is almost 10%. Men are twice as
likely as women to be affected, and the
recurrence rate varies between 50% and
70% for the 20 years after the initial dia-
gnosis.
Normal urine is composed of a complex
solution of ions, proteins, and inhibitory sub-
stances. Should the delicate balance between
them change, crystals form which precipitate
into stones. Predisposing factors for stone
formation include dehydration, chronic uri-
nary infection, excess secretion of stone
forming substances, foreign bodies, and dis-
eased tissue.
Most stones (60%-70%) are composed of
calcium oxalate. Stones of magnesium
ammonium phosphate make up the about
15% to 20% and the rest are composed of
calcium phosphate (5%), uric acid (5%) and
235

finally cystine (1%). Overall about 90% of
stones are radio-opaque.
Urinary tract stones may remain asymp-
tomatic but they classically present with
characteristics of ureteric colic. Patients have
severe intermittent unilateral pain, radiating
from the loin to the groin, and also the
external genitalia and the inner thigh.
Microscopic haematuria and, more rarely,
macroscopic haematuria are often associ-
ated. Tachycardia is often present and exam-
ination may find tenderness in the loin or
groin. If the patient is febrile, the diagnosis
should be guided towards infection with
obstruction or pyelonephritis. Excluding
conditions that may present in a similar
manner but which have devastating conse-
quences if remain undiagnosed is funda-
mental. The most important are ruptured
abdominal aortic aneurysm and ruptured
ectopic pregnancy.
Investigations
Initial investigations should be tailored
towards confirming the suspected diagnosis
and screening for renal function and sepsis.
Urine should always be cultured and serum
calcium should be measured as it could
expose surgically treatable hyperparathy-
roidism.
In the United Kingdom, intravenous
urography is the imaging technique most
commonly used for the diagnosis of sus-
pected renal stone disease. Advantages of
this procedure include the fact that is readily
available in most accident and emergency
departments and in addition, it is relatively
accurate, economic and safe. Furthermore,
the radiation dose is relatively small
(depending on number of films taken) and it
can demonstrate radiolucent stones as filling
defects.
Unenhanced helical computed tomogra-
phy scanning is the investigation of choice
for a patient presenting with acute renal
colic. It has a sensitivity of up to 98% for
236
renal and ureteric stones, and it allows the
detection of other pathology. Furthermore,
scanning takes only 5 minutes to do, can
provide digitally reconstructed images, and
does not carry the risk of anaphylactic reac-
tion. Conversely, computed tomography is
considerably more expensive, requires a
radiologist for accurate investigation, and is
not readily available throughout the United
Kingdom. Also, the dose of radiation is three
times higher than the average radiation
needed for intravenous urography.
Management
The immediate aim in the management of
ureteric colic is to relieve pain and prevent
permanent damage caused by either infec-
tion or the obstructed system. Non-steroidal
anti-inflammatory drugs are usually effective
for pain relief, if not, however, opioid anal-
gesics should be given. Patients should take
in adequate fluids.
At any point, conservative treatment
should be abandoned if there are signs of
infection (fever, tachycardia, increased pain,
or increased white cell count) or if there are
signs or renal impairment (increased creati-
nine or urea and electrolyte abnormalities).
In the presence of these factors the obstruc-
tion or infection should be managed actively
by the insertion of either a percutaneous
nephrostomy tube or a double J stent, before
definite treatment is considered.
It is widely accepted that stones less than
5 mm in diameter will usually pass sponta-
neously. If the stone is larger or if it is
unlikely to pass further intervention should
be considered.
In extracorporeal shock wave lithotripsy
shock waves are directed towards the stone
using ultrasound or fluoroscopic guidance.
The treatment can be carried out with out
the need of general anaesthesia, but more
than one session could be necessary.
Stone can be accessed in other ways. They
can be accessed directly using a uretero-
STUDENT BMJ VOLUME 11
Fig 1 (left), fig 2 (centre) and fig 3 (right)
scope or percutaneously and the stone can
be retrieved using a basket. Alternatively, the
stone can be fragmented using various elec-
trohydraulic devices, pneumatic devices, and
lasers.
Open surgery is hardly used nowadays
(about 1% of cases). But laparoscopic
removal is becoming increasingly popular
for stones failing less invasive treatment.
Medical management has mainly a pre-
ventive role. Each treatment plan should be
tailored to the needs of each individual
patient, always having in mind the results of
a metabolic and biochemical screen. In gen-
eral, the best recommendation is to maintain
a high daily intake of fluid and dietary fibre
and decrease the intake of animal protein,
dairy products, and salt.
Menelaos Philippou final year medical student,
University of Manchester
mphilippou@doctors.org.uk
Richard Napier-Hemy consultant urologist,
Manchester Royal Infirmary, Manchester
Further reading
● Von Staden H. “In a pure and holy
way”: personal and professional con-
duct in the Hippocratic oath. J Hist Med
Allied Sci 1996;51:406-8.
● Walsh PC, Retik AB, Vaughan ED,
Wein AJ. Campbell’s urology. 7th ed. Part
XII Urinary Lithiasis. London: WB
Saunders, 1997.
● Whitefield HN. The management of
ureteric stones. Part I: diagnosis. BJU
Int 1999;84:911-5.
● Whitefield HN. The management of
ureteric stones. Part II: therapy. BJU Int
1999;84:916-21.
● Parivar F, Low KR, Stoller LM. The
influence of diet on urinary stone
disease. J Urol 1996;155:432-40.
JULY 2003 studentbmj.com