differential diagnosis urolithiasis

Aryati.S 05010028

 symptoms similar to those of renal colic can be caused by noncalculus conditions

in women
gynecologic processes that must be considered include ovarian torsion, ovarian cyst and ectopic pregnancy

in men
symptoms of testicular processes, such as a tumor, epididymitis or prostatitis, may mimic the symptoms of distal ureteral stones

other general causes of abdominal pain, such as appendicitis, cholecystitis, diverticulitis, colitis, constipation, hernias or even arterial aneurysms, may produce symptoms that mimic renal colic other urological lesions may also mimic of urolithiasis
for example lesions such as congenital ureteropelvic junction obstruction, renal or ureteral tumors, and other causes of ureteral obstruction

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urolithiasis
Most urinary tract stones occur in the upper urinary tract. Their composition varies widely depending upon metabolic alterations, geography and presence of infection. Their size varies from gravel to staghorn calculi. Some are the result of inborn errors of metabolism - gout, cystinuria, primary hyperoxaluria. Most are radio-opaque. Although some renal stones remain asymptomatic, most will at some time result in pain. Small stones arising in the kidney are more likely to pass into the ureter where they may cause severe colicky pain; large stones may be asymptomatic because of their immobility. Superimposed infection may result from mucosal trauma and/or obstruction.

epidemiology
Some information about the epidemiology of renal stones is presented below: overall prevalence of urinary calculi is:
3% in the UK 12% in the USA

males are affected more than females - 2.5:1 bimodal age distribution - peak incidences in mid-20's and mid-50's, the later peak principally due to infective stones in women upper tract calculi predominate in developed countries bladder calculi are more common in developing countries stones are unilateral in 80% of cases across the population right and left upper tracts are equally affected incidence of upper tract calculi is increasing most disease is asymptomatic 40% of symptomatic stones pass spontaneously
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ethiology
The vast majority are idiopathic. Recognised causes include: hypercalciuria hyperoxaluria hyperuricaemia cystinuria schistosomiasis - in developing countries
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pathogenesis

Stone formation is due to supersaturation, that is, an urinary concentration of the stone's constituent in excess of the solubility in urine. Predisposing factors include: excess of normal constituents in blood and urine:
increased serum calcium in hyperparathyroidism increased serum uric acid in gout or following chemotherapy for leukaemia decreased urinary volume in hot climates chronic urinary obstruction due to an enlarged prostate hydronephrosis urinary infection producing epithelial sloughs upon which calculi may deposit foreign bodies such as a urinary catheter

impaired drainage:

presence of abnormal constituents: Which of these elements is involved may be suggested by the composition of the stone, but calculi often form in the absence of obvious precipitating factors. In fact many patients with increased urinary excretion of calcium, oxalates or uric acid do not form stones and furthermore, most calculi are unilateral. Alternative theories suggest: abnormal urinary tract mucoproteins may predispose to stone formation postulated inhibitors of stone formation may be deficient

sites of stone impaction

In the kidney important sites of impaction include: minor and major calyx system pelviureteric junction In the ureter: region of the pelvic brim - where the ureter arches over the iliac vessels vesicoureteric junction - the most narrow part of the normal urinary tract Stones in the bladder are often formed in situ, rather than originating from the upper tracts. Stones that do reach the bladder from the upper tracts are likely to pass easily down the urethra.

Stone location
Renal in the proximal ureter in the mid section of ureter distal ureter

Common symptoms
vague flank pain, hematuria flank pain, renal colic, upper abdominal pain renal colic, anterior abdominal pain, flank pain

renal colic, dysuria, urinary frequency, anterior abdominal pain, flank pain

Clinoical finding upper urinary tract

Kidney stones cause: flank pain:

spreads around the abdomen as the stone migrates tends to be greater with smaller, more mobile stones than with larger, less mobile stones
common microscopic or macroscopic acute loin tenderness, pyrexia and septicaemia acute pyelonephritis in the presence of urinary obstruction is a urological emergency

haematuria: urinary infection: Ureter: ureteric colic:

colicky pain from the flank through to the scrotum or labia majora

haematuria urinary infection Examination may reveal tenderness in the renal angle or along the line of ureter which is usually modest in comparison to the pain reported. It should be noted that the presentation of stones in the renal tract is exceedingly variable. At one extreme, a stone may be an incidental finding on X-ray whereas at the other, bilateral stones may produce bilateral obstruction leading to bilateral hydronephrosis and renal failure.

clinical finding lower urinary tract

Symptoms may include: pain:
in the suprapubic area, perineum, and tip of the penis or labium majora exacerbated by:
an upright posture - the stone lies on the trigone during any jolting movements at the end of micturition

urgency and frequency:

more troublesome during the day often with a sensation of incomplete emptying after micturition

strangury haematuria - at the end of micturition occasionally intermittent urinary obstruction Examination may reveal: men - prostatic enlargement women - palpable bladder stone on bimanual vaginal examination