In theory, calculi could form in the urinary tract

wherever urine and its contained solutes are in

contact with the urothelium. In practice, stones
form in the kidney and the bladder. Ureteric
calculi are in transit from the kidney to te
bladder. There are two types of urinary calculi :
1. Primary:
Develop in a normal urinary tract, in acid urine
and in metabolic disease.
2. Secondary:
Develop in infected alkaline urine and in
obstructive uropathy.
• A. Renal Calculi
The aetiology of renal calculi is unknown.

Suggested Theory of Renal Stone Formation

Primary calculi form in the suburothelial plane of a
renal papilla, resulting in erosion of papilla,
precipitation of urinary crystalloids on the nidus,
and stone formation.
Secondary calculi result from bacteria, debris, and
inflammatory products in infected and alkaline urine
precipitatinf within the renal tract and forming a
stone.
 There are five varieties of formed calculi :
1. Calcium oxalate (80 per cent
2. Phosphate (10 per cent)
3. Uric acid (8 per cent)
4. Cystine (2 per cent)
5. Xanthine and pyruvate stones—rare
Predisposing Factors in Renal Urolithiasis

Renal Stones
Renal stones may be either idiopathic, the causes
being dietary, dehydration stasis or infection, or
metabolic due to primary hyperparathyroidism,
idiopathic hypercalcaemia, milk-alkali syndrome,
hypervitaminosis D, sarcoidosis, multiple
myelomatosis, cystinuria, inborn errors of purine
metabolism.
• B. Bladder Stones

Incidence and Aetology

1. Middle East, Far East, Turkey—idiopathic
calculi, dietary factors (malnutrition),
dehydration (concentration of urinary solutes),
infection.
2. Egypt and East Africa—bilharzia—acquired
stone.
3. Western society—bladder outflow obstruction,
bladder diverticulae, foreign bodies in bladder,
post-irradiation, stasis and infection.
• C. Ureteric Calculi

Stones do not form in the ureter, except in

the obstructed ureter (megaureter). Small stones
pass from renal pelvis to bladder via the ureter.
Clinical Features
Three cardinal symptoms of urolithiasis are
pain, haematuria, and dysuria. An impacted
stone in the renal parenchyma is painless,
causing occasional haematuria and dysuria.
Stone in Renal Pelvis

1. Silent, occasional haematuria and dysuria.

2. Impaction on pelvi-ureteric junction—renal
colic.
3. Pain—continuous boring pain in the loin,
aggravated by jolting or movement, micro- or
macroscopic haematuria.
4. Staghorn calculus and large pelvic calculi—
often painless, urine always contains red blood
cells, protein, pus cells, and epithelial debris.
Stone in Ureter

Ureter colic—violent colicky pain in loin

radiating to groin and genitalia associated with
shock and vomiting. Haematuria is frequently
present due to damage to the urothelium by the
stone.
Bladder Stone

Relatively painless. Terminal haematuria,

dysuria and interruption of urine flow are due to
impaction of the stone in the internal urinary
meatus during micturition.
Physical Examination

Often unrewarding. Loin tenderness indicates a

urinary infection or distension of the renal pelvis
due to obstruction. The kidney is rarely palpable.
An impacted ureteric calculus will produce
shock and vomiting, and the intense pain of
ureteri colic. Prostatic enlargement and a
clinically palpable and distended bladder may be
associated with a bladder stone.
Diagnosis and Investigation

Patients with calculous disease of the urinary

tract present in three ways :
1. With renal pain or ureteric colic—urgent.
2. With urinary tract symptoms—pain,
haematuria, dysuria—semi-urgent.
3. Incidental discovery of urolithiasis on
abdominal X-rays for other reasons—non-
urgent.
 Urgent Investigation for Renal Pain or
Uteric Colic

1. Urine examination for red blood cells, protein

and infective organisms. Plain X-ray of
abdomen—70 per cent of calculi are radio
opaque.
2. IVU (emergency) for size and site of impaction
of calculus and secondary effects on the upper
urinary tract plus functional state of
contralateral kidney.
3. Delayed films are taken 2, 3, 4-12 hr after the
injection if the obstructed kidney shows no
function in the early stage of excretion.
 Routine Investigation for Urinary Tract
Symptoms or Incidental Discovery of a
Calculus

1. Urinary examination
2. Creatinine and BUN for renal function.
3. Ultrasonography
4. Plain abdominal film.
5. IVU
Management and Treatment of Urolithiasis

Treatment fals into two well-defined categories:

1. Management of acute symptoms produced by a
stone impacted in the pelvi-ureteric junction or
passing down the ureter—urgent.
2. Management of an established stone in the
urinary tract—routine.