Urology for medical students

Dr Palaniappan Sundaram
 Outline
• Case
• Pathogenesis
• Epidemiology
• Diagnosis of kidney stone
• Risk factors
• Management
• Conclusion
 Case 1
• 38 year old male
• Flank pain
– Acute, colicky
– Radiating to groin and
genitalia
• Nausea and vomiting
• Urinary urgency,
frequency, and dysuria
• This has happened once
before…
 What history would you take?

• Site • Severity (1 - 10)

• Onset • Assoc symptoms
– sudden or gradual – fever, chills
• Character – nausea or vomiting
– sharp and localised – dysuria or haematuria
– change in bowel habit
– dull
• PMH
– crampy
– prev urinary stones, AAA, prev
• Radiation
surgery
• Alleviating factors
• Medications
– worse on movement, position
– anticoagulants
• Timing
• Social Hx
– intermittent or constant
– smoking, recreational drugs
• Exacerbating factors
 What examination would you do?
• vitals signs • auscultate
• general – bowel sounds
– distress, pallor – bruits over kidneys, liver
• abdominal • complete above with
– inspection for hernia
– DRE/ VE
– palpation all areas, most
tender area last
– hernia
• both light and deep palpation – ext genitalia
• check for rebound
• identify masses
• percuss if any masses
• examine for liver, spleen and
kidneys
 Differential diagnosis
• UTI • Women
• Acute pyelonephritis – Ectopic Pregnancy
• Prostatitis – Ovarian torsion
– Ovarian cyst rupture
• Torsion
– PID
• GS causes
– divericulitis, appendicitis,
cholecystitis, AAA, DU,
GE
• Musculoskeletal pain
 Ureteric Stones
• classical hx
– sudden onset severe pain
– unable to get
comfortable
– nausea, vomiting
– dysuria (seen in most
distal ureteric
stone/bladder stone)
• lifetime prevalence 10%
• age of onset 30 - 60yrs
 KUB xray/ IVU

• Name the the calyx, papilla, psoas shadow

• course of the ureters
– start at the renal pelvis at L1
– travel downwards along lateral border of transverse
process
– cross over iliac vessels at SI joint
– after crosing over, travel towards ischial spines and
forward to bladder
• narrowest points
– PUJ
– iliac crossing
– VUJ
• beware of phlebolith (vein calcification)
– small rounded opacities with radiolucent centre
 KUB xray
• Low sensitivity and low specificity (44-77%)
• Does not need to be performed if NCCT is
considered
– Used in followup
– Radio opaque and radiolucent stones
• Uric acid
• Xanthine
• Matrix stones (proteinaceous material)
• Drug stones
 Management
• urine microscopy/ dipstix, renal panel, FBC
• treat with analgesia
• admit if febrile or persistent pain
• may need antibiotics and nephrostomy if there is pyonephrosis
• stones < 5mm may pass spontaneously
• definitive treatment
– depends on location and size of stone, obstruction, infection and
renal impairment
– Ureteroscopy, ESWL, medical expulsion therapy/conservative for
ureteric stones
– PCNL, ESWL, flexible ureteroscopy for renal stones
 Urine microscopy findings
• Microscopic haematuria
• Small amount of blood in urine
• Still yellow in color
• Single, most discriminating predictor of kidney
stone if patient presents with unilateral flank
pain
– Present in 95% of patients on Day #1
– Present in 65-68% of patients on Day #3 or #4
• Non-contrast helical CT • Ultrasonography
• More sensitive (93%) and
specific (97%)
• Poorly sensitive (45%)
• Radiation exposure, cumulative but specific (88 – 94%)
• No radiation
 Management principles
• Treat infection/sepsis
– culture
– decompression
• Treat pain
– analgesia
• diclofenac, ibuprofen, indomethacin, tramadol (2nd choice)
– if not, admit for PCN, stent or removal
• Will it pass spontaneously?
– MET only in patients with no pain/ infection/ renal impairment
(distal >5mm)
– Potcit or NaHCO3 til pH btw 7.0 - 7.2
 Why does stone form?
• Ions are normally soluble in urine
• Calcium, phosphate and oxalate
• Balanced by crystallization inhibitors: ions (citrate and
magnesium) and macromolecules
• Urine sometimes supersaturates, favoring
precipitation of crystals
– Usually related to low urine volume
– Acidic(<5.5) or alkaline(>7.2) pH favour crystal
formation
 Epidemiology
• Prevalence is different between countries (1-
20%)
• Approximately 1/10 affected in lifetime
• Increased incidence of stones from 3.8% in
1970s to 8.8% in 2000s
• Peak incidence in 30-60
• Male > Female (2-3:1)
• Geography: Hotter and drier climates
 Risk factors
• Early onset • Hyper PTH
• Familial • Malabsorptive GI
• Anatomical abnormalities disease
– PUJO • Sarcoidosis
– Ureterocele
• Metabolic syn
– Stricture
– Calyceal divertic
• Genetic diseases
– VUR – PH
– Medullary sponge – Cystinuria
– Horseshoe – RTA type 1
Success of ESWL Improve efficacy of Contraindications Complications
• Size ESWL • preg • Haematoma 1%
• Location • SW rate • untreated uti • Sepsis 1 - 3%
• Stone density • Stepwise ramping • distal obstruction • Colic 2 - 4%
• Skin stone • Acoustic coupling • anticoagulated • Steinstrasse 4 - 7%
distance • Careful localisation • obesity
• Pain control • AAA
• MET
• Abx prophylaxis
Complications
Stenting
• Bleeding
– inserted in at risk population
• Sepsis
• Ureteral stricture 1% • infection
• Ureteral avulsion <1% • perforation
• Stenting and staged • bleeding
procedure • obstruction/oedema
• residual fragments
1. URS
2. ESWL

1. URS
2. ESWL
 RIRS

• Ureteral access sheaths

– multiple easy access to kidney
– improves vision with continuous outflow
– decreases intra renal pressure
– reduces operating time
– risk of ureteral injury
For larger stones
Contraindications Complications
– standard 24 - 30F
– untreated uti – bleeding 5%
– mini <20F
– tumour – sepsis 2%
– embolisation 1%
Puncture – anticoagulated
– US/ fluoro – adj organ injury <1%

Dilatation
– telescopic/ single
 Types of Stones
• Calcium stones
– Calcium oxalate (~80%)
– Calcium phosphate (~5-10%)
• Struvite stones (~10-15%)
– Magnesium ammonium phosphate
• Uric acid stones (~5-10%)
• Cystine stones (~1-2%)
 Stone analysis
• Fourier transform infrared spectroscopy
 Stones
Composition
– calcium oxalate/
phosphate (80%)
• assoc with hyperparathyroidism/
renal tubular acidosis/medullary
sponge kidney

– struvite
• assoc with uti (urease producing
organism like proteus), forms in
alkaline urine
 Stone
Composition
– uric acid
• assoc with gout, forms in
acidic urine
– cystine
• assoc with cystinuria
 Ca Ox stone
• Absorptive hypercalciuria
– Excess salt
• Dietary hyperoxaluria
– Spinach, nuts, chocolate
 Ca PO4
• HPT
• RTA
• Sarcoidosis
 Struvite
• Alkaline pH, usually >7
• Urease producing bacteria
– Proteus
– Pseudomonas
– Klebsiella
– Providencia
– Citrobacter
• Tends to form staghorns
 Uric acid
• Low urine volumes
• Acidic urine
• Excess purine intake
 Case 2
• 2 week history of left flank pain
• Known to have ureteric stones
• Whilst waiting for stone to pass, pain
worsened
• Lightheaded and weak
• Left costovertebral angle tenderness
Management
 Questions?
• Which type of kidney stone is the most
common?
– a) Calcium
– b) Uric acid
– c) Cystine
– d) Cholesterol
• Which of the following options outline
conservative prevention strategies?
– a) Surgery
– b) Alpha blocker medication
– c) Increase fluid intake
– d) Increase sodium and animal protein intake
• Which of the following is true?
– a) All adults should have a full metabolic workup
with their first kidney stone
– b) All children should have a full metabolic work-
up with their first kidney stone
– c) Struvite stone formers do not need antibiotic
treatment
– d) Kidney stones larger than 10mm usually pass
spontaneously