ALG Urolithiasis (Nephrolithiasis) 1323

increased temperature, with an increased

BASIC INFORMATION risk of dehydration and urinary concentration.
Calcium oxalate or mixed calcium oxalate/
DIAGNOSIS U
DEFINITION calcium phosphate stones account for nearly DIFFERENTIAL DIAGNOSIS
Urolithiasis is the presence of calculi within the 70% to 80% of stones. Urinary tract infection
urinary tract from the kidney to the urethra. The Pyelonephritis
PHYSICAL FINDINGS & CLINICAL
five major types of urinary stones are calcium Diverticulitis
PRESENTATION
oxalate (70%-80%), calcium phosphate (10%- Pelvic inflammatory disease
20%), uric acid (10%), struvite (7%), and cystine Stones may be asymptomatic, or they may Ovarian pathology
(1%) (Table 1). cause the following signs and symptoms as a Dysmenorrhea
result of obstruction: Factitious (illicit substance-seeking behav-
SYNONYMS Acute, often severe, flank pain (renal colic). ior), often with recurrent stone formers
Nausea and vomiting.

and Disorders
Diseases
Kidney stones Appendicitis
Kidney calculi Hematuria, gross or microscopic. Small-bowel obstruction
Ureteral stones Patients are unable to find a position of Ectopic pregnancy
Ureteral calculi comfort. Constipation
Nephrolithiasis Pain radiating from the flank downward and Malignancy (primary urinary tract or retroper-
Ureterolithiasis anteriorly with referred pain to the groin and itoneal lymphadenopathy causing ureteral/
ICD-10CM CODES
genitalia with stone progression down the
ureter.
kidney obstruction)
Musculoskeletal back pain
I
N20.9Urinary calculus, unspecified Urinary urgency and frequency with distal The differential diagnosis of obstructive urop-
N20.0Calculus of kidney ureteral stones can mimic a urinary tract athy is described in Section II.
N20.1Calculus of ureter infection.
N20.2Calculus of kidney with calculus of Fever and chills may accompany acute colic WORKUP
ureter with superimposed infection. Fig. E1 describes an algorithm for evaluation
N21.0Calculus in bladder of suspected renal colic.
N21.1Calculus in urethra ETIOLOGY
Stone composition of recovered stones
N21.8Other lower urinary tract calculus Urine supersaturation of various solutes and should be determined by infrared spectros-
N21.9Calculus of lower urinary tract, stone constituents is the driving force in copy or X-ray crystallography.
unspecified kidney stone formation. All urine contains A clinical algorithm for the evaluation of
dissolved stone solutes, which can precipi- nephrolithiasis is described in Fig. E2.
EPIDEMIOLOGY & tate under conditions that supersaturate the Box E3 describes events in the medical his-
DEMOGRAPHICS urine, such as low urine volume, low or high tory that may be significant with regard to
urine pH, and elevated urine solute levels. urolithiasis.
In the U.S., the lifetime prevalence of neph-
Low urine volume is a common issue in many
rolithiasis is approximately 10% in males and
stone formers. LABORATORY TESTS
females.
Idiopathic hypercalciuria. Urinalysis: Hematuria may be present, but
Peak incidence occurs in the fourth to sixth
Hyperparathyroidism with resulting hypercal- its absence does not exclude stones. Urine
decade of life.
cemia and hypercalciuria. pH may help identify stone type: pH >7.5 is
Stone prevalence is increasing and females
Malabsorption (e.g., inflammatory bowel dis- associated with struvite stones; pH <5.5 is
now have stones almost as often as males.
ease) with increased oxalate absorption. generally associated with uric acid stones,
Between 1 and 2 million emergency depart-
Chronic diarrheal states. and low serum bicarbonate concentration
ment visits annually are due to kidney stones
Gastric bypass surgery. with urine pH 6 is consistent with a renal
and renal colic.
Primary hyperoxaluria: genetic, rare, and tubular acidosis.
The incidence of symptomatic nephrolithiasis
usually presenting as a childhood disorder. Urine culture and sensitivity results should be
is greatest during the summer as a result of
Low urine pH due to metabolic syndrome obtained in all patients.
(e.g., overweight, diabetes), often causes uric Serum chemistries include electrolytes, BUN,
acid stones. creatinine, calcium, phosphate, uric acid, and
TABLE 1 Stone Composition and Medullary sponge kidney.
Relative Occurrence may consider parathyroid hormone.
Hyperuricosuria (e.g., metabolic defects, Additional tests: 24-hr urine collection for
dietary excess) (Box E1). volume, creatinine, calcium, uric acid, phos-
Occurrence
Stone Composition (%) Type I (distal tubule) renal tubular acidosis phate, oxalate, and citrate excretion is gen-
(>1% of calcium phosphate stones). erally reserved for patients with recurrent
Calcium-containing stones Chronic infections with urease-producing stones, young patients, or bilateral stones.
Ca oxalate 60 organisms (e.g., Proteus, Providencia, A 24-hr urine collection may be appropriate
Mixed Ca oxalate/hydroxyapatite 20 Pseudomonas, Klebsiella). Struvite, or mag- for motivated, first-time stone patients inter-
Brushite 2 nesium ammonium phosphate crystals, is ested in preventing recurrent stones.
Noncalcium containing stones produced when the urinary tract is colonized
Uric acid 7
by bacteria, producing elevated concentra- IMAGING STUDIES
tions of ammonia (Box E2). Common diagnostic modalities for renal colic
Magnesium ammonium 7
phosphate (struvite)
Cystinuria, autosomal recessive, and 1% of are summarized in Table 2. Noncontrast CT
stones. scanning has the greatest sensitivity and
Cystine 1-3 (10% of
stones in
Medications including protease inhibitors specificity. Ultrasonography may be an ade-
children) (e.g., indinavir, ritonavir), topiramate, and quate initial study in many instances, espe-
Xanthine <1
chronic laxative overuse. cially in patients known to have a history of
Anatomic changes predisposing to urinary stones and in patients where radiation should
Medication-related stones <1
stasis, including malrotated and horseshoe be avoided (e.g., pregnancy and children).
From Lipshultz LI etal: Urology and the primary care practitioner, kidney.
ed 3, Philadelphia, 2008, Elsevier.

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1324 Urolithiasis (Nephrolithiasis) ALG

TABLE 2 Common Diagnostic Imaging Modalities for Renal Colic

Modality Information Provided Radiation Dose Contrast Approximate Cost Time
CT Renal stones, including size and position 4-10 mSv No $750-$1000 Less than 5 min to perform,
of stones and evidence of obstruction 30 min for interpretation
Alternative diagnoses, such as AAA,
appendicitis, and free air
CT with IV Same as noncontrast CT 4-10 mSv Yes $750-$1000 Less than 5 min, after delay
contrast Delineation of renal mass lesions to measure creatinine
Additional information about vascular dis-
sections and mesenteric ischemia
CT with IV and Same as CT with IV contrast 4-10 mSv Yes $750-$1000 Less than 5 min, after delay
oral contrast Potentially improved diagnosis of bowel of approximately 2 hr to
abnormalities ingest oral contrast
Intravenous Structural and functional information 1.5 mSv Yes $350 Approximately 75 min
urogram about obstruction
Rarely, identification of other pathology,
such as AAA
X-ray Possible identification of stone, but not 0.5-1 mSv No $250 Less than 5 min
useful for hydronephrosis or most other
pathology
Ultrasound Identification of hydronephrosis or hydro- No No $150 Approximately 15-30 min
ureter bedside ultrasound is
Possible identification of stone quicker
Used to assess for AAA or biliary disease

CT, Computed tomography; IV, intravenous.

From Lipshultz LI etal: Urology and the primary care practitioner, ed 3, Philadelphia, 2008, Elsevier.

Dilated renal calyx,

evidence of
hydronephrosis
Stone
Stone
Acoustic
shadow

Acoustic
shadow

A B
FIG. 3 Ultrasound of renal stone. Ultrasound can be used to assess for renal stones and complications
such as hydronephrosis. Stones can be difficult to detect, whereas hydronephrosis is usually readily observed.
Because stones are dense, they reflect sound and prevent its through transmission. As a result, stones are
echogenic (bright) on ultrasound, and cast an acoustic shadow (black). A, Short-axis view of kidney. B, Close-
up. (From Broder JS: Diagnostic imaging for the emergency physician, Philadelphia, 2011, Saunders.)

Kidney ultrasound (Fig. 3): Initial ultrasonog-
raphy is associated with lower cumulative
radiation exposure than initial CT, without
significant differences in serious adverse
events, pain scores, return emergency
department visits, or hospitalizations. It is
reasonable to use ultrasonography as the ini-
tial imaging modality in suspected nephroli-
thiasis; however, a CT scan is the optimal test
for planning surgical management of stones.
Accuracy of sonography in detecting distal
ureteral stones is variable due to variable
stone size, body habitus, and expertise of the
technician and radiologist. The absence of an
ipsilateral ureteral jet supports for a condition
of renal blockage, but is not pathognomonic.
Unenhanced (noncontrast) helical CT scan-
ning (Fig. E4), is rapid and accurate (sensitiv-
ity, nearly 100%; specificity, 94%-96%) and
can identify all stone types in all locations
except for indinavir stones, which are now
quite rare, since indinavir is no longer com-
monly used. These stones are not radiopaque
and contrast-enhanced CT may be required
to diagnose them.
Abdominal radiography can identify radi-
opaque stones (e.g., calcium-containing but
not radiolucent uric acid stones), and 20 to
30% of stones will not be visible.
CT scans may be ordered by urologists
planning surgical intervention because a CT
yields information on adjacent organs and
stone density that ultrasound and plain film
radiography cannot reveal.
TREATMENT
ACUTE GENERAL Rx
Diagnosis with labs and imaging
Pain control: NSAIDs are excellent drugs
for managing renal colic (e.g., ketorolac).
Opiates may be required for severe pain.
IV fluids and antiemetics may be required.
Patients that cannot be pain controlled may
require urgent kidney drainage (ureteral stent
by a urologist or nephrostomy tube place-
ment). For patients that have a stone with a

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high probability of passage, medical expul-
sive therapy with -blockers or calcium
channel blockers (used less often due to
side effects) may be helpful. New Level 1
evidence suggests that medical expulsive
treatment may not be superior to place-
bo; however, numerous older studies have
shown benefit to passage of distal stones >5
mm in size with the use of medical expulsive
therapy.
PREVENTION
Increase low-calorie fluid intake. Generally,
patients at increased risk for the develop-
ment of stones should increase fluid intake
to maintain a urine volume of 2.5 to 3 L/day.
RDA of dietary calcium 800-1200 mg/day is
recommended. Lower calcium consumption
results in less gut oxalate binding and more
colonic oxalate absorption, which in turn
increases urinary oxalate and risk for calci-
um-based stones. Limiting animal protein to
one serving daily is often recommended.
Greater fruit and vegetable intake increases
urinary excretion of citrate (stone inhibitor).
Dietary sodium restriction is recommended
to <2 g daily because this decreases calcium
excretion.
Dietary oxalate restriction in patients with
hyperoxaluria.
Increased dietary citrate (e.g., lemons,
oranges).
Stone specific therapy:
1. Uric acid calculi can be prevented or even
dissolved with urine pH over 6 to 6.5. This
is often accomplished with potassium
citrate, taken two or three times daily
with food.
2. Calcium stones:
In general, cannot be dissolved and
either remain, pass, or are removed.
With hypercalciuria, thiazide diuretics
and low-sodium diet are appropri-
ate. Potassium citrate supplementa-
tion for patients with calcium stones
and low 24-hr urine citrate excretion.
Potassium citrate may also be effective
with calcium stones even when urine
citrate excretion is not low.
Urate-lowering treatment for patients
with hyperuricosuria but not hyper-
calciuria.
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ALG Urolithiasis (Nephrolithiasis)
3. Struvite stones:
 Surgical interventions are usually
required. Shock wave lithotripsy (SWL),
percutaneous nephrolithotomy (PCNL),
and/or ureteroscopy will usually be
needed, depending on stone size and
configuration.
 Urease inhibitor treatment by ace-
tohydroxamic acid in patients who
are not rendered stone free or are
poor surgical candidates. This agent is
poorly tolerated and infrequently used
in contemporary practice.
4. Cystine stones
High fluid intake of 3 to 4 L daily is the principal
therapy. Urine alkalinization to pH >6.57 with
potassium citrate. Thiol drugs such as penicil-
lamine and tiopronin reduce the poorly soluble
cystine to a soluble cysteinedrug complex.
Tiopronin is better tolerated than penicillamine.
Surgical Therapy:
Surgical treatment is needed for patients
with: severe pain unresponsive to medica-
tion, possible infection from an obstructing
stone, acute kidney injury from ureteral
obstruction, refractory nausea/vomiting,
and prolonged kidney obstruction (i.e., risk
of irreversible renal damage).
 Ureteral stones can often be managed
with ureteroscopy or SWL.
Stones in the kidney can be managed
with ureteroscopy or SWL if <1 to 2 cm
in size and in a favorable location. As a
stone become larger and more complex,
PCNL becomes the preferred means of
management.
Indications for PCNL are described in Table
E3.
Fig. E5 describes the management of ureteral
stones.
Guidelines for ureteral stone treatment:
1. Proximal ureteral stones <1 cm diameter:
SWL or ureteroscopy preferred.
2. Proximal ureteral stones >1 cm diameter:
SWL, ureteroscopy, or PCNL for complex
and/or large stones.
3. Distal ureteral stones <1 cm diameter:
SWL or ureteroscopy, although ureteros-
copy is generally preferred.
4. Distal ureteral stones >1 cm diameter:
SWL or ureteroscopy. Ureteroscopy is
generally preferred.
1325
Fig. E5 describes an approach to the man-
agement of ureteral calculi.
U
CHRONIC Rx
Maintenance of proper hydration and dietary
restrictions (see Acute General Rx)
DISPOSITION
>50% to 80% of patients will pass a ureteral
stone within 4 to 6 weeks of presentation
Stone recurrence is variable and based on
size, location, and number of stones, along
with patient comorbidities and stone-forming
and Disorders
Diseases
tendencies. The Recurrence of Kidney Stone
(ROKS) nomogram was developed to predict
recurrence in first-time stone formers.
REFERRAL
Urology referral is appropriate when spontane-
ous passage is unlikely, when a patient cannot I
be discharged from the emergency department,
or when patients have complicated or recurrent
stones.
PEARLS &
CONSIDERATIONS
COMMENTS
Use the ROKS nomogram to calculate recur-
rence risk in first-time stone-formers.
Approximately 75% to 80% of patients will
not need admission or surgery for a ureteral
stone.
Patients should be referred to a urologist if
they have multiple stones at presentation,
complex stones, or have had multiple prior
episodes.
SUGGESTED READINGS
Available at www.expertconsult.com
RELATED CONTENT
Kidney Stones (Patient Information)
Urinary Tract Infection (Patient Information)
AUTHOR: LAMA NAZZAL, M.D., M.SC., and
PETER L. STEINBERG, M.D.
Urolithiasis (Nephrolithiasis)
EVIDENCE-BASED MEDICINE
Abstract[1]
Background:
There is a lack of consensus about whether the initial imaging method
for patients with suspected nephrolithiasis should be computed tomog-
raphy (CT) or ultrasonography.
Methods:
In this multicenter, pragmatic, comparative effectiveness trial, we ran-
domly assigned patients 18 to 76 years of age who presented to the
emergency department with suspected nephrolithiasis to undergo initial
diagnostic ultrasonography performed by an emergency physician
(point-of-care ultrasonography), ultrasonography performed by a radiol-
ogist (radiology ultrasonography), or abdominal CT. Subsequent man-
agement, including additional imaging, was at the discretion of the
physician. We compared the three groups with respect to the 30-day
incidence of high-risk diagnoses with complications that could be related
to missed or delayed diagnosis and the 6-month cumulative radiation
exposure. Secondary outcomes were serious adverse events, related
serious adverse events (deemed attributable to study participation), pain
(assessed on an 11-point visual-analogue scale, with higher scores in-
dicating more severe pain), return emergency department visits, hospi-
talizations, and diagnostic accuracy.
Results:
A total of 2759 patients underwent randomization: 908 to point-of-care
ultrasonography, 893 to radiology ultrasonography, and 958 to CT. The
incidence of high-risk diagnoses with complications in the first 30 days
was low (0.4%) and did not vary according to imaging method. The
mean 6-month cumulative radiation exposure was significantly lower in
the ultrasonography groups than in the CT group (P < 0.001). Serious
adverse events occurred in 12.4% of the patients assigned to point-of-
care ultrasonography, 10.8% of those assigned to radiology ultrasonog-
raphy, and 11.2% of those assigned to CT (P = 0.50). Related adverse
events were infrequent (incidence, 0.4%) and similar across groups. By
7 days, the average pain score was 2.0 in each group (P = 0.84). Return
emergency department visits, hospitalizations, and diagnostic accuracy
did not differ significantly among the groups.
Conclusions:
Initial ultrasonography was associated with lower cumulative radiation
exposure than initial CT, without significant differences in high-risk diag-
noses with complications, serious adverse events, pain scores, return
emergency department visits, or hospitalizations.
Currently, kidney stones are typically diagnosed with high sensitivity
and specificity via a CT scan of the abdomen and pelvis.2 Will, or
should, the results of this large, geographically diverse, randomized,
multicenter, trial be viewed as establishing the comparative therapeutic
equivalence of these tools and thereby alter our diagnostic approach
to suspected nephrolithiasis? To answer this question, we must carefully
understand the results of this study.
To evaluate the relative effectiveness of various imaging modalities,
eligible patients were randomized to either receive ultrasonography by
an ultrasound-certified emergency physician, a radiologist, or an ab-
dominal CT. The diagnostic accuracy was assessed via either stone
passage or a patient report of surgical stone removal.
The key primary outcome was not diagnostic accuracy per se but
rather focused on missed predefined high-risk diagnoses, complications
potentially related to a delay in diagnosis (occurring within 30 days of
examination), and the cumulative radiation exposure.
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1325.e1
The number of high-risk diagnoses with complications was small, and
although it tended to be slightly higher in the emergency department
(ED) ultrasound group, it did not reach statistical significance, nor did any
of the other outcome parameters studied.
The statistics were handled using an intention-to-treat model. Ulti-
mately, about 41% of the patients in the ED ultrasound group and about
27% of the patients in the radiology ultrasound group required CT imag-
ing to establish a diagnosis of stone disease. When this is taken into
account, the sensitivity of ultrasonography to detect renal stones is less
than that of CT at 54% (95% confidence interval [CI]: 48-60); for point-
of-care ultrasonography, it is 57% for radiology ultrasonography (95%
CI: 51-64), and 88% for CT (95% CI: 84-92; P < .001).
Thus, there are several important caveats to this study. First, as the
authors clearly point out, their results do not suggest that at-risk patients
should undergo only ultrasound imaging. Instead, their findings sug-
gested that ultrasonography is the most appropriate initial diagnostic
imaging test for the detection of renal stones. Additional images may be
required based on the clinical judgment of the physician.
The second caveat is that eligibility criteria were carefully defined.
Several groups of patients were deemed ineligible for inclusion. These
included anyone being evaluated for an alternative diagnosis such as
appendicitis, cholecystitis, or aneurysm, and patients who were obese,
pregnant, had a solitary kidney, were receiving dialysis, or had a prior
transplantation. The third is that the ED physicians performing the study
were certified in ultrasonography, and therefore the results may not be
generalizable to other clinical settings.
Nonetheless, the results of the study are important. CT imaging and
stone evaluations can involve significant exposure to ionizing radiation.
In fact, Ferrandino and colleagues found that the typical acute stone
evaluation at an academic medical center (which included an intrave-
nous pyelogram, an abdominal radiograph, and a CT of the abdomen and
pelvis) had a mean radiation exposure of 29.7 mSv.3 The International
Commission on Radiation Exposure recommends a total annual expo-
sure of under 50 mSv.4 In addition to using ultrasonography as a first-
line approach to the diagnosis of stone disease, the applicability of
low-dose CT5,6 scans should continue to be explored.
R. Garrick, MD
Evidence-Based References
1. Smith-Bindman R, etal.: Ultrasonography versus computed tomography for
suspected nephrolithiasis, N Engl J Med 371:11001110, 2014. .
2. Coursey CA, Casalino DD, Reimer EM, etal.: ACR appropriateness criteria:
acute onset flank pain and suspicion of stone disease, Ultrasound Q 28:227
233, 2012.
3. Ferrandino MN, Bagrodia A, Pierre SA, etal.: Radiation exposure in the acute
and short-term management of urolithiasis with biases at two academic cen-
ters, J Urol 181:668672, 2009.
4. National Research Council: Health Risks from Exposure to Low Levels
of Ionizing Radiation: BEIR VII Phase 2, Washington, DC, 2006, National
Academies Press.
5. Ciaschini MW, Remer EM, Baker ME, Lieber M, Herts BR: Urinary calculi:
radiation dose reduction of 50% and 75% at CT effect on sensitivity, Radiology
251:105111, 2009.
6. Poletti PA, Platon A, Rutschmann OT, Schmidlin FR, Iselin CE, Becker CD: Low
dose versus standard-dose CT protocol in patients with clinically suspected
renal colic, AJR Am J Roentgenol 188:927933, 2007.
Urolithiasis (Nephrolithiasis) 1325.e2

SUGGESTED READINGS
Assimos D, etal.: Surgical management of stones: American Urological
Association/Endourological Society Guideline, PART I, J Urol 196:11531160,
2016.
Dropkin BM, etal.: The natural history of nonobstructing asymptomatic renal
stones managed with active surveillance, J Urol 193:1265, 2015.
Fink HA, etal.: Medical management to prevent recurrent nephrolithiasis in adults:
a systematic review for an American College of Physicians clinical guideline,
Ann Intern Med 158:535543, 2013.
Frassetto L, Kohlstadt I: Treatment and prevention of kidney stones: an update, Am
Fam Physician 84(11):12341242, 2011.
Moesbergen TC, etal.: Distal ureteral calculi: US follow-up, Radiology 260:575,
2011.
Pearle M: Shock-wave lithotripsy for renal calculi, N Engl J Med 367:5057, 2012.
Pearle MS, etal.: American Urological Association. Medical management of kidney
stones: AUA guideline, J Urol 192:316324, 2014.
Pickard R, etal.: Medical expulsive therapy in adults with ureteric colic: a mul-
ticentre, randomised, placebo-controlled trial, Lancet 386(9991):341349,
2015.
Scales Jr CD, etal.: Urologic Diseases in America Project. Prevalence of kidney
stones in the United States, Eur Urol 62(1):160165, 2012.
Smith-Bindman R, etal.: Ultrasonography versus computed tomography for sus-
pected nephrolithiasis, N Engl J Med 371:11001110, 2014.
Worcester EM, Coe FL: Calcium kidney stones, N Engl J Med 363:954963, 2010.
Zhang W, etal.: Retrograde intrarenal surgery versus percutaneous neph-
rolithotomy versus extracorporeal shockwave lithotripsy for treatment of
lower pole renal stones: a meta-analysis and systematic review, J Endourol
29(7):745759, 2015.

BOX E1Uric Acid Stones BOX E2Factors Associated With

Struvite Stone Formation
Low urine pH (5.5)
High animal protein diet Urease-producing bacteria*:
Diarrhea Proteus
Insulin resistance (high body mass index, Haemophilus
metabolic syndrome, type 2 diabetes) Yersinia species
Low Urine Volume Staphylococcus epidermidis
Inadequate fluid intake Pseudomonas
Excessive extrarenal fluid losses Klebsiella
Diarrhea Serratia
Insensible losses (e.g., perspiration) Citrobacter
Ureaplasma
Hyperuricosuria
Elevated urinary pH
Excessive dietary purine intake
Hyperuricemia From Floege J etal: Comprehensive clinical neph-
Gout rology, ed 4, Philadelphia, 2010, Saunders.
Intracellular-to-extracellular uric acid
shift
Myeloproliferative disorders
Tumor lysis syndrome
Inborn errors of metabolism
Lesch-Nyhan syndrome
Glucose-6-phosphatase deficiency

From Floege J etal: Comprehensive clinical

nephrology, ed 4, Philadelphia, 2010,
Saunders.

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Urolithiasis (Nephrolithiasis) 1325.e3

CT of abdomen and pelvis

No evidence of nephrolithiasis Ureteral stone or secondary signs

Investigate nonurologic causes Pain control

Urgent intervention Nonurgent

required intervention

Insert stent or Assess likelihood of

nephrostomy tube stone passage

High Low

Conservative Urologic
management intervention
to remove
stone
No (e.g., ESWL,
Stone passed? ureteroscopy)

Yes
Prevention:
1. Stone analysis
2. Metabolic evaluation

Preventive
recommendations

Monitor response to
recommendations

FIG. E1 Algorithm for evaluation of suspected renal colic. SWL, Extracorporeal shock wave lithotripsy.
(From Goldman L, Schafer AI: Goldmans Cecil medicine, ed 24, Philadelphia, 2012, Saunders.)

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 Urolithiasis (Nephrolithiasis)
(1) Examination of sediment from urine specimen immediately after voiding
(2) Obtain plain abdominal radiograph, ultrasound, and/or CT urogram
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Radiodense stone Radiolucent stone

(also consider tumor of renal pelvis,
blood clot, sloughed renal papilla)

Calcium oxalate or Struvite-apatite cr ystalluria Cystine crystalline

apatite cr ystalluria Urine pH 7.5 Acid urine Uric acid crystalluria
Pyuria and bacilluria Positive cyanide Urine pH 5.5
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nitroprusside test Concentrated urine

Calcium oxalate-apatite stone
(confirm by analysis) Struvite-carbonate apatite stone
(confirm by analysis) Cystine stone Uric acid stone
(confirm by analysis) (confirm by analysis)

Hypercalcemia Normal serum Ca Infection stone caused by

urease-producing bacilli
Evaluate mechanism for urinary infection Hyperuricemia Normal serum
Search for underlying metabolic cause of uric acid
High serum PTH Normal or low stone that became secondarily infected
High urine serum PTH and Gout
cyclic AMP urine cyclic AMP Malignancy Purine gluttony
Idiopathic uric
Hypercalciuria Hypocitraturia acid stone
(300 mg Ca/day or No acidosis (200 mg/day) Normal urine Ca
Primary hyper- Sarcoidosis, other Diarrheal
parathyroidism 4 mg Ca/kg/day) diseases
granulomatous
diseases,
lymphomas [high
serum 1,25(OH)2- Metabolic acidosis
vitamin D3] (venous blood pH 7.34 Hyperuricosuria Hyperoxaluria Normal urinary
Hyperthyroidism serum HCO3 22 mEq/L Distal renal (urine uric acid (urine oxalate uric acid and
(high T3, T4) serum CI 108 mEq/L tubular 800 mg/day 45 mg/day) oxalate excretion
Myeloma (osteoclast urine pH always 6.0 acidosis in men;
activating factor) low urine citrate) 750 mg/day
Malignant tumor in women)
PTH-like peptide in Primary hyperoxaluria Idiopathic calcium stone
hypercalcemia of Acquired hyperoxaluria disease
malignancy; Idiopathic hypercalciuria Small bowel disease Habitually low fluid
prostaglandins Renal Ca leak Hyperuricosuria Gluttony for oxalate- intake and thus
[may include medullary sponge kidney; and Ca stone rich food concentrated urine
secondary hyperparathyroidism and activation syndrome Ascorbic acid abuse ? Deficiency of
of 1,25(OH)2-vitamin D3 synthesis] (some also inhibitor of crystal
Renal P leak have hyper- nucleation or
[activation of 1,25(OH)2-vitamin D3 synthesis; calciuria) growth
probably indirect] ? Presence of
Absorptive hypercalciuria promoter of crystal
[mediated via increased 1,25(OH)2-vitamin D3- nucleation or
stimulated intestinal Ca absorption or by augmented growth
gut Ca absorption independent of vitamin D]

FIG. E2 Evaluation of patients with suspected nephrolithiasis (flank pain, ureteral colic, hematuria, fever). AMP, Adenosine monophosphate; CT, computed
tomography; PTH, parathyroid hormone. (Modified from Stein JH [ed]: Internal medicine, ed 5, St Louis, 1998, Mosby.)

1325.e4
Urolithiasis (Nephrolithiasis) 1325.e5

BOX E3Components of the Medical History That Are Significant for

Urolithiasis

Diseases associated with disturbances of calcium metabolism: primary hyperpara-

thyroidism, Wilsons disease, medullary sponge kidney, osteoporosis, immobilization,
sarcoidosis, osteolytic metastases, plasmacytoma, neuroendocrine tumors, Pagets
disease
Dietary history: purine gluttony, calcium excess, milk alkali, oxalate excess, sodium
excess, low citrus fruit intake
Medications: uricosurics, diuretics, analgesics, vitamins C and D, antacids (especially
phosphorus-binding agents), acetazolamide, calcium channel blockers, triamterene,
estrogens, theophylline, protease inhibitors (indinavir), sulfonamides
Diseases associated with disturbances of oxalate metabolism: primary hyperoxaluria
types I and II, Crohns disease, ulcerative colitis, intestinal bypass surgery (especially
jejunoileal bypass), ileal resection
Diseases associated with disturbances of purine metabolism
Intrinsic metabolic disorders: anemia, neoplastic disorders (especially leukemias),
intoxication, myocardial infarction, irradiation, cytotoxic chemotherapy
Enzyme deficiency: primary gout, Lesch-Nyhan syndrome
Altered excretion: renal insufficiency, metabolic acidosis
Infectious history: organisms (particularly Proteus and Klebsiella), febrile, upper tract
involvement, and dates (if hospitalized)
Modified from Nseyo UO (ed): Urology for primary care physicians, Philadelphia, 1999, Saunders.

FIG. E4 Kidney, ureter, and bladder (KUB) radiograph in a patient presenting with hematuria shows a radi-
opaque shadow (arrow) along the course of the distal right ureter that proved to be a calculus. (From Nseyo U,
Weinman E, Lamm DL: Urology for primary care physicians, Philadelphia, 1999, WB Saunders.)

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Urolithiasis (Nephrolithiasis) 1325.e6

TABLE E3 Indications for Percutaneous Nephrolithotomy

Indicator Description Treatment
Stone size >2-3 cm or staghorn
Composition* Struvite stones Complete removal necessary to eliminate
infection and minimize stone recurrence
Calcium oxalate monohydrate stones Difficult to pulverize by SWL
Cystine stones Difficult to pulverize by SWL
Stone position Lower pole stones Fragments less easily evacuated from
dependent lower pole calyces, especially
if collecting system dilated
Anatomic abnor- PUJ obstruction; calyceal diverticula Prevent passage of fragments after SWL
malities
Patient charac- Morbid obesity; ureteral obstruction Stone cannot be placed in focal point of
teristics SWL machine

SWL is the first choice for stone intervention, except in those circumstances that may favor PCNL.
SWL, Extracorporeal shock wave lithotripsy; PCNL, percutaneous nephrolithotomy; PUJ, pelviureteral junction.
*Stone composition can be defined with certainty only by direct stone analysis, but advances in imaging may ultimately provide a
means to accurately assess stone composition in situ before treatment, thus allowing the urologist to select the treatment most
likely to be successful.
From Floege J etal: Comprehensive clinical nephrology, ed 4, Philadelphia, 2010, Saunders.

Stone size

5 mm 5-10 mm 10 mm

Observation
Proximal Distal Distal

Success Failure
Ureteroscopy SWL Ureteroscopy SWL

SWL
Ureteroscopy
Success Failure Success Failure

SWL
Ureteroscopy Ureteroscopy
? PNL

Success Failure
Proximal

Ureteroscopy
? PNL
SWL Ureteroscopy PNL

FIG. E5 Management of urinary calculi. PNL, Percutaneous nephrostolithotomy; SWL, shock wave litho-
tripsy. (From Noble J: Primary care medicine, ed 3, St Louis, 2001, Mosby.)

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