Dr.

Ahmed Al-Kandari
Consultant Urologist
Associate Professor Kuwait University
Urolithiasis
Incidence.
Etiology.
Clinical presentations.
Differential Diagnosis.
Diagnostic work up.
Treatment.
Prognosis and prevention.
Urolithiasis
The average annual incidence of hospital admission for
non-recurrent urolithiasis in Kuwait was 43.44 per
100,000 population,
men and women (ratio, 9:1) with a median age of 41.91
years.
the hospital admissions for non-recurrent
urolithiasis, 57.2% of cases were acute. Overall, the
most predominant symptom was flank pain.

Al-Hunayan et al : Int J Urol. 2004 Nov;11(11):963-8

Pathophysiology of stones
Renal stones occur as a result of the following 3
factors:

Supersaturation of stone-forming compounds in urine

Presence of chemical or physical stimuli ( Urine
obstruction)in urine that promote stone formation
Inadequate amount of compounds in urine that inhibit
stone formation (eg, magnesium, citrate)
Factors that Influence Renal
Stone Formation
Promoters of calculi Inhibitors of calculi
formation formation
1. Supersaturation of 1. Magnesium
urine
2. Citrate
2. Urine pH: acidic/basic
3. Pyrophophate
3. Dehydration
4.Metabolic conditions
5. Endocrine
 Types of urinary stones
Renal stones are classified based on the type of major
solute present :

1. Calcium Stones ( 75%) : Ca-Oxalate, Ca, Phosphate or

carbonate
2. Struvite Stones ( 15%) : Infection induced stones-Urea
splitting organisms.
3. Uric acid stones ( 6%)
4. Cystine stones ( 2%)
5. Combination stones ( Uric acid with calcium )
6. Rare types : Xanthine, matrix, Indinavir induced.
 Calcium stones

The most common renal stones

(75% of total)
Two types- Ca Phosphate or
oxalate(one half of calcium stones
are composed of a mixture of
both) , less common Ca-
carbonate.

Irregular in shape and covered

with sharp projections which tend
to cause bleeding

Very hard and absorbs x-rays well

(radio-opaque)
 Calcium stones
Major Risk Factors for
Calcium stone formation:

Low urine volume

Hypercalciuria
Hyperoxaluria
Hyperphosphaturia
Low levels of inhibitors
Hyperparathyroidism
Vitamin D toxicity
 Struvite stones
15% of all kidney stones.
Known as Triple-Phosphate
stones (Magnesium, calcium,
ammonium phosphate stones).
Alkalinization of urine is an
important factor for their
formation. This decreases
solubility of solutes.
Seen in urinary tract infections
with urea-splitting bacteria
(proteus). Urease splits urea in
NH3 increasing urine pH.
 Uric acid stones
Account for 6 % of renal stones
Pure uric acid stones are
radiolucent and appear on
excretion urogram as a filling
defect, which can be mistaken
for a transitional tumor of the
upper urinary tract
Occasionally and when
containing some calcium , uric
acid stones, may cast a faint
radiological shadow
Acidification of urine promotes
uric acid precipitation.
 Cystine stones
Associated with cysteinuria
Uncommon, account for only
approximately 2% of urinary stones
Due to rare metabolic inborn error:
a genetic defect in the uptake of
cystine from renal tubular cells
increases its concentration that
leads to supersaturation.
Typically faintly radio-opaqe but
may be more opaque due to the
sulphur that they contain, and are
very hard, and commonly fail SWL.
Urolithiasis-Etiolgy
1. Genetic. ( cystine, calcium stones )
2. Environmental. ( all ):
a. Dehydration, and increased heat.
b. High sodium , oxalate and protein intake ( calcium
stones).
3. Short bowel ( Crohns, ) : high oxalate.
4. Infection
5. Anatomic ( obstruction)
6. Metabolic : Hypercalcemia, RTA.
Urolithiasis-Clinical presentations
1. Renal or ureteric colic.
Features:
1. Sudden , increases gradually .
2. Loin to groin and genitals.
3. Dysuria, hematuria , and LUTS.
4. Nausea and vomiting.
( the lower the stone is the more irritative bladder
symptoms).
2. Stones can be asymptomatic.
Urolithiasis- Serious Clinical
presentations
1. Sepsis : flank pain with high fever.
( This is an emergency since obstruction and infection
can lead to septicemia).
2. Renal failure:
If obstruction due to stone is bilateral or in a solitary
kidney then anuria and renal failure is imminent.
Differential diagnoses
1. Acute appendicitis ( for Rt ureteric stones).
2. Biliary colic, acute cholecystitis ( Rt kidney or ureteric
stones).
3. Acute diverticulitis. ( left side).
4. Acute salpingitis, ectopic pregnany.
5. Abdominal aortic aneurysm ( especially in old patient).
6. UTI.
7. Small bowel obstruction.
8. Pancreatitis.
9. Musculoskeletal pain.
Urolithiasis- Diagnostic workup
History and physical exam.
Urine analysis and culture.
Renal function test.
Full biochemical profile.
Abdominal U/S.
CT scan ( without and with IV contrast).
MR Urogram.
Radio isotope scan.
Imaging-KUB, U/S
Imaging : Plain CT scan
The imaging of choice
CT scan-stone ureter
Urolithiasis treatment- Emergency
A. If sepsis or renal
impairment develops then
emergency referral and
intervention ( D-J stent or
nephrostomy is essential and
later stone treatment will be
done.

B. If the pain is intractable

and recurrent and associated
with dehydration then
admission for hydration and
pain control is advisable.
Urolithiasis treatment- Emergency
1. Emergency evaluation with : urine test, S-creatinine,
U/S abdomen, KUB, Plain CT scan.
2. If dehydrated , start IV fluids, analgesics:
noracotics ( Pethidine) for severe pain, NSAID
( Diclofenac) or Paracetamol for mild to moderate pain.
Antispasmodics are not very effective.
3. If no fever, and renal function is normal and acute
pain subsides the option of OPD treatment is
acceptable.
Urolithiasis treatment- Elective

A. Small stones ( in kidney or

ureter)( less than 5 mm)
have high chance of spontaneous
passage ( over 80%), so the
treatment is conservative:
1. Analgesics.
2. Hydration.
3. Expulsive therapy ( Tamsulosin,
alfuzosin).
4. Rowatinex
5. F/U with imaging.

If this approach fails then endoscopic

approach is done.
Urolithiasis treatment-Elective
Kidney stones : less than 2 cm and not very dense
Treatment : SWL. +/- D-J stent.

Kidney stones : more that 2 cm or failed previous SWL

Treatment: PCNL .

Ureteric stones ( upper) over 0.5 cm-

Treatment SWL. If it fails then Flexible URS.
Urteric stones ( middle or lower) over 0.5 cm
Treatment: URS ( usually semirigid or flexible).
Shock wave lithotripsy (SWL)
Out patient procedure.
IV or some sedation.
No aspirin or
anticoagulants.
Pregnancy is contra
indicated since radiation
is used to localize the
stone.
Success rate is 70% on
average.
Ureteroscopy ( URS)- with laser
Use of Double J stent is common after URS
Can cause dysuria,
urgency , hematuria ,
UTI.
Should be removed and
not neglected
Nephrostomy tube
Can be put under local
anesthesia with
ultrasound guidance.
There is a bag attached
to the tube.
There is a possibility of
tube dislodgements.
PCNL
PCNL
Urolithiasis treatment
Nowadays we rarely do open surgery for stones.

Less common is laparoscopic stone surgery.

 Diet therapy
Diet Therapies
1. All stone formers should
increase fluid intake that will
achieve a urine volume of at
least 2.5 liters daily.
2. Patients with calcium stones
and relatively high urinary
calcium should limit sodium
intake and consume 1,000-1,200
mg per day of dietary calcium.
3. Patients with calcium oxalate
stones and relatively high
urinary oxalate to limit intake of
oxalate-rich foods and maintain
normal calcium consumption.
 Diet therapy
11. Patients with calcium
stones and relatively low
urinary citrate need to
increase their intake of fruits
and vegetables and limit non-
dairy animal protein.
12. Patients with uric acid
stones or calcium stones and
relatively high urinary uric
acid need to limit intake of
non-dairy animal protein.
13. Patients with cystine
stones need to limit sodium
and protein intake.
Pharmacotherapy
Pharmacologic Therapies
1. Thiazide diuretics to patients with high or
relatively high urine calcium and recurrent calcium
stones.
2. Potassium citrate therapy to patients with
recurrent calcium stones and low or relatively low
urinary citrate.
3. Allopurinol to patients with recurrent calcium
oxalate stones who have hyperuricosuria and normal
urinary calcium.
Pharmacotherapy
4. Thiazide diuretics and/or potassium citrate to patients
with recurrent calcium stones in whom other metabolic
abnormalities are absent.
5. Potassium citrate to patients with uric acid and cystine
stones.
6. Clinicians should not routinely offer allopurinol as first-
line therapy to patients with uric acid stones.
7. cystine-binding thiol drugs, such as alpha-
mercaptopropionylglycine (tiopronin), to patients with
cystine stones who are unresponsive to dietary
modifications and urinary alkalinization, or have large
recurrent stone burdens.
 Follow up
1. Obtain a single 24-hour urine specimen for stone risk factors within
six months of the initiation of treatment.
2. Clinicians should obtain a single 24-hour urine specimen annually or
with greater frequency.
3. Clinicians should obtain periodic blood testing to assess for adverse
effects in patients on pharmacological therapy.
4. Obtain a repeat stone analysis, when available, especially in patients
not responding to treatment.
5. Monitor patients with struvite stones for reinfection with urease-
producing organisms.
6. Obtain follow-up imaging studies to assess for stone growth or new
stone formation based on stone activity (plain abdominal imaging,
renal ultrasonography or low dose computed tomography [CT]).