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Kidney stone disease: Difference between revisions
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<section begin="urology | <section begin="urology intro" /><section begin="urology stone" /><section begin="urology colic" /><section begin="radiology" />'''Kidney stone disease''', also called '''nephrolithiasis''' or '''urolithiasis''', refers to the presence of symptomatic kidney stones in the urinary tract. When stones are present in the ureter it may be called '''ureterolithiasis''', while stones in the bladder are usually simply called '''bladder stones''' or '''bladder calculi'''. It's a relatively common condition, with a lifetime prevalence of 10 - 20 percent.<section end="radiology" /> | ||
Many have asymptomatic kidney stones (which is not considered kidney stone disease), but in some cases stones can cause [[Obstructive uropathy|urinary obstruction (obstructive uropathy)]] and resulting damage to the kidney, as well as episodes of severe pain called renal colic.<section end="urology colic" /><section end="urology | Many have asymptomatic kidney stones (which is not considered kidney stone disease), but in some cases stones can cause [[Obstructive uropathy|urinary obstruction (obstructive uropathy)]] and resulting damage to the kidney, as well as episodes of severe pain called renal colic. The vast majority of kidney stones pass without intervention within a few days or weeks.<section end="urology colic" /><section end="urology intro" /> | ||
== Epidemiology == | == Epidemiology == | ||
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** Low fluid intake | ** Low fluid intake | ||
** Family history | ** Family history | ||
** Hyperparathyroidism | |||
* Calcium oxalate stone | * Calcium oxalate stone | ||
** Hypercalcuria | ** Hypercalcuria | ||
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The renal colic pain associated with kidney stones is thought to occur when stones enter the ureter, causing distension of the kidney capsule due to urinary obstruction, and due to ureteric spasm. Stones in the renal pelvis themselves are usually asymptomatic.<section end="urology stone" /><section begin="urology colic" /><section begin="urology clinical" /> | The renal colic pain associated with kidney stones is thought to occur when stones enter the ureter, causing distension of the kidney capsule due to urinary obstruction, and due to ureteric spasm. Stones in the renal pelvis themselves are usually asymptomatic.<section end="urology stone" /><section begin="urology colic" /><section begin="urology clinical" /> | ||
== Clinical features == | == Clinical features == | ||
Kidney stones may be asymptomatic, especially if they are in the renal pelvis. Kidney stones may also cause haematuria. | Kidney stones may be asymptomatic, especially if they are in the renal pelvis. Kidney stones may also cause haematuria. Concurrent fever with renal colic is a sign of infection together with urinary obstruction, which may be severe. | ||
=== Renal colic === | === Renal colic === | ||
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A presumptive diagnosis may be made when the patient has typical renal colic, as kidney stone is highly likely in that case. | A presumptive diagnosis may be made when the patient has typical renal colic, as kidney stone is highly likely in that case. | ||
Haematuria on [[urine analysis]] is seen in most cases of kidney stone (90%), but absence of haematuria does not exclude the diagnosis. It may be necessary to measure the serum calcium and uric acid level | Haematuria on [[urine analysis]] is seen in most cases of kidney stone (90%), but absence of haematuria does not exclude the diagnosis. It may be necessary to measure the serum calcium and uric acid level to look for underlying cause. A first episode of renal colic should be investigated with [[kidney function tests]] to rule out acute kidney injury as a complication. | ||
<section begin="radiology" />Whether imaging is necessary in case of uncomplicated (no fever or sign of infection, pain can be controlled with NSAIDs, mild-moderately decreased kidney function) is controversial. In Norway, no imaging is obtained during the initial presentation; imaging is obtained after 3 - 4 weeks. According to most other guidelines however, CT is indicated urgently to assess for obstruction. | |||
=== Imaging === | === Imaging === | ||
A low-dose non-contrast [[CT]] is usually the first choice as this has little radiation exposure and can detect the majority of stones. [[Ultrasonography]] is a reasonable alternative first choice, especially in pregnant and children, but many stones are not visible on ultrasound (70% sensitive and specific). Kidney, ureter, bladder (KUB) [[radiography]] was previously widely used, but it is not sensitive and so is rarely used nowadays. | A low-dose non-contrast [[CT]] is usually the first choice as this has little radiation exposure and can detect the majority of stones. [[Ultrasonography]] is a reasonable alternative first choice, especially in pregnant and children, but many stones are not visible on ultrasound (70% sensitive and specific). Kidney, ureter, bladder (KUB) [[radiography]] was previously widely used, but it is not sensitive and so is rarely used nowadays. | ||
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If the stone causes urinary obstruction, one may see [[hydronephrosis]] and dilated proximal ureters.<section end="radiology" /><section end="urology clinical" /> | If the stone causes urinary obstruction, one may see [[hydronephrosis]] and dilated proximal ureters.<section end="radiology" /><section end="urology clinical" /> | ||
== Management == | == Management == | ||
Asymptomatic stones need no management or follow-up. | Asymptomatic stones need no management or follow-up. Uncomplicated small (< 5 mm) stones need only symptomatic treatment and follow-up imaging after 4 - 6 weeks to see if the stone has passed. These cases can be treated out-patient. | ||
Consider hospital admission and treatment to remove or crush the stones in: | |||
* Complicated stones (causing obstruction, acute kidney injury, infection) | |||
* Larger stones (> 5 mm) | |||
* Stones which haven't passed after 4 - 6 weeks | |||
For stones in the distal ureter, an alpha blocker like tamsulosin may be considered as it may fascilitate passage of the stone. | |||
=== Symptomatic treatment for renal colic === | |||
An [[NSAID]] like ketorolac or diklofenac is the best first choice for renal colic. In addition to relieving pain they also decrease ureteral smooth muscle tone. Hydration, preferably intravenous, is important. A spamsolytic like [[butylscopolamine]] may be used as well. | |||
=== Extracorporeal shockwave lithotripsy (ESWL) === | |||
* First choice to remove stones in most cases | |||
* Procedure | |||
** The stone is located by x-ray or US | |||
** Uses shockwaves to fragment the stones into fragments which can pass spontaneously | |||
** May have to be repeated | |||
* Indications | |||
** Kidney stone < 20 mm | |||
** Ureter stone < 10 mm | |||
** Uric acid stones | |||
* Contraindications | |||
** Non-urological | |||
*** Untreated hypertension | |||
*** Pregnancy | |||
*** Uncorrected bleeding disorder | |||
*** Aortic aneurysm | |||
** Urological | |||
*** Kidney dysfunction | |||
*** Untreated UTI | |||
*** Obstruction distal to stone | |||
* Complications | |||
** Generally very safe | |||
** Perirenal or intrarenal haematoma | |||
** Haematuria | |||
=== Percutaneous nephrolithotomy (PCNL) === | |||
* Percutaneous access into the renal pelvis -> stones fragmented by shockwaves or laser -> fragments are removed by forceps | |||
* Indications | |||
** Stones unsuitable for ESWL | |||
** ESWL treatment failure | |||
* Contraindications | |||
** Uncorrected bleeding disorder | |||
** Untreated UTI | |||
* Complications | |||
** Injuries of adjacent organs | |||
** Haematoma | |||
** AV fistula | |||
=== | === Ureterorenoscopy (URS) === | ||
* Indications | |||
** Ureteric stones | |||
** Ureteral strictures | |||
* Complications rare | |||
=== Open surgery === | |||
* For complex stones (staghorn calculi), or if other methods have failed | |||
[[Category:Urology]] | [[Category:Urology]] | ||