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Common Urological Problems

Urinary Stone Disease Symptoms & Signs at Presentation

  • - General Urology - Common Urological Problems - Urinary Stone Disease
  • Jul 25, 2010
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Tags: | asymptomatic bacteriuria | caliceal calculi | crystalluria | genitofemoral nerve |

B. HEMATURIA
A complete urinalysis helps to confirm the diagnosis of a urinary stone by assessing for hematuria and crystalluria and documenting urinary pH.  Patients frequently admit to intermittent gross hematuria or occasional tea-colored urine (old blood). Most patients will have at least microhematuria.  Rarely (in 10–15%  of cases),  complete ureteral obstruction presents without microhematuria.

C. INFECTION
Magnesium ammonium phosphate (struvite)  stones are synonymous with infection stones.  They are commonly associated with Proteus,  Pseudomonas,  Providencia,  Klebsiella, and Staphylococcus infections. They are rarely if ever associated with Escherichia coli infections. Calcium phosphate stones are the second variety of stones associated with infections.  Calcium phosphate stones with a urine pH <6.6 are frequently referred to as brushite stones, whereas infectious apatite stones have a urinary pH >6.6.

Rarely, matrix stones with minimal crystalline components are associated with urinary tract infections.  All stones, however,  may be associated with infections secondary to obstruction and stasis proximal to the offending calculus.

Culture-directed antibiotics should be administered before elective intervention.

Urinary Stone Disease

Urinary Stone Disease

Infection may be a contributing factor to pain perception. Uropathogenic bacteria may alter ureteral peristalsis by the production of exotoxins and endotoxins.  Local inflammation from infection can lead to chemoreceptor activation and perception of local pain with its corresponding referral pattern.

1. Pyonephrosis-
Obstructive calculi may culminate in the development of pyonephrosis.  Unlike pyelonephritis, pyonephrosis implies gross pus in an obstructed collecting system. It is an extreme form of infected hydronephrosis.

Presentation is variable and may range from asymptomatic bacteriuria to florid urosepsis. Bladder urine cultures may be negative.  Radiographic investigations are frequently nondiagnostic. Renal ultrasonography may be misguiding because of the nonspecific and variable appearance of pyonephrosis. Renal urine aspiration is the only way to make the definitive diagnosis.  If the condition is noted at the time of a percutaneous nephrolithotomy,  the procedure should be postponed to allow for adequate percutaneous drainage and treatment with appropriate intravenous antibiotics (Figure 16–8). If unrecognized and untreated, pyonephrosis may develop into a renocutaneous fistula.

2. Xanthogranulomatous pyelonephritis-
Xanthogranulomatous pyelonephritis is associated with upper-tract obstruction and infection.  One-third of patients present with calculi; two-thirds present with flank pain, fever, and chills. Fifty percent present with persistent bacteriuria. Urinalysis usually shows numerous red and white cells.  This condition is a common imitator of other pathologic states of the kidney. It usually presents in a unilateral fashion. Open surgical procedures, such as a simple nephrectomy for minimal or nonrenal function,  can be challenging owing to marked and extensive reactive tissues.

D. ASSOCIATED FEVER
The association of urinary stones with fever is a relative medical emergency.  Signs of clinical sepsis are variable and include fever, tachycardia, hypotension, and cutaneous vasodilation.

Costovertebral angle tenderness may be marked with acute upper-tract obstruction;  however,  it cannot be relied on to be present in instances of longterm obstruction. In such instances a mass may be palpable resulting from a grossly hydronephrotic kidney. Fever associated with urinary tract obstruction requires prompt decompression. This may be accomplished with a retrograde catheter (double-J,  or an externalized variety to serve as a port for selective urine collections, injection of contrast material,  or both).  If retrograde manipulations are unsuccessful,  insertion of a percutaneous nephrostomy tube is required.

image Figure 16–8.  Bilateral renal calculi seen on scout radiograph with numerous bilateral percutaneous nephrostomy tubes to drain severe bilateral pyonephrosis.


E. NAUSEA AND VOMITING
Upper-tract obstruction is frequently associated with nausea and vomiting.  Intravenous fluids are required to restore a euvolemic state.  Intravenous fluids should not be used to force a diuresis in an attempt to push a ureteral stone down the ureter. Effective ureteral peristalsis requires coaptation of the ureteral walls and is most effective in a euvolemic state.


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Marshall L. Stoller, MD

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REFERENCES

  1. Ackermann D et al: Influence of calcium content in mineral water on chemistry and crystallization conditions in urine of calcium stone formers. Eur Urol 1988;14:305.
  2. Allie-Hamdulay S et al: Prophylactic and therapeutic properties of a sodium citrate preparation in the management of calcium oxalate urolithiasis:  Randomized,  placebo-controlled trial.  Urol Res 2005;33:116.
  3. Bilezikian JP et al:  Primary hyperparathyroidism:  New concepts in clinical,  densitometric and biochemical features.  J Intern Med 2005;257:6.
  4. Fellstrom B et al: Dietary habits in renal stone patients compared with healthy subjects. Br J Urol 1989;63:575.
  5. Gentle DL et al: Geriatric nephrolithiasis. J Urol 1997;158:2221.
  6. Heller HJ et al: Effect of dietary calcium on stone forming propensity. J Urol 2003;169:470.
  7. Langley SE, Fry CH: The influence of pH on urinary ionized [Ca2+]:

Full References  »

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