Stone Disease and Renal Colic - Clin Med

What does this refer to

• ____________: is characterized by the formation of solid concretions in the urinary tract.

• This common condition can cause acute and recurrent pain, obstruction, and renal damage.

• Renal colic is the hallmark presentation, often requiring emergency care.

Renal stone disease (urolithiasis)

What does this refer to

• Lifetime incidence: 10–15% in men, 7% in women; incidence is rising globally.

• Men are affected more frequently; peak onset is between 30–50 years.

• Recurrence rate within 5 years is about 50% without preventive measures.

Epidemiology of Renal stone disease (urolithiasis)

What does this refer to

• Kidneys filter blood to form urine, which passes through the ureters to the bladder.

• The renal calyces, pelvis, and ureters are common sites for stone lodging.

• Normal urine flow and composition help prevent stone formation.

Anatomy and Physiology of Renal Stone Disease

What does this refer to

• Stone formation occurs due to supersaturation of urine with solutes like calcium, oxalate, or uric acid.

• Crystallization is facilitated when inhibitors (e.g., citrate) are deficient.

• Stagnant urine flow and acidic pH favor nucleation and stone growth.

Pathophysiology of Stone Formation

What type of renal stone does this refer to

• most common; forms in acidic urine and low citrate levels.

Calcium oxalate

What type of renal stone does this refer to

• associated with alkaline urine and renal tubular acidosis.

Calcium phosphate

What type of renal stone does this refer to

• : associated with gout, high purine diets, acidic urine.

Uric acid

What type of renal stone does this refer to

• infection-related, associated with urease-producing bacteria.

Struvite

What type of renal stone does this refer to

• rare, hereditary, caused by defective renal tubular reabsorption

Cystine

What does this refer to

• Low fluid intake and dehydration increase urine concentration.

• Diet high in oxalate, sodium, and animal protein promotes stone formation.

• Medical conditions: hyperparathyroidism, obesity, IBD, gout.

• Genetic predisposition and family history are significant contributors.

Risk Factors for Stone Formation

What does this refer to

• Sudden, severe, colicky flank pain often radiating to groin or scrotum/labia.

• Nausea, vomiting, restlessness, and hematuria are common.

• Pain is often intermittent and positional due to ureteral peristalsis.

Clinical Presentation of Renal Colic

What does this refer to

• Pain characteristics: onset, radiation, duration, and severity.

• History of previous stones, family history of urolithiasis.

• Dietary habits, hydration status, medication use (diuretics, supplements).

• Associated urinary symptoms: dysuria, frequency, hematuria.

History Taking for Renal Colic

What does this refer to

• Costovertebral angle tenderness is common.

• Vital signs may reveal fever, tachycardia (suggesting infection).

• Abdominal exam may show mild distension or guarding.

• Restlessness is typical in contrast to peritonitis (patient remains still).

Physical Examination of Renal Colic

What does this refer to

• Urinalysis: hematuria, crystals, signs of infection (leukocytes, nitrites).

• Serum creatinine, BUN, electrolytes to assess renal function.

• CBC if infection is suspected (leukocytosis).

Initial Investigations

What imaging modalities is used for Renal Stone Disease

• _______ is the gold standard for diagnosis (high sensitivity/specificity).

Non-contrast CT scan

What imaging modalities is used for Renal Stone Disease

• preferred in pregnancy and pediatrics; detects hydronephrosis.

Ultrasound

What imaging modalities is used for Renal Stone Disease

• detects radiopaque stones (not uric acid or cystine).

X-ray KUB

What imaging modalities is used for Renal Stone Disease

• historical, rarely used now.

IV pyelogram

What does this refer to

• Appendicitis, diverticulitis, bowel obstruction may mimic symptoms.

• Ectopic pregnancy or ovarian torsion in females.

• Abdominal aortic aneurysm (AAA) in older patients with vascular disease.

Differential Diagnosis for Renal Stone Disease

What stone size does this refer to

• likely to pass spontaneously (~90%).

• Location affects likelihood of passage (distal > proximal).

Size < 5 mm

What stone size does this refer to

• 50% passage rate; consider MET (medical expulsive therapy).

• Location affects likelihood of passage (distal > proximal).

Size 5–10 mm

What stone size does this refer to

• unlikely to pass; consider urologic intervention

• Location affects likelihood of passage (distal > proximal).

Size > 10 mm

What does this refer to

What does this refer to

• Encourage oral hydration if tolerated; IV fluids for severe symptoms.

• NSAIDs (e.g., ketorolac) preferred for pain due to anti-inflammatory effect.

• Opioids used if NSAIDs contraindicated or inadequate.

• Antiemetics for nausea/vomiting (ondansetron, metoclopramide)

• Antibiotics to cover common urinary pathogens:

  • Sulfonamides

  • Flouroquinolones

• Alpha-blockers

Medical Management of Renal Stone Disease

What does this refer to

• Tamsulosin relaxes ureteral smooth muscle, aiding stone passage.

• Most effective for distal ureteral stones 5–10 mm in size.

• Used for 2–4 weeks with monitoring for side effects (e.g., hypotension).

Alpha-blockers

What does this refer to

• Stones >10 mm, failure of MET, severe pain or obstruction.

• Infected obstructed system is a urologic emergency.

• Non-functioning kidney, bilateral obstruction, or solitary kidney obstruction.

Surgical Management Indications

What does this refer to

• Endoscopic procedure to visualize and remove ureteral stones.

• Often combined with laser lithotripsy to fragment stones.

• Stent may be placed post-procedure to prevent obstruction.

Ureteroscopy

What does this refer to

• Non-invasive technique using external shockwaves to fragment stones.

• Best for stones <2 cm in kidney or upper ureter.

• May require multiple sessions; complications include hematuria and obstruction from fragments.

Shockwave Lithotripsy (SWL)

What does this refer to

• Used for large, complex, or staghorn calculi.

• Involves direct access to kidney through skin with nephroscope.

• Requires general anesthesia; higher risk but most effective for large stones.

Percutaneous Nephrolithotomy (PCNL)

What does this refer to

• Combination can rapidly lead to sepsis (urosepsis).

• Requires urgent decompression: nephrostomy or ureteral stent.

• Broad-spectrum IV antibiotics until culture results available.

Infection and Obstruction

What does this refer to

• Increasing incidence linked to diet and obesity.

• Presentation may differ: irritability, nonspecific abdominal pain.

• Requires metabolic workup and long-term follow-up due to high recurrence.

Pediatric Stone Disease

What does this refer to

• Use ultrasound first; MRI without contrast if further imaging needed.

• Avoid NSAIDs in third trimester; use acetaminophen or opioids if needed.

• Ureteroscopy preferred for intervention; SWL and PCNL contraindicated.

Pregnancy Considerations

What does this refer to

• Consider for recurrent stone formers or young patients.

• 24-hour urine collection: calcium, oxalate, citrate, uric acid, volume.

• Identify underlying metabolic abnormalities for targeted prevention.

Metabolic Evaluation

What does this refer to

• Increase fluid intake to achieve >2.5 L urine/day.

• Limit high-oxalate foods (spinach, nuts, chocolate).

• Moderate calcium intake (not excessive restriction).

• Reduce sodium and animal protein.

Dietary Prevention

What does this refer to

• Thiazide diuretics reduce urinary calcium for calcium stones.

• Allopurinol lowers uric acid levels in uric acid/hyperuricosuric stones.

• Potassium citrate increases urine pH and citrate level (inhibits stone formation).

Pharmacologic Prevention

What does this refer to

• High recurrence warrants thorough metabolic and dietary evaluation.

• Lifestyle changes including increased fluid intake are key.

• Long-term monitoring and medical prophylaxis may be necessary

Recurrent Stone Disease

What does this refer to

• Teach early symptoms: flank pain, hematuria, urinary urgency.

• Emphasize daily fluid goals and proper hydration habits.

• Discuss dietary risks and preventive strategies.

• Provide follow-up plan and warning signs for emergency care.

Patient Education

What does this refer to

• Hydronephrosis from obstruction may lead to renal damage.

• Infection, pyelonephritis, or abscess formation.

• Chronic obstruction may result in renal atrophy and loss of function.

Complications

What does this refer to

• Immediate pain control and imaging for suspected renal colic.

• Urologic consultation if signs of infection, obstruction, or acute kidney injury.

• Hospitalization for sepsis, intractable pain, or dehydration.

Emergency Management

What does this refer to

• Re-imaging in 2–4 weeks to confirm stone passage or resolution.

• Monitor renal function and evaluate for recurrent symptoms.

• Adjust preventive therapy based on stone composition and labs.

Follow-up and Monitoring

What does this refer to

• Chemical analysis identifies stone type (oxalate, uric acid, etc.).

• Essential for guiding prevention and recurrence reduction.

• Send first stone passed or removed for analysis.

Stone Analysis

What does this refer to

• Pain and recurrence anxiety can impact quality of life.

• Chronic pain may require multidisciplinary management.

• Psychological support and lifestyle counseling are helpful.

Psychosocial Considerations

How would you manage this

• 35-year-old male with severe right flank pain and hematuria.

• CT confirms 4 mm distal ureteral stone.

Managed with NSAIDs, hydration, and tamsulosin; passed spontaneously.

How would you manage this case

• 60-year-old female with fever, flank pain, and known 12 mm stone.

• CT shows hydronephrosis and perinephric stranding.

Managed with IV antibiotics and emergent nephrostomy tube placement.

How would you manage this case

• Recurrent uric acid stones in a 50-year-old male with gout.

• Low urine pH and high uric acid in 24-hour urine.

Treated with allopurinol and potassium citrate; dietary purine restriction.

How would you manage this case

• 28-year-old pregnant woman with left-sided renal colic.

• Ultrasound reveals mild hydronephrosis and no visible stones.

Managed conservatively with hydration and acetaminophen; symptoms resolved.

What does this refer to

• Renal stone disease is common and often recurrent.

• Accurate diagnosis and management prevent complications.

• Prevention through lifestyle and medical therapy is critical.

Summary