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Case study 1

A 56 year old male presents to the emergency department with 2 hours of excruciating pain in the right flank and groin radiating into the scrotum

He has had associated nausea and vomiting.
No fever or chills

He had a few twinges of less severe pain over past 2 months

At time of exam he is very anxious, writhing, unable to find comfortable position


Describe the workup of case study 1

Exam: Right costovertebral angle tenderness, Mild RLQ tenderness, Abdomen is not rigid, no guarding or rebound tenderness, No testicular mass or tenderness

Blood work: CBC, BMP normal

UA shows moderate blood with many RBCs, No sign of UTI

Imaging: Noncontrast CT abdomen/pelvis


What is on your differential diagnosis?

- Renal or ureteral stone
- Hydronephrosis (ureteropelvic junction obstruction, sloughed papilla)
- Bacterial cystitis or pyleonephritis
- Acute abdomen (bowel, biliary, pancreas or aortic abdominal aneurysm sources)
- Gynecologic in females(ectopic pregnancy, ovarian cyst torsion or rupture)
- Radicular pain (L1 herpes zoster, sciatica)
- Referred pain (orchitis)


Describe the CT results

- Stone stuck in the ureter
- Kidney is dilated


What are urinary calculi?

- Kidney stones are solutes that occur in amounts too high to stay dissolved (supersaturated) in urine
Solutes precipitate and aggregate to form concretions or stones


What is the most common composition of stones?

Calcium oxalate


What are the other compositions of stones?

From most to least common
- Uric acid
- Struvite (magnesium ammonium phosphate)
- Calcium phosphate
- Cystine


Describe the gold standard imaging protocol for a suspected stone

- CT is best imaging modality to detect urinary calculi. Detects over 96% of stones (study of choice *****)


What are some other imaging options for a stone?

- KUB x-ray may detect 70-80% of stones but may miss smaller calculi. Overlying bowel gas can obscure visualization
- Intravenous urogram (IVU) commonly was utilized prior to wide spread use of CT. Detects up to 80-90% of stones but more time consuming.
- Renal ultrasound (US) can detect most intrarenal stones and hydronephrosis, but not sensitive for ureteral stones. Study of choice for suspected stone in pregnant women


What happens in the first 2 hours of having a renal obstruction

- Increased renal pelvic pressures
- Increased renal blood flow
- As renal pelvic pressure increases, glomerular filtration (GFR) decreases

This back flow pressure and stretching is what hurts like crazy


What happens at 6-24 hours after developing a renal obstruction?

- Renal pelvic pressures remain elevated
- Renal blood flow diminishes


What happens at more than 24 hours after developing a renal obstruction?

- Renal pelvic pressures trend down towards baseline (but remain elevated)
- Renal blood flow continues to diminish.
- If persistent, the obstruction (high grade complete obstruction) leads to renal ischemia and permanent damage typically occurs within 2 weeks


What should you note about this timeline of renal obstruction?

The pattern of pain tends to increase and decrease

The stone will get stuck, cause pain, but then move or rotate and decrease the blockage (incomplete block)


What is the expectant management when trying to allow a stone to pass?

- 2/3 of ureteral stones will pass within 4 weeks of symptom onset
- Complete obstruction is rare so risk of renal deterioration from observation is low
- Strain urine for stone passage
- Medical expusion therapy (Alpha blockers, Calcium channel blockers, NSAIDS)
- Oral stone dissolution (Uric acid stones only, urinary alkalization, potassium citrate, sodium bicarbonate)


What are indications for urgent intervention for urinary stones?

- Obstructed upper tract with infection
- Impending renal deterioration
- Pain refractory to analgesics
- Intractable nausea/vomiting
(Patient preference


What are the surgical stone interventions?

- Extracorporeal Shock Wave Lithotripsy (ESWL)
- Ureteroscopy +/- laser lithotripsy
- Percutaneous Nephrolithotomy (PCNL)
- Open or laparoscopic lithotomy


Describe Extracorporeal Shock Wave Lithotripsy (ESWL)

- 4-15 mm stones in kidney or proximal ureter
- Stone must be radio-opaque


Describe Ureteroscopy +/- laser lithotripsy

All stones amendable but large renal stone treatment is tedious


Describe Percutaneous Nephrolithotomy (PCNL)

- Renal calculi >15-20 mm
- More invasive and requires hospital observation


Describe Open or laparoscopic lithotomy

- Most invasive
- Rarely necessary


How can you prevent stone formation?

- ADEQUATE HYDRATION!! (2.5-3 L/DAY) *******
- Dietary modifications
- Full metabolic evaluation for patients with recurrent stones or strong family history


Describe the dietary modifications

- Low animal protein, low sodium, low oxalate diets
- Normal dietary calcium
- Citrate therapy


Describe the full metabolic evaluation

- Serum chemistries
- 24 hour urine collection
- Medications and additional therapies directed at metabolic abnormalities


Case 2

- A 63-year old male presents with complaint of weak urinary stream, increased urinary urgency, and nocturia x 4.
- He complains he is always tired due to lack of sleep from his nocturia.
- No UTIs or gross hematuria
- No abdominal or flank pain


Describe the work up for case 2

Physical Exam
- Abdomen is soft, nontender, bladder is not palpable
- Phallus is circumcised, no lesions, no testicular mass
- Prostate is moderately enlarged, nontender, symmetric with no nodules

UA shows no blood or infection

PSA 2 (normal


What is on your differential diagnosis at this point?

- Benign prostatic hyperplasia
- Prostatitis
- Overactive bladder
- Prostate cancer
- Bladder cancer
- Urethral stricture
- Bladder or urethral calculus


What are the two types of lower urinary tract symptoms (LUTS)?

- Irritative (storage)
- Obstructive (voiding)


What are the irritative (storage) symptoms?

- Frequency
- Urgency
- Nocturia
- Dysuria


What are the obstructive (voiding) symptoms?

- Hesitancy
- Intermittency
- Straining
- Weak stream
- Terminal dribbling
- Sensation of incomplete bladder emptying


What is the AUA symptom index?

- This shows the IPSS score, also known as the AUA Symptom Score. This is a 7-question survey that patients can often fill out in the waiting room.