SOCA REVIEW GENITOURINARY SYSTEM CASE 1: URINARY STONE

BASIC SCIENCE
1. 2.

ANATOMY OF URINARY TRACT (REVIEW) HISTOLOGY OF URINARY TRACT (REVIEW)

CLINICAL SCIENCE
1.

FLANK PAIN a. Definition i. An unpleasant sensation associated with actual or potential tissue damage, and mediated by specific nerve fibers to the brain where its conscious appreciation may be modified by various factors and felt in the costovertebral angle just lateral to the sacrospinalis muscle and just below the 12th rib b. Classification i. Local = felt in or near the involved organ. Felt in the costovertebral angle just lateral to the sacrospinalis muscle and just below the 12th rib. (T10-12, L1) ii. Referred = originated in a diseased organ but is felt at some distance from that organ. Classification: 1. Upper ureter = severe pain in the ipsilateral testicle (T11-12). 2. Midportion of ureter, right = Mc Burneys point, left = (T12, L1). 3. Bladder = inflammation and edema of the ureteral orifice, symptom of vesical irritability. c. Differentiation between dull and colicky pain i. Dull pain = typical renal pain and constant ache in the costovertebral angle just lateral to the sacrospinalis muscle and just below the 12th rib. ii. Colicky pain = stimulated by acute obstruction, severity and colicky nature of this pain are caused by the hyperperistaltis and spasm. This pain radiated from the costovertebral angle down towards lower anterior abdominal quadrant, along the course of ureter. d. Cause of flank pain i. Distension of the renal capsule ii. Sudden edema iii. Sudden renal back pressure HEMATURIA a. Definition i. Any condition in which the urine contains blood or red blood cells. (as few as 5 X 106 red cells per milliliter / 1 microlitre of blood per mililitre of urine). b. Cause

2.

Lesion anywhere within the urinary system including the kidney itself, the renal pelvis, ureter, bladder, and urethra. ii. The relationship of the blood to urine: 1. Bladder or above (uniform discoloration of urine) 2. Urethra (blood separate / mixed with urine) iii. The relationship of the structure: 1. Renal parenchyma accompanied by proteinuria and casts, abnormal morphology of red blood cells 2. Renal tumors / lesions in the renal pelvis or belowisolated or associated with pyuria if there is any infection. Red blood cells have biconcave appearance. c. Distinguishing factor from other condition i. Certain dye and occasional drug. ii. Intravascular hemolysis and rhabdomyolisis. iii. Bleeding outside the urinary tract. d. Diagnostic method i. Plain abdominal X-ray. ii. Ultrasonography (provide information about renal size, renal mass lesions, and renal pelvic and ureteric dilatation.
i. 3.

URINARY STONE a. Definition i. Polycrystalline aggregates composed of varying amounts of crystalloid and organic matrix. b. Epidemiology i. 450,000 visits to EDs annually. ii. Approximately 12% for men and 7% for women in the United States. iii. Male-to-female ratio is approximately 3:1. c. Pathogenesis i. Supersaturation that depends on: urinary pH, ionic strength, solute concentration, and complexation. ii. The nucleation theory. iii. The crystal inhibitor theory (including magnesium, citrate, pyrophosphate, and a variety of trace metals). d. Composition of stone i. Stone analysis, based on initial 24-h urine collection for calcium stone formers.

Risk factor i. Crystalluria. ii. Socioeconomic factors. iii. Diet. iv. Occupation. v. Climate. vi. Family history. vii. Medications. f. Clinical sign & symptom i. Pain. ii. Hematuria. iii. Infection. iv. Associated Fever. v. Nausea and Vomiting. g. Diagnostic modality i. History. ii. Physical Examination. iii. Radiologic Investigations. 1. Computed tomography. 2. Intravenous pyelography. 3. Tomography. 4. KUB films and directed ultrasonography. 5. Retrograde pyelography. 6. Magnetic resonance imaging. 7. Nuclear scintigraphy. h. Differential diagnosis i. A full differential diagnosis of the acute abdomen should be made, including acute appendicitis, ectopic and unrecognized pregnancies, ovarian pathologic conditions including twisted ovarian cysts, diverticular disease, bowel obstruction, biliary stones with and without obstruction, peptic ulcer disease, acute renal artery embolism, and abdominal aortic aneurysm i. Management
e.

Conservative Observation. Dissolution Agents. Extracorporeal Shock Wave Lithotripsy. Ureterorenoscopy procedure with ultrasound. Pneumatic stone crusher for breaking stones. Open surgery (ureterolithotomy). j. Complication i. Infected hydronephrosis. ii. Calyceal rupture. iii. Complete ureteral obstruction. k. Prognosis i. Approximately 80% of ureteral stones pass spontaneously without hospitalization or invasive intervention. ii. Approximately 20% of patients require hospitalization due to dehydration, continued pain or vomiting, or inability to pass the stone spontaneously. iii. Recurrence rates after an initial episode of ureterolithiasis are 14%, 35%, and 52% at 1, 5, and 10 years, respectively. Risk of recurrence can be reduced drastically by specific medical therapy based on analysis of the stone and serum and urine metabolic profiles. l. Recognize obstructive nephropathy m. Prevention i. Education. ii. Preventive measures. iii. Lifestyle changes, fluid intake should be about 1, 6 L/24 h. iv. Motivated patient.
i. ii. iii. iv. v. vi.

PATOMEKANISME RENAL CALCULUS

Precipitation Formation of crystal in the urine

Supersaturation of one or more salt in the urine crystal growth inhibiting factor complexity solute concentration ionic strength

Growth into structure with adequate mass to obstruct the urinary tract

Agglomeration Crystallization

Less dense and amorphous calculus Dense calculus with elegant geometric surface

Renal calculus

Acute obstruction Urinary tract irritation

Severe colicky pain that radiate from the costovertebral angle down toward the lower anterior abdominal quadrant, along the course of ureter Back pain from renal capsular distension

Pain at the right flank

Pain radiate to the testicle (T11-T12)

Pain at the right testicle