Urethrolithiasis

Definition

Stone urethra (Urethrolithiasis) usually comes from kidney stones or ureters that descend into the
jar, then into the urethra. The urethral stone is the primary stone stone formation in the urethra is
very rare, unless formed in the diverticular urethra. The incidence of urethral stones is no more than
1% of all urinary tract stones.1 The composition of urethral stones is no different from bladder
stones. Two thirds of urethral stones are located in the posterior urethra and the rest are in the
anterior urethra.4

Etiology

Epidemiologically there are several factors that facilitate the formation of stones in the urinary tract
in a person. Factors that include intrinsic factors, namely the state that comes from a person's body
and extrinsic factors, namely the influence that comes from the surrounding environment.1

These intrinsic factors include:

1. Herediter

• Dent's disease is an increase of 1.25 dehydroxy vitamin D so that the absorption of calcium in the
intestine increases, due to heredity): the disease is allegedly derived from his parents. Hereditary
diseases that cause Urolithiasis include: hyperkalsiuria, proteinuria, glikosuria, aminoasiduria and
phosphaturia that eventually lead to calcium oxalate stones and renal failure.

• Barter syndrome, in this condition occurs polyuria, low density of hypercalciuria and
nephrocalcinosis.7

2. Age

This disease is most often found at the age of 30-50 years. Results of research conducted on patients
with BSK in DR Kariadi Hospital for five years (1989-1993), the most frequencies in the decade four
to six.7

3. Sex

The number of male patients is three times more than that of female patients. Testosterone serum
results in increased endogenous oxalate production by the liver. Low serum testosterone in women
and children leads to lower urinary tract stones in women and children.7

Extrinsic factors include:

1. Geography: In some areas the incidence rate of urinary tract stones is higher than in other areas,
so known as the area of stone belt (belt stone), while the Bantu area in South Africa almost no
urinary tract stones found.

2. Climate and temperature

3. Water intake: Lack of water intake and high levels of calcium minerals in the water consumed,
may increase the incidence of urinary tract stones.

4. Diets of purines, oxalates, and calcium make it easier for urinary tract stones.

5. Work: Often found in people who work a lot of sitting and less activity or sedentary life.1

Etiology of urinary tract stones5

Idiopathic
Fimosis
Stricture of meatus
Prostate hypertrophy
urine flow disorders Vesiko-ureteral reflux
Ureterokele

Constrict uteropelvik relationships

hyperparathyroidism
Metabolic disorders Hyperuricemia

hypercalciuria

Urinary tract infections by energetic microorganisms make urease (proteus mirabilis)

Lack of drinking
Dehydration
High environmental temperature
Foreign object Catheter fragments
Foreign object
Skistosoma eggs

Dead tissue  renal papillary necrosis

Children in developing countries

Multifactor
Multi trauma patients

Diagnosis

For diagnosis, anamnesis is necessary, physical examination and is supported by radiological,

laboratory and other investigations to determine the possibility of urinary tract obstruction,
infection, and renal phenophonal disorders.

Anamnesis:

a. Current medical history 9

In this assessment, the things that need to be asked are client complaints such as pain (location,
time, spread, intensity, duration), urinary stones expenditure, BAK pattern, blood in urine and
others. Patients with urinary tract stones have varying complaints from no complaints. mild back
pain to colic, dysuria, haematuria, urinary retention, anuria. These complaints may be accompanied
by complications of fever, signs of renal failure.4

b. Past medical history

Previous diseases that need to be asked to the client is whether the client has experienced previous
stone disease, had experienced urinary tract infections, history of sandy urine or other urinary tract
diseases.

c. Family history

It should be asked: fluid intake, diit (milk, cheese, purine), medications (analgesic, vitamin D,
chemotherapy), long immobilization, gout, or ever removing stones.1

d. Habits and lifestyle

At this examination, the nurse asks the daily client's habits, the usual activities of the previous client,
as well as the usual food and drinks in the client's consumption.

Physical examination:

The physical examination of patients with urinary tract stones may vary starting without physical
abnormality until signs of severe pain depend on the location of the stone and the complications
caused.

• Common physical examination: hypertension, febrile, anemia, shock

• Special physical examination of urology

a. Angle kosto vertebra: tenderness, tenderness, kidney enlargement

b. Supra symphysis: tenderness, palpable stones, full jar

c. External genitalia: palpable stones in the urethra

d. Anal Plugs: palpable stones on a jar (bimanual palpation) .4

Laboratory examination:

Laboratory tests are needed to look for urinary disorders that can support the presence of stones in
the urinary tract, determine the function of the kidneys, and determine the cause of the occurrence
of stones.2

Urine

• urinary pH> 7.6 usually found in organ urea splitting bacteria can be shaped magnesium
ammonium phosphate. low pH leads to the removal of uric acid stones (organic)

• Sediment: Red blood cells increase, found in patients with stones, when an infection occurs then
white blood cells will increase

• Urine cultures
Blood

• Hb, anemia will occur in kidney function disorders

• Leukocytosis is caused by infection

• Ureum creatinine to see kidney function

• Ca, Phosphorus and uric acid.5

Radiologic Examination

• BNO

BNO or Buik Nier Overzich or plain abdominal photograph is a radioligi examination on the abdomen
that is performed to determine whether there is congenital abnormalities, kidney tumors or
abdominal tumors, urinary tract stones and tumor content. BNO plain can be done by anyone and
anytime because it does not require preparation. This examination is performed by supine position
with the upper limit of the xyphoideus process, the lower limit of the pubic symphysis and the lateral
border seen throughout the abdomen.10 In BNO stones the stone can be seen as a radio-opaque
stone while the invisible stones are called radiolucent rocks, the order of stones according to their
density, from the most opaque to the most radiolucent; calcium phosphate, calcium oxalate,
magnesium ammonium phosphate, uric acid, xanthin.5

 Photo BNO-IVP

BNO IVP or BNO intravenous pyelography excertion urography is a BNO examination using contrast
drugs included via blood vessels. This examination according to Thomas B and James H using
medium contrast iodine. The indication of this examination is the same as the BNO examination, but
it provides a better anatomical examination. In contrast to a plain BNO examination, BNO IVP can
not be performed on everyone because this examination should only be done if ureum <60 mg,
creatinine <2 mg, has undergone a Discharge planning examination of BNO and skin tests against
contrast drugs. Contra indications of this examination are contrast drug allergy, decreased renal
function, acute urinary tract infection and excessive fluid retention. Preparations performed for this
examination include eating low-residual foods such as soy sauce and reducing drinking 24 hours
before the examination, fasting 8 hours before the examination, and eating 30 grams of English salt
the night before the examination.

• Retrograde pyelograph

This examination is an examination performed if the examination using BNO IVP is not good. This
check is performed to determine the location, length and height of the etiology of the obstruction
that occurs. This examination should not be performed on clients with acute urinary tract infections.
This examination is performed by contrast through the ureter catheter

• CT Scan Urology
CT Scan is an examination that uses a combination of X-Ray and a 3D computer so that it can
produce clearer images. CT Scan involves a special drug called a contrast medium. The position used
on this check is supine. This examination is performed to indicate the position of the stone and
conditions that may be caused by the presence of such stones such as hydrouretra or
hydronephrosis.

Ultrasound examination

Ultrasound is a very helpful non-invasive examination that can be used to perform antegrad
pyelography.5 The ultrasound is performed when the patient is unlikely to undergo IVU examination,
ie under conditions: allergic to contrast materials, decreased renal function, and in pregnant women
. Ultrasound examination to assess the presence of kidney stones or jars, hydronephrosis,
pionefrosis or renal wrinkling.1

Clinical features

• Urethra Stone

o A smooth urine suddenly stops accompanied by severe pain (gland penis, penis, perineum and
rectum) occurs urinary retention (total or partial)

Signs

The pain in the stone place is:

o Glands penis fossa navikularis

o Urethra anterior pars bulbosa and pendularis

• Perineum and rectum bulbus urethra pars prostatika (palpable with RT)

1) Mice suddenly stop until urine retention, which may be preceded by a low back pain. If the stone
originates from the ureter that descends into the jar and then into the uretha, it is usually the
patient complains of low back pain before complaining of the difficulties of micturition

2) Severe pain in the glans penis or on where the stones are located.

3) The stone in the anterior urethra is often palpable by the patient in the form of a hard lump in the
urethra of pars bulbosa and the pendularis, sometimes seen in the external urethral meatus. Stones
that are in the posterior urethra, pain is felt in the perineum or rectum

Management

the management of urinary tract stones should be thorough so that it is not only removing
stones, but must be accompanied by healing therapy of stone disease or at least accompanied by
preventive therapy.

This is because the stone itself is only a gehala of stone disease so the expulsion of the stone in any
way is not a perfect therapy. Furthermore, please note that removal of new stones is needed when
the stone causes a disruption of the urinary tract. If the stone does not give impaired kidney
function, the stone does not need to be lift let alone ureter rock is expected to rock out of itself.

Treatment may be medical and symptomatic therapy or with a solvent. It may also be surgical
or with less invasive measures, such as percutaneous nephrostomy, or no surgery at all in shock
waves.

Indications of urinary tract stool removal

• Urinary tract obstruction

• Infection

• Pain absorbs or pain reappears

• The stone is somewhat causing infection or obstruction

• Rapidly growing metabolic stones.

Stones can be removed by:

1. Medikamentosa

Medical therapy is intended for stones of less than 5 mm, because the stone is expected to come out
spontaneously. The therapy provided is more symptomatic, which aims to reduce pain, facilitate the
flow of urine by giving diuretikum, and drink a lot in order to push the stone out

2. ESWL (Extracorporeal Shockwave Lithotripsy)

ESWL tools can break down kidney stones without going through an invasive action and without
anesthesia. The stone is broken down into small fragments so easily removed through the urinary
tract. Not infrequently, broken pieces of stone that are out cause a feeling of colicky pain and cause
hematuria.

3. Endourology

Endourological action is a minimally invasive action to remove the stone, the action consists of
breaking the stone, and then removing it from the urinary tract through a device that is inserted
directly into the urinary tract. The device is inserted through the urethra or through a small incision
of the skin (percutaneous). The process of breaking rocks can be done mechanically, using hydroulic
energy, sound wave energy, or with laser energy. Some endourological actions to remove stones in
the kidney are:

a. PNL (Percutaneous Nephro Litholapaxy)

That is to remove the stone inside the kidney channel by inserting the endoscope to the kidney
kalises system through the incision on the skin. The stone is then removed or broken down into
small fragments.
b. Lithotripsy is to break the jar or urethral stone by inserting a stone breaker (lithotritor) into the
jar. Fractional stones are removed with an ellic evakuator.

4. Open Surgery

The surgery includes, among others, pielolitotomy or nephrolithotomy to remove stones in the
kidney tract. Not infrequently patients have to undergo nephrectomy action because the kidneys are
not working and there has been pionefrosis, cortexnya is very thin or experienced shrinkage due to
stones that cause obstruction and chronic infections

5. Prevention in the form of avoiding dehydration by drinking enough and cultivated urine
production as much as 2-3 L / day, adequate daily activity and Diet to reduce levels of the
components of stone formers.1

Prevention

To prevent the formation of crystals of magnesium ammonium phosphate, all the stones in the
urinary bladder should be removed because the B.proteus bacterium is not only in the urine but also
in a stone never achieved by antibiotics. Therefore, for the new struvit absolutely must be prevented
the presence of residual stone for the infection can be completely eradicated. In addition, urinary
tract anatomy reconstruction is very important because recurrent infections are partly due to
imperfect urine flow

Crystallization of uric acid is highly dependent on urinary pH. When urine pH is always he over
6.2, will not form uric acid crystals. Urinary uric acid expenditure can be prevented by diet and high
serum uric acid levels may be given alopurinol

Differential diagnosis

Renal colic and ureter may be accompanied by further consequences, such as intestinal distention
and pionefrosis with fever, therefore, if ureteric or renal colic suspected, especially the right, it is
necessary to consider the possibility of colic gastrointestinal tract, gallbladder, and acute
appendicitis. In addition, women should also consider the possibility of adnexitis.

In the event of hematuria, it is necessary to consider the possibility of malignancy especially when
hematuria occurs without pain. In addition, it should also be remembered that urinary tract stones
that many years can cause a tumor that is generally epidermoid carcinoma due to stimulation and
inflation.

Especially for kidney stones with hydronephrosis, it is necessary to consider the likelihood of kidney
tumors ranging from polycystic kidney types to grawitz tumors.

In ureteral stones, especially of a radiolucent type, especially when accompanied by hematuria not
accompanied by colic, it is necessary to consider the possibility of ureteric tumors although these
tumors are rare.

Alleged bladder stones also need to be compared with the possibility of bladder tumors, especially if
the stone is radiolucent.
The prostate stones are usually not difficult to diagnose because of their typical radiological
features, which are small, such as a collection of sand in the prostate region. However, rectal
examination can give the impression of a malignancy, especially if there are enough stones that are
palpable, such as prostate carcinoma. In such uncertain circumstances, prostate biopsy is necessary.

Complications

Complications of urinary tract stones are usually obstruction, secondary infection, and prolonged
irritation of the urothelium that can lead to the growth of frequent malignancies of epidermoid
carcinoma. Especially in the urethra can occur diverticulum urethra and Formed fistulas located
proximal from the ureter due to urinary extravasation when obstruction lasts long.

Initial Management

The act of removing the stone depends on the position, size and shape of the stone. Often a stone
that is not too large size can come out spontaneously provided there is no abnormality or narrowing
of the urethra. a small anterior diurethral stone can be tried to remove by first lubrication by
inserting a mixture of 2% jelly and lidocaine intraurethra in the hope that the stone can come out
spontaneously. while the stone in the urethra externa meatus or fossa navikularis can be taken by
forceps after first widening the meatus urethra (meatotomi). The stone is still quite large and
located in the posterior urethra pushed first into the jar and then performed lithotripsy (breaking
stone). For large stones and attached to the urethra, it is difficult to move even though it has been
attempted to be pushed to proximal (dilubrikasi), may need to be urethrolitotomy or destroyed by
breaking transurethral stones.1 Not infrequently urethral stones that are <1cm in size can go out on
their own with the help of catheter urethra for three days, the stone will be carried away with the
first urine flow. Urethral stones should be removed by external urethratomy. The complications that
can occur as a result of surgery are urethral stricture

Suprapubic cystostomy, performed on multiple reporting cases of urethral stones causing penile
gangrene, Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine,
General Hospital, Port of Spain, Trinidad and Tobago12
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