Urolithiasis

Zheng Xuepei MD
 Introduction
Urinary calculi, urinary stones
A common disease of urinary system
Described in old medical book
named “Huang-Di-Nei-Jing” in
ancient china.
Found in bodies of mummies 3000
years ago in Egypt .
 Incidence
1. 20~50 years of age, most in
30~40.
2. Males more than females ( 4 : 1 ).
3. Southern areas more than
Northern areas.
4. Upper urinary tract stones six
times more than lower urinary
tract stones.

5. Primary stones four times more

than secondary stones.
 Etiology
1. Pathogenesis:
Not completely clear.

Urolithiasis is a disease of
pathological mineralization..
2. Components of stones
Crystal components: 98%

Calcium oxalate;

Uric acid and

urate;

Others
Matrix: 2%
Protein ( 65% );
Carbohydrate ( 15% );
Inorganic mineral (10%);
Water (10%)
 3. Theories
1. super-saturation-crystallization.
Normal urine is often in the state of over-
saturation, if the crystal components is
supersatuated, crystalization may occur.
Saturation→supersaturation
→nucleation →crystal growth or aggregation
→ crystal retention →stone formation.
2. Theory of inhibitors:
Decrease of inhibitors.
Inhibitors can inhibit the
process of stone formation.
magnesium, citrate,
pyrophosphate, et al
3. Theory of matrix:
Matrix is the component of stone, it
may accelerate the formation of stone.

4. Theory of comprehensive factors.

All above.
4. Etiological factors
1. Factors of urinary tract:
Infection: necrotic tissue, mass of
bacteria and mucus may form a nucleus.
Obstruction : crystals are retained.
Foreign bodies: thread, catheter,
calcareous material is deposited on them.
2. Factors of urine:
super-saturation of stone-forming
components:
Calcium: Hyperparathyroidism,

Idiopathic hypercalciuria
Bone fracture
Oxalate: Hyperoxalaluria
Uric acid: Gout
Changes of urine ph value:
Aciduria: uric acid and cystine
stones.
Alkalinuria: phosphate stone
Decrease of urinary output:
Insufficient ingestion of fluids,
Perspiration, urine is concentrated.
Decrease of urinary inhibitors:
Citrate, magnesium, citrate,
Pyrophosphate, etc.
3. Other factors:
Climate
Geographic factors
Water
Metabolic factors
Genetic factors
 5. Classification
Primary stone ( metabolic stone ):
Calcium oxalate,
Cystine,
Uric acid and urate
Secondary stone ( infectious stone ):
Calcium phosphate
Ammoniomagnesium phosphate
Calcium oxalate:
Brown color, very hard, granular
surface like a mulberry seed, radiopaque.
Ammoniomagnesium phosphate and
calcium phosphate:
Dirty white, hard, friable, coarse on
surface, staghorn shape, radiopaque and
laminated in plain film.
Urate and uric acid stone:
Yellowish-red, smooth, hard, oval,
radiolucent.

Radiolucent stone is also called

as negative stone.
 6. Pathology
1. Direct injury: congestion, edema, rupture and
bleeding of mucosa.
2. Obstruction:
Dilation and hydrops above the obstruction.
Renal parenchyma atrophied in severe case.
Difficult urination and retention of urine.
 3. Infection:
Obstruction→infection
→pyonephrosis →severe injury of renal
function.
Stone , obstruction and infection
are cause and effective relationship
among them.
4. Canceration:
Long-term irritation on mucosa,
 Treatment
1. Adequate fluid intake
Sufficient fluid intake, by minimizing
urine concentration, aids in prevention of
stone formation. 3000ml of water should
consumed in 24 hours by stone formers .
Evidence does not support the belief that
distilled water helps to prevent urinary calculi,
nor the hard water is a risk factor.
2. Get rid of risk factors:
Relieve urinary tract obstruction:
BPH, urethral and ureteral stricture.
Control urinary tract infection:
Maintenance of free urine drainage:
patients such as fracture and poliomyelitis
who require bed rest,, need exercise and change
position several times daily.
3. Diet:
According to the components of
stone, measurements are adopted.
Foods in high oxalates:
Spinach, tea, potato, etc.
Foods rich in calcium:
Dairy products, bean curd.
4. Medication:
oxalate stone:
Vitamin B6
Magnesium oxide.
Phosphate stones:
Infection should be controlled.
Low phosphorous and low calcium diet.
Ammonia chloride 3g daily,
Acidifying the urine ;
Increase the solubility of phosphate.
uric acid stones:
foods Rich in purines should be limited.
lean meats, animal liver, braines, kidneys, beef,
beans, coffee, tea, etc.

Sodium bicarbonate 4g daily,

Alkalinizing the urine;
Increase the solubility of uric acid.
 Section Two
Calculus of kidneys and ureters
Calculus in the pelvis or a calix,
high incidence in young and middle
aged males, mostly unilateral.
Most Ureterolith come from
kidney, stay at middle and lower
segments because of gradually
thinner of the ureter.
There are three physiological
strictures along the ureter, they
locate at pelvic-ureter juncture,
cross-over iliac vessel and
intravesical ureter respectively.

Lower one third segment is the most

common location of ureter stone.
There is irritation of the pelvic
mucosa, causing infection which
soon involves the parenchyma;
The stone may cause obstruction
to urinary flow from the pelvis or
from a calix with resulting dilitation
and increased infection,
Kidney become entirely destroyed.
Clinical Manifestations
Symptoms of kidney calculi are similar to that
of ureter stones.
There may be none; These are the silent
stone which are fixed solidly in a calix or in
the pelvis and several calices (staghorn
calculus) and do not obstruct urinary outflow.
Stone may be found occasionally through
health examination or x-ray films.
1. Pain
pain is the most common symptom of
renal calculi. dull ache in the lumbar
region to sharp, severe colic which
occurs when the stone obstructs the
outflow of urine from the kidney.
Pain is usually intermittent, its severity
being in direct proportion to the degree
of obstruction; frequently a dull aching
pain occurs between colicky attacks.
Typical renal pain is referred to the lower
abdomen and groin, and sometimes to
the testis or labia on the involved side.
2. Hematuria:
blood may appear in the urine.
It is the results of injury of stones
on mucosa; most are microscopic,
only a few are macroscopic
hematuria..
3. Other symptoms:
Infection symptoms: pyuria, fever,
chill, knock pain at renal region.
Terminal stone of ureter: Frequency,
urgency, terminal pain of urination,
hydronephrosis: enlarged kidney can
be palpated.
 Obstruction of bilateral ureters
by stones: insufficient of renal
function, tired, nausea, anemia,
less urine or anuria.
Sometimes symptoms of
infection may be the only
manifestation of urinary stone.
 Diagnosis
1. Diagnosis of most patients with
urolithiasis can be confirmed through
history, physical examination , x-ray
films and laboratory procedures.
2. Renal function should be evaluated, if
the obstruction and infection are
present, the causes and components of
stone , so as to draw up a suitable
medical regimen.
3. Laboratory procedures:
Values of phosphorous,
calcium and uric acid in serum and
urine should be assayed, so as to
screen primarily
hyperparathyroidism, idiopathic
hypercalciuria and hyperuricosuria.
4. Urological x-rays:
95% of urolithiasis can be showed
distinctly on plain films.
Negative stone: do not show on
plain films. But have a defect
within the shadow of contrast
medium.
5. B-ultrasound examination:
6. CT examination:
This can find stones not
dense enough to cast a shadow in
x-ray films.
 Differential Diagnosis
1. Stones of gallbladder and calcified
mesenteric lymph nodes:
Stone of right kidney is
located at the back of front edge of
vertibra body .
2. Phleboliths and bone island:
Urogram of urinary tract.
Treatment
Medical treatment
Indications: the stone is less than
0.6 cm in diameter, smooth, and there
is no obstruction or infection.
1. Adequate fluid intake:
Keep the daily urine more than
2000ml, so as to reduce the
deposition of crystals, and be helpful
to discharge the stones.
2. Discharge stones with modern
and Traditional Chinese Medicine.
Antispastic
Diuretic drugs
Acupuncture.
3. Treatment of renal colic:
Renal colic is an emergency
condition, and need treatment
immediately.
Atropine,
Dolantin,
Antacin,
Progesterone,
 ESWL
Extracorporeal shock wave lithotripsy

Stones localized by x-ray or supersound

detection, lithotripsied by focused high energy
shock wave frome lithotripter on the stone.
Indication: renal stone less than 3cm,
ureteral stones.
Contraindications:
Urinary tract obstruction below the
stone;
Pregnant women;
Obesity
Insufficiency of blood coagulation
function.
 Surgical Treatment
Indications:
1. Stones larger than 1cm in diameter, there
is less chance to discharge naturally.
2. Stones complicated with obstruction or
infection. If renal function is affected, and
no effect after common treatment.
3. Obstructive factors in the urinary tract
below the stones should be removed
Using a ureteral calculus
dislodger

Transurethral
ureteropyeloscope.
Ureterolithotomy:
Indications: Stone 1cm in diameter,
no effects after non surgical treatment,
or complicated with obstruction or
infection.
Pyelolithotomy:
Indications: Stones larger than 1 cm
in diameter, or complicated with
obstruction or infection.
Nephrolithotomy:
Indications: stone of calyx not
removed through pelvis, or stones
of multiple calyces.
Anatrophic nephrolithotomy:
Indications: complex staghorn
renal stone,.
Nephrectomy:
Indications: renal function
has been destroyed by stone, or
pyonephrosis. Contralateral kidney
is good.
 Percutaneous
nephrolithotomy
 Treatment Principles for
Bilateral Urinary Tract Stones
1. Bilateral ureteral calculus:
Ureteral stones with severe obstruction
should be treated firstly.
Contralateral ureter Stones can also be
taken out at the same time if possible.
2. Ureteral stone complicated with
contralateral renal stone:
Ureteral stone should be taken out firstly.
3. Bilateral renal stones:
Stones that can be taken out
Easily and safely should be firstly
considered.
If there are severe
obstruction , insufficient renal
function, or general condition is
poor, nephropyelostomy is
necessary. Stones can be
removed afterwards.
4. Anuria caused by acute complete
obstruction in patients with bilateral upper
tract stones or stones of solitary kidney.
Perform operation immediately .
Catheterization through ureter or
percutaneous nephrostomy is available if
general condition is poor.
Section Three Bladder
Stones
Primary bladder stones:
Incidence: a common
disease 50 years ago, now rarely
happened.
Boys
Causes: malnutrition, low-
protein diet.
Secondary bladder stones:
Incidence: much more common
in males than females, ratio 20/1,
Age group: older males
Causes:
1. Retention of urine:
2. Foreign bodies: grass,
thread, catheters.
3. Immobilization: paraplegia;

poliomyolitis.
4. Renal stone trapped in the
bladder.
 Symptoms
1. Urinary stream stops and
difficult urination:
2. Irritation symptoms :
frequency, urgency and terminal
pain during urination.
3.Hematuria: mucosa injury by
stone,
 Diagnosis
1. Typical history and symptoms:
2. X-ray examinations:
Plain film at bladder region:
size, shape, number of stones.
KUB film: upper urinary tract stone ?
Urogram: stones in ureter or diverticulum ?
3. B ultrasound and cystoscopy.
4. Diagnosis of causes.
 Treatment
Most stones are cured through cystoscope,
while open operation is rarely used.
1. Lithotriptoscopy:
Electrohydraulic lithotripsy.
Mechanical lithotripsy.
Ultrosound lithotripsy.
Laser lithotripsy.
Pneumatic ballistic lithotripsy.
2. Suprapubic cystolithotomy:
Indication:
larger stone;
Bladder stone of children;
Calculus in diverticulum of
bladder.
3. Suprapubic cystostomy is used in bladder
stones with severe infection or of children.
 Section 4 Stones in
Urethra
Most stones in urethra are come
from kidney or bladder; Much a
few are formed primarily in
diverticulum of urethra, or caused
by urethral stricture or foreign
bodies.
Over 50% of the stone in the
anterior urethra.
 Clinical Manifestation
1. Difficult urination, pain during
urination, thinned urinary stream
or dribbling.
2. Pain in perineum region.
3. Acute retention of urine.
 Diagnosis
1. Palpation of urethra:
Stones in anterior urethra:
Stones in posterior urethra:
digital palpation through
rectum.
Urethral sound
2. B ultrasound and x-ray examination.
 Treatment
1. Stones in meatus:
Inject paraffin oil, press and pull, or
clamp out.
2. Stones in prior urethra:
Pull out the stone by urethroscope.
Urethrotomy is avoided as possible.
3. Stones in the posterior urethra:
Pull into the bladder, and treatment
as bladder stone.