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S BANDI MACKAY UROLOGY
Investigation and
Management of Renal
Colic
Dr Sanjeev Bandi MBBS FRCSI FRACS(Urology)
Mackay Urology
S BANDI MACKAY UROLOGY
Nephrolithiasis
Majority (approx 80) are calcium
stones
Others include uric acid struvite and
cystine
S BANDI MACKAY UROLOGY
Risk Factors
Past Medical Hx of renal calculi
Family Hx of renal calculi consider hereditary diseases
associated with stones
Enhanced enteric oxalate absorption Gastric bypass short bowel
syndrome
Patient factors HTN obesity gout DM
extreme exercise poor oral fluid intake
Persistantly acidic urine
Chronic diarrhoea metabolic disorders (gout DM obesity)
Recurrent upper UTIs
UTI due urease-producing organisms (Protease Klebsiella) increases risk of struvite stones
S BANDI MACKAY UROLOGY
Renal Colic Symptoms most at passage of stone from
renal pelvis into ureter
Thought to be due to obstruction and distention of the renal capsule
Colicky (due to ureteric spasm) and migratory as the stone travels down the ureter
Passage of a stone usually associated with haematuria
Other Symptoms may include NampV dysuria and urgency
Significant complications include obstruction infection and ARF
S BANDI MACKAY UROLOGY
Differential Diagnosis
Renal cell carcinoma
Pyelonephritis
Gynae - ectopic pregnancycyst accident dymenorrhoea
Surgical - bowel obstruction mesenteric ischaemia appendicitis diverticulitis
Biliary coliccholecystitis
Herpes zoster
AAA
S BANDI MACKAY UROLOGY
Diagnosis
Non-con helical CT 3-5mm cuts
May identify alternative diagnosis
Some information regarding stone compostiosn
Radiation dose
Low dose CT have similar sensitivity and specificity expect with small (lt2mm) stones and in obese patients
Ultrasound
No radiation
Sensitive for obstruction
May be able to identify
radiolucent stones
Harder to detect
smaller stones and
distal ureteric stones
Useful if patient is
pregnant or unsure
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
USS v CT in the EDSmith-Bindman Aubin Bailitz et al Ultrasonography versus
computed tomography for suspected nephrolithiasis NEJM
20143711100
Pts with clinical suspicion of renal colic randomised to non-conrast CT USS by radiologist bedside US by trained ED physician
Sensitivity
USS 57 (radiologist) 54 (ED physician)
CT 88
Radiation dose higher in CT group
Significant missed diagnoses similar
USS 05 CT 03
Adverse events amp repeat visits to ED similar
Length of stay in ED longer when US performed by Radiologist
S BANDI MACKAY UROLOGY
Other imaging modalitiesAXRXRay KUB
Will detect large radiopaque stones
Potential to miss uric acid stones smaller stones and stones overlying bone
Does not detect signs of obstruction
IVPMore specific and sensitive than plain XR
Detects obstruction
Potential for contrast reactions significant radiation dose
MRI Some role in pregnancy
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Further investigation
Bloods
FBE UECreatinine LFTrsquos Inflammatory markers
calcium urate
Urine
pH crystals oxalate
Straining urine for stones
Cytology and Culture
Genetic testing
Dentrsquos disease adenine
phosphoribosyltransferase deficiency
cystinuria
S BANDI MACKAY UROLOGY
Management
Analgesia and hydration
NSAIDs v opiates
NSAIDs can reduce smooth muscle tone in
the ureter
Possibly best in combination
NSAIDs should be avoidedused with care
in severe dehydration and impaired renal
function
S BANDI MACKAY UROLOGY
Passing a stone lt5mm likely to pass without intervention
gt10mm unlikely to pass without intervention
Increased intervention requirements with larger stones
Likelihood of stone passing also affected by position Stones at the vesicoureteric junction more
likely to be passed than those in the proximal ureter
S BANDI MACKAY UROLOGY
Medical Expulsive Therapy Alpha-blockers - prazosin tamsulosin (tamsulosin is
a selective 1A receptor blocker so less Side Effects
than with prazosin but cost implications as not on
PBS)
The randomized control trials have shown no benefit
in stones less than 5mm and some questionable
benefit in stones larger than 10mmEur Urol 2016 Aug 6 pii S0302-2838(16)30429-8 doi
101016jeururo201607024 [Epub ahead of print]
Medical Expulsive Therapy for Ureterolithiasis The EAU Recommendations in
2016 Tuumlrk C1 Knoll T2 Seitz C3 Skolarikos A4 Chapple C5 McClinton S6 European Association of Urology
Calcium channel blockers ndash (nifedipine)-
decreases human ureteral peristalsis and has limited
use in renal colic management
S BANDI MACKAY UROLOGY
Urological referral
Urosepsis
Acute Renal Failure(ARF)
Anuria
Uncontrolled pain
Stones not passed after trial of
medical therapy (usually about 4
weeks)
S BANDI MACKAY UROLOGY
Intervention Emergency
infected obstructed kidney bilateral obstruction with AKI or obstructed single kidney with AKI requires urgent decompression via percutaneous drainage or ureteric stenting
Shock wave lithotripsy
Ureteroscopic lithotripsy
Percutaneous nephrolithotomy with endoscopic stone removal
Open surgical removal
S BANDI MACKAY UROLOGY
Stone analysis
Increased fluid intake
Dietary and lifestyle factors
Obesity diabetes exercise
Low sodium diet for calcium stones
Low purine diet for uric acid stones
Avoidance of muscle building
supplements which are high in purines
Prevention of stone recurrence
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Additional treatments Thiazide diuretics in combination with low
sodium diet for calcium stones
Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention)
Increased fluid intake urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine)and D-Pencillaminefor cystine stones
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
S BANDI MACKAY UROLOGY
Nephrolithiasis
Majority (approx 80) are calcium
stones
Others include uric acid struvite and
cystine
S BANDI MACKAY UROLOGY
Risk Factors
Past Medical Hx of renal calculi
Family Hx of renal calculi consider hereditary diseases
associated with stones
Enhanced enteric oxalate absorption Gastric bypass short bowel
syndrome
Patient factors HTN obesity gout DM
extreme exercise poor oral fluid intake
Persistantly acidic urine
Chronic diarrhoea metabolic disorders (gout DM obesity)
Recurrent upper UTIs
UTI due urease-producing organisms (Protease Klebsiella) increases risk of struvite stones
S BANDI MACKAY UROLOGY
Renal Colic Symptoms most at passage of stone from
renal pelvis into ureter
Thought to be due to obstruction and distention of the renal capsule
Colicky (due to ureteric spasm) and migratory as the stone travels down the ureter
Passage of a stone usually associated with haematuria
Other Symptoms may include NampV dysuria and urgency
Significant complications include obstruction infection and ARF
S BANDI MACKAY UROLOGY
Differential Diagnosis
Renal cell carcinoma
Pyelonephritis
Gynae - ectopic pregnancycyst accident dymenorrhoea
Surgical - bowel obstruction mesenteric ischaemia appendicitis diverticulitis
Biliary coliccholecystitis
Herpes zoster
AAA
S BANDI MACKAY UROLOGY
Diagnosis
Non-con helical CT 3-5mm cuts
May identify alternative diagnosis
Some information regarding stone compostiosn
Radiation dose
Low dose CT have similar sensitivity and specificity expect with small (lt2mm) stones and in obese patients
Ultrasound
No radiation
Sensitive for obstruction
May be able to identify
radiolucent stones
Harder to detect
smaller stones and
distal ureteric stones
Useful if patient is
pregnant or unsure
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
USS v CT in the EDSmith-Bindman Aubin Bailitz et al Ultrasonography versus
computed tomography for suspected nephrolithiasis NEJM
20143711100
Pts with clinical suspicion of renal colic randomised to non-conrast CT USS by radiologist bedside US by trained ED physician
Sensitivity
USS 57 (radiologist) 54 (ED physician)
CT 88
Radiation dose higher in CT group
Significant missed diagnoses similar
USS 05 CT 03
Adverse events amp repeat visits to ED similar
Length of stay in ED longer when US performed by Radiologist
S BANDI MACKAY UROLOGY
Other imaging modalitiesAXRXRay KUB
Will detect large radiopaque stones
Potential to miss uric acid stones smaller stones and stones overlying bone
Does not detect signs of obstruction
IVPMore specific and sensitive than plain XR
Detects obstruction
Potential for contrast reactions significant radiation dose
MRI Some role in pregnancy
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Further investigation
Bloods
FBE UECreatinine LFTrsquos Inflammatory markers
calcium urate
Urine
pH crystals oxalate
Straining urine for stones
Cytology and Culture
Genetic testing
Dentrsquos disease adenine
phosphoribosyltransferase deficiency
cystinuria
S BANDI MACKAY UROLOGY
Management
Analgesia and hydration
NSAIDs v opiates
NSAIDs can reduce smooth muscle tone in
the ureter
Possibly best in combination
NSAIDs should be avoidedused with care
in severe dehydration and impaired renal
function
S BANDI MACKAY UROLOGY
Passing a stone lt5mm likely to pass without intervention
gt10mm unlikely to pass without intervention
Increased intervention requirements with larger stones
Likelihood of stone passing also affected by position Stones at the vesicoureteric junction more
likely to be passed than those in the proximal ureter
S BANDI MACKAY UROLOGY
Medical Expulsive Therapy Alpha-blockers - prazosin tamsulosin (tamsulosin is
a selective 1A receptor blocker so less Side Effects
than with prazosin but cost implications as not on
PBS)
The randomized control trials have shown no benefit
in stones less than 5mm and some questionable
benefit in stones larger than 10mmEur Urol 2016 Aug 6 pii S0302-2838(16)30429-8 doi
101016jeururo201607024 [Epub ahead of print]
Medical Expulsive Therapy for Ureterolithiasis The EAU Recommendations in
2016 Tuumlrk C1 Knoll T2 Seitz C3 Skolarikos A4 Chapple C5 McClinton S6 European Association of Urology
Calcium channel blockers ndash (nifedipine)-
decreases human ureteral peristalsis and has limited
use in renal colic management
S BANDI MACKAY UROLOGY
Urological referral
Urosepsis
Acute Renal Failure(ARF)
Anuria
Uncontrolled pain
Stones not passed after trial of
medical therapy (usually about 4
weeks)
S BANDI MACKAY UROLOGY
Intervention Emergency
infected obstructed kidney bilateral obstruction with AKI or obstructed single kidney with AKI requires urgent decompression via percutaneous drainage or ureteric stenting
Shock wave lithotripsy
Ureteroscopic lithotripsy
Percutaneous nephrolithotomy with endoscopic stone removal
Open surgical removal
S BANDI MACKAY UROLOGY
Stone analysis
Increased fluid intake
Dietary and lifestyle factors
Obesity diabetes exercise
Low sodium diet for calcium stones
Low purine diet for uric acid stones
Avoidance of muscle building
supplements which are high in purines
Prevention of stone recurrence
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Additional treatments Thiazide diuretics in combination with low
sodium diet for calcium stones
Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention)
Increased fluid intake urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine)and D-Pencillaminefor cystine stones
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
S BANDI MACKAY UROLOGY
Risk Factors
Past Medical Hx of renal calculi
Family Hx of renal calculi consider hereditary diseases
associated with stones
Enhanced enteric oxalate absorption Gastric bypass short bowel
syndrome
Patient factors HTN obesity gout DM
extreme exercise poor oral fluid intake
Persistantly acidic urine
Chronic diarrhoea metabolic disorders (gout DM obesity)
Recurrent upper UTIs
UTI due urease-producing organisms (Protease Klebsiella) increases risk of struvite stones
S BANDI MACKAY UROLOGY
Renal Colic Symptoms most at passage of stone from
renal pelvis into ureter
Thought to be due to obstruction and distention of the renal capsule
Colicky (due to ureteric spasm) and migratory as the stone travels down the ureter
Passage of a stone usually associated with haematuria
Other Symptoms may include NampV dysuria and urgency
Significant complications include obstruction infection and ARF
S BANDI MACKAY UROLOGY
Differential Diagnosis
Renal cell carcinoma
Pyelonephritis
Gynae - ectopic pregnancycyst accident dymenorrhoea
Surgical - bowel obstruction mesenteric ischaemia appendicitis diverticulitis
Biliary coliccholecystitis
Herpes zoster
AAA
S BANDI MACKAY UROLOGY
Diagnosis
Non-con helical CT 3-5mm cuts
May identify alternative diagnosis
Some information regarding stone compostiosn
Radiation dose
Low dose CT have similar sensitivity and specificity expect with small (lt2mm) stones and in obese patients
Ultrasound
No radiation
Sensitive for obstruction
May be able to identify
radiolucent stones
Harder to detect
smaller stones and
distal ureteric stones
Useful if patient is
pregnant or unsure
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
USS v CT in the EDSmith-Bindman Aubin Bailitz et al Ultrasonography versus
computed tomography for suspected nephrolithiasis NEJM
20143711100
Pts with clinical suspicion of renal colic randomised to non-conrast CT USS by radiologist bedside US by trained ED physician
Sensitivity
USS 57 (radiologist) 54 (ED physician)
CT 88
Radiation dose higher in CT group
Significant missed diagnoses similar
USS 05 CT 03
Adverse events amp repeat visits to ED similar
Length of stay in ED longer when US performed by Radiologist
S BANDI MACKAY UROLOGY
Other imaging modalitiesAXRXRay KUB
Will detect large radiopaque stones
Potential to miss uric acid stones smaller stones and stones overlying bone
Does not detect signs of obstruction
IVPMore specific and sensitive than plain XR
Detects obstruction
Potential for contrast reactions significant radiation dose
MRI Some role in pregnancy
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Further investigation
Bloods
FBE UECreatinine LFTrsquos Inflammatory markers
calcium urate
Urine
pH crystals oxalate
Straining urine for stones
Cytology and Culture
Genetic testing
Dentrsquos disease adenine
phosphoribosyltransferase deficiency
cystinuria
S BANDI MACKAY UROLOGY
Management
Analgesia and hydration
NSAIDs v opiates
NSAIDs can reduce smooth muscle tone in
the ureter
Possibly best in combination
NSAIDs should be avoidedused with care
in severe dehydration and impaired renal
function
S BANDI MACKAY UROLOGY
Passing a stone lt5mm likely to pass without intervention
gt10mm unlikely to pass without intervention
Increased intervention requirements with larger stones
Likelihood of stone passing also affected by position Stones at the vesicoureteric junction more
likely to be passed than those in the proximal ureter
S BANDI MACKAY UROLOGY
Medical Expulsive Therapy Alpha-blockers - prazosin tamsulosin (tamsulosin is
a selective 1A receptor blocker so less Side Effects
than with prazosin but cost implications as not on
PBS)
The randomized control trials have shown no benefit
in stones less than 5mm and some questionable
benefit in stones larger than 10mmEur Urol 2016 Aug 6 pii S0302-2838(16)30429-8 doi
101016jeururo201607024 [Epub ahead of print]
Medical Expulsive Therapy for Ureterolithiasis The EAU Recommendations in
2016 Tuumlrk C1 Knoll T2 Seitz C3 Skolarikos A4 Chapple C5 McClinton S6 European Association of Urology
Calcium channel blockers ndash (nifedipine)-
decreases human ureteral peristalsis and has limited
use in renal colic management
S BANDI MACKAY UROLOGY
Urological referral
Urosepsis
Acute Renal Failure(ARF)
Anuria
Uncontrolled pain
Stones not passed after trial of
medical therapy (usually about 4
weeks)
S BANDI MACKAY UROLOGY
Intervention Emergency
infected obstructed kidney bilateral obstruction with AKI or obstructed single kidney with AKI requires urgent decompression via percutaneous drainage or ureteric stenting
Shock wave lithotripsy
Ureteroscopic lithotripsy
Percutaneous nephrolithotomy with endoscopic stone removal
Open surgical removal
S BANDI MACKAY UROLOGY
Stone analysis
Increased fluid intake
Dietary and lifestyle factors
Obesity diabetes exercise
Low sodium diet for calcium stones
Low purine diet for uric acid stones
Avoidance of muscle building
supplements which are high in purines
Prevention of stone recurrence
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Additional treatments Thiazide diuretics in combination with low
sodium diet for calcium stones
Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention)
Increased fluid intake urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine)and D-Pencillaminefor cystine stones
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
S BANDI MACKAY UROLOGY
Renal Colic Symptoms most at passage of stone from
renal pelvis into ureter
Thought to be due to obstruction and distention of the renal capsule
Colicky (due to ureteric spasm) and migratory as the stone travels down the ureter
Passage of a stone usually associated with haematuria
Other Symptoms may include NampV dysuria and urgency
Significant complications include obstruction infection and ARF
S BANDI MACKAY UROLOGY
Differential Diagnosis
Renal cell carcinoma
Pyelonephritis
Gynae - ectopic pregnancycyst accident dymenorrhoea
Surgical - bowel obstruction mesenteric ischaemia appendicitis diverticulitis
Biliary coliccholecystitis
Herpes zoster
AAA
S BANDI MACKAY UROLOGY
Diagnosis
Non-con helical CT 3-5mm cuts
May identify alternative diagnosis
Some information regarding stone compostiosn
Radiation dose
Low dose CT have similar sensitivity and specificity expect with small (lt2mm) stones and in obese patients
Ultrasound
No radiation
Sensitive for obstruction
May be able to identify
radiolucent stones
Harder to detect
smaller stones and
distal ureteric stones
Useful if patient is
pregnant or unsure
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
USS v CT in the EDSmith-Bindman Aubin Bailitz et al Ultrasonography versus
computed tomography for suspected nephrolithiasis NEJM
20143711100
Pts with clinical suspicion of renal colic randomised to non-conrast CT USS by radiologist bedside US by trained ED physician
Sensitivity
USS 57 (radiologist) 54 (ED physician)
CT 88
Radiation dose higher in CT group
Significant missed diagnoses similar
USS 05 CT 03
Adverse events amp repeat visits to ED similar
Length of stay in ED longer when US performed by Radiologist
S BANDI MACKAY UROLOGY
Other imaging modalitiesAXRXRay KUB
Will detect large radiopaque stones
Potential to miss uric acid stones smaller stones and stones overlying bone
Does not detect signs of obstruction
IVPMore specific and sensitive than plain XR
Detects obstruction
Potential for contrast reactions significant radiation dose
MRI Some role in pregnancy
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Further investigation
Bloods
FBE UECreatinine LFTrsquos Inflammatory markers
calcium urate
Urine
pH crystals oxalate
Straining urine for stones
Cytology and Culture
Genetic testing
Dentrsquos disease adenine
phosphoribosyltransferase deficiency
cystinuria
S BANDI MACKAY UROLOGY
Management
Analgesia and hydration
NSAIDs v opiates
NSAIDs can reduce smooth muscle tone in
the ureter
Possibly best in combination
NSAIDs should be avoidedused with care
in severe dehydration and impaired renal
function
S BANDI MACKAY UROLOGY
Passing a stone lt5mm likely to pass without intervention
gt10mm unlikely to pass without intervention
Increased intervention requirements with larger stones
Likelihood of stone passing also affected by position Stones at the vesicoureteric junction more
likely to be passed than those in the proximal ureter
S BANDI MACKAY UROLOGY
Medical Expulsive Therapy Alpha-blockers - prazosin tamsulosin (tamsulosin is
a selective 1A receptor blocker so less Side Effects
than with prazosin but cost implications as not on
PBS)
The randomized control trials have shown no benefit
in stones less than 5mm and some questionable
benefit in stones larger than 10mmEur Urol 2016 Aug 6 pii S0302-2838(16)30429-8 doi
101016jeururo201607024 [Epub ahead of print]
Medical Expulsive Therapy for Ureterolithiasis The EAU Recommendations in
2016 Tuumlrk C1 Knoll T2 Seitz C3 Skolarikos A4 Chapple C5 McClinton S6 European Association of Urology
Calcium channel blockers ndash (nifedipine)-
decreases human ureteral peristalsis and has limited
use in renal colic management
S BANDI MACKAY UROLOGY
Urological referral
Urosepsis
Acute Renal Failure(ARF)
Anuria
Uncontrolled pain
Stones not passed after trial of
medical therapy (usually about 4
weeks)
S BANDI MACKAY UROLOGY
Intervention Emergency
infected obstructed kidney bilateral obstruction with AKI or obstructed single kidney with AKI requires urgent decompression via percutaneous drainage or ureteric stenting
Shock wave lithotripsy
Ureteroscopic lithotripsy
Percutaneous nephrolithotomy with endoscopic stone removal
Open surgical removal
S BANDI MACKAY UROLOGY
Stone analysis
Increased fluid intake
Dietary and lifestyle factors
Obesity diabetes exercise
Low sodium diet for calcium stones
Low purine diet for uric acid stones
Avoidance of muscle building
supplements which are high in purines
Prevention of stone recurrence
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Additional treatments Thiazide diuretics in combination with low
sodium diet for calcium stones
Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention)
Increased fluid intake urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine)and D-Pencillaminefor cystine stones
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
S BANDI MACKAY UROLOGY
Differential Diagnosis
Renal cell carcinoma
Pyelonephritis
Gynae - ectopic pregnancycyst accident dymenorrhoea
Surgical - bowel obstruction mesenteric ischaemia appendicitis diverticulitis
Biliary coliccholecystitis
Herpes zoster
AAA
S BANDI MACKAY UROLOGY
Diagnosis
Non-con helical CT 3-5mm cuts
May identify alternative diagnosis
Some information regarding stone compostiosn
Radiation dose
Low dose CT have similar sensitivity and specificity expect with small (lt2mm) stones and in obese patients
Ultrasound
No radiation
Sensitive for obstruction
May be able to identify
radiolucent stones
Harder to detect
smaller stones and
distal ureteric stones
Useful if patient is
pregnant or unsure
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
USS v CT in the EDSmith-Bindman Aubin Bailitz et al Ultrasonography versus
computed tomography for suspected nephrolithiasis NEJM
20143711100
Pts with clinical suspicion of renal colic randomised to non-conrast CT USS by radiologist bedside US by trained ED physician
Sensitivity
USS 57 (radiologist) 54 (ED physician)
CT 88
Radiation dose higher in CT group
Significant missed diagnoses similar
USS 05 CT 03
Adverse events amp repeat visits to ED similar
Length of stay in ED longer when US performed by Radiologist
S BANDI MACKAY UROLOGY
Other imaging modalitiesAXRXRay KUB
Will detect large radiopaque stones
Potential to miss uric acid stones smaller stones and stones overlying bone
Does not detect signs of obstruction
IVPMore specific and sensitive than plain XR
Detects obstruction
Potential for contrast reactions significant radiation dose
MRI Some role in pregnancy
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Further investigation
Bloods
FBE UECreatinine LFTrsquos Inflammatory markers
calcium urate
Urine
pH crystals oxalate
Straining urine for stones
Cytology and Culture
Genetic testing
Dentrsquos disease adenine
phosphoribosyltransferase deficiency
cystinuria
S BANDI MACKAY UROLOGY
Management
Analgesia and hydration
NSAIDs v opiates
NSAIDs can reduce smooth muscle tone in
the ureter
Possibly best in combination
NSAIDs should be avoidedused with care
in severe dehydration and impaired renal
function
S BANDI MACKAY UROLOGY
Passing a stone lt5mm likely to pass without intervention
gt10mm unlikely to pass without intervention
Increased intervention requirements with larger stones
Likelihood of stone passing also affected by position Stones at the vesicoureteric junction more
likely to be passed than those in the proximal ureter
S BANDI MACKAY UROLOGY
Medical Expulsive Therapy Alpha-blockers - prazosin tamsulosin (tamsulosin is
a selective 1A receptor blocker so less Side Effects
than with prazosin but cost implications as not on
PBS)
The randomized control trials have shown no benefit
in stones less than 5mm and some questionable
benefit in stones larger than 10mmEur Urol 2016 Aug 6 pii S0302-2838(16)30429-8 doi
101016jeururo201607024 [Epub ahead of print]
Medical Expulsive Therapy for Ureterolithiasis The EAU Recommendations in
2016 Tuumlrk C1 Knoll T2 Seitz C3 Skolarikos A4 Chapple C5 McClinton S6 European Association of Urology
Calcium channel blockers ndash (nifedipine)-
decreases human ureteral peristalsis and has limited
use in renal colic management
S BANDI MACKAY UROLOGY
Urological referral
Urosepsis
Acute Renal Failure(ARF)
Anuria
Uncontrolled pain
Stones not passed after trial of
medical therapy (usually about 4
weeks)
S BANDI MACKAY UROLOGY
Intervention Emergency
infected obstructed kidney bilateral obstruction with AKI or obstructed single kidney with AKI requires urgent decompression via percutaneous drainage or ureteric stenting
Shock wave lithotripsy
Ureteroscopic lithotripsy
Percutaneous nephrolithotomy with endoscopic stone removal
Open surgical removal
S BANDI MACKAY UROLOGY
Stone analysis
Increased fluid intake
Dietary and lifestyle factors
Obesity diabetes exercise
Low sodium diet for calcium stones
Low purine diet for uric acid stones
Avoidance of muscle building
supplements which are high in purines
Prevention of stone recurrence
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Additional treatments Thiazide diuretics in combination with low
sodium diet for calcium stones
Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention)
Increased fluid intake urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine)and D-Pencillaminefor cystine stones
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
S BANDI MACKAY UROLOGY
Diagnosis
Non-con helical CT 3-5mm cuts
May identify alternative diagnosis
Some information regarding stone compostiosn
Radiation dose
Low dose CT have similar sensitivity and specificity expect with small (lt2mm) stones and in obese patients
Ultrasound
No radiation
Sensitive for obstruction
May be able to identify
radiolucent stones
Harder to detect
smaller stones and
distal ureteric stones
Useful if patient is
pregnant or unsure
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
USS v CT in the EDSmith-Bindman Aubin Bailitz et al Ultrasonography versus
computed tomography for suspected nephrolithiasis NEJM
20143711100
Pts with clinical suspicion of renal colic randomised to non-conrast CT USS by radiologist bedside US by trained ED physician
Sensitivity
USS 57 (radiologist) 54 (ED physician)
CT 88
Radiation dose higher in CT group
Significant missed diagnoses similar
USS 05 CT 03
Adverse events amp repeat visits to ED similar
Length of stay in ED longer when US performed by Radiologist
S BANDI MACKAY UROLOGY
Other imaging modalitiesAXRXRay KUB
Will detect large radiopaque stones
Potential to miss uric acid stones smaller stones and stones overlying bone
Does not detect signs of obstruction
IVPMore specific and sensitive than plain XR
Detects obstruction
Potential for contrast reactions significant radiation dose
MRI Some role in pregnancy
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Further investigation
Bloods
FBE UECreatinine LFTrsquos Inflammatory markers
calcium urate
Urine
pH crystals oxalate
Straining urine for stones
Cytology and Culture
Genetic testing
Dentrsquos disease adenine
phosphoribosyltransferase deficiency
cystinuria
S BANDI MACKAY UROLOGY
Management
Analgesia and hydration
NSAIDs v opiates
NSAIDs can reduce smooth muscle tone in
the ureter
Possibly best in combination
NSAIDs should be avoidedused with care
in severe dehydration and impaired renal
function
S BANDI MACKAY UROLOGY
Passing a stone lt5mm likely to pass without intervention
gt10mm unlikely to pass without intervention
Increased intervention requirements with larger stones
Likelihood of stone passing also affected by position Stones at the vesicoureteric junction more
likely to be passed than those in the proximal ureter
S BANDI MACKAY UROLOGY
Medical Expulsive Therapy Alpha-blockers - prazosin tamsulosin (tamsulosin is
a selective 1A receptor blocker so less Side Effects
than with prazosin but cost implications as not on
PBS)
The randomized control trials have shown no benefit
in stones less than 5mm and some questionable
benefit in stones larger than 10mmEur Urol 2016 Aug 6 pii S0302-2838(16)30429-8 doi
101016jeururo201607024 [Epub ahead of print]
Medical Expulsive Therapy for Ureterolithiasis The EAU Recommendations in
2016 Tuumlrk C1 Knoll T2 Seitz C3 Skolarikos A4 Chapple C5 McClinton S6 European Association of Urology
Calcium channel blockers ndash (nifedipine)-
decreases human ureteral peristalsis and has limited
use in renal colic management
S BANDI MACKAY UROLOGY
Urological referral
Urosepsis
Acute Renal Failure(ARF)
Anuria
Uncontrolled pain
Stones not passed after trial of
medical therapy (usually about 4
weeks)
S BANDI MACKAY UROLOGY
Intervention Emergency
infected obstructed kidney bilateral obstruction with AKI or obstructed single kidney with AKI requires urgent decompression via percutaneous drainage or ureteric stenting
Shock wave lithotripsy
Ureteroscopic lithotripsy
Percutaneous nephrolithotomy with endoscopic stone removal
Open surgical removal
S BANDI MACKAY UROLOGY
Stone analysis
Increased fluid intake
Dietary and lifestyle factors
Obesity diabetes exercise
Low sodium diet for calcium stones
Low purine diet for uric acid stones
Avoidance of muscle building
supplements which are high in purines
Prevention of stone recurrence
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Additional treatments Thiazide diuretics in combination with low
sodium diet for calcium stones
Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention)
Increased fluid intake urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine)and D-Pencillaminefor cystine stones
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
USS v CT in the EDSmith-Bindman Aubin Bailitz et al Ultrasonography versus
computed tomography for suspected nephrolithiasis NEJM
20143711100
Pts with clinical suspicion of renal colic randomised to non-conrast CT USS by radiologist bedside US by trained ED physician
Sensitivity
USS 57 (radiologist) 54 (ED physician)
CT 88
Radiation dose higher in CT group
Significant missed diagnoses similar
USS 05 CT 03
Adverse events amp repeat visits to ED similar
Length of stay in ED longer when US performed by Radiologist
S BANDI MACKAY UROLOGY
Other imaging modalitiesAXRXRay KUB
Will detect large radiopaque stones
Potential to miss uric acid stones smaller stones and stones overlying bone
Does not detect signs of obstruction
IVPMore specific and sensitive than plain XR
Detects obstruction
Potential for contrast reactions significant radiation dose
MRI Some role in pregnancy
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Further investigation
Bloods
FBE UECreatinine LFTrsquos Inflammatory markers
calcium urate
Urine
pH crystals oxalate
Straining urine for stones
Cytology and Culture
Genetic testing
Dentrsquos disease adenine
phosphoribosyltransferase deficiency
cystinuria
S BANDI MACKAY UROLOGY
Management
Analgesia and hydration
NSAIDs v opiates
NSAIDs can reduce smooth muscle tone in
the ureter
Possibly best in combination
NSAIDs should be avoidedused with care
in severe dehydration and impaired renal
function
S BANDI MACKAY UROLOGY
Passing a stone lt5mm likely to pass without intervention
gt10mm unlikely to pass without intervention
Increased intervention requirements with larger stones
Likelihood of stone passing also affected by position Stones at the vesicoureteric junction more
likely to be passed than those in the proximal ureter
S BANDI MACKAY UROLOGY
Medical Expulsive Therapy Alpha-blockers - prazosin tamsulosin (tamsulosin is
a selective 1A receptor blocker so less Side Effects
than with prazosin but cost implications as not on
PBS)
The randomized control trials have shown no benefit
in stones less than 5mm and some questionable
benefit in stones larger than 10mmEur Urol 2016 Aug 6 pii S0302-2838(16)30429-8 doi
101016jeururo201607024 [Epub ahead of print]
Medical Expulsive Therapy for Ureterolithiasis The EAU Recommendations in
2016 Tuumlrk C1 Knoll T2 Seitz C3 Skolarikos A4 Chapple C5 McClinton S6 European Association of Urology
Calcium channel blockers ndash (nifedipine)-
decreases human ureteral peristalsis and has limited
use in renal colic management
S BANDI MACKAY UROLOGY
Urological referral
Urosepsis
Acute Renal Failure(ARF)
Anuria
Uncontrolled pain
Stones not passed after trial of
medical therapy (usually about 4
weeks)
S BANDI MACKAY UROLOGY
Intervention Emergency
infected obstructed kidney bilateral obstruction with AKI or obstructed single kidney with AKI requires urgent decompression via percutaneous drainage or ureteric stenting
Shock wave lithotripsy
Ureteroscopic lithotripsy
Percutaneous nephrolithotomy with endoscopic stone removal
Open surgical removal
S BANDI MACKAY UROLOGY
Stone analysis
Increased fluid intake
Dietary and lifestyle factors
Obesity diabetes exercise
Low sodium diet for calcium stones
Low purine diet for uric acid stones
Avoidance of muscle building
supplements which are high in purines
Prevention of stone recurrence
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Additional treatments Thiazide diuretics in combination with low
sodium diet for calcium stones
Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention)
Increased fluid intake urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine)and D-Pencillaminefor cystine stones
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
USS v CT in the EDSmith-Bindman Aubin Bailitz et al Ultrasonography versus
computed tomography for suspected nephrolithiasis NEJM
20143711100
Pts with clinical suspicion of renal colic randomised to non-conrast CT USS by radiologist bedside US by trained ED physician
Sensitivity
USS 57 (radiologist) 54 (ED physician)
CT 88
Radiation dose higher in CT group
Significant missed diagnoses similar
USS 05 CT 03
Adverse events amp repeat visits to ED similar
Length of stay in ED longer when US performed by Radiologist
S BANDI MACKAY UROLOGY
Other imaging modalitiesAXRXRay KUB
Will detect large radiopaque stones
Potential to miss uric acid stones smaller stones and stones overlying bone
Does not detect signs of obstruction
IVPMore specific and sensitive than plain XR
Detects obstruction
Potential for contrast reactions significant radiation dose
MRI Some role in pregnancy
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Further investigation
Bloods
FBE UECreatinine LFTrsquos Inflammatory markers
calcium urate
Urine
pH crystals oxalate
Straining urine for stones
Cytology and Culture
Genetic testing
Dentrsquos disease adenine
phosphoribosyltransferase deficiency
cystinuria
S BANDI MACKAY UROLOGY
Management
Analgesia and hydration
NSAIDs v opiates
NSAIDs can reduce smooth muscle tone in
the ureter
Possibly best in combination
NSAIDs should be avoidedused with care
in severe dehydration and impaired renal
function
S BANDI MACKAY UROLOGY
Passing a stone lt5mm likely to pass without intervention
gt10mm unlikely to pass without intervention
Increased intervention requirements with larger stones
Likelihood of stone passing also affected by position Stones at the vesicoureteric junction more
likely to be passed than those in the proximal ureter
S BANDI MACKAY UROLOGY
Medical Expulsive Therapy Alpha-blockers - prazosin tamsulosin (tamsulosin is
a selective 1A receptor blocker so less Side Effects
than with prazosin but cost implications as not on
PBS)
The randomized control trials have shown no benefit
in stones less than 5mm and some questionable
benefit in stones larger than 10mmEur Urol 2016 Aug 6 pii S0302-2838(16)30429-8 doi
101016jeururo201607024 [Epub ahead of print]
Medical Expulsive Therapy for Ureterolithiasis The EAU Recommendations in
2016 Tuumlrk C1 Knoll T2 Seitz C3 Skolarikos A4 Chapple C5 McClinton S6 European Association of Urology
Calcium channel blockers ndash (nifedipine)-
decreases human ureteral peristalsis and has limited
use in renal colic management
S BANDI MACKAY UROLOGY
Urological referral
Urosepsis
Acute Renal Failure(ARF)
Anuria
Uncontrolled pain
Stones not passed after trial of
medical therapy (usually about 4
weeks)
S BANDI MACKAY UROLOGY
Intervention Emergency
infected obstructed kidney bilateral obstruction with AKI or obstructed single kidney with AKI requires urgent decompression via percutaneous drainage or ureteric stenting
Shock wave lithotripsy
Ureteroscopic lithotripsy
Percutaneous nephrolithotomy with endoscopic stone removal
Open surgical removal
S BANDI MACKAY UROLOGY
Stone analysis
Increased fluid intake
Dietary and lifestyle factors
Obesity diabetes exercise
Low sodium diet for calcium stones
Low purine diet for uric acid stones
Avoidance of muscle building
supplements which are high in purines
Prevention of stone recurrence
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Additional treatments Thiazide diuretics in combination with low
sodium diet for calcium stones
Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention)
Increased fluid intake urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine)and D-Pencillaminefor cystine stones
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
S BANDI MACKAY UROLOGY
USS v CT in the EDSmith-Bindman Aubin Bailitz et al Ultrasonography versus
computed tomography for suspected nephrolithiasis NEJM
20143711100
Pts with clinical suspicion of renal colic randomised to non-conrast CT USS by radiologist bedside US by trained ED physician
Sensitivity
USS 57 (radiologist) 54 (ED physician)
CT 88
Radiation dose higher in CT group
Significant missed diagnoses similar
USS 05 CT 03
Adverse events amp repeat visits to ED similar
Length of stay in ED longer when US performed by Radiologist
S BANDI MACKAY UROLOGY
Other imaging modalitiesAXRXRay KUB
Will detect large radiopaque stones
Potential to miss uric acid stones smaller stones and stones overlying bone
Does not detect signs of obstruction
IVPMore specific and sensitive than plain XR
Detects obstruction
Potential for contrast reactions significant radiation dose
MRI Some role in pregnancy
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Further investigation
Bloods
FBE UECreatinine LFTrsquos Inflammatory markers
calcium urate
Urine
pH crystals oxalate
Straining urine for stones
Cytology and Culture
Genetic testing
Dentrsquos disease adenine
phosphoribosyltransferase deficiency
cystinuria
S BANDI MACKAY UROLOGY
Management
Analgesia and hydration
NSAIDs v opiates
NSAIDs can reduce smooth muscle tone in
the ureter
Possibly best in combination
NSAIDs should be avoidedused with care
in severe dehydration and impaired renal
function
S BANDI MACKAY UROLOGY
Passing a stone lt5mm likely to pass without intervention
gt10mm unlikely to pass without intervention
Increased intervention requirements with larger stones
Likelihood of stone passing also affected by position Stones at the vesicoureteric junction more
likely to be passed than those in the proximal ureter
S BANDI MACKAY UROLOGY
Medical Expulsive Therapy Alpha-blockers - prazosin tamsulosin (tamsulosin is
a selective 1A receptor blocker so less Side Effects
than with prazosin but cost implications as not on
PBS)
The randomized control trials have shown no benefit
in stones less than 5mm and some questionable
benefit in stones larger than 10mmEur Urol 2016 Aug 6 pii S0302-2838(16)30429-8 doi
101016jeururo201607024 [Epub ahead of print]
Medical Expulsive Therapy for Ureterolithiasis The EAU Recommendations in
2016 Tuumlrk C1 Knoll T2 Seitz C3 Skolarikos A4 Chapple C5 McClinton S6 European Association of Urology
Calcium channel blockers ndash (nifedipine)-
decreases human ureteral peristalsis and has limited
use in renal colic management
S BANDI MACKAY UROLOGY
Urological referral
Urosepsis
Acute Renal Failure(ARF)
Anuria
Uncontrolled pain
Stones not passed after trial of
medical therapy (usually about 4
weeks)
S BANDI MACKAY UROLOGY
Intervention Emergency
infected obstructed kidney bilateral obstruction with AKI or obstructed single kidney with AKI requires urgent decompression via percutaneous drainage or ureteric stenting
Shock wave lithotripsy
Ureteroscopic lithotripsy
Percutaneous nephrolithotomy with endoscopic stone removal
Open surgical removal
S BANDI MACKAY UROLOGY
Stone analysis
Increased fluid intake
Dietary and lifestyle factors
Obesity diabetes exercise
Low sodium diet for calcium stones
Low purine diet for uric acid stones
Avoidance of muscle building
supplements which are high in purines
Prevention of stone recurrence
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Additional treatments Thiazide diuretics in combination with low
sodium diet for calcium stones
Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention)
Increased fluid intake urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine)and D-Pencillaminefor cystine stones
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
S BANDI MACKAY UROLOGY
Other imaging modalitiesAXRXRay KUB
Will detect large radiopaque stones
Potential to miss uric acid stones smaller stones and stones overlying bone
Does not detect signs of obstruction
IVPMore specific and sensitive than plain XR
Detects obstruction
Potential for contrast reactions significant radiation dose
MRI Some role in pregnancy
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Further investigation
Bloods
FBE UECreatinine LFTrsquos Inflammatory markers
calcium urate
Urine
pH crystals oxalate
Straining urine for stones
Cytology and Culture
Genetic testing
Dentrsquos disease adenine
phosphoribosyltransferase deficiency
cystinuria
S BANDI MACKAY UROLOGY
Management
Analgesia and hydration
NSAIDs v opiates
NSAIDs can reduce smooth muscle tone in
the ureter
Possibly best in combination
NSAIDs should be avoidedused with care
in severe dehydration and impaired renal
function
S BANDI MACKAY UROLOGY
Passing a stone lt5mm likely to pass without intervention
gt10mm unlikely to pass without intervention
Increased intervention requirements with larger stones
Likelihood of stone passing also affected by position Stones at the vesicoureteric junction more
likely to be passed than those in the proximal ureter
S BANDI MACKAY UROLOGY
Medical Expulsive Therapy Alpha-blockers - prazosin tamsulosin (tamsulosin is
a selective 1A receptor blocker so less Side Effects
than with prazosin but cost implications as not on
PBS)
The randomized control trials have shown no benefit
in stones less than 5mm and some questionable
benefit in stones larger than 10mmEur Urol 2016 Aug 6 pii S0302-2838(16)30429-8 doi
101016jeururo201607024 [Epub ahead of print]
Medical Expulsive Therapy for Ureterolithiasis The EAU Recommendations in
2016 Tuumlrk C1 Knoll T2 Seitz C3 Skolarikos A4 Chapple C5 McClinton S6 European Association of Urology
Calcium channel blockers ndash (nifedipine)-
decreases human ureteral peristalsis and has limited
use in renal colic management
S BANDI MACKAY UROLOGY
Urological referral
Urosepsis
Acute Renal Failure(ARF)
Anuria
Uncontrolled pain
Stones not passed after trial of
medical therapy (usually about 4
weeks)
S BANDI MACKAY UROLOGY
Intervention Emergency
infected obstructed kidney bilateral obstruction with AKI or obstructed single kidney with AKI requires urgent decompression via percutaneous drainage or ureteric stenting
Shock wave lithotripsy
Ureteroscopic lithotripsy
Percutaneous nephrolithotomy with endoscopic stone removal
Open surgical removal
S BANDI MACKAY UROLOGY
Stone analysis
Increased fluid intake
Dietary and lifestyle factors
Obesity diabetes exercise
Low sodium diet for calcium stones
Low purine diet for uric acid stones
Avoidance of muscle building
supplements which are high in purines
Prevention of stone recurrence
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Additional treatments Thiazide diuretics in combination with low
sodium diet for calcium stones
Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention)
Increased fluid intake urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine)and D-Pencillaminefor cystine stones
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Further investigation
Bloods
FBE UECreatinine LFTrsquos Inflammatory markers
calcium urate
Urine
pH crystals oxalate
Straining urine for stones
Cytology and Culture
Genetic testing
Dentrsquos disease adenine
phosphoribosyltransferase deficiency
cystinuria
S BANDI MACKAY UROLOGY
Management
Analgesia and hydration
NSAIDs v opiates
NSAIDs can reduce smooth muscle tone in
the ureter
Possibly best in combination
NSAIDs should be avoidedused with care
in severe dehydration and impaired renal
function
S BANDI MACKAY UROLOGY
Passing a stone lt5mm likely to pass without intervention
gt10mm unlikely to pass without intervention
Increased intervention requirements with larger stones
Likelihood of stone passing also affected by position Stones at the vesicoureteric junction more
likely to be passed than those in the proximal ureter
S BANDI MACKAY UROLOGY
Medical Expulsive Therapy Alpha-blockers - prazosin tamsulosin (tamsulosin is
a selective 1A receptor blocker so less Side Effects
than with prazosin but cost implications as not on
PBS)
The randomized control trials have shown no benefit
in stones less than 5mm and some questionable
benefit in stones larger than 10mmEur Urol 2016 Aug 6 pii S0302-2838(16)30429-8 doi
101016jeururo201607024 [Epub ahead of print]
Medical Expulsive Therapy for Ureterolithiasis The EAU Recommendations in
2016 Tuumlrk C1 Knoll T2 Seitz C3 Skolarikos A4 Chapple C5 McClinton S6 European Association of Urology
Calcium channel blockers ndash (nifedipine)-
decreases human ureteral peristalsis and has limited
use in renal colic management
S BANDI MACKAY UROLOGY
Urological referral
Urosepsis
Acute Renal Failure(ARF)
Anuria
Uncontrolled pain
Stones not passed after trial of
medical therapy (usually about 4
weeks)
S BANDI MACKAY UROLOGY
Intervention Emergency
infected obstructed kidney bilateral obstruction with AKI or obstructed single kidney with AKI requires urgent decompression via percutaneous drainage or ureteric stenting
Shock wave lithotripsy
Ureteroscopic lithotripsy
Percutaneous nephrolithotomy with endoscopic stone removal
Open surgical removal
S BANDI MACKAY UROLOGY
Stone analysis
Increased fluid intake
Dietary and lifestyle factors
Obesity diabetes exercise
Low sodium diet for calcium stones
Low purine diet for uric acid stones
Avoidance of muscle building
supplements which are high in purines
Prevention of stone recurrence
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Additional treatments Thiazide diuretics in combination with low
sodium diet for calcium stones
Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention)
Increased fluid intake urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine)and D-Pencillaminefor cystine stones
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Further investigation
Bloods
FBE UECreatinine LFTrsquos Inflammatory markers
calcium urate
Urine
pH crystals oxalate
Straining urine for stones
Cytology and Culture
Genetic testing
Dentrsquos disease adenine
phosphoribosyltransferase deficiency
cystinuria
S BANDI MACKAY UROLOGY
Management
Analgesia and hydration
NSAIDs v opiates
NSAIDs can reduce smooth muscle tone in
the ureter
Possibly best in combination
NSAIDs should be avoidedused with care
in severe dehydration and impaired renal
function
S BANDI MACKAY UROLOGY
Passing a stone lt5mm likely to pass without intervention
gt10mm unlikely to pass without intervention
Increased intervention requirements with larger stones
Likelihood of stone passing also affected by position Stones at the vesicoureteric junction more
likely to be passed than those in the proximal ureter
S BANDI MACKAY UROLOGY
Medical Expulsive Therapy Alpha-blockers - prazosin tamsulosin (tamsulosin is
a selective 1A receptor blocker so less Side Effects
than with prazosin but cost implications as not on
PBS)
The randomized control trials have shown no benefit
in stones less than 5mm and some questionable
benefit in stones larger than 10mmEur Urol 2016 Aug 6 pii S0302-2838(16)30429-8 doi
101016jeururo201607024 [Epub ahead of print]
Medical Expulsive Therapy for Ureterolithiasis The EAU Recommendations in
2016 Tuumlrk C1 Knoll T2 Seitz C3 Skolarikos A4 Chapple C5 McClinton S6 European Association of Urology
Calcium channel blockers ndash (nifedipine)-
decreases human ureteral peristalsis and has limited
use in renal colic management
S BANDI MACKAY UROLOGY
Urological referral
Urosepsis
Acute Renal Failure(ARF)
Anuria
Uncontrolled pain
Stones not passed after trial of
medical therapy (usually about 4
weeks)
S BANDI MACKAY UROLOGY
Intervention Emergency
infected obstructed kidney bilateral obstruction with AKI or obstructed single kidney with AKI requires urgent decompression via percutaneous drainage or ureteric stenting
Shock wave lithotripsy
Ureteroscopic lithotripsy
Percutaneous nephrolithotomy with endoscopic stone removal
Open surgical removal
S BANDI MACKAY UROLOGY
Stone analysis
Increased fluid intake
Dietary and lifestyle factors
Obesity diabetes exercise
Low sodium diet for calcium stones
Low purine diet for uric acid stones
Avoidance of muscle building
supplements which are high in purines
Prevention of stone recurrence
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Additional treatments Thiazide diuretics in combination with low
sodium diet for calcium stones
Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention)
Increased fluid intake urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine)and D-Pencillaminefor cystine stones
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Further investigation
Bloods
FBE UECreatinine LFTrsquos Inflammatory markers
calcium urate
Urine
pH crystals oxalate
Straining urine for stones
Cytology and Culture
Genetic testing
Dentrsquos disease adenine
phosphoribosyltransferase deficiency
cystinuria
S BANDI MACKAY UROLOGY
Management
Analgesia and hydration
NSAIDs v opiates
NSAIDs can reduce smooth muscle tone in
the ureter
Possibly best in combination
NSAIDs should be avoidedused with care
in severe dehydration and impaired renal
function
S BANDI MACKAY UROLOGY
Passing a stone lt5mm likely to pass without intervention
gt10mm unlikely to pass without intervention
Increased intervention requirements with larger stones
Likelihood of stone passing also affected by position Stones at the vesicoureteric junction more
likely to be passed than those in the proximal ureter
S BANDI MACKAY UROLOGY
Medical Expulsive Therapy Alpha-blockers - prazosin tamsulosin (tamsulosin is
a selective 1A receptor blocker so less Side Effects
than with prazosin but cost implications as not on
PBS)
The randomized control trials have shown no benefit
in stones less than 5mm and some questionable
benefit in stones larger than 10mmEur Urol 2016 Aug 6 pii S0302-2838(16)30429-8 doi
101016jeururo201607024 [Epub ahead of print]
Medical Expulsive Therapy for Ureterolithiasis The EAU Recommendations in
2016 Tuumlrk C1 Knoll T2 Seitz C3 Skolarikos A4 Chapple C5 McClinton S6 European Association of Urology
Calcium channel blockers ndash (nifedipine)-
decreases human ureteral peristalsis and has limited
use in renal colic management
S BANDI MACKAY UROLOGY
Urological referral
Urosepsis
Acute Renal Failure(ARF)
Anuria
Uncontrolled pain
Stones not passed after trial of
medical therapy (usually about 4
weeks)
S BANDI MACKAY UROLOGY
Intervention Emergency
infected obstructed kidney bilateral obstruction with AKI or obstructed single kidney with AKI requires urgent decompression via percutaneous drainage or ureteric stenting
Shock wave lithotripsy
Ureteroscopic lithotripsy
Percutaneous nephrolithotomy with endoscopic stone removal
Open surgical removal
S BANDI MACKAY UROLOGY
Stone analysis
Increased fluid intake
Dietary and lifestyle factors
Obesity diabetes exercise
Low sodium diet for calcium stones
Low purine diet for uric acid stones
Avoidance of muscle building
supplements which are high in purines
Prevention of stone recurrence
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Additional treatments Thiazide diuretics in combination with low
sodium diet for calcium stones
Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention)
Increased fluid intake urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine)and D-Pencillaminefor cystine stones
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
S BANDI MACKAY UROLOGY
Further investigation
Bloods
FBE UECreatinine LFTrsquos Inflammatory markers
calcium urate
Urine
pH crystals oxalate
Straining urine for stones
Cytology and Culture
Genetic testing
Dentrsquos disease adenine
phosphoribosyltransferase deficiency
cystinuria
S BANDI MACKAY UROLOGY
Management
Analgesia and hydration
NSAIDs v opiates
NSAIDs can reduce smooth muscle tone in
the ureter
Possibly best in combination
NSAIDs should be avoidedused with care
in severe dehydration and impaired renal
function
S BANDI MACKAY UROLOGY
Passing a stone lt5mm likely to pass without intervention
gt10mm unlikely to pass without intervention
Increased intervention requirements with larger stones
Likelihood of stone passing also affected by position Stones at the vesicoureteric junction more
likely to be passed than those in the proximal ureter
S BANDI MACKAY UROLOGY
Medical Expulsive Therapy Alpha-blockers - prazosin tamsulosin (tamsulosin is
a selective 1A receptor blocker so less Side Effects
than with prazosin but cost implications as not on
PBS)
The randomized control trials have shown no benefit
in stones less than 5mm and some questionable
benefit in stones larger than 10mmEur Urol 2016 Aug 6 pii S0302-2838(16)30429-8 doi
101016jeururo201607024 [Epub ahead of print]
Medical Expulsive Therapy for Ureterolithiasis The EAU Recommendations in
2016 Tuumlrk C1 Knoll T2 Seitz C3 Skolarikos A4 Chapple C5 McClinton S6 European Association of Urology
Calcium channel blockers ndash (nifedipine)-
decreases human ureteral peristalsis and has limited
use in renal colic management
S BANDI MACKAY UROLOGY
Urological referral
Urosepsis
Acute Renal Failure(ARF)
Anuria
Uncontrolled pain
Stones not passed after trial of
medical therapy (usually about 4
weeks)
S BANDI MACKAY UROLOGY
Intervention Emergency
infected obstructed kidney bilateral obstruction with AKI or obstructed single kidney with AKI requires urgent decompression via percutaneous drainage or ureteric stenting
Shock wave lithotripsy
Ureteroscopic lithotripsy
Percutaneous nephrolithotomy with endoscopic stone removal
Open surgical removal
S BANDI MACKAY UROLOGY
Stone analysis
Increased fluid intake
Dietary and lifestyle factors
Obesity diabetes exercise
Low sodium diet for calcium stones
Low purine diet for uric acid stones
Avoidance of muscle building
supplements which are high in purines
Prevention of stone recurrence
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Additional treatments Thiazide diuretics in combination with low
sodium diet for calcium stones
Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention)
Increased fluid intake urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine)and D-Pencillaminefor cystine stones
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
S BANDI MACKAY UROLOGY
Management
Analgesia and hydration
NSAIDs v opiates
NSAIDs can reduce smooth muscle tone in
the ureter
Possibly best in combination
NSAIDs should be avoidedused with care
in severe dehydration and impaired renal
function
S BANDI MACKAY UROLOGY
Passing a stone lt5mm likely to pass without intervention
gt10mm unlikely to pass without intervention
Increased intervention requirements with larger stones
Likelihood of stone passing also affected by position Stones at the vesicoureteric junction more
likely to be passed than those in the proximal ureter
S BANDI MACKAY UROLOGY
Medical Expulsive Therapy Alpha-blockers - prazosin tamsulosin (tamsulosin is
a selective 1A receptor blocker so less Side Effects
than with prazosin but cost implications as not on
PBS)
The randomized control trials have shown no benefit
in stones less than 5mm and some questionable
benefit in stones larger than 10mmEur Urol 2016 Aug 6 pii S0302-2838(16)30429-8 doi
101016jeururo201607024 [Epub ahead of print]
Medical Expulsive Therapy for Ureterolithiasis The EAU Recommendations in
2016 Tuumlrk C1 Knoll T2 Seitz C3 Skolarikos A4 Chapple C5 McClinton S6 European Association of Urology
Calcium channel blockers ndash (nifedipine)-
decreases human ureteral peristalsis and has limited
use in renal colic management
S BANDI MACKAY UROLOGY
Urological referral
Urosepsis
Acute Renal Failure(ARF)
Anuria
Uncontrolled pain
Stones not passed after trial of
medical therapy (usually about 4
weeks)
S BANDI MACKAY UROLOGY
Intervention Emergency
infected obstructed kidney bilateral obstruction with AKI or obstructed single kidney with AKI requires urgent decompression via percutaneous drainage or ureteric stenting
Shock wave lithotripsy
Ureteroscopic lithotripsy
Percutaneous nephrolithotomy with endoscopic stone removal
Open surgical removal
S BANDI MACKAY UROLOGY
Stone analysis
Increased fluid intake
Dietary and lifestyle factors
Obesity diabetes exercise
Low sodium diet for calcium stones
Low purine diet for uric acid stones
Avoidance of muscle building
supplements which are high in purines
Prevention of stone recurrence
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Additional treatments Thiazide diuretics in combination with low
sodium diet for calcium stones
Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention)
Increased fluid intake urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine)and D-Pencillaminefor cystine stones
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
S BANDI MACKAY UROLOGY
Passing a stone lt5mm likely to pass without intervention
gt10mm unlikely to pass without intervention
Increased intervention requirements with larger stones
Likelihood of stone passing also affected by position Stones at the vesicoureteric junction more
likely to be passed than those in the proximal ureter
S BANDI MACKAY UROLOGY
Medical Expulsive Therapy Alpha-blockers - prazosin tamsulosin (tamsulosin is
a selective 1A receptor blocker so less Side Effects
than with prazosin but cost implications as not on
PBS)
The randomized control trials have shown no benefit
in stones less than 5mm and some questionable
benefit in stones larger than 10mmEur Urol 2016 Aug 6 pii S0302-2838(16)30429-8 doi
101016jeururo201607024 [Epub ahead of print]
Medical Expulsive Therapy for Ureterolithiasis The EAU Recommendations in
2016 Tuumlrk C1 Knoll T2 Seitz C3 Skolarikos A4 Chapple C5 McClinton S6 European Association of Urology
Calcium channel blockers ndash (nifedipine)-
decreases human ureteral peristalsis and has limited
use in renal colic management
S BANDI MACKAY UROLOGY
Urological referral
Urosepsis
Acute Renal Failure(ARF)
Anuria
Uncontrolled pain
Stones not passed after trial of
medical therapy (usually about 4
weeks)
S BANDI MACKAY UROLOGY
Intervention Emergency
infected obstructed kidney bilateral obstruction with AKI or obstructed single kidney with AKI requires urgent decompression via percutaneous drainage or ureteric stenting
Shock wave lithotripsy
Ureteroscopic lithotripsy
Percutaneous nephrolithotomy with endoscopic stone removal
Open surgical removal
S BANDI MACKAY UROLOGY
Stone analysis
Increased fluid intake
Dietary and lifestyle factors
Obesity diabetes exercise
Low sodium diet for calcium stones
Low purine diet for uric acid stones
Avoidance of muscle building
supplements which are high in purines
Prevention of stone recurrence
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Additional treatments Thiazide diuretics in combination with low
sodium diet for calcium stones
Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention)
Increased fluid intake urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine)and D-Pencillaminefor cystine stones
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
S BANDI MACKAY UROLOGY
Medical Expulsive Therapy Alpha-blockers - prazosin tamsulosin (tamsulosin is
a selective 1A receptor blocker so less Side Effects
than with prazosin but cost implications as not on
PBS)
The randomized control trials have shown no benefit
in stones less than 5mm and some questionable
benefit in stones larger than 10mmEur Urol 2016 Aug 6 pii S0302-2838(16)30429-8 doi
101016jeururo201607024 [Epub ahead of print]
Medical Expulsive Therapy for Ureterolithiasis The EAU Recommendations in
2016 Tuumlrk C1 Knoll T2 Seitz C3 Skolarikos A4 Chapple C5 McClinton S6 European Association of Urology
Calcium channel blockers ndash (nifedipine)-
decreases human ureteral peristalsis and has limited
use in renal colic management
S BANDI MACKAY UROLOGY
Urological referral
Urosepsis
Acute Renal Failure(ARF)
Anuria
Uncontrolled pain
Stones not passed after trial of
medical therapy (usually about 4
weeks)
S BANDI MACKAY UROLOGY
Intervention Emergency
infected obstructed kidney bilateral obstruction with AKI or obstructed single kidney with AKI requires urgent decompression via percutaneous drainage or ureteric stenting
Shock wave lithotripsy
Ureteroscopic lithotripsy
Percutaneous nephrolithotomy with endoscopic stone removal
Open surgical removal
S BANDI MACKAY UROLOGY
Stone analysis
Increased fluid intake
Dietary and lifestyle factors
Obesity diabetes exercise
Low sodium diet for calcium stones
Low purine diet for uric acid stones
Avoidance of muscle building
supplements which are high in purines
Prevention of stone recurrence
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Additional treatments Thiazide diuretics in combination with low
sodium diet for calcium stones
Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention)
Increased fluid intake urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine)and D-Pencillaminefor cystine stones
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
S BANDI MACKAY UROLOGY
Urological referral
Urosepsis
Acute Renal Failure(ARF)
Anuria
Uncontrolled pain
Stones not passed after trial of
medical therapy (usually about 4
weeks)
S BANDI MACKAY UROLOGY
Intervention Emergency
infected obstructed kidney bilateral obstruction with AKI or obstructed single kidney with AKI requires urgent decompression via percutaneous drainage or ureteric stenting
Shock wave lithotripsy
Ureteroscopic lithotripsy
Percutaneous nephrolithotomy with endoscopic stone removal
Open surgical removal
S BANDI MACKAY UROLOGY
Stone analysis
Increased fluid intake
Dietary and lifestyle factors
Obesity diabetes exercise
Low sodium diet for calcium stones
Low purine diet for uric acid stones
Avoidance of muscle building
supplements which are high in purines
Prevention of stone recurrence
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Additional treatments Thiazide diuretics in combination with low
sodium diet for calcium stones
Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention)
Increased fluid intake urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine)and D-Pencillaminefor cystine stones
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
S BANDI MACKAY UROLOGY
Intervention Emergency
infected obstructed kidney bilateral obstruction with AKI or obstructed single kidney with AKI requires urgent decompression via percutaneous drainage or ureteric stenting
Shock wave lithotripsy
Ureteroscopic lithotripsy
Percutaneous nephrolithotomy with endoscopic stone removal
Open surgical removal
S BANDI MACKAY UROLOGY
Stone analysis
Increased fluid intake
Dietary and lifestyle factors
Obesity diabetes exercise
Low sodium diet for calcium stones
Low purine diet for uric acid stones
Avoidance of muscle building
supplements which are high in purines
Prevention of stone recurrence
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Additional treatments Thiazide diuretics in combination with low
sodium diet for calcium stones
Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention)
Increased fluid intake urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine)and D-Pencillaminefor cystine stones
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
S BANDI MACKAY UROLOGY
Stone analysis
Increased fluid intake
Dietary and lifestyle factors
Obesity diabetes exercise
Low sodium diet for calcium stones
Low purine diet for uric acid stones
Avoidance of muscle building
supplements which are high in purines
Prevention of stone recurrence
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Additional treatments Thiazide diuretics in combination with low
sodium diet for calcium stones
Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention)
Increased fluid intake urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine)and D-Pencillaminefor cystine stones
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
S BANDI MACKAY UROLOGY
S BANDI MACKAY UROLOGY
Additional treatments Thiazide diuretics in combination with low
sodium diet for calcium stones
Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention)
Increased fluid intake urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine)and D-Pencillaminefor cystine stones
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
S BANDI MACKAY UROLOGY
Additional treatments Thiazide diuretics in combination with low
sodium diet for calcium stones
Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention)
Increased fluid intake urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine)and D-Pencillaminefor cystine stones
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
D Pencillamine in Cystine
stones
S BANDI MACKAY UROLOGY
Penicillamine is a first-generation chelating
agent that combines with cystine to form a
soluble disulfide complex (50 times more
soluble than cystine) thus preventing stone
formation and possibly even dissolving
existing cystine stones
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
S BANDI MACKAY UROLOGY
In summary Renal colic usually presents as unilateral colicky
loinflank pain
Haematuria present in majority of cases
1st line imaging either CT or US
Smaller (lt10mm) stones usually managed conservatively
Fluids analgesia amp MET(Medical Expulsive Therapy)
Surgical options include ESWL and ureteroscopy
Emergency decompression indicated for infected obstructed kidney bilateral obstruction with AKI amp obstructed single kidney with AKI
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