soca review genitourinary system case 1-urinary stone

7/31/2019 Soca Review Genitourinary System Case 1-Urinary Stone

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SOCA REVIEW GENITOURINARY SYSTEM

CASE 1: URINARY STONE

BASIC SCIENCE

1. ANATOMY OF URINARY TRACT (REVIEW)

2. HISTOLOGY OF URINARY TRACT (REVIEW)

CLINICAL SCIENCE

1. FLANK PAIN

a. Definition

i. An unpleasant sensation associated with actual or potential tissue damage,

and mediated by specific nerve fibers to the brain where its conscious

appreciation may be modified by various factors and felt in the

costovertebral angle just lateral to the sacrospinalis muscle and just below

the 12th

ribb. Classification

i. Local = felt in or near the involved organ. Felt in the costovertebral anglejust lateral to the sacrospinalis muscle and just below the 12th rib. (T10-12,

L1)

ii. Referred = originated in a diseased organ but is felt at some distance fromthat organ. Classification:

1. Upper ureter = severe pain in the ipsilateral testicle (T11-12).

2. Midportion of ureter, right = Mc Burneys point, left = (T12, L1).

3. Bladder = inflammation and edema of the ureteral orifice, symptom

of vesical irritability.

c. Differentiation between dull and colicky paini. Dull pain = typical renal pain and constant ache in the costovertebral angle

just lateral to the sacrospinalis muscle and just below the 12th rib.

ii. Colicky pain = stimulated by acute obstruction, severity and colicky nature

of this pain are caused by the hyperperistaltis and spasm. This pain radiatedfrom the costovertebral angle down towards lower anterior abdominal

quadrant, along the course of ureter.

d. Cause of flank pain

i. Distension of the renal capsule

ii. Sudden edema

iii. Sudden renal back pressure

2. HEMATURIA

a. Definition

i. Any condition in which the urine contains blood or red blood cells. (as fewas 5 X 106 red cells per milliliter / 1 microlitre of blood per mililitre of

urine).

b. Cause


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i. Lesion anywhere within the urinary system including the kidney itself, the

renal pelvis, ureter, bladder, and urethra.

ii. The relationship of the blood to urine:

1. Bladder or above (uniform discoloration of urine)

2. Urethra (blood separate / mixed with urine)

iii. The relationship of the structure:1. Renal parenchyma accompanied by proteinuria and casts,

abnormal morphology of red blood cells

2. Renal tumors / lesions in the renal pelvis or belowisolated or

associated with pyuria if there is any infection. Red blood cells have

biconcave appearance.

c. Distinguishing factor from other condition

i. Certain dye and occasional drug.

ii. Intravascular hemolysis and rhabdomyolisis.

iii. Bleeding outside the urinary tract.

d. Diagnostic method

i. Plain abdominal X-ray.ii. Ultrasonography (provide information about renal size, renal mass lesions,

and renal pelvic and ureteric dilatation.

3. URINARY STONE

a. Definition

i. Polycrystalline aggregates composed of varying amounts of crystalloid and

organic matrix.

b. Epidemiology

i. 450,000 visits to EDs annually.

ii. Approximately 12% for men and 7% for women in the United States.

iii. Male-to-female ratio is approximately 3:1.c. Pathogenesis

i. Supersaturation that depends on: urinary pH, ionic strength, solute

concentration, and complexation.

ii. The nucleation theory.

iii. The crystal inhibitor theory (including magnesium, citrate, pyrophosphate,

and a variety of trace metals).

d. Composition of stone

i. Stone analysis, based on initial 24-h urine collection for calcium stone

formers.


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e. Risk factor

i. Crystalluria.

ii. Socioeconomic factors.iii. Diet.

iv. Occupation.

v. Climate.

vi. Family history.

vii. Medications.

f. Clinical sign & symptom

i. Pain.

ii. Hematuria.

iii. Infection.

iv. Associated Fever.

v. Nausea and Vomiting.g. Diagnostic modality

i. History.ii. Physical Examination.

iii. Radiologic Investigations.

1. Computed tomography.

2. Intravenous pyelography.

3. Tomography.

4. KUB films and directed ultrasonography.

5. Retrograde pyelography.

6. Magnetic resonance imaging.

7. Nuclear scintigraphy.

h. Differential diagnosis

i. A full differential diagnosis of the acute abdomen should be made,

including acute appendicitis, ectopic and unrecognized pregnancies, ovarian

pathologic conditions including twisted ovarian cysts, diverticular disease,bowel obstruction, biliary stones with and without obstruction, peptic ulcer

disease, acute renal artery embolism, and abdominal aortic aneurysm

i. Management


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i. Conservative Observation.

ii. Dissolution Agents.

iii. Extracorporeal Shock Wave Lithotripsy.

iv. Ureterorenoscopy procedure with ultrasound.

v. Pneumatic stone crusher for breaking stones.

vi. Open surgery (ureterolithotomy).j. Complication

i. Infected hydronephrosis.

ii. Calyceal rupture.

iii. Complete ureteral obstruction.

k. Prognosis

i. Approximately 80% of ureteral stones pass spontaneously without

hospitalization or invasive intervention.ii. Approximately 20% of patients require hospitalization due to dehydration,

continued pain or vomiting, or inability to pass the stone spontaneously.

iii. Recurrence rates after an initial episode of ureterolithiasis are 14%, 35%,

and 52% at 1, 5, and 10 years, respectively. Risk of recurrence can bereduced drastically by specific medical therapy based on analysis of the

stone and serum and urine metabolic profiles.

l. Recognize obstructive nephropathy

m. Prevention

i. Education.

ii. Preventive measures.

iii. Lifestyle changes, fluid intake should be about 1, 6 L/24 h.

iv. Motivated patient.

PATOMEKANISME RENAL CALCULUS

PrecipitationFormation of crystal in the urine


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Supersaturation of one or more salt in the urine

crystal growth inhibiting factor

complexity solute concentration

ionic strength

Growth into structure with adequate mass to obstruct the urinary tract

AgglomerationCrystallization

Less dense and amorphous calculus

Dense calculus with elegant geometric surface

Renal calculus


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soca review genitourinary system case 1-urinary stone

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