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Primary Care

Kidney Stones: Diagnosis, Work Up and Management

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SUMMARY:

Nephrolithiasis, or kidney stones, is a common condition which affects up to 8.8% of the U.S. population. The incidence has been increasing over time, especially in the “stone belt” located in the Southeastern and South-Central United States.  It is most often characterized by colicky flank pain.  Calculi have various compositions including calcium oxalate, uric acid, struvite, calcium phosphate and, cystine.    

Symptoms

  • Flank pain
  • Pain radiating to groin
  • Nausea
  • Vomiting
  • Urinary urgency
  • Abdominal pain
  • Urinary frequency
  • Dysuria
  • Hematuria

Risk Factors

  • Urinary obstruction
  • Hypertension
  • Gout
  • Obesity
  • Diabetes
  • Dietary
    • Excessive intake: Protein | Carbohydrates | Sodium
    • Low fiber | High oxalate | Carbonated drinks with phosphoric acid
    • Poor dietary fluid intake
  • Urine composition
    • pH, Hyperuricosuria | Hypomagnesuria | Hypercalciuria | Xanthinuria Hypocitraturia
  • Recurrent UTI with urease producing organisms
  • Medications
    • Topiramate Triamterene | Furosemide | Acetazolamide
    • Vitamin C | Vitamin D

Differential Diagnosis

GI

  • Intestinal obstruction
    • Abdominal pain | Unable to pass flatus or stool | Nausea and vomiting
  • Mesenteric ischemia
    • Acute severe abdominal pain | Nausea | Vomiting | Pain after eating
  • Cholecystitis
    • RUQ pain | Nausea and vomiting
  • Appendicitis
    • RLQ pain | Fever | Nausea and vomiting

GU

  • Renal or ureteral stone
    • Flank pain | Nausea and Vomiting | Dysuria
  • UTI
    • Suprapubic pain | Urinary frequency | Uinary urgency
  • Prostatitis
    • Dysuria | Difficulty urinating | Genital or perineal pain | Fever
  • Pyelonephritis
    • Fever | Chills | Flank pain | Dysuria

Cardiovascular

  • Abdominal aortic aneurysm
    • Abdominal pain | Pulsatile mass | Hypotension

Pulmonary

  • Pneumonia
    • Fever | Cough | Dyspnea
  • Rib fracture
    • Pain with inspiration |  History of trauma

Other

  • Ectopic pregnancy
    • Vaginal bleeding | Pelvic pain | Nausea
  • Ovarian cyst or torsion
    • Pelvic pain | Bleeding | Nausea and vomiting
  • Herpes Zoster
    • Radicular pain | Vesicular rash
  • Sciatica
    • Low back pain | Radicular pain down leg | Paresthesia

Diagnostic Evaluation    

  • Urinalysis
  • Urine Culture
  • Non-contrast CT scan of the abdomen and pelvis (gold standard)
  • Intravenous pyelogram (previous gold standard)
  • Ultrasound of the kidneys can be used effectively and avoids radiation in adults under 50
  • KUB – plain abdominal radiograph
  • CBC
  • Creatinine

Treatment

  • The most important key to managing patient with nephrolithiasis is determining whether urgent intervention is needed

Pain Control

  • NSAID
    • More effective pain relief with fewer side effects
    • May be contra-indicated in renal impairment
  • Narcotic
    • Used if NSAID is ineffective

Expectant Management

  • Stone size and location are important
  • Stones < 5 mm in diameter are likely to pass spontaneously
  • Likelihood of stones passing spontaneously decreases as stone size increases
  • Can facilitate passage within the distal ureter with medical expulsive therapy
    • Alpha blockers
      • Tamsulosin: 0.4 mg per day
      • Doxazosin: 4 mg per day
    • Calcium channel blockers
      • Nifedipine: less effective
  • Repeat imaging after 2 weeks to assess stone position and look for hydronephrosis
  • Referral to urology if no improvement after 2 to 4 weeks

Urgent Intervention

  • Urgent intervention required for the following
    • Obstructed upper urinary tract with infection/sepsis
    • Pain refractory to analgesics
    • Anuria
    • Impending renal deterioration (abnormal creatinine)
    • Intractable nausea and vomiting
    • Solitary kidney
    • Hemodynamic instability
    • Patient preference
  • Surgical management
    • Ureteroscopy
    • Extracorporeal shockwave lithotripsy
    • Percutaneous nephrolithotomy
    • Patient with signs of obstruction and infection may require ureteral stent

Complications

  • Abscess formation
  • Urosepsis
  • Ureteral injury, scarring, stenosis
  • Urinary fistula
  • Renal function loss

Follow-up and Prevention

  • Stone composition analysis
  • 24-hour urinalysis
    • Total volume | Calcium | Oxalate | Sodium | Uric acid | Citrate | Creatinine | Magnesium | Phosphate | Cystine.
  • Serum studies depend upon stone composition and clinical picture
    • Calcium | Phosphorous | Uric acid | Creatinine
  • Lifestyle modification
    • Increase oral fluid intake to generate 2.5 L of urine in 24 hours
    • Balanced diet high in fiber and vegetables and limited sodium and animal protein
  • Medications to be used with corresponding kidney composition 
    • Thiazide diuretics: Calcium stones
    • Allopurinol: Calcium stones | Uric acid stones
    • Citrate supplementation: Calcium stones | Uric acid stones | Cystine stones
  • Repeat a 24-hour urine within 6 months of dietary changes or starting treatment with medications to assess response to therapy

Primary Sources – Learn More

Kidney Stones: Treatment and Prevention – American Family Physician (aafp.org)

AUA: Medical Management of Kidney Stones

AUA/Endourology: Surgical Management of Kidney Stones

Clinical Effectiveness Protocols for Imaging in The Management of Ureteral Calculous Disease: AUA Technology Assessment – American Urological Association (auanet.org)

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