Urinary Tract Stones (Calculi)

Urinary Tract Stones (Calculi)

Urinary Tract Stones (Calculi)

urinary calculi: composition ,frequency, and characteristics Type of stone frequency (%) effect of ph on solubility radiographic density (bone=1.0) Calcium stones 80 Oxalate 35 little effect 0.50 (monohydrate and dihydrate) phosphate 10 increased at ph <5.5 0.1 Oxalate and 35 variable variable phosphate Struvite 10 increased at ph <5.5 0.20 Uric acid 8 increased at ph >6.8 0.05 Cystine 1 increased at ph >7.5 0.15 Other types 1 triamterene xanthine increased at ph >6.8 0.05 Matrix (noncrystalline)


Factors associated with urolithiasis Factor conditions of increased incidence Genetics /heredity cystinuria – autosomal recessive renal tubular acidosis type I medullary sponge kindneyGeography high temperature/humidity Diet increased intake of calcium or oxalateOccupation sedentary

Type of stone eticologic factos

Calcium oxalate supersaturation of urine with calcium Calcium phosphate from (1) renal leak ,(2) intestinal absorption, Calcium carbonate (3) bone resorption ; hyperoxalueia Uric acid hyperuricosuria , low uriea ph Cystine cystinuria Magnesium ammonium alkaline urine produced by urea-splitting phosphate (struvite) organisms Matrix alkaling urine produced by urea-splitting organisms

Types of urinary calculi and etiologic factors

Temperature PH



Epidemiology of stones : USA---- 400.000 hospitalization annually Men: Women 3:1Etiology and Pathogenesis Multifactorial processSupersaturation - Nucleation and aggregation of crystals - exmp. : Uric acid , cystine , xanthineInhibitors Pyrophosphete , Citrrate , mngnesium , zine Matrix : non crystalline mucoprotein – proteus-infection Exogenenous sutstances Indinavir – antiviral Triamterene } rudolucent stones


Stone of the upper urinary tract clinical presentation obstration : pain – Hematuria nausea , vomiting -- urine infection silent stones Diagnosis : - urine A.KUB , ULS IVP Axinlor spirel CT. Treatment 1. Conservative Treatment – Hydation Low grade obstruction Stone 4mm --- 90 % passage Stone 6mm --- 20 % passage intervention : infection high grad obstructionExpectant treatment narrowing sides


PUJ ( ureteropelvic Junction ) Pelvic brim Ureterovesical Junction Stone extraction Nepheroscopy ( PCNL ) Uretoroscopy

Shock wave hithotripsy ureterolithotomy .

Bladder Stones outlet obstruction Foreign Bodies Passed Ureter stones Clinical Presentation :Pain – Hypogastrim Referred to penis Intermittent Stream Dysuria , Hematuria

Treatment

Lithotrities (cystolitholapaxy) (Mechanical crushing devices)



Electrolaydraulic Lithotripsy uslithotripsy pneumatic lithotripsy cystolithotomy

Recurrent stone Disease predisposing factors can be identified in 80%

Cretinine

Cretinine

Etiology


Hypercalciuria Resorptive Hypercalciuria Hyperparathyroidism  50% - Ca-oxlaete Metastatic bone Multiple myeloma Immobilization ( Spinal cord injury ) Cushings disease Hyperthyroidism


Absorptive Hypercalciuria  50% Ca – Stones Exaggerated intestinal response to Dvit Renal Hypercalciuria  10% of Hypercalciuria Treatment : Hydrochlorothiazide 50 mg 1x2 potassium supplementation !

Treatment

Hydration Fluid intake > 3 L. Alkalinization - sodium Bicarbonate Potassium citrate Reduction of uric acid load 90 gr. Protien Allopurinol ( 200 – 600mg )

Hyperoxalueria

primary Hyperoxaluria  Rare autosomnl recessive disorder Treatment : 100 – 400 mg Phyricoxine Enteric Hyperoxaluria inflammatory bowel disease Small bowel bypass surgery Fatty acid  bind calcim Exogenous Hyperoxaluria ascprbic acid > 5 gr/ day .


Struvite stones ( Triple – Phosphete stones ) Composed of Mg- ammonium – Phosphat – Carbonate a patite PH markedly elerated Ammomin + bicarbonate in urine – Due to urea splitting organisms. Protius species 75% Klebsialla , pseudomonal , providencia Staphylococeus , and ureaplasma urealyticum