Urolithiasis

Background

Type

1. Calcium 75%
   1. hyperparathyroidism, hypercalcemia of malignancy, sarcoidosis, increased absorption from gut; thiazide diuretics; topiramate, protease inhibitors (indinavir or sulfadiazine)
2. Struvite 15%
   1. Proteus, Klebsiella, Pseudomonas, Staphylococcus
3. Uric Acid 6%

Pass Rates

Size

• 4mm ~75%
• 4-6mm ~50%
• >6mm ~10%

Location in Ureter

1. Distal ~70%
2. Middle ~50%
3. Proximal ~20%

DDx

1. Cholelithiasis (5%)
2. Appy (4%)
3. Pyelonephitis (3%)
4. Ovarian cyst (2%)
5. Renal mass (1.4%)
6. AAA w/or w/o rupture (1.4%)
   

Treatment

1. ED
   1. Toradol IV
   2. Morphine IV
2. Outpt
   1. NSAIDS PO
   2. Vicodin PO
   3. Smooth muscle relaxant (alpha-adrenergic blocker)
      1. Tamsulosin (Flomax) 0.4mg PO QHS x 21 days, OR
      2. Terazosin (Hytrin) 1mg PO QHS x 21 days

^IVF of no benefit in acute setting

Surgical Treatment

Persistent obstruction, failure of stone progression, or increasing or unremitting colic

Shock wave lithotripsy, ureteroscopy, or percutaneous nephrolithotomy

Disposition

Admit for:

1. Intractable pain (on orals)
2. Solitary or transplanted kidney
3. Presence of urinary tract infection (UTI), fever, sepsis, or pyonephrosis

Prognosis

Recurrence Rates

1 yr ~33%

5yr ~50%

1. Increasing H2O intake decreases rate
2. Protease inhibitors and diuretics increases rate

Source

10/07 DONALDSON (adapted from Tintinalli)