Urinary hesitancy

Urinary lithiasis is defined as the formation of inorganic, organic or mixed concretions called calculi in the urinary tract. Depending on where they are located in the urinary tract, the stones are named after the anatomical area in which they are found. Although the majority of stones form in the kidney, from where they migrate through the ureter to the bladder, the generic term urinary lithiasis also includes bladder, urethral and prostatic lithiasis, which are stones formed in these regions.

Epidemiology

Urinary lithiasis is one of the oldest documented human conditions, with a bladder stone found in the skeleton of a 6800-year-old Egyptian mummy.

The incidence of urinary lithiasis is between 45 and 80 per 100,000 people according to statistics, but the real figures are most likely higher. The peak incidence is between 40-65 years of age, but in recent years more and more young people are being diagnosed with lithiasis (sedentary lifestyle, fast-food, inadequate hydration, etc.). Lithiasis is more common in economically developed countries, but also in countries with warm climates.

Signs and symptoms

The clinical manifestations in which the lithiasis patient may present is very wide, ranging from asymptomatic forms, discovered during a routine ultrasound examination, to life-threatening septic states. An overwhelming number of patients present for consultation because of low back pain (most commonly caused by various pathologies of the spine), during which ultrasound examination also reveals urinary lithiasis (which is often not the real cause of the pain).

a) Lumbalgia (low back pain) - the most common resident lithiasis in the kidneys is manifested by dull, persistent, nonspecific, persistent low back pain, usually with urinary symptoms.

b) Renal colic - The migration of a stone to the ureter and obstruction of the ureter produces the most typical clinical phenomena, grouped in the renal colic syndrome.

Through the irritation produced on the ureteral mucosa, the migrating stone leads to ureteral spasm with sudden distension of the upper urinary tract and renal capsule, which generates pain. In the typical renal colic, it is lumbar, intermittent, "colicky", radiating into the flank and the iliac fossa, homolateral, along the approximate course of the ureter, towards the bladder and external genitalia, accompanied by urinary phenomena: polachiuria, alguria, bladder tenderness, hematuria, (at least microscopic) and vegetative vagal-type phenomena: nausea, vomiting, pallor. The patient is permanently agitated, almost pathognomonic, looking for an antalgic position that does not exist. The clinical examination, difficult to perform in full colic, may reveal a painful nephromegaly or tenderness of the ureteral points. The classic Giordano maneuver, used to evoke the presence of a suspected stone, has no justification in colic. The patient suffers enough without percussing his painful lumbar!

c) Other possible phenomena are infectious: urinary tract infections (urinary sediment with a mass of microbial flora and leukocytes, positive uroculture but without suggestive clinical manifestations), chronic lithiasic pyelonephritis with episodes of exacerbation, septic retention in the upper urinary tract or even septicemia.

Given the accompanying phenomena, which may mimic other diseases, and the fact that not all cases fully reproduce the described symptoms, in the differential diagnosis of renal colic should be included: acute appendicitis, penetrating crisis or perforation of gastro-duodenal ulcer, acute cholecystitis, acute pancreatitis, complicated ectopic pregnancy, adnexitis, basal pneumonia, pleurisy, acute lumbosciatica, shingles.

The diagnosis of lithiasis has the following objectives: confirmation of the presence of lithiasis, anatomical localization, functional impact on the urinary tract and subsequently the chemical composition of the lithiasis, detection of possible biochemical abnormalities.

Anamnesis

It is particularly useful; family history will be carefully followed, lithiasis demonstrating a family clustering possibly genetically dictated, but also by common dietary and lifestyle habits, and especially personal ones.

In the personal pathological history, the following should be taken into account: previous elimination of calculi, a history of recurrent urinary tract infections, colicky episodes or the concomitance of conditions favoring lithogenesis (see favoring factors), which may be suggestive for the presence of lithiasis. In the case of a lithiasis of known chemical composition, a recurrence of the same type may be presumed. IT IS VERY IMPORTANT TO PRESENT DOCUMENTS PROOF OF PREVIOUS LITHIZATION - localization, treatment, etc.

Clinical examination

With the exception of renal colic, (in which the characteristic attitude of the patient, agitated, sweating, in search of an analgesic position impossible to find) and complications of lithiasis (ureterohydronephrosis important. pionephrosis), the clinical examination brings little to the diagnosis. Palpation of a large kidney, painful ureteral points, and in women transvaginal palpation of a juxtavesical ureteral calculus are some possible clinical examination elements. The classic Giordano maneuver, i.e. the pain evoked by lumbar percussion, is particularly imprecise in "silent" lithiasis, and performing it in the midst of colic is proscribed as it resembles an act of sadism rather than a medical maneuver.

Imaging tests

The clinical examination has lost much of the importance it had in classical semiology due to the development of investigative technology, especially ultrasonography, which has become in the hands of the modern urologist an extension or even part of the clinical examination.

a) Ultrasound

Ultrasound allows to determine the presence of a renal, lumbar ureteral, juxtavesical, or bladder stone, uretero-pyelo-caliceal urinary stasis, complications such as perirenal abscess, or concomitant: renal or bladder tumors, prostatic hyperplasia, bladder diverticula and others. The ultrasonographic reflection of the stone is of "hyperechogenic image with posterior shadow cone", hardly confusable. The image resolution on modern machines allows the detection of stones of at least 3 - 4 mm, which makes the all too often used ultrasonographic diagnosis of "renal sand" dubious to say the least. In renal colic, ultrasonography detects distension of the urinary tract upstream of the obstruction (pyelocaliceal or ureteral distension).

Although it is not a functional exploration, ultrasonography can suggest data about renal functional status. Bilateral stasis suggests renal insufficiency, and hydronephrosis with parenchymal disappearance reduces the number of urographic exposures needed to assess kidney function. Ultrasonographic exploration of the contralateral kidney is also very useful. Ultrasonographic data are extremely valuable because of their accessibility, speed and accuracy, but they cannot be absolutized, but must be integrated into a cumulative exploration.

b) Radiologic examinations

Simple renal X-ray

Bearing in mind that 85-90% of calculi are radiopaque, it is of extremely high value in the diagnosis of lithiasis. It can be performed without prior preparation, even in the middle of a colic episode. Correctly positioned, it should encompass the last two pairs of ribs superiorly and the symphysis pubis inferiorly.

The most radiopaque are calcium phosphate stones. They are followed, in descending order, by calcium oxalate, magnesium ammonium phosphate, cystine (the latter are poor radiopaciform). Classically described as radiolucent are uric acid and xanthine stones. This presentation is of indicative value because most calculi have a mixed structure, and the presence of calcium salts in the structure of the calculi makes them radiopaque (x. secondary uric acid calculi impregnated with limestone, which may be radiopaque).

Differential diagnosis of opacities on plain renal X-ray should exclude: phleboli, lymph node calcifications, atheromas, costal calcifications, gallstones, etc.

Computed tomography (CT) - is a very reliable investigation that allows the detection of both radiolucent and radiopaque calculi, with sizes from 4 mm. It is, however, a costly investigation and is not routinely used in the diagnosis of lithiasis.

Laboratory tests (analysis)

In the investigation of a patient with lithiasis, the following are routinely followed: urea, creatinine, uric acid, urinalysis, serum ionogram (calcium, magnesium, phosphates) and urinalysis (calciuria, oxaluria, phosphaturia). In case of a sediment-loaded urine examination (leukocyte mass and/or microbial flora mass), uroculture will also be collected.

Treatment

- The therapeutic attitude depends on several factors: the location of the stones, their size and the type of stone (radiolucent or radiopaque).

Within our service, we can offer a wide range of treatments:

• Extracorporeal lithotripsy - a minimally invasive method that uses shock waves to fragment stones located in the pelvic or lumbar ureter or kidney, provided they are radio-opaque and no larger than 2cm in size (in the case of kidney stones)
• Semi-rigid ureteroscopy - for stones located in the ureter
• Holmium laser flexible ureteroscopy - for ureteral/ kidney stones
• Endoscopic bladder lithiasis lithotripsy

Latest medical review:

16.11.2024 – Dr. Pavel Onofrei, Medic Specialist Urologie