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'''See [[AUA: Evaluation and Medical Management of Stones (2019)|2019 AUA Evaluation and Medical Management of Stones]] Guideline Notes'''
'''See [[AUA: Evaluation and Medical Management of Stones (2019)|2019 AUA Evaluation and Medical Management of Stones]] Guideline Notes'''


== Diagnosis and Evaluation ==
== Imaging for Stone Disease ==
 
=== Plain abdominal film ===
* Can identify nephrocalcinosis, suggestive of RTA
* '''Radiolucent stones (6):'''
** '''Uric acid'''
** '''Matrix'''
** '''Medication stones (xanthine, triamterene, 2,8-dihydroxyadenine, indivir)'''
* '''Radioopaque stones: calcium oxalate, calcium phosphate, magnesium ammonium phosphate (struvite) and cystine stones'''
** '''Although magnesium ammonium phosphate and cystine stones are often radioopaque, they are not as dense as calcium oxalate or calcium phosphate stones'''
** Campbell’s says '''cystine stones''' radioopaque but other source (<nowiki>https://radiopaedia.org/articles/urolithiasis</nowiki>) says usually radiolucent. European Guidelines say they '''are''' '''poorly radioopaque'''§
* Underestimates >90% of stones >10mm
 
=== Ultrasound ===
* '''Limitations (2):'''
** '''Inability to visualize most ureteral stones'''
** '''Poor correlation between measured and actual stone size and location'''
*** '''US and CT measurements correlate 2/3 of the time'''
**** '''With stone <10mm, US underestimates size of stone 1/3 of the time'''
**** '''With stone >10mm, US overestimates size of stone 1/3 of the time'''
 
=== '''CT''' ===
* '''Pure uric acid stones have much lower Hounsfield units than calcium types'''
 
* '''Forniceal extravasation'''
** Usually associated with a small distal ureteral calculus.
** '''Should be similarly to other ureteral stones:''' intervention should be undertaken when there is an associated fever, nausea/vomiting, or unrelenting pain. Otherwise, conservative observation is appropriate.
 
== Diagnosis and Evaluation of Stone Disease ==


* Any evaluation for recurrent stone disease should be able to identify associated metabolic disorders such as distal renal tubular acidosis (RTA), primary hyperparathyroidism, enteric hyperoxaluria, cystinuria, and gouty diathesis
* Any evaluation for recurrent stone disease should be able to identify associated metabolic disorders such as distal renal tubular acidosis (RTA), primary hyperparathyroidism, enteric hyperoxaluria, cystinuria, and gouty diathesis
* First-time stone formers have been estimated to have a 50% risk for recurrence within the subsequent 10 years
*First-time stone formers have been estimated to have a 50% risk for recurrence within the subsequent 10 years
** Patients at higher risk for repeat episodes:
** Patients at higher risk for repeat episodes:
*** Family history of stones
*** Family history of stones
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*** UTI
*** UTI
*** Gout
*** Gout
* Indications for a metabolic stone evaluation
 
*# Recurrent stone formers
=== UrologySchool.com Summary ===
*# Strong family history of stones
* Screening evaluation
*# Intestinal disease
**
*# Pathological skeletal fractures
*Extended metabolic testing
*# Osteoporosis
*'''Abbreviated protocol for low-risk single-stone formers'''
*# History of UTI with calculi
*# Personal history of gout
*# Infirm health (unable to tolerate repeat stone episodes)
*# Solitary kidney
*# Anatomic abnormalities
*# Stones composed of cystine, uric acid, and struvite
*# Children should generally be evaluated because of concerns about renal damage and long-term sequelae of stone recurrence
* Abbreviated protocol for low-risk single-stone formers
** History
** History
*** Screen for factors that predispose to calculi
*** Screen for factors that predispose to calculi
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***** Half of infected calculi grow bacterial cultures that are different from the preoperative urine specimen
***** Half of infected calculi grow bacterial cultures that are different from the preoperative urine specimen
*** Urine microscopy for crystals may provide clues to diagnosis
*** Urine microscopy for crystals may provide clues to diagnosis
 
****Insert urine microscopy table
 
***Stone composition, if available
Insert table
****Can direct metabolic investigation or potentially obviate the need for a complete metabolic evaluation
 
** '''Imaging'''
*** '''Plain abdominal film'''
**** Can identify nephrocalcinosis, suggestive of RTA
**** '''Radiolucent stones (6):'''
***** '''Uric acid'''
***** '''Matrix'''
***** '''Medication stones (xanthine, triamterene, 2,8-dihydroxyadenine, indivir)'''
**** '''Radioopaque stones: calcium oxalate, calcium phosphate, magnesium ammonium phosphate (struvite) and cystine stones'''
***** '''Although magnesium ammonium phosphate and cystine stones are often radioopaque, they are not as dense as calcium oxalate or calcium phosphate stones'''
***** Campbell’s says '''cystine stones''' radioopaque but other source (<nowiki>https://radiopaedia.org/articles/urolithiasis</nowiki>) says usually radiolucent. European Guidelines say they '''are''' '''poorly radioopaque'''§
**** Underestimates >90% of stones >10mm
*** '''Ultrasound'''
**** '''Limitations (2):'''
***** '''Inability to visualize most ureteral stones'''
***** '''Poor correlation between measured and actual stone size and location'''
****** '''US and CT measurements correlate 2/3 of the time'''
******* '''With stone <10mm, US underestimates size of stone 1/3 of the time'''
******* '''With stone >10mm, US overestimates size of stone 1/3 of the time'''
*** '''CT'''
**** '''Pure uric acid stones have much lower Hounsfield units than calcium types'''
*** '''Forniceal extravasation'''
**** Usually associated with a small distal ureteral calculus.
**** '''Should be similarly to other ureteral stones:''' intervention should be undertaken when there is an associated fever, nausea/vomiting, or unrelenting pain. Otherwise, conservative observation is appropriate.
** '''Stone composition'''
*** Can direct metabolic investigation or potentially obviate the need for a complete metabolic evaluation


* '''Extensive diagnostic evaluation'''
* '''Extensive diagnostic evaluation'''
** Includes one or two 24-hour urine collections
** Includes one or two 24-hour urine collections
**Indications for a metabolic stone evaluation
**# Recurrent stone formers
**# Strong family history of stones
**# Intestinal disease
**# Pathological skeletal fractures
**# Osteoporosis
**# History of UTI with calculi
**# Personal history of gout
**# Infirm health (unable to tolerate repeat stone episodes)
**# Solitary kidney
**# Anatomic abnormalities
**# Stones composed of cystine, uric acid, and struvite
**# Children should generally be evaluated because of concerns about renal damage and long-term sequelae of stone recurrence
** '''Significant aberrations in total creatinine excretion from estimated volumes (males 20-25mg/kg and females 15-20mg/kg in 24 hours) imply incomplete collection, overcollection, greater than expected muscle mass, or less than expected muscle mass'''
** '''Significant aberrations in total creatinine excretion from estimated volumes (males 20-25mg/kg and females 15-20mg/kg in 24 hours) imply incomplete collection, overcollection, greater than expected muscle mass, or less than expected muscle mass'''
*** For abnormally collected 24 hour urine collections, can divide metabolite excretion by creatinine excretion to compare collections
*** For abnormally collected 24 hour urine collections, can divide metabolite excretion by creatinine excretion to compare collections
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*** Sulfate is added to assess the volume of protein loading from animal meat.
*** Sulfate is added to assess the volume of protein loading from animal meat.


Renal colic pain management[https://smhs.gwu.edu/urgentmatters/content/alternatives-opioids-pain-management-ed]
== Acute management ==


* Toradol 30 mg IV
* Renal colic pain management[https://smhs.gwu.edu/urgentmatters/content/alternatives-opioids-pain-management-ed]
* Cardiac Lidocaine 1.5 mg/kg IV in 100 mL NS over 10 minutes (MAX 200 mg)
** Toradol 30 mg IV
* Acetaminophen 1000 mg PO
** Cardiac Lidocaine 1.5 mg/kg IV in 100 mL NS over 10 minutes (MAX 200 mg)
* 1 L 0.9% NS bolus
** Acetaminophen 1000 mg PO
** 1 L 0.9% NS bolus


===== '''Conservative management''' =====
== Conservative management ==


* '''Fluid recommendations'''
* '''Fluid recommendations'''
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*** Follow-up is essential not only to monitor the efficiency of treatment but also to encourage patient compliance. If, however, a metabolic defect persists, a more selective medical therapy may be instituted.
*** Follow-up is essential not only to monitor the efficiency of treatment but also to encourage patient compliance. If, however, a metabolic defect persists, a more selective medical therapy may be instituted.


===== '''Selective medical therapy for nephrolithiasis''' =====
== Selective medical therapy for nephrolithiasis ==


* See Tables 52-9 and 52-10 for dosages and side effects
* See Tables 52-9 and 52-10 for dosages and side effects
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