Urolithiasis (Urinary Stones)

Introduction and Facts

Urolithiasis is a condition in which an individual's urinary tract forms stones in the form of crystals that settle from the urine (Mehmed & Ender, 2015). Urolithiasis is a collection of urinary tract stones, but in detail, there are several mentions. The following is the term stone disease based on the location of the stone, among others: (Prabawa & Pranata, 2014):

1) Nephrolithiasis is referred to as kidney stones

2) Ureterolithiasis is called a stone in the ureter

3) Vesikolithiasis is referred to as stones in the bladder/bladder stones

4) Urethrolithiasis is referred to as stones in the urethra

Pathophysiology

Many factors cause reduced urine flow and cause obstruction, one of which is urinary stasis and decreased urine volume due to dehydration and inadequate fluid intake; this can increase the risk of urolithiasis. Low urine flow is a common abnormal symptom (Colella, et al., 2005); in addition, various conditions triggering urolithiasis, such as different stone compositions, are the main factors in identifying the cause of urolithiasis.

Risk Factor

In general, urolithiasis occurs due to various causes called risk factors. Therapy and lifestyle changes are interventions that can change risk factors, but risk factors cannot be changed.

1) Gender. Patients with urolithiasis generally occur in men 70-81% compared to women 47-60%. One of the causes is an increase in testosterone levels and a decrease in estrogen levels in men in stone formation (Vijaya, et al., 2013). ).

2) Age. Urolithiasis is more common in adults than in old age, but when compared to children, old age is more common (Portis & Sundaram, 2001).

3) Family History. Patients who have a family history of urolithiasis may help form urinary tract stones in patients (25%). This may be due to an increase in the production of mucoproteins in the kidneys or bladder, which can form crystals and form stones or calculi (Colella, 2007), et al, 2005).

4) Dietary habits and obesity. Intake of foods high in sodium, oxalate, which can be found in tea, instant coffee, soft drinks, cocoa, strawberries, citron, and green vegetables, especially spinach, can cause stones (Brunner & Suddart, 2015).

5) Environmental factors. Factors related to the environment such as geographical location and climate. Some areas show a higher incidence of urolithiasis than other areas (Purnomo, 2012).

6) Work. Work that demands to work in a high-temperature environment and limited or limited fluid intake can spur the loss of a lot of fluid and is the most significant risk in the process of stone formation because of a decrease in the amount of urine volume (Colella, et al., 2005).

7) Liquid. Fluid intake is less if < 1 liter/day; this lack of fluid intake is the leading cause of urolithiasis, especially nephrolithiasis, because this can lead to reduced urine flow/urine volume (Domingos & Serra, 2011).

Clinical Symptoms and Complications

Urolithiasis can cause various symptoms depending on the location of the stone, the level of infection, and the presence or absence of urinary tract obstruction (Brooker, 2009).

Some clinical features that can appear in urolithiasis patients:

1) Pain in the kidneys can cause two types of pain: colic and non-colic pain. Colic pain occurs due to the stagnation of stones in the urinary tract resulting in resistance and irritability in the surrounding tissue (Brooker, 2009).

2) Disorders of micturition. The presence of an obstruction in the urinary tract and the flow of urine (urine flow) has decreased, so it is challenging to void spontaneously.

3) Hematuria. Stones trapped in the ureter (ureteric colic) often experience an urgency to urinate, but only a tiny amount of urine is passed. This situation will cause friction caused by stones so that the urine excreted is mixed with blood (hematuria) (Brunner & Suddart, 2015).

4) Nausea and vomiting. This condition is a side effect of discomfort in the patient because the pain is so intense that the patient experiences high stress and stimulates HCl secretion in the stomach (Brooker, 2009).

5) Fever, occurs because of germs that spread to other places.

6) Urinary bladder distension. A high accumulation of urine that exceeds the bladder's ability will cause maximal vasodilation in the bladder. Therefore, a dam will be felt (distension) when palpated in the bladder region (Brooker, 2009).

Diagnosis

According to Brunner & Suddart, (2015) and Purnomo, (2012), the diagnosis of urolithiasis can be established through several examinations such as:

1) Blood chemistry and 24-hour urine examination to measure levels of calcium, uric acid, creatinine, sodium, pH, and total volume (Portis & Sundaram, 2001).

2) Chemical analysis is carried out to determine the composition of the rock.

3) A urine culture is performed to identify the presence of bacteria in the urine (bacteriuria) (Portis & Sundaram, 2001).

4) Plain photo of the abdomen

5) Intravenous Pyelography (IVP). IVP is the standard procedure in describing the presence of stones in the urinary tract.

6) Ultrasound (USG). Ultrasound is very limited in diagnosing stones and is the management of urolithiasis.

Management

The goals in the medical management of urolithiasis are to remove stones, determine the type of stones, prevent the destruction of the nephrons, control infection, and overcome obstructions that may occur. The treatment of urolithiasis is based upon the patient's acute presentation and includes both conservative medical therapies and surgical interventions. Often when patients present, pain control is an important intervention. Oral and IV anti-inflammatory medications (NSAIDs) are indicated as first-line treatments for pain. Nausea and vomiting should be treated with IV antiemetic medications such as ondansetron, metoclopramide, promethazine, to name a few. The use of alpha-blocker drugs such as doxazosin and tamsulosin can help pass larger stones (5-10 mm), but this drug has not been proven to be useful for passing smaller stones.

Patients presenting with large stones, or if the presentation is consistent with acute renal failure, oliguria/anuria, SIRS criteria, associated infection, or a history of the solitary kidney is present, may require urgent/emergent urologic intervention. Intractable pain or vomiting, inability to tolerate oral intake, pregnancy, or pediatric patients may require hospitalization for closer observation.

Further interventions should be discussed with urology emergently, and an appropriate plan of care should be made according to the patient's risk factors, medical history, acute presentation, and urologist's comfort and preference. There are various methods of acute urologic interventions, including extracorporeal shockwave lithotripsy (ESWL), flexible ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL).

References:

1. Urolithiasis [Internet]. Available from: http://repository.umy.ac.id/bitstream/handle/123456789/7842/6.%20BAB%20II.pdf?sequ
2. Thakore P, Liang TH. Urolithiasis. National Library of Medicine [Internet]. 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559101/