Urinary stone disease is a condition with far-reaching implications. Patients with their initial instance of acute renal colic enter the health care system through 2 routes. Severe cases are generally seen in the emergency room, whereas more tolerable cases may be seen by primary care physicians. Patients with urinary stone disease are then managed in the long-term by a urologist. Timely and appropriate treatment of patients with urinary stone disease is essential to prevent the development of sepsis and progressive renal insufficiency. This article reviews the epidemiology, pathogenesis, presentation, and short- and long-term management of acute and chronic urinary stone disease.
[Show abstract][Hide abstract] ABSTRACT: The management of acute renal colic is a problem commonly encountered by both urologists and emergency medicine physicians. The classic approach to managing uncomplicated acute renal colic involves hydration, along with imaging and pain control. Previous studies have suggested that hydration has a significant impact on patient comfort, as well as spontaneous stone passage. This study evaluated the effects of maintenance v forced hydration and its effect on the pain experienced from renal colic.
Forty male and 18 female patients with a mean age of 41 years suspected to have acute renal colic were identified in the emergency department. After screening and informed consent, the patients were enrolled in the study, and 43 patients were eventually available for analysis. Patients received intravenous (IV) analgesia, imaging with a noncontrast CT scan of abdomen and pelvis, and assignment to either forced IV hydration with 2 L of normal saline over 2 hours (N = 20) or minimal IV hydration at 20 mL of normal saline per hour (N = 23). A visual analog pain scale was completed hourly for a total of 4 hours. Demographic information, laboratory and imaging results, narcotic use in morphine equivalents (ME), and pain scores were recorded and compared. Spontaneous stone passage rates were also calculated by careful patient follow-up. Results were considered statistically significant at p < 0.05.
Stone size was equivalent in the two treatment groups (p > 0.05). There was no difference in the narcotic requirement in ME (p = 0.644) between the two groups. Similarly, there was no difference in hourly pain score or stone-passage rates between the groups (p > 0.05).
Treatment of uncomplicated renal colic has traditionally included vigorous intravenous hydration, as well as medications for the control of pain and nausea. Our data suggest that maintenance intravenous fluids are as efficacious as forced hydration with regard to patient pain perception and narcotic use. Moreover, it appears the state of hydration has little impact on stone passage.
Journal of Endourology 11/2006; 20(10):713-6. DOI:10.1089/end.2006.20.713 · 1.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 1. Is this nephrolithiasis? Severe, acute flank pain points to an obstructive renal or ureteric stone, which can often be suspected based on clinical presentation. The classic presentation of nephrolithiasis includes acute, colicky, ipsi-lateral, costovertebral, or flank pain, which may radiate to the groin. Dysuria and uri-nary urgency and frequency are common, as are nausea and vomiting; however, patients may appear relatively asympto-matic depending on the size and location of the stone. The risk of kidney stones is increased by male gender, caucasian ances-try, a previous history of kidney stones, a positive family history, a high fat, protein, or salt diet, obesity, and dehydration. 2. Could it be something else? While Jeri presented with a fairly typical picture of nephrolithiasis, it is important to rule out several other conditions that account for up to 20% of renal colic-like presentations. 1 Jeri is a healthy 59-year-old female who presents to the ED with a one-hour-history of right flank pain that has begun to radiate to her groin. She describes the pain as a steady burning feeling with episodes of more intense, radiating pain. She finds it hard to get in a comfortable position due to the pain. She also feels like she needs to constantly void, though she is not passing much urine. She has nausea but no fever/chills or diarrhea. She has never had an episode of pain like this before. Her brother has a history of kidney stones. Upon examination, Jeri looks well but is in severe discomfort. She is pale and sweaty and begins to vomit. Her abdomen is soft and non-tender with quiet bowel sounds, although her right flank and costovertebral angle are quite tender to palpation.
[Show abstract][Hide abstract] ABSTRACT: To examine the relationship between GFR and 24-hour urine composition in patients with nephrolithiasis to understand how renal function may affect stone risk. Alterations in glomerular filtration rate (GFR) are associated with a number of physiological changes.
A retrospective, institutional review board-approved review of patients from 2 metabolic stone clinics was performed. One-way analysis of variance and multivariate linear regression models were used to evaluate the relationship between GFR quintile and 24-hour urine composition.
A total of 403 patients (241 male, 162 female) with a mean age of 52.6 ± 14.2 years were included in the study. On univariate analysis, decreasing GFR by quintile was associated with significant reductions in urine calcium, citrate, supersaturation of calcium oxalate, and supersaturation of calcium phosphate (P < .05 for each). In multivariate linear regression models, decreasing GFR by quintile was associated with significant decreases in urine calcium (β = -11.2, 95% CI = -18.3 to 4.01), urine citrate (β = -32.4, 95% CI = -54.1 to 10.8), oxalate (β = -1.83, 95% CI = -2.85 to 0.81), supersaturation of calcium oxalate (β = -0.58, 95% CI = 0.84 to 0.33) and supersaturation of calcium phosphate (β = -0.09, 95% CI = 0.17 to 0.02), as well as an increase in urine magnesium (β = 3.40, 95% CI = 0.7 to 6.1).
Reduction in GFR is associated with decreased urine calcium, oxalate, and citrate, and increased urine magnesium. These findings have implications for treatment of patients with stone disease and impaired renal function.
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