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when patients present
with nephrolithiasis there's two common
presentations that you will see
pain acute renal colic that is
unforgettable to the patient and
hematuria
blood in the urine let's talk a little
bit more about
acute renal colic it is typically
described as an abrupt onset of
intensifying pain over time
due to urethral colic meaning that
there's a stone lodged in the ureter
and if you've ever had a patient that's
had a kidney stone
they will say that that is one of the
worst pains they've ever had in their
life
that flank pain can oftentimes migrate
anteriorly
along the abdomen to the groin and they
may have
nausea emesis urinary urgency or
hematuria in association with that pain
ureteral stones in particular can mimic
things like acute cholecystitis
depending on where that stone is so they
might be having more right upper
quadrant pain or back pain
it could mimic acute appendicitis if
it's more epigastric or more in that
lower quadrant on the right
cystitis or diverticulitis are other
things that you need to think
about when it can in reality be a
ureteral stone
let's move on to a clinical case just to
illustrate a point here
a 39 year old woman presents to the
clinic with new onset gross hematuria of
one day's duration
she denies pain nausea history of trauma
no new medications including herbal
remedies
she's had a history of ephemeral and
abdominal wall hernia
and those have been repaired and also
notes a strong family history of renal
disease on her mother's side
physical exam is remarkable for a normal
blood pressure
and she has mild hepatomegaly and mild
discomfort over the bilateral upper
quadrants to deep palpation
otherwise the remainder of her exam is
unremarkable
her labs show a normal serum creatinine
and electrolytes urine analysis shows no
protein but greater than 40 red blood
cells per high power field
her microscopic exam shows no cellular
casser crystals
so what's the next step in figuring out
why this woman
is presenting with new onset gross
hematuria
let's go through our clinical case and
see if we have some diagnostic clues
she has gross hematuria taken together
with a history of
hernias a strong family history of renal
disease
that really points to a genetic disease
like perhaps polycystic kidney disease
she has apatomegaly and mild discomfort
to palpation
reflecting that she may have underlying
cystic disease
and hematuria in the absence of protein
area points to
an extra glomerular source included in
that
could be something like polycystic
kidney disease with a hemorrhagic cyst
so what's the next step that we want to
do we want to image this patient
and here's our result we image our
patient with a ct
scan of the abdomen pelvis non-contrast
and what you can see here
through this axial image of the kidneys
is
polycystic kidney disease this patient
in fact has multiple cysts
in each of her kidney taken along with
her family history
then it really indicates that this
patient has polycystic kidney disease
and the cause of her patient's painless
the cause of her painless hematuria is
due to
a hemorrhagic cyst from her polycystic
kidney disease
so my point is not all hematuria is
stones and you need to pay attention to
what's going on with your patients
so let's talk a little bit more about
hematuria so gross hematuria
is more common with larger stones that
means patients can see that with their
naked eye
it's often associated with loin pain and
ureteral colic but not always
it can be painless
so let's look more closely at some of
the causes of hematuria
there's hematuria due to glomerular
disease that's an intra-renal cause
meaning that that patient has nephritic
syndrome and those red cells typically
will have dysmorphic features meaning
that those membranes of the red blood
cells look abnormal
patients can have hematuria from having
interstitial nephritis or cystitis
they can have a congenital malformation
like medullary sponge kidney which
causes tubular ectasia
and then they can have red blood cells
as well in their urine
papillary necrosis this is something
that's been associated with phenasatin
and analgesic nephropathy as well as
sickle cell disease
trauma to the kidney things like
infection
either bladder infections with cystitis
prostatitis
acute pyelonephritis or even things like
tuberculosis and schistosomiasis if
you're in an endemic region
malignancies are also very common in
terms of causing hematuria
painless hematuria oftentimes is
described with renal cell carcinoma
we can see it certainly with
transitional cell carcinoma of the
urothelium
as well as prostate cancer in our
pediatric population wilms tumors
and of course like in our patient case
polycystic kidney disease typically from
hemorrhagic cystic disease
and finally last but not least not least
is nephrolithiasis
so other clinical manifestations of
nephrolithiasis include urinary tract
infection
a frequency or urgency to void patients
may also come in with asymptomatic urine
abnormalities meaning that they have
microscopic hematuria not visible
to the naked eye or low-grade protein
area or perhaps sterile pyria
and remember steropyria means that you
have white cells in the urine
in the absence of having bacteria
patients can also present with
obstructive uropathy or acute kidney
injury depending on where that stone is
so for example if you have a bilateral
staghorn calculi as shown in this image
here
that takes up the entire renal pelvis
and essentially obstructs outflow of
urine
or let's say you have a solitary kidney
with a calculus right at that
ureteropelvic junction
it'll obstruct outflow of urine and that
patient will present with an obstructive
uropathy and acute kidney injury
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