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 ureteral colic meaning that
there's a stone lodged in the ureter.
Now if you've ever had a
patient that's had a kidney stone,
they will say that that is one of the
worst pain they've ever had in their life.
That flank pain can oftentimes migrate
anteriorly along the abdomen to the groin
and they may have a 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 the 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 illustrat 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 a femoral and abdominal
wall hernia and those have been repaired
and also notes 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 cast or 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 the history
of hernias, a strong family history of renal disease.
It really points to a genetic diseases
like perhaps polycystic kidney disease.
She has hepatomegaly and
mild discomfort to palpation
reflecting that she may have underlying cystic disease.
And hematuria in the absence of
proteinuria points to an extraglomerular 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'd want to image this patient.
And here our result:
We image our patient with a CT scan of the abdomen
and 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 painless hematuria,
is due to a hemorrhagic cyst
from her polycystic kidney disease.
So my point is not all haematuria 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 intrarenal 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 Phenacetin or analgesic neuropathy
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 a
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 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
proteinuria or perhaps sterile pyuria.
And remember sterile pyuria 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 and you
have 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.