546 UNIT VIII RENAL AND UROLOGICAL DISORDERS
vary in intensity. This type of pain is often associated with increased intake of fluids that distends the calyx. Because of the intensity of the pain, the patient often presents with cool, clammy skin; nausea; and vomit- ing. Hematuria is noted because of damage caused by obstruction or movement of the stone.
CLINICAL CONCEPT Flank pain with radiation into the groin, hematuria, and crystalluria are classic signs of nephrolithiasis.
Diagnosis The clinical presentation may be similar with vary- ing types of stones; therefore, a definitive diagnosis requires stone analysis. The patient should strain their urine during the course of passing the stone. Kidney stones can vary from the size of the head of a pin to the size of a piece of gravel or larger (see Fig. 22-12). Serum electrolytes, creatinine, calcium, and uric acid should be measured in the blood. Routine urinanal- yses are conducted, along with analysis of any stone fragments. Urinalysis is done to check for key signs of nephrolithiasis or urolithiasis (stone in the ureter): hematuria, infection, and crystalluria. Two collections of 24-hour urine that analyzes volume, calcium oxa- late, citrate, uric acid, sodium, potassium, phosphorus, pH and creatinine are recommended. Serum PTH level and vitamin D levels should be measured if there are high urine calcium levels. The gold standard diagnos- tic test is a helical noncontrast CT scan. Renal ultra- sound is also useful as an alternative imaging study. Treatment The approach to definitive treatment is based upon symptom management, as well as the type and com- position of the renal calculi. Pain relief is a priority because of the excruciating nature of the pain that interferes with activities of daily living. Antibiotics may be necessary if UTI is present. Most renal stones
FIGURE 22-10. X-ray showing swelling of the renal pelvis termed hydronephrosis. It can develop in cases of severe obstruction of urine outflow. (From Living Art Enterprises, LLC/Science Source.)
causes compression of the kidney tissue, ischemia, and irreversible kidney damage. Clinical Presentation Pain is the major symptom of nephrolithiasis. The pain is described as renal or ureteral colic because it occurs in waves. It is also described as acute, excruciating pain in the flank and upper outer quadrant of the abdomen on the affected side, and it is often accompanied by radiating pain into the lower abdomen and groin (see Fig. 22-11). The patient is commonly bent over. They may writhe in pain or pace in an attempt to change their position to try to find one that is comfortable. Pain related to distention of the renal pelvis and calyx causes a dull, deep ache in the flank or back that may
FIGURE 22-11. Pain of nephrolithiasis usually begins in the costovertebral angle region of the back and radiates around into the abdomen and down into the groin.
FIGURE 22-12. Kidney stone. (From Southern Illinois University/Science Source.)
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