Nephrolithiasis Clinical Presentation

  • Author: J Stuart Wolf Jr, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS   more...
 
Updated: Jan 23, 2012
 

History

Patients with urinary calculi may report pain, infection, or hematuria. Small nonobstructing stones in the kidneys only occasionally cause symptoms. If present, symptoms are usually moderate and easily controlled. The passage of stones into the ureter with subsequent acute obstruction, proximal urinary tract dilation, and spasm is associated with classic renal colic.

Acute onset of severe flank pain radiating to the groin, gross or microscopic hematuria, nausea, and vomiting not associated with an acute abdomen are symptoms that most likely indicate renal colic caused by an acute ureteral or renal pelvic obstruction from a calculus. Renal colic pain rarely, if ever, occurs without obstruction.

Patients with large renal stones known as staghorn calculi (see the image below) are often relatively asymptomatic. The term "staghorn" refers to the presence of a branched kidney stone occupying the renal pelvis and at least one calyceal system. Such calculi usually manifest as infection and hematuria rather than as acute pain.

Complete staghorn calculus that fills the collectiComplete staghorn calculus that fills the collecting system of the kidney (no intravenous contrast material in this patient). Although many staghorn calculi are struvite (related to infection with urease-splitting bacteria), the density of this stone suggests that it may be metabolic in origin and is likely composed of calcium oxalate. Percutaneous nephrostolithotomy or perhaps even open surgical nephrolithotomy is required to remove this stone.

Asymptomatic bilateral obstruction, which is uncommon, manifests as symptoms of renal failure.

Important historical features are as follows:

  • Duration, characteristics, and location of pain
  • History of urinary calculi
  • Prior complications related to stone manipulation
  • Urinary tract infections
  • Loss of renal function
  • Family history of calculi
  • Solitary or transplanted kidney
  • Chemical composition of previously passed stones

Location and characteristics of pain

Most calculi originate within the kidney and proceed distally, creating various degrees of urinary obstruction as they become lodged in narrow areas, including the ureteropelvic junction, pelvic brim, and ureterovesical junction. Location and quality of pain are related to position of the stone within the urinary tract. Severity of pain is related to the degree of obstruction, presence of ureteral spasm, and presence of any associated infection.

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin, due to distention of the renal capsule. Stones impacted within the ureter cause abrupt, severe, colicky pain in the flank and ipsilateral lower abdomen with radiation to the testicles or the vulvar area. Intense nausea, with or without vomiting, usually is present.

Pain from upper ureteral stones tends to radiate to the flank and lumbar areas. On the right side, this can be confused with cholecystitis or cholelithiasis; on the left, the differential diagnoses include acute pancreatitis, peptic ulcer disease, and gastritis.

Midureteral calculi cause pain that radiates anteriorly and caudally. This midureteral pain in particular can easily mimic appendicitis on the right or acute diverticulitis on the left.

Distal ureteral stones cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female because the pain is referred from the ilioinguinal or genitofemoral nerves.

Stones lodged at the ureterovesical junction also may cause irritative voiding symptoms, such as urinary frequency and dysuria. If a stone is lodged in the intramural ureter, symptoms may appear similar to cystitis or urethritis. These symptoms include suprapubic pain, urinary frequency, urgency, dysuria, stranguria, pain at the tip of the penis, and sometimes various bowel symptoms, such as diarrhea and tenesmus. These symptoms can be confused with pelvic inflammatory disease, ovarian cyst rupture, or torsion and menstrual pain in women.

Calculi that have entered the bladder are usually asymptomatic and are passed relatively easily during urination. Rarely, a patient reports positional urinary retention (obstruction precipitated by standing, relieved by recumbency), which is due to the ball-valve effect of a large stone located at the bladder outlet.

Phases of acute renal colic attack

The actual pain attack tends to occur in somewhat predictable phases, with the pain reaching its peak in most patients within 2 hours of onset. The pain roughly follows the dermatomes of T-10 to S-4. The entire process typically lasts 3-18 hours. Renal colic has been described as having 3 clinical phases.

The first phase is the acute or onset phase.The typical attack starts early in the morning or at night, waking the patient from sleep. When it begins during the day, it tends to start slowly and insidiously. The pain is usually steady, increasingly severe, and continuous, sometimes punctuated by intermittent paroxysms of even more excruciating pain. The pain may increase to maximum intensity in as little as 30 minutes after onset or may take up to 6 hours or longer to peak. The typical patient reaches maximum pain 1-2 hours after the start of the renal colic attack.

The second phase is the constant phase. Once the pain reaches maximum intensity, it tends to remain constant until it is either treated or allowed to diminish spontaneously. The period of sustained maximal pain is called the constant phase of the renal colic attack. This phase usually lasts 1-4 hours but can persist longer than 12 hours in some cases. Most patients arrive in the ED during this phase of the attack.

The third phase is the abatement or relief phase.During this final phase, the pain diminishes fairly quickly, and patients finally feel relief. Relief can occur spontaneously at any time after the initial onset of the colic. Patients may fall asleep, especially if they have been administered strong analgesic medication. Upon awakening, the patient notices that the pain has disappeared. This final phase of the attack most commonly lasts 1.5-3 hours.

Other symptoms

Nausea and vomiting occur in at least 50% of patients with acute renal colic. Nausea is caused by the common innervation pathway of the renal pelvis, stomach, and intestines through the celiac axis and vagal nerve afferents. This is often compounded by the effects of narcotic analgesics, which often induce nausea and vomiting through a direct effect on gastrointestinal (GI) motility and an indirect effect on the chemoreceptor trigger zone in the medulla oblongata. Nonsteroidal anti-inflammatory drugs (NSAIDs) can often cause gastric irritation and GI upset.

The presence of a renal or ureteral calculus is not a guarantee that the patient does not have some other, unrelated medical problem causing the GI symptoms.

In some cases, a stone may pass before the definitive imaging procedure has been completed. In these cases, residual inflammation and edema still may cause some transient or diminishing obstruction and pain even without any stone being positively identified.

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Physical Examination

The classic presentation for a patient with acute renal colic is the sudden onset of severe pain originating in the flank and radiating inferiorly and anteriorly. The pain is usually, but not always, associated with microscopic hematuria, nausea, and vomiting. Dramatic costovertebral angle tenderness is common; this pain can move to the upper or lower abdominal quadrant as a ureteral stone migrates distally. However, the rest of the examination findings are often unremarkable.

Abdominal examination usually is unremarkable. Bowel sounds may be hypoactive, a reflection of mild ileus, which is not uncommon in patients with severe, acute pain. Peritoneal signs are usually absent—an important consideration in distinguishing renal colic from other sources of flank or abdominal pain. Testicles may be painful but should not be very tender and should appear normal.

Unlike patients with an acute abdomen, who usually try to lie absolutely still, patients with renal colic tend to move constantly, seeking a more comfortable position. (However, patients with pyonephrosis also tend to remain motionless.) The classic patient with renal colic is writhing in pain, pacing about, and unable to lie still, in contrast to a patient with peritoneal irritation, who remains motionless to minimize discomfort.

Findings should correlate with the reports of pain, so that complicating factors (eg, urinary extravasation, abscess formation) can be detected. Beyond this, the specific location of tenderness does not always correlate with the exact location of the stone, although the calculus is often in the general area of maximum discomfort.

Approximately 85% of all patients with renal colic demonstrate at least microscopic hematuria, which means that 15% of all patients with kidney stones do not have hematuria. Lack of hematuria alone does not exclude the diagnosis of acute renal colic. Tachycardia and hypertension are relatively common in these cases, even in patients with no prior personal history of abnormal cardiac or blood pressure problems.

Fever is not part of the presentation of uncomplicated nephrolithiasis. The presence of pyuria, fever, leukocytosis, or bacteriuria suggests the possibility of a urinary infection and the potential for an infected obstructed renal unit or pyonephrosis. Such a condition is potentially life threatening and should be treated as a surgical emergency.

In patients older than 60 years presenting with severe abdominal pain and with no prior history of renal stones, look carefully for physical signs of abdominal aortic aneurysm (AAA) (see Abdominal Aortic Aneurysm).

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Complications

The morbidity of urinary tract calculi is primarily due to obstruction with its associated pain, although nonobstructing calculi can still produce considerable discomfort. Conversely, patients with obstructing calculi may be asymptomatic, which is the usual scenario in patients who experience loss of renal function due to chronic untreated obstruction. Stone-induced hematuria is frightening to the patient but is rarely dangerous by itself.

Serious complications of urinary tract stone disease include the following:

  • Abscess formation
  • Serious infection of the kidney that diminishes renal function
  • Urinary fistula formation
  • Ureteral scarring and stenosis
  • Ureteral perforation
  • Extravasation
  • Urosepsis
  • Renal loss due to long-standing obstruction

Infected hydronephrosis is the most deadly complication because the presence of infection adjacent to the highly vascular renal parenchyma places the patient at risk for rapidly progressive sepsis and death.

A ureteral stone associated with obstruction and upper UTI is a true urologic emergency. Complications include perinephric abscess, urosepsis, and death. Immediate involvement of the urologist is essential.

Calyceal rupture with perinephric urine extravasation due to high intracaliceal pressures occasionally is seen and usually is treated conservatively.

Complete ureteral obstruction may occur in patients with tightly impacted stones. This is best diagnosed via IVP and is not discernible on noncontrast CT scan. Patients with 2 healthy kidneys can tolerate several days of complete unilateral ureteral obstruction without long-term effects on the obstructed kidney. If a patient with complete obstruction is well hydrated and pain and vomiting are well controlled, the patient can be discharged from the ED with urologic follow-up within 1-2 days.

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Contributor Information and Disclosures
Author

J Stuart Wolf Jr, MD, FACS  The David A Bloom Professor of Urology, Director, Division of Endourology and Stone Disease, Department of Urology, University of Michigan Medical School

J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology

Disclosure: Nothing to disclose.

Coauthor(s)

David S Howes, MD  Professor of Medicine and Pediatrics, Emergency Medicine Residency Program Director Emeritus, Head, Phemister Society, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

David S Howes, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Sandy Craig, MD  Residency Program Director, Carolinas Medical Center; Associate Professor, Department of Emergency Medicine, University of North Carolina at Chapel Hill School of Medicine

Sandy Craig, MD is a member of the following medical societies: Alpha Omega Alpha and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Stephen W Leslie, MD, FACS  Founder and Medical Director, Lorain Kidney Stone Research Center; Associate Professor of Surgery at Creighton University School of Medicine, Chief of Urology at Creighton University Medical Center

Stephen W Leslie, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, National Kidney Foundation, and Ohio State Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard H Sinert, DO  Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robert E O'Connor, MD, MPH  Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Edward David Kim, MD, FACS  Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Sexual Medicine Society of North America, and Tennessee Medical Association

Disclosure: Lilly Consulting fee Advisor; Astellas Consulting fee Speaking and teaching; Watson Consulting fee Speaking and teaching; Allergan Consulting fee Speaking and teaching

Chief Editor

Bradley Fields Schwartz, DO, FACS  Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists

Disclosure: Nothing to disclose.

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Small renal calculus that would likely respond to extracorporeal shockwave lithotripsy.
Complete staghorn calculus that fills the collecting system of the kidney (no intravenous contrast material in this patient). Although many staghorn calculi are struvite (related to infection with urease-splitting bacteria), the density of this stone suggests that it may be metabolic in origin and is likely composed of calcium oxalate. Percutaneous nephrostolithotomy or perhaps even open surgical nephrolithotomy is required to remove this stone.
Distal ureteral stone observed through a small, rigid ureteroscope prior to ballistic lithotripsy and extraction. The small caliber and excellent optics of today's endoscopes greatly facilitate minimally invasive treatment of urinary stones.
Two calculi in a dependent calyx of the kidney (lower pole) visualized through a flexible fiberoptic ureteroscope. In another location, these calculi might have been treated with extracorporeal shockwave lithotripsy (ESWL), but, after being counseled regarding the lower success rate of ESWL for stones in a dependent location, the patient elected ureteroscopy. Note that the image provided by fiberoptics, although still acceptable, is inferior to that provided by the rod-lens optics of the rigid ureteroscope in the previous picture.
Nephrolithiasis: acute renal colic. Anatomy of the ureter.
Nephrolithiasis: acute renal colic. Distribution of nerves in the flank.
Nephrolithiasis: acute renal colic. Nerve supply of the kidney.
Nephrolithiasis: acute renal colic. Renal colic and flank pain.
Nephrolithiasis: acute renal colic. Nerve supply of the kidney.
Nephrolithiasis: acute renal colic. Distribution of renal and ureteral pain.
Noncontrast helical CT scan of the abdomen demonstrating a stone at the right ureterovesical junction.
Intravenous pyelogram (IVP) demonstrating dilation of the right renal collecting system and right ureter consistent with right ureterovesical stone.
Renal sonogram showing a dilated renal collecting system consistent with ureteral obstruction.
Transabdominal sonogram revealing a ureteral stone at the ureterovesical junction.
Table. Intravenous Pyelography Versus CT Scanning: Which Is Better?
Imaging Study (Pro/Con) Details
CT scanPro
  • Fast
  • No IV contrast necessary, so no risk of nephrotoxicity or acute allergic reactions
  • With only rare exceptions, shows all stones clearly
  • May demonstrate other pathology
  • Can be performed in patients with significant azotemia and severe contrast allergies who cannot tolerate IV contrast studies
  • Clearly shows uric acid stones
  • Shows perinephric stranding or streaking not visible on IVP and can be used as an indirect or secondary sign of ureteral obstruction
  • No radiologist needs to be physically present
  • Preferred imaging modality for acute renal colic in most EDs
Con
  • Without hydronephrosis, cannot reliably distinguish between distal ureteral stones and pelvic calcifications or phleboliths
  • Cannot assess renal function
  • No nephrogram effect study to help identify obstruction
  • Size and shape of stone only estimated
  • Lacks surgical orientation*
  • Unable to identify ureteral kinks, strictures, or tortuousities
  • May be hard to differentiate an extrarenal pelvis from true hydronephrosis
  • Gonadal vein sometimes can be confused with the ureter
  • Does not indicate likelihood of fluoroscopic visualization of the stone, which is essential information in planning possible surgical interventions
  • May require addition of KUB radiograph†
  • Cannot be performed during pregnancy because of high dose of ionizing radiation exposure
  • Usually more costly than an IVP in most institutions
  • Higher radiation dose than IVP
IVPPro
  • Clear outline of complete urinary system without any gaps
  • Clearly shows all stones either directly or indirectly as an obstruction
  • Nephrogram effect film indicates obstruction and ureteral blockage in most cases, even if the stone itself might not be visible
  • Shows relative kidney function
  • Definitive diagnosis of MSK
  • Ureteral kinks, strictures, and tortuousities often visible
  • Can modify study with extra views (eg, posterior oblique positions, prone views) to better visualize questionable areas
  • Stone size, shape, surgical orientation, and relative position more clearly defined
  • Orientation similar to urologists’ surgical approach
  • Limited IVP study can be considered in selected cases during pregnancy, although plain ultrasonography is preferred initially
  • Lower cost than CT scan in most institutions
  • Includes KUB film automatically
Con
  • Relatively slow; may need multiple delay films, which can take hours
  • Cannot be used in azotemia, pregnancy, or known significant allergy to intravenous contrast agents
  • Risk of potentially dangerous reactions to IV contrast material‡
  • Cannot detect perinephric stranding or streaking, which is visible only on CT scans
  • Harder to visualize radiolucent stones (eg, uric acid), although indirect signs of obstruction are apparent
  • Presence of a radiologist generally necessary, which can cause extra delay
  • Cannot be used to reliably evaluate other potential pathologies
*Many urologists find CT scans inadequate to help plan surgery, predict stone passage, or monitor patients.† This causes a delay, which may be significant in some institutions, and adds additional patient radiograph exposure and cost.‡ These include significant allergic responses and renal failure.
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