Urinary Stone Disease & Hematuria, What You Need to KnowNATHALY FRANÇOIS, MDMERCY UROLOGY CLINIC

MERCYCARE CME DAYSEPTEMBER 21, 2019

Objectives

- Discuss general information re: urinary stone disease & hematuria, that may help providers to manage patient expectations.

- Review recommended initial workup to help allow for efficient office visit with urologist.

URINARY STONE DISEASE:Introduction

-Urinary stones affect up to 8.8% of the US population.-10.6% of men-7.1% of women

-Incidence of stone disease is increasing.-greatest incidence in Southeastern and South Central US, the “Stone Belt,” which likely reflects hot weather climate and relative dehydration that occurs

-Overall mortality from stone disease is rare, but significant rate of renal deterioration (28%) with certain types of urinary stones.

https://www.auanet.org/education/auauniversity/for-medical-students/medical-students-curriculum/medical-student-curriculum/kidney-stones

URINARY STONE DISEASE:Introduction

-Stone composition, in decreasing frequency:-Ca oxalate, uric acid, struvite/infection, Ca phosphate, cystine-less common are drug-related and xanthine stones

-Calculi generally form due to too high amounts of typically soluble urinary chemicals that cannot stay dissolved.

Ca ox monohydrate

uric acid

Ca ox dihydrate

struvite/infection

cystine

URINARY STONE DISEASE:Risk Factors

-Urinary obstruction leading to renal stasis-Urine composition, i.e. pH, hyperCa-uria, hypocitraturia, hyperOx-uria-Poor dietary fluid intake

-Dietary factors, i.e. high sodium intake, low fiber, high oxalate, carbonated drinks with phosphoric acid (dark sodas)-HypoK+ –- intracellular acidosis promotes stone formation-Chronic diseases, i.e. obesity, DM, gout, sarcoidosis, IBD, 1-ary hyperPTH

-Recurrent UTIs-Medications, i.e. Topiramate, Indinavir, vitamin C, Furosemide, …

https://www.auanet.org/education/auauniversity/for-medical-students/medical-students-curriculum/medical-student-curriculum/kidney-stones

URINARY STONE DISEASE:DDx of Acute Renal Colic in Adult

-Renal or ureteral stone-Hydronephrosis (may be 2nd-ary to UPJ obstruction, ureteral stricture, …)-Bacterial cystitis or pyelonephritis-Lobar pneumonia-Rib fractures-Acute abdomen-GYN-related (i.e. ovarian cyst torsion or rupture, ectopic pregnancy)-Referred pain (i.e. orchitis)-Radicular pain (i.e. sciatica)

https://www.auanet.org/education/auauniversity/for-medical-students/medical-students-curriculum/medical-student-curriculum/kidney-stones

URINARY STONE DISEASE:Initial Evaluation

-GOLD STANDARD for suspected urinary stone in patient with acute renal colic/flank pain: non-contrast CT abdomen/pelvis.

-Contrast CT a/p – only if medication metabolite stones suspected, i.e. HIV patients on Indinavir.

-KUB – may be useful, as long as stone is radio-opaque.-more useful in following stones, less helpful for acute stones-may miss stones <4-5mm-struvite and cystine stones poorly seen; uric acid and matrix stones not seen

-Renal u/s – option for initial assessment of possible hydro, which may then prompt non-con CT scan.

URINARY STONE DISEASE:In PREGNANCY

ACOG’s recommendation:-”With few exceptions, radiation exposure through radiography, computed tomography (CT) scan, or nuclear medicine imaging techniques is at a dose much lower than the exposure associated with fetal harm. If these techniques are necessary in addition to ultrasonography or MRI or are more readily available for the diagnosis in question, they should not be withheld from a pregnant patient.”

-“Use of CT and associated contrast material should not be withheld if clinically indicated, but a thorough discussion of risks and benefits should take place.”https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Guidelines-for-Diagnostic-Imaging-During-Pregnancy-and-Lactation?IsMobileSet=false

***low-dose CT stone study is an option***

URINARY STONE DISEASE:Necessary Workup

-Midstream clean catch, or catheterized, urine for analysis & microscopy-urine culture as indicated -RECOMMENDED, as UA not always suspicious when the urine is infected-advise patients UCx may take up to 48h to finalize-AVOID ABx for > 3dd if urine suspicious, unless necessary pending FINAL urine c/s

-CBC

-Creatinine – elevated from patient’s baseline?

URINARY STONE DISEASE:Indications for Urgent Intervention

-Obstructed upper tract with infection-???febrile, ???tachycardic, ???hypotensive

-Impending renal deterioration-AKI – ?dehydration vs. renal/ureteral obstruction vs. both

-Pain refractory to analgesics

-Intractable nausea/vomiting, poor po intake

https://www.auanet.org/education/auauniversity/for-medical-students/medical-students-curriculum/medical-student-curriculum/kidney-stones

URINARY STONE DISEASE:Medical Expulsive Therapy (MET)-IF urgent intervention is not necessary:-patient may opt for spontaneous trial of stone passage (AKA MET):-most effective for small, distal ureteral stones-FLOMAX 0.4mg qhs – CAUTION: decreased BP, lightheadedness/dizziness-enhances stone expulsion, and reduces ureteral spasm-alternative: Ca channel blockers – rarely used compared to Flomax

-hydrate well-strain urine – encourage patients to bring passed stone in for analysis

https://www.auanet.org/education/auauniversity/for-medical-students/medical-students-curriculum/medical-student-curriculum/kidney-stones

URINARY STONE DISEASE:Medical Expulsive Therapy (MET)-Stone <5mm in diameter is likely to pass spontaneously

https://www.auanet.org/education/auauniversity/for-medical-students/medical-students-curriculum/medical-student-curriculum/kidney-stones

-As long as no associated infection, no impending renal failure, and pain is adequately controlled PO:-observation period of 2-4 weeks is OK, even in symptomatic patients-stone <10mm in ASYMPTOMATIC patients can be followed

URINARY STONE DISEASE:THE END… For Now

HEMATURIA:Introduction

-Hematuria – the presence of RBCs in the urine-GROSS hematuria (GH): blood visible in the urine-MICROSCOPIC hematuria (MH): blood not visible in the urine, but detected by microscopic examination of urine-defined by the AUA guidelines: > 3 RBCs/hpf on a single specimen

-Routine screening for MH in asymptomatic patient is not recommended-<5% likelihood of documenting a urologic malignancy in patients with MH

***NOTE: blood, whether trace-intact/small/moderate/large, in the urine on dipstick UA is not MH, needs to be confirmed with a microscopic urinalysis.***

HEMATURIA:Risk Factors for Malignancy

-Risk factors for malignancy in patients with hematuria:-older age-male-h.o. cigarette smoking-h.o. chemical exposures (i.e. cyclophosphamide, benzenes)-h.o. pelvic radiation-irritative voiding symptoms (i.e. urinary frequency/urgency, dysuria)-prior URO disease or treatment-h.o. chronic indwelling catheters-h.o. recurrent UTIs

https://www.auanet.org/education/auauniversity/for-medical-students/medical-students-curriculum/medical-student-curriculum/hematuria

HEMATURIA:Causes

-Glomerular vs. nonglomerular-glomerular:-suspect if red cell casts, dysmorphic RBCs, significant proteinuria (2+ or more)

-nonglomerular:-upper urinary tract-nephro-ureterolithiasis, pyelo, RCC, UCC, urinary obstruction, benign hematuria

-lower urinary tract-UTI, prostate enlargement, strenuous exercise, UCC, instrumentation, spurious hematuria (i.e. vaginal bleeding), benign hematuria (i.e. interstitial cystitis)

https://www.auanet.org/education/auauniversity/for-medical-students/medical-students-curriculum/medical-student-curriculum/hematuria

HEMATURIA:Necessary Workup

-UROLOGIC evaluation recommended if GH or asymptomatic MH (AMH), and any risk factors… but ANY GH or MH should be evaluated by UROLOGIST-hematuria can be intermittent in some patients with significant urologic disease

-per AUA guidelines: -once benign causes of AMH have been ruled out, refer for UROLOGIC evaluation-MH in patients on anti-coag STILL requires UROLOGIC evaluation-if patient with persistent AMH has 2 consecutive negative annual microUA, then no further UA for the purpose of eval of AMH necessary-for persistent AMH after negative UROLOGIC workup, YEARLY UA should be done-for persistent/recurrent AMH after negative UROLOGIC workup, repeat eval should be considered within 3-5 years https://www.auanet.org/guidelines/asymptomatic-microhematuria-(amh)-guideline

HEMATURIA:Necessary Workup

-H&P

-the usual 4 C’s-urine culture – rule out infection-urine cytology-CT urogram (CT a/p without/with contrast, and delayed images)-alternatives:-MR urogram (MRI without/with contrast, if CTU contraindicated)-renal u/s (IF CTU or MRU contraindicated) + retrograde pyelograms per UROLOGIST

-cystoscopy

URINARY STONE DISEASE & HEMATURIA:

Take Home Messages-acute FLANK PAIN: get renal u/s to assess for hydro, or CT stone study for stone-IF hydro or stone or other finding of concern – refer to UROLOGY

-obtain microscopic UA to confirm any blood on dipstick UA-IF >3 RBCs/hpf = MH – refer to UROLOGY

-helpful to get urine culture, urine cytology, CT urogram prior to UROLOGY visitfor MH or GH consultation

URINARY STONE DISEASE & HEMATURIA

-IF unsure: CALL US!

NATHALY FRANÇOIS, MDMERCY UROLOGY CLINICO: 319-398-6865M: 319-899-3570

Questions?

Thank you…