Review
The evaluation and management of urolithiasis in the ED: A review of the literature

https://doi.org/10.1016/j.ajem.2018.01.003Get rights and content

Abstract

Background

Urolithiasis is a common condition in the U.S. Patients frequently present to the emergency department (ED) for care, including analgesia and treatments to facilitate stone passage.

Objective

With the new evidence concerning the evaluation and treatment of urolithiasis, this review summarizes current literature regarding the ED management of urolithiasis.

Discussion

Urolithiasis occurs primarily through supersaturation of urine and commonly presents with flank pain, hematuria, and nausea/vomiting. History, examination, and assessment with several laboratory tests are cornerstones of evaluation. Urinalysis is not diagnostic, but it may be used in association with other assessments. Risk assessment tools and advanced imaging can assist with diagnosis. Computed tomography (CT) is often considered the gold standard. Newer low-dose CT imaging may reduce radiation. Recent studies support ultrasound as an alternate diagnostic modality, especially in pediatric and pregnant patients. Nonsteroidal anti-inflammatory drugs remain first-line therapy, with opioids or intravenous lidocaine reserved for refractory pain. Tamsulosin can increase passage in larger stones but has not demonstrated benefit in smaller stones. Nifedipine and intravenous fluids are not recommended to facilitate passage. Surgical intervention is based upon stone size, duration, and modifying factors. Patients who are discharged should be advised on dietary changes.

Conclusion

Urolithiasis is a common disease increasing in prevalence with the potential for significant morbidity. Focused evaluation with history, examination, and testing is important in diagnosis and management. Understanding the clinical features, risk assessment tools, imaging options, and treatment options can assist emergency physicians in the management of urolithiasis.

Introduction

Urolithiasis is a common condition evaluated and managed in the emergency department (ED). Nephrolithiasis refers to stones within the kidney, while ureterolithiasis refers to stones within the ureter. Urolithiasis refers to stones within the kidneys, ureters, bladder, or urethra. This review will focus on urolithiasis. Approximately 11–16% of men and 7–8% of women will experience symptoms from urolithiasis by age 70 [1], [2], [3], [4], [5]. Over 70% of the population affected with urolithiasis is between 20 and 50 years [3], [4], [5], [6], [7], with a recurrence rate approaching 50% over 10 years [6], [7], [8]. The prevalence of urolithiasis in 1994 was 5.2%, which has more than doubled in 2017. This increase in prevalence is associated with over one million ED visits annually, with over 40,000 surgical interventions [8], [9], [10], [11], [12]. Annual costs approach $5 billion, which will likely continue to increase [9], [10], [12], [13]. One major issue with urolithiasis is the morbidity due to renal colic, which may result in sudden, intense pain. Severe sequelae can include sepsis and death from an obstructed, infected stone. Recent prospective data suggest increase in infected urolithiasis incidence and rates of sepsis and severe sepsis, though mortality rates have remained stable [14]. Recurrence is also common, occurring in 15% of patients during the first year and 30–50% within 10 years [2], [12], [13], [14], [15], [16], [17].

Men experience stones in a 2:1 ratio when compared with females, predominantly due to diet, climate, and other risk factors [1], [2], [12], [16]. Additional risk factors for stone disease include obesity, decreased fluid intake, increasing age, Caucasian race, lower socioeconomic status, diabetes, and gout [1], [2], [5], [12], [16]. Conditions such as inflammatory bowel disease, pancreatitis, short gut syndrome, and hyperparathyroidism also increase the risk of stone formation due to the associated metabolic abnormalities [1], [2], [12], [18]

Section snippets

Methods and objectives

In light of new evidence for both the evaluation and treatment of urolithiasis, this review was designed to summarize the current literature regarding the treatment of urolithiasis for the emergency physician. Authors searched PubMed and Google Scholar for articles using a combination of the following keywords and Medical Subject Headings: “kidney stone”, “renal stone”, “nephrolithiasis”, and “urolithiasis”. The literature search was restricted to studies published in English. Authors decided

Anatomy and pathophysiology

Stone formation is predominantly due to an imbalance of urinary solute and solvent [19], [20], [21]. Solutes normally dissolve in a solution until a specific saturation point. Once the saturation point is exceeded, stones can form in the urine. Citrate, glycoproteins, and magnesium inhibit crystal formation, while other materials, referred to as ‘nucleating centers’ (eg, epithelial cells, urinary casts, and red blood cells), form areas for crystal collection [12], [18], [19], [20], [21], [22].

Conclusions

Urolithiasis is a common medical condition, resulting in over one million ED visits annually. The most common presentation includes flank pain, hematuria, nausea, and vomiting. However, classic symptoms may not always be present. Urinalysis should not be relied on for diagnosis or exclusion of urolithiasis. Risk assessment tools and advanced imaging may facilitate the diagnosis of urolithiasis. Imaging options include x-ray, CT, ultrasound, and MRI. While CT is often considered the gold

Conflicts of interest

None.

Acknowledgements

MG, BL, and AK conceived the idea for this manuscript and contributed substantially to the writing and editing of the review. Dr. White approved this topic for review. This manuscript did not utilize any grants, and it has not been presented in abstract form. This clinical review has not been published, it is not under consideration for publication elsewhere, its publication is approved by all authors and tacitly or explicitly by the responsible authorities where the work was carried out, and

References (125)

  • L.H. Smith

    Renal stones. Solutions and solute

    Endocrinol Metab Clin North Am

    (1990)
  • D.M. Kaplon et al.

    Patients with and without prior urolithiasis have hypocitraturia and incident kidney stones while on topiramate

    Urology

    (2011)
  • T.H. Mehta et al.

    Uric acid stones and hyperuricosuria

    Adv Chronic Kidney Dis

    (2012)
  • C. Türk et al.

    EAU guidelines on interventional treatment for urolithiasis

    Eur Urol

    (2016 Mar)
  • B.R. Matlaga et al.

    Endoscopic evidence of calculus attachment to Randall's plaque

    J Urol

    (2006)
  • P. Bove et al.

    Reexamining the value of hematuria testing in patients with acute flank pain

    J Urol

    (1999 Sep)
  • Y. Safriel et al.

    Hematuria as an indicator for the presence or absence of urinary calculi

    Am J Emerg Med

    (2003)
  • T. Kobayashi et al.

    Impact of date of onset on the absence of hematuria in patients with acute renal colic

    J Urol

    (2003)
  • O.W. Moe

    Kidney stones: pathophysiology and medical management

    Lancet

    (2006)
  • A.E. Krambeck et al.

    Effect of age on the clinical presentation of incident symptomatic urolithiasis in the general population

    J Urol

    (2013)
  • E.M. Worcester et al.

    Renal function in patients with nephrolithiasis

    J Urol

    (2006 Aug)
  • F.M. Abrahamian et al.

    Association of pyuria and clinical characteristics with the presence of urinary tract infection among patients with acute nephrolithiasis

    Ann Emerg Med

    (2013)
  • M. Dorfman et al.

    Pyuria and urine cultures in patients with acute renal colic

    J Emerg Med

    (2016)
  • C.Y. Pak et al.

    Adequacy of a single stone risk analysis in the medical evaluation of urolithiasis

    J Urol

    (2001)
  • J.H. Parks et al.

    A single 24-hour urine collection is inadequate for the medical evaluation of nephrolithiasis

    J Urol

    (2002)
  • E.M. Schoenfeld et al.

    Validity of STONE scores in younger patients presenting with suspected uncomplicated renal colic

    Am J Emerg Med

    (2016 Feb)
  • B. Kim et al.

    External validation of the STONE score and derivation of the modified STONE score

    Am J Emerg Med

    (2016 Aug)
  • B. Daniels et al.

    STONE PLUS: evaluation of emergency department patients with suspected renal colic, using a clinical prediction tool combined with point-of-care limited ultrasonography

    Ann Emerg Med

    (2016 Apr)
  • M. Dhar et al.

    Imaging in diagnosis, treatment, and follow-up of stone patients

    Adv Chronic Kidney Dis

    (2009 Jan)
  • A. Heidenreich et al.

    Modern approach of diagnosis and management of acute flank pain: review of all imaging modalities

    Eur Urol

    (2002 Apr)
  • J. Vieweg et al.

    Unenhanced helical computerized tomography for the evaluation of patients with acute flank pain

    J Urol

    (1998 Sep)
  • N.M. Fahmy et al.

    Effective radiation exposure in evaluation and follow-up of patients with urolithiasis

    Urology

    (2012 Jan)
  • P.R. Sierzenski et al.

    Applications of justification and optimization in medical imaging: examples of clinical guidance for computed tomography use in emergency medicine

    Ann Emerg Med

    (2014 Jan)
  • M. Hamm et al.

    Low dose unenhanced helical computerized tomography for the evaluation of acute flank pain

    J Urol

    (2002 Apr)
  • P.D. McLaughlin et al.

    The emergence of ultra-low–dose computed tomography and the impending obsolescence of the plain radiograph?

    Can Assoc Radiol J

    (2013 Nov)
  • S. Rob et al.

    Ultra-low-dose, low-dose, and standard-dose CT of the kidney, ureters, and bladder: is there a difference? Results from a systematic review of the literature

    Clin Radiol

    (2017 Jan)
  • J.K. Goertz et al.

    Can the degree of hydronephrosis on ultrasound predict kidney stone size?

    Am J Emerg Med

    (2010 Sep)
  • V.E. Noble et al.

    Renal ultrasound

    Emerg Med Clin North Am

    (2004 Aug)
  • M. Abdel-Gawad et al.

    A prospective comparative study of Color Doppler ultrasound with twinkling and noncontrast computerized tomography for the evaluation of acute renal colic

    J Urol

    (2016 Sep)
  • T. Asrat et al.

    Ultrasonographic detection of ureteral jets in normal pregnancy

    Am J Obstet Gynecol

    (1998 Jun)
  • T. Kanno et al.

    Determining the efficacy of ultrasonography for the detection of ureteral stone

    Urology

    (2014 Sep)
  • P.F. Fulgham et al.

    Clinical effectiveness protocols for imaging in the management of ureteral calculous disease: AUA technology assessment

    J Urol

    (2013 Apr)
  • A. Karabacakoglu et al.

    Diagnostic value of diuretic-enhanced excretory MR urography in patients with obstructive uropathy

    Eur J Radiol

    (2004 Dec)
  • S.A. Pathan et al.

    Delivering safe and effective analgesia for management of renal colic in the emergency department: a double-blind, multigroup, randomised controlled trial

    Lancet

    (2016 May 14)
  • M.F. de Souza et al.

    The analgesic effect of intravenous lidocaine in the treatment of chronic pain: a literature review

    Rev Bras Reumatol

    (2014 Sep–Oct)
  • A. Firouzian et al.

    Does lidocaine as an adjuvant to morphine improve pain relief in patients presenting to the ED with acute renal colic? A double-blind, randomized controlled trial

    Am J Emerg Med

    (2016 Mar)
  • K. Sakhaee et al.

    Kidney stones 2012: pathogenesis, diagnosis, and management

    J Clin Endocrinol Metab

    (June 2012)
  • V. Romero et al.

    Kidney stones: a global picture of prevalence, incidence, and associated risk factors

    Rev Urol

    (2010)
  • K. Sakhaee

    Nephrolithiasis as a systemic disorder

    Curr Opin Nephrol Hypertens

    (2008)
  • J. Uribarri et al.

    The first kidney stone

    Ann Intern Med

    (1989)
  • Cited by (52)

    • Is This Your Stone? Distinguishing Phleboliths and Nephroliths on Imaging in the Emergency Department Setting

      2022, Journal of Emergency Medicine
      Citation Excerpt :

      PubMed yielded 341 articles. The first 200 articles resulted by Google Scholar were also searched as part of recommendations by Bramer et al. and used in similar works (3,21–23). Articles reviewed included case reports and series, retrospective studies, prospective studies, systematic reviews and meta-analyses, and other narrative reviews.

    • Clinical differentiation between acute renal infarction and acute ureteral stone in the emergency department: A single-center retrospective case-control study

      2021, American Journal of Emergency Medicine
      Citation Excerpt :

      Nevertheless, selection bias due to matching may exist. Patients were not matched by sex and age because the average age of patients with US is lower than that of patients with RI; further, male sex is a risk factors, so there is a possibility of this predictive factor indicating the difference between the two groups [20]. Third, this study included patients who visited a single center, and our study patients reflect the regional characteristics of the research institute.

    • Intradermal sterile water injection in acute renal colic

      2021, American Journal of Emergency Medicine
    View all citing articles on Scopus
    View full text