The workup for prostatitis begins with the history and physical examination, determining symptom type, duration, severity (NIH-CPSI score) and risk factors for bacterial versus CPPS. The four-glass test (Meares-Stamey localisation test) collecting sequential urine and expressed prostatic secretion (EPS) samples is the gold standard for differentiating bacterial prostatitis and identifying the infecting organism. In practice, a two-glass test (urine before and after massage) is usually sufficient. Microscopy and culture of urine, culture of semen and microscopy of EPS complete the microbiological assessment. Functional and anatomical assessment is done with uroflowmetry, post-void residual ultrasound, TRUS (to assess prostate anatomy and rule out abscess) and validated symptom scoring.
A ureteric stone is a kidney stone that has migrated from the kidney into the ureter (the narrow tube, roughly 3-4mm internal diameter, that links the kidney to the bladder and drains urine downwards). Kidney stones form inside the collecting system of the kidney . Some minerals in the urine become supersaturated ( too concentrated ) and crystallize out of solution . Most small stones (less than 5mm) will pass spontaneously down the ureter with adequate fluid intake and time. The bigger stones, especially those above 5 to 6 mm, get stuck in the ureter and cause obstruction, spasm and the characteristic severe pain of renal colic.
The three natural anatomical narrowings of the ureter where stones are most likely to get stuck are the ureteropelvic junction (UPJ, where the kidney meets the upper ureter), the crossing of the iliac vessels (where the ureter passes over the pelvic blood vessels in the mid-ureter) and the ureterovesical junction (UVJ, where the ureter enters the bladder). The UVJ is the narrowest point, about 1 to 2 mm, and is where most symptomatic ureteric stones get stuck.
A stuck ureteric stone causes obstruction, urine is still made by the kidney but cannot pass the stone to get to the bladder. The back pressure makes the kidney swell (hydronephrosis) and stretches the ureter above the stone, producing the excruciating cramping pain of renal colic. If the obstruction is not relieved, either by the stone passing spontaneously or by surgical intervention, progressive and permanent damage to the kidney can result.
Kidney stones form in the collecting system of the kidney, the renal pelvis and calyces, when minerals crystallise out of supersaturated urine. Most stones stay forever in the kidney without causing pain (then they are called silent stones and may be incidentally seen on imaging). However, once a stone is small enough to enter the ureter from the kidney, which is usually when it is less than 8 to 10mm in diameter, it begins to move down the narrow tube driven by the peristaltic contractions of the ureter wall.
Passing down the stone may pass the UPJ with some difficulty and then through the abdominal ureter. The second narrowing may be encountered at the pelvic brim (crossing of the iliac vessels). If it does, it enters the pelvis of the bladder and has to traverse the intramural ureter, the part that goes through the wall of the bladder, which is the narrowest part at 1 to 2mm. About 80% of the stones that get into the ureter and are smaller than 5mm in diameter will eventually pass on their own. Spontaneous passage rate of stones >6mm is significantly less and often requires intervention
The stone composition determines the suitable treatment, risk of recurrence and the best preventative strategy. The type of stone is determined either by laboratory analysis of a passed stone or by CT scan density (Hounsfield units). The five primary types are:
Calcium Oxalate Stones – Most Common Type
Makes up 70-80% of all kidney and ureteric stones. Caused by . High urinary oxalate Low calcium intake Dehydration Dietary factors . Very dense on CT (high HU) Good response to Holmium laser URSL.
Represent 5 to 10% of the stones. Form in an acid urine common in gout, diabetes and high-protein diets. Unique feature is they are radiolucent (not seen on plain X-ray) but seen on CT. May be dissolved by urinary alkalisation (potassium citrate).
Forms in the presence of urea-splitting bacteria (Proteus, Klebsiella). Usually large and fast growing. May make staghorn calculi that fill the entire kidney. For a permanent cure, the stones must be removed and a specific antibiotic therapy administered.
Cystinuria, a rare autosomal recessive genetic disorder that impairs amino acid transport. Cystine stones are very hard, recurrent and demand life-long management (high fluid intake and urinary alkalinisation).
Many stones have more than one mineral component, such as calcium oxalate with calcium phosphate, or uric acid with calcium oxalate. Mixed stones are analysed in a laboratory after removal and prevention is directed to the predominant component.
Symptoms of a ureteric stone can be acute and agonizing, or more subtle warning signs. Never ignore these, an untreated stone can cause permanent damage to the kidney:
Severe Colicky Pain in Flank & Back (Renal Colic)
The classic presentation of a ureteric stone is sudden, severe, colicky pain in the flank or back, radiating in waves. Described as one of the most severe pains in medicine. Not relieved by any posture.
As the stone falls the pain moves from the side to the lower abdomen, groin, inner thigh or, in men, the testicle. The movement of the pain tells the urologist the location of the stone in the ureter.
Most ureteric stones are accompanied by blood in the urine, pink, red or brown as the stone scrapes the lining of the ureter. Visible blood in urine is always a cause for urgent investigation whatever the other symptoms.
Renal colic is severe and invokes an autonomic response . Nausea, vomiting , sweating and pallor are common. Many patients are unable to keep oral pain medication down and need intravenous pain relief in the ED.
Fever, rigors (shaking chills) or high temperature with symptoms of ureteric stone suggests infected obstructed urine above the stone (pyonephrosis). This is a urological emergency, urosepsis can develop in hours. Come to the Emergency Department right away. An emergency DJ stent or nephrostomy is needed to drain the infected kidney.
When the stone reaches the lower ureter near the bladder it causes irritation of the bladder and can mimic symptoms of a bladder infection. Stones in the distal ureter usually present with frequent urges to urinate and burning on urination.
A stone producing complete ureteric obstruction and a solitary functional kidney or bilateral stones may cause acute renal failure. Any sudden decrease in urine output in a stone patient requires immediate emergency evaluation.
Kidney stones are the origin of ureteric stones and there are a number of well-established causes of kidney stone formation . It is important to identify the specific cause to prevent future stone episodes:
Dehydration & Low Water Intake
Not all ureteric stones need surgical intervention. Not all stones are treated the same. Based on the size, location, density, degree of obstruction and your clinical condition, Dr. Vikas Singh determines the best treatment option for you:
Laser URSL (Ureteroscopic Laser Stone Removal)
A thin telescope is inserted up the urethra and up the ureter to the stone. A Holmium laser breaks the stone into a fine dust that passes naturally. Without cuts. Stone free rate 90-98 %. Most patients go home the next morning.
Uses a flexible ureteroscope to reach the upper ureteric and kidney stones that are not accessible to semi-rigid instruments. The 270° tip deflection enables us to reach all corners of the kidney and upper ureter. Intact, entirely through the urethra.
An internal ureteric stent is passed beside or beyond an obstructing stone to re-establish drainage from the kidney. This is critically important when the obstructed kidney is also infected. Saving lives in urosepsis. Definitive stone treatment is performed after stabilization
PCNL, a keyhole approach through the back, is used for very large stones at the ureteropelvic junction or impacted upper ureter where URSL would be too slow. It gives rapid, complete stone clearance in a single session.
Rarely used now for stones that cannot be safely accessed endoscopically because of anatomical abnormalities, failed previous endoscopy, or when concurrent ureteral repair is required. Laparoscopically performed through small keyhole ports.
The most important thing is the size of the rock. Stones < 4mm will pass spontaneously in 80 to 90% of patients within 4 to 6 weeks if well hydrated and pain well controlled. 4-6 mm stones have a 40-60% chance of passing Large stones (>6 mm) rarely pass spontaneously and usually require intervention. Other factors include the position of the stone (lower ureteric stones pass easier than upper), the composition of the stone (softer stones pass more readily) and the degree of obstruction. Each case is reviewed individually by Dr. Vikas Singh and he recommends a watchful waiting approach with close observation for small appropriate stones and immediate intervention for larger or obstructive stones.
A watchful waiting period of 4 to 6 weeks is generally appropriate for small stones managed conservatively with close monitoring of pain control, hydration and urine output. If there is fever, worsening pain, infection, vomiting that prevents adequate fluid intake, or evidence of significant kidney swelling on repeat imaging, do not delay intervention. If the stones are causing obstruction of a solitary kidney or bilateral obstruction, intervention is required urgently . The principle: observe a stone when it is safe to observe, not when observation risks the kidney.
URSL is performed under general or spinal anaesthesia, you will feel nothing during the procedure. Postoperatively, mild urinary stinging and discomfort, particularly from the DJ stent, are common for 1 to 2 weeks. Most patients characterize post-URSL discomfort as significantly less severe than the pain of their initial kidney stone prompting their surgery. At home, the usual oral painkillers (paracetamol and ibuprofen) keep you comfortable enough.
Following most URSL procedures a DJ stent is placed to keep the ureter open while post-operative swelling settles, and to allow safe passage of any residual fine stone dust down the ureter. DJ stents are also used to prevent ureteral spasm causing obstruction during healing. The stent stays in place for 1-4 weeks and is removed with a brief outpatient cystoscopy. It does cause transient urinary frequency, urgency and mild discomfort but reduces the risk of post-operative ureteral obstruction and stricture formation to a great extent.
Stone recurrence is common with about 50% of first time stone formers having a recurrence within 10 years. Prevention strategies vary according to stone type Calcium oxalate stones 2.5-3L of water each day decreased salt and animal protein moderate oxalate intake normal dietary calcium For uric acid stones alkalinize urine with potassium citrate, reduce purine rich foods, gout. Regular follow up imaging and metabolic evaluation with Dr Vikas Singh helps identify individual risk factors which can be specifically targeted for all stone types.
Yes, in most patients normal eating starts on the first day after URSL. Post-operative restrictions are not recommended. Specific dietary modifications are recommended long term for stone prevention. The most important dietary change for all stone types is to increase fluid intake to 2.5 to 3 litres of water a day. Specific dietary advice (reduction of oxalate, salt or protein depending on stone type) is given at the follow-up consultation after the stone analysis results are available.
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