Patient information: Kidney stones in adults

KIDNEY STONES OVERVIEW

Kidney stones (also called nephrolithiasis or urolithiasis) affect approximately 12 percent of men and 5 percent of women by age 70. Fortunately, treatment is available to effectively manage most stones. In addition, you can take steps to prevent kidney stones from recurring.

A detailed review of kidney stones in children is available separately. (See "Patient information: Kidney stones in children".) More detailed information about kidney stones is available by subscription. (See "Diagnosis and acute management of suspected nephrolithiasis in adults".)

HOW KIDNEY STONES DEVELOP

A kidney stone can form when substances such as calcium, oxalate, cystine, or uric acid are at high levels in the urine. Stones can also form if these substances are at normal levels. The substances form crystals, which become anchored in the kidney and gradually increase in size, forming a kidney stone.

Typically, the stone will move through the urinary tract (figure 1) and is passed out of the body in the urine. A stone may cause pain if it becomes stuck and blocks the flow of urine. Large stones do not always pass on their own and sometimes require a procedure or surgery to remove them.

KIDNEY STONE RISK FACTORS

Certain diseases and habits can increase your risk of developing kidney stones (table 1).

KIDNEY STONE SYMPTOMS

Pain — Pain is the most common symptom of kidney stones. Pain can range from a mild and barely noticeable ache to discomfort that is so intense it requires treatment in the hospital. Typically, the pain gets worse and better, but does not go away completely. Waves of severe pain, known as renal colic, usually last 20 to 60 minutes. Pain can occur in the flank (the side, between the ribs and the hip) or the lower abdomen (figure 1).

Blood in the urine — Most people with kidney stones will have blood in the urine (hematuria). The urine may be pink or reddish, or the blood may be visible only with urine dipstick testing or microscopic examination of the urine. (See "Patient information: Blood in the urine (hematuria) in adults".)

Gravel — You may pass "gravel" or small stones in your urine.

Other symptoms — Other kidney stone symptoms include nausea or vomiting, pain with urination, and an urgent need to urinate.

Asymptomatic kidney stones — Many people with kidney stones have no symptoms (asymptomatic means without symptoms). These kidney stones are usually found when an imaging study (such as an ultrasound, x-ray or CT scan) is performed is done for other purposes. Stones can remain in the kidneys for many years without ever causing symptoms. (See "The first kidney stone and asymptomatic nephrolithiasis in adults".)

KIDNEY STONE DIAGNOSIS

Kidney stones are usually diagnosed based upon your symptoms, a physical examination, and imaging studies.

Computed tomography (CT) scan — A CT scan creates a three dimensional image of structures within the body. A particular type of CT scan (called noncontrast helical CT) is often recommended if kidney stones are suspected.

Ultrasound — An ultrasound can also be used to detect kidney stones, although small stones or stones in the ureters may be missed. However, ultrasound is the procedure of choice for people who should avoid radiation, including pregnant women.

KIDNEY STONE TREATMENT

Treatment of kidney stones depends upon the size and location of your stone, as well as your pain and ability to keep down fluids. If you stone is likely to pass, your pain is tolerable, and you are able to eat and drink, you can be treated at home.

If you have severe pain or nausea, you will need to be treated with stronger pain medications and IV fluids, which are often given in the hospital. (See "Options in the management of renal and ureteral stones in adults".)

Home treatment — You can take non-prescription pain medication until the stone passes. This includes nonsteroidal antiinflammatory drugs such as ibuprofen (Advil, Motrin) or naproxen (Aleve). The recommended doses of these medications are provided in the table (table 2).

Other medications, such as nifedipine (Procardia®) or tamsulosin (Flomax®), may also be recommended to speed the passage of stones.

You will probably be asked to strain your urine to recover the stone; it can then be analyzed in a laboratory to determine the content of the stone (eg, calcium, uric acid, etc). Knowing what type of kidney stone you have is important in planning treatments to prevent future stones (see 'Kidney stone prevention' below.

If the stone does not pass — Stones larger than 9 or 10 millimeters rarely pass on their own and generally require a procedure to break up or remove the stone. Several procedures are available.

Shock wave lithotripsy (SWL) — Lithotripsy is the treatment of choice in many patients who need help passing a stone. Lithotripsy is particularly good for stones in the kidney and upper ureter. Lithotripsy may not be effective for treating large or hard stones. You may require medication to make you sleepy and reduce pain during treatment, although this depends upon the type of lithotripsy equipment used.

Lithotripsy is done by directing a high-energy shock wave toward the stone. This passes through the skin and bodily tissues and releases energy at the stone surface. This energy causes the stone to break into fragments that can be more easily passed.

Percutaneous nephrolithotomy (PNL) — Extremely large or complex stones, or stones resistant to shock wave lithotripsy, may require a minimally invasive surgical procedure to remove the stone. In this procedure, small instruments are passed through the skin (percutaneously) into the kidney to remove the stone.

Ureteroscopy — Ureteroscopy is a procedure that uses a thin scope, which is passed through the urethra and bladder, into the ureter and kidney. This scope contains a camera and other instruments, which allows the physician to see the stone and remove it, or to break it up into smaller pieces that can pass more easily. Ureteroscopy is often used to remove stones blocking the ureter, and sometimes for stones in the kidney.

Treatment of asymptomatic stones — If you have a kidney stone that is causing no symptoms, you may or may not be treated. The decision is based upon the size and location of your stone, as well as your ability to be treated quickly if symptoms were to develop. If there is a chance that you would not be able to get treatment quickly (eg, if you travel frequently), you are more likely to be treated.

Regardless of the decision to treat or not, you should be evaluated for underlying health conditions that can increase the risk of kidney stones (table 1).

KIDNEY STONE PREVENTION

After you have a kidney stone, you should have blood and urine tests to determine if you have certain health problems that increase the risk of kidney stones (table 1).

If you passed and saved the stone, it should be analyzed to determine the type of stone. Based upon these test results, one or more of the following may be recommended:

• You may be given a medication to reduce the risk of future stones.
• Drink more fluids to decrease the risk of another stone. The goal is to increase the amount of urine that flows through your kidneys and also to lower the concentrations of substances that promote stone formation. One expert recommends drinking enough fluid that you make about 2 liters of urine per day.
• You may be advised to make changes in your diet; the changes recommended will depend upon the type of kidney stone you have.

SUMMARY

• A kidney stone can form when there are normal or high levels of certain substances in the urine. These substances can form crystals. Crystals become attached to the kidney and gradually increase in size, forming a stone.
• Eventually, the stone moves through the urinary tract and is passed in the urine. Or, the stone can remain in the urinary tract, blocking urine flow, which can cause pain.
• Certain diseases and habits can affect a person's risk for developing kidney stones. These include a past history or family history of kidney stones, certain dietary habits, underlying medical problems, certain medications, and dehydration (table 1) (see 'Kidney stone risk factors' above.
• The most common symptom of a kidney stone is pain; other symptoms include hematuria (blood in the urine), passing small stones, nausea, vomiting, pain with urination, and an urgent need to urinate. Many patients with kidney stones have no symptoms (see 'Kidney stone symptoms' above.
• Testing is usually needed to diagnose a kidney stone. Computed tomography (CT scan) is the preferred test for most patients (see 'Kidney stone diagnosis' above.
• Treatment usually includes pain medication and increased fluids (to drink) until the stone is passed. Over the counter pain medication (eg, ibuprofen, Advil, Motrin) may be helpful. If the pain is not controlled, a stronger medication (narcotic) may be needed (see 'Home treatment' above.
• Small stones (less than 5 millimeters) usually pass without treatment. Larger stones (greater than 9 millimeters) rarely pass on their own. Treatment for larger stones is usually done in a hospital (see 'If the stone does not pass' above.
• Further testing is recommended for patients who have kidney stones several times in their life. Tests help to determine if an illness is causing kidney stones to form. Medications may be prescribed to prevent future stones. Drinking more fluids and changing the diet can help to prevent future kidney stones (table 1) (see 'Kidney stone prevention' above.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Kidney stones in children
Patient information: Blood in the urine (hematuria) in adults

Professional Level Information:
Clinical significance of residual stone fragments following stone removal
Cystine stones
Diagnosis and acute management of suspected nephrolithiasis in adults
Evaluation of the adult patient with established nephrolithiasis and treatment if stone composition is unknown
Management of struvite or staghorn calculi
Management of ureteral calculi
Nephrolithiasis during pregnancy
Nephrolithiasis in renal tubular acidosis
Options in the management of renal and ureteral stones in adults
Pathogenesis and clinical manifestations of struvite stones
Prevention of recurrent calcium stones in adults
Renal complications of shock wave lithotripsy
Risk factors for calcium stones in adults
The first kidney stone and asymptomatic nephrolithiasis in adults
Uric acid nephrolithiasis

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• National Institute of Diabetes and Digestive and Kidney Diseases

      (www.niddk.nih.gov)

• National Kidney Foundation

      (www.kidney.org)

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