Urolithiasis.
Syndrome of
swollen scrotum.
Pavlo Hoschynsky
Urolithiasis
Introduction
Urolithiasis is increasingly recognized in pediatric patients and is
encountered in a variety of clinical settings. The wide geographic variation in
the incidence of urolithiasis in childhood is related to climatic, dietary, and
socioeconomic factors. Approximately 7% of urinary calculi occur in children
younger than 16 years of age. Many children with stone disease have a
metabolic abnormality. Revolutionary advances in the minimally invasive and
noninvasive management of stone disease over the past 2 decades have
greatly facilitated the ease with which stones are removed. Given the frequency
with which stones recur, the development of a medical prophylactic program to
prevent stone recurrences is desirable. The lifetime prevalence of kidney stone
disease is estimated at 1% to 15%, with the probability of having a stone
varying according to age, gender, race, and geographic location. Stone disease
typically affects boys more commonly as much as two to three times more
frequently than females. Upper urinary tract stones occur more commonly in
boys than girls by a ratio of 1.4:1 to 2.1:1.
Classification of stones
Stone size:
 <5 mm,
 5-10 mm,
 > 10-20 mm,
 > 20 mm.
Classification of stones
Stone location:
 upper calyx,
 middle calyx or lower calyx,
 renal pelvis,
 upper ureter,
 middle ureter or distal ureter,
 urinary bladder.
Location of Renal stones
Classification of stones
X-ray characteristics
Radiopaque
Poor radiopaque
Radiolucent
Calcium oxalate
dehydrate
Magnesium ammonium
phosphate
Uric acid
Calcium oxalate
monohydrate
Apatite
Ammonium urate
Calcium
phosphates
Cystine
Xanthine
2,8dihydroxyadenine
'Drug-stones'
Stones classified according to their
aetiology
Non-infection stones
Calcium oxalates
Calcium phosphates
Uric acid
Infection stones
Magnesium-ammonium-phosphate
Apatite
Ammonium urate
Genetic causes
Cystine
Xanthine
2,8-dihydroxyadenine
'Drug stones'
Calcium oxalate monohydrates
Calcium
oxalate dihydrates
Uric acid
Struvite
Cystine
High risk stone formers
General factors
Early onset of urolithiasis in life (especially
children and teenagers)
Familial stone formation
Brushite containing stones (calcium hydrogen
phosphate; CaHP04. 2H20)
Uric acid and urate containing stones
Infection stones
Solitary kidney (The solitary kidney itself does
not have a particular increased risk of stone
formation, but the
prevention of a potential stone recurrence is of
more importance)
High risk stone formers
Diseases associated with stone formation
Hyperparathyroidism
Nephrocalcinosis
Gastrointestinal diseases or disorders (i.e. jejuno-ileal bypass, intestinal
resection, Crohn's disease,malabsorptive conditions)
Sarcoidosis
High risk stone formers
Genetically determined stone formation
Cystinuria (type A, B, AB)
Primary hyperoxaluria (PH)
Renal tubular acidosis (RTA) type 1
2,8-dihydroxyadenine
Xanthinuria
Lesh-Nyhan-Syndrome
Cystic fibrosis
High risk stone formers
Anatomical and urodynamic abnormalities associated with stone formation
Medullary sponge kidney (tubular ectasia)
Ureteropelvic junction (UPJ) obstruction
Calyceal diverticulum, calyceal cyst
Ureteral stricture
Vesico-uretero-renal reflux
Horseshoe kidney
Ureterocele
Urinary diversion (via enteric hyperoxaluria)
Neurogenic bladder dysfunction
Compounds that cause drug stones
Active compounds crystallizing in urine
• Allopurinol / oxypurinol
• Amoxicillin / ampicillin
• Ceftriaxone
• Ciprofloxacin
• Ephedrine
• Indinavir
• Magnesium trisilicate
• Sulfonamide
• Triamterene
Substances impairing urine composition
• Acetazolamide
• Allopurinol
• Aluminium magnesium hydroxide
• Ascorbic acid
• Calcium
• Furosemide
• Laxatives
• Methoxyflurane
• Vitamin D
Diagnostic steps in urolithiasis
(UTI urinary tract infection, CT computed tomography, MR1 magnetic resonance imaging, PTH
parathyroid hormone, pC02 partial pressure of carbon dioxide)
Fig.a,b. A 17-year-old girl with cystinuria. a) Abdominal plain radiograph
showing urolithiasis on the left, b) IVU showing hydronephrosis on the left due
to urolithiasis
Fig. a,b. A 4-year-old boy with incomplete RTA and hyperoxaluria, a Sonogram
of right kidney showing medullary nephrocalcinosis grade III (Dick et al. 1999).
b Sonogram of bladder showing an ureteral stone on the right immediately
before the ureterovesical junction
An 8-year-old boy with primary hyperparathyroidism, hypercalciuria, and urinary
tract infection. Abdominal plain radiograph showing a huge ureteral stone on
the left immediately before the ureterovesical junction
Bilateral Ureteric Calculus in a patient presenting with Anuria
Helical or Spiral CT provides 3D reconstruction. Helical refers to path the X ray follows on
Gantry. These are rapidly performed and do not require contrast agents for reconstruction.
Evaluation for a suspected stone.
(RBUS)-renal/bladder ultrasound
extracorporeal shockwave lithotripsy (ESWL)
percutaneous nephrolithotomy -(PCNL)
Recommendations for pain relief during renal colic:
-1st choice: treatment should be started with an NSAID(Diclophenac sodium,
Indomethacin, Ibuprofen)
-2nd choice: Hydromorphine(Pentazocine,Tramadol)
-Diclofenac sodium is recommended to counteract recurrent pain after an episode of
ureteral colic
For septic patients with obstructing stones, the collecting system should be
urgently decompressed, using either percutaneous drainage or ureteral stenting.
Definitive treatment of the stone should be delayed until sepsis is resolved.
Medical expulsive therapy
Alpha-blockers (Tamsulosin, 0.4 mg, doxazosin,terazosin, alfuzosin and naftopidil)
Calcium-channel blockers(nifedipine)
Corticosteroids
Chemolytic dissolution of stones:
-Percutaneous irrigation chemolysis
-Oral Chemolysis
Methods of percutaneous irrigation chemolysis
Stone composition Refs.
Irrigation solution
Comments
Struvite
Carbon apatite
1-6
10% Hemiacidrin with pH 3.5-4
Suby's G
Brushite
7
Combination with
Shockwave
lithotripsy for staghorn
stones
Risk of cardiac arrest due
to
hypermagnesaemia
Can be considered for
residual fragments
Takes significantly longer
time than for uric acid
stones
Used for elimination of
residual fragments
Oral chemolysis is the
preferred option
Cystine
Uric acid
Hemiacidrin
Suby's G
8-13
Trihydroxymethyl- aminomethan
(THAM; 0.3 or 0.6 mol/L) with pH
range
8.5-9.0
N-acetylcysteine (200 mg/L)
10,14-18 Trihydroxymethyl- aminomethan
(THAM; 0.3 or 0.6 mol/L) with pH
range
8.5-9.0
The figure shows a 12 month-old child treated with the Modulith SLK
(Storz Medical AG, Kreuzlingen).
Operation: percutaneous nephrolithotomy
■ Rarely used in pediatric surgery
■ Utilize a nephroscope or ureteroscope
■ Extract with visualization
■ Break larger stones using ultrasonography
Operation: open stone removal
■ Rarely necessary, only when urinary calculi are not amenable to ESWL
or PL
■ Make an incision below the 12th rib
■ Expose the kidney and the ureter
■ Open the renal pelvis and extract the stone (or ureter in the case of a
ureteral stone)
■ Wash the entire calyx system
■ Suture the pyelon or the ureter
Postoperative care
■ Ureter drain for 2–5 days with an antegrade contrast X-ray before drain
removal
■ Antibiotic therapy as prophylaxis in cases of vesicoureteral reflux
■ Urine culture once a month
■ Ultrasonography
Prognosis
■ Stone recurrence is rare if urine is sterile and an obstruction does not
occur
Medical treatment of recurrent stones
Scrotal Pain and Swelling
Outline


Embryology and anatomy
Causes of Pain and Swelling
 Torsion,
Epididymitis, Orchitis, Trauma
 History, Physical, Radiologic Exams, Labs

Causes of Swelling
 Hydrocele,
Idiopathic
Varicocele, Spermatocele, Tumor,
Embryology



Descent of testes at 32-40 wks gestation
Descends within processes vaginalis
 Outpouching of peritoneal cavity
Tunica vaginalis is potential space that remains
after closure of process vaginalis
Anatomy

Spermatic cord –testicular vessels, lymph, vas
deferens
 Epididymis
- sperm formed in testicle and undergo
maturation, stored in lower portion
 Vas Deferens – muscular action propels sperm up and
out during ejaculation


Gubernaculum – fixation point for testicle to
tunica vaginalis
Tunica Vaginalis – potential space
 Encompasses
anterior 2/3’s of testicle
 Tunica albuginea is inner layer opposing testis
Anatomy – Nuts and Bolts
Posterior
Anterior
Causes of Pain and Swelling

Pain
 Testicular torsion
 Torsion of appendix
 Epididymitis
 Trauma
 Orchitis

and Others
Swelling
 Hydrocele
 Varicocele
 Spermatocele
 Tumor
testis
Torsion


Inadequate fixation of testes to tunica vagnialis
at gubernaculum
Torsion around spermatic cord
 Venous
compression to edema to ischemia
Epidemiology


Accounts for 30% of all acute scrotal swelling
Bimodal ages – neonatal (in utero) and pubertal
ages
 65%


occur in ages 12-18yo
Incidence 1 in 4000 in males <25yo
Increased incidence in puberty due to inc weight
of testes
Predisposing Anatomy

Bell-clapper deformity
 Testicle
lacks normal
attachment at vaginalis
 Increased mobility
 Tranverse lie of testes
 Typically bilateral
 Prevalence 1/125
Torsion: Clinical Presentation

Abrupt onset of pain – usually testicular, can be
lower abdominal, inguinal
 Often < 12 hrs duration
 May follow exercise or minor trauma
 May awaken from sleep

Cremasteric contraction with nocturnal stimulation
in REM
 Up
to 8% report testicular pain in past
Torsion: Examination


Edematous, tender, swollen
Elevated from shortened spermatic cord
 Horizontal
lie common (PPV 80%)
 Reactive hydrocele may be present


Cremasteric reflex absent in nearly all
(unreliable in <30mo old) (PPV 95%)
Prehn’s sign elevation relieves pain in
epididymitis and not torsion is unreliable
Intermittent Torsion




Intermittent pain/swelling with rapid resolution
(seconds to minutes)
Long intervals between symptoms
PE: testes with horizontal lie, mobile testes,
bulkiness of spermatic cord (resolving edema)
Often evaluation is normal – if suspicious need
GU followup
Diagnosis – “Time is Testicle”
Ideally -- prompt clinical diagnosis
 Imaging

 Color
doppler – decreased intratesticular flow
False + in large hydrocele, hematoma
 Sens 69-100% and Spec 77-100%
 Lower sensitivity in low flow pre-pubertal testes

 Nuclear
Technetium-99 radioisotope scan
Show testicular perfusion
 30 min procedure time
 Sens and spec 97-100%





Acute torsion L testis
Dec blood flow on L
Late torsion on R
Inc blood flow around
but dec flow w/in testis
Images - Torsion

Decreased echogenicity
and size of right testicle

Nuclear medicine scan
shows "rim sign“ =no flow
to testicle and swelling
Management

Detorsion within 6hr = 100% viability
 Within 12-24 hrs = 20% viability
 After 24 hrs = 0% viability

Surgical detorsion and orchiopexy if viable
 Contralateral
exploration and fixation if bell-clapper
deformity

Orchiectomy if non-viable testicle

Never delay surgery on assumption of
nonviability as prolonged symptoms can
represent periods of intermittent torsion
Intravaginal torsion with ischemia in a adolescent boy.
Manual Detorsion
If presents before swelling
 Appropriate sedation
 In 2/3rds of cases testes
torses medially, 1/3rd lateral
 Success if pain relief, testes
lowers in scrotum
 Still need surgical fixation

Torsion: Special Considerations


Adolescents may be embarrassed and not seek
care until late in course
Torsion 10x more likely in undescended testicle
 Suspicious

if empty scrotum, inguinal pain/swelling
Adult Emergency Physicians accurate in bedside
US diagnoses with sens of 95% and specificity
of 94% (missed 1 epididymitis, no torsion)
Blavis M., Emergency Evaluation of Patients Presenting with A Cute Scrotum, Academy of Emergency Medicine.
Jan 2001
Neonatal Torsion




70% prenatal, 30% post-natal
Post-natal typically 7-10 days after birth
Unrelated to gestation age, birth weight
Post-natal presents in typical fashion
 Doppler
U/S and radionucleotide scans less accurate
with low blood flow in neonates
 Surgical intervention if post-natal

Prenatal torsion presents with painless testicular
swelling, rare testicular viability
 Rare
intervention in prenatal torsion
Perinatal torsion
Torsion of Appendix Testis

Appendix testis
 Small
vestigial structure,
remnant of Mullerium duct
 Pedunculated, 0.3cm long

Other appendix structures

Prepubertal estrogen may
enlarge appendix and cause
torsion
Torsion of Appendix Testis







Peak age 3-13 yo (prepubertal)
Sudden onset, pain less severe
Classically, pain more often in abd or groin
Non-tender testicle
 Tender mass at superior or inferior pole
May be gangrenous, “blue-dot” (21% of cases)
Normal cremasteric reflex, may have hydrocele
Inc or normal flow by doppler U/S
Torsion of Appendix Testis
Blue dot of gangrenous
appendix testis
Testicular Appendages
Appendix testis
Appendix epididymis
Torsion of Appendix Testis

Management supportive
 analgesics,

scrotal support to relieve swelling
Surgery for persistent pain
 no
need for contralateral exploration
Epididymitis




Inflammation of epididymis
Subacute onset pain, swelling localized to
epididymis, duration of days
 With time swelling and pain less localized
Testis has normal vertical lie
Systemic signs of infection
 inc


WBC and CRP, fever + in 95%
Cremasteric reflex preserved
Urinary complaints: discharge/dysuria PPV 80%
Epididymitis


Scrotum has overlying erythema, edema in 60%
Normal vertical
lie
Epididymitis



Sexually active males
 Chlamydia > N. gonorrhea > E. coli
Less commonly pseudomonas (elderly) and
tuberculosis (renal TB)
Young boys, adolescents often post-infectious
(adenovirus) or anatomic
 Reflux
of sterile urine through vas into epididymis
 50-75% of prepubertal boys have anatomic cause by
imaging
Etiologies of Epididymitis
Epididymitis Diagnosis





Leukocytosis on UA in ~40% of patients
PCR Chlamydia + in 50%, GC + in 20% of
sexually active
95% febrile at presentation
Doppler and Nuclear imaging show increased flow
If hx consistent with STD, CDC recommends:
 Cx
of urethral discharge, PCR for C and G
 Urine culture and UA
 Syphilis and HIV testing
Laboratory Adjuncts

Studies of acute phase reactants: CRP, IL-1, IL-6
 Documented
epididymitis have 4 fold increase in CRP
compared to testicular torsion
 PPV 94% and NPV 94% (inc 2 fold)
 Testicular tumor showed no increase in CRP
Doehn C., Value of Acute Phase Proteins in the Differential Diagnosis of A Cute Scrotum, Journal of Urology. Feb 2001.
Doppler Epididymitis

Left Epididymitis
 Inc
blood flow in
and around left testis
Epididymitis Treatment


Sexually active treat with
Ceftriaxone/Doxycycline or Ofloxacin
Pre-pubertal boys
 Treat for co-existing UTI if present
 Symptomatic tx with NASIDs, rest
 Referral all to GU for studies to rule out VUR,
post urethral valves, duplications

Negative culture has 100% NPV for anomaly
Orchitis

Inflammation/infection of testicle
 Swelling
pain tenderness, erythema and shininess to
overlying skin

Spread from epididymitis,
hematogenous, post-viral
 Viral:
Mumps, coxsackie,
echovirus, parvovirus
 Bacterial: Brucellosis
Mumps Orchitis




Extremely rare if vaccinated
20-30% of pts with mumps, 70% unilateral, rare
before puberty
Presents 4-6 days after mumps parotitis
Impaired fertility in 15%, inc risk if bilateral
Trauma


Result of testicular compression against the
pubis bone, from direct blow, or straddle injuries
Extent depends on location of rupture
 Tunica
albuginea ruptures (inner layer of tuncia
vaginalis) allows intratesticular hematoma to rupture
into hematocele
 Rupture of tunica vaginalis allow blood to collect
under scrotal wall causing scrotal hematoma


Doppler often sufficient to assess extent
Surgery for uncertain dx, tunica albuginea
rupture, compromised doppler flow
Testicular Hematoma

Blood as a filling
defect in testis
Other Causes of Pain


Incarcerated inguinal hernia
Henoch-Schonlein Purpura



Referred pain


Vasculitis of testicular vessels
Rarely presents with only scrotal pain
Retrocecal appendix, urolithiasis, lumbar/sacral nerve injury
Non specific scrotal pain

Minimal pain, nl exam – return immediately for inc symptoms
Scrotal Swelling
Hydrocele
 Varicocele
 Spermatocele
 Testicular Cancer

Hydrocele
Fluid accumulation
in potential space of
tunica vaginalis
 May be primary from
patent PV or secondary
to torsion/epididymitis

Hydrocele

Transilluminating
anterior cystic
mass
Hydrocele



Mass increases in size during day or with crying
and decreases at night if communicating
If non-communicating and <1 yo follow
If communicating (enlarging), scrotum tense
(may impair blood flow) requires repair
 Unlikely
hernia
to close spontaneously and predisposes to
Varicocele
Collection dilated veins in
pampiniform plexus
surrounding spermatic cord
 More common on left side

R
vein direct to IVC
 L vein acute angle to renal vein

~20% of all adolescent males
Varicocele




Often asymptomatic or c/o dull ache/fullness
upon standing
Spermatic cord has ‘bag of worms’ appearance
that increased with standing/valsalva
If prepubertal, rapidly enlarging, or persists in
supine position rule out IVC obstruction
Most management conservatively
 Surgery
if affected testis < unaffected testis volume
Spermatocele
Painless sperm containing
cyst of testis, epipdidymis
 Distinct mass from testis
on exam
 Transilluminates
 Do not affect fertility
 Surgery for pain relief only

Testicular Cancer

Most common solid tumor in 15-30 yo males
 20% of all cancers in this group

Painless mass
 Rapidly

growing germ cell tumors may cause
hemorrhage and infarction
 Present as firm mass
 Typically do not transilluminate
Diagnostic imaging with U/S initially
Acute Idiopathic Scrotal Edema

Scrotal skin red and tender




underlying testis normal
no hydrocele
Erythema extends off
scrotum onto perineum
Empiric tx, cause unknown
 Antihistamine, steroids
 Resolves w/in 48-72hrs
Conclusions


Clinical history and careful exam are key factors in
formulating accurate differential
Imaging and labs useful adjuncts in unclear cases
 U/S

superior to nuclear imaging if time essential
TIME IS TESTICLE
 Early

surgical intervention and GU involvement
Swelling without pain, usually less time sensitive
diagnostically
References






Ciftci, AO. Clinical Predictors for Diff. Diagnosis of Acute Scrotum,
European J. of Ped. Surgery. Oct 2004.
Blavis M., Emergency Evaluation of Patients Presenting with Acute
Scrotum, Academy of Emergency Medicine. Jan 2001
Doehn C., Value of Acute Phase Proteins in the Differential
Diagnosis of Acute Scrotum, Journal of Urology. Feb 2001.
Kaplan G., Scrotal Swelling in Children. Pediatrics in Review. Sep
2000.
Luzzi GA. Acute Epididymitis. BJU International. May 2001.
Fleisher G, Ludwig S, Henretig F. Textbook of Pediatric Emergency
Medicine. 2006.