1cm STONE

Ureteral Stone - Upper (Proximal)

Classification:
There are three physiologic narrowing of the ureter where stones may obstruct. The first narrowing of the ureter is the location where the renal pelvis of the kidney meets the ureter or the uretero-pelvic junction (UPJ). The next level of narrowing is where the ureter crosses the iliac vessels. At this point, the diameter of the ureter is narrowed to about 4 mm and urinary obstruction by a calculus can commonly occur. The third ureteral narrowing exist where the intramural portion of the ureter meets the bladder known as the ureteral vesico-junction, or UVJ, which measures approximately 1 - 5 mm. in size. The majority of stones become stuck at this level. Once a calculus reaches the distal ureter and approaches the bladder, symptoms of vesicle irritation are frequently noted.

Clinical Presentation:
The usual manifestations of a kidney stone small enough to pass into the ureter are ureteral colic and hematuria. This patient presents with a stone in the upper ureter will frequently experience acute onset of a sharp, spasmodic pain localized to the flank (side). As the stone progresses downward to the level of the bladder, the pain remains sharp and intermittent, corresponding to the ureteral peristalsis. The pain will frequently radiate to the lateral flank and abdominal area and may be accompanied by nausea and vomiting. If infection accompanies obstruction, then the patient may develop fever and/or chills associated with an infection of the kidney, also known as pyelonephritis.

As the stone passes into the distal ureter, the pain remains sharp. In males, pain may frequently radiate to the inguinal canal into the groin and to the corresponding testicle. In females, the pain may radiate to the ipsilateral labia.

It is not uncommon for patients with ureteral colic to present with nausea and vomiting. Abdominal distention due to a reflex ileus may be present and may potentially confuse the diagnosis. These symptoms may mimic the presentation of other disease processes, including gastroenteritis, acute appendicitis, colitis, diverticulitis, salpingitis, cholecystitis and bowel obstruction.

Less frequently, the passage of the stone may be less dramatic with patients describing a dull ache in the flank (side) that may be present for weeks without interfering with his or her routine. This pain is not as localized as that of acute colic and may be confused with other complaints. Other patients may present with microscopic hematuria or gross hematuria and/or a urinary tract infection (UTI).

Once the calculus reaches the distal ureter and approaches the bladder, symptoms of bladder irritation, frequency, and nocturia may be present.

Diagnosis:
Based on the location of this stone, a KUB (a), an IVP (b), or unenhanced helical CT Scan (c) will likely demonstrate this stone.

UPJ stone  
Ureteral stone. Early enhanced CT scan shows stone in the left ureter (yellow arrowheads).

Treatment options:
UPJ stone
Flexible ureteroscopy is employed when treating patients in the upper ureter or renal pelvis. Various lithotripsy modalities for intracorporeal stone fragmentation can be used to fragment proximal or renal pelvis stones (see section on treatment methods of lithotripsy).

 

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