Methodological Instructions for Students icon

Methodological Instructions for Students




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НазваMethodological Instructions for Students
Дата29.06.2012
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Methodological Instructions for Students



Theme: Urinary Stones (Urolithiasis).

Aim: To study symptoms, signs and laboratory findings of urolithiasis, its complications, indications for conservative and surgical treatment. Typical diagnostic and tactical mistakes and ways of prevention.

Professional Motivation:

Urinary lithiasis is one of the most common diseases of the urinary tract, it is known from the ancient times. It’s frequency among all urologic diseases is from 30 to 45%. Now there is some predominance of women among the patients, especially with corallire stones.

Basic Level:

1. Anatomy and physiology of urinary tract.

2. To know how to collect life history and physical examination.

3. Etiology and pathogenesis of the urolithiasis.

4. X-Ray, instrumental, laboratory, endoscopic methods in urolithiasis diagnosis.

5. Conservative measures of etiologic, pathogenetic and symptomatic treatment.

Students' Independent Study Program.

I. Objectives for Students' Independent Studies.

You should prepare for the practical class using the existing textbooks and lectures. Special attention should be paid to the following:

1. General clinical symptoms of the urinary stones.

The following factors are known to influence the formation and growth of uroliths: hyperexcretion of relatively insoluble urinary constituents (calcium, oxalate, cystine, uric acid xanthine, silicon dioxide), physical changes which occurs in the urine, a nidus (core or "nucleus")upon which precipitation occurs, structural anomalies, including calicestasis and medullary sponge kidney. There are such kinds of urinary stones: phosphate, oxalate, ammonium phosphate, cystine, uric acid, xanthine. If the stone is submucosal or adherent to the parenchyma there are no symptoms; if it obstructs the calix or the uretero-pelvic junction the colic will be due to hyperperistalsis. The main symptoms are the followings pain in loin, hematuria, passage of salts and stones. The intensity and irradiation of pain depends upon its location.

A dull pain is typical for hardly mobile stones. It is intensified while movements and great introduction of fluid and manifests as renal colic. It may be caused by sudden obstruction of the upper urinary tract and continues for different term. It is accompanied by general weakness, dryness in mouth, headache, fever, disuria, excitement. The lower stone passes the disuria intensifies. Micro and gross hematuria appears due to injury, pyelonephritis, venostasis of the mucosa of the calyces, renal pelvis, ureter. It stops after the complete obstruction. Ache precedes hematuria. Other diseases followed with hematuria are characterized the notifying the blood in urine by patient by himself initially and then ache appears. Massive hematuria may appear due to large stone that don’t completely obstruct urinary tract after long driving. This bleeding stops soon, but may relapse.

Complication of the urinary stone disease is the hydronephrotic degeneration of the kidney. It may not be manifested for a long period. In case of complete destruction of both kidneys because of pyelonephritis and hydronephrosis anuria develops as a terminal phase of the disease. Anuria is a result of chronic renal insufficiency. Anuria appears owing to obstruction of the ureter of the single kidney (that left after the removal of another kidney or congenital the only kidney) commonly. The reflective anuria appears when the second kidney dysfunction is present on account of circulative and spastic changes at the opposite side while renal colic.

2. Proving and formulation of clinical diagnosis.

Tenderness in the controverbal angle or over the kidney may or may not be present. Acute renal infection may cause more definite findings. The white blood cells may be increased in the blood count; protein may be noted because there is presence of hematuria, pus cells and bacteria may be seen. Renal function tests may be normal or depressed in case of bilateral obstruction. 90 % of renal stones are radiopaque and readily visible on a plain film of the abdomen unless they're small or overlie bone. Isotope studies may prove in farther assessing of X-ray examination.

3. Differential diagnosis with renal tumors, renal tuberculosis, nonspecific renal infections, acute surgical pathology of abdominal cavity.

Urography will establish the differential diagnosis with renal tumors, renal tuberculosis; nonspecific renal infections have the other symptoms of acute process: high temperature, dysuria, hyper-gamma-globulinemia etc. ; acute surgical pathology of abdominal cavity show other physical symptoms of abdominal pathology.

4. Medical tactics in patients with urinary stones: indications and contrindications to the surgical and conservative treatment.

Conservative treatment is neccesary in the following cases: submucosal stones, a small stone trapped in the minor calix and causing few of any symptoms, in the elderly poor-risk patients a coralline stone; is best left alone unless it causes significant symptoms, stones due to renal tubular acidosis. Surgical measures – removing of the stone are indicated if the stone is obstructive and саises due pain or progressive renal damage or if the infection complicated the stone can not be eradicated. To prevent relapsing the local reasons of relapses should be eradicated. Pyelolithtomy is used often. Depending the wall incised the anterior, posterior, superior and inferior methods of pyelolithotomy are differed. The most common is posterior pyelolithotomy because there are magistral vessels going across the anterior surface of the renal pelvis. Operation is performed “in situ”. The kidney isn’t mobilized from the surrounding tissues an dislocated into the operative wound.

Key words and phrases: urolithiasis, urinary stones, urinary tract, surgical and conservative treatment of urolithiasis.

^ II. Tests and Assignments for Self-assesment:

Multiply choice. Choose the correct answer/statement:

1. What kinds of stones formes in alkaline urine?

A. Phosphate.

B. Urate.

C. Cystine.

D. Oxalate.

2. The method to confirm renal colic is:

A. Urography.

B. Ultrasonography..

C. Chromocystoscopy.

D. Cystoscopy.

E. Retrograde pyelography.

Real life situations to be solved.

1. Patient S., 52 years old, complains on intensive pain in right iliac and lumbal regions, painful excretion of urine. Region of right ureter is tenderness, Pasternatski’y symptom present on the right side. No shades was found on urogram. What is the preliminary diagnose? What is the differential diagnose? What method is necessary to hold the specificity of the diagnosis?

2. In patient L., 34 years old, there is typical renal colic, but no changes in the urine analysis were found. What diagnostic procedure is necessary to specify the diagnosis? How can you explain absence of any changes in urine analysis?

^ III. Answers to the Self-Assesment.

The correct answers to the tests:

1-А.

2-C.

The correct answers to the real situations:

1-renal colic on the right side; appendicite; chromocystoscopy, ultrasonography, retrograde pneumoweteropyelography;

2-urography and excretory urography; if there is total ureter obstruction normal urine will arrive to the urinary bladder from the second kidney.

Work 1. Prove and formulate clinical diagnosis.

Student takes complains, disease and life history of the patient, physical examination, detects main clinical signs of the urolithiasis, forms diagnostic programme, formulates diagnosis

Questions for the student:

1. What are the clinical symptoms of urolithiasis?

2. What are the complications of urolithiasis?

3. What are the main methods of examination of the patients with urolithiasis?

Work 2. Make differential diagnosis of urolithiasis.

Student make differentional diagnosis of urolithiasis, using complains of disease and life history physical examination, laboratory and sonography signs.

Questions for the student:

1. What diseases it is necessary to differentiate?

2. What is the medical tactics in the patients with urolithiasis?

3. What are the modern methods of urolithiasis treatment?

Visual aids and material tools:

1. Slides:

1. 1 Different kinds of pyeloureteroplasty.

1. 2 Nephrectomy.

1. 3 Pyelolithotomy.

2. Pictures on the stand: urinary bladder stones.

3. Roentgenograms:

3. 1 Urography – stones of different regions of urinary tract.

3. 2 Excretory urography – ureteral stone.

3. 3 Excretory urography – coralline renal stone.

3. 4 Retrograde pyelography – coralline renal stone.

3. 5 Retrograde pneumoureterography – ureteral stone.

3. 6 Retrograde pneumoureteropyelography – renal stone.

3. 7 Urography – ureteral stone extraction.

Students Practical Activities:

Student must know:

1. Etiology and pathogenesis of the urolithiasis.

2. Chemical characteristics and conditions of the urinary stones formation.

3. Symptoms and clinical cdurse of the renal and ureteral stones.

4. Renal and ureteral stones diagnosis.

5. Differential diagnosis of the renal colic and acute surgical pathology of the abdominal cavity.

6. Conservative treatment of renal and ureteral stones.

7. Surgical treatment of renal and ureteral stones.

8. Treatment of renal colic.

9. Urolithiasis in childs and pregnants.

10. Complications of urolithiasis.

11. Reason and diagnostic of the urinary bladder stones.

12. Differential diagnostic of the urinary bladder stones.

13. Medical tactics in patients with urinary bladder stones.

Students should be able to:

1. Detect main clinical signs of the urinary stones.

2. Define necessary quantity and sequence of patients examination: physical, laboratory, roentgenological, endovesical.

3. Should be able to detect signs ofurolithiasis on urograms, excretory urograms with different contrasts and oxygen, retrograde ureteropyelograms etc.

4. Prove and formulate clinical diagnosis.

5. Spend differential diagnosis.

6. Prove conservative treatment and indications for the conservative treatment.

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