What is the diagnosis for a patient presenting with hematuria (blood in urine) and computed tomography (CT) scan results showing nephrolithiasis (kidney stones) without hydronephrosis (kidney swelling)?

From the Guidelines

For hematuria with CT findings of nephrolithiasis without hydronephrosis, I strongly recommend a thorough evaluation and management approach that prioritizes the patient's morbidity, mortality, and quality of life, including increased fluid intake, pain management, and close monitoring for potential complications, as outlined in the ACR Appropriateness Criteria for hematuria 1.

Initial Management

The patient should be advised to increase fluid intake to at least 2-3 liters daily to promote stone passage. Pain management using NSAIDs like ibuprofen (400-600mg every 6-8 hours) or prescription medications if pain is severe is also recommended. The absence of hydronephrosis suggests the stone is not causing significant urinary obstruction, which is reassuring, as noted in the ACR Appropriateness Criteria for hematuria 1.

Monitoring and Follow-up

Most kidney stones smaller than 5mm will pass spontaneously within 1-2 weeks with conservative management. During this time, straining all urine through a fine mesh to catch any passed stones for analysis is crucial. Medical expulsive therapy with tamsulosin 0.4mg daily may help facilitate stone passage if the stone is located in the ureter. If symptoms worsen (fever, uncontrolled pain, vomiting), seeking immediate medical attention is necessary as this could indicate infection or obstruction.

Prevention and Dietary Modifications

Follow-up with a urologist within 1-2 weeks to monitor stone progression and discuss prevention strategies based on stone composition is essential. Dietary modifications like reducing sodium, animal protein, and oxalate-rich foods may help prevent recurrence, though specific recommendations depend on stone composition, as suggested by the guidelines for managing hematuria 1.

Key Considerations

It is crucial to consider the patient's overall health status, including any potential risk factors for malignancy, such as gross hematuria, male gender, age >35 years, smoking, and occupational exposure to chemicals, as outlined in the ACR Appropriateness Criteria for hematuria 1. However, in this case, the presence of nephrolithiasis without hydronephrosis and the absence of other alarming symptoms suggest a more benign cause of hematuria. Nonetheless, close monitoring and follow-up are necessary to ensure the patient's condition does not worsen.

From the Research

Presentation of Nephrolithiasis

• Nephrolithiasis typically presents with acute flank or abdominal pain, nausea, vomiting, and hematuria 2
• Hematuria is present in 90% of cases, but its absence does not rule out nephrolithiasis 2
• The primary care physician has a responsibility to recognize and treat acute stone passage, as well as ensure that the patient with recurrent stones has metabolic evaluation and appropriate preventive care 3

Diagnostic Workup

• The diagnostic workup for nephrolithiasis consists of urinalysis, urine culture, and imaging to confirm the diagnosis and assess for conditions requiring active stone removal 4
• Imaging studies, such as non-contrast computed tomography of the abdomen and pelvis, can help identify the presence of stones and assess for hydronephrosis 5
• Urinalysis is an important screening test for patients presenting with symptoms suspicious for urolithiasis, and the presence of microscopic hematuria can be an indicator of ureteral stones 5

Management and Prevention

• Conservative management of nephrolithiasis consists of pain control, medical expulsive therapy with an alpha blocker, and follow-up imaging within 14 days to monitor stone position and assess for hydronephrosis 4
• Lifestyle modifications, such as increased fluid intake, should be recommended for all patients with kidney stones, and thiazide diuretics, allopurinol, or citrates should be prescribed for patients with recurrent calcium stones 4
• Metabolic evaluation may be indicated after a second episode of nephrolithiasis in adults or after a first episode in children or those with a family history of nephrolithiasis 2

Complications and Differential Diagnoses

• Nephrolithiasis can be associated with complications such as urinary tract infection, hydronephrosis, and renal failure 3
• Other differential diagnoses, such as Page kidney, should be considered in patients presenting with flank pain and hematuria, even if nephrolithiasis is suspected 6
• Page kidney is a diagnosis that describes compression of the renal parenchyma by a hematoma or mass causing secondary hypertension through the activation of the renin-angiotensin-aldosterone system 6