History

Urolithiasis in pregnancy poses a diagnostic challenge. Clinical manifestations of urolithiasis in pregnant patients often resemble signs and symptoms of pregnant patients without stones, not to mention many other sources of abdominal pathology (see DDx).^[13]

Flank pain (89%) and hematuria (95%) are the most common symptoms of kidney stones^[7]; however, these findings may also represent physiologic changes of pregnancy. Pregnancy-induced hydronephrosis can cause flank pain and even mimic renal colic,^[14]and microanatomic alterations in venous fragility of the collecting tubules may cause hematuria.^[15]Aside from its presentation in normal conditions, hematuria without discomfort is rare in the presence of a calculus.^[10]

Alternatively, pregnant patients with ureteral stones may report pain in atypical locations or the pain of premature labor. Signs of premature labor, ectopic pregnancy, or complicated labor often mimic clinical symptoms of renal-ureteral calculi. Therefore, maintaining a high degree of suspicion in all pregnant women with abdominal or pelvic pain, hematuria (gross or microscopic), or unresolved urinary tract infections is imperative.

The most common symptoms of urolithiasis of pregnancy include the following:

Flank pain
Pain radiating to the groin or labia
Nausea
Dysuria
Gross hematuria

Less-common symptoms of urolithiasis include the following:

Lower abdominal pain
Fever/chills
Vomiting

Other important historical findings pertinent to urolithiasis include the following:

Recurrent or persistent urinary tract infection (especially during the current pregnancy)
History of previous calculi, either in a previous pregnancy or in the nonpregnant state
Prior urologic surgery
History of prior complicated pregnancy or premature delivery

Sites of urolithiasis may be localized based on the patient's description of pain, as follows:

Urolithiasis that obstructs at the ureteropelvic junction generally manifests as deep flank pain without radiation to the groin
Urolithiasis within the mid-portion of the ureter can cause severe and intermittent pain, pain in the flank, and ipsilateral lower abdomen pain with radiation to the vulvar area
Urolithiasis in the distal ureter or ureterovesical junction may manifest as pain that radiates to the labia, and irritative voiding symptoms such as urinary frequency and dysuria

Physical Examination

Patients with renal colic are often extremely restless, exhibiting active movement on presentation. On inspection, the abdomen may be moderately distended, especially if the patient has coexisting ileus. On palpation, the abdomen is soft and tender in the upper quadrant. This differs significantly from the motionless presentation and rigid abdomen of a patient with peritonitis.

On auscultation, bowel sounds do not provide helpful clues because they may range from hyperactive to markedly diminished because the patient may have concurrent ileus. Other possible signs and symptoms include the following:

Costovertebral angle tenderness
Generalized flank tenderness
Voluntary guarding of the abdominal musculature

Differential Diagnoses

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Media Gallery

The arrow in this intravenous pyelogram of a gravid female indicates a filling defect at the ureterovesical junction. This finding is most likely consistent with a ureteral stone (distal).

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Author

Robert O Wayment, MD Urologist, Ogden Clinic Urology

Robert O Wayment, MD is a member of the following medical societies: American Urological Association, Western Section of the American Urological Association, Utah Urological Society

Disclosure: Nothing to disclose.

Coauthor(s)

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, Society of University Urologists

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Endourological Society Board of Directors; President Elect North Central Section of the American Urological Association<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eleanor Lederer, MD, FASN Professor of Medicine, Chief, Nephrology Division, Director, Nephrology Training Program, Director, Metabolic Stone Clinic, Kidney Disease Program, University of Louisville School of Medicine; Consulting Staff, Louisville Veterans Affairs Hospital

Eleanor Lederer, MD, FASN is a member of the following medical societies: American Association for the Advancement of Science, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: American Society of Nephrology<br/>Received income in an amount equal to or greater than $250 from: Healthcare Quality Strategies, Inc.

Chief Editor

Acknowledgements

Jeffrey B Garris, MD Chief, Assistant Professor, Department of Obstetrics and Gynecology, Division of Urogynecology and Reconstructive Pelvic Surgery, Tulane University School of Medicine

Jeffrey B Garris, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, American Urological Association, Association of Professors of Gynecology and Obstetrics, Louisiana State Medical Society, Royal Society of Medicine, and Sigma Xi

Disclosure: Nothing to disclose.

Rajesh Prasad, MD Staff Physician, Department of Surgery, Division of Urology, University of Cincinnati Medical Center

Disclosure: Nothing to disclose.

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