Batu atau benda lain yang berada di bagian atas atau tengah ureter sering menyebabkan nyeri ayng parah, nyeri punggunng (sudut costovertebral) atau nyeri pinggang. Nyeri dapat menjadi parah dan intermiten bila batu bergerak turun kebawah dan menyebabkan obstruksi intermiten. Batu yang menetap di bagian tertentu danpat menyebabkan nyeri yang ringan terutama jika hanya obstruksi parsial

Nyeri berhubungan dengan pengendapan mineral ureteral sering diproyeksikan ke dermatomal atau saraf spinal . Nyeri batu ureteral bagian atas terdapat pada region lumbal dan pinggang, Daerah midureter menyebabkan nyeri pada kaudal dan anterior menuju abdomen bagian tengah dan bawah.

3. Upper and midureterStones or other objects inthe upper or midureter often cause severe, sharp back (costovertebralangle) or flank pain. The pain may be moresevere and intermittent if the stone is progressing down theureter and causing intermittent obstruction. A stone thatbecomes lodged at a particular site may cause less pain,especially if it is only partially obstructive. Stationary calculithat result in high-grade but constant obstructionmay allow autoregulatory reflexes and pyelovenous andpyelolymphatic backflow to decompress the upper tract,with diminution in intraluminal pressure gradually easingthe pain. Pain associated with ureteral calculi often projectsto corresponding dermatomal and spinal nerve root innervationregions. The pain of upper ureteral stones thus radiatesto the lumbar region and flank. Midureteral calculitend to cause pain that radiates caudally and anteriorlytoward the mid and lower abdomen in a curved, band-likefashion. This band initially parallels the lower costal marginbut deviates caudad toward the bony pelvis andinguinal ligament. The pain may mimic acute appendicitisif on the right or acute diverticulitis if on the left side, especiallyif concurrent gastrointestinal symptoms are present.

Pengendapan mineral pada ureter bawah sering menyebabkan nyeri yang menyebar ke selangkangan atau testis pada pria dan labia mayor pada perempuan. Nyeri alih ini sering beraasah dari ilioinguinal atau cabang genital dari saraf genitofemoral. Batu pada ureter intramural dapat meniru gejala sisttis, uretrhitis atau prostatitis dengan menyebabkan nyeri suprapubil, frekuensi dan urgensi, disuria, stranguria atau gross hematuria.

4. Distal ureterCalculi in the lower ureter often causepain that radiates to the groin or testicle in males and thelabia majora in females. This referred pain is often generatedfrom the ilioinguinal or genital branch of the genitofemoralnerves. Diagnosis may be confused with testiculartorsion or epididymitis. Stones in the intramural uretermay mimic cystitis, urethritis, or prostatitis by causingsuprapubic pain, urinary frequency and urgency, dysuria,stranguria, or gross hematuria. Bowel symptoms are notuncommon. In women the diagnosis may be confusedwith menstrual pain, pelvic inflammatory disease, and rupturedor twisted ovarian cysts. Strictures of the distal ureterfrom radiation, operative injury, or previous endoscopicprocedures can present with similar symptoms. This painpattern is likely due to the similar innervation of the intramuralureter and bladder.

HematuriaHemaaturia yang muncul biasanya berupa gross hematuria, tetapi sekitar 10 -15% kasus pasien mengalami obstruksi tanpa mikrohematuria

EvaluasiDiferential diagnosisAppendisitis akut, kehamilan ektopik, patologi ovarium (kista ovaruim(, penyakit divertikel, Batu bilier dengan atau tanpa obstruksi, penyakit ulkus peptikum, emboli akut arteri renal, aneurisma aorta abdomen

EvaluationA. DIFFERENTIAL DIAGNOSISUrinary stones can mimic other retroperitoneal and peritonealpathologic states. A full differential diagnosis of theacute abdomen should be made, including acute appendicitis,ectopic and unrecognized pregnancies, ovarian pathologicconditions including twisted ovarian cysts, diverticulardisease, bowel obstruction, biliary stones with andwithout obstruction, peptic ulcer disease, acute renal arteryembolism, and abdominal aortic aneurysm, to mention afew. Peritoneal signs should be sought during physicalexamination.

Faktor RisikoKristaluriaSosioekonomiDietPekerjaanLingkunganRiwayat kluargaRiwayat pengobatan

B. HISTORYA proper evaluation requires a thorough medical history.The nature of the pain should be evaluated, including itsonset, character, potential radiation, activities that exacerbateor ease the pain, associated nausea and vomiting orgross hematuria, and a history of similar pain. Patientswith previous stones frequently have had similar types ofpain in the past, but not always.C. RISK FACTORS1. CrystalluriaCrystalluria is a risk factor for stones.Stone formers, especially those with calcium oxalate stones,frequently excrete more calcium oxalate crystals, and thosecrystals are larger than normal >12 mm). The rate of stoneformation is proportional to the percentage of large crystalsand crystal aggregates. Crystal production is determined bythe saturation of each salt and the urinary concentration ofinhibitors and promoters. Urine samples should be fresh;they should be centrifuged and examined immediately foroptimum results. Cystine crystals are hexagonal; struvitestones appear as coffin lids; brushite (CaHPO4) stones aresplinter-like and may aggregate with a spoke-like center;calcium apatite(Ca)5 (PO4)3 (OH)and uric acid crystalsappear as amorphous powder because the crystals areso small; calcium oxalate dihydrate stones are bipyramids;and calcium oxalate monohydrate stones are small biconcaveovals that may appear as a dumbbell. Cystine andstruvite crystals are always abnormal and require furtherinvestigations. Other

2. Socioeconomic factorsRenal stones are more commonin affluent, industrialized countries. Immigrants from

Figure 1613. Scout abdominal radiograph demonstratinghorseshoe kidney with lateral ureteral deviationand double-J ureteral stent. Extraosseous calcificationsare left lower calyceal stones.URINARY STONE DISEASE / 261less industrialized nations gradually increase their stoneincidence and eventually match that of the indigenouspopulation. Use of soft water does not decrease the incidenceof urinary stones.3. DietDiet may have a significant impact on the incidenceof urinary stones. As per capita income increases theaverage diet changes, with an increase in saturated andunsaturated fatty acids, an increase in animal protein andsugar, and a decrease in dietary fiber, vegetable protein,and unrefined carbohydrates. A less energy-dense diet maydecrease the incidence of stones. This fact has been documentedduring war years when diets containing minimalfat and protein resulted in a decreased incidence of stones.Vegetarians may have a decreased incidence of urinarystones. High sodium intake is associated with increasedurinary sodium, calcium, and pH, and a decreased excretionof citrate; this increases the likelihood of calcium saltcrystallization because the urinary saturation of monosodiumurate and calcium phosphate (brushite) is increased.Fluid intake and urine output may have an effect on urinarystone disease. The average daily urinary output instone formers is 1.6 L/day.4. OccupationOccupation can have an impact on theincidence of urinary stones. Physicians and other whitecollarworkers have an increased incidence of stones comparedwith manual laborers. This finding may be related todifferences in diet but also may be related to physical activity;physical activity may agitate urine and dislodge crystalaggregates. Individuals exposed to high temperatures maydevelop higher concentrations of solutes owing to dehydration,which may have an impact on the incidence ofstones.5. ClimateIndividuals living in hot climates are proneto dehydration, which results in an increased incidence ofurinary stones, especially uric acid calculi. Although heatmay cause a higher fluid intake, sweat loss results in loweredvoided volumes. Hot climates usually expose peopleto more ultraviolet light, increasing vitamin D3 production.Increased calcium and oxalate excretion has been correlatedwith increased exposure time to sunlight. This factorhas more impact on light-skinned people and may helpexplain why African Americans in the United States have adecreased stone incidence.6. Family historyA family history of urinary stones isassociated with an increased incidence of renal calculi. Apatient with stones is twice as likely as a stone-free cohortto have at least one first-degree relative with renal stones(30% versus 15%). Those with a family history of stoneshave an increased incidence of multiple and early recurrences.Spouses of patients with calcium oxalate stoneshave an increased incidence of stones; this may be relatedto environmental or dietary factors.7. MedicationsA thorough history of medicationstaken may provide valuable insight into the cause of urinarycalculi. The antihypertensive medication triamtereneis found as a component of several medications, includingDyazide, and has been associated with urinary calculi withincreasing frequency. Long-term use of antacids containingsilica has been associated with the development of silicatestones. Carbonic anhydrase inhibitors may be associatedwith urinary stone disease (1020% incidence). Thelong-term effect of sodium- and calcium-containing medicationson the development of renal calculi is not known.Protease inhibitors in immunocompromised patients areassociated with radiolucent calculi

Pemeriksaan Fisik

Pemeriksaan RadiologiFoto polos abdomenMelihat kemungkinan adanya batu radio-opak di saluran kemih. Bati-batu jenis kalsium oklsalat dan kalsium fosfat bersifat radio-opak dan paling sering diantara batu jenis lainnnya, sedangkan batu asam urat bersifat non-opak (radio-lusen).

Pielografi Intra VenaPemeriksaan ini bertujuan menilai keadaan anatomi dan fungsi ginjal. Slain itu dapat mendeteksi batu semi-opak ataupun batu non opak yang tidak dapat terlihat oleh foto polos abdomen. JIka IVP tidak dapat dilakukan karena akibat adanya penurunan fungsi ginjal, sebagi pengatinnya adalah pemeriksaan pielografi retrograde

UltrasonografiUSG dilakukan apabila pasien tidak mungkin menjalani pemeriksaan IVP, yaitu pada keadaan-keadaan: alergi terhadap bahan kontras, faal ginjal yang menurun, dan pada wanitahamil. Pemeriksaan SUG dapat menilai adanya batu di ginjal atau di buli-buli

Penatalaksanaan

MedikamentosaDitujukan untuk batu yang ukurannya kurang dari 5 mm. terapi bertuuan untuk mengurangi nyerim memperlancar aliran urine dengan pemberian diuretikum dan minum banyak

ESWL (Extracorporenal Shockwave Lithotripsy)Pemecahan batu dengan menggunakan gelombang kejut. Alat ini dapat memecahk batu tnapa melalui tindakan invasive dan tanpa pembiusan. Batu dipecah menjadi fragmen-fragmen kecil sehigga mudah dikeluarkan. Tidak jarang pecahan batu yang sedang keluar menimbulkan perasaan nyeri kolik dan menyebabkan hematuria.

EndoneurologiMerupakan tindakan invasive minimal untuk mengeluarkan batu saluran kemih yang terdiri atas memecah batu, dan kemudian mengeluarkannya dari saluran kemih melalui alat yang dimasukkan langsung ke dalam saluran kemih. Alat itu dimasukkan melalui uretra atau melalui insisi kecil pada kulit (perkutan). Beberapa tindakan endourologi:1. PNL (percutaneous Nephro Litholapaxy)Usaha mengeluarkan batu yang berada di dalam saluran ginjal dengan cara memasukkan alat endoskopi ke sistem kalises melalui insisi pada kulit. Batu kemudian dikeluarkan atau dipecah terlebih dahulu menjadi fragmen-fragmen kecil2. Litotripsi3. Ureteroskopi atau uretero-renoskopiMemasukkan alat ureteroskopi per-uretra guna melihat keadaan ureter atau sistem pielokaliks ginjal. Batu dipecah denan memakai energi tertentu melalui tuntunan ureteroskopi/ureterorenoskopi ini4.Ekstrasi DormiaMengeluarkan batu ureter dengan menjaring melalui alat keranjang dormia

Bedah laparoskopiPembedahan laparoskopi untuk mengambil batu saluran kemih

Bedah terbukaPembedahan terbuka antara lain pielolitotomi dan nefrolototomi pada ginjal dan ureterolitotomi pada ureter.