URETEROLITHIASIS

Ureterolithiasis is when kidney stones, or a kidney stone (also called calculus /

calculi) are formed in the ureters, hence the name ureterolithiasis.
Ureters are the ducts that move urine along from the kidneys to the urinary
bladder, also called cloaca.
Ureterolithiasis in its original Greek literally means "Urine Stone".
Ureterolithiasis is relatively common and kidney stones have been plaguing
mankind for many centuries.
Ureterolithiasis or kidney stones can cause a painful condition called a renal
colic attack in which either one or both of the ureters become blocked by
kidney stones.
Ureterolithiasis can cause a condition called renal colic. Renal colic is often
described as the strongest and most unbearable pain a person has ever felt in
their lives.
75 to 85 percent of kidney stones or calculi are calcium stones. About half of
ureterolithiasis or caluli are composed of both oxalate and calcium
phosophate.
The causes of kidney stones or ureterolithiasis vary. One in twenty people will
suffer from ureterolithiasis or kidney stones at some point in their lives, or 12
percent of the world population.
Various causes of kidney stones:

Eating habits or diet can cause ureterolithiasis (High animal protein,

sodium and sugar intake)
High calcium levels in urine or blood
Lack of fluid intake (Not drinking enough water)
Genetic disposition or family history of ureterolithiasis
Cystic kidney disease can cause ureterolithiasis
Metabolic disorders
Persisting urinary tract infections
High intake and saturation of vitamin C and D can cause kidney stones

Men are more likely than women to develop kidney stones (3 times more than
women), and the age most likely for them to develop is between 20 and 30
years old.

Genetics also play a role. The likelihood of dealing with kidney stones in a
persons life rises dramatically if other people in the family have dealt with
ureterolithiasis.
To find out how to diagnose a patient for kidney stones, a doctor will look at
the family history of ureterolithiasis.
During the kidney stone diagnosis they will also do a physical examination of
the patient and run urinalysis and radiographic studies.
A doctor can make a diagnosis by looking at the intensity and location of the
pain in a patient.
It is sometimes difficult figuring out how to diagnose kidney stones because
the pain is not usually constant. It sometimes comes and goes in waves and
spasms hampering efforts to diagnose ureterolithiasis.
Back pain may be present when they begin to create an obstruction. There
may be tenderness on the side where the kidney stones are located.
Kidney stone symptoms and the signs of kidney stones are easy to diagnose:

Symptoms of a kidney stone or multiple stones include vomiting

Signs may include vitamin A or vitamin C deficiency in the body
A stone, or multiple stones can cause decreased urine production
Excruciating pain radiating from side, back to groin or abdomen
Fever, night chills and sweats are symptoms
Frequent urination and pain during urination
A stone can cause pain that changes and fluxuates with intensity
Stones can cause redish, brownish urine that may have an odor
Wondering how to treat kidney stones or ureterolithiasis or trying to find
treatment options?
One treatment option is drinking lots of fluids or water to flush out the
urine. This may help small kidney stones pass through the urine.

Drinking a lot of water to treat kidney stones may also help prevent
future ureterolithiasis from happening and stop them from forming
altogether.

Water flushes out your body of excess vitamins and minerals which can
build up over time, causing ureterolithiasis.
Lithrotripsy treatment may be used to treat a person with ureterolithiasis
who has larger kidney stones that refuse to pass through the urine.
(ureterolithiasis.com)
Knowing the type of kidney stone helps determine the cause and may give clues on
how to reduce your risk of getting more kidney stones. Types of kidney stones
include:

Calcium stones. Most kidney stones are calcium stones, usually in the form
of calcium oxalate. Oxalate is a naturally occurring substance found in food.
Some fruits and vegetables, as well as nuts and chocolate, have high oxalate
levels. Your liver also produces oxalate. Dietary factors, high doses of vitamin D,
intestinal bypass surgery and several metabolic disorders can increase the
concentration of calcium or oxalate in urine. Calcium stones may also occur in the
form of calcium phosphate.

Struvite stones. Struvite stones form in response to an infection, such as a

urinary tract infection. These stones can grow quickly and become quite large,
sometimes with few symptoms or little warning.

Uric acid stones. Uric acid stones can form in people who don't drink enough
fluids or who lose too much fluid, those who eat a high-protein diet, and those
who have gout. Certain genetic factors also may increase your risk of uric acid
stones.

Cystine stones. These stones form in people with a hereditary disorder that
causes the kidneys to excrete too much of certain amino acids (cystinuria).

Other stones. Other, rarer types of kidney stones also can occur.

INFX
his recent article addresses an issue that receives little attention in the emergency medicine literature.
It attempts to determine whether a midstream clean-catch urine culture is an adequate test to define
the presence or absence of a urinary tract infection in patients who have an obstructing kidney stone.
The authors reiterate the common axiom that an obstructed ureter with stagnant urine is a potential
source for serious infection. In general, the definition of the UTI is based on an examination of the
urine for bacteriuria, leukocytes, and eventually a urine culture. That usually means obtaining urine
from the bladder, either with a spontaneously voided specimen or a catheter.

In urologic circles, prior to elective endoscopic manipulation of uncomplicated stones, it is desirable to

have a negative urine culture. In addition, procedures performed to remove stones (ureterorenoscopy
[URS] or lithotripsy) can themselves introduce systemic infection. Prophylactic antibiotic coverage is
the norm prior to urinary tract manipulation, even when dealing with a sterile milieu. When possible,
urologists avoid elective stone manipulation, surgically or with ultrasound, until they confirm a sterile
culture. In some cases, the stone itself is infected, and fragmentation of the calculus can release
bacteria into the urine and then systemically. In the ED, however, decisions about infection in the
presence of a stone can be problematic, yet important clinical interventions must be made with limited
information.
The authors indicate that in their practice, patients undergoing elective ureteroscopic procedures all
will be subjected to a midstream urine culture and sensitivity a week prior to the procedure. If an
infection is proven, antibiotics are administered prior to any surgical intervention. Another sterile urine
is required prior to rescheduling the surgery. Even if the patient has a sterile urine, prophylactic
antibiotics are used during the procedure.
Patients excluded from the trial were those at high risk for infection, including those with renal failure,
diabetes, immunocompromise, or previous manipulations or urologic procedures. Essentially, these
were otherwise healthy patients who had a stone, and represented a population unlikely to become
septic from either the stone or the procedure. Despite one's best intentions, an obstructed ureter and
a proximal urine infection often add up to sepsis in rapid fashion. These authors attempted to
determine whether a midstream urine culture and sensitivity urine that is distal to an obstruction
could reliably identify infected urine proximal to the stone.

UTI
A urinary tract infection (UTI) is an infection involving the kidneys, ureters, bladder, or urethra.
These are the structures that urine passes through before being eliminated from the body.

The kidneys are a pair of small organs that lie on either side of the spine at about waist
level. They have several important functions in the body, including removing waste and
excess water from the blood and eliminating them as urine. These functions make them
important in the regulation of blood pressure. Kidneys are also very sensitive to changes in
blood sugar levels and blood pressure and electrolyte balance.
Bothdiabetes and hypertension can cause damage to these organs.

Two ureters, narrow tubes about 10 inches long, drain urine from each kidney into the
bladder.

The bladder is a small saclike organ that collects and stores urine. When the urine
reaches a certain level in the bladder, we experience the sensation that we have to void,
then the muscle lining the bladder can be voluntarily contracted to expel the urine.

The urethra is a small tube connecting the bladder with the outside of the body. A muscle
called the urinary sphincter, located at the junction of the bladder and the urethra, must relax
at the same time the bladder contracts to expel urine.

Any part of this system can become infected. As a rule, the farther up in the urinary tract the
infection is located, the more serious it is.

The upper urinary tract is composed of the kidneys and ureters. Infection in the upper
urinary tract generally affects the kidneys (pyelonephritis), which can
cause fever, chills, nausea, vomiting, and other severe symptoms.

The lower urinary tract consists of the bladder and the urethra. Infection in the lower
urinary tract can affect the urethra (urethritis) or the bladder (cystitis).

In the United States, urinary tract infections account for more than 7 million visits to medical
offices and hospitals each year.

Urinary tract infections are much more common in adults than in children, but about 1%2% of children do get urinary tract infections.Urinary tract infections in children are more
likely to be serious than those in adults (especially in younger children).

Urinary tract infection is the most common urinary tract problem in children
besides bedwetting.

Urinary tract infection is second only to respiratory infection as the most common type of
infection.

These infections are much more common in girls and women than in boys and men
younger than 50 years of age. The reason for this is not well understood, but anatomic
differences between the genders (a shorter urethra in women) might be partially
responsible.

About 40% of women and 12% of men have a urinary tract infection at some time in their
life.

What causes a urinary tract infection?

The urine is normally sterile. An infection occurs when bacteria get into the urine and begin to
grow. The infection usually starts at the opening of the urethra where the urine leaves the body
and moves upward into the urinary tract.

The culprit in at least 90% of uncomplicated infections is a type of bacteria

called Escherichia coli, better know as E. coli. These bacteria normally live in the bowel
(colon) and around the anus.
These bacteria can move from the area around the anus to the opening of the urethra.
The two most common causes of this are improper wiping and sexualintercourse.

Usually, the act of emptying the bladder (urinating) flushes the bacteria out of the urethra.
If there are too many bacteria, urinating may not stop their spread.

The bacteria can travel up the urethra to the bladder, where they can grow and cause an
infection.

The infection can spread further as the bacteria move up from the bladder via the ureters.

If they reach the kidney, they can cause a kidney infection (pyelonephritis), which can
become a very serious condition if not treated promptly.

The following people are at increased risk of urinary tract infection:

People with conditions that block (obstruct) the urinary tract, such askidney stones

People with medical conditions that cause incomplete bladder emptying (for example,
spinal cord injury or bladder decompensation aftermenopause)

People with suppressed immune systems: Examples of situations in which the immune
system is suppressed are HIV/AIDS and diabetes. People who take immunosuppressant
medications such aschemotherapy for cancer also are at increased risk.

Women who are sexually active: Sexual intercourse can introduce larger numbers of
bacteria into the bladder. Urinating after intercourse seems to decrease the likelihood of
developing a urinary tract infection.

Women who use a diaphragm for birth control

Men with an enlarged prostate: Prostatitis or obstruction of the urethra by an enlarged

prostate can lead to incomplete bladder emptying, thus increasing the risk of infection. This
is most common in older men.

Males are also less likely to develop UTIs because their urethra (tube from the bladder) is
longer. There is a drier environment where a man's urethra meets the outside world, and
fluid produced in the prostate can fight bacteria.

Breastfeeding has been found to decrease the risk for urinary tract infections in children.

The following special groups may be at increased risk of urinary tract infection:

Very young infants: Bacteria gain entry to the urinary tract via the bloodstream from other
sites in the body.

Young children: Young children have trouble wiping themselves and washing their hands
well after a bowel movement. Poor hygiene has been linked to an increased frequency of
urinary tract infections.

Children of all ages: Urinary tract infection in children can be (but is not always) a sign of
an abnormality in the urinary tract, usually a partial blockage. An example is a condition in
which urine moves backward from the bladder up the ureters (vesicoureteral reflux).

Hospitalized patients or nursing-home residents: Many of these individuals are

catheterized for long periods and are thus vulnerable to infection of the urinary tract.
Catheterization means that a thin tube (catheter) is placed in the urethra to drain urine from
the bladder. This is done for people who have problems urinating or cannot reach a toilet to
urinate on their own.

What are urinary tract infectionsymptoms and signs?

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Lower urinary tract infection

Bladder (cystitis): The lining of the urethra and bladder becomes inflamed and irritated.

Dysuria: pain or burning during urination

Frequency: more frequent urination (or waking up at night to urinate, sometimes referred
to as nocturia); often with only a small amount of urine

Urinary urgency: the sensation of having to urinate urgently

Cloudy, bad-smelling, or bloody urine

Lower abdominal pain or pelvic pressure

Mild fever (less than 101 F), chills, and "just not feeling well" (malaise)

Urethra (urethritis): Burning with urination

Upper urinary tract infection (pyelonephritis)

Symptoms develop rapidly and may or may not include the symptoms for a lower urinary tract
infection.

Fairly high fever (higher than 101 F)

Shaking chills

Nausea

Vomiting

Flank pain: pain in the back or side, usually on only one side at about waist level

In newborns, infants, children, and elderly people, the classic symptoms of a urinary tract
infection may not be present. Other symptoms may indicate a urinary tract infection.

Newborns: fever or hypothermia (low temperature), poor feeding,jaundice

Infants: vomiting, diarrhea, fever, poor feeding, not thriving

Children: irritability, eating poorly, unexplained fever that doesn't go away, loss of bowel
control, loose bowels, change in urination pattern

Elderly people: fever or hypothermia, poor appetite, lethargy, change in mental status

Pregnant women are at increased risk for an UTI. Typically, pregnant women do not have
unusual or unique symptoms. If a woman is pregnant, her urine should be checked during
prenatal visits because an unrecognized infection can cause pregnancy complications.
Although most people have symptoms with a urinary tract infection, some do not.
The symptoms of urinary tract infection can resemble those of sexually transmitted diseases.
A urinary tract infection may result when bacteria become trapped in urine that pools above a blockage.

Diagnosis of a urinary tract infection is based on information someone gives about his or her
symptoms, medical and surgical history, medications, habits, and lifestyle. A physical
examination and lab tests complete the evaluation.
A doctor may simply perform a urine dipstick test in the office. Only a few minutes are needed to
obtain results. A doctor may also send a urine sample to the lab for culture testing (see below).
These results take a few days to come back. This tells the doctor the exact bacteria causing the
infection and to which antibiotics these bacteria have resistance or sensitivity. The culture is
usually sent for special populations, including men, because they are less likely to get UTIs. It is
not necessary to send a culture for everyone because the majority of UTIs are caused by the
same bacteria.

The single most important lab test isurinalysis. A urine sample will be tested for signs of
infection, such as the presence of white blood cells and bacteria.

In certain circumstances, urine also may be "cultured." This means that a small amount
of the urine is brushed on a sterile nutrient substance in a plasticplate. The plate is allowed
to sit for a few days and then examined to see what kind of bacteria are growing on it.
These bacteria are treated with different antibiotics to see which works best against them.
This helps determine the best treatment for the specific infection.

Blood tests usually are not required unless a complicated condition, such as
pyelonephritis or kidney failure, is suspected.

For a culture specimen, the patient will be asked to give a clean-catch, midstream urine
specimen. This avoids contamination of the urine with bacteria from the skin. Patients will be
instructed in how to do this.

Midstream means urinating a little into the toilet before collecting a specimen. The idea is
to avoid collecting the urine that comes out first, as this urine is often contaminated.

Clean-catch refers to a midstream sample that was collected after cleaning the area of
the urethral opening.

Adult women and older girls: Cleanse the area around the urethral opening gently (but
completely) using a sterile wipe or soap and water. Catch the urine midstream. For some
women, catheterization (inserting a tube into the bladder) may be the only way to obtain a
sterile, uncontaminated specimen.

Men and boys: A sterile specimen can usually be obtained with a midstream catch.
Uncircumcised males should retract the foreskin and cleanse the area before urinating.

Newborns: Urine may be obtained with a catheter or a procedure in which a needle is

introduced through the lower abdominal wall to draw (aspirate) urine from the bladder.

Infants and children: Either catheterization or the needle aspiration method is used.

If someone cannot produce a urine specimen or is unable to follow instructions for a clean-catch
specimen, a health-care professional may obtain a urine specimen by catheterization.

This means placing a thin tube (catheter) in the urethra to drain urine from the bladder.

The catheter usually is removed after the bladder is emptied.

The catheter may remain in place if someone is very ill or if it is necessary to collect all
urine or measure urine output.

Depending on their symptoms, sexually active women could require a pelvic examination
because pelvic infections can have similar symptoms as a urinary tract infection. Males will
require a genital examination, and depending on the symptoms, most likely a prostate
examination. A prostate infection (prostatitis) requires a longer course of antibiotics than a urinary
tract infection.
Men will most likely require a rectal examination so that the prostate can be checked. A prostate
infection (prostatitis) requires a longer course of antibiotics than a urinary tract infection.
In some cases, an imaging test may be indicated to detect any underlying problem in the urinary
tract that could cause an infection. This is usually only necessary in repeat infections or special
circumstances (unusual bacteria, suspected anatomic abnormalities).

An ultrasound examination can evaluate kidney and bladder problems.

A fluoroscopic study can show any physical problems that predispose children to urinary
tract infections.

Intravenous pyelogram (IVP) is a special series of X-rays that uses a contrast dye to
highlight abnormalities in the urinary tract.

Cystoscopy involves insertion of a thin, flexible tube with a tiny camera on the end
through the urethra into the bladder. This allows detection of abnormalities inside the
bladder that might contribute to infections.

A CT scan gives a very detailed three-dimensional picture of the urinary tract.

Imaging tests are most often needed for the following groups:

Children with urinary tract infections, especially boys

Up to 50% of infants and 30% of older children with a urinary tract infection have an
anatomic abnormality. The child's pediatrician should investigate this possibility.

Adults with frequent or recurrent urinary tract infections

People who have blood in the urine

What is the treatment for a urinary tract infection?

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The usual treatment for both simple and complicated urinary tract infections is antibiotics. The
type of antibiotic and duration of treatment depend on the circumstances.

Lower urinary tract infection (cystitis)

In an otherwise healthy person, a three-day course of antibiotics is usually enough. Some

providers prefer a seven-day course of antibiotics. Occasionally, a single dose of an
antibiotic is used. A health-care professional will determine which of these options is best.

In adult males, if the prostate is also infected (prostatitis), four weeks or more of antibiotic
treatment may be required.

Adult females with potential for or early involvement of the kidneys, urinary tract
abnormalities, or diabetes are usually given a five- to seven-day course of antibiotics.

Children with uncomplicated cystitis are usually given a 10-day course of antibiotics.

To alleviate burning pain during urination, phenazopyridine (Pyridium) or a similar drug,

can be used in addition to antibiotics for one to two days.

Upper urinary tract infection (pyelonephritis)

Young, otherwise healthy patients with symptoms of pyelonephritis can be treated as

outpatients. They may receive IV fluids and antibiotics or an injection of antibiotics in the
emergency department, followed by 10-14 days of oral antibiotics. They should follow up
with their health-care professional in one to two days to monitor improvement.

If someone is very ill, dehydrated, or unable to keep anything in his or her stomach
because of vomiting, an IV will be inserted into the arm. He or she will be admitted to the

hospital and given fluids and antibiotics through the IV until he/she is well enough to switch
to an oral antibiotic.

A complicated infection may require treatment for several weeks.

A person may be hospitalized if he or she has symptoms of pyelonephritis and any of the
following:

Appear very ill

Are pregnant

Have not gotten better with outpatient antibiotic treatment

Have underlying diseases that compromise the immune system (diabetes is one
example) or are taking immunosuppressive medication

Are unable to keep anything in the stomach because of nausea or vomiting

Had previous kidney disease, especially pyelonephritis, within the last 30 days

Have a device such as a urinary catheter in place

Have kidney stones

Urethritis in men and women can be caused by the same bacteria as sexually transmitted
diseases (STDs). Therefore, people with symptoms of STDs (vaginal or penile discharge for
example) should be treated with appropriate antibiotics.

What follow-up is needed for a urinary tract infection?

Follow a health-care professional's treatment recommendations. Finish all medications even if
feeling better before the medication is gone. A health-care professional will want the patient to
have a follow-up appointment to repeat the urinalysis and make sure he or she is getting better.

Children and adults with kidney involvement should be seen again in one to two days.

People recovering from uncomplicated lower urinary tract infections should be seen
within one week.

Occasionally, the infection does not go away with the first treatment. If someone is being treated
for an infection and has any of the following, call a health-care professional promptly:

Fever or pain with urination is not gone after two days of antibiotic treatment.

Someone cannot keep the medication down or it has severe side effects.

Someone is unable to keep foods, fluids, or medication down because of nausea or

vomiting.

Someone develops signs of kidney involvement (such as flank pain, shaking chills, high
fever).

Someone's symptoms are worse rather than better after two days of antibiotics.

IVP

Intravenous pyelogram
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An intravenous pyelogram (IVP) is a special x-ray examination of the kidneys, bladder, and ureters
(the tubes that carry urine from the kidneys to the bladder).
How the Test is Performed
An IVP is done in a hospital radiology department or a health care providers office by an x-ray
technologist.
You will need to empty your bladder immediately before the procedure starts.
The health care provider will inject an iodine-based contrast (dye) into a vein in your arm. A series of
x-ray images are taken at different times to see how the kidneys remove the dye and how it collects in
your urine.
A compression device (a wide belt containing two balloons that can be inflated) may be used to keep
the contrast material in the kidneys.
You will need to remain still during the procedure, which may take up to an hour.
Before the final image is taken, you will be asked to urinate again, to see how well the bladder has
emptied.
You can resume your normal diet and medications after the procedure. You should drink plenty of
fluids to help remove all the contrast dye from your body.
How to Prepare for the Test
As with all x-ray procedures, tell your health care provider if you:

Are allergic to contrast material

Are pregnant

Have any drug allergies

Your health care provider will tell you whether you can eat or drink before this test. You may be given
a laxative to take the afternoon before the procedure to clear the intestines so your kidneys can be
clearly seen.

You must sign a consent form. You will be asked to wear a hospital gown and to remove all jewelry.
How the Test will Feel
You may feel a burning or flushing sensation in your arm and body as the contrast dye is injected. You
may also have a metallic taste in your mouth. This is normal and will quickly disappear.
Some people develop a headache, nausea, or vomiting after the dye is injected.
The belt across the kidneys may feel tight over your belly area.
Why the Test is Performed
An IVP can be used to evaluate:

An abdominal injury

Bladder and kidney infections

Blood in the urine

Flank pain (possibly due to kidney stones)

Tumors

What Abnormal Results Mean

The test may reveal kidney diseases, birth defects of the urinary system, tumors, kidney stones, or
damage to the urinary system.
Risks
There is a chance of an allergic reaction to the dye, even if you have received contrast dye in the past
without any problem. If you have a known allergy to iodine-based contrast, an alternate test should be
performed. Alternatives include retrograde pyelography, MRI, or ultrasound.
There is low radiation exposure. Most experts feel that the risk is low compared with the benefits.
Children are more sensitive to the risks of radiation. This test is not likely to be done during
pregnancy.
Considerations
Computed tomography (CT) scans have replaced IVP as the main tool for checking the urinary
system. Magnetic resonance imaging (MRI) is also used to look at the kidneys, ureters, and bladder.
Alternative Names
Excretory urography; IVP

References
Fulgham PF, Bishoff JT. Urinary tract imaging: Basic principles. In: Wein AJ, ed. Campbell-Walsh
Urology. 10th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 4.

Intravenous Pyelogram (IVP)

An intravenous pyelogram (IVP) is an X-ray test that provides pictures of
the kidneys, the bladder, the ureters, and the urethra (urinary tract
). An IVP

can show the size, shape, and position of the urinary tract, and it can evaluate the
collecting system inside the kidneys.
During IVP, a dye called contrast material is injected into a vein in your arm. A series
of X-ray pictures is then taken at timed intervals.
IVP is commonly done to identify diseases of the urinary tract, such askidney
stones
, tumors, or infection. It is also used to look for problems with the

structure of the urinary tract that were present from birth (congenital).
An ultrasound or a computed tomography (CT) scan may be combined with an IVP if
more details about the urinary tract are needed. A computed tomography intravenous
pyelogram (CT/IVP) is usually done to look for the cause of blood in the urine.

Why It Is Done
An intravenous pyelogram (IVP) is done to:

Look for problems with the structure of the urinary tract.

Find the cause of blood in the urine.

Find the cause of ongoing back or flank pain.

Locate and measure a tumor of the urinary tract.

Locate and measure a kidney stone.

Find the cause of recurring urinary tract infections.

Look for damage to the urinary tract after an injury.

How To Prepare

Before having an intravenous pyelogram (IVP), tell your doctor if:

You are or might be pregnant.

You are breast-feeding. The contrast material used in this test can get into
your breast milk. Do not breast-feed your baby for 2 days after this test. During this time, you
can give your baby breast milk you stored before the test, or formula. Discard the breast milk
you pump for 2 days after the test.

You have an intrauterine device (IUD) in place.

You are allergic to the iodine dye used as the contrast material for X-ray tests or to
anything else that contains iodine.

You have ever had a serious allergic reaction (anaphylaxis), such as after being
stung by a bee or from eating shellfish.

Within the past 4 days, you have had an X-ray test using barium contrast material
(such as a barium enema).

You have had kidney problems in the past or have diabetes, especially if you
take metformin (Glucophage) to control your diabetes. The contrast material used during an
IVP can cause kidney damage in people who have poor kidney function. If you have had
kidney problems in the past, blood tests (creatinine, blood urea nitrogen) may be done
before the test to make sure that your kidneys are working properly.

How To Prepare continued...

You may need to stop eating and drinking for 8 to 12 hours before the IVP. You also
may need to take a laxative the evening before the test (and possibly have an
enema the morning of the test) to make sure that your bowels are empty.
This test is often done in children to see if they may have an abnormal backflow of
urine (vesicoureteral reflux). Prepare your child for exams and tests that are needed.
Explain them in a simple way. Use positive words as much as possible. Doing so will
help your child understand what to expect and can help reduce fears.
Talk to your doctor about any concerns you have regarding the need for the test, its
risks, how it will be done, or what the results will mean. To help you understand the
importance of this test, fill out the medical test information form.

How It Is Done

An intravenous pyelogram (IVP) is usually done by a radiology technologist. The IVP

pictures are interpreted by a doctor who specializes in interpreting imaging tests
(radiologist).
You will need to remove any jewelry that might interfere with the X-ray picture. You
will need to take off all or most of your clothes, and you will be given a cloth or paper
covering to use during the test. You will be asked to urinate just before the test
begins.

During the test

You will lie on your back on an X-ray table. An X-ray picture of your belly will be
taken and reviewed by the radiologist before the next part of the test begins.
The injection site on your arm will be cleaned and the contrast material will be
injected into a vein on the inside of your elbow. The dye travels through the
bloodstream, is filtered out by the kidneys, and passes into the urine. The urine then
flows into the tubes (ureters) that lead to thebladder.
X-ray pictures are taken several minutes apart as the dye goes through the urinary
tract. Each picture is developed right away. Sometimes more pictures are taken
based on earlier ones. You may be asked to turn from side to side or to hold several
different positions so the radiologist can take a complete series of X-rays.

How It Is Done continued...

During IVP, a compression device may wrapped around your belly to keep the dye in
the kidneys. The most common compression device is a wide belt containing two
inflated balloons that push in on either side of your belly to block the passage of dye
through the ureters. If you have recently had abdominal surgery or have an
abdominal disorder, the band will not be used.
A special type of X-ray technique called fluoroscopy may also be used during IVP.
During fluoroscopy, a continuous X-ray beam is used to display a moving image on a
video monitor.
IVP usually takes about an hour.

After the test

After the test is over, you will need to drink plenty of liquids to help flush the contrast
material out of your body.

How It Feels
You will feel no discomfort from the X-rays. The X-ray table may feel hard and the
room may be cool. You may find that the positions you need to hold are
uncomfortable.
You will feel a brief sting when the needle is inserted into the vein in your arm. When
the contrast material is injected, you may feel slight burning in your arm and flushing
throughout your body. You may also notice a salty or metallic taste in your mouth.
The compression belt may feel tight. If it is painful, tell the technologist and ask that it
be readjusted.
You may feel slightly weak, nauseated, or lightheaded for a short time after the test.

Risks
There is always a slight chance of damage to cells or tissue fromradiation, including
the low levels of radiation used for this test. But the chance of damage from the Xrays is usually very low compared with the benefits of the test.
There is slight risk of having an allergic reaction to the contrast material. The
reaction can be mild (itching, rash) or severe (trouble breathing or sudden shock).
Death resulting from an allergic reaction is very rare. Most reactions can be
controlled with medicine. Be sure to tell your doctor if you have asthma or allergies of
any kind, such as hay fever, iodine allergy, bee stings, or food allergies.
People with certain conditions (such as diabetes, multiple myeloma,chronic kidney
disease, sickle cell disease, or pheochromocytoma) have increased chances of
having sudden kidney failure from IVP. Older adults and people taking medicines that
affect the kidney may also have increased chances for problems after an IVP.

Intravenous Pyelogram (IVP)

Results

An intravenous pyelogram (IVP) is an X-ray test that provides pictures of the

kidneys, the bladder, the ureters, and the urethra (urinary tract
). Your doctor

may be able to talk to you about some results right away. Complete results are
usually ready in 1 to 2 days.
Intravenous pyelogram (IVP)

The kidneys, ureters, and bladder are normal in position, size, and shape.

Normal
:

The contrast material reaches the kidneys in a normal amount of time.

No blockage can be seen in the kidneys, ureters, or bladder.
In men, the prostate gland looks normal in position, size, and shape.
The kidneys, ureters, or bladder may be abnormal in position, size, or
shape. A kidney may be absent, or an extra kidney or ureter may be
present.
The kidneys are too large or too small.
The contrast material takes longer than normal to reach a kidney.

Abnor
mal:

An abnormal growth (such as a tumor), one or morecysts, an abscess, or

a kidney stone is seen.
A kidney is swollen with urine from a blockage such as a tumor or kidney
stone.
Injury to the kidney, ureter, or bladder is seen.
The kidney contains scarring.
In men, the prostate gland is too large.

What Affects the Test

Reasons you may not be able to have the test or why the results may not be helpful
include:

Being unable to remain still during the test.

Having a large amount of stool (feces) or gas in the large intestine (colon).

Having a recent test with barium (such as a barium enema).

An intravenous pyelogram (IVP) is not usually done for a pregnant woman because
the X-rays could damage the growing baby. If a view of a pregnant woman's kidneys
is needed, an ultrasound test may be done instead.

What is an Intravenous Pyelogram (IVP)?

An intravenous pyelogram (IVP) is an x-ray examination of the kidneys, ureters and
urinary bladder that uses iodinated contrast material injected into veins.
An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and
treat medical conditions. Imaging with x-rays involves exposing a part of the body to a
small dose of ionizing radiation to produce pictures of the inside of the body. X-rays
are the oldest and most frequently used form of medical imaging.
When a contrast material is injected into a vein in the patient's arm, it travels through
the blood stream and collects in the kidneys and urinary tract, turning these areas
bright white on the x-ray images. An IVP allows the radiologist to view and assess the
anatomy and function of the kidneys, ureters and the bladder.
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What are some common uses of the procedure?

View larger with caption

An intravenous pyelogram examination helps the radiologist assess abnormalities in

the urinary system, as well as how quickly and efficiently the patient's system is able
to handle fluid waste.
The exam is used to help diagnose symptoms such as blood in the urine or pain in the
side or lower back.
The IVP exam can enable the radiologist to detect problems within the urinary tract
resulting from:

kidney stones
enlarged prostate
tumors in the kidney, ureters or urinary bladder
surgery on the urinary tract
congenital anomalies of the urinary tract
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How should I prepare?

Your doctor will give you detailed instructions on how to prepare for your IVP study.
You will likely be instructed not to eat or drink after midnight on the night before your
exam. You may also be asked to take a mildlaxative (in either pill or liquid form) the
evening before the procedure.
You should inform your physician of any medications being taken and if there are any
allergies, especially to iodinated contrast materials. Also inform your doctor about
recent illnesses or other medical conditions.
You may be asked to remove some or all of your clothes and to wear a gown during the
exam. You may also be asked to remove jewelry, removable dental appliances, eye
glasses and any metal objects or clothing that might interfere with the x-ray images.
Women should always inform their physician and x-ray technologist if there is any
possibility that they are pregnant. Many imaging tests are not performed during
pregnancy so as not to expose the fetus to radiation. If an x-ray is necessary,
precautions will be taken to minimize radiation exposure to the baby. See the Safety
page for more information about pregnancy and x-rays.
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What does the equipment look like?

View larger with caption

The equipment typically used for this examination consists of a radiographic table,
one or two x-ray tubes and a television-like monitor that is located in the examining
room. Fluoroscopy, which converts x-rays into video images, is used to watch and
guide progress of the procedure. The video is produced by the x-ray machine and a
detector that is suspended over a table on which the patient lies.

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How does the procedure work?

X-rays are a form of radiation like light or radio waves. X-rays pass through most
objects, including the body. Once it is carefully aimed at the part of the body being
examined, an x-ray machine produces a small burst of radiation that passes through
the body, recording an image on photographic film or a special detector.
In an IVP exam, an iodine-containing contrast material is injected through a vein in the
arm. The contrast material then collects in the kidneys, ureters and bladder, sharply
defining their appearance in bright white on the x-ray images.
X-ray images may be maintained as hard film copy (much like a photographic negative)
or, more likely, as a digital image that is stored electronically. These stored images are
easily accessible and may be compared to current x-ray images for diagnosis and
disease management.
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How is the procedure performed?

View larger with caption

This examination is usually done on an outpatient basis.

You will lie on the table and still x-ray images are taken. The contrast material is then
injected, usually in a vein in your arm, followed by additional still images. The number
of images taken depends on the reason for the examination and your anatomy.
You must hold very still and may be asked to keep from breathing for a few seconds
while the x-ray picture is taken to reduce the possibility of a blurred image.
The technologist will walk behind a wall or into the next room to activate the x-ray
machine.
As the contrast material is processed by the kidneys, a series of images is taken to
determine the actual size of the kidneys and to image the urinary tract in action as it
begins to empty. The technologist may apply a compression band around the body to
better visualize the urinary structures.
When the examination is complete, you will be asked to wait until the radiologist
determines that all the necessary images have been obtained.

An IVP study is usually completed within an hour. However, because some kidneys
function at a slower rate, the exam may last up to four hours.
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What will I experience during and after the procedure?

The IVP is usually a relatively comfortable procedure.
You will feel a minor sting as the contrast material is injected into your arm through a
small needle. Some patients experience a flush of warmth, a mild itching sensation
and a metallic taste in their mouth as it begins to circulate throughout their body.
These common side effects usually disappear within a minute or two and are harmless.
Rarely, some patients will experience an allergic reaction. Itching that persists or is
accompanied by hives, can be easily treated with medication. In very rare cases, a
patient may become short of breath or experience swelling in the throat or other parts
of the body. These can be indications of a more serious reaction to the contrast
material that should be treated promptly. Tell the radiologist immediately if you
experience these symptoms as he/she is well prepared to treat this.
During the imaging process, you may be asked to turn from side to side and to hold
several different positions to enable the radiologist to capture views from several
angles. Near the end of the exam, you may be asked to empty your bladder so that an
additional x-ray can be taken of your urinary bladder after it empties.
The contrast material used for IVP studies will not discolor your urine or cause any
discomfort when you urinate.
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Who interprets the results and how do I get them?

A radiologist, a physician specifically trained to supervise and interpret radiology
examinations, will analyze the images and send a signed report to your primary care
or referring physician, who will discuss the results with you.
Follow-up examinations may be necessary, and your doctor will explain the exact
reason why another exam is requested. Sometimes a follow-up exam is done because a
suspicious or questionable finding needs clarification with additional views or a special
imaging technique. A follow-up examination may also be necessary so that any change
in a known abnormality can be monitored over time. Follow-up examinations are
sometimes the best way to see if treatment is working or if an abnormality is stable
over time.

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What are the benefits vs. risks?

Benefits

Imaging of the urinary tract with IVP is a minimally invasive procedure.

IVP images provide valuable, detailed information to assist physicians in
diagnosing and treating urinary tract conditions from kidney stones to cancer.
An IVP can often provide enough information about kidney stones and urinary
tract obstructions to direct treatment with medication and avoid more invasive
surgical procedures.
No radiation remains in a patient's body after an x-ray examination.
X-rays usually have no side effects in the typical diagnostic range for this exam.

Risks

There is always a slight chance of cancer from excessive exposure to radiation.

However, the benefit of an accurate diagnosis far outweighs the risk.
The effective radiation dose for this procedure varies. See the Safety page for
more information about radiation dose.
Contrast materials used in IVP studies can cause adverse allergic reactions in
some people, sometimes requiring medical treatment.
Women should always inform their physician or x-ray technologist if there is any
possibility that they are pregnant. See the Safety page for more information
about pregnancy and x-rays.

A Word About Minimizing Radiation Exposure

Special care is taken during x-ray examinations to use the lowest radiation dose
possible while producing the best images for evaluation. National and international
radiology protection organizations continually review and update the technique
standards used by radiology professionals.
Modern x-ray systems have very controlled x-ray beams and dose control methods to
minimize stray (scatter) radiation. This ensures that those parts of a patient's body not
being imaged receive minimal radiation exposure.
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What are the limitations of IVP exams?

An IVP shows details of the inside of the urinary tract including the kidneys, ureters
and bladder. Computed tomography (CT) ormagnetic resonance imaging (MRI) may add
valuable information about the functioning tissue of the kidneys and surrounding

structures nearby the kidneys, ureters and bladder. Small urinary tract tumors and
stones are more easily identified on these examinations.
IVP exams are not usually indicated for pregnant women.
The uses for IVP in infants and children are limited. Other tests, including

ultrasound, can be used in most cases to evaluate the kidneys and bladder. In general,
IVPs are rarely done in pediatric patients.

Unenhanced helical CT has become the imaging technique of choice for the examination of
patients with acute flank pain in whom the diagnosis is uncertain. Virtually all stones are of
sufficient attenuation to be revealed on CT. The only known exception is a stone that consists
entirely of protease inhibitors, such as indinavir sulfate (Crixivan; Merck, Rahway, NJ) [19]. In
addition to the direct visualization of a stone in the lumen of the ureter (Fig. 1), secondary signs
of obstruction on CT are commonly present. Ureteral dilatation (Fig. 2) has a sensitivity of
approximately 90% for use in making a diagnosis of acute ureteral obstruction. Similarly,
stranding of the perinephric fat (Fig. 3) and stranding of the periureteral fat (Fig. 4) both have
sensitivities of approximately 85%. Perhaps more importantly, in approximately 80% of patients
with acute flank pain ureteral dilatation and perinephric stranding will be present or absent
simultaneously. In this large subgroup of patients with acute flank pain, the presence of both
ureteral dilatation and perinephric stranding has a positive predictive value of nearly 100%, and
the absence of both findings has a negative predictive value of approximately 95% for the
diagnosis of acute ureterolithiasis.
On CT, secondary signs of obstruction can aid in the diagnosis of acute renal colic when a stone
is not readily apparent. The frequency of CT secondary signs of obstruction on CT has recently
been shown to correlate with the duration of pain [20]. This should be kept in mind when
interpreting CT studies, particularly in patients whose duration of pain is less than 2 hr. In
addition, secondary signs on CT can be used to make the diagnosis of a recently passed stone
[21]. In the latter case, some stones will actually be revealed while still present in the bladder. All
patients should be scanned in the prone position so that a stone that has already passed into the
bladder is not confused with a stone still lodged in the ureter at the ureterovesical junction [22].
Once the diagnosis of obstruction by a ureteral stone has been made on CT, prognosis and
patient treatment can be guided on the basis of the site of obstruction and the size of the stone.
In fact, the CT scout view can itself often be used as a baseline study in patients requiring
followup imaging and in patients who will undergo lithotripsy [23]. We performed an exhaustive
review of the literature in an attempt to find a single study that has shown that the degree of
obstruction (as determined on excretory urography) can be used to guide patient treatment or
determine prognosis. Our review failed to reveal any such article. In addition, several recent
studies strongly suggest that the secondary signs of obstruction on CT can in fact be used to
determine the degree of obstruction as well as help predict the likelihood of stone passage
[24, 25]. It would indeed be the ultimate irony if CT findings are shown to more accurately reflect
the degree of obstruction and predict the likelihood of stone passage than excretory urography.
With negative findings for acute ureterolithiasis on unenhanced helical CT, radiographers can
confidently exclude the diagnosis of clinically significant stone disease and many other causes of
acute flank pain. In addition, despite the lack of IV or oral contrast material, unenhanced CT can
reveal many other causes of acute flank pain that are unrelated to the urinary system, such as

pelvic masses, appendicitis, and diverticulitis. Unenhanced CT may also reveal abnormalities of
the urinary system unrelated to stone disease, such as pyelonephritis [26]. In some patients, it
may occasionally be necessary to repeat the CT scan after the administration of IV or oral
contrast material to make a diagnosis. Examples include patients with renal vein or renal artery
thrombosis and patients with renal infarcts. We would never hesitate to administer contrast
material when necessary and appropriate.
The one remaining pitfall in the interpretation of unenhanced helical CT is the confusion of a
phlebolith with a ureteral stone, especially in the pelvis. Two prior studies have addressed this
issue [27, 28], but the pitfall remains. However, with experience and by using the secondary
signs of obstruction, this difficulty can usually be overcome.

Read More: http://www.ajronline.org/doi/full/10.2214/ajr.175.1.1750003

Read More: http://www.ajronline.org/doi/full/10.2214/ajr.175.1.1750003