I n t e g r a t i ve I m a g i n g R ev i ew

Cheng et al.
CME
Urolithiasis: What the Radiologist Needs to
Know SAM What the Radiologist Needs to Know About Urolithiasis
Integrative Imaging
Review

What the Radiologist Needs to

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Know About Urolithiasis: Part 1

FOCUS ON:

Pathogenesis, Types, Assessment,

and Variant Anatomy
Phillip M. Cheng1 OBJECTIVE. This article reviews types of urinary calculi and their imaging appear-
Paymann Moin2 ances, presents direct and secondary imaging findings of urolithiasis, and provides an over-
Matthew D. Dunn 3 view of treatment methods. Pertinent imaging findings that impact clinical management are
William D. Boswell 4 highlighted. The implications of complex or variant genitourinary anatomy are reviewed. We
Vinay A. Duddalwar 1 outline a standard format for the reporting of urolithiasis to facilitate informed clinical man-
agement decisions.
Cheng PM, Moin P, Dunn MD, Boswell WD, Dud- CONCLUSION. Unenhanced CT is the preferred examination for evaluation of uroli-
dalwar VA thiasis because of its availability, ease of performance, and high sensitivity. An awareness of
the important imaging findings to report allows appropriate and efficient therapy.

Keywords: CT, flank pain, urolithiasis, urology
DOI:10.2214/AJR.10.7285
Received September 5, 2010; accepted after revision
December 13, 2011.
1
Department of Radiology, Keck School of Medicine,
University of Southern California, 1441 Eastlake Ave,
Ste G360A. Los Angeles, CA 90033-0377. Address
correspondence to P. M. Cheng (phillip.cheng@usc.edu).
2Advanced Imaging Center, Valencia, CA.
3
Department of Urology, Keck School of Medicine,
University of Southern California, Los Angeles, CA.
4
Department of Radiology, City of Hope, Duarte, CA.
CME/SAM
This article is available for CME/SAM credit.
WEB
This is a Web exclusive article.
AJR 2012; 198:W540W547
0361803X/12/1986W540
American Roentgen Ray Society
U
rolithiasis is a common clinical
entity. Renal calculi affect up to
6% of all American women and
12% of all American men during
their lifetimes [1, 2]. Overall, the prevalence
is increasing and is higher in developed
countries [3]. By one estimate, in the year
2000, the costs involved in the diagnosis and
treatment of urolithiasis approached $2.1
billion in the United States alone, increasing
more than 50% since less than a decade ear-
lier [4]. In the first part of this review, we dis-
cuss the pathogenesis of calculus formation,
the types of urinary calculi, clinical assess-
ment, imaging modalities for the evaluation
of urolithiasis, and variant genitourinary
anatomy. In the second part, we will describe
the imaging findings on CT, suggest a report-
ing technique, and discuss treatment options.
Pathogenesis of Calculus Formation
Factors that place a patient at risk for re-
nal calculus formation are overall poorly un-
derstood. The concept of urinary supersat-
uration is essential to theories on calculus
formation [5]. Supersaturation occurs when
a solution contains more dissolved material
than can remain in solution, which can result
in the precipitation of metabolite crystals.
Supersaturation values have been reported
to correlate with urinary calculus compo-
sition [6]. The probability of supersatura-
tion varies with the specific metabolites and
the patient phenotype. Patients with a high-
er risk for calculus disease or recurrence of
calculi include those with metabolic distur-
bances such as gout, renal tubular acidosis,
and hypercalciuria. Comprehensive clinical
evaluation can reveal metabolic disturbanc-
es in over 90% of patients with urolithiasis.
Recurrent urinary tract infections are also a
risk factor for calculus disease [7].
Types of Urinary Calculi
There are five main types of urinary cal-
culi: calcium, magnesium ammonium phos-
phate, uric acid, cystine, and medications
and their metabolites (Table 1).
Calcium-Based Calculi
Calcium-based calculi account for 70
80% of urinary tract calculi in the United
States [8]. Calcium oxalate calculi are the
most common type of calcium-based cal-
culi, comprising 60% of all types of calcu-
li [7]. Calcium-based calculi can measure as
high as 1700 HU on CT, with brushite calculi
among the most dense, composed of calcium
hydrogen phosphate dihydrate [9].
The most significant factor in the forma-
tion of calcium-based calculi is hypercalci-
uria [10]. Renal hypercalciuria is a result of
deficient reabsorption of calcium within the
renal tubules. Hypercalciuria may also result
from excessive intestinal absorption of calci-
um. Bone demineralization, which may occur

W540 AJR:198, June 2012

 Urolithiasis: What the Radiologist Needs to Know

TABLE 1: Characteristics of Different Types of Urinary Tract Calculi

Frequency
Composition (%) Imaging Pearl Causative Factors
Calcium 7080 Wide range of densities and gross morphologies Numerous, including primary hyperparathyroid-
ism, chronic diarrhea, and distal renal tubular
acidosis
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Magnesium ammonium phosphate 1520 Staghorn calculus refers to a struvite calculus Infection
(struvite) involving the renal pelvis and extending into at
least two calyces
Uric acid 510 Pure uric acid stones are radiolucent on radiography Gout, small-bowel disease, and high body mass
index
Cystine 13 May contain low-attenuation foci (voids) on CT Cystinuria
Medications and their metabolites 1 Indinavir can be radiolucent even on CT Prolonged or excessive use of some medications

in the setting of primary hyperparathyroidism
or prolonged immobilization, results in a re-
sorptive hypercalciuria [7]. These processes
are interrelated, and an abnormality of calci-
um metabolism at one site may result in sec-
ondary abnormalities at other sites.
Other underlying conditions that lead to
calcium-based calculus formation include
abnormal uric acid metabolism (with or
without primary gout), hypocitraturia (which
may arise in the setting of chronic diarrhea,
distal renal tubular acidosis, and thiazide
use), and hyperoxaluria [7].
Hyperoxaluria is a cause of calcium-based
calculus formation that can be primary, sec-
ondary, or idiopathic. Primary hyperoxaluria
is a rare autosomal recessive disease resulting
in enzymatic errors that lead to the increased
oxidation of glyoxylate to oxalate [11]. More
common is secondary hyperoxaluria, which
can be seen in the setting of bowel surgery,
inflammatory bowel disease, excessive in-
take of vitamin C, and renal insufficiency.
Magnesium Ammonium Phospate Calculi
Magnesium ammonium phosphate calculi
are also known as struvite calculi and account
for 1520% of all urinary calculi [8]. These
calculi are caused by urinary tract infections
resulting from urease-producing bacteria, such
as Proteus, Pseudomonas, and Klebsiella spe-
cies and enterococci [12]. It should be noted
that Escherichia coli is not urease producing.
Urease is an enzyme that hydrolyzes urea into
carbon dioxide and ammonia, raising the uri-
nary pH and promoting the formation of car-
bonate. Calcium carbonate then precipitates
with struvite, forming large calculi conform-
ing to and filling the renal collecting system
[13]. A struvite calculus involving the renal
pelvis and extending into at least two calyces
is often termed a staghorn calculus because of
its resemblance to a stags antler [14, 15].
Uric Acid Calculi
Uric acid calculi account for 510% of all
urinary calculi [8]. Hyperuricosuria and urine
acidity promote uric acid calculus formation
[16]. Common causes include gout and chronic
diarrhea. Patients with a high body mass index
or diabetes have more acidic urine and a much
higher propensity to form uric acid calculi as
compared with the general population [17, 18].
Pure uric acid calculi are radiolucent on
radiography but can be readily identified on
CT. The relatively low attenuation (< 500
HU) of uric acid calculi on CT should be
highly suggestive of their composition [19].
Cystine Calculi
Cystine calculi account for 13% of all uri-
nary calculi [8] and are primarily a consequence
of cystinuria, a metabolic disorder resulting from
genetic defects of renal transport [20]. Cystine
calculi are often referred to as ground-glass
calculi and can be radiolucent. It has been re-
ported that certain cystine calculi contain void
regions manifesting as low-attenuation foci on
a CT scan [21]. The utility of this observation
has not been tested in clinical practice.

TABLE 2: Modalities in the Evaluation of Urolithiasis

Modality Advantages
Radiography Relatively low radiation dose with respect
to CT; 90% of calculi are radiopaque
Excretory urography Some delineation of renal and collecting
system anatomy
Ultrasound Lack of ionizing radiation; intermediate
sensitivity for detection of renal calculi
and hydronephrosis
MR urography Nonionizing radiation; imaging of
secondary effects of urolithiasis and
other genitourinary abnormalities,
including malignancy
Unenhanced CT Delineation of urinary tract and
nongenitourinary anatomy; rapid
acquisition and interpretation; highlights
procedurally relevant anatomy
Disadvantages
Only 60% sensitivity in detection of urinary
calculi; patients source of pain may not
be urolithiasis
Exposure to contrast agent; length of
examination; contrast agent can obscure
calculi
Operator dependent; deep portions of
ureter difficult to image
Actual calculus difficult to visualize
Radiation exposure especially in the
recurrent stone former, young, or
pregnant patient
Preferred Utilization
Monitoring of calculus burden in patients
known to have urolithiasis
CT now preferred over excretory
urography in most settings for evaluation
of renal and collecting system anatomy
Pregnant or pediatric patients and
recurrent stone formers
Evaluation of urinary tract findings other
than urolithiasis such as stricture
First-line imaging investigation in the adult
with flank pain

AJR:198, June 2012 W541


Medication-Induced Calculi
Medication-induced calculi may be caused
by prolonged or excessive use of some med-
ications. Indinavir and similar protease in-
hibitors used in HIV treatment are particu-
larly well-known causes of urinary calculi
[22]. Common herbal supplements that may
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induce renal calculi include ephedrine, a
stimulant and weight loss product, as well
as guaifenesin, an expectorant [23]. Many
other medications and their metabolites can
result in the formation of matrix calculi. A
large series found the most common medica-
tion-associated calculi are related to indinavir
(52.9%), triamterene (18.1%), sulfonamides
(12.2%), and amorphous silica (10.1%) [24].
Some of these calculi, including indinavir-
related calculi, may be radiolucent on CT.
Therefore, even if a CT examination is nega-
tive, medication history and presentation can
be enough for the urologist to empirically
treat a patient with medication-induced cal-
culi. If doubt persists, IV contrast agent can
be administered and delayed images can be
obtained. An indinavir-related or other ra-
diolucent calculus will present as a filling
defect in the collecting system or ureter [25].
Treatment of medication-induced calculi lies
mainly in prevention, with changes in medi-
cation, dose adjustment, increased diuresis,
and possibly agents to alter urine pH [24].
Clinical Assessment
The most common presenting symptom of
obstructing urolithiasis is pain, which is typi-
Fig. 1Renal calculi confirmed by ultrasound.
A, Longitudinal gray-scale image from renal ultrasound shows several slightly echogenic foci (arrows) within renal sinus.
B, Color Doppler is applied, revealing several corresponding regions of twinkle artifact, confirming presence of renal calculi.
W542 AJR:198, June 2012
Cheng et al.
cally colicky in nature. The location of pain
correlates with the site of obstruction. Renal
pelvic or proximal ureteral obstruction is as-
sociated with flank pain, whereas lower ure-
teral obstruction is associated with pain radi-
ating to the testicle or labium. Stones at the
ureterovesical junction can cause urgency
and suprapubic discomfort [26]. Nausea and
vomiting may be present. Gross or micro-
scopic hematuria can be associated with renal
or ureteral stones, even in the absence of ob-
struction. Staghorn calculi may present as re-
current urinary tract infection rather than ob-
struction. If infection is superimposed on an
obstructed urinary system, patients can pres-
ent with florid urosepsis [27]. The latter situ-
ation can be fatal and thus requires immedi-
ate resuscitation and urinary decompression.
Initial clinical assessment includes a de-
tailed history to assess risk factors for stones
and identify underlying renal or urologic con-
ditions. Physical examination is typically non-
specific for urinary stones but is important for
evaluating for other conditions. Blood and
urine studies assess renal function and hema-
tologic status. In particular, electrolyte, blood
urea nitrogen, and creatinine levels reflect re-
nal and metabolic status. The WBC count may
be elevated in response to infection or stress;
the hemoglobin level can be depressed in some
cases of chronic calculus disease. Urinalysis de-
tects hematuria and pyuria and includes urine
pH, which can help guide management. A urine
culture in the setting of infection will help with
appropriate antibiotic selection [13, 28, 29].
A B
Imaging Modalities
Radiography
Many modalities have been used in the
evaluation of urolithiasis and its potential sec-
ondary complications (Table 2). For decades,
the kidney-ureter-bladder radiograph was the
initial examination of choice in the evaluation
of acute onset of flank pain. Approximately
90% of urinary tract calculi are radiopaque.
Secondary signs of renal colic may be seen on
radiography but are nonspecific. These may
include mild splinting, bowel ileus, and peri-
nephric fluid obscuring the renal outline.
Unfortunately, radiography has been found
to be only about 60% sensitive overall in the
detection of urolithiasis [30] because bow-
el contents, overlying soft tissues, gas, and
osseous structures may obscure small radi-
opaque calculi. In addition, a visualized cal-
culus may not be the source of the patients
pain. At our institution, a kidney-ureter-blad-
der radiograph is used for monitoring calcu-
lus burden in patients known to have uroli-
thiasis. In some cases, it may also be used
to monitor the progression of an obstructing
calculus. The intent in these cases is to signif-
icantly reduce a patients radiation exposure
compared with unenhanced CT [31].
Excretory Urography
Excretory urography allows increased de-
lineation of renal anatomy compared with the
kidney-ureter-bladder radiograph and may re-
veal the presence of a calculus causing ob-
struction. Excretory urography was formerly
 Urolithiasis: What the Radiologist Needs to Know
the study of choice for the imaging evaluation
of urolithiasis [32], but it has been supplanted
by CT. In cases of suspected radiolucent uric
acidbased calculi, identification of renal col-
lecting system filling defects may be helpful.
Unfortunately, these calculi can also be ob-
scured by contrast material. In addition, filling
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defects may be nonspecific in the setting of he-
maturia with flank pain. Urinary obstruction
may cause significant delay in the excretion of
contrast agent, thus increasing the study time.
In patients with renal insufficiency, the use of
contrast media may be contraindicated.
At institutions where excretory urogra-
phy is still performed, digital tomosynthesis
may provide an improvement in image qual-
ity over conventional excretory urography.
Digital tomosynthesis involves acquiring a
series of low-dose projection images with a
stationary digital detector during the sweep
of an x-ray tube over a limited angular range.
The diagnostic quality of digital tomosyn-
thesis is improved compared with the con-
ventional excretory urography, with a dose
that is slightly higher than that of digital ra-
diography but significantly lower than that
of low-dose CT [33]. Without IV contrast
agent, digital tomosynthesis has also been
found to be more sensitive for renal calculi
compared with digital radiography, although
sensitivity for ureteral calculi was not signif-
icantly increased [34].
Ultrasound
Ultrasound is advantageous in the setting of
the pediatric patient, pregnant patient, or a pa-
tient with recurrent bouts of urolithiasis [35],
because ultrasound does not use ionizing radi-
ation. In addition, ultrasound is not dependent
on calculus composition, because nearly all
calculi will show echogenicity and shadowing
if they can be included within the FOV.
Ultrasound may detect calculi as small as
0.5 mm [36], manifesting as echogenic foci
with shadowing within the urinary tract. To
confirm the visualization of a calculus, color
Doppler imaging can be used to elicit a twin-
kle artifact in the expected region of shadow-
ing on gray-scale imaging (Fig. 1). Twinkle
artifact is thought to be due to narrow-band
intrinsic machine noise [3739]. In vitro
studies suggest that stone surface composi-
tion correlates with the appearance of twin-
kle artifact [39]. Although twinkle artifact on
Doppler appears to increase ultrasounds sen-
sitivity for calculi compared with gray-scale
imaging alone [40], there may be a high false-
positive rate when 5-mm unenhanced CT im-
ages are used as the reference standard [41].
AJR:198, June 2012 W543
Ultrasound can also reveal secondary effects,
such as obstruction, superimposed infection, or
abscess formation. As on CT, obstruction can
be directly imaged as collecting system and
ureteral dilatation to the level of the calculus
[42]. However, dilatation without obstruction
can also be present and difficult to distinguish
on ultrasound [43, 44]. It has been postulated
that elevated renal resistive indexes on Doppler
sonography may be a useful indicator of acute
obstruction, but results have been mixed [44].
The direct visualization of ureteral calculi can
be also difficult with ultrasound because of
overlying bowel gas and the relative depth of
the ureter within the pelvis. Ultrasound visuali-
zation may be further complicated in obese pa-
tients by large amounts of intervening fat. With
this in mind, asymmetric ureteral jets within the
bladder on color Doppler can still be diagnostic
of a distal calculus [45].
The utility of ultrasound has garnered a
second look in the evaluation of urolithiasis
given technically improved equipment and
a renewed concern over individual exami-
nation and cumulative radiation dose from
CT. High ultrasound sensitivity and speci-
ficity for ureteral calculi has been shown us-
ing newer equipment and a strict preparation
protocol including fasting and bladder filling
[46]. A recent series showed that a negative
ultrasound in adults presenting with flank
pain in the emergency department setting re-
sulted in a low likelihood for urologic inter-
vention within 90 days of their initial visit
[47]. In addition, some centers are using the
combination of ultrasound with radiography
to lower a patients radiation dose to provide
somewhat less sensitive, though adequate,
results as compared with CT [48]. A recent
study suggests that ultrasound may be useful
for follow-up of distal ureteral calculi [49].
MRI
MR urography is an excellent modal-
ity for the delineation of secondary effects
of urolithiasis such as infection or obstruc-
tion [50]. Unfortunately, as with nearly any
calcified structure on MRI, the actual calcu-
lus is often not well visualized and will ap-
pear as a T1- and T2-weighted sequence sig-
nal void. These filling defects are not specific
for calculi, but differentiation can be made
from neoplasm on the basis of the lack of en-
hancement on contrast-enhanced imaging
[51]. Like ultrasound, MRI does not use ion-
izing radiation and can be of value alone or
in combination with radiography in the eval-
uation of the pediatric, pregnant, or serially
imaged patient [52].
CT
CT, both unenhanced and contrast en-
hanced, has quickly become the modality of
choice in the evaluation of suspected uroli-
thiasis since its early use for this indication
in the late 1990s [53, 54]. Unenhanced CT
performed in the emergency department set-
ting for the evaluation of urolithiasis makes
up just over 20% of all CT examinations con-
ducted for the evaluation of acute abdominal
pain [55]. Overall, this is a highly sensitive
study, approaching 100% in some series [54,
56, 57]. The standard examination, an unen-
hanced scan, eliminates the risk of renal in-
sufficiency or adverse reaction secondary to
contrast material exposure. The acquisition
of images takes only seconds with modern
equipment, resulting in more efficient imag-
ing evaluation. CT can measure stone attenu-
ation, evaluate secondary effects of obstruc-
tion, delineate surgically relevant anatomy,
and detect other potential sources of pain or
pathologic abnormality (Fig. 2).
A significant drawback is that CT utilizes
ionizing radiation. The average mean effective
dose reported for a single unenhanced CT for
flank plain has been reported to be 8.5 mSv
for MDCT [58]. Dose can rapidly accumulate
if a patient presents repeatedly. In this same
series, 4% of patients had three or more ex-
aminations, with one patient with a cumula-
tive dose of 153.7 mSv [58]. More recently,
low-dose protocols have been developed [59
Fig. 2Transverse contrast-enhanced CT shows
renal calculus (arrow) within mid left kidney. Renal
cell carcinoma (arrowheads) is also identified
within mid left kidney. CT has largely replaced
excretory urography and other forms of conventional
radiography partly because of its sensitivity in
detection of non-urolithiasis-related abnormalities.
 Cheng et al.
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A B
Fig. 3Dual-energy CT for stone characterization in two different patients. Dual-source scanner (Somatom Definition, Siemens Healthcare) was used at 80 and 140 kV,
and images were postprocessed with three-material decomposition algorithm on scanner console.
A, 48-year-old. Postprocessed color-coded axial dual-energy CT image shows right lower pole renal calculus color-coded blue, indicating nonuric acid stone.
B, 37-year-old. Postprocessed color-coded axial dual-energy CT image shows two left lower pole renal calculi color-coded red, indicating uric acid stone. (Courtesy of
Kadambakone A and Sahani D, Massachusetts General Hospital, Boston, MA)

A B
Fig. 431-year-old man with horseshoe kidney.
A, Unenhanced CT examination shows left hydronephrosis related to staghorn calculus.
B, More inferior transverse image from same study shows isthmus of horseshoe kidney.

62] with little loss in sensitivity in the detec-
tion of urinary and nonurinary diseases. Tube
current modulation, which is now universal on
newer machines, can help reduce dose. Newer
noise reduction technologies such as iterative
image reconstruction can facilitate dose re-
duction without sacrificing image quality [63].
Examinations can also be anatomically tai-
lored when the location of a calculus is known.
Dual-Energy CT
There has been recent interest in the use
of dual-energy CT for the characterization of
urinary calculi. Conventional CT attenuation
values (expressed in Hounsfield units) reflect
both the density and attenuation coefficient
of a substance and, therefore, may be the
same for different materials at a given x-ray
tube potential. Partial-volume effects further
complicate the use of attenuation values at
single-energy CT for small structures such as
renal calculi. Dual-energy CT uses two dif-
ferent tube potentials (i.e., kilovoltage) in one
acquisition to help distinguish different sub-
stances, on the basis of the unique energy de-
pendence of photoelectric absorption for dif-
ferent materials [64, 65]. For urinary stones,
postprocessing can be used to classify differ-
ent stone types according to attenuation mea-
surements at both energy levels, indepen-
dently of stone density (Fig. 3). Initial studies
showed the ability to differentiate uric acid
from nonuric acid stones [6670], with re-
cent work suggesting possibilities for differ-
entiating other stone types [71, 72]. Virtual
unenhanced images may also be generated
from dual-energy CT acquisitions, possibly
allowing detection of urinary calculi in the
pyelographic contrast-enhanced phase [73].
Complex or Variant Genitourinary
Anatomy
There are multiple variants of genitourinary
anatomy that may influence the appropriateness
and type of urologic intervention. These in-
clude both congenital and postsurgical variants.
A horseshoe kidney results from renal fu-
sion and subsequent ascent failure at the level

W544 AJR:198, June 2012

 Urolithiasis: What the Radiologist Needs to Know
of the inferior mesenteric artery. There is a
0.25% prevalence of horseshoe kidney with-
in the general population [74]. Collecting
system drainage of a horseshoe kidney is im-
paired because of malrotation and a high ure-
teral insertion. Up to 20% of horseshoe kid-
neys can present with calculi, most of which
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consist of calcium oxalate [74] (Fig. 4).
Retrorenal position of the colon, a sequela
of abnormal development of the lateroconal
fascia, is important information to commu-
nicate to reduce the possibility of bowel per-
foration in the event of a percutaneous inter-
vention [75, 76].
A pelvic kidney is due to failure of ascent,
but without an associated fusion abnormali-
ty. This is found in approximately 1 in 2000
3000 patients [77]. Like the horseshoe kidney,
a pelvic kidney is also more prone to calculus
formation, again because of malrotation and a
relatively high ureteral insertion [74]. The po-
sition of the kidney, with surrounding osseous
structures and abnormal rotation, can make it
difficult to treat calculi [78].
Crossed fused renal ectopia is found in ap-
proximately 1 in 1000 patients [79]. The or-
thotopic unit (i.e., the kidney on the normal
side) is most often normal without superim-
posed complications, whereas the crossed
fused ectopic unit is predisposed to hydrone-
phrosis and cystic dysplasia [80, 81].
The incidence of calculus formation in a
transplanted kidney ranges from 0.4% to 1%
[82]. Such patients are predisposed to a num-
ber of metabolic disturbances and, therefore,
should be evaluated for a metabolic abnor-
mality if they present with urolithiasis [83].
The urine of a patient who has undergone
renal transplant can be significantly more
concentrated and alkaline, predisposing to
calculus formation [84]. Risk factors for cal-
culus formation in a transplanted kidney in-
clude secondary hypoparathyroidism in the
setting of the prolonged renal insufficiency,
use of nonabsorbable suture, hypocalcemia,
recurrent urinary tract infections, and use of
posttransplant medications like cyclosporine
A [85]. Most calculi formed by the transplant
kidney consist of calcium oxalate [74].
The presence of a calyceal diverticulum
is essential to report to the urologist because
it may prompt a change in the technique for
calculus retrieval.
A solitary kidney is an indication for im-
mediate intervention and should be verbally
reported to the urologist or appropriate refer-
ring physician at the time of interpretation.
Other indications for immediate intervention
AJR:198, June 2012 W545
include evidence for infection, intractable
pain, or bleeding [86].
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