1. Prevention

2. Fluid Intake About 1.6 L/24 h Encouraged during mealtime
Increased approximately 2 h after meals
Encouraged to force a nighttime diuresis
Water produced as a metabolic by-product reaches its nadir at this time, and thus the body is relatively dehydrated.
Awakening and ambulating to void limit urinary stasis and offer an opportunity to ingest additional fluids.

3. Metabolic Intervention
Stone analysis
Outpatient urine collection during typical activities & fluid intake
Ca stone formers
Initial 24-h urine collection
Include tests for Ca, uric acid, oxalate, citrate, Na, volume, & pH
Hypercalciuria: most common abnormality

4. Oral Intervention Alkalinizing pH agents
Potassium citrate: oral agent that elevates urinary pH effectively by 0.7–0.8 pH units
Adverse effect: abdominal discomfort
Indications: Ca oxalate calculi 2° to hypocitraturia (<320 mg/day), including those with renal tubular acidosis; uric acid lithiasis & nonsevere forms of hyperuricosuric Ca nephrolithiasis.
Alternative alkalinizing agents: Na, potassium bicarbonate, orange juice, & lemonade
No effective long-term urinary acidifying agents

5. Oral Intervention Gastrointestinal absorption inhibitor
Cellulose phosphate binds Ca in the gut & inhibits Ca absorption & urinary excretion
Decreases urinary saturation of Ca phosphate & Ca oxalate
Phosphate supplementation
Indicated for renal PO4 leak

6. Oral Intervention Diuretics
Thiazides can correct renal Ca leak associated with renal hypercalciuria
Prevents 2° hyperparathyroid state & its associated elevated vitamin D synthesis & intestinal calcium absorption
Hypokalemia  hypocitraturia

7. Oral Intervention Calcium supplementation
Indication: Enteric hyperoxaluric Ca nephrolithiasis
Ca gluconate & Ca citrate
Uric acid-lowering medications
Allopurinol
Urease inhibitor
Acetohydroxamic acid: effective adjunctive treatment in chronic urea-splitting urinary tract infections associated with struvite stones
Prophylaxis after removal of struvite stone
Reversibly inhibits bacterial urease, decreasing urinary ammonia levels, and will subsequently acidify urine

8. Oral Intervention Prevention of cystine calculi
Penicillamine: reduces the amount of urinary cystine that is relatively insoluble
Mercaptopropionylglycine (Thiola)

9. Bladder Stones

10. Bladder Stones
Manifestation of an underlying pathologic condition, including voiding dysfunction or a foreign body
Most seen in men
Developing countries: frequently found in prepubescent boys
Stone analysis: ammonium urate, uric acid, or Ca oxalate stones
Irritative voiding symptoms, intermittent urinary stream, UTI, hematuria, or pelvic pain

11. Prostatic Stones
Prostatic calculi: found within prostate gland per se & are found uncommonly within the prostatic urethra
Represent calcified corpora amylacea & rarely found in boys
Usually of no clinical significance, rarely they are associated with chronic prostatitis
Large prostatic calculi: may be misinterpreted as a carcinoma
Dx: radiograph or transrectal ultrasound

12. Seminal Vesicle Stones
Smooth & hard
Associated with hematospermia
PE: stony hard gland; multiple stones present with crunching sensation
Confused with tuberculosis of the seminal vesicle

13. Urethral Stones Originate from bladder
Develop 2° to urinary stasis, urethral diverticulum, near urethral strictures, or at sites of previous surgery
Females: rarely develop urethral calculi due to short urethra & lower incidence of bladder calculi; associated with urethral diverticula
Symptoms : intermittent urinary stream, terminal hematuria, & infection
Dx: palpation, endoscopic visualization, or radiographic study

14. Prepucial Stones Occur in adults
Develop 2° to a severe obstructive phimosis or poor hygiene with inspissated smegma
Dx confirmed by palpation
Tx: dorsal prepucial slit or formal circumcision