Ureteric calculi or stones are those lying within the ureter, at any point from the ureteropelvic junction (UPJ) to the vesicoureteric junction (VUJ). They are the classic cause of renal colic-type abdominal pain. They are a subtype of the broader pathology of urolithiasis.
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The lifetime prevalence of ureteric calculi is relatively high, occurring in approximately 12% of men and 7% of women 1. The risk is increased with a past history of ureteric calculi and with positive family history. Most patients present between ages 30 and 60 years 2, with peak incidence between ages 35-45. Initial calculus presentation occurring past age 50 is uncommon.
Patients with ureteric calculi may present with peristaltic pain (renal colic), hematuria, nausea and vomiting.
The quality and location of pain are dependent on the location of the calculi within the ureter. Calculi within the ureteropelvic junction may cause deep flank pain due to distension of the renal capsule, without radiation to the groin, whereas pain from upper ureteral calculi radiates to the flank and lumbar areas. Calculi in the mid-ureter result in pain radiating anteriorly and caudally which may mimic appendicitis (on the right side) and diverticulitis (on the left side), while pain from distal ureteric calculi radiates to the groin via referred pain from the genitofemoral or ilioinguinal nerves.
Calculi in the ureterovesical junction may also cause irritative voiding symptoms such as dysuria and urinary frequency.
Up to 80% of renal calculi are formed by calcium stones 3. Other types include struvite, uric acid and cystine stones. In specific patient groups, mucoprotein (matrix), xanthine or indinavir (and other drug-related) stones may be (rarely) encountered.
Calculi formation is likely due to two mechanisms. The first is where stone-forming substances such as calcium or uric acid supersaturate the urine beginning crystal formation. The other mechanism depends on stone-forming substances depositing in the renal medullary interstitium forming a Randall plaque4 and eventually eroding into the papillary urothelium, creating a calculus.
In addition to history of prior ureteric calculi and family history, other risk factors for ureteric calculi include low fluid intake, frequent urinary tract infections and medications that may crystallize within the urine.
A plain abdominal (KUB) film can identify large radiopaque calculi. However, smaller calculi and/or radiolucent stones may go undetected. Obstruction/hydronephrosis cannot be adequately assessed.
For low-dose initial investigation, plain film with ultrasound is used in some centers for specific patient groups. For follow up, plain film is useful when a stone has been demonstrated on abdominal x-ray and/or CT scanogram.
Non-contrast CT (CT KUB) is the gold standard for imaging ureteric stones, with the vast majority (99%) being radiodense. Stones >1 mm in size are visualized, with the specificity of helical CT as high as 100% 5.
Scanning the patient in the prone position is preferred as this gives certainty as to whether a stone remains impacted within the ureterovesical junction or if it has passed freely into the bladder 9. A stone will always fall dependently and sit along the anterior bladder wall once it is free of the ostium in a prone patient. Alternatively, some centers will 'flip' the patient and re-scan the pelvis if a stone is identified at the ureterovesical junction/bladder base on the supine scan. The choice is often one of practicalities depending on the list supervision and staff involved.
CT KUB can also detect secondary signs of urinary tract obstruction, including ureterohydronephrosis and perinephric stranding.
In patients with little pelvic fat, distinguishing a ureteric calculus from a phlebolith can be challenging. Two signs have been found helpful:
While CT is the gold standard test, there is recent evidence that screening patients with ultrasound in the emergency department can help avoid CT in more than half of patients leading to reduced cumulative radiation dose without increasing complications, pain scores, emergency department visits or hospitalizations 8.
Ultrasound may be used for patients who need to avoid radiation, such as pregnant women. It is also useful for assessing for complications, such as hydronephrosis or pyonephrosis and in aiding percutaneous nephrostomy tube insertion in septic patients. Features include:
Treatment and prognosis
Most patients presenting with acute renal colic due to ureteric calculi can be managed conservatively with hydration and analgesia until the calculi pass. NSAIDs are as effective as opioids 6. Hospitalization may be required where oral analgesia is insufficient, in patients with a solitary kidney or in patients with urosepsis or acute kidney failure.
Calculus size and location as well as ureter anatomy are important factors in determining the likelihood of spontaneous calculus passage 7. Spontaneous passage by 20 weeks has been reported at the following rates (axial dimension) 11:
- 0-3 mm: 98%
- 4 mm: 81%
- 5 mm: 65%
- 6 mm: 33%
- >6.5 mm: 9%
However, even small calculi may be impossible to pass if they are located at the ureteropelvic junction or in patients with ureteral strictures. Passage of calculi may be facilitated by tamsulosin and nifedipine.
In calculi >10 mm or with failed conservative management, urological procedures such as extracorporeal shockwave lithotripsy (ESWL), ureteroscopic lithotripsy, or percutaneous nephrostomy may be required.
Once the calculus is passed it, should be sent for analysis to evaluate for possible underlying causes of stone disease and better plan for future prevention.
It is good practice to report if the calculus is visible on the scanogram of the study to establish if a plain radiograph is sufficient for follow up purposes rather than a higher radiation CT study.
- 1. Pearle MS, Calhoun EA, Curhan GC et-al. Urologic diseases in America project: urolithiasis. J. Urol. 2005;173 (3): 848-57. doi:10.1097/01.ju.0000152082.14384.d7 - Pubmed citation
- 2. Tamm EP, Silverman PM, Shuman WP. Evaluation of the patient with flank pain and possible ureteral calculus. Radiology. 2003;228 (2): 319-29. doi:10.1148/radiol.2282011726 - Pubmed citation
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- 4. Kim SC, Coe FL, Tinmouth WW et-al. Stone formation is proportional to papillary surface coverage by Randall's plaque. J. Urol. 2005;173 (1): 117-9. doi:10.1097/01.ju.0000147270.68481.ce - Pubmed citation
- 5. Dalrymple NC, Verga M, Anderson KR et-al. The value of unenhanced helical computerized tomography in the management of acute flank pain. J. Urol. 1998;159 (3): 735-40. Pubmed citation
- 6. Teichman JM. Clinical practice. Acute renal colic from ureteral calculus. N. Engl. J. Med. 2004;350 (7): 684-93. doi:10.1056/NEJMcp030813 - Pubmed citation
- 7. Miller OF, Kane CJ. Time to stone passage for observed ureteral calculi: a guide for patient education. J. Urol. 1999;162 (3 Pt 1): 688-90. Pubmed citation
- 9. Levine J, Neitlich J, Smith RC. The value of prone scanning to distinguish ureterovesical junction stones from ureteral stones that have passed into the bladder: leave no stone unturned. AJR Am J Roentgenol. 1999;172 (4): 977-81. doi:10.2214/ajr.172.4.10587131 - Pubmed citation
- 10. Dalrymple NC, Casford B, Raiken DP et-al. Pearls and pitfalls in the diagnosis of ureterolithiasis with unenhanced helical CT. Radiographics. 2000;20 (2): 439-47. doi:10.1148/radiographics.20.2.g00mc13439 - Pubmed citation
- 11. Jendeberg J, Geijer H, Alshamari M, Cierzniak B, Lidén M. Size matters: The width and location of a ureteral stone accurately predict the chance of spontaneous passage. European radiology. doi:10.1007/s00330-017-4852-6 - Pubmed
- Smith-Bindman R, Aubin C, Bailitz J et-al. Ultrasonography versus computed tomography for suspected nephrolithiasis. N. Engl. J. Med. 2014;371 (12): 1100-10. doi:10.1056/NEJMoa1404446 - Pubmed citation
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Anatomy, Abdomen and Pelvis, Ureter
The ureters are bilateral thin (3 to 4 mm) tubular structures that connect the kidneys to the urinary bladder, transporting urine from the renal pelvis into the bladder. The muscular layers are responsible for the peristaltic activity that the ureter uses to move the urine from the kidneys to the bladder.
Embryologically, the ureter originates from the ureteric bud, which is a protrusion of the mesonephric duct, a part of the genitourinary system development.
The ureters begin at the ureteropelvic junction (UPJ) of the kidneys, which lie posteriorly to the renal vein and artery in the hilum. The ureters then travel inferiorly inside the abdominal cavity. They pass over (anterior to) the psoas muscle and enter the bladder on the posterior bladder aspect in the trigone.
Three areas along the path of the ureter are clinically significant for renal stones lodging. These areas are: the ureteropelvic junction (UPJ), the ureterovesical junction (UVJ), and the crossover of the common iliac arteries. The UPJ is where the pelvis of the kidney transitions into the ureter and the UVJ is where the ureters enter the bladder.
The blood supply to the ureter is segmental. The upper ureter closest to the kidneys receives blood directly from the renal arteries. The middle part is supplied by the common iliac arteries, branches from the abdominal aorta, and the gonadal arteries. The most distal part of the ureter receives blood from branches of the internal iliac artery.
T12 through L2 provide innervation to the ureters, creating a ureteric plexus. Pain may refer to T12-L2 dermatomes.
Due to its location, the ureter can be damaged in colon and rectal surgery and gynecologic surgeries.
Structure and Function
The ureteric wall is composed of three main of tissue: inner mucosa, middle muscle layer and outer serosa. The lining of the inner layer is transitional epithelium. Deeper to it is the lamina propria, which is combined with the epithelium make up the mucosal lining. The next deeper layer of tissue is the smooth muscle layer or lamina propria. An inner longitudinal and an outer circular layer comprise the smooth muscle layer of the ureter.
The path of the ureter is along the anterior edge of the psoas muscle, which is the general area where the gonadal vessels cross anteriorly to the ureter a third of the way to the bladder. The ureter crosses over the common iliac arteries, showing the anatomical landmark of the bifurcation of the common iliac vessels into internal and externa iliac vessels. The ureters finally enter on the posterior wall of the bladder where they incorporate into the trigone. The ureters have specific anatomic relationships dependent upon which side of the body. The right ureter lies in close relationship to the ascending colon, cecum, and appendix. The left ureter is close to the descending and sigmoid colon.
The nomenclature of the ureter is based on its anatomic relationship to surrounding structures. The abdominal ureter is the segment of the ureter that extends from the renal pelvis to the iliac vessels. The pelvic ureter extends from the iliac vessels to the bladder. There is an alternative method of ureteral nomenclature: upper, middle, and lower segments. The upper ureter extends from the renal pelvis to the upper border of the sacrum. The middle ureter continues from the upper to lower borders of the sacrum. The distal ureter continues from the lower border of the sacrum to the bladder.
In week 4, the development of the urinary tract (Kidney, Ureter, Bladder) begins with pronephros, mesonephros, and metanphros, which form from the nephrogenic cord.
The stalk of the ureteric bud, which is a diverticulum from the mesonephric duct, gives rise to the ureter. The ureteric bud is regulated by different molecular pathways including GDNF-RET, BMP4(bone morphogenic protein 4), and Gremlin. There is a fine balance between ureteric bud growth and ureteric stalk elongation. This concerted effort to suppress ureteric bud development while also stimulating the elongation of the ureteric stalk is achieved by BMP4. And Gremlin secretion inhibits BMP4 and thus stimulates ureteric bud development. This finely orchestrated balance ensures that a single ureteric bud develops from each nephrogenic cord. 
The bud branches near the cranial aspect into the collecting tubules which become confluent and form the major calyces.
Disruptions in the embryologic development can cause conganital abnormalitis of the kidney and urinary tract (CAKUT).
Blood Supply and Lymphatics
The ureters receive their blood supply from multiple arterial branches. In the upper or abdominal ureter, the arterial branches stem from the renal and gonadal artery, abdominal aorta, and common iliac arteries. In the pelvic and distal ureter, the arterial branches come from the vesical and uterine arteries, which are branches of the internal iliac artery. The arterial supply will course along the ureter longitudinally creating a plexus of anastomosing vessels. This is of clinical significance because it allows for safe mobilization of the ureter during surgery when proper exposure from surrounding structures is crucial.
The venous and lymphatic drainage of the ureter mirrors that of the arterial supply. The lymphatic drainage is to the internal, external, and common iliac nodes. The lymphatic drainage of the left ureter is primarily to the left para-aortic lymph nodes while the drainage of the right ureter primarily drains to the right paracaval and interaortocaval lymph nodes.
The exact role of the innervation of the ureter is unclear, but the innervation for ureteral peristalsis originates from the intrinsic smooth muscular pacemaker sites. Within the renal collecting system, the minor calyces are the location for the pacemaker sites.
There is preganglionic sympathetic input from T10 through L2. The aorticorenal, superior, and inferior hypogastric autonomic plexuses give rise to the postganglionic fibers.
S2 through S4 provide parasympathetic innervation to the ureter.
The ureter is made up of 3 layers: innermost mucosa, muscularis, and the outer adventitia.
The mucosa is lined with circular transitional epithelium. The keratin in this layer is responsible for the waterproof propereties.
The musclaris layer is made up of 2 longitudinal layers and a circular layer in the middle. The peristaltic motion of the ureter arises from the continuous smooth muscle layer from the ureter to the minor renal calyces, where the pacemaker for ureteric persitalsis is thought to arise
The adventitia is made up of dense collagen and elastic fibers
Abnormalities of the ureteric bud give rise to duplications of the abdominal ureter. Abnormal division, specifically incomplete division of the metanephric diverticulum results in a bifid ureter with a divided kidney, while a complete division of the metanephric diverticulum results in a bifid ureter with a double kidney.
An ectopic ureter does not enter the urinary bladder and can open into the bladder neck or the prostatic urethra in males. In females, the ectopic ureter can open into the vestibule or vagina. This presents as urinary incontinence due to the direct communication between the urinary system and the vagina, causing continuous leakage of urine.
The most common causes of ureteral injury are iatrogenic. The overall incidence of iatrogenic ureteral injury varies between 0.5% to 10%. The most common type of procedure responsible for iatrogenic injury to the ureter is a hysterectomy (54%) due to the proximity of the uterine artery to the distal ureter. As the ureter courses into the pelvis, it nears the infundibulo-pelvic ligament where it courses below to the uterine artery. Ureteral injuries may present with flank pain, ileus, hematuria, and prolonged high drain outputs. Elevated laboratory levels include BUN and creatinine.
There are 3 specific areas of narrowing along the ureter. These areas of narrowing poise significant clinical sequelae when dealing with ureteral calculi. The first is the ureteropelvic junction or UPJ. This is the area where the renal pelvis tapers into the proximal ureter. The second region of narrowing occurs where the ureter crosses the iliac vessels. The narrowing is due to the extrinsic compression of the iliac vessels on the ureter and the angle of the ureter as it enters the pelvis. The ureterovesical junction or UVJ is the third site of ureteral narrowing. A retrospective study of 94 patients presenting to the emergency department for colic found that 60.6% of stones were located at the UVJ.
Labeled x-ray image and illustration of kidneys, ureter, bladder and abdomen. Contributed by Chelsea Rowe
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What to Know About Ureter Stones
Not sure what a ureter stone is? You’ve probably heard of kidney stones, or you may know someone who’s had a kidney stone. You may even have experienced one yourself.
A ureter stone, also known as a ureteral stone, is essentially a kidney stone. It’s a kidney stone that has moved from the kidney into another part of the urinary tract.
The ureter is the tube that connects the kidney to the bladder. It’s about the same width as a small vein. It’s the most common location for a kidney stone to become lodged and to cause pain.
Depending on the size and location, it can hurt a lot, and it may require medical intervention if it doesn’t pass, causes intractable pain or vomiting, or if it’s associated with fever or infection.
Urinary tract stones are fairly common. According to the American Urological Association, they affect almost 9 percent of the U.S. population.
This article will take a closer look at ureter stones, including the symptoms, causes, and treatment options. If you want to know how to prevent these stones, we’ve covered that, too.
What is a ureter stone?
Kidney stones are clusters of crystals that typically form in the kidneys. But these masses can develop and move anywhere along your urinary tract, which includes the ureters, urethra, and bladder.
A ureter stone is a kidney stone inside one of the ureters, which are the tubes that connect the kidneys to the bladder.
The stone will have formed in the kidney and passed into the ureter with the urine from one of the kidneys.
Sometimes, these stones are very small. When that’s the case, the stones may pass through your ureter and into your bladder, and eventually pass out of your body when you urinate.
Sometimes, however, a stone can be too large to pass and can get lodged in the ureter. It may block the flow of urine and can be extremely painful.
What are the symptoms?
The most common symptom of a kidney or ureter stone is pain.
You might feel pain in your lower abdomen or your flank, which is the area of your back just under your ribs. The pain can be mild and dull, or it can be excruciating. The pain may also come and go and radiate to other areas.
Other possible symptoms include:
- pain or a burning sensation when you pee
- blood in your urine
- frequent urge to urinate
- nausea and vomiting
If you experience any of these symptoms, call your healthcare provider.
What causes these stones?
Ureter stones are made up of crystals in your urine that clump together. They usually form in the kidneys before passing into the ureter.
Not all ureter stones are made up of the same crystals. These stones can form from different types of crystals such as:
- Calcium. Stones made up of calcium oxalate crystals are the most common. Being dehydrated and eating a diet that includes a lot of high-oxalate foods may increase your risk of developing stones.
- Uric acid. This type of stone develops when urine is too acidic. It’s more common in men and in people who have gout.
- Struvite. These types of stones are often associated with chronic kidney infections and are found mostly in women who have frequent urinary tract infections (UTIs).
- Cystine. The least common type of stone, cystine stones occur in people who have the genetic disorder cystinuria. They are caused when cystine, a type of amino acid, leaks into urine from the kidneys.
Certain factors can raise your risk of developing stones. This includes:
- Family history. If one of your parents or a sibling has had kidney or ureter stones, you may be more likely to develop them, too.
- Dehydration. If you don’t drink enough water, you tend to produce a smaller amount of very concentrated urine. You need to produce a larger amount of urine so salts will stay dissolved, rather than hardening into crystals.
- Diet. Eating a diet high in sodium (salt), animal protein, and high-oxalate food may raise your risk of developing stones. Foods high in oxalate include spinach, tea, chocolate, and nuts. Consuming too much vitamin C may also increase your risk.
- Certain medications. A number of different kinds of medications, including some decongestants, diuretics, steroids, and anticonvulsants, can increase your chance of developing a stone.
- Certain medical conditions. You may be more likely to develop stones if you have:
How are they diagnosed?
If you’re having pain in your lower abdomen, or you’ve noticed blood in your urine, your healthcare provider may suggest a diagnostic imaging test to look for stones.
Two of the most common imaging tests for stones include:
- A computed tomography (CT) scan. A CT scan is usually the best option for detecting stones in the urinary tract. It uses rotating X-ray machines to create cross-sectional images of the inside of your abdomen and pelvis.
- An ultrasound. Unlike a CT scan, an ultrasound doesn’t use any radiation. This procedure uses high-frequency sound waves to produce images of the inside of your body.
These tests can help your healthcare provider determine the size and location of your stone. Knowing where the stone is located and how big it is will help them develop the right type of treatment plan.
How are ureter stones treated?
Research suggests that many urinary stones resolve without treatment.
You may experience some pain while they pass, but as long as you don’t have a fever or infection, you might not have to do anything else other than drink high volumes of water to allow the stone to pass.
Small stones tend to pass more easily.
However, as one 2017 study notes, size matters.
Some stones, especially wider ones, do get stuck in the ureter because it’s the narrowest point in your urinary tract. This can cause severe pain and raise your risk of developing an infection.
If you have a larger or wider stone that’s unlikely to be passed on its own, your healthcare provider will likely want to discuss treatment options with you.
They may recommend one of these procedures to remove a ureter stone that’s too large to pass on its own.
- Ureteral stent placement. A small, soft, plastic tube is passed into the ureter around the stone, allowing urine to bypass the stone. This temporary solution is a surgical procedure that’s performed under anesthesia. It’s low risk but will need to be followed up by a procedure to remove or break up the stone.
- Nephrostomy tube placement. An interventional radiologist can temporarily relieve pain by placing this tube directly into the kidney through the back using only sedation and a combination of ultrasound and X-ray. This is commonly used if a fever or infection occurs with urinary obstruction from a stone.
- Shock wave lithotripsy. This procedure uses focused shock waves to break up the stones into smaller pieces, which can then pass through the rest of your urinary tract and out of your body without any extra help.
- Ureteroscopy. Your urologist will thread a thin tube with a scope into your urethra and up into your ureter. Once your doctor can see the stone, the stone can be removed directly or broken up with a laser into smaller pieces that can pass on their own. This procedure may be preceded by placement of a ureteral stent to allow the ureter to passively dilate over a few weeks before ureteroscopy.
- Percutaneous nephrolithotomy. This procedure is typically used if you have very large or an unusual-shaped stone in the kidney. Your doctor will make a small incision in your back and remove the stone through the incision with a nephroscope. Although it’s a minimally invasive procedure, you’ll need general anesthesia.
- Medical expulsive therapy. This type of therapy involves the use of alpha-blocker drugs to help the stone to pass. However, according to a 2018 review of studies, there’s a risk-benefit ratio to consider. Alpha- blockers help lower blood pressure, which can be effective for clearing smaller stones, but it also carries a risk of negative events.
What can you do to prevent ureter stones?
You can’t change your family history, but there are some steps you can take to reduce your chance of developing stones.
- Drink plenty of fluids. If you tend to develop stones, try to consume about 3 liters of fluid (approximately 100 ounces) every day. This will help boost your urine output, which keeps your urine from getting too concentrated. It’s best to drink water instead of juices or sodas.
- Watch your salt and protein intake. If you tend to eat a lot of animal protein and salt, you may want to cut back. Both animal protein and salt can raise the acid levels in your urine.
- Limit high-oxalate foods. Eating foods that are high in oxalate can lead to urinary tract stones. Try to limit these foods in your diet.
- Balance your calcium intake. You don’t want to consume too much calcium, but you don’t want to reduce your calcium intake too much because you’ll put your bones at risk. Plus, foods that are high in calcium can balance out high levels of oxalate in other foods.
- Review your current medications. Talk to your healthcare provider about any medications you’re taking. This includes supplements like vitamin C that have been shown to increase the risk of stones.
The bottom line
A ureter stone is basically a kidney stone that has moved from your kidney into your ureter. Your ureter is a thin tube that allows urine to flow from your kidney into your bladder.
You have two ureters — one for each kidney. Stones can develop in your kidney and then move into your ureter. They can also form in the ureter.
If you know you’re at risk of developing kidney stones, try to drink plenty of fluids and watch your intake of animal protein, calcium, salt, and high- oxalate foods.
If you start to experience pain in your lower abdomen or back, or notice blood in your urine, call your healthcare provider. Ureter stones can be very painful, but there are several effective treatment options.
Slowly, Kira's strapon pushes Stepa's sphincter in and enters it, well oiled, it slides inside, from which his ass starts to feel. Like a current, the sphincter seems to be covered with thunderbolts of pain, not strong, but palpable. Mmmmmm. Hush, Hush baby, this is only 3, 5 cm, everything will be HO-RO-SHO Kira says playfully.
She pulls out the strap-on from Stepa's ass, and then inserts it again, but this time.
Ureter distal right
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I obeyed and began to swallow everything. At this time, Nastya also received a stream of sperm. From this appeal, I began to flow and thought that my dream had come true. They ordered us to get up and, having laid a bedspread, forced us to. Take off our dresses.
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And then they started working together, literally tearing me apart. In the beginning it hurt a little, but after twenty seconds I got involved. I was literally bursting with pleasure, I moaned at the top of my voice, screamed something obscene (which I screamed, I am still ashamed to remember, but I urged the men.
At the top of my voice).