Aust. Radiol. (1979), 23, 117
Renal Calculiys. A Sexual Paradox ERIC M. BATESON, M.D., F.R.A.C.R., F.R.C.R. X-ray Department, Darwin Hospital, Darwin, ff.T. 5794. The majority of renal and ureteric calculi are idiopathic (Stanton-King, 197 1) but their incidence is affected by many factors. These include diet (Modlin, 1968), climate (Bateson, 1973, Frank et al, 1963), race (Bateson 1977, Henry and Tomlin, 1975, Vermooten, 1941), level of physical activity (Editorial, 1971), hereditary (Lavan et al, 1971) and the sex of the patient (Thomas, 1975). In relation to the latter factor, calculi are reported to be more common in males than females (Dodson and Clark, 1946, Lavan et al, 1971, McDonald, 1974 and Marshall et al, 1975). However, analysis of intravenous pyelograms performed at the Darwin Hospital showed that although ureteric calculi were more common in males, renal calculi were more common in females. This paradox was investigated by a retrospective study of intravenous pyelograms of the Darwin Hospital from January, 1971, to the end of December, 1975.
In addition, the examinations were analysed in relation to the clinical indication which is recorded on the X-ray request form for those intravenous pyelograms which demonstrate renal or ureteric calculi. All pyelograms which were requested because of renal tract colic were analysed for the presence or absence of calculi. During the period of the review, 3,028 intravenous pyelograms were performed at the Darwin Hospital, 1643 on male, and 1385 on female patients. Of these examinations, 280 demonstrated renal or ureteric calculi (or both), and 12 demonstrated large or staghorn calculi. Table I analyses the sex of the patient and the situation of the calculi with 85 per cent of the ureteric calculi being found in males and 74 per cent of the renal calculi being found in females. If both sexes are taken together, ureteric calculi were present in 64 per cent of all the patients with calculi. Analysis of the clinical indication for the radiological examinations which demonstrated MATERIAL AND METHODS renal and ureteric calculi is given in Table 11. Only Intravenous pyelograms, rather than clinical a minority of the patients with renal calculi records were analysed because it is a more reliable presented with renal colic and half of these had method, not only in demonstrating calculi but also concomitant ureteric calculi. However, 176 out of their position in the renal tract. of the total of 178 patients with ureteric calculi All intravenous pyelograms carried out at the had the examination (intravenous pyelogram) Darwin Hospital between January, 1971 through because of renal or ureteric colic. to December, 1975, were analysed for the presence Of the total of 3,208 patients who had intraor absence of calculi in the kidneys and ureters venous pyelograms, 230 were referred for the (cases with medullary sponge kidney or nephro- procedure because of renal or ureteric colic and calcinosis were excluded) and the calculi were of these, 201 patients were shown to have renal or classified as either renal or ureteric and were also ureteric calculi, or both (Table 111). This highly sub-divided into large and small calculi. positive result is probably due to the arrangTABLE I CALCULI
Female Total
URETERIC
180
100
RENAL
I00
Australasian Radiology, VoL XXIII. No. 2, July, I979
STAGHORN
I00
10 12
85
I00
TOTAL
100 280
36 100
117
E. M. BATESON TABLE I11
TABLE I1 CLINICAL PRESENTATIOK
R e d tract colic Lumbar pain Loin pain Renal tract infection Haematuria Accidental observation
WITH CALCULI Renal 21 31 10 29 2
NUMBER OF PATIENTS Without calculi
With calculi
~~
Renal tract colic Othercwical features
7 100
CLINICAL PRESENTATION
180
Total
II
201 79 280
1
I
29 2719 2748
Total
I
I
230 2798
I
I
3028
ment whereby patients referred for intravenous the time spent in the ureter, must affect the relative pyelograms because of renal tract colic have the incidence of calculi in these two situations. examination performed as an emergency procedure Vermuelen and Lyon (1968) also showed that and therefore without delay. Smith (1966) showed that the probability of demonstrating renal tract the crystallization of an embryonic calculus in the calculi decreases as the time interval between .renal papilla may only take a matter of hours. symptoms and radiological examination increases. Prince et al (1956) showed that a calculus could increase in size so that it becomes visible radiologically in two to three weeks. Once visible, a calculus DISCUSSION may be observed over periods of months or even The results confirm that ureteric calculi are years within the kidney, but of those calculi more common in males and renal calculi more which first present in the ureter, the time they common in females. There is minimal reference to initially spent in the kidney cannot be known. this in the literature but the result was confirmed Calculi usually pass rapidly along the ureter but by a further analysis of a series of renal tract a proportioq impact in the distal end and may calculi from Bentley Hospital in Western Australia remain in that situation for a short period unless (Bateson, 1973). The series consisted of 188 intra- removed surgically. Generally, it would b e reasonvenous pyelograms which demonstrated renal or able to assume that ureteric calculi spend more ureteric calculi. Of these examinations, 73 demon- time in the kidney than the ureter and, as some strated renal calculi, of which 44 were performed calculi remain within the kidney, renal should on female patients (60 per cent) and 131 demon- be more frequent than ureteric calculi. strated ureteric calculi, ofwhich96 were performed However, it is also important to consider the on male patients (73 per cent)*. clinical presentation of patients with these calculi. Before discussing the results, it is necessary to Only a minority of patients with renal calculi consider the relationship between calculi in the kidney and in the ureter. Vermuelen and Lyon presented with typical renal colic (Table II), the (1968) showed that the early stage of calculus majority having symptoms not directly related formation is clearly related to the renal papilla to the presence of a calculus suggesting that, in with crystalization in the collecting ducts and the many cases, the demonstration of a renal calculus formation of a small protruding calculus upon the is an incidental observation. In comparison, nearly papillary tip. The calculus may then grow larger all the patients with ureteric calculi presented with and impact in the collecting duct or may slough renal tract colic and the majority of patients with renal tract colic had calculi (Table 111). Therefore, away. Hence, when calculi form in the kidney, it would seem, that although the majority of some m y remain in situ in the renal pyramid or patients with ureteric calculi will have the stones may enter a minor calyx, or the renal pelvis. All demonstrated radiologically, only a minority of these forms present radiologically as renal calculi with renal calculi will have the stones and m a y enlarge. The majority of those that enter those detected. Therefore, the incidence of renal calculi the renal pelvis will also pass into the ureter and must be greater than studies of this type suggests, then present as ureteric calculi. The proportion of which also suggests that renal are more common calculi which remain in the kidney and the relative than ureteric calculi. period of time spent in the kidney compared with In addition, the stability of the embryonic *Sixteen examinations showed calculi in both kidneys calculus must also be taken into consideration and ureters. and this should be related to the size of the renal 118
Australnskrn Radiology, Vol XXIII, No. 2, July, 1979
RENAL CALCULUS. A SEXUAL PARADOX calculi. Ten of the twelve large calculi in the Darwin Hospital series were in female patients. Jennis et al, 1970, Lange et al, 1970 and Singh et al, 1973, all found a greater proportion of staghorn cdculi in female than in male patients. This suggests that when calculi form in the kidney of a female, they are more likely to remain there and increase in size. The relative absence of large calculi in the kidneys of male patients also suggests that in this sex the calculi are less stable and more likely to become detached and enter the ureter. This is another possible factor which may play a part in the different frequency of renal and ureteric stones in male and female patients. It is possible to theorize concerning the stability of embryonic calculi in the kidney. Ureteric calculi show an increased incidence in males living in more extreme climates with hot dry summers and cold wet winters (Bateson, 1973 and Prince ef al, 1956) and this may be related to the fact that calculus formation occurs when the urinary solutes are in high concentration (Hodgkinson and Pyrah, 1958). Males are more likely to be employed in strenuous occupations than females, particularly out of doors, and therefore wiU have a wider variation in their fluid intake with periods of high and low concentration of the urinary solutes. The variation of the concentration of urinary solutes may accelerate stone formation, the rate of enlargement of stones once formed and may also make renal calculi less stable in the male than in the female. SUMMARY An analysis of 280 intravenous pyelograms which demonstrated calculi in the renal tract showed that renal were more common in female and that ureteric calculi were more common in male patients. This paradox is difficult to explain. Several factors appear to be involved and these include, the period of time a calculus is present in the kidney compared with the time it is present in the ureter, the different clinical presentation of renal and ureteric calculi, and the different stability of renal calculi in male and female patients.
ACKNOWLEDGEMENTS I wish to acknowledge the help given by my
Australasian Radiology, Vol. XXIII, No. 2, July, I979
wife in the preparation of this paper and for typing the manuscript. REFERENCES Bateson, E. M. (1973): “Renal tract calculi and climate.” Med. J. Aust. 2 : 111. Bateson, E. M. (1977): “Do Australian Aborigines suffer from renal tract calculi?” Aust. N.Z. J. Med. 7 : 380. Dodson, A. I. and Clark, J. R. (1946): “Incidence of urinary calculi in the American Negro.” J. Amer. med. Ass. 132 : 1063. Editorial (1971): “Renal stones in top people.” Brit. med. J. 1 : 668. Frank, M., Atsmon, A., Sugar, P. and DeVries, A. (1963): “Epidemiological investigation of urolithiasis in the hot southern arid region of Israel.” Urol. Inr. 15 : 65. Henry, H. H. I1 and Tomlin, E. M. (1975): “Ureteral calculi: review of 17 years experience at a community hospital.” J. Urol. 113 : 762. Hodgkinson, A. and Pyrah, L. N. (1958): “The urinary excretion of calcium and magnesium phosphate in 344 patients with calcium stone of renal origin.” Brit. J. Surg. 46 : 10. Jennis, F., Lavan, J., Neale, F. C. and Posen, S. (1970): “Staghorn calculi of the kidney: clinical, bacteriological and chemical features.” Brit. J. Urol. 4 2 : 5 11. Lavan, J., Neale, F. C. and Posen, S. (1971): “Urinary calculi. Clinical, biochemical and radiological studies in 619 patients.”Med, J. Aust. 2 : 1049. Lange, J., Ballanger, R., Doutres, JC. and Latapy, J-P. (1970): “A propos de 105 cas de calcul cordiforme.” J. Urol. Nephrol. 16 : 912. McDonald, D. F. (1974): “Surgical management of staghorn renal calculi.” Southern med. J. 67 : 1067. Marshall, V., White, R. H., De Santonge, M. C., Tresidder, G. C. and Blandy, J. P. (1975): “The natural history of renal and ureteric calculi.” Bn‘t. J. Urol. 47 : 117. Modlin, M. (1968): “Renal stone.” Brit. J. Clin. Pract. 22 : 531. Prince, C. L., Scardino, P. L. and Wolan, C. T. (1956): “The effect of temperature, humidity and dehydration on the formation of renal calculi.” J. Urol. 75 : 204. Singh, M., Chapman, R., Tresidder, G. C. and Blandy, J. (1973): “The fate of unoperated staghorn calculus.” Brit. J. Urol. 45 : 5 8 1. Smith, I. (1966): “Urography during renal colic.” Brit. J. Surg. 53 :93. Stanton-King, J. (1971): “Currents in renal stone research.” Clin. Chem. 17 : 971. Thomas, W. C. Jnr. (1975): “Clinical concepts of renal calculus disease.” J. Urol. 11 3 : 423. Vermuelen, C. W. and Lyon, E. S. (1968): “Mechanism of genesis and growth of calculi.” Amer. J. Med. 45 : 684. Vermooten, V. (1941): “The origin and development in the renal papilla of Randall’s calcium plaques” J. Urol. 4 8 : 27.
119
Renal Calculiys. A Sexual Paradox ERIC M. BATESON, M.D., F.R.A.C.R., F.R.C.R. X-ray Department, Darwin Hospital, Darwin, ff.T. 5794. The majority of renal and ureteric calculi are idiopathic (Stanton-King, 197 1) but their incidence is affected by many factors. These include diet (Modlin, 1968), climate (Bateson, 1973, Frank et al, 1963), race (Bateson 1977, Henry and Tomlin, 1975, Vermooten, 1941), level of physical activity (Editorial, 1971), hereditary (Lavan et al, 1971) and the sex of the patient (Thomas, 1975). In relation to the latter factor, calculi are reported to be more common in males than females (Dodson and Clark, 1946, Lavan et al, 1971, McDonald, 1974 and Marshall et al, 1975). However, analysis of intravenous pyelograms performed at the Darwin Hospital showed that although ureteric calculi were more common in males, renal calculi were more common in females. This paradox was investigated by a retrospective study of intravenous pyelograms of the Darwin Hospital from January, 1971, to the end of December, 1975.
In addition, the examinations were analysed in relation to the clinical indication which is recorded on the X-ray request form for those intravenous pyelograms which demonstrate renal or ureteric calculi. All pyelograms which were requested because of renal tract colic were analysed for the presence or absence of calculi. During the period of the review, 3,028 intravenous pyelograms were performed at the Darwin Hospital, 1643 on male, and 1385 on female patients. Of these examinations, 280 demonstrated renal or ureteric calculi (or both), and 12 demonstrated large or staghorn calculi. Table I analyses the sex of the patient and the situation of the calculi with 85 per cent of the ureteric calculi being found in males and 74 per cent of the renal calculi being found in females. If both sexes are taken together, ureteric calculi were present in 64 per cent of all the patients with calculi. Analysis of the clinical indication for the radiological examinations which demonstrated MATERIAL AND METHODS renal and ureteric calculi is given in Table 11. Only Intravenous pyelograms, rather than clinical a minority of the patients with renal calculi records were analysed because it is a more reliable presented with renal colic and half of these had method, not only in demonstrating calculi but also concomitant ureteric calculi. However, 176 out of their position in the renal tract. of the total of 178 patients with ureteric calculi All intravenous pyelograms carried out at the had the examination (intravenous pyelogram) Darwin Hospital between January, 1971 through because of renal or ureteric colic. to December, 1975, were analysed for the presence Of the total of 3,208 patients who had intraor absence of calculi in the kidneys and ureters venous pyelograms, 230 were referred for the (cases with medullary sponge kidney or nephro- procedure because of renal or ureteric colic and calcinosis were excluded) and the calculi were of these, 201 patients were shown to have renal or classified as either renal or ureteric and were also ureteric calculi, or both (Table 111). This highly sub-divided into large and small calculi. positive result is probably due to the arrangTABLE I CALCULI
Female Total
URETERIC
180
100
RENAL
I00
Australasian Radiology, VoL XXIII. No. 2, July, I979
STAGHORN
I00
10 12
85
I00
TOTAL
100 280
36 100
117
E. M. BATESON TABLE I11
TABLE I1 CLINICAL PRESENTATIOK
R e d tract colic Lumbar pain Loin pain Renal tract infection Haematuria Accidental observation
WITH CALCULI Renal 21 31 10 29 2
NUMBER OF PATIENTS Without calculi
With calculi
~~
Renal tract colic Othercwical features
7 100
CLINICAL PRESENTATION
180
Total
II
201 79 280
1
I
29 2719 2748
Total
I
I
230 2798
I
I
3028
ment whereby patients referred for intravenous the time spent in the ureter, must affect the relative pyelograms because of renal tract colic have the incidence of calculi in these two situations. examination performed as an emergency procedure Vermuelen and Lyon (1968) also showed that and therefore without delay. Smith (1966) showed that the probability of demonstrating renal tract the crystallization of an embryonic calculus in the calculi decreases as the time interval between .renal papilla may only take a matter of hours. symptoms and radiological examination increases. Prince et al (1956) showed that a calculus could increase in size so that it becomes visible radiologically in two to three weeks. Once visible, a calculus DISCUSSION may be observed over periods of months or even The results confirm that ureteric calculi are years within the kidney, but of those calculi more common in males and renal calculi more which first present in the ureter, the time they common in females. There is minimal reference to initially spent in the kidney cannot be known. this in the literature but the result was confirmed Calculi usually pass rapidly along the ureter but by a further analysis of a series of renal tract a proportioq impact in the distal end and may calculi from Bentley Hospital in Western Australia remain in that situation for a short period unless (Bateson, 1973). The series consisted of 188 intra- removed surgically. Generally, it would b e reasonvenous pyelograms which demonstrated renal or able to assume that ureteric calculi spend more ureteric calculi. Of these examinations, 73 demon- time in the kidney than the ureter and, as some strated renal calculi, of which 44 were performed calculi remain within the kidney, renal should on female patients (60 per cent) and 131 demon- be more frequent than ureteric calculi. strated ureteric calculi, ofwhich96 were performed However, it is also important to consider the on male patients (73 per cent)*. clinical presentation of patients with these calculi. Before discussing the results, it is necessary to Only a minority of patients with renal calculi consider the relationship between calculi in the kidney and in the ureter. Vermuelen and Lyon presented with typical renal colic (Table II), the (1968) showed that the early stage of calculus majority having symptoms not directly related formation is clearly related to the renal papilla to the presence of a calculus suggesting that, in with crystalization in the collecting ducts and the many cases, the demonstration of a renal calculus formation of a small protruding calculus upon the is an incidental observation. In comparison, nearly papillary tip. The calculus may then grow larger all the patients with ureteric calculi presented with and impact in the collecting duct or may slough renal tract colic and the majority of patients with renal tract colic had calculi (Table 111). Therefore, away. Hence, when calculi form in the kidney, it would seem, that although the majority of some m y remain in situ in the renal pyramid or patients with ureteric calculi will have the stones may enter a minor calyx, or the renal pelvis. All demonstrated radiologically, only a minority of these forms present radiologically as renal calculi with renal calculi will have the stones and m a y enlarge. The majority of those that enter those detected. Therefore, the incidence of renal calculi the renal pelvis will also pass into the ureter and must be greater than studies of this type suggests, then present as ureteric calculi. The proportion of which also suggests that renal are more common calculi which remain in the kidney and the relative than ureteric calculi. period of time spent in the kidney compared with In addition, the stability of the embryonic *Sixteen examinations showed calculi in both kidneys calculus must also be taken into consideration and ureters. and this should be related to the size of the renal 118
Australnskrn Radiology, Vol XXIII, No. 2, July, 1979
RENAL CALCULUS. A SEXUAL PARADOX calculi. Ten of the twelve large calculi in the Darwin Hospital series were in female patients. Jennis et al, 1970, Lange et al, 1970 and Singh et al, 1973, all found a greater proportion of staghorn cdculi in female than in male patients. This suggests that when calculi form in the kidney of a female, they are more likely to remain there and increase in size. The relative absence of large calculi in the kidneys of male patients also suggests that in this sex the calculi are less stable and more likely to become detached and enter the ureter. This is another possible factor which may play a part in the different frequency of renal and ureteric stones in male and female patients. It is possible to theorize concerning the stability of embryonic calculi in the kidney. Ureteric calculi show an increased incidence in males living in more extreme climates with hot dry summers and cold wet winters (Bateson, 1973 and Prince ef al, 1956) and this may be related to the fact that calculus formation occurs when the urinary solutes are in high concentration (Hodgkinson and Pyrah, 1958). Males are more likely to be employed in strenuous occupations than females, particularly out of doors, and therefore wiU have a wider variation in their fluid intake with periods of high and low concentration of the urinary solutes. The variation of the concentration of urinary solutes may accelerate stone formation, the rate of enlargement of stones once formed and may also make renal calculi less stable in the male than in the female. SUMMARY An analysis of 280 intravenous pyelograms which demonstrated calculi in the renal tract showed that renal were more common in female and that ureteric calculi were more common in male patients. This paradox is difficult to explain. Several factors appear to be involved and these include, the period of time a calculus is present in the kidney compared with the time it is present in the ureter, the different clinical presentation of renal and ureteric calculi, and the different stability of renal calculi in male and female patients.
ACKNOWLEDGEMENTS I wish to acknowledge the help given by my
Australasian Radiology, Vol. XXIII, No. 2, July, I979
wife in the preparation of this paper and for typing the manuscript. REFERENCES Bateson, E. M. (1973): “Renal tract calculi and climate.” Med. J. Aust. 2 : 111. Bateson, E. M. (1977): “Do Australian Aborigines suffer from renal tract calculi?” Aust. N.Z. J. Med. 7 : 380. Dodson, A. I. and Clark, J. R. (1946): “Incidence of urinary calculi in the American Negro.” J. Amer. med. Ass. 132 : 1063. Editorial (1971): “Renal stones in top people.” Brit. med. J. 1 : 668. Frank, M., Atsmon, A., Sugar, P. and DeVries, A. (1963): “Epidemiological investigation of urolithiasis in the hot southern arid region of Israel.” Urol. Inr. 15 : 65. Henry, H. H. I1 and Tomlin, E. M. (1975): “Ureteral calculi: review of 17 years experience at a community hospital.” J. Urol. 113 : 762. Hodgkinson, A. and Pyrah, L. N. (1958): “The urinary excretion of calcium and magnesium phosphate in 344 patients with calcium stone of renal origin.” Brit. J. Surg. 46 : 10. Jennis, F., Lavan, J., Neale, F. C. and Posen, S. (1970): “Staghorn calculi of the kidney: clinical, bacteriological and chemical features.” Brit. J. Urol. 4 2 : 5 11. Lavan, J., Neale, F. C. and Posen, S. (1971): “Urinary calculi. Clinical, biochemical and radiological studies in 619 patients.”Med, J. Aust. 2 : 1049. Lange, J., Ballanger, R., Doutres, JC. and Latapy, J-P. (1970): “A propos de 105 cas de calcul cordiforme.” J. Urol. Nephrol. 16 : 912. McDonald, D. F. (1974): “Surgical management of staghorn renal calculi.” Southern med. J. 67 : 1067. Marshall, V., White, R. H., De Santonge, M. C., Tresidder, G. C. and Blandy, J. P. (1975): “The natural history of renal and ureteric calculi.” Bn‘t. J. Urol. 47 : 117. Modlin, M. (1968): “Renal stone.” Brit. J. Clin. Pract. 22 : 531. Prince, C. L., Scardino, P. L. and Wolan, C. T. (1956): “The effect of temperature, humidity and dehydration on the formation of renal calculi.” J. Urol. 75 : 204. Singh, M., Chapman, R., Tresidder, G. C. and Blandy, J. (1973): “The fate of unoperated staghorn calculus.” Brit. J. Urol. 45 : 5 8 1. Smith, I. (1966): “Urography during renal colic.” Brit. J. Surg. 53 :93. Stanton-King, J. (1971): “Currents in renal stone research.” Clin. Chem. 17 : 971. Thomas, W. C. Jnr. (1975): “Clinical concepts of renal calculus disease.” J. Urol. 11 3 : 423. Vermuelen, C. W. and Lyon, E. S. (1968): “Mechanism of genesis and growth of calculi.” Amer. J. Med. 45 : 684. Vermooten, V. (1941): “The origin and development in the renal papilla of Randall’s calcium plaques” J. Urol. 4 8 : 27.
119
