Clinical Imaging 36 (2012) 768 772

The relationship between ureteral stone characteristics and secondary signs

in renal colic
Nurith Hiller a,, Nadav Berkovitz a , Natalia Lubashevsky a ,
Shaden Salaima b , Natalia Simanovsky a
a

Department of Radiology, Hadassah Mount Scopus, Hebrew University Medical Center, Jerusalem, Israel
Department of Emergency Medicine, Hadassah Mount Scopus, Hebrew University Medical Center, Jerusalem, Israel
Received 6 December 2011; received in revised form 3 January 2012; accepted 5 January 2012

Abstract
Purpose: To assess correlations between stone size/location and severity of secondary signs for ureteral obstruction. Methods:
Unenhanced multi-detector computed tomography examinations of 150 patients with acute renal colic were reviewed. Stone size, location in
the ureter, kidney size and Hounsfield unit values, perinephric edema, and degree of hydronephrosis were assessed. Results: Pale kidney sign
was detected in 36%. Hydronephrosis was mild in 63% and severe in 21%; severe hydronephrosis was associated with larger stones. Midureter and ureteropelvic junction stones were more likely to cause hydronephrosis. Perinephric edema (56%) was not correlated with stone
size/location. Conclusion: Only severe hydronephrosis was significantly associated with larger stone size.
2012 Elsevier Inc. All rights reserved.
Keywords: Computed tomography; Obstruction; Stone; Ureter; Secondary signs

1. Introduction
Acute renal colic due to obstructing ureteral stone is a
common abdominal emergency, accounting for 1% of all
emergency department referrals [1]. In acute renal obstruction, there is a rapid increase in ureteral pressure and backow, resulting in dilatation of the ureter and renal collecting
system, diffusion of urine to the renal interstitium, and an
increase in renal lymphatic pressure, with subsequent perinephric edema and calyceal rupture, and extravasation of
urine into the perirenal space.
Unenhanced helical computed tomography (CT) of the
abdomen and pelvis is currently the preferred imaging study
for diagnosing urolithiasis in patients with acute ank pain,

Disclosure: The authors have no conicts of interest relating to any

product or competitive product relating to imaging assessment of uretal stones.
Corresponding author. Department of Radiology, Hadassah Mount
Scopus Medical Center, POB 24035, Jerusalem 91240, Israel. Tel.: +972 50
787 4980; fax: +972 2 642 0065.
E-mail address: hiller@netvision.net.il (N. Hiller).
0899-7071/$ see front matter 2012 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.clinimag.2012.01.018

with sensitivity and specicity of 9598% and 96100%,

respectively [2,3]. CT provides useful information for
selecting an appropriate treatment, including the size,
number, attenuation values, and precise location of stones
within the collecting system. If symptoms are not caused by
urolithiasis, CT can often identify the true cause [4].
However, there is a concern among clinicians about the
lack of physiologic information on unenhanced CT scan,
including renal function and the degree of ureteral
obstruction. Excretory urography is often required for
evaluating the function of the obstructed kidney.
Secondary signs of ureteral obstruction on nonenhanced
CT have been described previously [57] and are the result
of physiologic changes in the obstructed kidney. These
include hydronephrosis, hydroureter, unilateral renal enlargement, pale kidney sign, perinephric stranding, periureteral stranding, perinephric uid, and lateroconal fascial
thickening [8,9]. Some or all of these associated ndings are
almost always present on unenhanced CT of patients with
obstructed kidney, depending on the degree of pressure in
the collecting system. These secondary signs may help to

N. Hiller et al. / Clinical Imaging 36 (2012) 768772

conrm the diagnosis [7], guide patient management, and

evaluate prognosis [12,14,15].
The most important parameters in treatment selection of
patients with acute renal colic are size and location of the
stone, as these ndings can predict the likelihood of spontaneous stone passage [10]. To our knowledge, no correlative
prior study has examined the relationship between size and
location of ureteral stones demonstrated on CT and the
appearance and severity of secondary CT signs for renal colic.
We aimed to assess whether the characteristics of secondary signs for renal colic detected on unenhanced helical
CT are related to ureteral stone size and location.
2. Patients and methods
CT images of 150 consecutive patients with renal colic
due to ureteral calculi diagnosed in the emergency department from January to August 2010 were evaluated. Our
institutional review board waived the requirement for informed consent for this retrospective le review.
Patients were included in the study if they met the following criteria: (a) CT was performed during an acute attack
of renal colic, and (b) there was CT evidence of a single
ureteral calculi. Exclusion criteria included resolution of the
ank pain prior to CT examination, multiple ureteral stones,
or failure of the CT to demonstrate ureteral stone in a patient
with ank pain.
Examinations were performed with a 16-slice CT system
(LightSpeed, GE Healthcare, Milwaukee, WI, USA). CT was
performed craniocaudally using the following parameters: 100
kVp, automatic milliampere modulation (maximum 250 mA),
1.25 mm slice thickness, and 512512 matrix. Axial slices
were reconstructed in 3.75 mm slice thickness. Coronal and
sagittal reformations were created with 3 mm slice width. No
oral or intravenous contrast material was administered.
2.1. Image interpretation
All CT examinations were reviewed on our institutional
PACS system (Centricity PACS, GE Healthcare) using
PACS software for digital measurements. Studies were
interpreted at standard bone windows (width, 800; length,
2000) on a workstation, blindly, by three readerstwo
board-certied body radiologists with 20 years of experience
(N.H. and N.S.) and one radiology resident (N.B.). Cases of
interobserver disagreement were resolved by consensus.
A number of parameters were assessed
1.
2.
3.
4.

Side and location of the calculi

Maximal axis of the stone
Maximal length of each kidney
Difference in Hounseld unit (HU) for the normal vs.
obstructed kidney (pale kidney sign)
5. Dilatation in the renal collecting system (hydronephrosis) and ureter
6. Presence or absence of perirenal fat stranding or uid

769

Maximum stone axis was dened as the greatest axis on

axial images and coronal reformations. Stone location was
classied as ureteropelvic junction (UPJ), proximal (if above
the level of the top of the sacrum), mid (if at the level of
the sacrum), distal (if below the sacrum and above the
ureterovesical junction), or ureterovesical junction (UVJ).
Kidney length was dened as the maximum length on
coronal or sagittal reformations.
HU was measured on axial images in the mid-lateral
aspect of each kidney using the maximal region of interest
possible. We considered a decrease of more than 5 HU in the
affected vs. the normal kidney to be signicant, while a
difference of less than 5 HU between kidneys was considered comparable [5].
Collecting system dilatation was assessed subjectively by
comparing dilation in the two kidneys (hydronephrosis) with
previously reported ndings [9] and dened as absent, mild,
moderate, or severe.
2.2. Statistical analysis
The paired t test was used to test the difference between
paired quantitative measurements; the independent sample
t test was used to compare quantitative variables between
two groups. The chi-square test was used to test independence between two qualitative variables. The ANOVA procedure with post hoc test was used to compare quantitative
variables between three or more independent groups.

3. Results
Participants had a mean age of 42 years (range 1677)
and included 11 males (77.3%) and 34 females (22.7%).
Stones were right-sided in 82 patients (54.7%) and leftsided in 68 (45.3%). Stone locations were classied as UPJ
in eight patients (5.3%), proximal ureter in 32 (21.3%), mid
ureter in 10 (6.7%), distal ureter in 35 (23.3%), and UVJ in
65 (43.3%).
Maximal stone axis ranged from 2 to 16 mm (mean
6 mm).
The average lengthS.D. of affected kidneys was
10.21.1 cm (95% CI 10.110.4 cm). Average sizeS.D.
of normal kidney was 10.11.1 cm (95% CI 9.910.3 cm).
The difference in length was not statistically signicant
(P=.11, paired t test).
HU in the affected kidney ranged from 14.3 to 36.3 HU
(mean 31.4) and from 31.4 to 44.2 HU (mean 33.6) in the
normal kidney. In 149 patients, HU was lower in the affected
than in the normal kidney by an average of 4.3 HU (Fig. 1).
The normal kidney had a lower HU measurement in only one
patient. A signicant difference in kidney density (positive
pale kidney sign) was revealed in 36% of the patients. For
this group, the average maximal stone diameterS.D. was
63 mm (95% CI 56 mm), which was similar to the general
average stone size for all study group. Location of stone

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N. Hiller et al. / Clinical Imaging 36 (2012) 768772

Fig. 3. A comparison of percentages of stones with perinephric fat stranding

at differing levels of severity of hydronephrosis.

Fig. 1. Abdominal CT with coronal reconstruction at the level of the kidney

in a 42-year-old male with right renal colic. HU measurement is clearly
lower in the right obstructed kidney (circles).

impaction in the ureter for the patient subgroup with HU

difference greater than 5 closely resembled location in the
remainder of the study population.
There was no hydronephrosis in 24 patients (16%), mild
hydronephrosis in 95 (63%), and severe hydronephrosis in
31 (21%). There was no signicant relationship between the
difference in kidney Hounseld unit and the degree of
hydronephrosis. In cases without hydronephrosis, the mean
difference was 3.93.3 HU (95% CI 2.65.2 HU); for mild
hydronephrosis, 4.32.7 HU (95% CI 3.84.8 HU); and for
severe hydronephrosis, 4.53.2 HU (95% CI 3.45.6 HU)
(P=.69, ANOVA). Among patients with no hydronephrosis,
33% showed a Hounseld unit difference between kidneys
that was greater than 5, compared with 38% of patients with
mild and 31% of those with severe hydronephrosis.
The degree of hydronephrosis was compared to maximal
stone diameter. In patients with no hydronephrosis, average

Fig. 2. (A) Axial and (B) coronal images at the level of the kidney
demonstrating marked right-sided perirenal fat stranding and thickening of
the perirenal fascia (white arrows), due to a stone impacted in the proximal
ureter (black arrow) in a 51-year-old female.

stone diameter was 5.62 mm (95% CI 4.36.9 mm); with

mild hydronephrosis, 5.62.6 mm (95% CI 5.16.1 mm);
and with severe hydronephrosis, 8.33.2 mm (95% CI 7.2
9.4 mm). Ureteral stones in patients with severe hydronephrosis were signicantly larger than those in patients with
no or mild hydronephrosis (P=.001, ANOVA).
Perinephric fat stranding was seen in 84 patients (56%)
(Fig. 2A and B), while 66 (44%) showed none. Perinephric
fat stranding was seen in all patients with perinephric uid or
perirenal fascial thickening.
The nding of perinephric fat stranding was compared
with severity of hydronephrosis (Fig. 3). Fat stranding was
seen in 17% (4/24) of patients with no hydronephrosis,
in 46% (44/95) of those with mild hydronephrosis, and in
59% (19/32) of cases with severe hydronephrosis. As hydronephrosis increases in severity, so does the occurrence of
perinephric fat stranding (Pb.0001, chi-square test).
Average stone diameter was 5.82.7 mm (95% CI 5.2
6.4 mm) in patients with no stranding and 6.32.9 mm (95%
CI 5.67 mm) in those with stranding; however, this difference was not statistically signicant (P=.36, independent
sample t test).
The distribution of stone location in patients with perinephric fat effacement was similar to location in the study
population as a whole.
The association between stone location in the ureter and
the average maximal stone diameter is demonstrated in
Fig. 4, which shows that larger stones are more likely to

Fig. 4. Average maximal stone size in millimeters and location of stone in

the ureter.

N. Hiller et al. / Clinical Imaging 36 (2012) 768772

Fig. 5. The relationship between severity of hydronephrosis and stone

location within the ureter.

impact at a higher level of the ureter. ANOVA test showed a

signicant difference between stone size and location
(Pb.00001).
Fig. 5 shows the association between stone location in
the ureter and the degree of hydronephrosis. All stones
impacted in the mid ureter caused some degree of hydronephrosis. Stones impacted at the UPJ level were more likely to
cause severe hydronephrosis.
4. Discussion
The presence of secondary signs of ureteral obstruction
has been linked to both duration and severity of obstruction
[9,11]. In addition, both hydronephrosis and perinephric fat
stranding are indicators for the degree of ureteral obstruction
and have been shown to be associated with a higher rate of
spontaneous stone passage and with clinical signicance in
prognosis [12]. Pale kidney sign is not known to correlate
to clinical outcome, although it has the advantage of being
an objective, measurement-based indicator of obstruction
[5,13]. Maximal stone size and stone location in the ureter
are of paramount importance in estimating the likelihood of
spontaneous stone passage [10].
The relationships between these secondary signs, stone
size, and stone location were not previously studied. We
compared stone size and location with ndings for three
accepted secondary signs: degree of hydronephrosis, presence of perinephric fat stranding, and pale kidney sign.
Reported incidence of hydronephrosis in cases of ureteral
calculous varies from 69% to 83% [2,8,14], but only severe
hydronephrosis was signicantly associated with a largerthan-average stone size. No signicant difference in stone
size was found in patients with no or mild hydronephrosis,
although a previous study examining this issue had a small
patient population [12]. One possible explanation for the
relationship between severe hydronephrosis and larger stone
size may be the slow formation of large stones with gradual

771

accumulation of subclinical hydronephrosis before obstruction causes clinical presentation of renal colic and the need
for medical care [12].
Stranding of the perinephric fat, which represents uid
that has collected within the bridging septa of the perinephric fat as a result of increased lymphatic pressure [15], has
been reported as an important secondary sign for the diagnosis of ureterolithiasis at unenhanced helical CT [7,8,16].
Reported incidence in patients with stone-related ureteral
obstruction varies from 36% to 82% [2,3,8,14,17,18].
Although nonspecic, in the clinical setting of acute ank
pain, perinephric fat stranding proved to have a relatively
high sensitivity (82%) and specicity (94%) for the presence
of a ureteral calculus [7,12].
As fat stranding represents a release of uid due to high
pressure, an inverse correlation with the degree of hydronephrosis could be expected. However, CT ndings do not
support this theory; a higher degree of hydronephrosis
correlates positively with the severity of perinephric edema.
Perhaps both perinephric fat stranding and perinephric
edema have the same etiology of backward pressure, without
direct interrelation.
We did not nd a statistically signicant association
between perinephric fat stranding and stone size. This is
consistent with a previous report by Takahashi et al. [12].
It has been theorized that perinephric fat stranding and
hydronephrosis develop at different points during the evolution of ureteral obstruction. Hydronephrosis has been
described as relating to a subacute-to-chronic phase of obstruction [12,19]. Perinephric fat stranding seen at CT is
probably a manifestation of a rapid increase in collection
system pressure during the acute phase of ureteral obstruction [12]. With large, slowly forming stones, hydronephrosis
may build up subclinically until obstruction reaches a
threshold for pain elicitation; thus large stones would often
be found with high levels of hydronephrosis and severe
hydronephrosis would be associated with higher average
stone size. As perinephric fat stranding is formed in response
to acute obstruction, it is logical that it could occur regardless
of the stone size.
Pale kidney sign, referring to a renal parenchymal density
difference greater than 5 HU between affected and nonaffected kidney, was rst suggested by Georgiades et al.
[13]. The density difference between renal parenchyma of
obstructed and nonobstructed kidneys results from acute
adaptation to increased ureteral pressure and intrarenal
edema [6]. It has been reported to occur in 61% to 89% of
patients with ureteral stones [5,6]. In our patient series, the
affected kidney had a lower HU measurement compared to
the control kidney in 149 of 150 patients, but the difference
was greater than HU in only 36% of cases. It has been
suggested that this sign is directly related to the length of
time from onset of pain [20]. Duration from onset was not
investigated as a parameter in this retrospective study, and
short duration of pain is a likely causative factor for the
relatively low incidence of this sign in our study population.

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N. Hiller et al. / Clinical Imaging 36 (2012) 768772

No signicant correlation was found between larger stones

and decreased HU measurement in the affected kidney.
The larger the stone, the more likely it will impact at a
higher level of the ureter. A possible explanation may be
that small stones are more likely to pass the UPJ without
causing symptoms, while larger stones are more easily impacted. Small stones tend to impact at the UVJ level and then
cause pain.
All stones impacted in the mid ureter caused some degree
of hydronephrosis, possibly due to the presence of major
blood vessels crossing the ureter in that area, and thus adding
to backward pressure within the kidney.
The study carries several limitations. The relatively small
number of patients in the study limited the statistical signicance of some ndings. There would be an added benet to
repeating the study on a larger scale.
Time from the onset of symptoms was not taken into
consideration in regard to secondary signs for ureteral obstruction. A similar study duration of clinical signs before
CT evaluation might reveal a relationship between stone size
and secondary sign formation.
There is a selection bias in the study group, as only
acutely symptomatic patients were included. Including
asymptomatic patients would provide a better control for
some of the secondary ndings; however, such patients are
obviously more difcult to identify.
The research is purely retrospective and data regarding
the clinical outcome are lacking.
5. Conclusion
There is no direct correlation between ureteral stone
size and location, and the presence and severity of secondary CT signs for ureteral obstruction. Only severe hydronephrosis was signicantly associated with a larger average
stone size.
Acknowledgments
The authors wish to thank Shifra Fraifeld for her editorial
assistance in the preparation of this article.
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