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CME Article

Evaluation of Patients With Suspected

Ureteral Calculi Using Sonography as
an Initial Diagnostic Tool
How Can We Improve Diagnostic Accuracy?

Seong Jin Park, MD, PhD, Boem Ha Yi, MD, Hae Kyung Lee, MD,
Young Ho Kim, MD, Gong Jo Kim, MD, Hyun Cheol Kim, MD

Objective. The purpose of this study was to evaluate the usefulness of sonography as an initial diag-
nostic tool in patients with suspected ureterolithiasis. Methods. We performed a prospective study of
318 patients with suspected ureteral stones over a 14-month period. All patients underwent sonography
after fasting for 8 hours and bladder filling. If no cause of the flank pain was found by sonogra-
phy, computed tomography or intravenous urography was performed immediately to confirm the
absence of ureteral stones. Results. We found urolithiasis with sonography in 291 of 296 patients with
confirmed urolithiasis. The 5 remaining cases were identified after non–contrast-enhanced computed
tomography (n = 3), intravenous urography (n = 1), or the passage of a stone (n = 1, pregnant patient).
We detected 313 calculi in the 291 patients with sonography as follows: 307 ureteral calculi in 285
patients, 5 urinary bladder calculi that were probably passed from the ureter in 5 patients, and 1 ure-
thral calculus. The locations of the 313 calculi in the 291 patients with a sonographic diagnosis were
as follows: 21 were in the ureteropelvic junction, 96 in the proximal half of the ureter, 69 in the distal
half of the ureter, 121 in the ureterovesical junction, 5 in the urinary bladder, and 1 in the urethra.
Hydronephrosis was seen in 200 of the 291 patients with calculi identified by sonography (68.7%).
Twinkling artifacts helped confirm the presence of tiny calculi in 184 of the 214 calculi (86%).
Conclusions. Sonography can be used as an initial diagnostic tool in patients with suspected
ureterolithiasis. Key words: calculi; sonography; ureter.

A
Abbreviations
CT, computed tomography; IVU, intravenous urography;
UPJ, ureteropelvic junction; UVJ, ureterovesical junction
Received April 25, 2008, from the Departments of
Radiology (S.J.P., B.H.Y., H.K.L.) and Urology
(Y.H.K., G.J.K.), Soonchunhyang University Bucheon
Hospital, Gyeonggi-do, Korea; and Department of
Diagnostic Radiology, Kyung Hee University East
West Neo Medicine Hospital, Seoul, Korea (H.C.K.).
Revision requested May 15, 2008. Revised
manuscript accepted for publication May 19, 2008.
Address correspondence to Seong Jin Park, MD,
PhD, Department of Radiology, Soonchunhyang
University Bucheon Hospital, 1174, Jung-dong,
Wonmi-gu, Bucheon-si, Gyeonggi-do 420-021, Korea.
E-mail address: indawn@hanafos.com
CME Article includes CME test
cute flank pain caused by urolithiasis is a com-
mon condition in patients visiting emergency
departments or outpatient urology clinics.1,2
Radiologic studies including plain radiography,
intravenous urography (IVU), computed tomography
(CT), and sonography have always had important roles in
the workup of these patients. Intravenous urography fol-
lowing plain radiography has been a traditional radiologic
workup sequence. In the past several years, thin-section
non–contrast-enhanced CT has been the reference stan-
dard for diagnosing urinary tract calculi in adults.1–3
Non–contrast-enhanced CT has higher sensitivity and
specificity than either sonography or IVU for detecting
ureteral stones. In many studies, the sensitivity, specifici-
ty, and accuracy rates of CT for detecting urolithiasis have

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Evaluation of Patients With Suspected Ureteral Calculi
been reported as 96% to 100%, 95.5% to 100%,
and 96% to 98%, respectively.1,4–10 Sonography
has been shown to be effective in the diagnosis
of renal calculi1 but limited in the diagnosis of
ureteral calculi.11–14 Sonography had extremely
low sensitivity of 12% to 37% when only direct
visualization of ureteral calculi was included as a
diagnostic finding,11 but these data were from the
1980s and 1990s. Additional useful information
for diagnosing ureteral calculi by sonography has
since been reported, such as twinkling artifacts
and the application of endocavitary and high-
frequency transducers for small calculi.15,16
In recent years, new sonographic equipment
and technologies have been developed that
improve image resolution and lessen artifacts. To
our knowledge, only 1 study has reported the
sensitivity and specificity of sonography, 93%
and 95%, respectively, by definite demonstration
of lithiasis with new sonographic equipment and
technologies.17 We have recently improved our
ability to visualize ureteral calculi by using a
specific technique for preparing the patient
before scanning, new sonographic equipment,
and compression. Consequently, this study was
intended to evaluate the value of sonography as
a first-line diagnostic tool for ureterolithiasis.
Materials and Methods
All patients with acute flank pain who visited the
emergency department or outpatient urology
clinic underwent a physical examination and uri-
nalysis. Among these, 318 consecutive patients
with clinically suspected urinary tract calculi
underwent sonography (215 male and 103
female). Inclusion criteria were as follows: (1)
acute flank pain, (2) costovertebral angle tender-
ness on physical examination, and (3) hematuria
on urinalysis. Patients with fever, who were clini-
cally suspected of having acute pyelonephritis,
were excluded. The patients’ ages ranged from 15
to 76 years (mean, 42.2 years). Four of the patients
were pregnant (intrauterine), and the gestational
ages ranged from 13 to 32 weeks. A definitive
diagnosis of urolithiasis was made when the
patient passed a stone either naturally or after
extracorporeal shock wave lithotripsy, when a
stone was extracted by urologic procedures
including ureteroscopic lithotripsy and percuta-
1442
neous nephroscopic lithotripsy, or when a stone
was clearly seen within a markedly dilated ureter
on sonography, IVU, or CT.
Sonography was performed with the patients in
the supine position. An iU22 system with a C5-2
convex transducer (Philips Medical Systems,
Bothell, WA), an HDI 5000 system with a C4-2
convex transducer (Philips Medical Systems),
and an Accuvix XQ system with a C5-2 convex
transducer (Medison Co, Ltd, Seoul, Korea) were
used. All sonographic examinations were per-
formed by 1 of 2 experienced radiologists (S.J.P.
and B.H.Y.). For gray scale sonography, we rou-
tinely used several state-of-the-art technologies
for improving imaging quality, including the
SonoCT technology used in the HDI 5000 and
iU22 systems and full-spectrum imaging used in
the Accuvix XQ system. Our criteria for diagnosis
of ureterolithiasis on sonography only included
calcific echogenicity that appeared to be within
the ureter lumen associated with or without
hydronephrosis. The Soonchunhyang Medical
School Bucheon Hospital Clinical Research
Ethics Board approved this study. All patients
agreed to the procedures of the protocol.
We standardized the sonographic scanning
techniques to detect ureter stones. First, the
patients were prepared for sonographic scanning
by fasting for 8 h and then having their bladder
filled by an intravenous drip infusion of normal
saline with an infusion rate of less than 1 mL/s
and a fluid amount of less than 1000 mL before
sonography instead of using diuretics or direct
filling. Filling the bladder helped show not only
the distal ureter, including the ureterovesical
junction (UVJ), but also the ureter proximal to
crossing the iliac vessels because the high pres-
sure of the bladder during filling exacerbates
hydronephrosis. However, overdistension of the
bladder hinders the sonographic examination
because of abdominal muscle guarding against
compression by the ultrasound transducer
(Figure 1). To avoid overdistension of the bladder,
we did not use diuretics, which could fill the
bladder more rapidly than intravenous infusion
of fluid, and we started scanning within a few
minutes after patients had a voiding sense.
After preparation, sonography was performed
in the following order: first, the presence of
hydronephrosis and renal calculi was explored;
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Park et al

second, the ureteropelvic junction (UPJ) was
examined; third, the UVJ was examined; fourth,
the proximal ureter from the UPJ to the point
crossing the iliac vessel was examined; fifth, the
distal ureter from the end of the proximal ureter
to the UVJ was examined; sixth, the urinary blad-
der was examined; and seventh, if patients had
urethral symptoms, the urethra was examined
by a transrectal approach. For the kidney, UPJ,
and proximal ureter, a lateral approach, anterior
approach, or both approaches were applied. To
trace the entire proximal ureter, an anterior
approach that progressed through the window of
the linea semilunaris between the rectus abdo-
minis muscle and 3 layers of abdominal muscles
was useful. This window was not only the
thinnest portion of the abdominal wall but also
avoided any colonic gas. We were normally able
to trace the UPJ and entire proximal ureter
extending to the point where it crossed the iliac
vessels by using the sonographic window
described above. A lateral approach for the prox-
imal ureter could be achieved with a window
posterior to the ascending and descending
colon, especially in cases involving a thick body
habitus or an associated paralytic ileus. For the
distal ureter and UVJ, an anterior approach
through the window of the filled urinary bladder
was routine. For optimal resolution of the ureter
by sonography, compression techniques are
usually required to decrease the distance
between the transducer and the ureter; there-
fore, we applied the maximum amount of com-
pression that patients could tolerate while
scanning the ureter. For direct demonstration of
ureteral calculi, the B-mode gain settings includ-
ing the focal zone, depth, and time-gain com-
pensation curve were dynamically controlled.
We defined the presence of a calculus as a con-
stantly echogenic lesion clearly located within
the ureter, urinary bladder, or urethra. Color
Doppler imaging was used in 214 of the 313 cal-
culi shown by sonography to determine the pres-
ence or absence of a twinkling artifact from
ureteral calculi.
For visualization of twinkling artifacts, focal
zones were always placed near the depth of the
calculi with careful control of the B-mode gain
settings. For color Doppler sonography, a red-
and-blue color map was used, and the color win-
dow size was adjusted to cover the concerned
lesion and adjacent tissue. The presence of a
color signal was assessed relative to adjacent soft
tissue. When we found a ureteral calculus, we
recorded the location, largest diameter, number,
presence of a twinkling artifact, and degree of
hydronephrosis. We used the grading system
proposed by Ellenbogen et al18 to determine the
degree of hydronephrosis associated with ureter-
al calculi as follows: the degree of hydronephro-

Figure 1. Images from a 44-year-old man with left flank pain. A, Gray scale pelvic sonography shows faint echogenic spots (arrow)
in the left distal ureter through the partially filled urinary bladder. B, After filling of the urinary bladder, a sharply marginated calculus
(arrow) within the dilated left distal ureter is clearly depicted on gray scale sonography through the bladder window, which helps
delineate the left distal ureter and UPJ.
A B

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Evaluation of Patients With Suspected Ureteral Calculi
sis was graded on a scale of 0 to 3, with grade 0
indicating compact homogeneous central col-
lecting system echoes; grade 1, slight separation
of the collecting system echoes with a central
ovoid or fusiform anechoic area; grade 2, further
separation of the collecting system echoes with a
rounded anechoic area seen centrally; and grade
3, major portion of the kidney replaced by an
anechoic sac. The sonographic findings of distal
ureteral calculi were vague on transabdominal
sonography in 5 patients, so we performed tran-
srectal or transvaginal sonography to increase
the diagnostic confidence.
We tried to identify other reasons for the acute
flank pain if we did not find calculi. We were
unable to identify any cause of the flank pain in
15 patients, and we immediately performed
non–contrast-enhanced CT including the kid-
ney, ureter, and urethra with a Sensation 16 sys-
tem (Siemens AG, Erlangen, Germany) in 10
patients and IVU in 5 patients to determine
whether ureteral calculi were present. We defined
the criteria for diagnosis of ureteral calculi on
non–contrast-enhanced multidetector CT as the
presence of calcific density appearing within the
ureter lumen with visualization of the continuing
proximal and distal ureter to the level of the cal-
culus, including a tissue rim sign.19 We evaluated
the sensitivity, specificity, and accuracy of sonog-
raphy for detecting ureteral calculi and com-
pared the final diagnoses obtained from the
results of the clinical course, IVP, and CT.
Results
Urolithiasis was confirmed in 296 of 318 patients.
It was seen on sonography in 291 patients but was
missed in 5 patients; however, the urolithiasis in
these cases was identified after non–contrast-
enhanced CT (n = 3), IVU (n = 1), or passage of the
stone in a pregnant patient (n = 1). The 291
patients with urolithiasis diagnosed by sonogra-
phy included 285 patients with ureterolithiasis, 5
patients with lithiasis in the urinary bladder, and
1 patient with urethrolithiasis. In the 5 cases that
sonography missed, the clinical symptoms and
signs were typical, and swelling of a unilateral
ureteral orifice was present. We confirmed that
the stones in the urinary bladder and urethra
were passed from the ureter. We detected 313 cal-
1444
culi in the 291 patients identified by sonography,
including 307 ureteral calculi in the 285 patients
with ureteral lithiasis, 5 urinary bladder calculi in
5 patients, and 1 urethral calculus. We logically
suspected that these 6 calculi found in the uri-
nary bladder and urethra were passed from the
ureter because the patients had renal colic with-
in 1 hour, which was relieved just before sonog-
raphy. The overall sensitivity, specificity, and
accuracy of sonography for detecting ureteral
calculi were 98.3%, 100%, and 98.4%, respec-
tively. We found that 274 patients had a single
ureteral calculus, whereas 17 patients had 2 to 5
ureteral calculi.
Twenty-seven patients without evidence of
urolithiasis on sonography underwent non–
contrast-enhanced CT (n = 13), pre– and
post–contrast-enhanced CT (n = 5), IVU (n = 5),
or a nonradiologic workup (n = 4). In the case of
failed stone detection on sonography, urolithiasis
(n = 5) was confirmed by CT (n = 3), IVU (n = 1),
or stone passage (n = 1, pregnant patient). Stones
were found in the left proximal ureter (n = 1),
right UVJ (n = 1), and urinary bladder (n = 1) on
CT and in the right distal ureter (n = 1) on IVU.
Computed tomography showed the absence of
urolithiasis in 14 patients who underwent
non–contrast-enhanced CT (n = 10) and IVU (n = 4).
Five patients who underwent contrast-enhanced
CT were found to have acute pyelonephritis (n = 3),
renal infarction with renal arterial occlusion (n = 1),
and ureteral cancer (n = 1). The remaining 3
patients were found to have pelvic inflammatory
disease (n = 1), enteritis (n = 1), and transitional
cell carcinoma in the urinary bladder (n = 1).
Locations of the Calculi
The 313 calculi identified by sonography in the 291
patients included 21 in the UPJ, 96 in the proxi-
mal half of the ureter, 69 in the distal half of the
ureter, 121 in the UVJ, 5 in the urinary bladder,
and 1 in the urethra. In the 285 patients with
ureteral lithiasis, it involved the left ureter in 126
cases, right ureter in 154 cases, and both ureters
in 5 cases (Table 1).
Diameters of the Calculi
The ureteral calculi ranged in diameter from 1 to
22 mm as follows (mean ± SD, 7.5 ± 0.16 mm):
5 mm or less in 83 patients (26.5%), 6 to 10 mm in
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Park et al

Table 1. Locations of Lithiasis Table 2. Diameters of Lithiasis Measured by

Location Stones, n (%) Sonography
Diameter, mm Stones, n (%)
UPJ 21 (6.7)
Proximal ureter 96 (30.7) ≤5 83 (26.5)
Distal ureter 69 (22) 6 –10 194 (62)
UVJ 121 (38.7) 11–15 29 (9.3)
Urinary bladder 5 (1.6) >15 mm 7 (2.2)
Urethra 1 (0.3) Total 313 (100)
Total 313 (100)

194 patients (62%), 11 to 15 mm in 29 patients Numbers of Calculi

(9.3%), and greater than 15 mm in 7 patients (2.2%;
Table 2).
Twinkling Artifact
A total of 184 of the 214 calculi (86%) examined
by color Doppler sonography showed a twin-
kling artifact. These findings helped confirm that
this artifact was consistently present with tiny
calculi.
We detected multiple calculi (≥2) in 17 patients
on sonography. Real-time sonography and the
presence of a twinkling artifact aided in the deter-
mination that multiple calculi were present
(Figure 2). We could observe the transient sepa-
ration of 2 or more calculi in the ureteral lumen
by peristaltic movement in 14 patients.
A

Figure 2. Images from a 33-year-old man with typical sono-

graphic findings of ureterolithiasis and hydronephrosis. A, Gray
scale longitudinal sonography of the right proximal ureter
shows 2 echogenic calculi within the dilated proximal ureter. B,
Transverse sonography more clearly depicts an impacted stone
that appears as a central echogenic lesion (arrow) with posteri-
or shadowing within the surrounding swollen ureteral wall.
C, Color Doppler sonography shows a marked twinkling arti-
fact posterior to the ureteral calculi, which enhances diagnos-
tic confidence.

B C

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Evaluation of Patients With Suspected Ureteral Calculi

A B
Figure 3. Images from a 45-year-old woman with 2 tiny ureteral calculi. A, Gray scale pelvic sonography shows faint echogenic spots
(arrows) in the pelvic cavity. However, left side hydronephrosis was obvious, so we performed transvaginal sonography. B, Transvaginal
sonography clearly depicts 2 tiny calculi (arrows) in the distal ureter. Transvaginal sonography may enhance diagnostic confidence
when findings of distal ureteral calculi are unclear on transabdominal sonography.

Endocavitary Sonography 0 in 91 patients, grade 1 in 45, grade 2 in 115, and

We performed transrectal or transvaginal sonog-
raphy to enhance the diagnostic confidence in
5 patients who had vague findings of distal
ureteral calculi on transabdominal sonography.
We could detect calculi that were 1 mm in diam-
eter with transvaginal sonography (Figure 3).
Hydronephrosis
The 318 patients had the following grades of
hydronephrosis: grade 0 in 113 patients, grade 1
in 46, grade 2 in 119, and grade 3 in 40. Of the 291
patients with lithiasis identified with sonography,
the hydronephrosis grades were as follows: grade
grade 3 in 40. A total of 200 of the 291 patients
had hydronephrosis (68.7%; Figure 4). Two of the
5 patients with confirmed lithiasis not shown on
sonography had grade 2 hydronephrosis. One
patient with acute pyelonephritis and another
without evidence of lithiasis on sonography or CT
had grade 1 and 2 hydronephrosis, respectively.
Treatment
Immediate ureteroscopic lithotripsy was per-
formed in 123 of 296 patients, which confirmed
the presence of ureteral calculi. Extracorporeal
shock wave lithotripsy was performed in 62

Figure 4. Images from a 30-year-old man with ureterolithiasis not combined with hydronephrosis. A, Gray scale longitudinal sonog-
raphy of the left kidney shows no dilatation of the pelvocalyceal system. B, After sonographic observation of the UPJ and UVJ, lon-
gitudinal sonography of the left UVJ shows an echogenic calculus within the swollen UVJ (arrow) and a nondilated distal ureter.
A B

1446 J Ultrasound Med 2008; 27:1441–1450

2710jum1407-1490 online.qxp:Layout 1 9/17/08 1:13 PM
patients, and stone fragments were passed in all
of these patients. Conservative treatment includ-
ing pain control and hydration was implement-
ed in 88 patients. In 76 of these 88 patients,
natural passage of ureteral calculi was confirmed
by the patients. We could not confirm the pas-
sage of stones in 34 patients because 22 were lost
to follow-up or transferred to other clinics, and
12 stated that they did not see passage of a stone.
However, urolithiasis could be diagnosed in
these 12 patients by the presence of a stone on
more than 2 image modalities, their clinical sta-
tus, and laboratory findings.
Discussion
Many studies have compared the efficacy of dif-
ferent radiologic modalities for evaluating acute
flank pain. Since the mid-1990s, non–contrast-
enhanced CT has been considered the most pre-
cise imaging technique10,20–24 and the reference
standard for diagnosis of urolithiasis. Its advan-
tages include the freedom from intravenous
contrast agents, simplicity of performance, and
ability to be used on a patient immediately.
Non–contrast-enhanced CT can detect extrauro-
logic diseases and is fast and relatively easy to
learn.10,21,22 Nevertheless, CT has limitations: it is
not available outside hospital facilities and is cost-
ly.25 The amount of radiation in non–contrast-
enhanced helical CT is approximately 10 times
that of plain radiography of the abdomen and
pelvis.26 Moreover, many patients may receive an
additional radiation dose with follow-up studies
(if a calculus is not expelled) or with new
episodes of colic (75% of patients).27 Sonography
is a radiation-free diagnostic tool that can be
very accurate. In this study, the overall diagnostic
sensitivity, specificity, and accuracy of sonogra-
phy were 98.3%, 100%, and 98.4%, respectively.
Previous articles reported sensitivity rates of
sonography for detecting lithiasis of 12% to
93%,17,19,21,28,29 and a recently published article
reported that the sensitivity and specificity of
sonography for lithiasis were 78.6% and 100%,
which were better than in previous reports, and
those for obstruction were both 100%.2 Several
studies have been performed with low-dose CT
protocols to detect ureteral stones using a tube
charge current of 20 to 50 mA; the sensitivity
J Ultrasound Med 2008; 27:1441–1450
Page 1447
Park et al
was reported to be 89.5% to 97%, and the speci-
ficity was found to be 94.7% to 100%.30–32
Consequently, the diagnostic efficacy of sonog-
raphy in our study was better than that of low-
dose CT but did not reach the sensitivity of
normal-dose CT. Although low-dose CT has
many advantages, including simple preparation,
objective information, and easy application,
sonography also has great advantages; it is radia-
tion free, universally available, easily applicable,
and inexpensive compared with CT, and it
allows for repeated follow-up examinations.17
The higher sensitivity and accuracy of sonogra-
phy for detecting lithiasis might have been due
to the development of new sonographic equip-
ment, appropriate preparation for tracing the
entire ureter, and the relatively thinner body
habitus of Asian patients.
The new technology incorporated into the
sonographic equipment consisted of SonoCT
in the iU22 and HDI 5000 systems and full-
spectrum imaging in the Accuvix XQ system.
These technologies can provide better image
quality and noise reduction; however, SonoCT
may eliminate posterior shadowing of lithiasis.
Lee et al15 reported that only 44% of calculi
showed discrete posterior shadowing. Posterior
shadowing can be seen with traditional sono-
graphic equipment in only half of lithiasis cases,
but twinkling artifacts are generated in 83% of
lithiasis cases. Therefore, twinkling artifacts on
color Doppler imaging have replaced posterior
shadowing as a major diagnostic sonographic
finding.15 In this study, we found twinkling arti-
facts on color Doppler sonography in 86% of
lithiasis cases, and we think that twinkling arti-
facts are strongly supportive of urolithiasis.
We applied a strict preparation protocol for
sonography. Before scanning, patients fasted for 8 h.
Additionally, rapid intravenous infusion of fluid
was used to fill the bladder instead of using
diuretics or direct filling. Saline infusion by
catheterization causes air to collect in the blad-
der lumen, which can interfere with scanning of
the bladder and distal ureter, including the UVJ,
and overdistension of the bladder hinders the
sonographic examination because of abdominal
muscle guarding against compression by the
transducer. Appropriate bladder filling helps
show not only the distal ureter, including the
1447
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Evaluation of Patients With Suspected Ureteral Calculi
UVJ, but also the ureter proximal to crossing
the iliac vessels because high pressure in the
bladder during filling permits exacerbation
of hydronephrosis. Compression and intra-
cavitary sonography permitted a reduction in
the distance between the transducer and
ureters. We attempted to directly visualize the
urolithiasis.
Usually, transabdominal sonography can easily
identify the renal pelvis, proximal ureter, distal
ureter, and bladder and can be used to determine
the level of obstruction, but its ability to show
pathologic conditions in the mid ureter is limit-
ed.33–35 We divided the ureter into proximal and
distal portions from the UPJ to the UVJ based on
the level of crossing the iliac vessels because no
appreciable difference exists in the sensitivity,
specificity, and diagnostic accuracy of sonogra-
phy for detecting urolithiasis based on location.
The locations of the 313 calculi in the 291
patients with a sonographic diagnosis consisted
of the UPJ in 21 cases, proximal half of the ureter
in 96 cases, distal half of the ureter in 69 cases,
UVJ in 121 cases, urinary bladder in 5 cases, and
urethra in 1 case. In 285 patients with ureteral
lithiasis, the calculi were seen in the left ureter in
126 cases, right ureter in 154 cases, and both
ureters in 5 cases.
Compression can remove bowel gas anterior to
the ureter and help with tracing the ureter
between the level of the iliac wing and the dome
of the urinary bladder.
Although the distal ureter can be readily identi-
fied with transabdominal sonography because
the urinary bladder provides a good sonic win-
dow,36 an overdistended bladder may interfere
with identification of a small stone in the distal
ureter. On these occasions, intracavitary sonog-
raphy is helpful for confirming the presence of a
stone in the ureter and distinguishing between
other causes of ureteral obstruction such as a
urothelial tumor, blood clot, or fungus ball.37
In our experience, when transabdominal sono-
graphic findings of distal ureteral calculi are
vague, transrectal or transvaginal sonography
can enhance the diagnostic confidence.
We detected multiple ureteral calculi in 17
patients. Sonography operates in real time, and
separate twinkling artifacts helped identify the
presence of multiple calculi in individual ureters.
1448
We observed the separation of 2 or more calculi
in the ureteral lumen by peristaltic movement in
14 patients.
Detecting secondary signs of a ureteral stone,
including hydronephrosis, a perirenal fluid col-
lection, and a change in the resistive index of an
interlobar artery, is important. In one study, the
authors achieved 95% sensitivity and 67% speci-
ficity when they included definite ureteral
stones and hydronephrosis,38 and in another
report, the sensitivity jumped from 12% to 81%
when secondary signs of ureteral obstruction
were included in the diagnosis of urolithiasis.2
Direct visualization of urolithiasis is very impor-
tant; in one study, only cases with a definite
demonstration of ureteral calculi were classified
as positive, showing specificity of 95% and sensi-
tivity of 93%.17 However, only 43 of 62 patients
were confirmed to have ureteral stones. We had a
larger number of cases than the other reports.
In this study, we could detect hydronephrosis in
68.7% of ureteral calculi, which was a relatively
lower incidence of hydronephrosis in ureteral
colic. When calculi are shown in the distal ureter,
hydroureter without dilatation of the renal pelvis
might be seen and considered in the absence of
hydronephrosis. We applied strict criteria for diag-
nosing hydronephrosis in this study, which may
explain the lower incidence of hydronephrosis.
In summary, sonography is an excellent modal-
ity with many advantages for detecting ureteral
stones; it is radiation free, relatively inexpensive,
universally available, and easily applicable, and it
has high diagnostic efficacy. Specific techniques
for preparing the patient before scanning, new
sonographic equipment, compression tech-
niques, and additional intracavitary scanning can
enhance the diagnostic accuracy and confidence
for detecting ureteral calculi on sonography.
References
1. Tamm EP, Silverman PM, Shuman WP. Evaluation of the
patient with flank pain and possible ureteral calculus.
Radiology 2003; 228:319–329.
2. Ripollés T, Agramunt M, Errando J, Martinez MJ, Coronel B,
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