[Urinary disorders in small girls and pyuria of genital origin].
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Anti-Bacterial Agents↗
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Asymptomatic bacteriuria and inflammatory response to urinary tract infection of elderly ambulatory women in nursing homes.
BACKGROUND: Bacteriuria > or = 10(5) CFU/ml is evidence of urinary tract infection in the absence of associated signs or symptoms. The presence of pyuria with asymptomatic bacteriuria established the response of elderly women against microorganisms capable of causing invasiveness or tissue injury of the urinary tract. METHODS: The association between bacteriuria and pyuria was determined in 178 elderly, ambulatory women without symptoms of urinary tract infection in seven nursing homes. Urine culture results were subsequently analyzed in conjunction with absolute leukocyte count in urine. In this cross-sectional study, asymptomatic bacteriuria in elderly women was classified with and without pyuria. RESULTS: The prevalence of asymptomatic bacteriuria was found in 44 (24.7%) elderly women. The presence of pyuria had a sensitivity of 63.6% for bacteriuria and a specificity of 91%. The positive predictive value for the presence of pyuria predicting those with bacteriuria was 70%, and the negative predictive value for the absence of pyuria predicting those without bacteriuria was 88.4%. Escherichia coli was the most common organism isolated in 81.8% of the women. CONCLUSIONS: Bacteriuria > or 10(5) CFU/ml associated with pyuria was detected in 77% of elderly women with asymptomatic urinary tract infections. Bacteriuria of < 10(5) CFU/ml with pyuria proves less sensitive as an indicator of urinary tract infection. Elderly women with pyuria but without bacteriuria should be studied for other causes of urinary tract inflammation.
Aged↗
Study of urinary tract infection in children in one health district.
OBJECTIVES: To determine the number of children who had urine specimens sent for culture, who had infections or sterile pyuria, and who were investigated further. To relate the laboratory findings to the results of imaging. DESIGN: One year survey of urine specimens submitted to a laboratory; review of previous and subsequent laboratory reports; review of the findings of imaging of the urinary tract. SETTING: Portsmouth and South East Hampshire health district. SUBJECTS: An estimated population of 89,086 children aged 12 years or under. MAIN OUTCOME MEASURES: Urine bacterial count and results of imaging. RESULTS: 12,551 urine specimens were submitted from 7450 children, 3138 boys and 4312 girls. 2238 children had infection or sterile pyuria at least once during the study (13.9/1000 boys, 37/1000 girls). 996 (45%) of the children with infection or sterile pyuria underwent some form of imaging. 128 children who had infection or sterile pyuria were already known to have urinary tract abnormalities and 114 children had newly identified abnormalities (1.0/1000 boys, 1.5/1000 girls). 50 (44%) of the children with newly detected abnormalities had no pyuria and 48 (42%) had bacterial counts below 10(8)/l. Eight children who had sterile pyuria on presentation were found to have abnormalities on imaging. CONCLUSIONS: Urinary tract infection is much commoner in children than is widely believed. Low bacterial counts, the absence of pyuria, or a finding of sterile pyuria should not be disregarded.
Age Distribution↗
Is urine culture necessary to rule out urinary tract infection in young febrile children?
OBJECTIVE: To determine whether the absence of pyuria on the enhanced urinalysis can be used to eliminate the diagnosis of urinary tract infection, avoiding the need for urine culture and sparing large health care expenditures. DESIGN: Results of an enhanced urinalysis (hemocytometer counts and interpretation of Gram-stained smears) performed on uncentrifuged urine specimens obtained by catheter were correlated with urine cultures in young febrile children at the Children's Hospital of Pittsburgh Emergency Department. In a group of 4253 children (95% febrile) less than 2 years of age, pyuria was defined as > or = 10 white blood cells/mm3, bacteriuria as any bacteria on any of 10 oil immersion fields in a Gram-stained smear and a positive culture as > or = 50,000 colony-forming units/ml. A subgroup of 153 children with their first diagnosed urinary tract infection were enrolled in a separate treatment trial, acute phase reactants (peripheral white blood cell count, erythrocyte sedimentation rate and C-reactive protein) were obtained and 99Tc-dimercaptosuccinic acid renal scans were performed. RESULTS: The presence of either pyuria or bacteriuria and the presence of both pyuria and bacteriuria have the highest sensitivity (95%) and positive predictive value (85%), respectively, for identifying positive urine cultures. Because a white blood cell count in a hemocytometer is the technically simpler component of the enhanced urinalysis, we chose to analyze the false negative results and achievable cost savings of using pyuria alone as the sole criterion for omitting urine cultures. If in this study urine cultures had been performed only on specimens from children who had pyuria or were managed presumptively with antibiotics, cultures of 2600 (61%) specimens would have been avoided. Twenty-two of 212 patients with positive urine cultures would not have been identified initially. However, based on interpretation of acute phase reactants, initial 99Tc-dimercaptosuccinic acid scan results, response to management and incidence of renal scarring 6 months later, 14 of the 22 patients most likely had asymptomatic bacteriuria and fever from another cause. The remaining 8 patients probably had early urinary tract infection. CONCLUSIONS: The analysis of urine samples obtained by catheter for the presence of significant pyuria (> or = 10 white blood cells/mm3) can be used to guide decisions regarding the need for urine culture in young febrile children.
Bacteriological Techniques↗
Causes of the acute urethral syndrome in women.
To determine the cause of the acute urethral syndrome, we studied 59 women with dysuria and frequent urination without "significant bacteriuria" (defined as greater than or equal to 10(5) organisms per milliliter), 35 women with typical cystitis and 66 women with no symptoms of urinary-tract infection. Although none of the 59 women with urethral syndrome had greater than 3.4 x 10(4) bacteria per milliliter in either of two successive midstream urine specimens, samples of bladder urine obtained by suprapubic aspiration or catheterization from 24 women contained coliforms, and samples from three contained Staphylococcus saprophyticus; all but one of these 27 women also had pyuria. Of the 32 women with sterile bladder urine, 10 of 16 with pyuria and one of 16 without pyuria were infected with Chlamydia trachomatis (P = 0.002). Chlamydial infection was found in 11 of 42 women with urethral syndrome and pyuria, in three of 66 without symptoms, and in one of 35 with cystitis (P less than 0.01 when the group with urethral syndrome is compared with either of the other groups). Thus, 42 of 59 women with urethral syndrome had abnormal pyuria and 37 of these 42 were infected with coliforms, S. saprophyticus, or C. trachomatis, whereas few women without pyuria had demonstrable infection. Bacteriuria of greater than or equal to 10(5) per milliliter may be an insensitive diagnostic criterion when applied to symptomatic lower-urinary-tract infection.
Acute Disease↗
Suprapubic aspiration under ultrasound guidance in children with fever of undiagnosed cause.
OBJECTIVES: To assess the ease of use of suprapubic aspiration of urine under ultrasound guidance in babies with fever of uncertain cause and to assess the importance of bacterial counts and pyuria in relation to abnormalities of the urinary tract and the importance of pyuria in the absence of bacteriuria. DESIGN: Analysis of urine samples obtained by suprapubic aspiration in babies and children from July 1991 to June 1992. The clinical records of the children with bacteriuria and sterile pyuria were examined retrospectively. SETTING: Neonatal and paediatric wards of a district general hospital. SUBJECTS: 508 babies and children who had fever of uncertain cause or were seriously ill. RESULTS: No difficulties arose in the collection of 545 specimens. Bacteria were isolated from the specimens of 44 children, 24 of whom had abnormalities of the urinary tract. The bacterial count was < 10(8)/l in 18 of the children with bacteriuria, 10 of whom had abnormalities. No white cells were seen in 22 of the 46 bacteriuric specimens; nine of the children with no pyuria had vesicoureteric reflux. 439 of the 499 non-bacteriuric specimens showed no white cells. 60 children had pyuria without bacteriuria. CONCLUSIONS: The use of ultrasound guidance simplifies suprapubic aspiration of urine in babies. Low bacterial counts may be associated with abnormalities of the urinary tract. Laboratory techniques capable of detecting such counts reliably should be used. Pyuria is absent in half of babies and very young children with bacteriuria. It rarely occurs without bacteriuria, and if it does an explanation should be sought.
Bacteriuria↗
Clinical significance of urinary white blood cell count and serum C-reactive protein level for detection of non-palpable prostate cancer.
AIM: The clinical significance of the urinary white blood cell (U-WBC) count and serum C-reactive protein (CRP) level was evaluated in an effort to improve the efficiency of prostate biopsies. METHODS: We enrolled 228 consecutive patients with serum prostate-specific antigen (PSA) ranging from 3.0 to 20.0 ng/mL, normal digital rectal examination findings, and who underwent prostate biopsies between January 2001 and August 2004. Of these, 157 patients had histologically confirmed benign prostatic disease and the remaining 71 patients had prostate cancer. Patients with a pretreatment U-WBC count < or =3 or >3/high power field were defined as non-pyuria and pyuria, respectively. The patients were also separated into two groups based on the serum CRP level prior to biopsy. Several clinical factors were compared among these subgroups. RESULTS: Inflammation was histologically detected at rates of 58.1% and 34.1% in the pyuria and non-pyuria groups, respectively (P = 0.0014). The rates of cancer detection were significantly lower in the pyuria, than in the non-pyuria group (P = 0.0384). The cancer detection rates did not significantly differ according to serum CRP levels prior to biopsy. CONCLUSION: The U-WBC count appears to be a reliable indicator of minute prostatic inflammation. The serum PSA level was elevated in patients with asymptomatic prostatitis. Counting U-WBC is a simple, convenient and non-invasive method that should be valuable part of routine urological examinations.
Adult↗
Indinavir-associated interstitial nephritis and urothelial inflammation: clinical and cytologic findings.
The objective of the present study was to characterize the genitourinary syndromes that accompany indinavir-associated pyuria. Of 23 indinavir-treated patients with persistent pyuria, 4 had isolated interstitial nephritis, 10 had both interstitial nephritis and urothelial inflammation, 7 had isolated urothelial inflammation, and 2 had pyuria with nonspecific urinary tract inflammation. A total of 21 patients had multinucleated histiocytes identified by cytologic testing of urine specimens. Urine abnormalities resolved in all 20 patients who stopped receiving indinavir therapy. Pyuria continued in the 3 patients who continued receiving indinavir. Six patients had elevated serum creatinine levels, which returned to baseline levels when indinavir was discontinued. In conclusion, indinavir-associated pyuria was frequently associated with evidence of interstitial nephritis and/or urothelial inflammation, multinucleated histiocytes were commonly present in urine specimens, and cessation of indinavir therapy was associated with prompt resolution of urine abnormalities.
Adult↗
Urine microscopy on a counting chamber for diagnosis of urinary infection.
Several quantitative methods of urine microscopic examination for bacteriuria and pyuria on a blood cell counting-chamber have been found reliable for the diagnosis of urinary tract infection (UTI). However, no one technique has become popular or widely used because of laborious procedures associated with the method. We investigated the usefulness of microscopic examination of uncentrifuged urine on disposable counting-chambers. A total of 89 urine samples were obtained from 53 children (24 male and 29 female). Urine samples were examined for bacteriuria and pyuria using a disposable counting chamber and its reliability was analyzed in predicting significant bacteriuria defined by routine urine culture. Significant bacteriuria was diagnosed in 23 of 89 urine samples by urine culture. Microscopic urine examination on disposable counting-chambers was very easy without the need to set up or wash chambers and provided immediate information. Urine bacterial concentration determined by the counting-chamber method was closely correlated to that determined by bacterial culture. The counting-chamber method identified bacteriuria correctly in 21 of 23 urine samples diagnosed as significant bacteriuria (sensitivity = 91%) and also gave a correct diagnosis of 64 of 66 urine samples with non-significant bacteriuria (specificity = 98%). Nineteen of the 23 urine samples with significant bacteriuria also had pyuria. The positive predictive value of concomitant bacteriuria and pyuria was 100%. When neither bacteriuria nor pyuria was found, the negative predictive value was 100%. It was concluded that urine microscopy using disposable counting chambers was very easy, inexpensive, quick and reliable and thus an extremely useful method for diagnosing UTI.
Adolescent↗
The prevalence of bacteriuria among high risk neonates in Nigeria.
Among the 446 high risk neonates studied for significant bacteriuria and pyuria in the neonatal wards of the Obafemi Awolowo University teaching hospital Complex, Ile-Ife, 7.6% and 5.8% were positive for significant bacteriuria and pyuria respectively, while none of the 81 infants in the control group were positive. Males and females were similarly affected and there was no seasonal variation in the prevalence of pyuria or bacteriuria. It is noteworthy that 25 (96%) of the 26 pyuria neonates also had bacteriuria emphazising the significance of pyuria as a possible screening method for urinary tract infections in neonates. The clinical problems in the neonates studied included prematurity, low birthweight, neonatal jaundice, fever, CNS symptoms, ophthalmia neonatorum, prolonged rupture of the membranes (PROM), respiratory distress, septic cord/skin, diarrhoea, vomiting and feeding problems. Only prematurity and low birthweight were significantly associated with bacteriuria in the neonates studied. The organisms encountered in this study were Escherichia coli (58.4%), Klebsiella species (35.3%) and Proteus species (5.9%). Of the bacterial isolates, 67% were sensitive to Ampicillin and 97% to Gentamycin. The combination of these antibiotics was effective in all cases in the present study. The study has highlighted the need for routine urine culture in our high risk neonates.
Bacteriuria↗
Effects of urinary tract inflammation and sample blood contamination on urine albumin and total protein concentrations in canine urine samples.
BACKGROUND: Urinary tract inflammation and hemorrhage are believed to be common causes of proteinuria in dogs based on results of studies that measured total urine protein concentration. A method to quantify urine albumin (UAlb) concentration in dogs recently has become available; however, the effect of inflammation on albuminuria is unknown. OBJECTIVES: The goals of this study were to determine the effects of urinary tract inflammation, as indicated by pyuria and sample blood contamination, on UAlb concentration and on urine protein:creatinine (UPC) ratio in dogs. METHODS: Urine samples were obtained from dogs with pyuria that were presented to a veterinary teaching hospital or were part of a laboratory colony. To mimic the effects of hematuria, canine whole blood was added to a microscopically normal canine urine sample that had baseline albumin and total protein concentrations below the limits of detection. UAlb concentration was measured using a canine albumin-specific competitive ELISA. UPC ratio was determined using routine methods. RESULTS: Of 70 samples with pyuria, 67% had negligible UAlb concentrations and 81% had normal UPC ratios. UAlb concentration but not UPC ratio was significantly higher (P < 0.05) in samples with concurrent hematuria or bacteriuria. When whole blood was added to normal urine, UAlb concentration did not exceed 1 mg/dL until the sample became visibly pink; the UPC did not exceed 0.4 at any dilution. CONCLUSIONS: Many dogs with pyuria do not have albuminuria or proteinuria; however, albuminuria may be more likely in dogs with pyuria and concurrent hematuria or bacteriuria. Hematuria may not cause an increase in UAlb concentration until it becomes macroscopic and even then may not increase the UPC ratio.
Albuminuria↗
Home-voided urine specimens in women. Diagnostic agreement with clean-catch midstream specimens.
One hundred and fifty women who brought a home-voided urine sample to a general practitioner were asked at the same consultation to provide another sample under controlled conditions. Seventy-three women had lower urinary tract symptoms and 77 were asymptomatic. The two samples were analysed for pyuria (greater than or equal to 5 leucocytes/HPF) and bacteriuria (greater than or equal to 10(4) v. greater than or equal to 10(5) cfu/ml). The agreement when diagnosing pyuria and bacteriuria was estimated by Kappa (K). The home-voided sample was taken with adequate sampling technique by only 12% of women. Moreover, its bladder incubation time was twice that of the surgery sample (5.4 h v. 2.4 h). There was, however, no difference in the distribution of pyuria or bacteriuria between the paired samples. Agreement, which was high for the diagnosis of pyuria (K = 0.80), was significantly lower for the diagnosis of bacteriuria (K = 0.52, P less than 0.01). A home-voided sample seems sufficient in the diagnosis of the dysuria-pyuria syndrome in women.
Adolescent↗
Laboratory in the diagnosis and management of urinary tract infections.
The laboratory is essential in the diagnosis and management of UTIs. The presence of pyuria and bacteriuria, the two most important indicators of UTIs, are most accurately determined by standard techniques. In quantitating pyuria, the finding of greater than or equal to 10 leukocytes/mm3 of urine by either hemocytometry or direct microscopy correlates highly with symptomatic, culture-proven UTIs. The determination of bacteriuria by direct microscopy is inaccurate, particularly at lower levels of bacteriuria; thus, quantitative urine cultures remain the most accurate measure of bacteriuria. Significant bacteriuria, previously defined as greater than or equal to 10(5) CFU/ml of urine, has been redefined with the observation that as few as 10(2) CFU/ml can be associated with significant pyuria and symptoms suggestive of cystitis. The need for routine and posttreatment urine cultures in nonpregnant women with acute dysuria remains controversial, but current data suggest that they are usually unnecessary. Rapid diagnostic tests for detection of pyuria and bacteriuria are designed to increase efficiency and decrease cost in the diagnosis of UTI. Unfortunately, none of these techniques can quantitate pyuria or bacteriuria as accurately as the standard methods, but the level of accuracy offered by the standard methods is not always necessary in the care of patients with uncomplicated UTIs. These tests are particularly well suited for screening asymptomatic high-risk populations. Noninvasive localization techniques continue to be explored as possible alternatives to invasive localization procedures, but they remain largely research tools that are not readily available to the practicing clinician. Understanding the applicability and appropriate use of newer technologies in the evaluation of patients with UTIs and how these technologies complement the standard diagnostic techniques will lead to better, more efficient, and less costly patient care.
Bacterial Infections↗
Persistent flank pain, low-grade fever, and malaise in a woman treated with indinavir.
This case report describes a 32-year-old woman treated with indinavir who developed mild to moderate flank pain, malaise, and low-grade fever. Sterile pyuria preceded increased serum creatinine levels. Workup revealed persistent pyuria, normal-sized kidneys, a normal intravenous pyelography, and negative urinary cultures. Renal biopsy showed interstitial nephritis and chronic inflammation. Collecting ducts contained crystals. Two months after treatment with indinavir was discontinued, serum creatinine levels returned to normal and pyuria disappeared. Sterile pyuria in patients taking indinavir may help to identify patients at risk for renal dysfunction and interstitial nephritis. Markedly increasing the fluid intake above the recommended dosage may ameliorate or even reverse the process of tubulointerstitial disease.
Adult↗
Urinary tract infections in young febrile children.
UTI is a common and important clinical problem in infants and young children, with a prevalence of 5.3% among febrile infants seen in our Emergency Department. White females with rectal temperature > or = 39 degrees C are at particularly high risk (prevalence, 17%). Several studies have highlighted the limitations of the standard urinalysis for identifying UTI in infants and young children and have recommended performance of both urinalysis and urine culture. Alternative methods such as dipstick urinalysis, although attractive because of ease of performance, are inadequate as a screen for UTI. Hemocytometer WBC counts of an uncentrifuged urine specimen can be performed in an office or hospital-based laboratory with minimal training. Performance of Gram-stained smears, however, is most appropriate for the hospital-based laboratory. In the hospital setting where both tests can readily be performed, the positive predictive value of the combination of pyuria and bacteriuria (85%) allows prompt institution of antimicrobial therapy before culture results are available, whereas the lower positive predictive value of the single finding of either pyuria or bacteriuria (40%) justifies delaying treatment decisions until culture results are available. In the office setting where hemocytometer counts can easily be performed, culturing only specimens with pyuria and those of children presumptively treated with antimicrobials will result in the identification of almost all patients with true UTI, sparing large health care expenditures. Although the urine culture is traditionally regarded as the gold standard of UTI, positive urine cultures may occur secondary to contamination or in cases of ABU, leading to a false diagnosis of UTI. In contrast we found pyuria to be a reliable marker to discriminate infection from colonization of the urinary tract. The sustained absence of an inflammatory response, on repeat UA within 24 h, constitutes strong evidence that infection is absent. Management of ABU is controversial; many experts recommend withholding antibiotics because eradication of low virulence organisms may be followed by colonization with more virulent species that cause pyelonephritis. Preliminary results of our ongoing treatment trial suggest that management of young febrile children with UTI as outpatients receiving oral cefixime is as efficacious as inpatient management with intravenous cefotaxime. Results of renal ultrasound and DMSA scan at the time of infection have not modified management in any patient. Accordingly selective rather than routine performance of ultrasound is recommended. A voiding cystourethrogram at 1 month and a DMSA scan 6 months later have been valuable in identifying patients with vesicoureteral reflux and renal scarring, respectively. Among patients initially identified as having acute pyelonephritis, the incidence of renal scarring at 6 months has been substantially more frequent (approximately 40%) than we had expected. However, the long term implications of small scars identified with renal scintigraphy remain to be determined.
Anti-Bacterial Agents↗
Staining of urinary leucocytes as an aid to the diagnosis of inflammation in the urinary tract.
Five hundred specimens of urine have been examined for pyuria and bacteriuria, the leucocytes being stained by the Sternheimer-Malbin method. Most urines contained either less than 1 or more than 10 leucocytes per cmm; a few specimens contained 1 to 10 cells per cmm, whatever their viable bacterial count. The presence of leucocytes in urine was usually related to the bacterial count, pyuria being commonest in urines showing ;significant bacteriuria'. However, urinary tract instrumentation caused pyuria in the absence of infection. Leucocytes with nuclei staining blue by the Sternheimer-Malbin technique were considered to be indicative of active inflammation, but the incidence of such cells appeared to be a reflection of the total leucocyte count of the specimen rather than of its viable bacterial count. In the majority of cases the diagnosis of infection can be made on the basis of the bacterial count and the degree of pyuria. The staining technique appears to have a limited use, restricted to the interpretation of cases in which the results of culture and conventional leucocyte counts are ambiguous.
Bacteriuria↗
A reassessment of the importance of "low-count" bacteriuria in young women with acute urinary symptoms.
OBJECTIVE: To determine whether a statistical association exists between "low-count" bacteriuria (> 10(2) to 10(4) colony-forming units/mL) and acute urinary symptoms in young women. DESIGN: Prospective, case-control study. SETTING: Gynecology clinic at a student health center. PATIENTS: Women with or without urinary or vaginal symptoms. MEASUREMENTS: History of urinary infections and sexual activity. Quantitative determination of bacteriuria and pyuria and bacterial species; urine leukocyte esterase test; specific gravity; creatinine levels; vaginal leukocytes; and in-vitro culture of urine. RESULTS: The frequency of recent sexual activity, pregnancies, and contraceptive practices was not statistically different between women with acute urinary symptoms and asymptomatic controls. Escherichia coli and Staphylococcus saprophyticus were the only microorganisms statistically associated with urinary symptoms and pyuria (P < 0.001). Low counts of these organisms were found in 10.2% of asymptomatic women. As the bacterial count increased, the association between these organisms and symptoms increased, and a step-wise increase occurred in the frequency and magnitude of pyuria, but the specific gravity and urine creatinine levels remained unchanged. Escherichia coli, even at low counts, grew well in the patients' own urine. Pyuria (> 20 leukocytes/mm3) was present in 19.6% of asymptomatic women and was associated with vaginal leukorrhea. CONCLUSIONS: "Low-count" bacteriuria was statistically more frequent among young women with urinary symptoms than among asymptomatic controls. The low counts could not be explained by dilution of the urine or failure of the bacteria to grow well in the patients' urine. These findings suggest that the infection was not established in the bladder urine and that "low-count" bacteriuria might be an early phase of urinary tract infection.
Acute Disease↗
[A phytogenic drug kanefron H in patients with chronic cystitis and urolithiasis].
To evaluate efficacy of kanefron H (KH) in combined therapy of chronic cystitis and urolithiasis (after extracorporeal shock-wave lithotripsy-ESWL), we examined 48 women suffering from chronic cystitis. The patients were divided into two groups by the presence of pyuria: 20 patients of group 1 had pyuria, 28 patients of group 2 had no pyuria. Each group was subdivided into two groups in relation to KH. Subgroup 1a received phosphomycin as monotherapy, subgroup 1b--phosphomycin with KH (2 pellets 3 times a day for 30 days). Subgroup 2a was initially treated with anti-inflammatory drugs, local medication physiotherapy, circulation improving drugs for 10 days. Then the patients were followed up for a months without any treatment. Subgroup 2b received the same initial course but it was followed for 30 days with KH. 79 patients with urolithiasis (uroliths and ureteroliths) have undergone ESWL. 45 entered KH group (2 pellets 3 times a day), 34--the control group (spasmolytic and anti-inflammatory therapy). KH in combined treatment of chronic cystitis raises efficacy of the initial therapy (antibacterial or combined, made in the absence of pyuria), promotes achievement of longer disease remission, elimination of concrement fragments from the urinary tract. Long-term administration of KH induce no side effects. Thus, KH can be recommended in chronic cystitis and urolithiasis in patients exposed to ESWL as an effective and safe drug.
Adolescent↗