British Journal of Urology (1977), 49, 589-595


The Prevalence of Calcified Upper Urinary Tract Stone Disease in a Random PopulationCumbernauld Health Survey R.







Royal Infirmary, Glasgow; Monklands and District General Hospital, Airdrie; University of Glasgow :and Glasgow Area Health Authority

The most common practice employed when referring to the “incidence” of stone disease is to relate the number of cases dealt with per 100,000 hospital admissions. Other methods of assessing “incidence” include surgical incidence, selected group incidence and true population sampling (Andersen, 1968). No method is ideal and most are inaccurate in strictly epidemiological terms in that, before one can refer to the “incidence” of a disease, the “prevalence” figure must be known. In epidemiological terms the prevalence of a disease is the number of subjects who have the condition at a given time and the incidence is found by discovering the number of subjects who develop the condition in the population at a suitable interval after the prevalence figure is determined. The present study was undertaken to assess the value of multiphasic screening to detect abdominal pathology with special reference to the prevalence of upper urinary tract stone disease in the new town of Cumbernauld. Methods A random sample (7,000) of the population was obtained from a computer record by a separate organisation (Cumbernauld Development Corporation). The population tends to the younger age-groups (Figs 1 and 2) but proof of the randomisation being effective is seen when the ages of the first 1,000 subjects studied were compared with Scotland as a whole (Fig. 3). The individuals were sent a specially designed record form. They were invited to attend the local health centre and, after checking the questionnaire, further details were obtained regarding urinary symptomatology. The height and weight for each individual were obtained and a plain abdominal radiograph was taken. A sample of blood was withdrawn and, after separation, analysed for urea, creatinine, calcium, inorganic phosphate, protein, alkaline phosphatase and urate values. A mid-stream sample of urine was checked for blood, sugar, protein and bile (Ames Labstix). A dip slide of the urine sample was incubated and after 20-24 hours was read for significant infection. The slides were impregnated with a nitrofurantoin/liquorice complex “Ceduran” (Tillots Lab.). All abdominal X-rays were reported separately by 2 different consultants. Where the reports disagreed a third consultant acted as referee in reachng the final diagnosis. All subjects with possible calcified stones in the kidneys or gall bladder were asked to attend for intravenous urography or for cholecystography as appropriate. Biochemical and bacteriological abnormalities were rechecked. The survey took place between 22nd January 1976 and 25th February 1977. The compliance rate was just under SO%, i.e. 3,398 persons appeared at the survey centre (1,650 males, 1,748 females). Of these, 106 subjects had no abdominal X-ray mainly because the subjects were female and could Read at the 33rd Annual Meeting of the British Association of Urological Surgeons in Aberdeen, June 1977. 589




Scotland v Cumberland d






5 4


!% 3

30 % 20 10



30 - 34



SO -54

Age Groups Fig. 1. Age distribution for men in Curnbernauld, Scotland.


Age distribution



Scotland v Cumbernauld $!




SO - 54

Age Groups Fig. 2. Age distribution for women in Curnbernauld, Scotland.






not be X-rayed because (a) they were pregnant, (b) they were menopausal or (c) because of the “ten-day rule” and they did not attend when recalled. A few films were spoilt or the numbers were duplicated. In addition, 663 volunteers were interviewed (Table I). The first 2,000 subjects are now complete as at 31st May 1977 and the results of this sample are discussed. Results-in 2,000 Subjects

(I) Radiological Abnormalities As would be expected, the majority of radiological abnormalities were of a skeletal nature (Table 11). The term osteoarthritis covers minor changes as well as gross findings. The study is designed to allow computer analyses of radiological abnormalities and symptomatology such as backache. One of the subjects with a secondary deposit was known to have a bowel carcinoma and was already undergoing X-ray therapy. The second was referred for investigation. (11) Surgical or Potential Surgical Abnormalities (Non-urological) Gall-stones were of immediate interest and to date 12 positive gall-stone cases have been identified (Table 111). One man was diagnosed as having an aortic aneurysm and, on referral to a vascular surgeon, underwent surgery. (III) Biochemical Abnormalities Apart from the abnormal values obtained (Table IV), the biochemists now have a random population sample which can be classified in age and sex groups to give normal ranges. Of interest was % 76


14.0 12.0





% 4 .0



20 - 24

30 -35

40 - 4 4

50 -54

Age groups Fig. 3. Random sample ages in first 1,000.

60 - 64



the numbers with high urea and creatinine values-on rechecking most of these high values have not been substantiated. The blood urate values are also of interest as they have, on follow-up, revealed many persons with gout-like symptoms.

(Zv) Bacteriological Abnormalities As would be expected the rate of positive significant infection is higher in women (8.50%) than in men (1-25 %)(Table V). This particular aspect of the study is dependent on good urine sampling. Those subjects with significant cultures have been followed up by checking mid-stream specimens of urine. (y) Urinary Tract A bnormalities-Stone Prevalence

Those subjects who had possible calcified calculi in the kidneys have been followed up with intravenous urography (Table VT). Ureteric calculi are notoriously difficult to diagnose on a plain film and only those shadows which were agreed to be possible ureteric stones by all three consultants were investigated by urography. No ureteric stones have been proven so far but 2 subjects had ureteric calcification confirmed and one of these was due to tuberculosis. In the first 2,000 subjects the prevalence of stone disease has been shown to be 3.83 % with a male to female ratio of 1 : 1.05. The compliance rate for urography was good particularly among females (Table VII).

Table I

Table I1

Epidemiological SurveyCumbernauld 1976-77

Skeletal Abnormalities-2,000 Subjects Female

Random sample Attended survey Volunteers No X-ray undertaken Total in random sample

7,000 3,398 663 106 3,292

O.A. Spine Spina bifida occulta Scoliosis Osteoporosis Transitional vertebra Narrow disc space Old T.B. O.A. hips Paget’s disease Minor abnormalities Secondary deposit

Table III

521 153 283 117 66 37 6 6 1 125 1

602 197 27 1 94 35 23 2 16

5 48 1

Radiological Abnormalities (Possible) in Abdominal Viscera and Vasculature

Table lV Type



Possible gall-stones Splenic calcification Pancreatic calcification Splenomegaly/hepatomegaly Vascular calcification Aortic calcification/enIargement Minor findings Gynaecological abnormalities

23 4 1 5 125 1 4 -

30 10 1 17 78 4 6 37

Biochemical Abnormalities-2,000





High urea High creatinine High alkaline phosphatase High urate (blood) High calcium

88 126 83 75 25

59 35 55 80 31




Proper population surveys of stone disease are rare (Ahlgren and Lorstad, 1965). With respect to Scotland we have found 2 conflicting statements regarding stone disease, viz. Thomas (1949) who states Scotland is an area of low incidence and Reaser (1935) who stated the opposite. Anderson (1964) in a survey of hospital admissions on the island of Lewis calculated the “incidence” to be 68 per 100,000 hospital admissions. The concept of using hospital admission rates allows comparison to be made between hospitals but does not reflect the true prevalence of stone disease. There may be widely different local factors operating which are most obvious in large countries such as the USA, where an incidence figure of 94.7 per 100,000 does not bring out such subtle differences as exist between different states (Boyce, Garvey and Strawcutter, 1956). Scandinavian authorities have tried t o define geographical areas when referring to the incidence of stones by concentrating on one particular hospital in a relatively easily defined area (Hedenberg, 1951 ; Norlin et al., 1976). Such figures, interesting as they are, may simply relate the referral rate or the radiodiagnostic facilities and many contemporary authors are clearly unhappy about hospital figures being true points of reference in determining “incidence” (Almby, Meirik and Schonebeck, 1975; Ljunghall and Hedstrand, 1975). Previous work in our own unit suggested the prevalence of the disease to be of the order of 3 % (McKay et al., 1975). The present work gives the prevalence rate in a random population and with Table VI

Table V

Urine Abnormalities-2,000 Type



Dip s 1i des-posit ive

25 (1.25 %) 22 3 36 52

163 (8.5 %> 152

Ceduran sensitive Ceduran insensitive Proteinuria Glycosuria

Abnormalities of the Urinary Tract-2,000 Subjects


TYP~ Possible stone right kidney Possible stone left kidney Possible bilateral stones Possible ureteric stone Prostatic calcification Unequal kidney size Possible bladder stone Possible prostatic carcinoma Bladder implant

I1 38 13

Table VII

Prevalence of Stone Disease-2,000


NO. 0-1,OOO

NO. 1,001-2,OOO






Stones-right kidney Stones-left kidney Bilateral calculi Parathyroid adenoma T.B. kidney Calcified cyst No I.V.P. % Stones (proven) % Stones (2,000)

6 11

6 18 -

5 I1 2



11 9 -


1 I 4

1 -










27 29 5 4 12

26 33 8



1 5




such a figure it is possible to study particular groups within the population. It has helped to define such significant factors as a trace element poisoning in a specialised group of workers (Scott et al., 1976). Similarly, when other specialised groups are defined (Larsen and Phillips, 1962; Blacklock, 1965; Scott, 1971) then it is possible to speculate as to why any one of them do or do not have a significantly greater liability to suffer from stone disease. The present survey has, by its multiphasic composition, helped to define a large number of variables which could be significant not only with respect to stone disease but such imprecisely studied data as the blood urate levels thought to be associated with coronary heart disease (Annotation, Lancet, 1969). The use of the dip-slide technique has been further explored and has revealed a higher than expected number of positive results (Asscher, 1974). There is a good correlation between dip-slide accuracy and plate cultures (McAllister, 1973). It is recommended that technical staff should be employed to interpret these slides (McAllister, 1974) as a variable interpretation of the slides has been uncovered in this study. The technique, however, is clearly useful and especially valuable in symptomatic urinary tract infc ction. Conclusion The survey has proved useful. The prevalence rate (3.83 %) of stone disease has been established in 2,000 subjects. Inter-group comparisons can now be made against the normal population in this area. Factors which are associated with stone disease or which may have a bearing on its progress have been studied and the true incidence of the disease is now obtainable in the future. Summary It is difficult to obtain the true prevalence of stone disease in a community. A proper random sample of a population has been studied and a figure of 3.83 % of calcified stones have been found in 2,000 subjects. The significance of biochemical, bacteriological, skeletal and other surgical abnormalities is discussed. It is now possible to study individual groups within the population with respect to stone disease. We wish to acknowledge the Lanarkshire Area Health Board for financial support, Tillots Laboratories and Ames Labstix for materials. The survey was dependent on the organisational abilities of Mrs Jean Breakey to whom we are grateful.

References AHLGREN, S. A. and LORSTAD, M. (1965). Renal and ureteric calculi in a Swedish district. I. An epidemiological investigation of 1429 roentgenologically verified cases. Acta Chirurgica Scandinavica, 130, 344-353. ALMBY, B., MEIRIK,0. and SCHONEBECK, J. (1975). Incidence, morbidity and complications of renal and ureteral calculi in a well defined geographical arza. Scandinavian Journal of Urology and Nephrology, 9, 249-253. D. A. (1968). The incidence of urinary calculi. Hospital Medicine, 2, 1024-1033. ANDERSEN, G. S. (1964). Urinary calculus in an island community. British Journal of Urology, 36, 556-557. ANDERSON, ANNOTATION (1969). Epidemiology of serum uric acid. Lancet, 2, 417-418. ASSCHER, A. W. (1974). Urinary tract infection. Lancet, 2, 1365-1367. BLACKLOCK, N. J. (1965). The pattern of urolithiasis in the Royal Navy. Journalof the Royal Naval Medical Service, 51, 99-111. BOYCE,W. H., GARVEY, F. K. and STRAWCWER,H. E. (1956). Incidence of urinary calculi among patients in general hospitals 1948-1952. Journal ofthe American Medical Association, 161, 1437-1442. I. (1951). Renal and ureteral calculi, study of the occurrence in Sweden during 1911-38 with some HEDENBERG, notes on geographical distribution. Acta Chirurgica Scandinavica, 101, 17-36. LARSEN, J. F. and &LIP, J. (1962). Studies on the incidence of urolithiasis. Urologia Internationalis, 13, 53-64.



LJUNGHALL, S. and HEDSTRAND, H. (1975). Epidemiology of renal stones in a middle-aged male population. Acta Medica Scandinavica, 197, 439-445. MCALLISTER, T. A. (1973). The day of the dipslide. Nephron, 1 1 , 123-133. MCALLISTER, T. A. (1974). Urinary tract infections in Scottish rural general practice. Journal of International Medical Research, 2, 400-408. MCKAY,I., SINCLAIR, J., SCOTT,R. and DUNCAN, J. G. (1975). Radiologic and postmortem survey of abdominal lesions. Urology, 4, 274-77. NORLIN,A., LINDELL,B., GRANBERG, P. 0. and LINDVALL, N. (1976). Urolithiasis-a study of its frequency. Scandinavian Journal of Urology and Nephrology, 10, 150-153. REASER,E. F. (1935). Racial incidence of urolithiasis. Journal of Urology, 34, 148-155. SCOTT,R. (1971). The incidence of renal colic in the medical profession in the West of Scotland. Health Bulletin, 29, 27-29. SCOTT,R., PATERSON, P. J., MILLS,E. A., MCKIRDY,A., FELL,G. S., OTTOWAY,J. M., H u s s m , F. E. R., FITZGERALD FINCH, 0. P., YATES,A. J., LAMONT, A. and ROXBURGH,S. (1976). Clinical and biochemical abnormalities in coppersmiths exposed to cadmium. Lancet, 2, 396-397. THOMAS,J. M. R . (1949). Vesical calculus in Norfolk. British Journal of Urology, 21, 20-23.

The Authors R . Scott, FRCSG, FRCSE, Consultant Urologist, Royal Infirmary, Glasgow. R. Freeland, DPH, DMRDRCP&S, Consultant Radiologist, Monklands and District General Hospital, Airdrie. W. Mowat, DMRD, Consultant Radiologist, Monklands and District General Hospital, Airdrie. Mary Gardiner, BSc, FRIC, Principal Biochemist, Royal Infirmary, Glasgow. V. Hawthorne, M.D. MRCPG, Senior Lecturer in Epidemiology and Preventive Medicine, University of Glasgow. R. M. Marshall, PhD, Senior Systems Designer, Glasgow Area Health Authority. J. C. J. Ives, FRCSG, FCPath, Consultant Bacteriologist, Royal Infirmary, Glasgow.

Doctors Taking Part Allam, B. Bell, G. Brown, D.

Cameron, A. Campbell, Alexander

Campbell, Alistair Campbell, Hazel Donnelly, T. Dumbuya, S. Fitzpatrick, R.

Flint, E. Gillani, Sema Herd, G.

Iqhbal, M . Johnstone, A.

Kirkpatrick, R. Lawson, W.

Lonie, J.

Mearns, G . Milligan, J.

Mills, E. Orr, S. Paterson, P. Reavey, J.

Requests for reprints to Mr R. Scott, Consultant Urologist, Royal Infirmary, Glasgow.

Sorooshian, K. Thomson, G. Watson, M. Yates, A.

The prevalence of calcified upper urinary tract stone disease in a random population--Cumbernauld Health Survey.

British Journal of Urology (1977), 49, 589-595 @ The Prevalence of Calcified Upper Urinary Tract Stone Disease in a Random PopulationCumbernauld Hea...
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