Kidney stones – urolithiasis or urolithiasis, is when urinary stones (calculi) form in the kidneys. Why are kidney stones dangerous? Urinary stones are one of the causes of kidney failure. But the result of recovery and the effect of treatment is unsatisfactory, which leads to the development of severe complications.
Kidney stones in men and women are a polyetiological disease associated with metabolism in the body, due to which a stone (calculus) appears. This disease affects not only the kidney, but also the entire urinary system of the patient.
There are differences in the existing size and shape of kidney stones, they are small as sand and up to 10 mm, medium 10-20 mm, complex large stones from 20 mm to approximately 50 mm. The reasons for the formation of the disease are a complex chemical and physical process, the formation of crystals from salts in human urine and their further sedimentation. Kidney stones come in different shapes: flat, round, angular and complex.
Manifestations of diseases occur in one or both organs. Kidney stone formation and symptoms occur three times more frequently in men than in women. Although the latter are susceptible to the formation of the most complex forms of kidney stones, the consequences of which can cause serious harm, this disease is called coral nephrolithiasis.
In one of three situations, urolithiasis is diagnosed among all diseases of the urinary genital tract. Basically, signs of kidney stones are detected in patients 20–60 years old, but in principle, patients of all ages and even children are susceptible to this disease.
Concretions can be single or numerous. They have different shapes. Located in one or both organs, they can be located in the renal pelvis, calyxes in the kidneys: lower, middle, upper. Based on their composition, kidney stones are divided into:
Due to the fact that the visibility of stones on X-ray is directly related to their mineral composition, they are divided according to X-ray characteristics:
You can more accurately examine the stone and its density and determine its structure using CT. A more detailed study by the attending physician of what the stone consists of will allow you to competently and correctly prescribe treatment.
The main appearance of stones is:
Physical activity and shaking can remove kidney stones. While the stone does not move from its place, the patient may not feel it, and when the pain with kidney stones becomes strong man cannot find peace or a comfortable position and walks from corner to corner. Renal colic lasts 1–2 hours, can last intermittently for a whole day, after which sand and small pebbles are often released with urine.
The presence of kidney stones disrupts urodynamics, changes kidney function, and inflammation occurs. The symptoms of the disease do not differ between males and females. With prolonged urinary retention, toxic poisoning occurs, which will cause vomiting, itching, and convulsions.
The formation of kidney stones, causes and their identification, we will consider in order. This disease is provoked the following factors:
A man is what he eats. So what eating habits can trigger the onset of disease and kidney stones? Poor nutrition such as:
A specialist can diagnose the disease by palpation of the abdomen and by the nature of the existing symptoms of the disease. It is necessary to find out the reasons that could disrupt the metabolism, determine previous diseases, the development of kidney stones, and the conditions in which the sick person lives. But you should also pass:
In the best of cases, the genitourinary tract removes the stone on its own; it is imperative to examine the stone for its chemical components.
For a more detailed approval of the treatment plan for kidney stones in men and women, the doctor will prescribe an ultrasound scan of the diseased organ to find out what condition the kidney is in, and also to see the condition bladder and will do a urography. How a more extensive examination is used:
How to treat the disease and whether it is possible to get by using medications will be described below. The methods used are conservative and surgical. The smallest stones up to 3 mm are well removed with the help of a dairy-vegetable diet and therapeutic alkaline mineral waters. If the stones do not come out on their own, drugs are used that dissolve them:
For concomitant infections, antibiotics and antimicrobials are prescribed. To relieve severe pain due to colic, treatment with anti-inflammatory drugs is prescribed: diclofenac, ibuprofen, indomethacin - for a period of 3-7 days. And also to relieve painful spasms, no-shpu and papaverine are used. It is unlikely that stones larger than 5 mm will be able to come out on their own. The stone is destroyed by crushing. Open abdominal surgery, with removal of the stone mechanically through incisions in the kidney and bladder, is the most dangerous and old way stone removal.
As a rule, they are now used modern methods crushing stones:
Today, complex surgical intervention is rarely performed and only when another way to remove and remove the stone is impossible.
In the presence of small stones, you can use conservative treatment to regulate metabolic processes, relieve inflammation and promote independent removal of the stone. The complex of treatment measures includes:
Spa treatment will be beneficial both for the removal of small stones and sand, but also as therapy after its removal or removal. Sanatoriums using alkaline mineral waters in treatment are visited by patients with the presence of oxalate, cystine, and urate stones. A sanatorium with acidic mineral waters treats phosphate stones.
Removing or removing stones cannot guarantee complete recovery; stones can form even after recovery. The patient will be observed at the dispensary for about 5 years. Prevention of the disease cannot be ruled out throughout this period. And it is also necessary:
An integrated approach to treatment will be more effective.
For prevention and as an aid to traditional treatment, to remove the stone folk recipes treatment:
lemon water with glycerin – grind 10 pcs. lemons along with the peel (remove the seeds) and pour 2 liters. boiled water, add 2 tbsp. l. glycerin, leave for 30 minutes, take a whole glass every 10 minutes until you drink everything, apply a warm heating pad to where the diseased kidney is located.
In the body of every person, salts in the kidneys, as well as in urine, are always present in small quantities. This is not a pathology. We can talk about a disease when mineral compounds begin to concentrate in quantities exceeding permissible norm. We will discuss below what causes and symptoms precede this disease. The substances that are formed in the urine depend on the current state of acidity in it. Salts are formed when external environment has excessive alkalization.
The main reasons for the formation of salt in the kidneys are:
These are the main reasons for the possible detection of salt during examination in the kidneys. If there are any suspicions or prerequisites that an adult or child may have such a disease, then you need to visit a urologist and consult. It can occur without any sign until symptoms of a more serious pathology appear, such as kidney stones.
Many diseases of the urinary system have similar symptoms; with salts in the kidneys, the following symptoms are distinguished:
The cause of diseases such as kidney stones, urethritis and cystitis is salts in the kidneys.
It also happens that drug therapy is not needed for salts in the kidneys; it is enough just to normalize the patient’s diet. Or perhaps you just need to treat chronic diseases of the genitourinary system.
Treatment involves the following areas:
For both an adult patient and a child, the prescribed diet does not mean that they need to deny themselves meat, dairy and other necessary products for the normal functioning of the body. But it is important to control their daily consumption so as not to exceed the norm.
Remember! To prevent salts in the kidneys, you should control your diet.
If the patient is interested in how to remove salts from the kidneys, then first of all, the diet should be salt-free. No treatment will be effective unless you stop eating salt. Then the symptoms not only will not go away, but can also lead to more serious complications. To prevent this from happening, you need to follow a few simple rules:
When following a diet, you should not eat:
Allowed to eat:
This diet will help with mild form the disease can be dealt with even without drug treatment. Even if the form is more complex, in any case you will have to adhere to such a diet so as not to worsen your situation.
Besides traditional medicine treatment can be carried out and folk remedies. Treat different decoctions and infusions can also be used for a child, but it is advisable to first consult with a urologist so as not to cause harm.
According to medical statistics, urolithiasis is one of the ten most common human diseases. If kidney stones occur, the symptoms of the disease will not take long to appear. Symptoms of urolithiasis, the process of formation of kidney stones, diagnosis and main methods of treatment should be considered in more detail.
Experts have identified external and internal factors that contribute to the appearance and development of urolithiasis. Despite its sufficient study, the exact causes of the formation of kidney stones cannot be named.
External factors include:
Kidney stones can occur under the influence of the following main internal factors:
Almost all of the above internal factors are based on causing the appearance kidney stones, there is a violation acid-base balance in the human body.
The process of stone formation takes a long period.
Everything is in the urine minerals must be in strictly defined quantities.
Under certain conditions, during a complex physical and chemical process, an elementary basis appears - a micelle, from which a stone is formed in the future. To do this, material in the form of fibrin threads, cellular detritus, bacteria, etc. is first taken from urine. Then, an increased concentration of salt and protein in the urine and their altered ratio take part in the formation of kidney stones.
Kidney stones can vary in size, shape, location and location. The places where stones form in the kidneys can be different. The size of these formations usually depends on the duration of the disease. At first they are microscopic in size and are called sand. Those formations that somehow managed to gain a foothold in the kidneys or urinary tract begin to increase in size over time and can reach several cm.
What do the stones look like externally? The shape of kidney stones largely depends on their chemical composition. In this regard, they can have a regular shape with a smooth and even surface or be angular, irregular shape, with many sharp edges.
The chemical composition of kidney stones is different and largely depends on the causes of their occurrence. Common types of kidney stones can be identified:
The urate type of stones consists of uric acid salts, which occurs when urine has an acidic reaction. Urates have a dense structure with a smooth surface.
Carbonate stones are formed due to calcium salts of carbonic acid. They happen various shapes, soft and smooth to the touch, almost always light in color.
The cause of the appearance of oxalates is calcium salts of oxalic acid. The stones have an uneven surface, dark color, dense structure.
Phosphates consist of salts of phosphoric acid. Kidney stones of this type have a rough surface, quickly crumble to the touch, are soft, and light gray in color. To ensure rapid growth of these stones, an alkaline environment is required.
Protein stones are a mixture of fibrin, salts and bacteria. The stones are almost always light in color and small in size. They have a smooth surface to the touch.
Sometimes there is a mixed type of kidney stones, which is considered the most difficult option for treatment.
Symptoms of kidney stones can vary. For renal formations small sizes, up to 5 (mm), it is difficult for the patient to determine the signs of the onset of urolithiasis. Sometimes a patient learns about the kidney stones he has by chance, while undergoing a routine ultrasound examination of the kidneys.
Urolithiasis actively begins to manifest its symptoms when the process of its development has gone quite far. The main symptoms of kidney stones include:
Many of the symptoms listed above may correspond to other serious illnesses. For example, sharp pain in the right kidney can be differentiated with acute appendicitis or with cholecystitis. Therefore, it is important to immediately contact a specialist who will perform an initial examination and perform the necessary diagnostics of the kidneys and nearby organs.
When making an initial appointment with a medical specialist, it is necessary to describe in detail all the signs of the disease. If a stone passes on its own in the urine, it must be submitted to a doctor for a study to determine its chemical composition. This is done to prescribe the correct treatment.
But how to determine the type of stone? To do this, the following checks can be carried out: 
An experienced doctor to determine accurate diagnosis, determining the number of stones and their exact location, assessing the danger in relation to other organs, may prescribe:
http://youtu.be/Sh5NubtNL_Y
If necessary, the doctor may additionally prescribe any other diagnostic test. It should be noted that diagnosing kidney stones with modern high-tech equipment will not be difficult. After an accurate diagnosis is made, an individual treatment plan is drawn up for each patient.
Treatment of this disease has the following goals:
For small stones, conservative treatment is prescribed, and for larger stones, surgery is prescribed.
Conservative treatment includes:
To relieve acute pain due to kidney stones, the doctor prescribes injections of morphine, Baralgin with atropine solution, novocaine blockade, a warm bath, and a heating pad.
Indications for surgical intervention may include:
Today, minimally invasive surgery methods are used:
If these methods are ineffective, open surgery is resorted to. Operated patients are recommended to follow a lifelong diet and follow all doctor’s recommendations.
If the disease is advanced or if all the doctor’s recommendations are not followed, the consequences can be disastrous, even death.
http://youtu.be/t8WYc8QZXpA
Thus, the presence of kidney stones requires immediate and complete treatment under the guidance of an experienced doctor. Only in this case can you count on a favorable prognosis.
Symptoms of kidney stones almost always vary from person to person, so describe your case in the comments, or write in the question and answer section.
Factors contributing to the development of KSD can be divided into exogenous and endogenous. The first group includes the nature of nutrition (a large amount of protein in the diet, insufficient fluid intake, deficiency of certain vitamins, etc.), physical inactivity, and also play a role in age, gender, race, environmental, geographical, climatic and living conditions, profession, intake of certain medications.
Endogenous factors include genetic factors, urinary tract infections and their anatomical changes leading to impaired urine outflow, endocrinopathies, metabolic and vascular disorders in the body and kidney.
Under the influence of these factors, there is a disruption of metabolism in biological environments and an increase in the level of stone-forming substances (calcium, uric acid, etc.) in the blood serum and, as a consequence, an increase in their excretion by the kidneys and supersaturation of urine.
In this regard, salts fall out in the form of crystals, which entails the formation of first microliths and then urinary stones.
However, oversaturation of urine alone is not enough to cause stone formation. For its formation, other factors are necessary: a violation of the outflow of urine, a urinary tract infection, a change in urine pH (normally this value is 5.8–6.2) and others.
There are many classifications of urinary stones, but the mineralogical classification is currently the most widespread. Up to 70–80% of urinary stones are inorganic calcium compounds: oxalates (wedelite, wevelite), phosphates (whitlockite, apatite, carbonatapatite), etc.
Stones made from uric acid derivatives are found in 10-15% of cases (ammonium and sodium urates, uric acid dihydrate), and magnesium-containing stones - in 5-10% of cases (newerite, struvite). And the occurrence of protein stones (cystine, xanthine) is least common - up to 1% of cases.
However, mixed stones are most often formed in the urine. The need is due to the peculiarities of methods of removal and conservative anti-relapse treatment for one or another type of stones.
Modern medicine does not offer a unified concept of the causes of urolithiasis. Among the factors causing ICD are the following:
Doctors consider the following diseases to predispose to the appearance of stones: hyperparathyroxism, renal acidosis, cystinuria, sarcoidosis, Crohn's disease, frequent urinary tract infections, as well as long-term immobilization.
The problem is that urolithiasis is a recurrent disease. Stone formation often becomes chronic. Experts list the following risk factors for recurrent stone formation:
Violation of purine, oxalic acid or phosphorus-calcium metabolism often leads to crystalluria. In chronic pyelonephritis, the main role in stone formation is played by the metabolic products of microorganisms (phenols, cresols and volatile fatty acids), as well as the presence of protein in the urine, which serves as the basis for the precipitation of crystals and the formation of microlites.
Sometimes the stones have a homogeneous composition, however, often, kidney stones are mineral composition are mixed in nature, so we can only talk about the predominance of one type or another mineral salts, from which the base of the stone is formed.
Therefore, strict dietary regulations are not always advisable, although exceptions from daily diet products such as coffee, strong tea, chocolate, fried meat, as well as limiting the consumption of animal protein and foods containing large amounts of calcium are necessary measures for any type of stone formation.
The role of vitamins and minerals in diet therapy for urolithiasis should not be underestimated. But you should not get carried away with multivitamin complexes, especially those containing calcium. Such drugs are aimed at children and old age when the need for calcium increases.
At the same time, it must be remembered that calcium is absorbed only in the presence of a sufficient amount of vitamin D, which an adult also does not need to consume separately when good nutrition, since vitamin D is formed in the body under the influence of ultraviolet radiation and accumulates in the liver (for the winter).
Large amounts of vitamin D are found in fatty fish. In addition, to prevent stone formation, food must contain sufficient amounts of potassium and magnesium. It must be taken into account that magnesium is also absorbed only in the presence of vitamin B6.
Thus, diets for urolithiasis should be balanced and take into account the peculiarities of the nature of stone formation.
Sand and kidney stones are a consequence of metabolic disorders, which are often hereditary. Sand and kidney stones can be salts of calcium, phosphorus, magnesium, oxalic and uric acid.
In addition, there are cysteine and xanthine stones, which arise from protein metabolism disorders. But most often sand and kidney stones have a mixed composition.
Factors predisposing to the formation of sand and kidney stones are a sedentary lifestyle, diet (various hereditary metabolic disorders require special diet), living conditions, profession, urinary tract infections, anatomical and physiological features of the structure of the urinary tract, vascular disorders.
A sign of the appearance of sand and stones in the kidneys is renal colic. Renal colic indicates sand or stone passing through (or stuck in) the urinary tract.
In this case, severe pain appears in the lumbar region, radiating to groin area and in the thigh. When passing sand, pain often appears when urinating, a change in the color of urine from a large amount of sand or from blood.
At the same time, small stones and sand cause the greatest concern, while large stones usually do not make themselves felt for the time being. But if a large stone gets stuck, it can cause serious complications.
First of all, the patient himself pays attention to the fact that after pain in the lower back, the color of his urine changes, and this should be a reason to consult a doctor.
The doctor first prescribes laboratory tests of blood and urine in order to identify the presence and nature of sand and exclude inflammatory diseases of the urinary tract.
The next stage is ultrasound and X-ray examination urinary tract. In most cases, these research methods can detect kidney stones, but there are stones that cannot be detected with these studies.
If, nevertheless, signs of the disease and laboratory tests indicate that there should still be a stone, then the necessary treatment in such cases is carried out.
Food should not contain spicy foods, concentrated meat broths, coffee, chocolate, cocoa, legumes, or alcohol. If oxalic acid salts (oxalates) predominate in the urine, then you will need to limit milk and dairy products, chocolate, coffee, sorrel, lettuce, strawberries, and citrus fruits.
If calcium and phosphorus salts predominate in the urine, you need to limit the amount of milk, cottage cheese, cheese and fish.
With any type of salts, the patient must drink daily (first courses included) up to 2 or more liters of water per day (weak tea, compote, juices, low-mineralized mineral water, etc.).
This is necessary so that a large amount of liquid washes away the sand and does not allow it to accumulate in the urinary tract, forming stones.
If you have, you have already been examined about this and are sure that the cause of colic is sand or small stones, then you can use heat to relieve pain. This could be a heating pad or a warm bath.
Heat promotes expansion of the urinary tract and in such conditions a small pebble or coarse sand will come out. To enhance the effect, you need to take an antispasmodic (for example, no-shpa) - this will also relieve the spasm.
If the pain does not go away, then you need to call ambulance, since prolonged spasm of the urinary tract can lead to complications.
Attention! This method is not suitable for unexamined patients, since the pain may be caused by a tumor, and it will grow rapidly from the heat.
A significant factor in the mechanism of stone formation are changes that lead to stagnation of urine, for example, abnormal structure of the calyx and pelvis, valves and narrowing of the ureter, incomplete emptying of the bladder with prostate adenoma, urethral strictures, and organic diseases of the spinal cord.
The effect of obstructed urine outflow is that salts precipitate in stagnant urine and an infection develops. Obstructed outflow from the pelvis slows down the circulation of urine in the renal tubules, thereby disrupting the secretion and resorption of the constituent elements of urine.
The important role of impaired dynamics of urinary excretion is evidenced by the fact that in the vast majority of cases (80-90%) stones are formed in one, and not in both kidneys.
True, with primary hydronephrosis, stones are rarely formed, but this is explained by the low concentration of urine due to atrophy of the renal parenchyma.
Clinical and experimental observations indicate a connection between kidney stone disease and chronic infection not only urinary system, but also other organs and tissues.
With infection of the urinary system itself, the significance of microorganisms seems even clearer. The formation of phosphates and carbonates is especially favored by infectious pathogens that break down urea with the formation of ammonia and alkaline reactions of urine.
This property is mainly possessed by Proteus bacillus and pyogenic staphylococcus. Due to the fact that this flora very often accompanies these stones, they recur especially often.
Infection plays a particularly important role in the etiology of secondary stones, which develop based on the inflammatory process, in the urinary organs in the presence of concomitant disturbances in the dynamics of urinary excretion.
Relapse rate after surgical removal kidney stones are three times higher in the presence of infection in the kidneys than in aseptic stones.
There are primary stones, formed in the tubules and on the renal papillae in normal, uninfected urine (mostly oxalates and urates), and secondary stones, formed in the renal pelvis (phosphates and carbonates). The formation of secondary stones, which usually occur in the presence of a urinary system infection and impaired urine outflow, is explained by the fact that the inflammatory process changes the pH of the urine and disrupts the integrity of the epithelial cover of the renal pelvis and calyces.
The amount of colloids secreted by the kidneys ( daily amount they are equal to 1 -1.5 g) decreases, physical and chemical properties they change under the influence of infection. Precipitation of crystalloids and hydrophobic colloids occurs.
Inflammation products - mucus, pus, bacterial bodies, rejected epithelium - participate in the formation of the organic core of the stone, on which the crystalline shell of the stone is formed.
This process develops faster than with primary stones, since in stagnant, infected urine, often an alkaline reaction, the precipitation of salts occurs very intensively.
It is known that small kidney stones up to 1-1.5 cm in diameter often pass away on their own. Naturally, the question arises why these stones were not identified earlier, when their sizes were smaller, measured in tenths of a millimeter or microns.
With secondary stones, the reason for this is a violation of the dynamics of urination, which underlies their pathogenesis, as well as the rapid growth of stones under the influence of concomitant urinary infection.
As for the primary stones formed during normal peristalsis of the renal cavities and ureters, with the free outflow of urine and the absence of urinary infection, the reason is that the primary stones are formed on the renal papillae or in the renal tubules and remain fixed for a certain time.
Based on extensive experimental, radiological and clinical studies, it has been proven that primary stones originate at or near the apices of the renal papillae.
A calcareous plaque is deposited in the lumen of the collecting duct of the papilla or outside it, which forms a bed (matrix) of the stone, as it grows, the epithelial cover above it falls away, exposing an uneven surface, thus coming into contact with urine.
The further formation of the stone, i.e. the deposition of salts falling out of the urine on the bed, is essentially a natural and at the same time a secondary process. All sorts of things foreign body in the urinary system, it reduces the ability of urine to retain salts in a supersaturated solution.
They precipitate and settle on the core, the uneven surface of which, which has a higher surface tension compared to urine, becomes an adsorption center for them. Having reached a certain size, the stone is torn away from the papilla with or without a bed (see Fig. 2 and 3).
Rice. 2. Normal renal papilla
Rice. 3. Renal papilla after stone separation
In the first case, there may be no relapse; in the second, a new stone forms on the same bed. On small stones of the ureter you can sometimes find a slightly concave surface with which the stone was adjacent to the bed, and on it whitish calcareous chips related to the substance of the bed.
Urolithiasis or urolithiasis is a disease associated with metabolic disorders in the body, which leads to the deposition of salts, the appearance of sand and the formation of stones in the kidneys and urinary tract.
Recently, due to changes in diet, sedentary lifestyle, and exposure to various unfavorable environmental factors, urolithiasis is becoming more common.
Epidemiology
Urolithiasis has been known since ancient times. Urine stones have been found in Egyptian mummies of people who died and were buried before our era. The first description of a patient with urinary stones dates back to 4800 BC. Many great people suffered from this disease - Peter I, Isaac Newton, Napoleon, Benjamin Franklin.
Urolithiasis is one of the most common diseases of the kidneys and urinary tract, and patients with this pathology make up 30-40% of all patients in a urological hospital. According to global data, this disease affects about 4% of the population. In developed countries of the world, for every 10 million people, 400 thousand suffer from urolithiasis. In the United States, more than 1 million Americans are hospitalized each year for kidney and urinary tract stones.
The prevalence of urolithiasis in the general population is 1-5%. Proportion of urolithiasis among all urological diseases is 40%. The disease occurs more often in men than in women (ratio 3:1). Urolithiasis in 65-70% of cases is diagnosed in people aged 20-55 years, i.e. in the most productive period of life. Relapses of the disease within 5 years depend on the clinical form of the disease and methods of stone removal and are observed in 15-40% of cases. The medical and economic significance of the problem of urolithiasis lies in the long periods of rehabilitation of patients and loss of ability to work.
Urolithiasis is rightfully considered a disease of civilization.
Risk factors
■ Family history: 55% of patients had immediate relatives with urolithiasis.
■ History of urolithiasis: the likelihood of recurrent symptoms within 20 years after the first episode of the disease is 80%.
■ Exposure to increased physical activity (for example, professional athletes) or work associated with prolonged hyperthermia (for example, divers, hot shop workers), lifestyle features (sedentary lifestyle).
■ Monotonous food, change of place of residence, stress. Lack of vitamins A and group B.
■ Increased fluid loss.
■ Taking increased doses of vitamins A and C.
■ Diseases and pathological syndromes that contribute to the development of urolithiasis:
Etiology
Urolithiasis is a polyetiological disease, i.e. its occurrence, development and course are associated with many factors.
For patients with any form of urolithiasis, it is necessary to analyze the causes of stone formation in order to subsequently prescribe treatment or remove the stone.
It should be noted that none of the types surgical intervention is not a method of treating urolithiasis, but only relieves the patient of the stone.
Thus, among the factors influencing the formation of calcium oxalate stones, diseases are often identified endocrine system (parathyroid glands), gastrointestinal tract and kidneys. Violation of purine metabolism leads to the development of urate nephrolithiasis.
Chronic inflammatory diseases of the genitourinary system can contribute to the formation of phosphate (struvite) stones.
Thus, depending on etiological factors and developing metabolic disorders urinary stones of different chemical composition are formed.
There are several basic theories of stone formation, in which one or more main factors prevail:
We can also highlight the main reasons for the formation of stones:
Climatic factor. Air temperature and humidity, hot climate, increased sweating, as a result of which the concentration of certain salts in the body increases, and stones may begin to form.
Geographical factor. The composition of water and dietary habits play a role here (spicy and sour foods increase acidity). A constant lack of vitamins in food and ultraviolet rays can contribute to stone formation.
Various diseases of the kidneys and genitourinary system. A very important role is played by infection of the urinary system (pyelonephritis, cystitis), as well as a violation of the outflow of urine (anomalies in the development of the kidneys and urinary tract, narrowing of the urinary tract for various reasons, a solitary kidney, etc.).
General diseases. Bone injuries and diseases - osteomyelitis, osteoporosis. Chronic diseases of the stomach and intestines, such as chronic gastritis, colitis, peptic ulcer, intestinal surgery. Severe dehydration body, which can be due to an infectious disease or poisoning.
Classification of urinary stones
Currently, the “Mineralogical classification of urinary stones” (Table 1) is internationally recognized, used for a clearer understanding of the structure of the stone and the ability to correctly establish a diagnosis, as well as treat the patient.
As is known, about 80% of urinary stones are inorganic calcium compounds:
· oxalates - 60-70%;
· phosphates - 15-20%;
· carbonates - 1-5%.
Uric acid stones occur in 15% of all urinary stones, and they become more common with age.
The rarest are protein stones - about 0.4-0.6% (cystine, xanthine, etc.).
Table 1.
|
|
Mineralogical name |
Chemical name | |
|
Oxalate |
Wewellite |
Calcium oxalate monohydrate |
CaC 2 O 4 . H 2 O |
|
Weddellite |
Calcium oxalate dihydrate |
CaC 2 O 4 . 2H 2 O |
|
|
Phosphate |
Hydroxyapatite |
Calcium hydroxyphosphate |
Ca 5 (PO 4) 3 OH |
|
Carbonatapatite |
Calcium carbonate phosphate |
Ca 5 (P0 4) 3 (CO 3) 0.5 |
|
|
Octocalcium phosphate |
Calcium hydrogen phosphate |
Ca 4 H(PO 4) 3 |
|
|
Whitlockit |
Calcium phosphate |
Ca 3 (PO 4) 2 |
|
|
Calcium hydrogen phosphate dihydrate |
CaHP0 4 . 2H 2 O |
||
|
Magnesium ammonium phosphate hexahydrate |
MgNH 4 PO 4 . 6H2O |
||
|
Newberite |
Magnesium hydrogen phosphate trihydrate |
MgHPO4. 3H2O |
|
|
Uric acid dihydrate |
Uric acid dihydrate |
C 5 H 4 O 3 N 4 . 2H2O |
|
|
Uric acid |
Uric acid |
C 5 H 4 O 3 N 4 |
|
|
Ammonium urate |
Ammonium urate |
NH 4 C 5 H 3 O 3 N |
|
|
Sodium urate |
Sodium urate |
NaC 5 H 3 O 3 N 4 |
|
|
Carbonate |
Calcite, aragonite |
Calcium carbonate | |
|
Cystine |
|
[-S-СH 2 -CH(NH 2)–COOH] 2 |
|
|
Xanthine |
|
C 5 H 4 O 2 N 4 |
|
|
|
Hypoxanthine | ||
|
Calcium sulfate | |||
|
|
|
protein |
Stones consisting of one type of salt occur in approximately 50% of cases, in the rest - mixed (polymineral) stones are formed in the urine.
Xanthine stone
Oxalate stones:
Quote Patients with Ca-oxalate stones should consume well balanced diet, in which products from various groups included in the general diet. Obtaining calcium from outside is ensured by consuming milk and dairy products, which are the most important calcium-containing foods. In patients with elevated oxalic acid levels, foods rich in oxalate should be limited (Table 18). Table 18 - Oxalate content of selected foods. Product Average content of oxalic acid (100 g of product) Cocoa 625 mg Nuts 200 - 600 mg Tea leaves 375 - 1450 mg Spinach 570 mg Rhubarb 530 mg The following products are recommended: meat, poultry, fish in moderation, preferably boiled, in including boiled sausages (milk, dietary), sausages, eggs in any processing, salads from boiled meat and fish; milk, kefir, cottage cheese, sour cream (except for situations with an increase in the level of calcium in the urine, with a high urine pH, during exacerbation); fats: butter and vegetable oils, unsalted lard; cereals: buckwheat, oatmeal, pearl barley, millet, pasta, soups made from them; bread: wheat, rye, flour products, especially coarsely ground with the inclusion wheat bran; vegetables and fruits: cucumbers, cabbage, peas, eggplants, turnips, pumpkin, lentils, apricots, bananas; soups, sauces; cold vegetable appetizers, squash and eggplant caviar; compotes, jelly, mousses; tea, weak coffee with milk, decoctions of dried fruits, rose hips, wheat bran, fruit drinks, kvass. Exclude from the diet: liver, kidneys, tongue, brains, salted fish, jellies and gelatin-based jellies, legumes; limit cheeses, exclude salty cheeses; sorrel, spinach, rhubarb, mushrooms, strawberries, pears, gooseberries, beans, salted vegetables, limit beets (in case of exacerbation), relatively limit carrots, onions, tomatoes; meat, mushroom and fish broths and sauces; salty snacks, smoked meats, canned food, caviar, pepper, mustard, horseradish; chocolate, figs; limit black currants, blueberries, sweets, jam, confectionery; cocoa, strong coffee; There is no need to strictly limit tomatoes, cabbage and other vegetables. Given that increased uric acid excretion increases the risk of oxalate stone formation, it is advisable to reduce the consumption of foods rich in purines. Eating foods rich in dietary fiber, which is the non-metabolized part plant products, promotes the binding of minerals in the intestines, thereby reducing their absorption. This measure is especially important in patients with absorptive hypercalciuria. Considering that the formation of stones from calcium oxalate is a multifactorial process, increasing diuresis throughout the day is the most important metaphylactic measure. This is especially important for patients whose urine examination did not reveal any metabolic disorders. Dilution of urine and a decrease in the concentration of salts in it provides diuresis of about 2 - 2.5 liters of urine per day. Depending on the tension physical activity and ambient temperature, the amount of liquid drunk should vary between 2.5 - 3 liters. This amount of liquid should be distributed evenly throughout the day. A very good habit is to drink extra fluid before each act of urination. It is very important to drink extra fluids before bed to avoid highly concentrated urine during sleep. Alkaline drinks are preferred because they increase urine pH and citric acid excretion. Suitable mineral water for this purpose is rich in bicarbonate ion and moderate calcium content (at least 1500 mg HCO3-/l; maximum 200 mg calcium/l. Drinks that do not cause changes in urine: kidney tea; fruit tea; mineral water with low mineral content. Drinks that should be limited: coffee and black tea are limited due to caffeine-dependent increase in uric acid excretion. Black tea also contains a significant amount of phosphorus and oxalate. Milk is limited due to the content of calcium, animal protein and phosphates. coffee 2 cups per day, black tea - 2 cups per day, milk - 2 glasses per day; drinks containing sugar increase calcium excretion; alcoholic drinks increase the excretion of uric acid and promote acidification of urine. Brushite stones are in most cases monominerals and have high risk recurrence. In this case, it is necessary to exclude obstruction of the urinary tract and special attention pay attention to urine dilution. This is achieved by drinking large amounts of fluid under the control of urine density. It is necessary to achieve a diuresis of at least 2.0 - 2.5 liters per day. To do this, you need to drink 2.5 - 3.0 liters of fluid per day and it is very important that the fluid intake is uniform throughout the day. It is recommended to develop the habit of drinking fluid before each urination and before going to bed at night. No less important is the question - what drinks to drink? Mineral waters with a low calcium and bicarbonate content (HCO3- maximum 500 mg/l and Ca2+ maximum 150 mg/l) are preferred. Cranberry juice also has an acidifying and bacteriostatic effect. However, cranberry juice consumption should be limited due to increased oxalate excretion. The daily volume of fluid should be supplemented with kidney tea, fruit tea, and apple juice. You should limit coffee, tea and milk (no more than two cups per day). You should not drink citrus juices, mineral waters rich in calcium and HCO3- ion, lemonades containing sugar and alcohol. You should avoid visiting a sauna, prolonged exposure to the sun or in hot climates, and excessive physical exertion due to fluid loss. The formation of calcium phosphate stones can sometimes be the result of prolonged immobilization. This occurs due to the resorption of calcium and phosphorus from the bones, urodynamic disturbances, and infection of the urinary tract. Physical activity in this case is a good metaphylactic measure. To monitor the effectiveness of metaphylaxis, monitoring is recommended serum level calcium, potassium and creatinine, and in urine - pH levels, calcium, potassium, citric acid, nitrite test. With this type of urolithiasis, you need to adhere to balanced diet. It is not recommended to follow a strict vegetarian diet. It is necessary to control calcium intake: avoid eating hard cheeses, replacing them with yogurt and cottage cheese. The acceptable level of protein consumption is 150 g per day in the form of meat, fish or sausages. With hyperphosphaturia, it is necessary to consume high fiber and low-calorie foods in small portions several times a day. The following products are recommended: meat, poultry, fish in any processing, including in the form of appetizers, soups and sauces; eggs in any preparation (1 time per day); fats: butter and vegetable oil, lard; cereals in any preparation, but without milk; bread, flour products in any form; vegetables: green peas, pumpkin; mushrooms; sour varieties of apples, cranberries, lingonberries, compotes, jelly and fruit drinks on them; honey, sugar, confectionery; weak tea and coffee (without milk), rosehip decoction. Exclude or limit: smoked meats, pickles; milk, fermented milk products: cottage cheese, cheese, sweet dishes with milk and cream; meat and cooking fats; baked goods; potatoes and vegetables, except those mentioned above; vegetable salads, vinaigrettes, canned vegetables; spices, fruit, berries and vegetable juices.
Urolithiasis (UCD) is a metabolic disease caused by various endogenous and (or) exogenous causes. It is often hereditary and is determined by the presence of a stone in the patient’s urinary system. KSD is one of the most common urological diseases, prone to relapse, and is often characterized by a persistent, severe course.
The incidence of urolithiasis in the world ranges from 0.5 to 5.3%; in Russia, this figure is on average 38.2% of all urological patients. The disease can be diagnosed in both a seven-month-old child and an elderly person, but in 68% of cases, ICD develops in working age (20-60 years). Bilateral urolithiasis is diagnosed in 15 - 30% of patients with urolithiasis. There are regions where this disease is particularly common and endemic. Such regions in Russia are: the North Caucasus, the Urals, the Volga region, the Don and Kama basins. According to many researchers and the State Statistics Committee of the Russian Federation, today there is an increase in the incidence of urolithiasis among all groups of the population.
Stones are more often formed in males; in women, severe forms of the disease are more common, for example coral nephrolithiasis, when the stone occupies almost the entire abdominal cavity system of the kidney. To be fair, it should be noted that thanks to modern technologies diagnosis and treatment of urolithiasis, the prevalence of coral nephrolithiasis has decreased significantly in recent years, while the proportion of other, milder forms of this disease has increased, which is associated with the increasing influence of a number of unfavorable external environmental environmental factors on the human body. The increase in the incidence of urolithiasis is provoked, among other factors, by the conditions of modern life: physical inactivity leading to disturbances in phosphorus-calcium metabolism, the nature of nutrition (abundance of protein in food or a monotonous diet). All of the above allowed us to call this disease, associated with metabolic disorders in the body, a disease of civilization. A number of other factors also predispose to the development of ICD: climatic, geographical and living conditions, profession and inherited genetic factors.
Among the causes of the formation of kidney stones, more or less pronounced local changes may dominate: urinary tract infection, anatomical and pathological changes in the upper urinary tract, nephroptosis and others leading to disruption of the normal outflow of urine from the kidneys, as well as metabolic and vascular disorders in the kidney .
There is currently no unified concept of the etiopathogenesis of urolithiasis. KSD is considered a polyetiological disease associated with complex physicochemical processes that occur both in the body as a whole and at the level of the urinary system and are both congenital and acquired. At the same time, in each specific case, with a thorough and thorough examination of the patient and collection of anamnesis, it is possible to identify the factors that underlie the development of ICD. Since attempts to explain the development of ICD by any one cause have been unsuccessful, in each specific case, before prescribing treatment, it is necessary to carry out comprehensive examination in order to determine the cause of the development of the disease in a given patient.
The most advanced is the etiopathogenetic scheme of the stone formation process, which is generally accepted and includes causes of endogenous and exogenous origin. The mechanism of stone formation depends on a number of physicochemical processes and goes through a number of stages, from saturation and supersaturation of urine with salts to the phases of enucleation, crystallization and growth of crystals until they acquire clinically significant sizes, when these processes are not hampered (or are completely absent) by mechanisms of inhibition of crystal growth .
The addition of a urinary infection significantly aggravates the course of the disease. It can be considered as an important additional local factor that provokes the emergence and maintenance of the chronic (recurrent) course of urolithiasis due to the adverse effect on the urine of metabolic products of a number of microorganisms, which contribute to its sharp alkalization and the rapid formation of amorphous phosphate crystals, and in the presence of a crystallization nucleus - to the rapid growth of the stone .
The most studied endogenous cause of calcium metabolism disorder (the basis of most urinary stones) is dysfunction of the parathyroid glands. Thus, in coral or often recurrent nephrolithiasis, hyperparathyroidism is an etiopathogenetic factor in at least 30 - 40% of cases.
Climatic, environmental and food exogenous factors (nitrates, sulfates and other compounds contained in mineral fertilizers, as well as pesticides and penetrating into the body with water and food) can have a direct toxic or indirect effect on the human body, causing metabolic disorders in biological environments . As a result, they can lead to dysfunction of the nephron and, in particular, its tubular apparatus (tubulopathies), which is accompanied by an increase in the level of stone-forming substances in the blood serum and urine. Similar changes occur in patients with diseases of the gastrointestinal tract or with fractures of long bones, prolonged immobilization, etc.
In turn, an increase in the concentration of stone-forming substances in the blood serum and, as a consequence, an inevitable increase in their excretion by the kidneys leads to a supersaturation of the urine with them, which can manifest itself in the formation of salt crystals and microlites, which undoubtedly create favorable conditions for the formation of urinary stones. In many people, the urine is often oversaturated with stone-forming substances, but they do not form stones, that is, the mere fact of oversaturation of urine (crystalluria and microliths in the urine) is not enough to diagnose urolithiasis, for the development of which some other factors are also necessary. It has been established that a number of substances affect the colloidal stability of urine, help maintain salts in a dissolved state and prevent their crystallization. Substances that maintain urine salts in a dissolved state and prevent their precipitation include: hypuric acid, xanthine, sodium chloride, citrates, magnesium, inorganic pyrophosphate, inorganic ions of zinc, manganese, cobalt, etc. Even in small concentrations, these substances inhibit crystallization, however, in the vast majority of patients with urolithiasis they are absent or present in insufficiently small quantities. So, if under normal conditions magnesium ions bind up to 40% of oxalic acid in the urine, then their deficiency is manifested by the formation of calcium oxalate crystals.
In other words, the metastable state of salt in a saturated solution can easily be disturbed, and if local factors are also present, the growth of crystals and microlites occurs due to the deposition of more and more salts on them, as on the core, which in turn leads to the formation directly stone and ICD.
One of the main factors that maintain the metabolic state of most salts in balance, which can be successfully influenced, is the concentration of hydrogen ions, expressed in urine pH values and normally ranging from 5.6 to 6.0.
Currently, the mineralogical classification of urinary stones is accepted throughout the world. 70-80% of urinary stones are inorganic calcium compounds: oxalates (wedelite, wevelite); phosphates (whitlockite, brushite, apatite, carbonate-patite, hydroxyapatite), calcium carbonate. Magnesium-containing stones occur in 5 - 10% of cases (newerite, struvite, magnesium ammonium phosphate monohydrate) and are often combined with infection in the urine. Uric acid stones account for up to 10 - 15% of all urinary stones (ammonium urate, sodium urate, uric acid dihydrate), and the older the patient, the more often uric acid stones occur. Less common than others are protein stones - 0.4-0.6% of cases (cystine, xanthine, etc.), indicating a violation of the metabolism of the corresponding amino acids in the patient’s body. However, in pure form stones are detected in no more than 40% of cases. In other cases, stones of mixed (polymineral) composition (in various variants) are formed in the urine, and the formation of stones is characterized by parallel metabolic and often infectious processes.
Diagnosis of nephrourethrolithiasis is based on the patient’s complaints and medical history. The disease manifests itself most clearly (paroxysmal, intractable renal colic) with small (up to 1.0 cm) stones of the kidneys and ureters, while coral-shaped and large stones can exist asymptomatically for a long time (sometimes until the kidney completely dies). Ultrasonic and x-ray examination in almost 100% of cases it allows us to diagnose stones in the urinary tract. Based on the analysis of the data obtained during the survey, a therapeutic tactics, which must be strictly individual, that is, selected taking into account clinical course diseases.
The course of ICD is extremely diverse. In some patients, this disease has the character of an unpleasant one-time episode, but often ICD proceeds persistently, with frequent relapses or takes a protracted, chronic course. In the absence of clinical observation and treatment, the disease can lead to kidney death, pyonephrosis, chronic renal failure, disability and even death of the patient. The high prevalence of the disease and the possibility of serious, life-threatening complications for patients indicate the importance of this problem in terms of its timely diagnosis and treatment.
The effectiveness of treatment based on biochemical research blood and urine of patients, none of the clinicians doubts. Thus, a 10-year study showed that relapse of the disease (after removal of the stone) in patients who did not receive adequate treatment and were left without observation was observed in 78.5% of cases, while in people who received anti-relapse treatment, the frequency of disease recurrence was in 3 times less (21.5%). Careful clinical observation and examination of patients over a long period of time after spontaneous passage of stones or their removal in various ways made it possible to establish that the main factor in the relapse of the disease is severe metabolic disorders in the body of patients and urinary tract infection.
Knowledge chemical structure removal of stones is extremely necessary not only from the standpoint of developing conservative anti-relapse treatment, but also in terms of choosing different modern methods their removal.
Therefore, examination and subsequent treatment of patients must be carried out in accordance with a strictly defined algorithm. The doctor should not limit himself only to removing the stone in one way or another (DLT, endosurgery, open surgery); measures to prevent (metaphylaxis) relapses of the disease are also mandatory. Unfortunately, most patients, and some doctors, still do not understand that surgical methods for removing stones are not methods of treating urolithiasis and are themselves fraught with the emergence of additional complicating factors that can aggravate the course of the disease.
In recent decades, significant progress has been made in the treatment of urolithiasis. Doctors have learned to destroy and remove stones of all types, regardless of their size and chemical composition, without the use of surgical incisions. The introduction of extracorporeal shock wave lithotripsy (ESWL) into urological practice has significantly increased the efficiency of stone removal in most patients with urolithiasis and minimized the number of complications compared to the open surgical method. EBRT is undoubtedly a less invasive method. Due to its relative simplicity, DLT has become widespread in many countries of the world; with its help, it is possible to relieve up to 80% of patients from kidney and ureteral stones. Even those patients who were denied surgery due to concomitant diseases (heart attack, stroke, ischemic heart disease, etc.) can today get rid of stones in the kidneys and ureters. The youngest patient in whom EBRT was successfully used was 9 months old. Thanks to the use of DLT, it became possible for the first time to remove stones on an outpatient basis. Currently, up to 40% of patients with urolithiasis are treated on an outpatient basis. The periods of hospitalization and recovery after radiotherapy are shorter compared to similar periods after various open operations; the incidence and severity of postoperative complications and postoperative mortality decreased significantly. However, this method has certain contraindications: blood coagulation disorders, acute concomitant diseases, inflammatory processes in the kidney and organic changes in the upper urinary tract and a pronounced decrease in kidney function. Therefore, the final decision on the possibility of using DLT can only be made by specialists from urological clinics involved in the treatment of urolithiasis.
However, it should be noted that as a result of DLT, unlike other methods, the stone does not come out entirely, but the destroyed fragments pass away on their own; in rare cases, this process is complicated by blockage of the ureter, renal colic and acute pyelonephritis. All this requires mandatory monitoring of patients in a clinic. Percutaneous and transurethral endoscopic removal of stones from the kidneys and ureters can be considered as “moderately traumatic” methods. They are no less effective than DLT, and in addition to simultaneous stone removal, in some cases they can eliminate the cause of stone formation (ureteral stricture). Open surgery for this disease has not lost its clinical significance and is used when it is necessary to simultaneously perform reconstruction of the urinary tract, as well as in the most severe form of urolithiasis, such as coral nephrolithiasis. All three methods often complement each other, and therefore the acquisition of a lithotripter alone is not enough to begin treating patients with urolithiasis, unless the clinic uses two other methods, which is stipulated in regulatory documents Ministry of Health of the Russian Federation.
KSD should be considered primarily as a surgical disease, since in order to rid patients of stones it is often necessary to resort to one or another surgical method of removing them. The exception is stones consisting of uric acid salts - urates, which can be successfully dissolved with citrate mixtures (uralite U, blemarene, etc.). Therapy with citrate mixtures for 2 - 3 months often leads to complete dissolution of such stones. For stones of a different composition, stone-dissolving therapy is ineffective and treatment is symptomatic until surgical removal. Drug therapy for urolithiasis is used in symptomatic therapy - until stones are removed - or stone expulsion therapy - when they are small in size (up to 0.5 cm), when they can pass away on their own.
Removing a stone or its spontaneous passage from the urinary tract does not exclude the possibility of a relapse of this disease, since the main processes leading to the formation of stones are, as a rule, not eliminated. Therefore, the effectiveness of treatment for urolithiasis in general largely depends on the effectiveness of complex treatment of the patient at the outpatient stage, which is still the weakest link.
At this stage, if there are indications for treatment, nutritionists, endocrinologists, nephrologists, etc. should be involved.
The complex of therapeutic measures aimed at correcting metabolic disorders of stone-forming substances in the body includes: diet therapy, maintaining adequate water balance, antibacterial therapy, herbal medicine, physiotherapeutic and balneological procedures, physical therapy, spa treatment.
Diet therapy depends primarily on the composition of the removed stones and identified metabolic disorders. However, we can recommend some general principles in maintaining diet and water balance: maximum limitation of the total amount of food with its variety, limiting the consumption of food rich in stone-forming substances, drinking fluid in an amount that allows you to maintain the daily amount of urine from 1.5 to 2.5 liters. Part of the liquid can be taken in the form of cranberry or lingonberry fruit drinks, or mineral water.
Before appointment preventive treatment it is necessary to conduct an examination to determine the functional state of the kidneys, liver, serum concentration and renal daily excretion of stone-forming substances and the microbiological state of the urinary system. Monitoring the effectiveness of treatment in the first year of observation is carried out once every 3 months and consists of performing an ultrasound of the kidneys, biochemical analysis blood and urine for the functional state of the kidneys and the state of metabolism of stone-forming substances. In the presence of an infectious-inflammatory process in the urinary system, a microbiological analysis of urine is performed once every 3 months to determine the sensitivity of the microflora to antibacterial drugs. Subsequently, comprehensive monitoring is carried out once every 6 months.
When choosing a drug for a patient with ICD, the doctor must answer the following questions:
1. Does the patient have any concomitant diseases that may affect the choice of ICD medications? 2. What is it like functional state kidneys, liver and other organs, which may influence the choice of therapy? 3. What is the possible impact of medications prescribed to the patient on the course of ICD? 4. What is the price/effectiveness status for the selected drug?
During the treatment process, it is also necessary to check once every 3 months in the 1st year of observation, and subsequently once every six months:
If the patient refuses the prescribed treatment, the reason is determined.
Drug therapy for urolithiasis is aimed at preventing stone recurrence; prevention of stone recurrence and growth; treatment (litholysis).
Drug therapy (treatment) is prescribed for the following conditions: after open surgery; after DLT; after nephrolitholapaxy; after instrumental stone removal; after spontaneous passage of a stone; with the “accidental” discovery of a kidney stone.
Pharmacotherapy aimed at correcting metabolic disorders is prescribed according to indications based on examination data of the patient. The number of treatment courses during the year is determined individually, under medical and laboratory supervision.
Drugs that are used for all forms of KSD include: angioprotectors, antiplatelet agents, anti-inflammatory, antibacterial, antiazotemic, diuretics, stone expellants and herbal preparations, analgesics, antispasmodics.
Conditions for drug correction of metabolic disorders may be as follows.
The duration of the course of treatment can be set individually, according to the indications.
If a biochemical examination of the patient reveals a triad of signs: hypercalcemia, hypophosphatemia and hypercalciuria, then an endocrinological examination for hyperparathyroidism is indicated. In the absence of the specified complex of metabolic disorders, if there is a bilateral form of urolithiasis or rapidly recurrent stone formation (within several months), the patient is also advised to determine the serum concentration of ionized calcium, conduct a Howard test and examine the parathyroid glands using ultrasound. At positive test Howard and the detection of hyperplasia of the parathyroid glands is carried out surgical treatment for the purpose of their detection and removal. In case of an infectious-inflammatory process in the urinary system, antibacterial treatment is prescribed after determining the results of urine culture, antibiogram, and endogenous creatinine clearance. Herbal medicine is indicated for infectious and inflammatory processes in the urinary system in patients with urolithiasis during and after treatment with antibacterial chemotherapy and in the absence of microflora sensitivity to them. During herbal medicine, herbs that have a diuretic and anti-inflammatory effect are used: the duration of the course of treatment is from 1 to 3 months, it is determined individually (the effectiveness of treatment is 60 - 70%). Efficiency criterion: increase in urine volume, decrease in leukocyturia.
To correct disorders of purine metabolism and urate stones, the following groups of drugs are used: xanthine oxidase inhibitors - 1 month (efficacy 92%); uricuretics - 1 - 3 months; citrate mixtures - 1 - 6 months. Daily fluid intake for this form of urolithiasis is desirable in an amount of at least 2 - 2.5 liters. Diet therapy consists of limiting the intake of fried and smoked meat, meat broths, offal, legumes, coffee, chocolate, alcohol, and excluding spicy foods. Criterion for treatment effectiveness: reduction or normalization of serum concentration and/or daily renal excretion of uric acid.
For hyperuricuria, xanthine oxidase inhibitors are used - 1 course of treatment for a month (80% effective) or uricuretics + citrate mixtures: 1 course of treatment - from 1 to 3 months (90% effective). Efficiency criterion: decrease in serum uric acid concentration, increase in urine pH to the range of 6.2 - 6.8 (urine alkalinization). When using citrate mixtures, 1 course of treatment is prescribed lasting from 1 to 3 months (efficacy 96%). Effectiveness criterion: increasing urine pH to the range of 6.2-6.8 (urine alkalinization).
If urine pH is below 5.8, crystalluria of uric acid or urate, citrate mixtures are prescribed under the control of a general urinalysis: the duration of the course (1 - 6 months) is set individually (100% effective). Efficiency criterion: increasing urine pH to 6.2 - 6.8 (urine alkalinization). For the purpose of litholysis of uric acid kidney stones, citrate mixtures are prescribed for 1 - 3 - 6 months (efficiency 83 - 99%), or uriuretics in combination with citrate mixtures for 1 - 3 months (efficiency 83 - 99%). Efficiency criterion: partial or complete litholysis.
To correct disorders of oxalic acid metabolism and calcium oxalate stones, the following groups of drugs are used: B vitamins, thiazides, diphosphonates, magnesium oxide, citrate mixtures. Daily fluid intake is at least 2 - 2.5 liters. The diet includes limiting the consumption of milk, cheese, chocolate, sorrel, lettuce, black currants, strawberries, strong tea, and cocoa. For hyperoxaluria and oxalate crystalluria, vitamin B6 is prescribed 0.02 g 3 times a day orally for a month (efficacy 86%); magnesium oxide 0.3 g 3 times a day for a month (efficacy 82%). Efficacy criterion: reduction or normalization of daily renal excretion of oxalates.
For hypercalciuria, thiazides are prescribed, the course of treatment is 1 month (100% effective), or diphosphonates (Xidifon), the course of treatment is 1 month (60% effective). Efficiency criterion: reduction or normalization of daily excretion of total calcium, reduction in the degree of oxalate crystalluria.
To correct metabolic disorders caused by calcium phosphate stones, the following groups of mandatory medications are used: diphosphonates, diuretics, antiazotemic, anti-inflammatory, stone-expelling drugs and herbal preparations, acid balance correction agents.
The daily fluid intake for calcium phosphate urolithiasis should be at least 2 - 2.5 liters. The diet includes limiting the consumption of milk, cheese, and fish products. If there is hypercalciuria, diphosphonates are used, the course of treatment is 1 month (efficacy 45 - 50%). Efficiency criterion: reduction in the degree of phosphate crystalluria. For phosphate crystalluria, diuretics and anti-inflammatory drugs, as well as herbal preparations, are effective; the course of treatment is 1 - 3 months (efficacy - 40 - 45%). Efficiency criterion: reduction in the degree of phosphate crystalluria.
In order to correct metabolic disorders due to cystine stones, the daily fluid intake should be at least 3 liters. Citrate mixtures are used, the course of treatment is 1 - 6 months (efficacy - 60%). The criterion for effectiveness is a decrease in cystine crystalluria.
Sanatorium-resort treatment is indicated for urolithiasis both during the absence of a stone (after its removal or spontaneous passage) and in the presence of a stone. It is permissible in the presence of small kidney stones, if their size and shape, as well as the condition of the upper urinary tract, allow us to hope for their spontaneous passage under the influence of the diuretic effect of mineral waters.
For patients with uric acid and calcium oxalate urolithiasis with an acidic urine reaction, treatment with mineral waters is indicated at the resorts: Zheleznovodsk (Slavyanovskaya, Smirnovskaya), Essentuki (No. 4, 17), Pyatigorsk, etc. with low-mineralized alkaline mineral waters. For calcium oxalate urolithiasis, treatment at the Truskavets (Naftusya) resort is also indicated, where the mineral water is slightly acidic and low-mineralized. For calcium phosphate urolithiasis, caused by a violation of phosphorus-calcium metabolism and, as a rule, an alkaline reaction of urine, resorts are indicated: Pyatigorsk, Kislovodsk, Truskavets, etc., where the mineral water is slightly acidic in nature. For cystine stones, the following resorts are recommended: Zheleznovodsk, Essentuki, Pyatigorsk. Treatment at the above resorts is possible at any time of the year. Drinking similar bottled mineral waters does not replace a stay at the resort. For therapeutic and prophylactic purposes, these waters can be drunk no more than 0.5 liters per day, under strict laboratory control of the metabolism of stone-forming substances.
Contraindications to sanatorium-resort treatment are: acute inflammatory diseases of the genitourinary system (pyelonephritis, cystitis, prostatitis, epididymitis, etc.); chronic diseases kidneys with pronounced renal failure; urolithiasis in the presence of stones that require surgical removal; hydronephrosis; pyonephrosis; tuberculosis of the genitourinary system and any systems and organs; macrohematuria of any origin; diseases manifested by difficulty urinating ( benign hyperplasia prostate, urethral stricture).
If there is concomitant pyelonephritis, it must be treated. It should be noted that only when removing a stone from the kidney and upper urinary tract in one way or another is it created necessary conditions for complete elimination of urinary infection. For this purpose, antibacterial therapy is prescribed, which is advisable to carry out according to the results of urine cultures for flora, the degree of bacteriuria and sensitivity to antibacterial drugs against the background of drugs that improve microcirculation (pentoxifylline), antiplatelet agents (chimes, persantine), calcium antagonists (verapamil, etc.).
Thus, no method of treating urolithiasis can be considered in isolation from others, and the treatment of such patients should only be comprehensive. After stone removal, patients require clinical observation and consultation with a urologist for 5 years, since this factor significantly affects the long-term results of treatment. At the same time, they are prescribed conservative therapy aimed at eliminating the infection and correcting metabolic disorders based on the data laboratory research which should be carried out at least once every 6 months. Timely referral of the patient for consultation to a clinic specializing in the treatment of patients with urolithiasis will avoid running forms ICD and obtain the missing information about further treatment tactics.
N. K. Dzeranov, doctor medical sciences Research Institute of Urology, Ministry of Health of the Russian Federation, Moscow
Percutaneous nephrolitholapaxy (PCNL) will always occupy its niche in the treatment of urolithiasis. With the constant development of optics and stone fragmentation techniques, PCNL remains an effective method with the least difficulties in its use. According to many years of experience, the indications for PCNL are the following: contraindications or ineffectiveness of ELT, coral stones, large or small in size and weight, cystitis stones, abnormal kidneys or features of the patient’s anatomy, transplanted kidney.
PCNL is the most effective method of intervention. Cystine stones are hard and soft. Soft stones are more resistant to shock wave therapy. It was assumed that in the presence of cystine staghorn stones, it would be sufficient to fragment the stones and treat with medication. However, this treatment is ineffective against recurrent stones. For optimal results, these patients should undergo PCNL.
(Segura J.V. Percutaneous treatment of nephrolithiasis // Digital Urology Journal).
