Urolithiasis( urolithiasis) - Causes, symptoms and treatment. MF.

Urolithiasis( urolithiasis) is a metabolic disease caused by various causes, often of a hereditary nature, characterized by the formation of stones in the urinary system( kidneys, ureters, bladder or urethra).Stones can form at any level of the urinary tract, beginning from the renal parenchyma, in the ureters, in the bladder and ending with the urethra.

The disease can be asymptomatic, manifested by pain of varying intensity in the lumbar region or renal colic.

The history of the names of urinary stones is very fascinating. For example, struvite( or tripillyl phosphate), named after the Russian diplomat and naturalist G. von Struve( 1772-1851).Earlier, these stones were called guanitas, because they were often found in bats.

Calcium oxalate dihydrate( oxalate) stones are often called wadelites, becauseThe same stones are found in samples of rock taken from the bottom of the Weddell Sea in Antarctica.

Prevalence of urolithiasis

Urolithiasis is widespread, and in many countries of the world there has been a trend towards increased morbidity.

In the CIS countries, there are areas where this disease occurs especially often:

• Ural;
• Volga region;
• Pools of the Don and Kama;
• Transcaucasia.

Among foreign regions is more common in such areas as:

• Asia Minor;
• Northern Australia;
• North-East Africa;
• Southern areas of North America.

In Europe, urolithiasis is widespread in:

• Scandinavian countries;
• of England;
• the Netherlands;
• Southeast France;
• South of Spain;
• Italy;
• Southern regions of Germany and Austria;
• of Hungary;
• Throughout Southeast Europe.

In many countries of the world, including Russia, urolithiasis is diagnosed in 32-40% of cases of all urological diseases, and takes the second place after infectious and inflammatory diseases.

Urolithiasis is diagnosed at any age, most often in the able-bodied( 20-55 years).In childhood and senile age - the cases of primary detection are very rare. Men are sick 3 times more often than women, but coral stones are most often found in women( up to 70%).In most cases, stones form in one of the kidneys, but in 9-17% of cases, urolithiasis is bilateral.

Kidney stones are single and multiple( up to 5000 stones).The size of the stones varies from 1 mm, to giant ones - over 10 cm and weighing up to 1000 g.

Causes of urolithiasis

There is currently no single theory of the causes of urolithiasis. Urolithiasis is a multifactorial disease, it has complex multiple mechanisms of development and various chemical forms.

The main mechanism of the disease is considered to be congenital - a slight metabolic disorder, which leads to the formation of insoluble salts that form in the stones. The chemical structure distinguishes between different stones - urate, phosphate, oxalate, etc. However, even if there is an inherent predisposition to urolithiasis, it will not develop if there are no predisposing factors.

The following metabolic disorders are the basis of urinary stone formation:

• hyperuricemia( increased uric acid level in the blood);
• hyperuricuria( increased uric acid level in urine);
• hyperoxaluria( increase in the level of oxalate salts in urine);
• hypercalciuria( increased level of calcium salts in urine);
• hyperphosphaturia( increase in the level of phosphate salts in urine);
• change in the acidity of urine.

In the emergence of these metabolic shifts, some authors prefer the effects of the external environment( exogenous factors), others - endogenous reasons, although their interaction is often observed.

Exogenous causes of urolithiasis:

• climate;
• geological structure of the soil;
• chemical composition of water and flora;
• food and drinking regimen;
• conditions of life( monotonous, sedentary lifestyle and recreation);
• working conditions( harmful production, hot shops, heavy physical labor, etc.).

Food and drinking regimes of the population - the total calorie content of food, the abuse of animal protein, salt, products containing large amounts of calcium, oxalic and ascorbic acid, a deficiency in the body of vitamins A and B - play a significant role in the development of the ICD.

Endogenous causes of urolithiasis:

• of the infection of both the urinary tract and the outside of the urinary system( angina, furunculosis, osteomyelitis, salpingo-oophoritis);
• metabolic diseases( gout, hyperparathyroidism);
• deficiency, absence or hyperactivity of a number of enzymes;
• severe injuries or diseases associated with prolonged immobilization of the patient;
• diseases of the digestive tract, liver and biliary tract;
• is a hereditary predisposition to urolithiasis.

A certain role in the genesis of urolithiasis is played by such factors as sex and age: men are sick 3 times more often than women.

Along with common causes of endogenous and exogenous nature in the formation of urinary stones, local changes in the urinary tract( developmental anomalies, additional vessels, constrictions, etc.), which cause a disruption of their function, are also irreversible.

Symptoms of urolithiasis

The most typical symptoms of urolithiasis are:

• pain in the lumbar region of - may be permanent or intermittent, blunt or acute. The intensity, localization and irradiation of pain depend on the location and size of the stone, the degree and severity of the obstruction, as well as the individual structural features of the urinary tract.

Large pelvic stones and coral stones of the kidney are inactive and cause dull pain, more often permanent, in the lumbar region. For urolithiasis is characterized by the relationship of pain with movement, shaking, riding, heavy physical exertion.

For small stones, the most common are attacks of renal colic, which is associated with their migration and a sharp violation of the outflow of urine from the calyx or pelvis. Pain in the lumbar region is often irradiated along the ureter, into the ileum. When the stones move to the lower third of the ureter, irradiation of the pain changes, they begin to spread lower into the groin, the testicle, the glans penis in men and the labia in women. There are imperative urge to urinate, frequent urination, dysuria.

• renal colic - paroxysmal pain caused by a stone, occurs suddenly after driving, shaking, abundant fluid intake, alcohol. Patients constantly change position, do not find their place, often groan and even cry. This characteristic behavior of the patient often makes it possible to establish the diagnosis "at a distance".Pain lasts for several hours and even days, occasionally abating. The cause of renal colic is a sudden disturbance of the outflow of urine from the calyx or pelvis, caused by occlusion( upper urinary tract) by a stone. Quite often, an attack of renal colic can be accompanied by chills, fever, leukocytosis.
• nausea, vomiting, bloating, tension of abdominal muscles, hematuria, pyuria, dysuria - symptoms often associated with renal colic.
• self-standing stone
• extremely rare - obstructive anuria ( with a single kidney and bilateral stones of the ureter)

In children none of these symptoms are typical of urolithiasis.

Stones of the renal calyx

Stones of kidney calyces may be the cause of obstruction and renal colic.

In small stones, pain usually occurs intermittently at the time of transient obstruction. The pain is dull, of varying intensity and is felt deep in the lower back. It can intensify after a lot of drinking. In addition to obstruction, the cause of pain may be inflammation of the renal calyx in case of infection or accumulation of the smallest crystals of calcium salts.

The stones of the renal calyces are usually plural, but small, so they should spontaneously leave. If the stone lingers in the renal calyx despite the current of urine, the probability of obstruction is very high.

Pain caused by small stones of the kidney cups, usually disappears after distant lithotripsy. Stones of the renal pelvis

Stones of the renal pelvis with a diameter of more than 10 mm.usually cause obstruction of the ureteropelvic segment. This causes severe pain in the costal-vertebral corner below the XII rib. By nature, the pain is different from blunt to painfully acute, its intensity, as a rule, is constant. Pain often radiates into the lateral parts of the abdomen and hypochondrium. It is often associated with nausea and vomiting.

Coralloid stone occupying the whole renal pelvis or part of it, does not always cause obstruction of the urinary tract. Clinical manifestations are often meager. Only pain in the lower back is possible. In this regard, coral stones are a finding in the survey for a recurrent urinary tract infection. In the absence of treatment, they can lead to serious complications.

Stones of upper and middle ureter

Stones of the upper or middle third of the ureter often cause severe acute pain in the lower back.

If the stone moves along the ureter, causing the obstruction, causing the pain, the pain is unstable, but more intense.

If the stone is motionless, the pain is less intense, especially with partial obstruction. With motionless stones that cause severe obstruction, compensatory mechanisms are activated that reduce pressure on the kidney, thereby reducing the pain syndrome.

With the stone of the upper third of the ureter, pain radiates to the lateral abdomen, with the middle third stone in the iliac region, in the direction from the lower edge of the ribs to the inguinal ligament.

Lower ureter stones

Pain in the stone of the lower third of the ureter often radiates to the scrotum or vulva. The clinical picture may resemble a testicular torsion or acute epididymitis.

A stone located in the intramural part of the ureter( at the level of the entrance to the bladder), according to clinical manifestations, resembles acute cystitis, acute urethritis or acute prostatitis, since it can have pain in the suprapubic region, rapid, painful and difficult urination, imperative urges, macrogemuria,and men have pain in the area of ​​the external opening of the urethra.

Bladder stones

Stones of the bladder, mainly manifested by pain in the lower abdomen and the suprapubic region, which can give to the perineum, the genitals. Pain appears during movement and when urinating.

Another manifestation of bladder stones is frequent urination. Sharp causeless desires appear during walking, shaking, physical activity. During the urination, the so-called "pawning" symptom can be noted - suddenly the urine stream is interrupted, although the patient feels that the bladder is not completely emptied, and urination resumes only after a change in the position of the body.

In severe cases, with very large stone sizes, patients can only urinate lying down.

Symptoms of kidney stone disease

Manifestations of urolithiasis may resemble symptoms of other diseases of the abdominal cavity and retroperitoneal space. That is why the doctor-urologist first of all needs to exclude such manifestations of an acute abdomen as acute appendicitis, uterine and ectopic pregnancy, cholelithiasis, peptic ulcer, etc., which must sometimes be done together with physicians of other specialties. Based on this, the diagnosis of IBD can be both difficult and time-consuming, and includes the following procedures:

1. Examination by the urologist-physician , elucidating a detailed medical history with a view to maximizing the understanding of the etiopathogenesis of the disease and correcting metabolic and other disorders for the prevention of the disease andmetaphylaxis of relapses. Important points of this phase are: clarification:

• kind of activities;
• the time of onset and the nature of the course of urolithiasis;
• previous treatment;
• family history;
• -style food;
• presence in the history of Crohn's disease, intestinal surgery or metabolic disorders;
• drug history;
• presence of sarcoidosis;
• presence and nature of urinary tract infection;
• presence of abnormalities of the genitourinary organs and operations on the urinary tract;
• presence in the anamnesis of traumas and immobilization.

2. Visualization of the calculus :

• ultrasound of the kidneys, upper and lower urinary tract;
• performance of review and excretory urography or spiral computed tomography.

3. Clinical analysis of blood, urine, urine pH.Biochemical examination of blood and urine.
4. Sowing of urine on the microflora and determining its sensitivity to antibiotics.
5. If necessary, exercise tests with calcium ( differential diagnosis of hypercalciuria) and ammonium chloride( diagnosis of renal-tubular acidosis), study of parathyroid hormone.
6. Stone analysis ( if available).
7. Biochemical and radioisotope research of kidney function .
8. Retrograding ureteropyelography, ureteropyeloscopy, pneumopyelography .
9. Study of the tomographic density of stones ( used to predict the effectiveness of lithotripsy and prevent possible complications).

Treatment of urolithiasis

How to get rid of stones

Due to the fact that the causes of urolithiasis are not clear until the end, removing the stone from the kidney by surgery does not mean the patient's recovery.

Treatment of patients with urolithiasis can be both conservative and operative.

General principles of treatment of urolithiasis include 2 main directions: destruction and / or elimination of the calculus and correction of metabolic disorders. Additional methods of treatment include: improvement of microcirculation in the kidneys, adequate drinking regimen, sanitation of the urinary tract from existing infection and residual stones, diet therapy, physiotherapy and sanatorium treatment.

After determination of the diagnosis, determination of the size of the calculus, its location, assessment of the state of urinary tract patency and kidney function, as well as taking into account the concomitant diseases and previous treatment, it is possible to proceed with the selection of the optimal method of treatment to remove the patient from the existing stone.

Methods of elimination of the calculus:

1. various conservative methods of treatment, contributing to the removal of the stone with small concretions;
2. symptomatic treatment, which is most often used in renal colic;
3. operative removal of a stone or removal of a kidney with a stone;
4. drug litholysis;
5. "local" litholysis;
6. instrumental removal of stones that have descended into the ureter;
7. percutaneous removal of kidney stones by extraction( litholapoxy) or contact lithotripsy;
8. ureterolitolapoxy, contact ureterolithotripsy;
9. remote lithotripsy( DLT);

All of the above methods of treatment of urolithiasis are not competitive and do not exclude each other, and in some cases are complementary. However, it can be said that the development and implementation of remote lithotripsy( DLT), the creation of high-endoscopic techniques and equipment were revolutionary events in urology at the end of the twentieth century. It was thanks to these epoch-making events that the beginning of a low-invasive and low-traumatic urology was initiated, which today with great success develops in all fields of medicine and reached its epoch, connected with the creation and wide introduction of robotics and telecommunication systems.

The newly developed minimally invasive and low-traumatic methods of treatment of urolithiasis radically changed the mentality of a whole generation of urologists, the distinctive feature of today's essence is that regardless of the size and location of the stone, as well as its "behavior", the patient should and can be rid of it! And this is correct, because even small, asymptomatically located in the calyx stones should be eliminated, since there is always a risk of their growth and development of chronic pyelonephritis.

At present, remote lithotripsy( DLT), percutaneous nephrolithotripsy( LAP), ureterorenoscopy( URS) is most widely used to treat urolithiasis, due to which the number of open operations is minimized, and in most clinics in Western Europe - to zero.

Diet for urolithiasis

The diet of patients with urolithiasis requires:

• consumption of at least 2 liters of fluid per day;
• , depending on the revealed metabolic disturbances and the chemical composition of the stone, it is recommended that the intake of animal protein, table salt, products containing calcium in large amounts, purine bases, oxalic acid be recommended;
• a positive effect on the state of metabolism is the consumption of foods rich in fiber.

Physiotherapy for urolithiasis

The complex conservative treatment of patients with urolithiasis includes the appointment of various physiotherapy methods:

• sinusoidal modulated currents;
• dynamic amplipulse therapy;
• ultrasound;
• laser therapy;
• inductothermy.

In the case of physiotherapy in patients with urolithiasis complicated by a urinary tract infection, it is necessary to take into account the phases of the inflammatory process( shown during latent flow and remission).

Sanatorium treatment for urolithiasis

Sanatorium treatment is indicated for urolithiasis both during the absence of a stone( after its removal or self-separation), and in the presence of a calculus. It is effective in kidney stones, the size and shape of which, as well as the state of the urinary tract allow one to hope for their independent withdrawal under the influence of the diuretic action of mineral waters.

Patients with uric acid and calcium oxalate urolithiasis are treated at resorts with poorly mineralized alkaline mineral waters:

• Zheleznovodsk( "Slavyanovskaya", "Smirnovskaya");
• Essentuki( Yessentuki No. 4, 17);
• Pyatigorsk, Kislovodsk( Narzan).

With calcium oxalate urolithiasis, treatment at the resort of Truskavets( Naftusya), where mineral water is weakly acidic and slightly mineralized, can also be indicated.

Treatment at the resorts is possible at any time of the year. The use of similar bottled mineral waters does not replace the stay at the resort.

Admission of the above-mentioned mineral waters, as well as mineral water "Tib-2"( North Ossetia) with a therapeutic and prophylactic purpose is possible in an amount of no more than 0.5 l / day under strict laboratory control of stone-forming substance exchange rates.

Treatment of urinary stones

In the medical treatment of urolithiasis, the doctor sets the following goals:

• prevention of stone recurrence;
• prevention of growth of the stone itself( if it already exists);
• dissolution of stones( litholysis).

In case of urolithiasis, it is possible to perform stepwise treatment: in case of ineffectiveness of dietary therapy, it is necessary to prescribe medications in addition.

One course of treatment, as a rule, is 1 month. Depending on the results of the examination, treatment can be resumed.

The following medicines are used in the treatment of uric acid stones:

1. Allopurinol( Allupol, Purinol) - up to 1 month;
2. Blomaren - 1-3 months.

Treatment of calcium oxalate stones

In the medical treatment of urolithiasis, the doctor sets the following goals:

• prevention of stone recurrence;
• prevention of growth of the stone itself( if it already exists);
• dissolution of stones( litholysis).

In case of urolithiasis, it is possible to take step-by-step treatment: in case of ineffectiveness of diet therapy, it is necessary to additionally prescribe medications.

One course of treatment, as a rule, is 1 month. Depending on the results of the examination, treatment can be resumed.

In the treatment of calcium oxalate stones, the following medicines are used:

1. Pyridoxine( vitamin B6) - up to 1 month;
2. Magnesium oxide or asparaginate - up to 1 month;
3. Hypothiazide - up to 1 month;
4. Blamaren - up to 1 month.

Treatment of calcium phosphate stones

In the medical treatment of urolithiasis, the doctor sets the following goals:

• prevention of stone recurrence;
• prevention of growth of the stone itself( if it already exists);
• dissolution of stones( litholysis).

In case of urolithiasis, it is possible to take step-by-step treatment: in case of ineffectiveness of diet therapy, it is necessary to additionally prescribe medications.

One course of treatment, as a rule, is 1 month. Depending on the results of the examination, treatment can be resumed.

In the treatment of calcium phosphate stones, the following medicines are used:

1. Antibacterial treatment - in the presence of infection;
2. Magnesium oxide or asparaginate - up to 1 month;
3. Hypothiazide - up to 1 month;
4. Phytomedication( plant extracts) - up to 1 month;
5. Boric acid - up to 1 month;
6. Methionine - up to 1 month.

Treatment of cystine stones

In the medical treatment of urolithiasis, the doctor sets the following goals:

• prevention of stone recurrence;
• prevention of growth of the stone itself( if it already exists);
• dissolution of stones( litholysis).

With urolithic disease, it is possible to take step-by-step treatment: in case of ineffectiveness of dietary therapy, it is necessary to additionally prescribe medications.

One course of treatment, as a rule, is 1 month. Depending on the results of the examination, treatment can be resumed.

In the treatment of cystine stones, the following medicines are used:

1. Ascorbic acid( vitamin C) - up to 6 months;
2. Penicillamine - up to 6 months;
3. Blamaren - up to 6 months.

Complications of urolithiasis

Prolonged standing of the stone without a tendency to self-exclusion leads to progressive suppression of the function of the urinary tract and the kidney itself, down to its( kidney) death.

The most frequent complications of urolithiasis are:

• Chronic inflammatory process at the location of the stone and the kidney itself( pyelonephritis, cystitis), which, under adverse conditions( hypothermia, acute respiratory disease), can become acute( acute pyelonephritis, acute cystitis).
• In turn, acute pyelonephritis can be complicated by parainesis, the formation of pustular abscesses( apostematous pyelonephritis), carbuncle or kidney abscess, necrosis of the renal papillae and eventually to sepsis( fever), which is an indication for surgery.
• Pionephrosis - is the terminal stage of purulent-destructive pyelonephritis. Pinephrotic kidney is an organ that has undergone purulent fusion, consisting of separate cavities filled with pus, urine and tissue degradation products.
• Chronic pyelonephritis leads to rapidly progressive chronic renal failure and, ultimately, to nephrosclerosis.
• Acute renal failure is extremely rare due to obstructive anuria with a single kidney or bilateral stones of the ureter.
• Anemia due to chronic hemorrhage( hematuria) and impaired hematopoietic function of the kidneys.

Prevention of urolithiasis

Prophylactic therapy aimed at correction of metabolic disorders is prescribed by indications on the basis of the patient's examination data. The number of courses of treatment during the year is set individually under medical and laboratory supervision.

Without prevention for 5 years in half of patients who have got rid of stones by one of the ways of treatment, urinary stones are formed again. Training of the patient and the actual prevention is best started immediately after spontaneous retreatment or surgical removal of the stone.

Lifestyle:

• fitness and sports( especially for occupations with low physical activity), however excessive exercises should be avoided in untrained people
• avoid drinking alcohol
• avoid emotional stress
• urolithiasis is often found in obese patients. Weight reduction by reducing the consumption of high-calorie foods reduces the risk of the disease.

Increased fluid intake:

• All patients have urolithiasis. Patients with a urine density of less than 1.015 g / l.stones are formed much less often. Active diuresis promotes the removal of small fragments and sand. Optimal diuresis is considered in the presence of 1.5 liters.urine per day, but in patients with urolithiasis it should be more than 2 liters per day.

Calcium consumption.

• Indications: Calcium oxalate stones.
• Higher calcium intake reduces oxalate excretion.

Eating fiber.

• Indications: Calcium oxalate stones.
• You should eat vegetables, fruits, avoiding those that are rich in oxalate.

Oxalate retention.

• A low level of calcium with food increases the absorption of oxalate. When the calcium level with food increased to 15-20 mmol per day, the urinary oxalate level decreased. Ascorbic acid and vitamin D can contribute to increasing the excretion of oxalate.
• Indications: hyperoxaluria( urinary oxalate concentration in urine more than 0.45 mmol / day).
• Decreased oxalate use may be beneficial in patients with hyperoxaluria, but in these patients, the delay of oxalate should be combined with other treatments.
• Restriction of the use of foods rich in oxalates, with calcium oxalate stones.

Products rich in oxalates:

• Rhubarb 530 mg / 100 g;
• Sorrel, spinach 570 mg / 100 g;
• Cocoa 625 mg / 100 g;
• Tea leaves 375-1450 mg / 100 g;
• Nuts.

Vitamin C:

• Vitamin C up to 4 grams per day can occur without the risk of calcification. Higher doses contribute to the endogenous metabolism of ascorbic acid into oxalic acid. This increases the excretion of oxalic acid by the kidneys.

Decreased protein intake:

• Animal protein is considered one of the important risk factors for stone formation. Excessive use can increase the excretion of calcium and oxalate and reduce the excretion of citrate and urine pH.
• Indications: Calcium oxalate stones.
• It is recommended to take approximately 1 g / kg.of protein in a day.

Thiazides:

• Indications for the appointment of thiazides is hypercalciuria.
• Drugs: hypothiazide, trichlorothiazide, indopamide.
• Side effects:

1. mask normocalcemic hyperparathyroidism;
2. development of diabetes and gout;
3. erectile dysfunction.

Orthophosphates:

• There are two types of orthophosphates: acid and neutral. They reduce the absorption of calcium and calcium excretion as well as reduce bone reabsorption [64].In addition, they increase the excretion of pyrophosphate and citrate, which increases the inhibitory activity of urine. Indication: hypercalciuria.
• Complications:

1. diarrhea;
2. spasms in the abdomen;
3. nausea and vomiting.

• Orthophosphates can be an alternative to thiazides. Used for treatment in individual cases, but can not be recommended as a first line remedy. They can not be prescribed for stones associated with a urinary tract infection.

Alkaline citrate:

• Mechanism of action:

1. reduces supersaturation of calcium oxalate and calcium phosphate;
2. inhibits the process of crystallization, growth and aggregation of the stone;
3. reduces the supersaturation of uric acid.

• Indications: calcium stones, hypocitrusturia.

Magnesium:

• Indications: Calcium oxalate stones with or without hypomagnesium.
• Side effects:

1. diarrhea;
2. disorders of the central nervous system;
3. fatigue;
4. drowsiness;

• Do not use magnesium salts without using citrate.

Glycosaminoglycans:

• Mechanism of action - inhibitors of the growth of calcium crystals of oxalate.
• Indications: Calcium oxalate stones.