Urolithiasis is a common urological disease manifested by the formation of stones in various parts of the urinary system, most often in the kidneys and bladder. There is often a tendency to severe recurrent course of urolithiasis. Urolithiasis is diagnosed according to clinical symptoms, the results of X-ray examination, CT, ultrasound of the kidneys and bladder. The fundamental principles of the treatment of urolithiasis are: conservative stone-dissolving therapy with citrate mixtures, and if it is not effective, remote lithotripsy or surgical removal of concretions.
ICD 10
N20-N23 Urolithiasis
Meaning
Urolithiasis is a common urological disease manifested by the formation of stones in various parts of the urinary system, most often in the kidneys and bladder. There is often a tendency to severe recurrent course. Disease can occur at any age, but it most often affects people 25-50 years old.
Children and elderly patients are more likely to form bladder stones, while middle-aged and young people mainly suffer from kidney and ureter stones. There is an increase in the frequency of urolithiasis, which is believed to be associated with an increase in the influence of adverse environmental factors.
Causes
Currently, the causes and mechanism of the development of urolithiasis have not yet been fully studied. Modern urology has many theories explaining the individual stages of the formation of stones, but it is not yet possible to combine these theories and fill in the missing gaps in a single picture of the development of urolithiasis. There are three groups of predisposing factors that increase the risk of developing urolithiasis.
- External factors. The probability of developing urolithiasis increases if a person leads a sedentary lifestyle, leading to a violation of phosphorus-calcium metabolism. The occurrence of urolithiasis can be triggered by dietary characteristics (excess protein, acidic and spicy food that increases the acidity of urine), water properties (water with a high content of calcium salts), lack of B vitamins and vitamin A, harmful working conditions, taking a number of drugs (large amounts of ascorbic acid, sulfonamides).
- Local internal factors. Urolithiasis occurs more often in the presence of abnormalities of the urinary system (single kidney, narrowing of the urinary tract, horseshoe kidney), inflammatory diseases of the urinary tract.
- Common internal factors. The risk of urolithiasis increases with chronic gastrointestinal diseases, prolonged immobility due to illness or injury, dehydration with poisoning and infectious diseases, metabolic disorders due to a deficiency of certain enzymes.
Men are more likely to suffer from urolithiasis, but women are more likely to develop severe forms of urolithiasis with the formation of staghorn calculus that can occupy the entire kidney cavity.
Pathogenesis
So far, researchers are only studying various groups of factors, their interaction and role in the occurrence of urolithiasis. It is assumed that there are a number of permanent predisposing factors. At a certain point, an additional factor joins the constant factors, which becomes an impetus for the formation of stones and the development of urolithiasis. Having affected the patient’s body, this factor may subsequently disappear.
Urinary infection aggravates the course of urolithiasis and is one of the most important additional factors stimulating the development and recurrence of urolithiasis, since a number of infectious agents in the process of vital activity affect the composition of urine, promotes its alkalinization, crystal formation and stone formation.
Classification
Stones of the same type are formed in about half of patients with urolithiasis. In this case, in 70-80% of cases, stones are formed consisting of inorganic calcium compounds (carbonates, phosphates, oxalates). 5-10% of stones contain magnesium salts. About 15% of stones in urolithiasis are formed by uric acid derivatives. Protein stones are formed in 0.4-0.6% of cases (when the metabolism of certain amino acids in the body is disrupted). In other patients with urolithiasis, polymineral stones are formed.
Symptoms of urolithiasis
The disease proceeds in different ways. In some patients, urolithiasis remains a single unpleasant episode, in others it takes on a recurrent character and consists of a number of exacerbations, in others there is a tendency to a prolonged chronic course of urolithiasis.
Concretions in urolithiasis can be localized in both the right and left kidney. Bilateral stones are observed in 15-30% of patients. The clinic of urolithiasis is determined by the presence or absence of urodynamic disorders, changes in renal functions and an associated infectious process in the urinary tract.
With urolithiasis, pain appears, which can be acute or dull, intermittent or permanent. The localization of pain depends on the location and size of the stone. Hematuria develops, pyuria (with the addition of infection), anuria (with obturation). If there is no obstruction of the urinary tract, urolithiasis is sometimes asymptomatic (13% of patients). The first manifestation of urolithiasis is renal colic.
Renal colic
When the ureter is blocked by a stone, the pressure in the renal pelvis rises sharply. Stretching of the pelvis, in the wall of which there is a large number of pain receptors, causes severe pain. Stones less than 0.6 cm in size, as a rule, move away on their own. With narrowing of the urinary tract and large stones, the obstruction is not spontaneously eliminated and can cause damage and death of the kidney.
A patient with urolithiasis suddenly has severe pain in the lumbar region, regardless of the position of the body. If the stone is localized in the lower parts of the ureters, there are pains in the lower abdomen radiating into the groin area. Patients are restless, trying to find a body position in which the pain will be less intense. Possible frequent urination, nausea, vomiting, intestinal paresis, reflex anuria.
Physical examination reveals a positive symptom of Pasternatsky, soreness in the lumbar region and along the ureter. Microhematuria, leukocyturia, mild proteinuria, increased ESR, leukocytosis with a shift to the left are determined in the laboratory. If there is a simultaneous blockage of two ureters, a patient with urolithiasis develops acute renal failure.
Hematuria
In 92% of patients with urolithiasis after renal colic, microhematuria is noted, which occurs due to damage to the veins of the fornic plexuses and is detected during laboratory tests.
Staghorn calculus
In some patients with urolithiasis, large stones form, almost completely occupying the cup-pelvis system. This form of urolithiasis is called coralloid nephrolithiasis (CN). CN is prone to persistent recurrent course, causes gross violations of renal functions and often causes the development of renal failure.
Renal colic is unusual for coralloid nephrolithiasis. At first, the disease is almost asymptomatic. Patients may present nonspecific complaints (increased fatigue, weakness). There may be indistinct pain in the lumbar region. In the future, all patients develop pyelonephritis. Gradually, renal functions decrease, renal insufficiency progresses.
Complications
Urolithiasis is complicated by infectious diseases of the urinary system in 60-70% of patients. Often, a history of chronic pyelonephritis is noted, which occurred even before the onset of urolithiasis. Streptococcus, Staphylococcus, E. coli, vulgar proteus acts as an infectious agent in the development of complications of urolithiasis. Pyuria is characteristic.
Pyelonephritis, concomitant with urolithiasis, is acute or becomes chronic. Acute pyelonephritis with renal colic can develop at lightning speed. There is significant hyperthermia, intoxication. If there is no adequate treatment, bacterial shock is possible.
Diagnostics
The diagnosis of urolithiasis is based on anamnestic data (renal colic), urination disorders, characteristic pain, changes in urine (pyuria, hematuria), urinary stones, ultrasound, radiological and instrumental studies:
- Ultrasound. With the help of echography, any X-ray positive and X-ray negative stones are detected, regardless of their size and location. Ultrasound of the kidneys allows us to assess the effect of urolithiasis on the state of the calyx-pelvic system. Ultrasound of the bladder allows to identify stones in the underlying parts of the urinary system. Ultrasound is used after remote lithotripsy for dynamic monitoring of the course of litolytic therapy of urolithiasis with X-ray negative stones.
- X-ray diagnostics. Most of the stones are detected during a survey urography. It should be borne in mind that soft protein and uric acid stones are X-ray negative and do not give shadows on survey images. Computed tomography. CT is the main method of diagnosing urolithiasis. With its help, the exact localization, size and density of stones are determined.
Differential diagnosis
Modern techniques make it possible to identify any types of stones, therefore, it is usually not necessary to differentiate urolithiasis from other diseases. The need for differential diagnosis may arise in an acute condition – renal colic.
Usually, the diagnosis of renal colic does not cause difficulties. With atypical course and right-sided localization of a stone that causes obstruction of the urinary tract, sometimes it is necessary to carry out differential diagnosis of renal colic in urolithiasis with acute cholecystitis or acute appendicitis. The diagnosis is based on the characteristic localization of pain, the presence of dysuric phenomena and changes in urine, the absence of symptoms of irritation of the peritoneum.
Treatment of urolithiasis
General principles of therapy
Both surgical methods of treatment and conservative therapy are used. The treatment tactics are determined by the urologist depending on the age and general condition of the patient, the localization and size of the stone, the clinical course of urolithiasis, the presence of anatomical or physiological changes and the stage of renal failure.
As a rule, surgical treatment is necessary to remove stones with urolithiasis. The exception is stones formed by uric acid derivatives. Such stones can often be dissolved by conservative treatment of urolithiasis with citrate mixtures for 2-3 months. Stones of a different composition cannot be dissolved.
The removal of stones from the urinary tract or surgical removal of stones from the bladder or kidney does not exclude the possibility of recurrence of urolithiasis, therefore it is necessary to carry out preventive measures aimed at preventing relapses. Patients with urolithiasis are shown complex regulation of metabolic disorders, including care for maintaining water balance, diet therapy, herbal medicine, drug therapy, physical therapy, balneological and physiotherapy procedures, spa treatment.
Diet therapy
The choice of diet depends on the composition of the detected and removed stones. General principles of diet therapy for urolithiasis:
- A varied diet with a restriction of the total amount of food;
- Restriction in the diet of products containing a large amount of stone-forming substances;
- Intake of sufficient fluid (it is necessary to provide daily diuresis in the amount of 1.5-2.5 liters.).
With urolithiasis with calcium oxalate stones, it is necessary to reduce the use of strong tea, coffee, milk, chocolate, cottage cheese, cheese, citrus fruits, legumes, nuts, strawberries, black currants, lettuce, spinach and sorrel. With ICD with urate stones, it is necessary to limit the intake of protein foods, alcohol, coffee, chocolate, spicy and fatty dishes, exclude meat food and offal (liver sausages, pates) in the evening.
With phosphorus-calcium stones, milk, spicy dishes, spices, alkaline mineral waters are excluded, and the consumption of cheese, cheese, cottage cheese, green vegetables, berries, pumpkins, beans and potatoes is limited. Sour cream, kefir, red currant cranberries, sauerkraut, vegetable fats, flour products, lard, pears, green apples, grapes, meat products are recommended.
Stone formation in urolithiasis largely depends on the pH of urine (normally – 5.8-6.2). The intake of certain types of food changes the concentration of hydrogen ions in the urine, which allows you to independently regulate the pH of urine. Vegetable and dairy foods alkalize urine, and animal products acidify. It is possible to control the level of urine acidity with the help of special paper indicator strips, freely sold in pharmacies.
If there are no stones on the ultrasound (the presence of small crystals – microliths is allowed), “water strokes” can be used to wash the kidney cavity. The patient takes 0.5-1 liter of liquid on an empty stomach (slightly mineralized mineral water, tea with milk, decoction of dried fruits, fresh beer). In the absence of contraindications, the procedure is repeated every 7-10 days. If there are contraindications, “water strokes” can be replaced by taking a potassium-sparing diuretic or a decoction of diuretic herbs.
Phytotherapy
During the treatment of urolithiasis, a number of herbal medicines are used. Medicinal herbs are used to accelerate the discharge of sand and stone fragments after remote lithotripsy, as well as as a preventive measure to improve the state of the urinary system and normalize metabolic processes. Some herbal preparations contribute to an increase in the concentration of protective colloids in the urine, which prevent the crystallization of salts and help prevent the recurrence of urolithiasis.
Treatment
With concomitant pyelonephritis, antibacterial drugs are prescribed. It should be remembered that the complete elimination of urinary infection with urolithiasis is possible only after eliminating the root cause of this infection – a kidney stone or urinary tract. There is a good effect when prescribing norfloxacin. When prescribing drugs to a patient with urolithiasis, it is necessary to take into account the functional state of the kidneys and the severity of renal insufficiency.
Normalization of metabolic processes
Metabolic disorders are the most important factor causing relapses of urolithiasis. To reduce the level of uric acid, benzbromarone and allopurinol are used. If the acidity of urine cannot be normalized by diet, these drugs are used in combination with citrate mixtures. In the prevention of oxalate stones, vitamins B1 and B6 are used to normalize oxalate metabolism, and magnesium oxide is used to prevent crystallization of calcium oxalate.
Antioxidants are widely used to stabilize the function of cell membranes – vitamins A and E. With an increase in the level of calcium in the urine, hypothiazide is prescribed in combination with drugs containing potassium (potassium orotate). In case of violations of phosphorus and calcium metabolism, long-term intake of diphosphonates is indicated. The dose and duration of taking all drugs is determined individually.
Urolithiasis therapy in the presence of kidney stones
If there is a tendency to self-discharge of stones, patients with urolithiasis are prescribed medications from the group of terpenes (extract of ammi dental fruits, etc.) that have bacteriostatic, sedative and antispasmodic effects.
Relief of renal colic is carried out with antispasmodics (drotaverine, metamizole sodium) in combination with thermal procedures (hot water bottle, bath). If ineffective, antispasmodics are prescribed in combination with painkillers.
Surgical treatment
If the calculus in urolithiasis does not go away spontaneously or as a result of conservative therapy, surgical intervention is required. Indications for surgery for urolithiasis are severe pain syndrome, hematuria, pyelonephritis attacks, hydronephrotic transformation. Choosing the method of surgical treatment of urolithiasis, preference should be given to the least traumatic method.
Endoscopic operations
The essence of the intervention is contact crushing of concretions with the help of special endoscopic instruments. In routine practice , it is performed:
- Contact cystolithotripsy. It is carried out with bladder stones. The operation is carried out in two stages: crushing of the stone (littoripsia) and its extraction (lithoextraction). The stone is destroyed by pneumatic, electrohydraulic, ultrasonic or laser method through the cystoscope channel.
- Contact ureterolithotripsy. Indication – ureteral concretions. The operation is performed using a ureteroscope, methods of crushing stones – laser, ultrasound, pneumatics.
- Flexible retrograde nephrolithotripsy. It is used for kidney stones less than 2 cm in diameter.
Contraindications to transurethral surgical interventions may be prostate adenoma (due to the inability to insert an endoscope), urinary tract infections and a number of diseases of the musculoskeletal system in which a patient with urolithiasis cannot be properly placed on the operating table.
In some cases (localization of concretions in the cup-pelvic system and the presence of contraindications to other methods of treatment), percutaneous nephrolitholapaxy is used to treat urolithiasis. This technique allows you to crush any concretion (including coral) through a small puncture in the kidney (laser, ultrasound).
Laparoscopic surgical interventions
In the past, open surgery was the only way to remove a stone from the urinary tract. Often during such an operation there was a need to remove the kidney. Nowadays, the list of indications for open surgery for urolithiasis has been significantly reduced, and improved surgical techniques and laparoscopic surgical techniques almost always allow you to save the kidney.
Types of operations:
- Pyelolithotomy. It is carried out if the concretion is in the pelvis. There are several methods of operation. As a rule, a posterior pyelolithotomy is performed. Sometimes, due to the anatomical features of a patient with urolithiasis, anterior or inferior pyelolithotomy becomes the best option.
- Nephrolithotomy. The operation is indicated for especially large stones that cannot be removed through an incision in the pelvis. Access is via the renal parenchyma. Source: https://www.krasotaimedicina.ru/diseases/zabolevanija_urology/urolithiasis
- Ureterolithotomy. It is carried out if the stone is localized in the ureter.
Remote lithotripsy
Crushing is performed using a reflector emitting electrohydraulic waves. Remote lithotripsy can reduce the percentage of postoperative complications and reduce the traumatization of a patient suffering from urolithiasis. After crushing, sand and fragments of stones leave with urine. In some cases, the process is accompanied by easily relieved renal colic.
This intervention is contraindicated in pregnancy, blood clotting disorders, cardiac disorders (cardiopulmonary insufficiency, artificial pacemaker, atrial fibrillation), active pyelonephritis, excessive weight of the patient (over 120 kg), inability to bring the concretion into the focus of the shock wave.
No type of surgical treatment excludes the recurrence of urolithiasis. To prevent relapses, it is necessary to carry out long-term, complex therapy. After the removal of concretions, patients with urolithiasis should be monitored by a urologist for several years.