Formation of kidney stones. Types of kidney stones - classification, chemical composition, features of formation and treatment Carbonatapatite causes of formation diet and treatment

The disease can be asymptomatic, manifested by pain of varying intensity in the lumbar region or renal colic.
Epidemiology
Urolithiasis (urolithiasis, urolithiasis) is widespread, and in many countries of the world there is a trend towards an increase in incidence. In our country and the CIS countries, there are areas where this disease occurs especially often and is endemic: the Urals, the Volga region, the Don and Kama basins, some Asian republics, Transcaucasia. Among foreign regions, Asia Minor, the southern and eastern regions of Asia, Northern Australia, North-East Africa, the southern regions of North America, the eastern and western coasts of South America are endemic. In Europe, ICD is widespread in the Scandinavian countries, England, the Netherlands, southeastern France, southern Spain, Italy, southern Germany and Austria, Hungary, and throughout Southeastern Europe.
Among urological diseases, nephrolithiasis is the second most common after urinary tract infections (UTIs). ICD can be first detected at any age, most often in working age (30-55 years).
Classification
Currently, the nomenclature of urinary stones uses their mineralogical names. Using high-precision methods - infrared spectrophotometry, X-ray diffraction, scanning microscopy, 44 of their chemical varieties are determined.
Despite the large variation in the identified components of urinary stones, according to their chemical composition they are all combined into three groups, which reflect the main modern classification of the ICD:
. uric acid stones;
. calcium oxalate stones;
. phosphate stones.
Group 4, infected stones, are often reported. However, given the fact that 96% of phosphate stones are associated with urinary infection, and uric acid and calcium oxalate stones in most cases are aseptic, in medical practice it is advisable to be guided by the three above-mentioned forms of ICD.
11 chemical types of stones are of practical medical importance (Table 1).
At the same time, stones consisting of calcium oxalate and carbonate, as well as phosphate stones, are classified as inorganic, and uric acid, cystine and xanthine stones are classified as organic.
The frequency of occurrence of different types of stones varies widely, which is associated with territorial features:
. the proportion of uric acid stones varies from 2.3 to 44%;
. oxalate and mixed stones with a calcium-oxalate component occur in 50-70% of cases;
. calcium phosphate stones are found in 0.3-18.9% of cases.
In Moscow, the most common stones are calcium oxalate monohydrate (wevelite), carbonate apatite, calcium oxalate dihydrate (vedelite), struvite, and anhydrous uric acid.
There is also a classification of urinary stones, which is based on their location, but for etiopathogenetic pharmacotherapy, as a rule, only the chemical composition of the stone is important.
Etiology and pathogenesis
Currently, there is no unified theory of the etiopathogenesis of urolithiasis. KSD is a multifactorial disease, has complex, diverse development mechanisms and various chemical forms.
The formation of urinary stones is based on the following metabolic disorders: hyperuricemia, hyperuricuria, hyperoxaluria, hypercalciuria, hyperphosphaturia, changes in urine acidity. In the occurrence of these metabolic changes, some authors give preference to environmental influences, others to endogenous causes, although their interaction is often observed.
Exogenous causes of nephrolithiasis are considered:
. climate,
. geological structure of the soil,
. chemical composition of water and flora,
. food and drinking regime,
. living and working conditions.
Despite the fact that the first three of the above points are the most controversial, they are considered as possible links in the etiopathogenesis of the disease.
The food and drinking regimes of the population - the total calorie content of food, abuse of animal protein, salt, foods containing large amounts of calcium, oxalic and ascorbic acids, lack of vitamins A and B in the body play a significant role in the development of KSD.
Endogenous etiological factors can be of a very different nature. Against the background of UTI, foreign bodies formed (fibrin, clots, cellular detritus, etc.) can serve as crystallization centers. In recent years, certain importance has been attached to intracellular urease-producing infection.
Some metabolic disorders (hyperparathyroidism, gout, deficiency, absence or hyperactivity of a number of enzymes) play an undoubted role in the pathogenesis of KSD.
There is a relationship between the formation of stones and severe injuries or illnesses associated with prolonged immobilization.
Diseases of the digestive tract, liver and biliary tract are of particular importance.
Many authors have shown the existence of a hereditary predisposition to KSD and identified HLA antigens, the presence or absence of which contributes to the occurrence of this disease and to some extent determines the nature of its course.
Factors such as gender and age play a certain role in the pathogenesis of nephrolithiasis. By the way, men get sick 3 times more often than women.
Along with the general causes of an endogenous and exogenous nature in the formation of urinary stones, organic changes in the urinary tract (developmental anomalies, additional vessels) that cause disruption of their function are also of unconditional importance.
Clinical picture
The most characteristic symptom of KSD is pain in the lumbar region, especially paroxysmal pain (renal colic). No less often observed are hematuria (micro- and macrohematuria), pyuria, dysuria, and spontaneous stone passage; Obstructive anuria is extremely rare (with a single kidney and bilateral ureteral stones). In children, none of these symptoms are typical for ICD.
Treatment
Treatment of patients with urolithiasis can be either conservative or surgical.
Types of surgical treatment:
. open operations (pyelolithotomy, ureterolithotomy, etc.);
. external shock wave lithotripsy;
. percutaneous nephrolitholapaxy;
. transurethral endoscopic operations.
If hyperfunction and hyperplasia of the parathyroid glands are detected, the patient is advised to have them surgically removed.
Conservative therapy for urolithiasis includes:
. pharmacotherapy,
. diet therapy,
. physiotherapy,
. Spa treatment.
Pharmacotherapy
“Stone expelling” therapy is indicated for small, uncomplicated ureteral stones that can pass on their own, as well as after extracorporeal lithotripsy. As a rule, it includes antispasmodics, non-steroidal anti-inflammatory drugs, and herbal medicines.
The prescription of antibacterial drugs, taking into account the data of bacteriological examination of urine and endogenous creatinine clearance, is indicated in the case of UTI.
Etiopathogenetic therapy can be aimed at preventing relapse of stone formation and stone growth, as well as dissolving stones (litholysis).
For disorders of purine metabolism (hyperuricemia, hyperuricuria) and to prevent the formation of uric acid stones, allopurinol is prescribed 100 mg 4 times a day for 1 month. Allopurinol, by inhibiting xanthine oxidase, prevents the transition of hypoxanthine to xanthine and the formation of uric acid from it, reduces the concentration of uric acid and its salts in body fluids, promotes the dissolution of existing urate deposits, and prevents their formation in tissues and kidneys.
For litholysis of uric acid stones, blemarene is used, which promotes alkalinization of urine and dissolution of uric acid crystals. The dose of the drug is selected individually to achieve a urine pH range of 6.2-7.0.
For calcium oxalate and calcium phosphate stones, pyridoxine, magnesium preparations, hydrochlorothiazide (reduces the severity of hypercalciuria), as well as etidronic acid (Xidifon) are used.
Xidifon is an inhibitor of osteoclastic bone resorption. The drug prevents the release of ionized calcium from bones, pathological calcification of soft tissues, crystal formation, growth and aggregation of calcium oxalate and calcium phosphate crystals in the urine. By maintaining Ca2+ in a dissolved state, it reduces the possibility of the formation of insoluble Ca2+ compounds with oxalates, mucopolysaccharides and phosphates, thereby preventing relapses of stone formation. Xidifon is prescribed orally in the form of a 2% solution, which is prepared by adding 9 parts of distilled or boiled water to 1 part of a 20% solution. The drug is taken 15 ml 3 times a day 30 minutes before meals. The initial course of treatment is 14 days. In case of crystalluria and the presence of kidney stones, 5-6 courses are carried out with 3-week breaks for 1-2 years. To prevent stone formation, Xydifon therapy is continued for 2-6 months.
In addition, for calcium phosphate stones, boric acid or methionine is used to acidify the urine.
Diet therapy
The diet of patients with urolithiasis includes:
. drinking at least 2 liters of fluid per day;
. depending on the identified metabolic disorders and the chemical composition of the stone, it is recommended to limit the intake of animal protein, table salt, and foods containing large amounts of calcium, purine bases, and oxalic acid;
. Consuming foods rich in fiber has a positive effect on metabolism.
Physiotherapy
As part of the complex conservative treatment of patients with urolithiasis, various physiotherapeutic methods are used (amplipulse therapy, laser magnetic therapy, ultrasound therapy), aimed at both accelerating the passage of stones from the ureter and treating concomitant pyelonephritis.
Spa treatment
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 effective for kidney stones, the size and shape of which, 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.
Patients with uric acid and calcium oxalate urolithiasis are indicated for treatment at resorts with low-mineralized alkaline mineral waters, such as Zheleznovodsk (Slavyanovskaya, Smirnovskaya); Essentuki (Essentuki No. 4, 17); Pyatigorsk, Kislovodsk (Narzan). For calcium oxalate urolithiasis, treatment at the Truskavets (Naftusya) resort, where the mineral water is slightly acidic and low-mineralized, may also be indicated.
Treatment at resorts is possible at any time of the year. The use of similar bottled mineral waters does not replace a spa stay.
Taking the above mineral waters for therapeutic and prophylactic purposes is possible in an amount of no more than 0.5 l/day under strict laboratory control of the metabolism of stone-forming substances.

Literature
1. Agafonov N.V. Rationale for dietary prevention of recurrent urolithiasis: Abstract of thesis. Candidate of Medical Sciences. - Dnepropetrovsk, 1987. - 204 C.
2. Adamu Yu.D. Primary hyperparathyroidism as a cause of recurrent stone formation after extracorporeal lithotripsy: Abstract of Candidate of Medical Sciences. - St. Petersburg, 1995. - 16 C.
3. Alexandrov V.P. Etiology and pathogenesis of urolithiasis (clinical, biochemical and immunogenetic aspects): Dissertation of Doctor of Medical Sciences - Leningrad, 1988. - 452 C.
4. Aleksandrov V.P., Tiktinsky O.L., Novikov I.F. and others. Features of stone formation in the kidneys in patients in families with a history of urolithiasis. // Urol. and nephrol. - 1993. - N4. - 16-19.
5. Gazymov M.M. The role of genetic, endocrine and metabolic factors in the occurrence of nephrolithiasis and in determining the tactics of its treatment: Abstract of thesis of Doctor of Medical Sciences. - M., 1990. - 42 S.
6. Darenkov A.F., Popovkin N.N., Nenasheva N.P., Grishkova N.V. Prevalence of urolithiasis among the adult population of the Russian Federation. // Abstracts. Plenum of the All-Russian Scientific Society of Urologists, September 24-25, 1992, Rostov-on-Don, 1992. - P.43-45.
7. Dzeranov N.K., Konstantinova O.V. Urolithiasis//In the book. Rational pharmacotherapy in urology, ed. ON THE. Lopatkina, T.S. Perepanova. M., Litterra, 2006. 824 p.
8. Dzeranov N.K., Darenkov A.F., Konstantinova O.V., Beshliev D.A. and others. The role of dynamic observation in the prevention of recurrent stone formation.//Urology and nephrology. -1998. -N2. -P.12 -14.

Urolithiasis (urolithiasis)- a metabolic disease, which, due to an imbalance in the physico-chemical balance of urine under the influence of endogenous and exogenous factors, is manifested by the formation of stones in the urinary tract. Stones can be located in all parts of the urinary tract - from the calyx to the external opening of the urethra (Fig. 8.1). Most often they are localized in the kidney, ureter and bladder (Fig. 8.2; Fig. 60, see color insert).

8.1. KIDNEY AND URETER STONES

Epidemiology. The incidence of urolithiasis in the world ranges from 1.5 to 4.0% of the population, although the frequency of this pathology varies widely in different countries. The disease is most common in the countries of the Balkan Peninsula, Brazil, Turkey, India, and several regions of the United States. In Russia, urolithiasis (UCD) is most common in the Volga region, Central Asia, the North Caucasus, and the Urals. As a rule, it ranks third in prevalence among urological diseases, accounting for 30-35% of their structure and second in frequency only to urinary tract infections and prostate pathology. Persons of active working age - from 25 to 55 years old - are most susceptible to this disease. Disability due to nephrolithiasis accounts for up to 6% of the overall structure of disability.

Etiology and pathogenesis. ICD is a polyetiological disease. The occurrence and formation of urinary stones is influenced by a variety of endogenous and exogenous causes. General and local factors take part in their formation. Urolithiasis is a disease of the whole organism, and the presence of stones in the urinary tract is its consequence, a local manifestation of urolithiasis.

In recent years, there has been a noticeable revival of interest in the fundamental aspects of stone stones, which is due to the emerging opportunities for in-depth study of the molecular, crystallographic and biochemical processes underlying stone formation.

Currently, there is no unified theory of the pathogenesis of urolithiasis. There are causal (etiological) and formal (pathogenetic) genesis of the formation and growth of urinary stones.

Causal genesis. The leading place among the stone formation factors belongs to congenital enzymopathies (tubulopathies), anatomical malformations of the urinary tract and hereditary renal syndromes. Enzymopathies (tubulopathy), hereditary or acquired, are disorders of metabolic processes in the body or the functions of the renal tubules. Most

Rice. 8.1. Localization of urinary stones

ways:

1 - cup stone; 2 - pelvis stone;

3- stone in the middle third of the ureter;

4- stone of the juxtavesical ureter; 5 - bladder stone; 6 - urethral stone

common enzymopathies - oxaluria, uraturia, aminaciduria, cystinuria, galactosuria and etc.

Etiological factors of ICD are usually divided into exogenous and endogenous. To exogenous include geographical factors, gender, age, dietary habits, composition of drinking water, living and working conditions, lifestyle (physical inactivity), etc. Increased stone formation in countries with hot climates is caused precisely by exogenous factors and is explained by dehydration, increased urine concentration in combination with high mineralization of drinking water.

Endogenous factors divided into general and local. TO general include hypercalciuria, vitamin deficiency A and D, overdose of vitamin D, bacterial intoxication in general infections and pyelonephritis, prolonged immobilization in fractures of large bones, weightlessness, prolonged use or large doses of a number of substances and medications (sulfonamides, tetracyclines, antacids, acetylsalicylic and ascorbic acid , glucocorticoids, etc.). Local factors- these are various congenital and acquired diseases of the urinary tract, leading to disturbances in urodynamics: narrowing of the ureteropelvic segment and ureter, nephroptosis, anomalies of the kidneys and urinary tract, vesicoureteral reflux, urinary tract infection, neurogenic disorders of urinary outflow, diversion urine into the intestinal segments, long-term presence of drainage in the urinary tract, etc. If the patient has several factors predisposing to stone formation, the risk of developing urolithiasis increases significantly.

Rice. 8.2. Urinary stones of the kidney (a), ureter (b), bladder (c)

Formal genesis ICD is explained by two main theories: colloid and crystalloid.

Colloidal or matrix theory is based on the fact that if the quantitative and qualitative relationships between colloids and crystalloids in the urine are violated, pathological crystallization may occur. The initial phase of stone formation is the agglomeration of specific organic molecules from mucopolysaccharides and mucoproteins. Matrix substance is found in all urinary stones of patients with nephrolithiasis, as well as in their urine tests. According to the matrix theory, a high molecular weight substance should form an organic matrix that adsorbs calcium and other ions. Subsequently, crystallization of sparingly soluble salts occurs on it. However, comparative studies of the amount of uromucoid in healthy people and in patients with urolithiasis did not reveal significant differences in its content.

This concept of stone formation is countered by crystallization theory, which rejects the matrix as the primary stone-forming factor. According to it, the main importance is attached to crystallization processes that occur in supersaturated solutions, such as urine. In this case, the stone is formed as a result of a physicochemical process, when precipitation of lithogenic salts from supersaturated urine is observed. However, quite often no differences are found in the composition of the urine of a healthy person and a patient with urolithiasis, and only taking into account the laws of equilibrium of solutions and crystallographic data has it become possible to explain these contradictions.

Thus, stone formation consists of two processes that mutually determine each other - the formation of the nucleus and stone formation itself.

The diversity and inconsistency of theories of formal genesis do not allow us to recognize a single pathophysiological cause of urolithiasis or a set of factors causing the formation of urinary stones. Currently, in the causes of stone formation, taking into account the above theories, much attention is paid to the characteristics of urine. In recent years, many researchers have drawn attention to the fact that it is not the chemical composition of the core and the stone itself, but various changes in the physicochemical properties of urine (pH, colloid content,

the presence of crystallization inhibitors, saturation with sparingly soluble compounds, electrolyte composition, etc.) determine the formation and growth of stone.

The process of stone formation begins with a disruption of colloid-crystalline relationships in the urine. Under these conditions, crystallization of sparingly soluble substances occurs, which are normally in a state of thermodynamic equilibrium, the maintenance of which, along with crystallization inhibitors, is greatly facilitated by the so-called protective colloids of urine. The latter consist mainly of low-molecular protein compounds, nucleoalbumins and mucins. The penetration of glycoproteins and proteins from the blood serum into the urine sharply disrupts the colloid-crystalloid balance and promotes the formation of stone formation centers, which can be precipitated salt crystals or protein-glycoprotein substances. In general, the process of stone formation still appears to be complex and multifaceted, in which, to one degree or another, the factors that determine the foundations of the theories of formal and causal genesis of ICD are important.

Classification of urinary stones. The generally accepted classification of urinary stones, although it assumes (by name) that they are monomineral, however, in fact, the presence of one or another mineral in greater quantities compared to others determines its name. Urinary stones in most cases are polymineral, that is, they have a mixed chemical composition.

Currently, a mineralogical classification of urinary stones is used. The most common type of kidney stones are calcium-containing urinary stones, namely calcium oxalate (70%) or calcium phosphate, which account for up to 50% of all stones. Among urinary stones, the most common are oxalates (wewellite, weddellite), phosphates (hydroxylapatite, struvite, carbonate apatite, etc.), as well as urates (uric acid and its salts). Other biominerals are observed much less frequently.

Oxaluria occurs with increased excretion of oxalates in the urine (more than 40 mg/day). This is common in chronic inflammatory bowel disease and other illnesses that cause chronic diarrhea and severe dehydration. Only in rare cases, calcium oxalate stones are formed due to excessive formation of oxalates during poisoning with ethylene glycol, oxalic acid, as well as vitamin B6 deficiency, phenylketonuria and primary oxaluria. With long-term diarrhea, oxalate metabolism changes. Due to malabsorption, fats accumulate in the intestinal lumen, with which calcium easily binds. The low content of free calcium in the intestine leads to easy absorption of oxalates due to diffusion. Even a slight increase in this process and an increase in the level of oxalates in the urine creates conditions for the formation of crystallization nuclei and their subsequent growth. As a result, the oxalic acid anion combines with the calcium cation and a sparingly soluble salt is formed - calcium oxalate in the form of monohydrate (wewellite) or dihydrate (weddellite).

Oxalates are usually dark in color with an uneven prickly surface and very dense.

Phosphate stones most often have an infectious origin and are called struvite stones. They consist of a mixture of ammonium and magnesium phosphate, as well as carbonate apatite. The formation of these stones is associated with bacteria that break down urea into ammonia and carbon dioxide (Escherichia coli, Pseudomonas aeruginosa, Klebsiella, etc.), which leads to the release of bicarbonate and ammonium. As a result, the urine pH rises above 7.0, and with an alkaline reaction, it becomes oversaturated with magnesium, ammonium, phosphate and carbonate apatites, which leads to the formation of stone. Conditions that contribute to the development of infection in the urinary tract (malformations, neurogenic dysfunction, nephro- and epicystostomy, long-term catheterization of the bladder) predispose to the formation of phosphate stones. Their formation is also associated with the development of hyperfunction of the parathyroid glands, which leads to a decrease in phosphate resorption in the kidneys. Among all kidney stones, phosphates occur in 15-20% of cases, and they are found 2 times more often in women than in men.

Phosphate stones are usually grayish or white in color and their structure is fragile.

Urate stones make up 5-7% of all urinary stones. The risk of their formation is especially high in gout, myeloproliferative diseases and in cancer patients receiving chemotherapy. Uraturia is a consequence of impaired purine synthesis. The main risk factor for the formation of urate stones is a persistently low urine pH level.

Urates consist of crystals of uric acid and (or) its salts, so they are yellow-brown, sometimes brick-colored with a smooth or slightly rough surface, and quite dense.

Cystine And xanthine stones are rare. Cystine stones occur with cystinuria, when the tubular reabsorption of four basic amino acids (cystine, ornithine, lysine, arginine) is impaired, and therefore their concentration in the urine increases. Cystine, compared to other amino acids, has poor solubility in urine, and therefore precipitates to form cystine stones. Xanthine stones form when there is a congenital defect in the enzyme xanthine oxidase. Due to the inability to convert xanthine into uric acid, its excretion by the kidneys increases. Xanthine is a sparingly soluble salt, which is why xanthine stones are formed.

Even less common cholesterol stones.

The modern classification of urinary stones basically contains the division of urinary stones into two large groups - crystalline And protein. The main and predominant is the first group, in which two subgroups are distinguished - inorganic And organic stones. In the first subgroup, the decisive cation is inorganic calcium or magnesium. This subgroup includes oxalates and phosphates; they are based on a chemical substance that is homogeneous in composition. In the second subgroup, the anion comes first. It includes uric acid and its salts, cystine, xanthine. Thus, inorganic and organicocrystalline groups of stones are distinguished, which is the basis for their classification.

A very important factor in the classification of urinary stones is urine pH. The crystalline component of a urinary stone is formed from salts of uric, oxalic and phosphoric acids at concentrations of hydrogen ions in the urine specific for each type of stone. Urine pH is a risk factor for the development of urolithiasis and must be taken into account when dividing urinary stones into groups. The optimal pH values ​​for crystallization of uric acid salts are up to 5.5, oxalic acid is 6.0-6.8, and phosphoric acid is above 7.0. Thus, in a generalized form, the classification of urinary stones is as follows:

A. Crystalline stones.

I. Inorganic stones:

■ at urine pH 6.0: calcium oxalate (wewellite, weddellite);

■ at urine pH 6.5: calcium phosphate (hydroxylapatite, brushite, whitlockite);

■ at urine pH 7.1: magnesium ammonium phosphate (struvite).

II. Organic stones:

■ at urine pH 5.5-6.0: uric acid, its salts (urates), cystine, xanthine;

■ at urine pH 6.0: ammonium urate.

B. Protein stones (with urine pH 6.0-7.5).

Classification of urolithiasis. Based on localization in the organs of the urinary system, they are distinguished: renal pelvis stones And calyx(nephrolithiasis), ureters(ureterolithiasis), Bladder(cystolithiasis), urethra(urethrolithiasis), multifocal lithiasis(various combinations of these localizations). Kidney and ureteral stones may be one- And double-sided, single And multiple. Due to their specificity, special groups are divided into coral-shaped And recurrent kidney stones, solitary kidney stones, urolithiasis in pregnant women, children and the elderly.

The shape, size, mobility of stones, and their location greatly influence the symptoms of the disease. Nephrolithiasis is characterized by a triad of symptoms: pain, hematuria and stone passage in the urine. In a certain proportion of patients, the disease manifests itself with only one or two symptoms, and sometimes remains asymptomatic for a long time. A latent course is most often observed in the presence of large, inactive stones that do not interfere with the outflow of urine.

The pain is localized mainly in the lumbar region or in the corresponding flank of the abdomen; it can be sharp or dull, periodically occurring or constant. Small moving stones passing through the ureter lead to its obstruction and the development of a characteristic symptom complex called renal colic (see Chapter 15.1).

Clinical picture renal colic is characterized by suddenly appearing severe paroxysmal pain in one side of the lumbar region. It immediately reaches such intensity that patients are unable to tolerate it, they behave restlessly, rush about, continuously change body position, trying to find relief (see Chapter 15.1).

Hematuria is observed in 75-90% of patients with urolithiasis and is mostly microscopic in nature. The flow of blood into the urine, as well as pain, increases with movement. For kidney and ureteral stones it has

place is total hematuria, and with bladder stones, terminal hematuria is observed, accompanied by dysuric phenomena. Hematuria is absent when the ureter is completely obstructed by a stone, as a result of which urine does not flow from the blocked kidney into the bladder.

The passage of stones in the urine is a pathognomonic, that is, a reliable sign of ICD. It is observed in 10-15% of patients with urolithiasis. After the stone passes, the pain syndrome stops. The sizes of stones discharged in urine are small and range from 0.2 to 1 cm in diameter. In some patients, stones are released repeatedly over a long period of time, which is why they are called “stone excretors.”

Diagnostics The ICD begins with an assessment of the patient’s complaints and a study of the medical history (stone passage, hereditary factors, previous methods of conservative and surgical treatment). Pale and dry skin as a manifestation of chronic renal failure and anemia are observed in patients with severe forms of nephrolithiasis. Palpation and tapping of the lumbar region can cause pain (positive Pasternatsky's sign). In the presence of calculous hydro or pyonephrosis, an enlarged kidney is palpated.

Blood test they begin with a clinical analysis, which most often does not show deviations from the norm outside of an exacerbation of the disease. With exacerbation of calculous pyelonephritis, leukocytosis is observed with a shift in the leukocyte formula to the left, an increase in ESR, which indicates the degree of activity of the inflammatory process in the kidneys. Moderate leukocytosis can be observed with renal colic. Anemia and creatininemia are characteristic of chronic renal failure. Determination of the electrolyte composition of blood serum and acid-base status is indicated for patients with bilateral kidney stones, with recurrent urolithiasis, especially complicated by chronic renal failure. The detection of hypercalcemia and hyperphosphatemia indicates the need for more detailed studies of the function of the parathyroid glands (determining the level of parathyroid hormone, calcitonin).

Urine study after its macroscopic assessment, they begin with a general analysis. It contains a moderate amount of protein (0.03-0.3 g/l), single (usually hyaline) casts, leukocytes, erythrocytes, and bacteria. The constant presence of salt crystals in the urine indicates a tendency to form stones and their possible composition, especially with the characteristic urine pH. Urine acidity levels must be determined numerically, taking into account the importance of pH in the formation of urinary stones. In cases where a patient’s general urine test does not show deviations from the norm, one of the methods for accurately counting blood cells (Nechiporenko’s method, etc.) is used to identify hidden erythrocyte and leukocyturia. To assess the concentration function of the kidneys, a urine sample according to Zimnitsky is used. The excretion of nitrogen metabolism products (urea, creatinine, uric acid) and electrolytes (sodium, potassium, calcium, phosphorus, chlorine, magnesium) is studied. These studies are most valuable for patients with severe nephroureterolithiasis. It is necessary to test urine for microflora to determine its sensitivity to antibiotics, as well as determine the microbial count of urine. For the purpose of efficiency

Rice. 8.3. Sonogram. Renal pelvis stone (arrow)

During the treatment of calculous pyelonephritis, urine culture must be repeated several times during the course of treatment.

Radiation methods are the main ones in making a final topical diagnosis.Ultrasound allows you to assess the shape, size and position of the kidneys, their mobility, determine the location of the stone and its size, the degree of expansion of the renal cavity system and the condition of its parenchyma. On a sonogram, the stone is visualized as a hyperechoic formation with a clear acoustic shadow distal to it (Fig. 8.3). In and-

The darkest areas of the ureter on sonograms are its pelvic and prevesical sections. If they are sufficiently expanded, the stones of these sections are well visualized (Fig. 8.4).

The advantages of sonography are:

■ possibility of use during an attack of renal colic;

with intolerance to iodine-containing radiocontrast drugs; with severe allergic reactions; in pregnant women;

■ the possibility of frequent use in monitoring the migration of stones or the passage of its fragments after extracorporeal lithotripsy;

■ diagnosis of X-ray negative stones.

A disadvantage of sonography is the inability to visualize most of the ureter.

Survey and excretory urography. Most urinary stones are radiopaque, only a tenth of them do not produce images on radiographs, that is, they are radiopaque (stones of uric acid and its salts, cystine, xanthine, protein, etc.). A survey of the kidneys and urinary tract when examining patients with urolithiasis should always precede x-ray contrast methods. On a survey radiograph, shadows of various shapes, numbers and sizes are identified, located in the area of ​​​​the projection of the kidneys and urinary tract (Fig. 8.5, 8.6).

Rice. 8.4. Sonogram. Stone (1) of the prevesical ureter, causing its expansion (2)

Rice. 8.5. Plain X-ray of the urinary tract. Left kidney stone (arrow)

Rice. 8.6. Plain X-ray of the urinary tract. Stone in the middle third of the right ureter (arrow)

It is difficult to distinguish the shadows of stones if they are projected onto the bones of the skeleton. Sometimes, with the help of a survey X-ray, one can even judge the chemical composition of the stone by the density of the resulting shadows, their surface, size and shape. These shadows must be differentiated from shadows from gall bladder stones, phleboliths, fecal stones, calcified lymph nodes and myomatous nodes, lesions in renal tuberculosis, neoplasms, echinococcosis, etc. It is advisable to take multi-axial X-rays (semi-lateral, lateral, with the patient in the supine position). stomach, etc.).

Excretory urography allows you to confirm or exclude that the shadow identified on the survey image belongs to the urinary tract, clarify the localization of the stone, identify the presence of X-ray negative stones and obtain information about the separate functional state of the kidneys and urinary tract (Fig. 8.7). It is advisable to perform it in a pain-free period, since during an attack of renal colic, the radiopaque substance does not enter the urinary tract from the affected side. This fact in itself confirms the diagnosis of renal colic, but does not provide complete information about the condition of the pyelocaliceal system and ureter. With a ureteral stone, radiopaque contrast material is located above it in the dilated ureter, indicating the stone (Fig. 8.8). In case of radiopaque kidney or ureteral stones, filling defects corresponding to the stones are determined against the background of a contrast agent. An excretory urogram is not informative in case of chronic renal failure, since due to impaired renal function, the release of a radiopaque substance does not occur.

Rice. 8.7. Excretory urogram. Left renal pelvis stone (arrow), hydronephrosis

Rice. 8.8. Excretory urogram. Expansion of the ureter and cavity system of the right kidney (1) above the stone (2)

Retrograde ureteropyelography Currently, ICD has become less used for diagnosing. It is indicated in the absence of contrast agent release according to excretory urography, doubts about whether the shadow identified on the survey image belongs to the ureter (performed in two projections) and the detection of X-ray negative stones. Antegrade

Rice. 8.9. CT, axial projection. Right kidney stone (arrow)

Rice. 8.10. CT, frontal projection. Bilateral kidney stones (1) and middle third of the right ureter (2)

Rice. 8.11. Multislice CT with three-dimensional construction. Right ureteral stone (arrow)

pyeloureterography for the same indications is performed in the presence of non-phrostomy drainage.

CT allows you to clarify the location, especially of X-ray negative stones, determine their density, study the anatomical and functional state of the kidneys and urinary tract, identify concomitant diseases of the abdominal organs and retroperitoneal space (Fig. 8.9, 8.10). The information content of the method increases when using such modifications as spiral and multislice CT with three-dimensional image reconstruction and virtual endoscopy. With their help, you can reliably

but to establish the presence of stones of any size, location and radiopacity (Fig. 8.11), including in abnormal kidneys (Fig. 8.12).

One of the advantages of CT is the ability to perform computer densitometry, which allows one to determine the structural density of the stone at the preoperative stage and choose the optimal treatment method. Relatively

The significant density of kidney and stone during computer densitometry is measured in Hounsfield units (Hounsfield unit- HU).

MRI allows you to identify the level of obstruction of the urinary tract by a stone without the use of contrast agents, including in patients with renal colic (Fig. 8.13). It has undeniable advantages over other methods when examining patients with renal failure or intolerance to X-ray contrast agents.

Radionuclide(radioisotope renography, dynamic and static scintigraphy) research methods allow you to get an idea of ​​the anatomical and functional features of the kidneys, observe them in dynamics and study their separate functions. The practical value of these methods increases in case of intolerance to radiocontrast drugs.

Rice. 8.12. Multislice CT with three-dimensional construction. Stone of iliac kidney (arrow)

Rice. 8.13. MRI. Stones of the lower calyx (1), renal pelvis (2) and ureter (3) on the right

By using endoscopic methods Research can not only establish a diagnosis, but also, if a stone is present, proceed to therapeutic manipulations to destroy and remove it. With cystoscopy, you can identify bladder stones (Fig. 17, see color insert) or see a ureteral stone emerging from the mouth and strangulated in it (Fig. 16, see color insert). An indirect sign of an intramural ureteral calculus is elevation, swelling, hyperemia and gaping of the ureteral orifice. In some cases, it produces mucus, cloudy urine or blood-stained urine.

Chromocystoscopy- the simplest, fastest and most informative

mative method for determining separate kidney function (Fig. 14, see color insert). It is of great importance in the differential diagnosis of renal colic with acute surgical diseases of the abdominal organs. If a shadow suspicious for a stone raises doubts, resort to catheterization of the ureter (Fig. 21, see color insert). In this case, the catheter can either stop near the stone, or after sensing an obstacle, it can be moved higher. After insertion of the catheter, X-ray images of the corresponding part of the urinary tract are taken in two projections. If on radiographs the shadow suspicious for a stone and the shadow of the catheter are combined, this indicates a ureteral stone. The diagnosis is undoubted if a catheter can be used to move a suspicious shadow up the ureter.

Ureteroscopy(Fig. 28, see color insert) and nephroscopy(Fig. 31, see color insert) are the most informative methods for diagnosing kidney and ureteral stones.

Differential diagnosis Urolithiasis is carried out with some urological diseases, such as nephroptosis, hydronephrosis, neoplasms and renal tuberculosis. At the same time, it is necessary to remember that a combination of ICD with the listed diseases is also possible.

In the presence of pain, it is especially important to distinguish kidney and ureteral stones from acute surgical diseases of the abdominal organs, since in the first case, treatment is usually conservative, and in the second, emergency surgical intervention is required. Renal colic most often has to be differentiated from acute appendicitis, cholecystitis, perforated gastric and duodenal ulcers, acute intestinal obstruction, strangulated hernia, and acute gynecological diseases (see Chapter 15.1).

Coraloid nephrolithiasis- this is the most severe form of urolithiasis, accompanied by the formation of large stones that fill the renal collecting system in the form of a cast (Fig. 8.14).

Such a stone with numerous processes in cups resembles coral, which is why it got its name. In the structure of urolithiasis, coral nephrolithiasis accounts for 5-20%. This form can be worn one- And bilateral character. The disease has a long chronic course, accompanied by exacerbations of chronic pyelonephritis and increasing symptoms of chronic renal failure. Coral nephrolithiasis is easily diagnosed using modern research methods, such as Ultrasound(Fig. 8.15), overview(Fig. 8.16) and excretory urogram, CT(Fig. 8.17) and MRI.

A mandatory research method is to determine the condition of the parathyroid glands. To do this, blood parathyroid hormone and sonography of the parathyroid glands are examined. Stones often and quickly recur, especially if they are caused by hyperparathyroidism.

Complications KSD are observed frequently. First of all, this is the addition of a secondary infection, which is manifested by calculous pyelonephritis, papillary necrosis, pyonephrosis and paranephritis. When the stone is located in the lower urinary tract, cystitis, urethritis, and orchiepididymitis develop. With exacerbation of pyelonephritis, patients experience a rise in body temperature with chills, and a large number of leukocytes are determined in a urine test. Together

Rice. 8.14. Coral kidney stone

Rice. 8.15. Sonogram. Coral kidney stone

Rice. 8.16. Plain X-ray of the urinary tract. Coral stone of the right kidney (arrow)

However, it is necessary to remember that leukocyturia can be a leading symptom of many other diseases of the urinary and genital organs: prostatitis, urethritis, cystitis, tuberculosis of the urinary system, etc. In clinical practice, there are also combinations of ICD with the listed diseases, which makes diagnosis even more difficult.

The most common complication of ureterolithiasis is hydronephrotic transformation, which in a bilateral process leads to chronic renal failure. The latter is also observed with large bilateral kidney stones (often coral-shaped) and with stones of a single kidney. Less common is nephrogenic hypertension caused by chronic pyelonephritis with cicatricial degeneration of the renal parenchyma.

A serious complication of ICD is excretory anuria. It occurs when stones obstruct both ureters or the ureter of a single kidney and requires emergency intervention to restore patency of the urinary tract.

Treatment ICD is complex and is aimed at eliminating pain, restoring impaired urine outflow, destruction and/or removal of stones, correction of urodynamic disorders, prevention of inflammatory complications, preventive and metaphylactic measures. Considering the many

Because there are different clinical forms of ICD, a treatment plan is drawn up individually for each patient.

Conservative treatment includes relief of an attack of renal colic (see Chapter 15.1.), stone-expelling (lithokinetic) therapy and litholysis (dissolution of stones).

Stone expulsion therapy. Spontaneous passage of stones can occur in 80% of cases if the stone size is no more than 4 mm in diameter. With large sizes, the likelihood of spontaneous passage of the stone

Rice. 8.17. Multislice CT

with three-dimensional construction. Double sided

coral kidney stones

decreases. The probability of passage of ureteral stones, depending on the location, is 25% for the upper third of the ureter, 45% for the middle third, and 70% for stones in the lower third of the ureter. The complex of therapeutic measures aimed at expelling stones includes: active regimen, physical therapy (walking, running, jumping), increasing diuresis (diuretics, drinking plenty of fluids or intravenous fluids), analgesic, antispasmodic drugs, alpha-blockers ( tamsulosin, alfuzosin, doxazazin), herbal uroseptics, antibacterial therapy, physiotherapy (amplipulse, ultrasound stimulation, local vibration therapy, etc.).

Litolysis (dissolution of stones) can be descending and ascending. Descending litholysis effective for urate stones and is based on the prescription of drugs that promote their dissolution (blemaren, uralit-U, magurlit). Ascending litholysis is carried out by administering drugs through a ureteral catheter or renal drainage.

Dynamic observation and stone-expelling therapy are indicated for stone sizes of no more than 5 mm without disruption of urodynamics with relieved pain syndrome. In all other cases, the stone must be destroyed and/or removed. For this purpose, extracorporeal lithotripsy, contact ureterolithorypsy and ureterolithoextraction, percutaneous nephroureterolithotripsy, laparoscopic and extremely rarely open operations are currently used.

External shock wave lithotripsy- a method consisting in the destruction of a stone by a shock wave generated by a special apparatus, focused and directed at it through the soft tissues of the human body - remote lithotripter. Modern remote lithotripters consist of a shock wave generator, a system for focusing and targeting the stone. The shock wave is created by a generator, forming a high pressure front, which is focused on the stone and, quickly moving through the water

Rice. 8.18. Remote shock wave lithotripters: A- MIT companies (Russia); b- Dornier Lithotriptor S(Germany)

Rice. 8.19. Plain X-ray of the urinary tract. Before a session of extracorporeal lithotripsy for a stone in the left renal pelvis (arrow), a stent was installed

environment, influences it with its destructive energy. The pressure in the focal zone reaches 160 kPa (1600 bar), which leads to the disintegration of the stone. Modern models of remote lithotripters use the following methods of generating shock waves: electrohydraulic, electromagnetic, piezoelectric, laser radiation (Fig. 8.18).

The stone is located and the shock wave is focused on it using X-ray and/or ultrasound guidance.

External shock wave lithotripsy is indicated and is most effective for renal pelvis stones up to 2.0 cm in size and ureteral stones up to 1.0 cm in size. The density of the stone is also of a certain importance. In some cases, crushing of larger stones is possible, but with mandatory preliminary drainage of the kidney with a stent (Fig. 8.19).

Contraindications to extracorporeal lithotripsy are divided into technical, general somatic and urological. The first include the patient’s body weight of more than 130 kg, height of more than 2 m and deformation of the musculoskeletal system, which does not allow the patient to be positioned and the stone to be brought into the focus of the shock wave. General somatic symptoms include pregnancy, disorders of the blood coagulation system, and gross cardiac arrhythmias. Urological contraindications are considered to be an acute inflammatory process in the genitourinary system, a significant decrease in kidney function and obstruction of the urinary tract below the stone. Due to the constant improvement of devices for stone disintegration, its efficiency increases every year, and today it is 90-98%.

In order to prevent complications of extracorporeal lithotripsy associated with ureteral occlusion (acute pyelonephritis, stone path, intractable renal colic), long-term drainage of the urinary tract with a ureteral stent is used (Fig. 22, see color insert).

Endoscopic contact lithotripsy is carried out by bringing an energy source to the stone under visual control and destroying it as a result of direct (contact) impact. Depending on the type of energy generated, contact lithotripters can be pneumatic, electrohydraulic, ultrasonic, laser and electrokinetic. There are contact ureterolithotripsy and nephrolithotripsy.

Rice. 8.20. Stone extractors: four-branch (a) and six-branch (b) Dormia loop, stone grabber (c)

For ureteral stones, retrograde or antegrade ureteroscopy is first performed. Stones smaller than 0.5 cm can be immediately removed under visual control (ureterolithoextraction). For this purpose, various specially designed extractors are used. Among them, the Dormia loop (basket) and metal grips for stones became the most widespread (Fig. 8.20).

Contact ureterolithotripsy is performed for larger stones, after which their fragments can also be removed. Retrograde ureteroscopy, ureterolithotripsy and ureterolithoextraction(Fig. 8.21) most effective for stones of the lower third of the ureter(Fig. 8.22).

Percutaneous contact nephro- and ureterolithotripsy consists of puncture of the renal collecting system through the skin of the lumbar region. After that, the created channel is expanded to the appropriate size and an endoscope is installed along it into the cavity system. Under visual control, contact crushing of the stone is carried out with the removal of its fragments (Fig. 8.23; Fig. 33, see color insert). This method can destroy stones of any size, including coral-shaped ones, in one or two sessions (Fig. 8.24).

Currently, due to the high effectiveness of the above treatment methods, laparoscopic and, especially, open organ-preserving operations for kidney and ureteral stones (nephro-, pyelo-, ureterolithotomy) are used extremely rarely. Nephrectomy is performed in case of cicatricial degeneration of the kidney with the absence of its function or calculous pyonephrosis.

Metaphylaxis is an important part of the complex treatment of patients with urolithiasis. In the early postoperative period, it is aimed at removing stone fragments, eliminating the inflammatory process in the urinary tract,

Rice. 8.21. Retrograde ureteroscopy (1) with ureterolithoextraction with Dormia loop (2), ureterolithotripsy (3)

Rice. 8.22. Survey X-ray

urinary tract during ureteroscopy

with contact crushing of stone (arrow)

ureter

pathways, normalization of urodynamics and restoration of kidney function. The listed measures are needed by patients with both low and high risk of urolithiasis recurrence. Subsequent long-term metaphylaxis is necessary to prevent relapse of urolithiasis and includes the identification of specific metabolic disorders, their drug correction, and dynamic monitoring of metabolic parameters in the blood and urine.

Prevention of recurrent stone formation consists of consuming up to 2.5-3 liters of fluid per day while maintaining a daily diuresis of more than 2 liters, a balanced diet limiting table salt to 4-5 g/day and animal protein to 0.8-1.0 g/day. kg/day. Normalization of common risk factors includes: limiting stress, sufficient physical activity, balanced fluid loss. In patients with a high risk of recurrent stone formation, along with general metaphylaxis, specific measures to prevent the recurrence of urolithiasis are indicated, which depend on the mineral composition of the stone. For hyperparathyroidism, parathyroidectomy is performed.

Depending on the composition of urinary stones and crystalluria, an appropriate diet and drugs that correct the pH of the urine are prescribed.

Rice. 8.23. Nephroscopy and nephrolithotripsy

Uric acid urolithiasis (uraturia). Patients with urate crystalluria need to exclude from the diet foods rich in purine bases and nucleoproteins (liver, kidneys, brains, fish roe). For hyperuricemia, alcohol consumption is limited and foods containing large amounts of fiber and citrus fruits are recommended. Recommended drinks include hydrocarbonate mineral waters and diluted apple juice. Limit coffee beans (up to two cups per day), black tea (up to two cups per day). The level of hydrogen ion concentration in urine must be maintained within

In general, the pH is 6-6.5 due to a dairy-vegetable diet and the introduction of alkalis into the body. The patient is prescribed 0.5 mmol of alkali per 1 kg of weight in the form of NaHCO 3 or a mixture of potassium citrate and citric acid (5-6 doses per day). Citrate mixtures are absorbed more slowly in the intestine and, accordingly, are excreted in the urine longer. The drugs Urolit-U, Magurlit, Blemaren are prescribed, which contain alkali granules, a pH indicator and a comparison scale for determining the pH of urine. The presence of hyperuricemia in a patient with urate crystalluria is an indication for the use of allopurinol, which blocks the transition of hypoxanthine to xanthine and uric acid. Treatment begins with 200-300 mg/day, the dose can be increased to 600 mg/day.

Rice. 8.24. Plain radiograph of the kidney during percutaneous contact ultrasound nephrolithotripsy

Oxalate urolithiasis (oxaluria). Limit the consumption of foods containing oxalic acid and calcium (spinach, lettuce, rhubarb, sorrel, tomatoes, onions, carrots, beets, celery, parsley, asparagus, coffee, cocoa, strong tea, chicory, milk, cottage cheese, strawberries, gooseberries, red currants, plums, cranberries, etc.). The diet includes meat, boiled fish, rye and wheat bread, boiled potatoes, pears, apples, melons, dogwoods, quinces, peaches, apricots, fruit and berry juices, cauliflower and white cabbage, turnips, cucumbers. Treatment of oxaluria is based on limiting the introduction of exogenous oxalate into the body, correcting dysmetabolic disorders and restoring the crystal-inhibitory activity of urine. Calcium supplements, vitamin D, ascorbic acid, alpha-tocopherol, nicotinamide, unithiol and retinol are prescribed. For hypersecretory function of the stomach, retinol is used simultaneously with magnesium oxide, 0.5 g three times a day.

Phosphate urolithiasis (phosphaturia). The diet includes the consumption of meat food, since its consumption is accompanied by the most intense oxidation of urine. Patients are advised to increase their consumption of meat, poultry, fish, various flour, cereal and pasta products, butter, sugar and sweets, decoction of wheat coarse, bread kvass, honey. Citric acid is added to food, which binds calcium. Sauerkraut juice, sour and salty fruits and vegetables, and birch sap are useful. Limit the consumption of sour cream and eggs, vegetables (pumpkin, Brussels sprouts, peas), fruits and berries (cherry plum, apples, lingonberries, prunes, currants). The consumption of dairy products (except for sour cream, which can be eaten in small quantities), smoked foods, canned food, spices (pepper, horseradish, mustard), tea and coffee is prohibited.

Treatment consists of acidifying the urine. For this purpose, methionine is prescribed, 500 mg 3 times a day. To reduce the absorption of phosphates in the intestine and their excretion, aluminum hydroxide is used, 2-3 g 3 times a day.

Sanatorium-resort treatment is indicated for uncomplicated urolithiasis with or without the presence of stones during the period of remission of the disease. The most famous resorts are: Kislovodsk (Narzan), Zheleznovodsk (Slavyanovskaya, Smirnovskaya), Essentuki (No. 4, Novaya), Pyatigorsk and Truskavets (Naftusya). Taking mineral waters for therapeutic and prophylactic purposes is possible in doses of no more than 0.5 liters per day under strict laboratory control of the metabolism of stone-forming substances.

8.2. BLADDER STONES

Bladder stones They occur predominantly in older men and children and are a consequence of bladder outlet obstruction.

Etiology and pathogenesis. Stones can migrate from the upper urinary tract or form directly in the bladder. In both cases they are secondary with the only difference being that in the first they are secondary in relation to the site of formation, and in the second - in relation to the primary obstructive disease (benign hyperplasia, prostate cancer).

glands, urethral strictures, neurogenic bladder dysfunction, etc.), as a result of which they are formed due to stagnation of urine in the bladder. Stones can form on foreign bodies that remain in the bladder for a long time, primarily on ligatures made of non-absorbable material (ligature stones). Stone formation in women is observed in diseases of the bladder neck due to radiation cystitis, and in vesicovaginal fistulas.

Symptoms and clinical course. The main symptoms of bladder stones are pain in the suprapubic region, dysuria and hematuria. Pain in the projection of the bladder at rest decreases or goes away. It is characterized by its appearance and/or intensification during movement, walking, shaking, with irradiation into the urethra and genitals. The accompanying urinary disorders (pollakiuria, stranguria, terminal hematuria) also depend on physical activity, so bladder stones are characterized by dysuric phenomena in the daytime. A reliable sign of a bladder stone is the symptom of interruption (“backing up”) of the urine stream, which disappears when the patient assumes a horizontal position. Sometimes patients can only urinate while lying down. Wedging of a stone into the neck of the bladder or its entry into the urethra leads to acute urinary retention. Hematuria occurs as a result of damage to the bladder mucosa and/or the development of an inflammatory process.

Diagnostics based on characteristic complaints and anamnesis data. The presence of nephrolithiasis with the passage of stones, infravesical obstruction (hyperplasia, prostate cancer, anomalies, urethral stricture, etc.), previous operations on nearby organs, and radiation therapy are determined. The examination of male patients should end with rectal palpation of the prostate gland, which allows one to suspect its disease, and in women - with a vaginal examination to identify radiation injuries and vaginal urinary fistulas.

IN urine test erythrocytes and leukocytes are detected. Salt crystals can be episodic and often depend on the nature of nutrition and pH of the water.

chi. Bacteriological culture of urine makes it possible to identify its microflora and determine the titer of bacteriuria, which is important when carrying out antibacterial treatment.

Ultrasound allows you to identify hyperechoic formations with an acoustic shadow, their number and size

(Fig. 8.25).

A plain radiograph can reveal radiopositive stones in the projection of the bladder (Fig. 8.26, 8.27).

Excretory urography with descending cystography allows you to evaluate

Rice. 8.25. Sonogram. Bladder stone (arrow)

Rice. 8.26. Plain X-ray of the urinary tract. Bladder stone (arrow)

Rice. 8.27. Plain X-ray of the urinary tract. Large bladder stones (arrows)

renal function and the condition of the urinary tract, identify concomitant urological diseases; on a descending cystogram for X-ray negative stones, the corresponding filling defects are determined.

CT makes it possible to identify both X-ray positive and X-ray negative bladder stones (Fig. 8.28). The modern and most informative methods of examining patients are spiral and multi-slice CT with the possibility of three-dimensional image reconstruction.

Urethrocystoscopy (Fig. 17, see color insert) allows you to determine the capacity of the bladder and the condition of its mucous membrane, detail the shape, color,

size and number of stones, as well as identify concomitant diseases (prostatic hyperplasia, urethral stricture, diverticulum, tumor, etc.).

Treatment operational. Two methods are used: stone crushing (cysto-lithotripsy) and stone cutting (cis-tolithotomy).

Stone crushing is the operation of choice and is performed through external lithotripsy or endoscopic contact

Rice. 8.28. CT, axial projection at the pelvic level. Bladder stones (arrows)

destruction of stones. In the latter case, contact lithotripters with various types of energy (electrohydraulic, ultrasonic, pneumatic and laser) and a mechanical lithotripter are used. It consists of two jaws, which, after insertion into the bladder, open, a stone is clamped between them under visual control, then the jaws are compressed, as a result of which the stone is destroyed.

Cystolithotomy currently used rarely and, as a rule, when performing open operations on the prostate gland.

Forecast depends on the severity of the disease, leading to bladder outlet obstruction with subsequent stone formation. If the underlying disease is eliminated, the prognosis is favorable, otherwise recurrent stone formation is possible.

8.3. URETHAL STONES

Urethral stones observed only in men. They can either form directly in the urethra in the presence of narrowings, valves or diverticula, or enter the urethra from the overlying urinary tract.

Symptoms and clinical course. Patients complain of pain in the urethra, difficult, painful urination and a thin stream of urine with splashing. Complete obstruction of the urethra by a stone is manifested by acute urinary retention.

Diagnostics. Based on a thorough collection of complaints and anamnesis, a diagnosis can be assumed. Anterior urethral stones are easily identified by palpation of the urethra, and posterior urethral stones by digital rectal examination. Leukocyturia and hematuria are characteristic. The final diagnosis is made based on Ultrasound, radiography of the pelvic area, urethral examination bougies or metal catheters (characteristic sensation of metal touching stone) and urethroscopy.

Treatment Treatment of urethral stones involves their endoscopic removal. Scaphoid stones are removed using tweezers or a clamp. The narrowed external opening of the urethra is expanded with conical bougies or dissected.

Control questions

1. List the main causes of kidney stones.

2. Give the classification of urinary stones.

3. How is kidney and ureteral stones diagnosed?

4. What is the difference between hematuria due to nephrolithiasis and kidney tumor?

5. What diseases should be differentiated from renal colic?

6. What complications are possible with urolithiasis?

7. List the principles of conservative treatment of urolithiasis.

8. What are the indications and contraindications for extracorporeal lithotripsy?

9. What types of endoscopic operations are performed for kidney and ureteral stones?

10. What is the metaphylaxis of nephrolithiasis?

Clinical task 1

A 23-year-old patient was admitted as an emergency with complaints of dull pain in the right iliac region, nausea, dry mouth, frequent painful urination, and an increase in body temperature to 38.9 °C. She became acutely ill about 9 hours ago. On examination, the condition is of moderate severity, lethargic, adynamic. The tongue is dry, not coated. Pulse 92 beats per minute, blood pressure - 110/70 mm Hg. Art. Palpation reveals pain and tension in the anterior abdominal wall in the right iliac region, as well as positive symptoms of peritoneal irritation. Palpation and tapping in the lumbar region are painless. In the blood, pronounced leukocytosis is detected with a shift in the leukocyte formula to the left. In urine analysis, leukocytes are 2-3, red blood cells are 0-1 in the field of view. According to ultrasound, no pathology of the kidneys or bladder was detected. There are no shadows of stones on a plain radiograph of the urinary tract.

What diseases can be suspected? How to make a differential diagnosis?

Clinical task 2

A 46-year-old patient was hospitalized in the urology department with complaints of constant pain in the lower back on the left. The examination revealed no changes in clinical and biochemical blood tests. The analysis showed moderate leukocyte turia up to 8-10 per field of view, erythrocyturia 15-20 per field of view. A plain radiograph (Fig. 8.29) and an excretory urogram (Fig. 8.30) were performed.

What is determined on radiographs? Make a diagnosis. What treatment tactics should I choose?

Rice. 8.29. Plain X-ray of a 46-year-old patient

Rice. 8.30. Excretory urogram of the same patient

Rice. 8.31. Plain X-ray of the urinary tract of a 54-year-old patient

Clinical task 3

The patient, 54 years old, complained of pain in the lower abdomen, frequent painful urination mixed with blood. The above phenomena intensify with movement and walking. Periodically, a “blocking” stream of urine occurs. From the anamnesis it is known that two years ago the patient underwent extirpation of the uterus and appendages. The operation took longer than usual due to technical difficulties and bleeding. In the process, there was a suspicion of a bladder injury. Its eroded areas were sutured with double-row silk sutures. In the postoperative period, urine mixed with blood was released through the catheter for two days. After discharge from the hospital, I felt well during the first year. Later I began to notice the above phenomena

with a tendency to worsen. On examination, the condition is satisfactory, the abdomen is soft, painful above the womb. In urine analysis, leukocytes and erythrocytes cover the entire field of view, protein 1.65 g/l. The patient underwent a plain radiograph of the urinary tract (Fig. 8.31).

Symptoms of kidney stones are almost always individual, so describe your case in the comments, or write in the question and answer section.

Causes of kidney stones

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.

Causes causing the formation of stones (list)

Modern medicine does not offer a unified concept of the causes of urolithiasis. Among the factors causing ICD are the following:

• hereditary predisposition;
• various kidney anomalies (horseshoe kidney, duplication, dystopia, ureterocele, spongy kidney, etc.);
• urodynamic disorders, inflammatory changes, urinary tract obstruction;
• congenital and acquired diseases of other organs;
• endocrine disorders (hyperparathyroidism, diabetes mellitus);
• sedentary lifestyle, physical inactivity, blood stagnation in the pelvic organs, microcirculation disorders;
• climatic and biogeochemical factors, the content of various impurities in drinking water;
• environmental pollution, poor socio-economic conditions;
• the presence of pesticides, herbicides, insecticides in soil and food;
• the influence of preservatives, dyes, stabilizers, emulsifiers and other food additives;
• uncontrolled use of medications, especially diuretics, antacids, acetazolamide, corticosteroids, theophylline, citramon, alopurinol and vitamins D and C;
• laxative abuse;
• prolonged stress;
• inflammatory processes, both bacterial and autoimmune, the presence of metabolic products of microorganisms in the body;
• dietary features and associated changes in urine pH, impaired protein digestibility, excess products of purine metabolism, hypercaloric nutrition;
• lack of crystallization inhibitors (zinc, manganese, cobalt ions) and solubilizers (substances that maintain colloidal stability of urine and help maintain salts in dissolved form, for example, such as magnesium, sodium chloride, hippuric acid, xanthine, citrates);
• metabolic disorders (hyperuricemia, hyperoxaluria, cystinuria, urine pH< 5,0 или > 7,0).

Reasons for the reappearance of stones

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:

• stones containing brushite;
• stones containing uric acid, ammonium urate, or sodium urate;
• infection stones;
• residual stones or their fragments, more than three months after therapeutic treatment;
• first episode of stone formation before the age of 25;
• frequent formation of stones (3 or more in 3 years);
• familial urolithiasis;
• genetic: cystine, xanthine, dehydroxyadenine stones, primary hyperoxaluria, renal tubular acidosis, cystinuria, hypercalciuria;
• the only working kidney;
• nephrocalcinosis;
• dysfunction of the parathyroid glands, hyperparathyroidism;
• medications: preparations containing calcium and vitamin D, ascorbic acid in large doses, sulfonamides, triamterene, indinavir;
• gastrointestinal diseases and conditions: Crohn's disease, small intestinal resection, small intestinal bypass anastomosis, malabsorption syndrome;
• anomalies: spongy kidney, horseshoe kidney, diverticulum or calyx cyst, stenosis of the ureteropelvic segment, ureteral stricture, vesicoureteral reflux, ureterocele.

What contributes to the formation of kidney stones

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 microliths.

Sometimes the stones have a homogeneous composition, however, often, kidney stones have a mixed mineral composition, so we can only talk about the predominance of one or another type of mineral salts from which the base of the stone is formed.

Therefore, strict dietary prescriptions are not always advisable, although excluding foods such as coffee, strong tea, chocolate, fried meat from the daily diet, 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 with a proper diet, 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.

Where do kidney stones and sand come from?

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 a special diet), living conditions, profession, urinary tract infections, anatomical and physiological features of the structure of the urinary tract, vascular disorders.

Signs of sand in the kidneys

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 the groin area and 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.

How to identify sand and kidney stones

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 of the 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.

Diet for sand and kidney stones

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.

First aid for renal colic

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 an ambulance, as 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.

The effect of stagnation of urine on the formation of kidney stones

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 stones and chronic infection not only of the urinary system, but also of 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.

Formation of primary and secondary kidney stones

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.

The relapse rate after surgical removal of kidney stones is 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 an infection of the urinary system and impaired outflow of urine, 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 (their daily amount is 1-1.5 g) decreases, and their physicochemical properties 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.

Secondary kidney stones

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 a 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 tips 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. Any foreign body in the urinary system 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.

Correctly selected diet for urolithiasis- This is one of the most important factors in preventing recurrent stone formation. The diet is determined by the type of stones, so it is extremely important to accurately determine the chemical composition of urinary stones. Below are dietary recommendations for the main types of urinary stones.

Diet for oxalate stones (oxalates)

Limit: foods rich in oxalic and ascorbic acid, as well as calcium - sorrel, spinach, beets, potatoes, cottage cheese and cheese, beans, figs, parsley, plums, gooseberries, strawberries, citrus fruits, strong tea, coffee, cocoa, chocolate.

Recommended: oatmeal, buckwheat, millet porridge, nuts, carrots, apples, pears, quinces, grapes, white and black bread; butter and vegetable oil, boiled meat, poultry and fish, cauliflower and white cabbage, green peas, turnips, cucumbers, apricots, peaches; alkaline mineral waters, kombucha.

Diet for urate stones (urates)

Limit: concentrated meat and fish broths, offal, sorrel, spinach, peas, beans, beans, red wine, beer, pickles, smoked meats, marinades, coffee, cocoa, chocolate.

Recommended: tea with lemon, citrus juice in between meals (prevents the formation of urates); eat meat, fish and poultry only in boiled form, no more than three times a week; milk and all dairy dishes, eggs, rice and oatmeal, vegetables, fruits, day-old bread, black and red caviar, honey, marmalade, marshmallows, walnuts.

Diet for phosphate stones (phosphates)

Limit: foods rich in calcium: milk and dairy products, including yogurt, cheese, feta cheese; spices, sauces, savory snacks and seasonings.

Recommended: meat and fish in all types, including mild fish snacks, soaked herring; weak tea and coffee without milk, bread, eggs and egg dishes (1 - 2 times a week), butter and vegetable oil; peas, pumpkin, Brussels sprouts, red currants, sour apples.

The general law for all patients with urolithiasis, regardless of the type of stones, is drinking plenty of fluids. Drink at least 1.5-2.0 liters of fluid per day (including tea and soups). The urine should be “like water”, because with a low concentration of salts, they will not fall out in the form of crystals and lead to the formation of stones!

However, there are often cases when the exact composition of the stones cannot be determined (for example, it was not possible to catch a loose stone, the examination did not reveal biochemical abnormalities). In such cases, it remains to adhere to general recommendations, the main one of which is drinking plenty of fluids. The diet should be varied, balanced, with enough vegetables and fruits. Avoid coffee and chocolate.
And do not forget to periodically monitor the condition of your kidneys using ultrasound and urine tests.

Classification of kidney stones according to various criteria is the main criterion for choosing further methods of treating urolithiasis.

Diagnosis of the chemical composition of solid formations, their quantity, shape helps the doctor to create an accurate picture of the pathology and prescribe the most effective course of therapy.

In addition, the belonging of a stone to a certain group presupposes the prescription of a specific diet.

Stones are formed from a mixture of minerals and organic substances. Modern medicine offers four main groups of kidney stones:

– Oxalates and phosphates. This is the most common category of education. Stones are diagnosed in 70% of patients diagnosed with urolithiasis. The basis of formations of inorganic origin are calcium salts.

– Struvite and phosphate-ammonium-magnesium stones. This type of stones occurs in 20% of patients. The cause of the formations is diseases of the urinary tract of an infectious nature. That is why they are called infectious.

– Urats. Diagnosed in 10% of all patients. The cause of the appearance is excess uric acid and some pathologies of the digestive tract.

– Xanthine and cystine stones. Quite rare formations. Occurs in 5% of patients. Experts associate their appearance with congenital pathologies and genetic disorders.

It is quite difficult to detect stones that are pure in composition; half of the patients are diagnosed with mixed type formations.

What are kidney stones?

There are quite a lot of classification criteria.

1. By quantity: half of the patients are diagnosed with single stones; often one has to deal with the formation of two or three stones in the kidneys; the least rare case is multiple formations in the kidneys.
2. By location in the body: unilateral and bilateral.
3. Shape: round, flat, with edges, spikes, coral-shaped.
4. By size: the size of the formation can vary from the eye of a needle to the size of the entire kidney cavity.
5. According to the location: stones form in the kidney, bladder or ureter.

Types of Kidney Crystals

The most common classification of solid formations by chemical composition. If earlier doctors assumed that the formation of stones was associated with the quality of water that the patient drinks, the climate and geographical features of the area where he lives, today there are many supporters of a different hypothesis among specialists. It is generally accepted that the process of urolithiasis begins in the body when the ratio of salts and colloids in urine is disrupted.

The classification of stones by chemical composition is as follows:

• oxalates – formed from salts of oxalic acid;
• phosphates – formed from calcium phosphate;
• urates – the main component is uric acid salts;
• carbonates – formed from calcium salts of carbonic acid;
• struvite - formed from ammonium phosphate.

Classification of stones by chemical composition

In addition, it is necessary to isolate stones of organic origin. These include:

• cystine and xanthine;
• cholesterol;
• protein.

Did you know that open operations to remove stones are being replaced by more gentle surgical methods of treatment? , surgical and conservative treatment, as well as the causes of stone formation.

You will find recipes for herbal remedies for various kidney diseases.

Urats

The main feature of urates is their ability to appear in a variety of places in the urinary system.

The age of the pathology varies from 20 to 55 years.

The patient’s age directly affects the location of the stone in the body.

In children and elderly patients, urates are formed in the bladder; in middle-aged people, stones are diagnosed in the kidneys and ureter.

Among the main factors influencing the formation of urates, experts identify:

• poor water quality;
• unfavorable environmental situation;
• sedentary lifestyle;
• metabolic disorders;
• unhealthy diet: excess of sour, salty foods, as well as fried foods;
• lack of B vitamins.

The shape of the stones is round, the surface is smooth, the structure is loose. The color range varies from yellow to brown.

Treatment of stones is associated with the elimination of the inflammatory process. Therapy also involves prescribing nutritional therapy and taking medications.

Urate or uric acid kidney stones are distinguished by their ability to dissolve quickly, which is why patients are prescribed plenty of fluids and a course of treatment with medicinal herbs.

Considering that urates are a fairly common type of stones and pathology can appear at any age, experts recommend adhering to the basic rules of a healthy lifestyle: moving and eating a balanced diet.

Such preventative measures will help avoid problems with stones in the future.

Struvite

These formations belong to the category of phosphate stones.

The formations contain ammonium magnesium phosphate and carbonate apatite.

Struvite can form only in an alkaline environment affected by infection.

Thus, the main reasons for the formation of struvite stones are:

• alkaline urine reaction;
• the presence of certain bacteria in the urinary tract.

Struvite is characterized by its ability to quickly increase in size, filling the entire cavity of the kidney and causing complications such as sepsis and acute renal failure. It is also worth noting that struvite tends to form in women.

During therapy, it is important that the smallest particles of stones leave the body. Otherwise, the disease will reappear.

Cystine stones

A rather rare type of stones, the formation of which is caused by a genetic pathology - cystinuria.

Children and young people are most susceptible to the development of cystine stones.

The main component of the stone is amino acid.

Doctors call the main feature of the symptoms of the disease constant pain, even after taking painkillers.

Treatment of the pathology is as follows:

• changing the acidity of urine with citrates;
• special diet;
• drug treatment;
• crushing stones;
• surgery if conservative therapy is ineffective.

In some cases, the only way to cure the patient is a kidney transplant.

Mixed stones

They are formed mainly as a result of long-term use of certain medications.

The stones combine the characteristics of salt and protein kidney formations.

Treatment in this case is determined individually in each clinical case, depending on the test results obtained and the severity of the disease.

From the author

Five secrets to healthy kidneys.

1. Movement and active lifestyle.
2. Proper nutrition.
3. The kidneys should be warm.
4. Prevent illness: drink kidney infusions, brew half a glass.

And, of course, do not self-medicate. In this situation, any rash act can aggravate the problem.

Video on the topic

I had no idea that kidney stones come in so many varieties. And each type of stone has its own reason. You need to see a good doctor who will make the correct diagnosis and prescribe treatment that will help with a specific type of stone.

• If you have not yet gone to the doctor with a question about what type of stones you have, then I warn you in advance that no one will determine this for you, the doctor will prescribe 2 or 3 drugs for different types of stones for good luck, so that during the reception process you can guess which one you should take . And you will never find out what stones you have from your doctor. But the theory described above exists, but doctors do not use it in practice, at least in a simple clinic. Ha ha ha. …..Thank you to the authors for the article, it’s good.

  • Nina, what kind of heresy are you talking about? The doctor sends the patient to a biochemical laboratory, where the composition of the stone will be determined. After this, an appropriate diet is prescribed. Doctors are no more stupid than you, believe me))