Urolithiasis diagnosis of diseases. Urolithiasis disease. Dissolving stones with medications

For quotation: Pushkar D.Yu., Rasner P.I., Kupriyanov Yu.A., Maltsev E.G., Gurov E.Yu., Umyarov M.S., Sidorenkov A.V. Urolithiasis // Breast cancer. 2014. No. 17. P. 14

Urolithiasis (URolithiasis) is a disease associated with the formation of stones (calculi) in the kidneys and/or other organs of the urinary system. People of all age groups can suffer from urolithiasis, from newborns to the elderly. The type of urinary stone usually depends on the age of the patient. In older people, uric acid stones predominate. Protein stones form much less frequently.

It should be noted that more than 60% of the stones are mixed in composition. Urinary stones almost always form in the kidneys. They mainly enter the ureter and bladder from the kidney. In most cases, KSD is a one-sided process, but sometimes stones are detected in both kidneys at once. The number of stones can vary widely - from single to multiple (several dozen). Stones can be small (2–3 mm) and large (up to 15 cm). There are descriptions of stones whose weight was several kilograms.

The main reason for the formation of kidney stones is metabolic disorders, especially changes in the water-salt and chemical composition of the blood. In addition to hereditary predisposition, risk factors for urolithiasis include dietary habits determined by the specific national cuisine or the special preferences of a particular patient.

There is also the problem of so-called “secondary” stones. They are formed against the background of a violation of the outflow of urine, as a result of which crystals of salts, which are dissolved in high concentrations, precipitate (crystallization theory of stone formation). The quality and chemical composition of drinking water are of great importance. There are well-known regions of Russia in which the incidence rates of urolithiasis are significantly higher than the national average - the Caucasus, the Volga region. Among the foreign regions are Africa, the countries of Central and Southeast Asia, and the islands of the Indian Ocean.

Factors in the development of KSD are also a sedentary lifestyle, a lack of dietary vitamins A and B, the use of certain medications (sulfonamides, excessive consumption of ascorbic acid), as well as prolonged immobilization of the patient (consequences of injuries, fractures, etc.). In addition, these are chronic diseases of the gastrointestinal tract (gastritis, colitis, peptic ulcer, etc.) and the genitourinary system (pyelonephritis, prostatitis, prostate adenoma, cystitis, etc.); dysfunction of the parathyroid glands; osteomyelitis, osteoporosis, other bone diseases or injuries; constant consumption of foods that increase the acidity of urine (spicy, sour, salty); drinking hard water with a high salt content.

Types of stones by composition

Urate stones (Fig. 1) occur in 5–15% of people with urolithiasis. These are stones consisting of uric acid and its salts (sodium and potassium), hard and smooth, brick or yellow-orange in color. Due to their low density (the absence of calcium in their composition), urate stones are not visible on X-rays. They are diagnosed using ultrasound and laboratory urine analysis.

The reasons for the formation of such stones are poor nutrition, insufficient fluid intake (less than 2 l/day), metabolic failure, tubular kidney damage.

If urate stones are detected, you should be tested for uric acid levels and rule out the development of a disease such as gout. Stones that arise due to the deposition of large amounts of uric acid salts can signal the development of joint diseases, and vice versa.

Urate stones are the only ones that can be dissolved, especially if they are small in size. This requires alkalization of urine, a special diet, and the use of diuretics.

Oxalate stones (Figure 2) are the most common type of stone. Formed in the kidneys due to an excess of calcium salts of oxalic acid. They have a high density, so they are easy to diagnose both with ultrasound and X-ray examination. Oxalates are stones of high density, black-gray in color, with a spiky surface. These spines often scratch the lining of the urinary tract, which can cause red blood cells to appear in the urine. The movement of stones through the urinary tract can cause severe pain (renal colic). The pain can be localized in the lower back, groin area, and sides of the abdomen.

Often the formation of oxalate stones occurs in people who eat excess amounts of citrus fruits and juices, sorrel, spinach, lettuce, beets, as well as tea, coffee and chocolate. Also, the risk of oxalate formation is high in people who consume small amounts of calcium, since this mineral binds and removes oxalic acid salts from the body. Other reasons for the formation of oxalate stones include vitamin B6 deficiency and certain diseases of the small intestine (resection, Crohn's disease).

Oxalate stones cannot be dissolved. If the size of the stones is small (up to 4 mm), you can try to remove them from the body with urine. To do this, you need to drink a lot of fluid (up to 2.5 l/day), adhere to a diet and take measures to alkalize urine. Passing a stone is a long and painful process, so you need to set yourself up for 3-4 weeks. treatment and, if necessary, relieve pain with antispasmodics and painkillers. If the stone is large, it must be removed.

The most common methods used to remove oxalate stones are:

1) lithotripsy - crushing stones using electromagnetic shock waves;

2) puncture nephrolitholapaxy - crushing the stone after puncture of the kidney and insertion of instruments into its cavity system;

3) contact lithotripsy - carrying out instruments for crushing and extracting stone fragments through natural pathways (urethra, bladder, ureter to the area where the stone is located) without additional incisions and punctures.

The extent of the operation depends on the location and size of the stone. Open surgery to remove the stone has become rare these days.

Phosphate stones (Fig. 3) consist of calcium salts of phosphoric acid. Smooth or slightly rough white stones have a soft consistency. Most often they are formed in alkaline urine due to metabolic disorders. The presence of phosphates can be easily detected by doing a urine test - in this case the pH value is above 6.2. If white, loose flakes are observed in the urine, this most likely indicates the presence of phosphate stones. Treatment in this case should be aimed at acidifying the urine. This can be achieved by eating sour juices, mineral waters, infusions of grape root, barberry, and rose hips. As a rule, as a result of such treatment, phosphate stones, despite their rapid growth, are easily crushed and stop increasing in size.

Struvite stones (Fig. 4) are stones characterized by rapid growth and a soft structure. Their surface is smooth or rough, the color of such stones is white or light gray. Stones of this type are formed as a result of stagnation of urine or the activity of bacteria and are infectious in nature. Most often, struvite stones occur in women. Struvite is dangerous because in a few months it can develop into coral stones and fill the entire kidney from the inside, creating an impression of the pelvis.

These stones are diagnosed using ultrasound, x-rays, computed tomography and urinalysis. If struvite stones form in the urine, under magnification, crystals similar in shape to the lid of a coffin are found.

Treatment of struvite stones with herbal medicine and medications is ineffective. If the stone is small, a lithotripter is used to crush it, and if the stone is large, then surgery is needed.

If you have renal colic, pain in the lower back, groin or sides, you should immediately consult a doctor. Nephrolithiasis, detected in the early stages, is easily treatable and most often resolves without negative consequences.

Symptoms of ICD

The classic manifestation of ICD is renal colic - a sudden attack of severe pain in the lumbar region, caused by a violation of the outflow of urine through the urinary tract. Colic often occurs after a bumpy ride, heavy physical activity, or drinking large amounts of liquid. The nature and location of pain may depend on the position of the stone. Most often, stones in renal colic are detected in the area where the ureter originates from the pelvis or lower in the ureter. Until the moment when the stone manifests itself in this way, ICD may be asymptomatic. If the stone is located in the lower parts of the ureter, pain, in addition to the lumbar region, may appear in the lower abdomen and radiate to the groin area and external genitalia. The pain occurs suddenly at any time of the day. Changing body position does not affect the intensity of pain. Typical accompanying pain is nausea, vomiting, changes in the frequency of the urge to urinate, blood in the urine and pain when urinating. Long-term disruption of the outflow of urine can cause inflammatory changes in the kidney or loss of its functional ability, resulting in shrinkage. An increase in body temperature to 38–40°C is characteristic of the addition of inflammation against the background of impaired urine outflow.

If the size of the stone does not exceed 5–6 mm (the diameter of the ureter), then it may pass on its own. Once in the bladder, the calculus most often comes out unhindered (the diameter of the urethra exceeds the diameter of the ureter). If the stone is large, remains in one place for a long time without a tendency to move, or is located in an area of ​​narrowing of the urinary tract, then specialist intervention may be required. After contacting a specialized institution, the minimum list of examinations includes blood and urine tests, ultrasound, and a plain X-ray (urography). A more in-depth study may include taking x-rays with preliminary injection of radiopaque agents into the vein or computed tomography.

A person can carry a kidney stone all his life and not know about it. But a 3–4 mm stone that begins to move along the ureter can cause renal colic, in which a person will experience very severe, excruciating pain.

Treatment of urolithiasis

First of all, when treating ICD, it is necessary to relieve an attack of renal colic. The next steps in treatment are removing the stone, treating the infection, and preventing the stones from reoccurring.

Currently, the treatment of urolithiasis includes conservative and surgical methods.

Conservative treatment is quite effective if the kidney stones are small in size (up to 3–5 mm). Specific medications, diet and drinking regimen are prescribed. If the inflammatory process begins, antibacterial therapy is carried out. Systematic intake of antispasmodics and herbal diuretics is prescribed.

Surgical treatment is carried out strictly according to indications and in cases of ineffectiveness of conservative therapy.

Diet for ICD

Diet plays an extremely important role in the treatment of urolithiasis. Its selection should be carried out by a doctor depending on the chemical composition of the stones. Products that provoke the growth and formation of new deposits are excluded from the patient’s diet, or their consumption is limited. Following a diet helps reduce the concentration of stone-forming substances, which helps stop the growth and softening of stones, as well as their passage.

Diet for stones
high urate content

The goal of the diet for such stones is to reduce the level of uric acid and its salts in the body.

The number of meals per day is 5–6 with an equal break.

Features of this diet:

Exclusion of foods high in purines (specific protein);

Maintaining normal levels of proteins, fats, and carbohydrates in food;

Eating foods that contain sufficient alkaline radicals (to increase alkaline levels).

Preferred products: fermented milk products (including kefir and milk), various cereals (oats, buckwheat, millet), fruits (especially sweet ones), vegetables (any), natural juices (not store bought, as they may contain contain preservatives and taste regulators), animal proteins (eggs, lean fish, lean meat, chicken), for sweets it is better to use natural honey.

Foods to avoid: fried or smoked meats, mushrooms, spicy seasonings, products made from cocoa beans (including chocolate, cocoa), coffee, canned fish.

Diet for phosphate stones

The purpose of the diet is to normalize the acid balance and thereby stop the appearance of calcium salts. This is achieved:

Increasing consumption of foods containing vitamin A and calcium;

Refusal to consume salt;

Water load – up to 2.5 l/day;

Increased acidity of urine.

Allowed foods: low-fat fish and meat products (including boiled and even fried), pasta, soups (including with cereals and beans, the broth for such soup should not be too fatty), sour fruits ( especially apples and currants).

Prohibited products: natural juices (fruit, vegetable, berry), dairy products, fruits and vegetables with a high content of alkaline elements.

Alcohol is not good for any diet. In addition, it is recommended to limit or minimize the consumption of cocoa and coffee.

Diet for stones with high
oxalate content

The goal of the diet is to reduce the consumption of foods containing oxalic acid. It is necessary to completely exclude from the diet such products as sorrel, rhubarb, and all cocoa derivatives (especially chocolate). It is necessary to reduce the consumption of potatoes, carrots, tomatoes, onions, beets, and gelatin.

Foods that help lower oxalic acid levels: apples, grapes, plums and many other fruits.

While using this diet, it is very important to drink plenty of fluids – about 2 l/day, not drink alcohol and reduce the amount of sweets. Fasting days will be of great benefit, during which you are only allowed to drink juices, eat vegetables (of course, those that are not prohibited in this diet) and apples.

Diet for stones with high
carbonate content

You should carefully monitor the amount in food of those foods that increase the alkaline balance. Water load – at least 2 l/day. The diet should not be too long - it is not harmless to the body.

Products that should be limited: first of all, these are any food products containing calcium, including milk, yoghurts, cottage cheese, cheeses and other fermented milk products.

Recommended products: high in protein (fish, meat, chicken), cereals (primarily oatmeal) and flour products (for example, pasta). All of these foods should increase the acid level of urine in order to reduce the risk of new and enlarged carbonate stones.

For all types of urolithiasis, it is necessary to increase the volume of fluid consumed (at least 2 l/day), especially in summer, and avoid the feeling of thirst. Regularly take diuretic infusions or decoctions of various herbs, do not overeat, limit the consumption of spicy, sour, fatty foods. Losing weight by limiting your intake of high-calorie foods reduces your risk of developing the disease. It is necessary to exclude alcohol from the diet, increase physical activity, try to avoid emotional stress, and avoid overcooling.

The recommendations described above are quite universal. A more careful diet for patients with urolithiasis is compiled based on the doctor’s recommendations, taking into account the type and size of kidney stones, as well as the chemical composition of urine.

Surgical treatment aims to remove large stones (more than 8–10 mm) or stones of any size that cause any complications.

We will not consider open operations in our review, since with the advent of endovideosurgical techniques they are used only in exceptional cases.

External shock wave lithotripsy (ESWL) is the impact on a calculus in the urinary tract with a shock wave of a very short duration (from 0.3 to 0.8 μsec). This technique is most preferable because it is most easily tolerated by patients. Some crushings can be performed without anesthesia, while others can be performed under general anesthesia. It depends on the equipment and characteristics of the stone. Unfortunately, it is not always possible to crush urinary stones in this way. Classic indications for performing ESWL are the size of the stone no more than 2.5 cm, its location in the kidney, good visualization, low density of the stone, absence of obstruction of urine outflow (otherwise the stone fragments will not be able to pass away with the urine flow).

Contact lithotripsy (CLT) is the destruction of cameos of the ureters, bladder and kidneys using special instruments: ureteroscope - used to crush ureteral stones, nephroscope - kidney stones, cystoscope - bladder stones; laser fiber or ultrasound directly contacts the stone and destroys it. The optimal use of CLT is for ureteral stones, stones with a high density (more than 1000 HU), more than 10 mm in size, stones that are not very visible with X-ray and ultrasound guidance due to the specific chemical composition and/or location area (in these cases, ESWL is ineffective) . CLT is also used after 2 unsuccessful attempts at ESWL, when the stone remains in one place for a long time, etc. CLT is performed in an operating room under anesthesia, the type of which is determined individually and is determined by the patient’s age, duration of the operation, the presence of concomitant diseases, etc.

At the end of the procedure, a ureteral stent is installed for a period of 10 to 30 days. A stent is a thin and flexible tube that has many holes along its length and ensures good outflow of urine from the kidney in the event of postoperative swelling of the ureteral mucosa.

In the presence of acute purulent inflammation, crushing the stone is impossible - more extensive surgical intervention is necessary!

Percutaneous nephrolithotripsy (PNL) (percutaneous lithotripsy)

An instrument is inserted through a 1 cm long puncture in the lumbar region into the abdominal cavity system of the kidney. The stone is destroyed under visual control using one of the available methods, and its fragments are removed. It is possible to remove stones in the kidney and upper ureter.

Indications for PCNL are large kidney stones (more than 2-2.5 cm, and if the stone is localized in the lower calyx - more than 1-1.5 cm), multiple kidney stones, large stones of the upper ureter (more than 1 cm), and also a combination of kidney stones and narrowing of the ureteropelvic segment. PCNL is also indicated when extracorporeal lithotripsy is ineffective, when the stone could not be destroyed in 1–2 sessions.

Prevention of ICD

A proper diet is the key to success in preventing urolithiasis. It is necessary to limit the consumption of fatty, fried, spicy and salty foods, and not to overeat. Drinking 2 l/day of clean (not mineral) water should become the rule.

If renal colic takes you by surprise, you need to call a doctor; taking a medication with an antispasmodic effect may help. If the attack does not stop or recurs, hospitalization in a urological hospital is required.

Attention!

You need to make sure that you are having an attack of renal colic, and not an acute inflammatory disease of one of the abdominal organs. In acute inflammatory processes in the abdominal cavity, heat is strictly contraindicated, as it causes a more rapid development of the disease. And painkillers, dulling the pain, “blur” the clinical picture of the disease, make it difficult to recognize it and thus can lead to a delay in surgery, which in most cases of acute inflammatory diseases of the abdominal organs is the only correct method of treatment.

Patients with urolithiasis are advised to undergo a preventive examination by a urologist at least twice a year and undergo an ultrasound examination of the urinary system.

Among the most indolent pathologies in the field of urology, urolithiasis of the kidneys ranks first. For a long time, the patient does not realize that he has stones. Only due to their mobility and the appearance of concomitant symptoms is it possible to learn about the development of the disease. At the first symptoms, you should consult a doctor, undergo an examination, and receive the necessary treatment.

Urolithiasis (UCD) of the kidneys, or urolithiasis, is a disease whose development takes more than six months. Initially, sand forms, then, if the patient continues to lead an unhealthy lifestyle, stone-like deposits form. Concretions (their second name) can be single or multiple. Depending on the chemical composition, they are divided into oxalates, urates, phosphates, xanthines, cystines and struvites.

Localization of stones inside the kidney is the most dangerous of all types of urolithiasis, since damage to the organ occurs and problems with the outflow of urine. Factors predisposing to the development of urolithiasis are varied, but are associated with the patient’s lifestyle. Therefore, minimizing the development of urolithiasis is within his competence.

Causes of stone formation

The likelihood of stone formation increases if the patient:

1. Abuses sour, spicy, salty foods
2. Leads a sedentary lifestyle
3. Does not eliminate inflammatory and infectious processes in the organs of the urogenital tract
4. Has a hereditary predisposition to the development of urolithiasis
5. Drinks unfiltered water

Other predisposing factors are disorders of protein metabolism, enzyme deficiency, problems with the functioning of the gastrointestinal tract, and dehydration.

Symptoms

The development of urolithiasis occurs asymptomatically. Only a change in the position of the solid conglomerate leads to the appearance of signs. The condition is defined as renal colic and is accompanied by characteristic phenomena, including:

• Pain syndrome. Localization – lumbosacral back, with transition to the groin, suprapubic region
• Dyspeptic phenomena. Nausea and prolonged, repeated vomiting are constant manifestations of an attack of renal colic.
• Increased body temperature. Caused by the onset of complications (for example, inflammatory processes of the urogenital tract) or psycho-emotional arousal
• The appearance of blood in the urine (hematuria). The symptom is caused by damage to the kidney tissue by stony deposits during its mobility
• Reducing daily diuresis. A reduction in urine volume is caused by a stone blocking the ducts.
• Neurological disorders. Irritability, short temper, and general restlessness are explained by pain. The patient cannot assume a certain body position

Other symptoms depend on the location of the stone inside the pelvis, its size and composition, and the age of the colic. Of no small importance is the presence of concomitant pathologies and complications in the patient that resulted from urolithiasis. Physical activity and bumpy riding can trigger colic.

Possible complications

The following complications may develop as a result of urolithiasis:

1. Pyelonephritis (inflammation of the renal pyelocaliceal system). The condition is caused by the stone remaining in an unchanged position for a long time, which contributes to the accumulation of pathogenic microflora around it
2. Hypertensive crisis. The pathology is associated with an increase in blood pressure due to compression of the renal artery by stone-like deposits
3. Paranephritis. An extremely serious condition in which the parenchyma melts due to a purulent process. The reason for its development is complicated pyelonephritis
4. Iron-deficiency anemia. Refers to the effects of constant blood loss during urination

The occurrence of any of these complications can be avoided if you promptly seek qualified medical help. Only by using proven, competent methods can you save a kidney with a calculus inside.

Urolithiasis during pregnancy

KSD, worsened during pregnancy, poses a threat to the development of pyelonephritis. Inflammation of the pyelocaliceal system never resolves on its own and always requires drug treatment. It is this fact that is incompatible with the period of pregnancy and aggravates it. Regarding the use of medications, gynecologists do not object to administering an injection of No-shpa directly during renal colic. But other medications are strictly contraindicated for pregnant women.

The second risk that women with urolithiasis are exposed to during pregnancy is a violation of the outflow of urine (if the canal is blocked by a stone). This creates problems with urination and causes pain in the lumbosacral back. Also, stagnation of urine contributes to the attachment of pathogenic microflora and the development of inflammatory and infectious processes.

The presence of a calculus and its movement inside the pelvis do not directly affect the course of pregnancy. The operation is not performed during pregnancy; women are recommended to treat stones with medication only after childbirth.

Disease in children

The following factors contribute to the development of urolithiasis in children:

• Hormonal problems that cause disturbances in calcium metabolism in the body
• Predominance of sour and salty foods in the diet
• Limited mobility
• Drinking contaminated water
• The presence of inflammatory diseases of the urogenital tract, in which a change in the chemical composition of urine occurs
• Hereditary predisposition

If the child does not have signs of hydronephrosis - hydronephrosis of the kidneys, and purulent damage to this organ, crushing the stones is carried out in a conservative way.

Which doctor should I contact?

As with the elimination of other pathologies related to the urinary system, treatment of urolithiasis is carried out by a urologist. You can contact a specialist in this profile without first visiting a therapist. The urologist prescribes diagnostic procedures and, based on their answers, prepares the necessary treatment. It comes down to removing stones using a conservative or surgical method.

Diagnostics

To confirm the presence of urolithiasis, assess the general condition of the paired organ, determine the parameters of the stone (size, location), the following is carried out:

• Biochemical, clinical examination of blood and urine. An increase in ESR and leukocytes in the blood are signs of inflammation, but with urolithiasis they indicate an ongoing complication. A decrease in hemoglobin levels indicates the need to compensate for the iron removed from the body during hematuria.
• Ultrasound of the kidneys. A quick and simple method for confirming the presence of stones, clarifying their parameters, and localization.
• Excretory urography. A solution containing iodine is administered intravenously to the patient. Then a series of x-rays are taken (often after 15 and 40 minutes). An iodine-containing solution fills the ureters, making it possible to visualize the condition of the urinary system as a whole.
• Survey X-ray examination. Provides a general clinical picture, including the relative position of the kidneys. This type of diagnosis is carried out simultaneously with excretory urography.

Other research methods are prescribed only when there is doubt regarding the size, type of stones, or their location; blood supply and general condition of the kidneys.

Treatment

The scope of therapeutic intervention depends on the diagnostic results. Stones are removed conservatively or surgically. In the first case, physiotherapy is additionally used. The number of procedures is prescribed taking into account the size and composition of the stone.

Conservative therapy

The table shows the drugs that are prescribed for conservative therapy, their dosages, and the regimen of use.

Pharmacological group and name of the drug, scheme of its administration	Destination purpose
Antispasmodics: No-Spa – 2 ml, intramuscularly or 1 tablet. 3 r. in a day. Papaverine – 1 tablet. 3 r. per day or 2 ml simultaneously with No-shpa, during renal colic. Diprofen – ½ tablet. 3 r. in a day. The listed drugs are not administered intravenously.	Improving overall well-being by eliminating pain and spasms. Relaxation of the ureters and unhindered movement of stone deposits outward.
Analgesics: Dexalgin – 2 ml, intramuscularly or intravenously slowly Baralgin – 5 ml IM slowly Ketanov – 1 ml intramuscularly Renalgan – up to 3 ml per 1 injection (intravenous) or 5 ml (im) In order not to cause damage to the veins, it is better to administer intravenous drugs only after dissolution with sodium chloride.	Elimination of pain, relaxation of the walls of the urogenital tract, which helps the stone leave the kidney.
Medicines that help eliminate urolithiasis and suppress pathogenic microflora: Phytolit - 1 t. 3 r. in a day. 5-NOK – 1 t. 4 r. day. Urolesan – 15 drops 3 rubles. in a day. Since the Urolesan solution has an unpleasant taste, it can be placed on a piece of sugar and consumed in this form.	Suppression of the inflammatory and infectious process that has arisen inside the urogenital tract. Destruction of the stone into small fragments.
Diuretic drugs: Furosemide (administer 4 ml intramuscularly) or Lasix (4 ml intramuscularly).	Stimulation of urine production and increased excretion. Together, these properties contribute to the leaching of stone.

When is surgery needed?

The need for surgical intervention is considered only in the absence of a positive result from conservative therapy. A surgical approach is a necessary measure in a condition where urolithiasis is complicated by a purulent process and destruction of the parenchyma. The operation is also prescribed to eliminate large stones that cannot be crushed by a laser beam or ultrasonic vibrations.

Diet

Nutrition for urolithiasis has its own characteristics. The consumption of salty, sour, spicy foods and dishes is contraindicated. It is forbidden to drink coffee or drink alcohol. The doctor prepares a diet based on the chemical composition of the rocky sediment:

• With phosphates, in addition to the basic recommendations, the consumption of legumes, potatoes, herbs, nuts, eggs and confectionery is contraindicated.
• Eliminating urates involves eliminating the presence of cheese, mushrooms, broth, herbs, sausage, fish and smoked meats in the diet.
• If you have oxalates, you should not eat chocolate, all foods containing vitamin C, broths, spices, and offal.
• The presence of xanthines suggests avoiding salty cheese, fatty meats and fish, greens, marinade, and canned food.
• When treating cystines, there is a ban on the consumption of fruit drinks, lettuce, cherries, fruit juices and all dishes enriched with spices.

Stone crushing methods

There are several types of their destruction - through the use of ultrasound, laser or through abdominal surgery. The choice of a specific method depends on the individual equipment of the clinic where the intervention is planned; size and location of the stone.

Characteristics of each operation:

1. Ultrasonic lithotripsy (stone crushing). Provides standard preliminary preparation - cleansing the intestines with an enema, refusing to eat food on the eve of the operation. Involves the use of ultrasonic vibrations. Allows you to crush the tumor into the smallest fragments, and then wash it out of the body with saline solution. The risk of damage to the parenchyma is eliminated.
2. Laser lithotripsy. Preparation involves refusing to eat food (the evening before the operation) and water (on the day of the intervention). The tumor is crushed using a high-precision beam. In this case, the image of the kidney condition is transmitted to the monitor screen of the laser unit. This type of lithotripsy provides a favorable outlook. The possibility of injury to the organ is excluded.
3. Abdominal surgery (open). It is a traditional surgical procedure (with tissue dissection). It is carried out only for large, multiple neoplasms. It involves a long recovery period, restrictions on physical activity and nutrition.

In modern urology, the method of open surgery is used only when there are serious reasons. Abdominal surgery is not the primary option for eliminating urolithiasis.

Only a urologist can prescribe a specific method of lithotripsy. The specialist takes into account the diagnostic results and factors related to the patient’s health status.

Prevention

Not every person develops stony deposits during their lifetime. Their formation requires a long-term unhealthy lifestyle. The following will help reduce the risk of developing urolithiasis:

• Normalization of nutrition and drinking regime. It is not recommended to consume sour, spicy, salty snacks, fast food, carbonated drinks, and unfiltered water.
• Increasing the volume of physical activity.
• Timely elimination of inflammation of the urogenital tract.
• Regular medical examinations and a more attentive attitude to health if there is a hereditary predisposition to urolithiasis.

It is also important to stop dysfunction of the digestive organs, normalize body weight, avoid a monotonous diet, and stop drinking alcohol.

Conclusion

Urolithiasis of the kidneys is a pathological condition that is characterized by the formation of stones of various sizes and composition. The pathology is treated conservatively or through surgery. But even after prompt removal of stone-like deposits, there is no guarantee that they will not form again. Especially if the patient has a hereditary predisposition and eats foods unfavorable to the body. Early contact with a specialist increases the likelihood of treating urolithiasis using a conservative method.

Video: Urolithiasis - removal of stones and treatment of renal colic

– a common urological disease, manifested by the formation of stones in various parts of the urinary system, most often in the kidneys and bladder. There is often a tendency to severe recurrent urolithiasis. Urolithiasis is diagnosed based on clinical symptoms, results of X-ray examination, CT scan, ultrasound of the kidneys and bladder. The fundamental principles of treatment of urolithiasis are: conservative stone-dissolving therapy with citrate mixtures, and if it is not effective, remote lithotripsy or surgical removal of stones.

General information

Urolithiasis (UCD) is a common urological disease, manifested by the formation of stones in various parts of the urinary system, most often in the kidneys and bladder. There is often a tendency to a severe relapsing course. Urolithiasis can occur at any age, but most often affects people 25-50 years old.

In children and elderly patients with urolithiasis, bladder stones are more likely to form, while middle-aged and young people mainly suffer from stones in the kidneys and ureters. There has been an increase in the incidence of urolithiasis, which is believed to be associated with an increase in the influence of unfavorable environmental factors.

Causes

Currently, the causes and mechanism of development of urolithiasis have not yet been fully studied. Modern urology has many theories that explain the individual stages of stone formation, but so far it has not been possible to combine these theories and fill in the missing gaps in a single picture of the development of urolithiasis. There are three groups of predisposing factors that increase the risk of developing urolithiasis.

• External factors. The likelihood of developing urolithiasis increases if a person leads a sedentary lifestyle, which leads to disruption of phosphorus-calcium metabolism. The occurrence of urolithiasis can be triggered by dietary habits (excess protein, sour and spicy foods that increase the acidity of urine), water properties (water with a high content of calcium salts), lack of B vitamins and vitamin A, harmful working conditions, taking a number of drugs (large quantities ascorbic acid, sulfonamides).
• Local internal factors. Urolithiasis most often occurs in the presence of anomalies in the development of the urinary system (single kidney, narrowing of the urinary tract, horseshoe kidney), inflammatory diseases of the urinary tract.
• General internal factors. The risk of urolithiasis increases with chronic gastrointestinal diseases, prolonged immobility due to illness or injury, dehydration due to poisoning and infectious diseases, metabolic disorders due to a deficiency of certain enzymes.

Men are more likely to suffer from urolithiasis, but women more often develop severe forms of urolithiasis with the formation of staghorn stones, which can occupy the entire kidney cavity.

Pathogenesis

So far, researchers are only studying various groups of factors, their interaction and role in the occurrence of urolithiasis. It is believed that there are a number of consistent predisposing factors. At a certain point, an additional factor joins the constant factors, becoming an impetus for the formation of stones and the development of urolithiasis. Having affected the patient’s body, this factor may subsequently disappear.

Urinary infection aggravates the course of urolithiasis and is one of the most important additional factors stimulating the development and recurrence of urolithiasis, since a number of infectious agents in the process of life affect the composition of urine, promote its alkalization, the formation of crystals and the formation of stones.

Classification of stones

Stones of one type are formed in approximately half of patients with urolithiasis. In this case, in 70-80% of cases, stones are formed consisting of inorganic calcium compounds (carbonates, phosphates, oxalates). 5-10% of stones contain magnesium salts. About 15% of stones in urolithiasis are formed by uric acid derivatives. Protein stones are formed in 0.4-0.6% of cases (when the metabolism of certain amino acids in the body is disrupted). In other patients with urolithiasis, polymineral stones form.

Symptoms of urolithiasis

The disease progresses in different ways. In some patients, urolithiasis remains a single unpleasant episode, in others it takes on a recurrent nature and consists of a series of exacerbations, in others there is a tendency to a protracted chronic course of urolithiasis.

Stones in urolithiasis can be localized in both the right and left kidney. Bilateral stones are observed in 15-30% of patients. The clinical picture of urolithiasis is determined by the presence or absence of urodynamic disturbances, changes in renal function and an associated infectious process in the urinary tract.

With urolithiasis, pain appears, which can be acute or dull, intermittent or constant. The location of pain depends on the location and size of the stone. Hematuria, pyuria (with infection), anuria (with obstruction) develops. If there is no obstruction of the urinary tract, urolithiasis is sometimes asymptomatic (13% of patients). The first manifestation of urolithiasis is renal colic.

Renal colic

When the ureter is blocked by a stone, the pressure in the renal pelvis increases sharply. Stretching of the pelvis, in the wall of which there are a large number of pain receptors, causes severe pain. Stones smaller than 0.6 cm in size usually pass on their own. With narrowing of the urinary tract and large stones, the obstruction does not resolve spontaneously and can cause damage and death of the kidney.

A patient with urolithiasis suddenly experiences severe pain in the lumbar region, independent of body position. If the stone is localized in the lower parts of the ureters, pain occurs in the lower abdomen, radiating to the groin area. Patients are restless and try to find a body position in which the pain will be less intense. Possible frequent urination, nausea, vomiting, intestinal paresis, reflex anuria.

A physical examination reveals a positive Pasternatsky sign, pain in the lumbar region and along the ureter. Microhematuria, leukocyturia, mild proteinuria, increased ESR, leukocytosis with a shift to the left are determined in the laboratory. If simultaneous blockage of two ureters occurs, a patient with urolithiasis develops acute renal failure.

Hematuria

In 92% of patients with urolithiasis after renal colic, microhematuria is observed, which occurs as a result of damage to the veins of the fornical plexuses and is detected during laboratory tests.

Coraloid nephrolithiasis

In some patients with urolithiasis, large stones form, almost completely occupying the pyelocaliceal system. This form of urolithiasis is called coral nephrolithiasis (CN). KN is prone to a persistent relapsing course, causes severe impairment of renal function and often becomes the cause of the development of renal failure.

Renal colic is not typical for coral nephrolithiasis. At first, the disease is almost asymptomatic. Patients may present nonspecific complaints (fatigue, weakness). Mild pain in the lumbar region is possible. Subsequently, all patients develop pyelonephritis. Gradually, renal function decreases, and renal failure progresses.

Complications

Urolithiasis is complicated by infectious diseases of the urinary system in 60-70% of patients. Often there is a history of chronic pyelonephritis, which arose even before the onset of urolithiasis. Streptococcus, staphylococcus, Escherichia coli, and Proteus vulgaris act as infectious agents in the development of complications of urolithiasis. Pyuria is characteristic.

Pyelonephritis, accompanying urolithiasis, occurs acutely or becomes chronic. Acute pyelonephritis with renal colic can develop at lightning speed. Significant hyperthermia and intoxication are noted. If adequate treatment is not given, bacterial shock may occur.

Diagnostics

The diagnosis of ICD is based on anamnestic data (renal colic), urination disorders, characteristic pain, changes in urine (pyuria, hematuria), passage of stones in the urine, data from ultrasound, radiological and instrumental studies:

• Ultrasound. Using echography, any x-ray positive and x-ray negative stones are identified, regardless of their size and location. Ultrasound of the kidneys allows you to assess the effect of urolithiasis on the condition of the collecting system. Ultrasound of the bladder allows you to identify stones in the underlying parts of the urinary system. Ultrasound is used after external lithotripsy for dynamic monitoring of the progress of litholytic therapy for urolithiasis with X-ray negative stones.
• X-ray diagnostics. Most stones are detected during survey urography. It should be taken into account that soft protein and uric acid stones are X-ray negative and do not give a shadow on survey photographs. CT scan. CT is the main method for diagnosing urolithiasis. With its help, the exact location, size and density of stones is determined.

Differential diagnosis

Modern techniques make it possible to identify any type of stones, so it is usually not necessary to differentiate urolithiasis from other diseases. The need to carry out differential diagnosis may arise in an acute condition - renal colic.

Usually, diagnosing renal colic is not difficult. With an atypical course and right-sided localization of a stone causing obstruction of the urinary tract, it is sometimes necessary to carry out a differential diagnosis of renal colic in urolithiasis with acute cholecystitis or acute appendicitis. The diagnosis is based on the characteristic localization of pain, the presence of dysuric phenomena and changes in urine, and the absence of symptoms of peritoneal irritation.

Treatment of urolithiasis

General principles of therapy

Both surgical treatment methods and conservative therapy are used. Treatment tactics are determined by the urologist depending on the age and general condition of the patient, the location and size of the stone, the clinical course of urolithiasis, the presence of anatomical or physiological changes and the stage of renal failure.

As a rule, surgical treatment is necessary to remove stones from urolithiasis. The exception is stones formed by uric acid derivatives. Such stones can often be dissolved by conservative treatment of urolithiasis with citrate mixtures for 2-3 months. Stones of other compositions cannot be dissolved.

The passage of stones from the urinary tract or surgical removal of stones from the bladder or kidney does not exclude the possibility of recurrence of urolithiasis, therefore it is necessary to implement preventive measures aimed at preventing relapses. Patients with urolithiasis are recommended for complex regulation of metabolic disorders, including care for maintaining water balance, diet therapy, herbal medicine, drug therapy, physical therapy, balneological and physiotherapeutic procedures, and sanatorium-resort treatment.

Diet therapy

The choice of diet depends on the composition of the stones found and removed. General principles of diet therapy for urolithiasis:

1. A varied diet with a limited amount of food;
2. Restriction in the diet of foods containing large amounts of stone-forming substances;
3. Take a sufficient amount of fluid (daily diuresis of 1.5-2.5 liters should be ensured).

For urolithiasis with calcium oxalate stones, it is necessary to reduce the consumption of strong tea, coffee, milk, chocolate, cottage cheese, cheese, citrus fruits, legumes, nuts, strawberries, black currants, lettuce, spinach and sorrel. In case of ICD with urate stones, you should limit the intake of protein foods, alcohol, coffee, chocolate, spicy and fatty foods, and exclude meat foods and offal (liver sausages, pates) in the evening.

If you have phosphorus-calcium stones, avoid milk, spicy foods, spices, alkaline mineral waters, and limit the consumption of feta cheese, cheese, cottage cheese, green vegetables, berries, pumpkins, beans and potatoes. Sour cream, kefir, red currants, lingonberries, sauerkraut, vegetable fats, flour products, lard, pears, green apples, grapes, and meat products are recommended.

Stone formation in urolithiasis largely depends on the pH of the urine (normally 5.8-6.2). Eating certain types of food changes the concentration of hydrogen ions in the urine, which allows you to independently regulate the pH of the urine. Plant and dairy foods alkalize urine, and animal products acidify. You can control the acidity level of urine using special paper indicator strips, freely sold in pharmacies.

If there are no stones on ultrasound (the presence of small crystals - microlites is allowed), “water shocks” can be used to flush the kidney cavity. The patient takes 0.5-1 liter of liquid on an empty stomach (low-mineralized mineral water, tea with milk, dried fruit decoction, fresh beer). If there are no contraindications, the procedure is repeated every 7-10 days. In cases where there are contraindications, “water shocks” can be replaced by taking a potassium-sparing diuretic drug or a decoction of diuretic herbs.

Phytotherapy

During the treatment of urolithiasis, a number of herbal medicines are used. Medicinal herbs are used to accelerate the passage of sand and stone fragments after extracorporeal lithotripsy, and also as a prophylactic agent to improve the condition of the urinary system and normalize metabolic processes. Some herbal preparations help increase the concentration of protective colloids in the urine, which prevent the process of salt crystallization and help prevent relapse of urolithiasis.

Treatment of infectious complications

With concomitant pyelonephritis, antibacterial drugs are prescribed. It should be remembered that complete elimination of urinary infection in urolithiasis is possible only after eliminating the root cause of this infection - a stone in the kidney or urinary tract. There is a good effect when prescribing norfloxacin. When prescribing drugs to a patient with urolithiasis, it is necessary to take into account the functional state of the kidneys and the severity of renal failure.

Normalization of metabolic processes

Metabolic disorders are the most important factor causing relapses of urolithiasis. Benzbromarone and allopurinol are used to reduce uric acid levels. If the acidity of urine cannot be normalized by diet, the listed drugs are used in combination with citrate mixtures. When preventing oxalate stones, vitamins B1 and B6 are used to normalize oxalate metabolism, and magnesium oxide is used to prevent crystallization of calcium oxalate.

Antioxidants that stabilize the function of cell membranes - vitamins A and E - are widely used. If the level of calcium in the urine increases, hypothiazide is prescribed in combination with drugs containing potassium (potassium orotate). For disorders of phosphorus and calcium metabolism, long-term use of bisphosphonates is indicated. The dose and duration of taking all drugs is determined individually.

Treatment of urolithiasis in the presence of kidney stones

If there is a tendency to spontaneous passage of stones, patients with urolithiasis are prescribed medications from the group of terpenes (extract of the fruit of ammi dentifrice, etc.), which have a bacteriostatic, sedative and antispasmodic effect.

Relief of renal colic is carried out with antispasmodics (drotaverine, metamizole sodium) in combination with thermal procedures (heating pad, bath). If ineffective, antispasmodics are prescribed in combination with painkillers.

Surgery

If a stone due to urolithiasis does not pass away spontaneously or as a result of conservative therapy, surgical intervention is required. Indications for surgery for urolithiasis are severe pain, hematuria, attacks of pyelonephritis, hydronephrotic transformation. When choosing a method of surgical treatment of urolithiasis, preference should be given to the least traumatic method.

Endoscopic operations

The essence of the intervention is contact crushing of stones using special endoscopic instruments. In routine practice, the following is performed:

• Contact cystolithotripsy. Performed for bladder stones. The operation is carried out in two stages: crushing the stone (lithoripsia) and removing it (lithoextraction). The stone is destroyed by pneumatic, electrohydraulic, ultrasonic or laser methods through the cystoscope channel.
• Contact ureterolithotripsy. Indication: ureteral stones. The operation is performed using a ureteroscope; stone crushing methods include laser, ultrasound, and pneumatics.
• Flexible retrograde nephrolithotripsy. Used for kidney stones less than 2 cm in diameter.

Contraindications to transurethral surgical interventions may include prostate adenoma (due to the inability to insert an endoscope), urinary tract infections and a number of diseases of the musculoskeletal system in which a patient with urolithiasis cannot be correctly placed on the operating table.

In some cases (localization of stones in the pyelocaliceal system and the presence of contraindications to other treatment methods), percutaneous nephrolitholapaxy is used to treat urolithiasis. This technique allows you to crush (laser, ultrasound) any calculus (including staghorn) through a small puncture in the kidney.

Laparoscopic surgeries

In the past, open surgery was the only way to remove stones from the urinary tract. Often during such surgery there was a need to remove a kidney. Nowadays, the list of indications for open surgery for urolithiasis has been significantly reduced, and improved surgical techniques and laparoscopic surgical techniques almost always make it possible to save the kidney.

Types of operations:

1. Pyelolithotomy. It is carried out if the stone is in the pelvis. There are several surgical techniques. Typically, a posterior pyelolithotomy is performed. Sometimes, due to the anatomical characteristics of a patient with urolithiasis, anterior or inferior pyelolithotomy becomes the best option.
2. Nephrolithotomy. The operation is indicated for particularly large stones that cannot be removed through an incision in the pelvis. Access is through the renal parenchyma.

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In the diagnosis of urolithiasis, an important role is played by collecting anamnesis. It is necessary to find out the nature and duration of pain (localization, intensity, irradiation, etc.); whether the pain is accompanied by nausea, vomiting, chills; the presence of hematuria in the urine, its duration, intensity and nature of occurrence; determine whether the patient’s stones passed earlier; presence of a urological history, operations on the urinary tract and for urolithiasis; does the patient have diseases of the gastrointestinal tract, liver and biliary tract, parathyroid glands; cases of urolithiasis in the family and relatives; taking pharmacological drugs that promote stone formation (sulfonamides, vitamins, etc.); whether there were any fractures or diseases of the musculoskeletal system

Mandatory methods of physical examination are: visual examination of the lower back and external genitalia; palpation of the abdominal kidney area, external genitalia; two-manual vaginal examination in women; digital rectal examination of the prostate.

Deep palpation of the kidneys with the patient in the lateral position makes it possible to diagnose an enlarged and painful kidney. Pasternatsky's symptom (kidney tapping with impaired urine outflow) is usually positive. The main methods for diagnosing urolithiasis are laboratory and instrumental studies.

Ultrasound scan of the kidneys and bladder is the most informative, harmless and priority method, especially in pregnant women and children (Fig. 1). Modern ultrasound devices make it possible not only to diagnose a stone in any zone of the renal collecting system, but also to ascertain the increased size of the kidney, the thickness of the parenchyma, the presence or absence of foci of destruction, as well as the degree of expansion of the collecting system (if the stone is located in the ureter and outside the area reach of ultrasound examination). The section of the ureter from the upper to the lower third is an inaccessible area for ultrasound examination. Ultrasound scanning of a full bladder allows you to diagnose prevesical ureteral stones and ureterocele stones.

Rice. 1. Ultrasound picture of a kidney stone

X-ray examination is of decisive importance in the diagnosis of urolithiasis. A survey image in almost 96% of cases allows one to see the shadow of a stone in the projection of the urinary system (Fig. 2). A survey x-ray should show all parts of the urinary system (from the X vertebra to the symphysis of the pelvic bones). Only X-ray negative stones (urate, cystine, xanthine) are not visible on the survey image.

For coral stones, a survey photograph is taken in two projections - straight and three-quarters - to get a complete picture of the size of the stone and how much it fills the calyces of the kidney. However, the presence on a plain radiograph of a shadow suspicious for a kidney or ureteral calculus should not be considered as a definitive diagnosis of urolithiasis. The detection of a shadow can be caused by a stone in the gallbladder, pancreas, fecal stones, calcified lymph nodes, or barium residues after a previously performed x-ray examination of the gastrointestinal tract. All of them can imitate the picture of urolithiasis.

An indirect distinctive feature of phleboliths is clear round contours with a clearing in the center. That is why a survey image in almost 98% of cases is supplemented by excretory urography. This study is not indicated for patients with acute renal colic, in whom excretory urography on the affected side is uninformative due to impaired microcirculation.

Rice. 2. Renal pelvis stone on the right: a - survey urography; b - excretory urography

Excretory urography gives a clear idea of ​​the anatomical state of the kidneys and the location of the stone, indirectly indicating their functional state, as well as the functional state of the upper and lower urinary tracts. The timeliness (7-10 minutes) of accumulation of contrast agent in the kidney with visualization of the collecting system allows us to judge their functional state, determine the type of pelvis (intra- and extrarenal type), the degree of retention (expansion) of the collecting system. The shadow of the stone represents a contrast defect of the urinary system. Visualization of the ureter makes it possible to differentiate phleboliths from stones, over which, as a rule, stasis of the contrast agent is determined - the “index finger” symptom. Three-quarter (semilateral) and postvoid x-rays help make a definitive diagnosis of a ureteral stone.

Taking one of the pictures during excretory urography (15 minutes) in a standing position (especially in women) allows you to exclude or confirm the diagnosis of nephroptosis, which can also be the cause of stone formation.

Excretory urography is not very informative in case of X-ray negative ureteral stones, except in cases of stasis (the “index finger” symptom) over an obstacle, which can occur in cases of ureteral tumor.

In those rare cases when the diagnosis remains doubtful after the examination or the shadow of the stone is not visible, retrograde ureteropyelography is undertaken. Having brought the catheter to the obstacle, a liquid contrast agent containing iodine or oxygen is injected - pneumopyelography. Interpretation of the results of retrograde pyelography in the presence of a defect should not be hasty, since a similar defect may be caused by a tumor of the pelvis or the entry of air bubbles. If, upon administration of a contrast agent, the stone is defined as a “minus” contrast shadow, then after the administration of oxygen a “plus” shadow occurs (Fig. 3). Retrograde pyelography is also undertaken to exclude ureteral stricture located below the location of the stone and its extent.

Rice. 3. Retrograde ureteropyelography. Stone in the upper third of the ureter on the right.

In rare cases, invasive intervention is used to differentiate between a stone and a tumor of the ureter - diagnostic retrograde endoscopic ureteropyeloscopy. This manipulation can result in crushing the stone (contact lithotripsy) or biopsy of tumor tissue.

Nuclear Magnetic Resonance The study significantly increased the diagnostic informativeness of the study, since the quality of the image is not affected by aerocol, which is often an obstacle to the interpretation of excretory urograms. It must be remembered that nuclear magnetic resonance imaging does not involve an x-ray load on the patient, which allows it to be performed even on pregnant women.

CT scan It is used extremely rarely for the diagnosis of stones, since it carries a large x-ray load and does not provide an idea of ​​the anatomical and functional state of the urinary tract. For coral stones, computed tomography allows one to obtain a clear stereometric picture of the coral stone and establish the density of the stone structure (in terms of the possibility of using external shock wave lithotripsy).

Radioisotope research(dynamic nephroscintigraphy) allows you to study the functional state of the kidneys, assessing their secretory and evacuation abilities. In patients with a kidney stone, as well as those previously operated on the kidney, an isotope study makes it possible to study the segmental state of glomerular and tubular function.

No less important is a radionuclide study of the function of the parathyroid glands from the perspective of the genesis of stone formation and the choice of treatment: taking blood from the parathyroid veins to determine the level of parathyroid hormone, which is indicated for bilateral and rapidly relapsing nephrolithiasis.

Angiographic examination due to the introduction of highly informative and minimally invasive research methods, they are used less and less, however, they provide invaluable assistance to the surgeon when performing repeated open surgical interventions for coral nephrolithiasis, when nephrotomies are supposed to be performed, allows one to evaluate angioarchitecture and develop measures to prevent injury to large vessels (Fig. 4) .

Rice. 4. Angiogram of a patient with a coral stone on the right

Laboratory research in the diagnosis of urolithiasis play an important role in establishing the chemical structure of the stone and metabolic disorders. Knowledge of the latter allows you to prescribe reasonable metaphylactic treatment and monitor its effectiveness.

In an emergency situation, a detailed clinical blood test can reveal leukocytosis, band shift, increased ESR, indicating the development of an inflammatory process in the kidney. These data may predetermine the tactics of further treatment. Along with the above laboratory tests, the study of the following functional indicators is shown: blood urea level, blood creatinine level, endogenous creatinine clearance, uric acid level in blood and urine, calcium level in blood and urine, protein level in urine, specific gravity (relative density) of urine.

Culture of urine for microflora and determination of its sensitivity to antibiotics must be done before prescribing antibiotics, since their use can significantly affect the result of the study.

To prevent relapse of stone formation in patients with uric acid and calcium oxalate urolithiasis, it is necessary to perform additional research methods: determination of average blood molecules, blood chlorides, blood pH, level of ionized blood calcium (with recurrent and coral nephrolithiasis), daily excretion of citrates, magnesium, potassium, urine osmolarity (in patients with reduced clearance of endogenous creatinine), performing the Howard test (allows us to identify dysfunction of the parathyroid glands, which may be the reason for the ineffectiveness of treatment and the malignant course of urolithiasis).

Differential diagnosis urolithiasis presents certain difficulties, especially in patients with an acute attack of renal stones, similar in clinical picture to acute diseases of the abdominal organs or pelvic organs. Knowledge of the main symptoms of those diseases with which renal colic has to be differentiated allows for a timely and correct diagnosis.

At acute appendicitis pain begins in the epigastric region, gradually localizing in the right iliac region, and almost from the onset of the disease is accompanied by an increase in body temperature. Position the patient on the right side with the legs pressed to the stomach. When lying on the left side, the pain intensifies, which is caused by tension of the mesenteric root and irritation of the peritoneum. As a rule, all symptoms of peritoneal irritation are positive. A blood test reveals an increase in ESR and leukocytosis from the first hours of the disease.

Ultrasound and X-ray examination: the absence of shadows of stones in the projection of the urinary system, expansion of the collecting system, disturbances in the passage of urine through the upper urinary tract, as well as changes in urine and blood tests allow one to lean towards the diagnosis of acute appendicitis. A more complex situation arises when carrying out differential diagnosis in children and when renal colic is complicated by acute pyelonephritis; the percentage of diagnostic errors reaches 32. In doubtful cases, the final diagnosis can be established only after laparoscopy.

Acute cholecystitis. The sudden onset of severe pain in the right hypochondrium with this disease most often occurs after consuming fatty, heavy food, alcohol, etc. The pain radiates to the right subclavian fossa (phrenicus symptom), right scapula. Ortner's sign (tapping on the right hypochondrium) is sharply positive. Acute cholecystitis is accompanied by a progressive increase in body temperature, leukocytosis and a shift in the blood count to the left. Tension of the muscles of the anterior abdominal wall is noted, a positive symptom of peritoneal irritation. With obstructive cholecystitis, ectericity of the sclera and jaundice of the skin are observed.

A perforated ulcer of the stomach or duodenum is characterized by acute, sudden, “dagger-shaped” pain in the epigastrium. Pale skin, vomiting, usually mixed with blood - “coffee grounds”. The patient’s position is motionless, the abdomen is “board-shaped” on palpation, the symptoms of peritoneal irritation in all parts of the abdomen are sharply positive due to the contents of the gastrointestinal tract entering the abdominal cavity. Tympanitis is determined by percussion over the upper abdomen.

Acute pancreatitis characterized by sudden onset pain in the epigastric region, radiating to the back, shoulder, hypochondrium and quickly acquiring a permanent encircling character. Body temperature may remain normal for a long time. The pain is accompanied by nausea and vomiting, and peritoneal symptoms are observed. The general serious condition of the patient is accompanied by a sharp increase in blood and urine diastasis.

Ectopic pregnancy preceded by menstrual irregularities. Sudden, severe pain in the lower abdomen forces the patient to take a forced position with her legs brought to her stomach, radiating to the sacrovertebral region. Almost from the first hours of the disease, symptoms of peritoneal irritation develop. There is pallor of the skin and chills, which is usually associated with internal bleeding.

Many diseases of the pelvic organs, spine, and abdominal cavity have clinical manifestations that mimic urolithiasis, however, a detailed examination of the history of the disease and the patient’s life, a thorough physical and clinical laboratory examination make it possible to establish the correct diagnosis and prescribe appropriate treatment.

Lopatkin N.A., Pugachev A.G., Apolikhin O.I. and etc.

Urolithiasis disease- symptoms and treatment

What is urolithiasis? We will discuss the causes, diagnosis and treatment methods in the article by Dr. A.E. Rotov, a urologist with 19 years of experience.

Definition of disease. Causes of the disease

Urolithiasis disease- one of the oldest diseases that has plagued humans for thousands of years and has not lost its relevance to this day. The famous ancient doctors Hippocrates and Avicenna described this disease and even performed surgical operations to remove stones (it’s terrible to imagine yourself in the place of their unfortunate patients!). Many powerful people and great minds, including Peter the Great, Napoleon, Newton, could not avoid this disease. In the modern world, we, unfortunately, are seeing a steady increase in the incidence of urolithiasis (UCD), which is associated with poor nutrition, poor environment, poor-quality drinking water, physical inactivity and other “benefits” of civilization.

According to statistics, urolithiasis ranks second in the structure of urological diseases in Russia, second only to infectious and inflammatory diseases of the genitourinary system. The relevance of our topic is associated not only with the high prevalence of urolithiasis, but also with the unpredictability of its course and the risk of serious complications. Many people do not realize that they have kidney stones until the first attack of renal colic, which occurs against the background of “full health.” If timely and qualified assistance in this case is late, then the consequences can be very dire, including the loss of a kidney.

What are causes of urinary stones formation? We have already mentioned some of them.

• hereditary predisposition - attention to those who have people in their family with urolithiasis;
• congenital or acquired metabolic disorders;
• poor nutrition, excessive consumption of animal and vegetable protein, lack of vegetables and fruits, some vitamins and microelements;
• insufficient fluid intake (the minimum recommended daily intake for a healthy person is 1.5 liters, for a patient with urolithiasis - at least 2.5 liters), low-quality “hard” water;
• sedentary lifestyle;
• unfavorable environmental factors: dry hot climate, frequent overheating, etc.

If you notice similar symptoms, consult your doctor. Do not self-medicate - it is dangerous for your health!

Symptoms of urolithiasis

The pain is initially localized in the lumbar region, radiating down the abdomen, sometimes to the genitals, and is often accompanied by nausea and vomiting. The pain can be so severe that the patient “cannot find a place for himself” and rushes about until the ambulance arrives. A frequent accompaniment of renal colic is the presence of blood in the urine, so when such attacks occur, it is recommended to urinate in a jar to monitor the color of the urine and the passage of stones.

Large or coral-shaped kidney stones can manifest as long-term dull, aching pain of low intensity in the lumbar region and also blood in the urine, especially after physical activity or long walking/running.

In the later stages, when kidney function is impaired and chronic renal failure develops, general well-being suffers, weakness, fatigue occur, and appetite worsens. During this period, blood pressure often rises and headaches occur.

When the inflammatory process occurs, there is an increase in body temperature (sometimes to high numbers, over 38-39 degrees), accompanied by chills.

Pathogenesis of urolithiasis

The insidiousness of this disease is that for a long time a person may not be aware of the formation of kidney stones in his kidneys, that is, the disease proceeds secretly. Manifestation occurs at the moment when the stone begins to shift, disrupting the natural outflow of urine, which is accompanied by an attack of intense pain, called renal colic. Usually an attack occurs after physical exertion, a long journey (especially by train), or drinking alcohol. Often these factors occur on vacation, threatening to turn your vacation into a struggle for survival (literally).

Complications of urolithiasis

Despite the successes achieved in the fight against stones thanks to modern technologies, complications of urolithiasis still occur in the practice of a urologist. These include persistent disruption of the outflow of urine from the kidney (hydronephrosis) and inflammation of the kidney (pyelonephritis). With hydronephrosis, an obstruction to the outflow of urine leads to an expansion of the renal cavity system and a gradual depression of its functional state (up to complete atrophy). The tricky thing is that at this stage the pain, as a rule, has already subsided, and the person feels practically nothing and, accordingly, does not see a doctor. A serious complication of urolithiasis is acute pyelonephritis, which can turn into a purulent phase within a short time, which may require urgent surgical intervention, including removal of the affected kidney. The recurrent nature of stone formation in the absence of adequate treatment leads to a chronic inflammatory process - chronic pyelonephritis, which usually affects both kidneys. The outcome of prolonged inflammation can be loss of functional activity, shrinkage of the kidneys with the development of chronic renal failure and the need for hemodialysis.

Diagnosis of urolithiasis

To detect stones in a timely manner, it is enough to undergo an annual kidney ultrasound. When an attack of renal colic occurs, ultrasound is also the main diagnostic method, however, computed tomography of the urinary system (even without intravenous contrast) has higher sensitivity, allowing the detection of up to 95% of stones.

Excretory (or intravenous) urography provides valuable information on the anatomical features of the kidneys and upper urinary tract. Stones that do not contain calcium salts (for example, urate or cystine stones) are not visible on x-ray film (therefore they are called x-ray negative).

Laboratory tests (general analysis of morning urine, biochemical analysis of blood and daily urine) make it possible to identify a concomitant inflammatory process (pyelonephritis), assess the functional state of the kidneys, the presence of metabolic disorders, and increased concentrations of stone-forming salts and minerals.

Treatment of urolithiasis

Treatment of urolithiasis depends on the size and location of the stone (kidney, ureter or bladder), the condition and characteristics of the urinary tract (for example, narrowings or fixed bends that make it difficult to pass the stone), and the presence of complications. In mild cases, if the stones are small (usually up to 5 mm), drug stone therapy can be used with the prescription of diuretics, antispasmodics and painkillers. Herbal products are widely used. To speed up the spontaneous passage of stones, it is recommended to drink plenty of fluids in combination with physical activity.

Some types of urinary stones (for example, urates) can be easily dissolved using so-called citrate mixtures (Blemaren or Uralit-U). This method is based on increasing the solubility of urate stones by shifting the acidity of urine (pH) to the alkaline side. The dissolution process is quite lengthy and labor-intensive, requiring regular monitoring of the pH (indicator strips are included in the package), but with the right approach it allows you to completely get rid of stones without additional intervention.

(or non-contact crushing of stones) is a unique method of getting rid of kidney and ureteral stones, when the stones are destroyed directly in the body without the introduction of instruments. Crushing is carried out using a special apparatus - a lithotripter.

Previously, due to their high cost, such complexes were installed only in large research centers and hospitals, but today the method is more accessible, including in commercial clinics. A modern device for remote lithotripsy is a fairly compact shock wave generator combined with a device for targeting the stone. Structurally, ultrasonic or x-ray guidance is possible. At the same time, ultrasonic guidance is advantageous in the absence of ionizing radiation (radiation exposure) and the possibility of continuous monitoring of stone destruction in real time. In addition, ultrasound can be used to target stones that are X-ray negative (that is, invisible to X-rays). The crushing procedure usually takes no more than an hour and does not require serious pain relief. Recently, external lithotripsy has been performed on an outpatient basis, that is, without hospitalization.

During crushing, the stone is destroyed by shock waves into small fragments, which then independently pass through the natural urinary tract. To facilitate and speed up this process, antispasmodic and diuretic drugs are often prescribed. With the help of extracorporeal lithotripsy, kidney stones of relatively low density up to 2 cm in size can be effectively destroyed.

When a stone gets stuck in the ureter and blocks the outflow of urine, which is manifested by recurrent attacks of renal colic, which are difficult to relieve with conventional medications, endoscopic intervention is used to quickly remove the stone and restore the outflow of urine - transurethral contact lithotripsy. As the name suggests, in this operation, performed through the urethra (urethra), the instrument, under visual control, is brought directly to the stone and the latter is destroyed by contact - laser, ultrasound or a pneumatic probe.

The advantage of contact lithotripsy is the complete destruction and removal of the stone immediately during surgery, restoration of urine outflow and the absence of the stage of passage of fragments. In some cases, for additional drainage of the upper urinary tract, a plastic catheter (internal stent) is installed in the ureter after surgery. Contact lithotripsy is usually performed under spinal anesthesia and requires short-term hospitalization. An additional advantage of transurethral lithotripsy is the ability to simultaneously eliminate narrowing or fixed kinks of the ureter below the stone, which can be an insurmountable obstacle to the passage of stones (or even fragments after remote crushing).

Large and dense kidney stones, which cannot be destroyed using extracorporeal lithotripsy, are today removed through a small puncture in the lower back. This operation is called percutaneous nephrolithotripsy. Under ultrasound and X-ray guidance, an instrument is inserted into the kidney through a puncture, with the help of which, under visual control, the stone is destroyed and fragments are removed. As with transurethral contact lithotripsy, destruction is achieved using a laser, ultrasound or pneumatic probe. This method can destroy stones of any size and density. True, in some cases it is necessary to make additional punctures for this. The operation often ends with the installation of a thin drainage tube (nephrostomy) into the kidney through an existing puncture, which is removed after a few days. Percutaneous nephrolithotripsy is usually performed under general anesthesia and requires hospitalization for a period of 3 to 5 days. The most modern modification of this operation is minipercutaneous laser nephrolithotripsy. The main difference is the use of miniature instruments with a diameter of about 5 mm, which is approximately half the size of traditional ones. Thus, the puncture in the skin becomes almost invisible, the recovery period is reduced, as well as the likelihood of complications.

Another modern and minimally invasive method for removing stones from the kidneys and ureters is flexible transurethral contact lithotripsy (or fibroureteronephrolithotripsy, or retrograde intrarenal surgery). The main advantage of this method is the absence of cuts and punctures, that is, damage to the skin. A flexible miniature instrument equipped with an actively moving tip with a high-quality video camera is inserted through the natural urinary tract (urethra). Depending on the task, the instrument is passed into the ureter or into the kidney and brought to the stone. The latter is destroyed with the help of a laser into “dust” (dusting effect), which does not require the extraction of fragments - they are washed off with a flow of liquid during the operation. This method is ideal for relatively small and dense kidney stones, especially multiple ones located in different calyxes. The flexibility of the fibroureterorenoscope allows it to be passed through narrowings and fixed bends, without the risk of damage. The main disadvantage of this technology is the very high cost of the equipment. Therefore, not all even large urological centers have a fibroureterorenoscope in their arsenal.

Laparoscopy for kidney and ureteral stones is used quite rarely, mainly when urolithiasis is combined with urinary tract anomalies (for example, a large stone in the pelvis and narrowing of the ureteropelvic segment), when it is necessary to simultaneously remove the stone and eliminate the anomaly.

Thus, as we see, today open operations (that is, performed through a skin incision) are almost completely replaced from the arsenal of means for removing urinary stones. This made it possible to make surgical treatment of urolithiasis quick, easy and safe, which is especially important given the tendency of the disease to recur.

Forecast. Prevention

Proper and timely treatment allows you to quickly and safely get rid of the stone and prevent complications. Given the tendency of the disease to recur, special attention should be paid to preventing the recurrence of stones.

The growing trend in the incidence of urolithiasis observed in recent years determines the importance of preventing this disease. This is of particular importance in people with a hereditary predisposition to the formation of urinary stones.

The main methods of prevention are:

• drinking enough fluid (at least 1.5 liters per day for a healthy person and at least 2.5 liters for patients with urolithiasis);
• proper balanced nutrition with sufficient consumption of fiber, vegetables and fruits, vitamins and microelements;
• regular physical activity, sports.

Patients with urolithiasis must necessarily determine the composition of urinary stones. The most reliable method is chemical analysis of the loose (or removed) stone. Depending on the composition (urates, phosphates or oxalates), the doctor will select the appropriate diet and medications.

Diet is very important to prevent the recurrence of kidney stones. All patients with urolithiasis are recommended to limit table salt to 5-6 grams per day (food is prepared without salt and add salt already on the plate), limit animal and vegetable protein (up to 1 gram per kg of body weight). For urate stones (that is, consisting of uric acid salts), in addition to the above-mentioned dietary restrictions, dark beers, red wine, pickles, smoked meats, offal, coffee, cocoa and chocolate are not recommended.

With a bilateral recurrent nature of stone formation, when serious metabolic disorders in the body are expected, one should try to establish and, if possible, eliminate these disorders. For this purpose, a biochemical analysis of daily urine for calcium, phosphates, urates, citrates and oxalates, and a biochemical blood test (calcium, phosphorus, magnesium, parathyroid hormone) are often prescribed. It is also very important to regularly, 1-2 times a year, do an ultrasound of the kidneys, which will identify small stones at an early stage, when they can be removed with the help of medications without resorting to complex and expensive interventions.