Carbonate apatite in the kidneys is the cause of formation. Conservative treatment of urolithiasis

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 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 paid 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 seems 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 to form a sparingly soluble salt - 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 form.

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, an inorganic and organic-crystalline group of stones is distinguished, which is the basis for their classification.

A very important factor in classifying 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. According to 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). Vi-

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 localization, 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 which the created channel is expanded to the appropriate size and an endoscope is installed 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 recommended, 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 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 dysuria during the day. 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. The scaphoid stones are removed using tweezers or a clamp. The narrowed external opening of the urethra is expanded with conical bougies or dissected.

Security 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 radiograph 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).

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 occur 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 to know the composition of stones is due to the peculiarities of methods of removal and conservative anti-relapse treatment for a particular type of stone.

What are the causes of urolithiasis?
The exact causes of kidney stones are currently unknown. Most experts are inclined to believe that there is no one specific cause of urolithiasis, but there are a number of factors and conditions that contribute to the development of urolithiasis:

• Chronic urinary infection (pyelonephritis, glomerulonephritis) – infections of the urinary system are one of the main causes of the formation of kidney stones. As a rule, against the background of chronic pyelonephritis or glomerulonephritis (less often against the background of cystitis), the course of urolithiasis becomes more severe and frequent exacerbations of this disease occur. Against the background of chronic inflammation, there is a large amount of proteins in the urine on which salt crystals are deposited.
• Hereditary predisposition - the risk of kidney stones is higher in people whose relatives (parents, brothers, sisters) also suffer from urolithiasis;
• Physical inactivity – a sedentary lifestyle (mainly sedentary work) leads to disruption of phosphorus-calcium metabolism, which in turn causes the formation of stones in the urinary system;
• Poor nutrition – eating large amounts of meat predisposes to the development of urolithiasis;
• Congenital kidney diseases - anatomical defects of the urinary tract (narrowing of the ureter, abnormal development of the kidneys, polycystic kidney disease, etc.) lead to impaired outflow of urine from the kidney, its stagnation, which contributes to the formation of stones;
• Disorders of calcium metabolism in the body (mainly due to disease of the parathyroid glands) are sometimes the basis for the formation of stones in the urinary system;
• Unfavorable environmental conditions
• Diseases of the gastrointestinal tract and bone fractures also lead to disruption of calcium metabolism and an increase in the concentration of stone-forming substances in the blood.

How do kidney stones form?
The formation of kidney stones most often takes several months or years. The main condition for the development of kidney stones is an increase in the concentration of salts and protein in the urine (for example, against the background of chronic pyelonephritis). Kidney stones are formed due to the precipitation of urine salts on small protein particles, which play the role of a framework for the future stone. At the beginning of the disease, several small stones several millimeters in size are formed. Small stones are most often quickly eliminated from the kidneys on their own through urine. Those stones that become fixed in the kidneys continue to become overgrown with new layers of salt over time and increase in size. Over the course of several years, a kidney stone can “grow” up to several centimeters.

What types of kidney stones can there be?
Kidney stones can vary in chemical composition, size, shape, and location. Depending on the chemical composition, stones can be:

• calcium oxalate (vedellite, wewellite)
• calcium phosphate (apatite, brushite, whitlockite)
• consisting of uric acid (sodium urate, ammonium urate)
• containing magnesium (newberite, struvite)
• cystine or protein
• stones with mixed chemical composition

The size of kidney stones can vary from a few millimeters (sand in the kidneys) to 7-10 cm. In some cases, giant stones weighing several hundred grams are formed in the kidneys of patients with urolithiasis, which completely block the flow of urine from the kidney.
The shape of kidney stones is determined primarily by their chemical composition. Calcium stones are typically smooth and flat, like pebbles; urate stones, on the other hand, are angular with many sharp edges.

Kidney stones – urolithiasis or urolithiasis, is when urinary stones (calculi) form in the kidneys. Why are kidney stones dangerous? Urinary stones are one of the causes of kidney failure. But the result of recovery and the effect of treatment is unsatisfactory, which leads to the development of severe complications.

Urolithiasis

Kidney stones in men and women are a polyetiological disease associated with metabolism in the body, due to which a stone (calculus) appears. This disease affects not only the kidney, but also the entire urinary system of the patient.

There are differences in the existing size and shape of kidney stones, they are small as sand and up to 10 mm, medium 10-20 mm, complex large stones from 20 mm to approximately 50 mm. The reasons for the formation of the disease are a complex chemical and physical process, the formation of crystals from salts in human urine and their further sedimentation. Kidney stones come in different shapes: flat, round, angular and complex.

Manifestations of diseases occur in one or both organs. Kidney stone formation and symptoms occur three times more frequently in men than in women. Although the latter are susceptible to the formation of the most complex forms of kidney stones, the consequences of which can cause serious harm, this disease is called coral nephrolithiasis.

In one of three situations, urolithiasis is diagnosed among all diseases of the urinary genital tract. Basically, signs of kidney stones are detected in patients 20–60 years old, but in principle, patients of all ages and even children are susceptible to this disease.

Description of stones

Concretions can be single or numerous. They have different shapes. Located in one or both organs, they can be located in the renal pelvis, calyxes in the kidneys: lower, middle, upper. Based on their composition, kidney stones are divided into:

Due to the fact that the visibility of stones on X-ray is directly related to their mineral composition, they are divided according to X-ray characteristics:

• well radiopaque (calcium phosphates, oxalates).
• poorly radiopaque (magnesium, ammonium, cystine, apatite phosphates).
• X-ray negative (urates, uric acid, xanthine, medicinal stones).

You can more accurately examine the stone and its density and determine its structure using CT. A more detailed study by the attending physician of what the stone consists of will allow you to competently and correctly prescribe treatment.

Symptoms of the disease

The main appearance of stones is:

• renal colic - sharp, stabbing, cramping, acute pain in the area of ​​the affected organ or lower back;
• a diseased kidney that spreads to neighboring organs;
• pain in the lower abdomen;
• bloating;
• burning pain when the patient urinates;
• frequent urge to go to the toilet or, conversely, urinary retention;
• removal of sand or stones from urine;
• change in urine color, cloudiness due to mucus;

• there is blood secreted into the urine;
• nausea with vomiting;
• loss of appetite;
• body temperature rises;
• feeling of cold sweat;
• high blood pressure;
• there is a feeling of weakness in the body.

Physical activity and shaking can remove kidney stones. While the stone does not move from its place, the patient may not feel it, and when the pain due to kidney stones becomes severe, the person does not find peace and a comfortable position and walks from corner to corner. Renal colic lasts 1–2 hours, can last intermittently for a whole day, after which sand and small pebbles are often released with urine.

The presence of kidney stones disrupts urodynamics, changes kidney function, and inflammation occurs. The symptoms of the disease do not differ between males and females. With prolonged urinary retention, toxic poisoning occurs, which will cause vomiting, itching, and convulsions.

Causes of disease

The formation of kidney stones, causes and their identification, we will consider in order. This disease is provoked by the following factors:

• inherited predisposition;
• hardness of water containing a large amount of salts;
• poor nutrition, passion for excessively salty, sour, hot, spicy foods;
• low presence in ultraviolet light;
• lack of vitamins;
• living in hot countries;
• injuries and diseases of the bone skeleton;
• acute lack of water in the body or dehydration, the cause of this is infection or poisoning;
• diseases that are in a chronic stage, such as pyelonephritis, cystitis, adenoma, gastritis, ulcers, colitis;

• sedentary lifestyle;
• work involving heavy physical labor;
• work in hazardous production;
• long-term abuse of potent drugs;
• pathologies of the genitourinary system and kidney organs;
• drooping and inflamed kidney;
• stagnation of urine associated with injuries, spinal cord lesions, tumors of the genitourinary organs, the presence of foreign bodies, anomalies at birth;
• kidney injuries.

A man is what he eats. So what eating habits can trigger the onset of disease and kidney stones? Poor nutrition such as:

• excessive salt intake;
• frequent consumption of animal protein;
• alcohol abuse;
• excessive passion for caffeine;
• frequent consumption of vegetables high in oxalic acid;
• long fasting.

Diagnostic procedures

A specialist can diagnose the disease by palpation of the abdomen and by the nature of the existing symptoms of the disease. It is necessary to find out the reasons that could disrupt the metabolism, determine previous diseases, the development of kidney stones, and the conditions in which the sick person lives. But you should also pass:

• clinical urine and blood tests;
• advanced biochemistry of urine and blood;
• level of oxalates, phosphates, calcium, uric acid;
• bacteriological analysis of urine.

In the best of cases, the genitourinary tract removes the stone on its own; it is imperative to examine the stone for its chemical components.

For a more detailed approval of the treatment plan for kidney stones in men and women, the doctor will prescribe an ultrasound of the diseased organ to find out what condition the kidney is in, and also look at the condition of the bladder and perform urography. How a more extensive examination is used:

• CT or MRI – determination of the types and sizes of stones;
• nephroscintigraphy of the kidneys will show functional disorders;
• a test for susceptibility to antibiotics will determine the level of inflammation.

Treatment of kidney diseases

How to treat the disease and whether it is possible to get by using medications will be described below. The methods used are conservative and operative. The smallest stones up to 3 mm are well removed with the help of a dairy-vegetable diet and medicinal alkaline mineral waters. If the stones do not come out on their own, drugs are used that dissolve them:

• Canephron – treats calcium oxalate and urate stones;
• blemarene – urate and mixed stones;
• cystone – applicable for all types of stones;
• phytolith – stops further growth of the calculus.

For concomitant infections, antibiotics and antimicrobials are prescribed. To relieve severe pain due to colic, treatment with anti-inflammatory drugs is prescribed: diclofenac, ibuprofen, indomethacin - for a period of 3-7 days. And also to relieve painful spasms, no-shpu and papaverine are used. It is unlikely that stones larger than 5 mm will be able to come out on their own. The stone is destroyed by crushing. Open abdominal surgery, with removal of the stone mechanically through incisions in the kidney and bladder, is the most dangerous and oldest method of stone removal.

As a rule, modern methods of stone crushing are now used:

• Shock wave therapy, crushing occurs due to sound or electromagnetic waves.
• Laser crushing using a nephroscope inserted through the urethra. The laser beam destroys the calculus into fragments. This therapy is used to destroy and subsequently remove staghorn stones.
• Urethrorenoscopy – crushing stones without incisions or punctures using a urethroscope.
• Endoscopic removal or crushing of stones through a puncture in the lumbar region.

Today, complex surgical intervention is rarely performed and only when another way to remove and remove the stone is impossible.

Conservative treatment

In the presence of small stones, you can use conservative treatment to regulate metabolic processes, relieve inflammation and promote independent removal of the stone. The complex of treatment measures includes:

• diet;
• correct water and electrolyte balance;
• healthy lifestyle and physical development;
• the use of herbal medicine in treatment;
• physiotherapeutic procedures;
• balneology;
• visiting health resorts.

Spa treatment will be beneficial both for the removal of small stones and sand, but also as therapy after its removal or removal. Sanatoriums using alkaline mineral waters in treatment are visited by patients with the presence of oxalate, cystine, and urate stones. A sanatorium with acidic mineral waters treats phosphate stones.

Disease prevention

Removing or removing stones cannot guarantee complete recovery; stones can form even after recovery. The patient will be observed at the dispensary for about 5 years. Prevention of the disease cannot be ruled out throughout this period. And it is also necessary:

• see a doctor regularly;
• do not initiate treatment for diseases that can cause stones;
• use water filters, you need to drink clean water without impurities;
• drink more than two liters of water per day;
• maintain an active lifestyle, constantly engage in physical activity;
• give up bad habits;
• eat right, taking into account the composition of the stones that were previously discovered;
• don't get too cold.

An integrated approach to treatment will be more effective.

Treatment with folk remedies

For prevention and to help with traditional treatment, traditional treatment recipes are used to remove the stone:

• decoction of rosehip roots – 35 g. dried crushed root per 2 tbsp. boiling water should be simmered for 15 minutes in a water bath, left for 6 hours, taken half a glass 4 times a day before meals half an hour, the course of treatment is 1–4 weeks;
• a decoction of dried watermelon rinds (berries from your garden) - add water equal to the amount of dried crushed rinds and boil for half an hour, drink a glass 3-5 times a day before meals;
• tea from dried apple peels - 2 tsp. chopped peel per 1 tbsp. boiling water, infuse and drink instead of tea;

lemon water with glycerin – grind 10 pcs. lemons along with the peel (remove the seeds) and pour 2 liters. boiled water, add 2 tbsp. l. glycerin, leave for 30 minutes, take a whole glass every 10 minutes until you drink everything, apply a warm heating pad to where the diseased kidney is located.

Salts in the kidneys - symptoms, how to treat?

In the body of every person, salts in the kidneys, as well as in urine, are always present in small quantities. This is not a pathology. We can talk about a disease when mineral compounds begin to concentrate in quantities exceeding the permissible norm. We will discuss below what causes and symptoms precede this disease. The substances that are formed in the urine depend on the current state of acidity in it. Salts form when the external environment is overly alkalized.

Causes of salt formations in the kidneys

The main reasons for the formation of salt in the kidneys are:

• genetic predisposition;
• Calcium and uric acid are present in excess in the blood, thereby causing disease. In most cases, this occurs due to a violation of material metabolism;
• There is a limited amount of fluid in the body. When it is lacking, this leads to the formation of specific highly concentrated urine. This is the reason why salt is formed in the kidneys. The loss of such an amount of fluid is very often due to the fact that the patient was taking diuretics - diuretics;
• kidney infection.

These are the main reasons for the possible detection of salt during examination in the kidneys. If there are any suspicions or prerequisites that an adult or child may have such a disease, then you need to visit a urologist and consult. It can occur without any sign until symptoms of a more serious pathology appear, such as kidney stones.

How does the disease manifest?

Many diseases of the urinary system have similar symptoms; with salts in the kidneys, the following symptoms are distinguished:

• urination becomes more frequent;
• pain when urinating;
• hematuria – blood appears in the urine;
• heaviness or burning, as well as discomfort in the lower abdomen;
• renal colic.

The cause of diseases such as kidney stones, urethritis and cystitis is salts in the kidneys.

Treatment

It also happens that drug therapy is not needed for salts in the kidneys; it is enough just to normalize the patient’s diet. Or, perhaps, you just need to treat chronic diseases of the genitourinary system.

Treatment involves the following areas:

• a diet that is aimed at preventing the formation of calculi (stones);
• increasing diuresis (urine volume) to remove salts - the patient must drink at least three liters of water daily;
• drug therapy includes treatment with drugs (diuretics and anti-inflammatory nonsteroids) that can dissolve salt and sand, as well as small stone formations.

How to organize proper nutrition?

For both an adult patient and a child, the prescribed diet does not mean that they need to deny themselves meat, dairy and other necessary products for the normal functioning of the body. But it is important to control their daily consumption so as not to exceed the norm.

Remember! To prevent salts in the kidneys, you should control your diet.

If the patient is interested in how to remove salts from the kidneys, then first of all, the diet should be salt-free. No treatment will be effective unless you stop eating salt. Then the symptoms not only will not go away, but can also lead to more serious complications. To prevent this from happening, you need to follow a few simple rules:

• Do not add salt to food when cooking. Before use, you can add a little salt to them, but you need to take into account that the daily salt intake for a patient is 2-3 g;
• We must not forget that some products, such as bread, already contain salt.

When following a diet, you should not eat:

• sausage products;
• pickles, marinades and smoked meats;
• offal;
• salted fish;
• salty hard cheese;
• dried fruits and nuts;
• curd products;
• bananas.

Allowed to eat:

• pasta;
• porridges made from cereals;
• fresh, boiled or stewed vegetables;
• soups cooked with vegetables;
• berries and fruits;
• steamed or boiled fish;
• egg products, only with moderate consumption;
• kefir and yogurt, as well as sour cream.

This diet will help with mild forms of the disease to cope with it even without drug treatment. Even if the form is more complex, in any case you will have to adhere to such a diet so as not to worsen your situation.

Folk remedies

In addition to traditional medicine, treatment can also be carried out using folk remedies. You can treat a child with various decoctions and infusions, but it is advisable to first consult with a urologist so as not to cause harm.

According to medical statistics, urolithiasis is one of the ten most common human diseases. If kidney stones occur, the symptoms of the disease will not take long to appear. Symptoms of urolithiasis, the process of formation of kidney stones, diagnosis and main methods of treatment should be considered in more detail.

The main causes of kidney stones

Experts have identified external and internal factors that contribute to the appearance and development of urolithiasis. Despite its sufficient study, the exact causes of the formation of kidney stones cannot be named.

External factors include:

• insufficient amount of water consumed during the day;
• water composition with a predominance of lime salts;
• eating large amounts of meat or fish;
• preference for salty, spicy, sour foods;
• deficiency of vitamins A, D;
• hot climate;
• unfavorable environment;
• sedentary lifestyle.

Kidney stones can occur under the influence of the following main internal factors:

1. In the presence of hormonal changes, in particular hyperfunction of the parathyroid gland.
2. Diseases of the gastrointestinal tract.
3. Various genitourinary infections.
4. Congenital defects of the urinary system.
5. Diseases in which the patient is forced to remain motionless for a long time.
6. Heredity.

The basis of almost all of the above internal factors that cause the appearance of kidney stones is a violation of the acid-base balance in the human body.

Mechanism of stone formation

The process of stone formation takes a long period.

All minerals in urine must be present in strictly defined quantities.

Under certain conditions, during a complex physical and chemical process, an elementary basis appears - a micelle, from which a stone is formed in the future. To do this, material in the form of fibrin threads, cellular detritus, bacteria, etc. is first taken from urine. Then, an increased concentration of salt and protein in the urine and their altered ratio take part in the formation of kidney stones.

Kidney stones can vary in size, shape, location and location. The places where stones form in the kidneys can be different. The size of these formations usually depends on the duration of the disease. At first they are microscopic in size and are called sand. Those formations that somehow managed to gain a foothold in the kidneys or urinary tract begin to increase in size over time and can reach several cm.

What do the stones look like externally? The shape of kidney stones largely depends on their chemical composition. In this regard, they can have a regular shape with a smooth and even surface or be angular, irregular in shape, with many sharp edges.

Types of kidney stones

The chemical composition of kidney stones is different and largely depends on the causes of their occurrence. Common types of kidney stones can be identified:

• urate;
• carbonate;
• oxalate;
• phosphate;
• protein.

The urate type of stones consists of uric acid salts, which occurs when urine has an acidic reaction. Urates have a dense structure with a smooth surface.

Carbonate stones are formed due to calcium salts of carbonic acid. They come in various shapes, are soft and smooth to the touch, and are almost always light in color.

The cause of the appearance of oxalates is calcium salts of oxalic acid. The stones have an uneven surface, dark color, and dense structure.

Phosphates consist of salts of phosphoric acid. Kidney stones of this type have a rough surface, quickly crumble to the touch, are soft, and light gray in color. To ensure rapid growth of these stones, an alkaline environment is required.

Protein stones are a mixture of fibrin, salts and bacteria. The stones are almost always light in color and small in size. They have a smooth surface to the touch.

Sometimes there is a mixed type of kidney stones, which is considered the most difficult option for treatment.

Symptoms of urolithiasis

Symptoms of kidney stones can vary. With small renal formations, up to 5 (mm), it is difficult for the patient to determine the signs of urolithiasis. Sometimes a patient learns about the kidney stones he has by chance, while undergoing a routine ultrasound examination of the kidneys.

Urolithiasis actively begins to manifest its symptoms when the process of its development has gone quite far. The main symptoms of kidney stones include:

• sharp cutting pain in the side or lower back;
• dull aching pain in the lower back or lower abdomen;
• cloudy urine;
• presence of blood in the urine;
• increased urge to urinate;
• urinary retention;
• passage of sand or stones during urination;
• increased body temperature, fever;
• state of nausea.

Many of the symptoms listed above may correspond to other serious illnesses. For example, sharp pain in the right kidney can be differentiated from acute appendicitis or cholecystitis. Therefore, it is important to immediately contact a specialist who will perform an initial examination and perform the necessary diagnostics of the kidneys and nearby organs.

Diagnostic testing for kidney stones

When making an initial appointment with a medical specialist, it is necessary to describe in detail all the signs of the disease. If a stone passes on its own in the urine, it must be submitted to a doctor for a study to determine its chemical composition. This is done to prescribe the correct treatment.

But how to determine the type of stone? To do this, the following checks can be carried out:

• daily urine collection;
• biochemical blood test;
• biochemical examination of the stone.

To establish an accurate diagnosis, determine the number of stones and their exact location, and assess the danger to other organs, an experienced doctor may prescribe:

• Ultrasound of the kidneys, abdominal organs;
• excretory urography;
• plain x-ray of the abdominal organs;
• MRI of the kidneys;
• spiral computed tomography;
• general blood and urine analysis.

http://youtu.be/Sh5NubtNL_Y

If necessary, the doctor may additionally prescribe any other diagnostic test. It should be noted that diagnosing kidney stones with modern high-tech equipment will not be difficult. After an accurate diagnosis is made, an individual treatment plan is drawn up for each patient.

Treatment of urolithiasis

Treatment of this disease has the following goals:

• getting rid of kidney stones;
• preventing their reappearance.

For small stones, conservative treatment is prescribed, and for larger stones, surgery is prescribed.

Conservative treatment includes:

• drinking plenty of water;
• strict adherence to the diet;
• the use of drugs that dissolve stones.

To relieve acute pain due to kidney stones, the doctor prescribes injections of morphine, Baralgin with atropine solution, novocaine blockade, a warm bath, and a heating pad.

Indications for surgical intervention may include:

• stones larger than 5 (mm);
• recurrent illness;
• presence of a single kidney;
• incessant pain, etc.

Today, minimally invasive surgery methods are used:

• endoscopic and laparoscopic operations,
• crushing stones through a lumbar puncture;
• ultrasound treatment.

If these methods are ineffective, open surgery is resorted to. Operated patients are recommended to follow a lifelong diet and follow all doctor’s recommendations.

If the disease is advanced or if all the doctor’s recommendations are not followed, the consequences can be disastrous, even death.

http://youtu.be/t8WYc8QZXpA

Therefore, the presence of kidney stones requires immediate and complete treatment under the guidance of an experienced doctor. Only in this case can you count on a favorable prognosis.

Quote Patients with Ca-oxalate stones should eat a well-balanced diet, in which foods from various groups are included in the overall diet. Obtaining calcium from the outside is ensured by consuming milk and dairy products, which are the most important foods containing calcium. In patients with elevated oxalic acid levels, foods rich in oxalate should be limited (Table 18). Table 18 - Oxalate content of selected foods. Product Average content of oxalic acid (100 g of product) Cocoa 625 mg Nuts 200 - 600 mg Tea leaves 375 - 1450 mg Spinach 570 mg Rhubarb 530 mg The following products are recommended: meat, poultry, fish in moderation, preferably boiled, in including boiled sausages (milk, dietary), sausages, eggs in any processing, salads from boiled meat and fish; milk, kefir, cottage cheese, sour cream (except for situations with an increase in the level of calcium in the urine, with a high urine pH, during exacerbation); fats: butter and vegetable oils, unsalted lard; cereals: buckwheat, oatmeal, pearl barley, millet, pasta, soups made from them; bread: wheat, rye, flour products, especially coarsely ground with the inclusion of wheat bran; vegetables and fruits: cucumbers, cabbage, peas, eggplants, turnips, pumpkin, lentils, apricots, bananas; soups, sauces; cold vegetable appetizers, squash and eggplant caviar; compotes, jelly, mousses; tea, weak coffee with milk, decoctions of dried fruits, rose hips, wheat bran, fruit drinks, kvass. Exclude from the diet: liver, kidneys, tongue, brains, salted fish, jellies and gelatin-based jellies, legumes; limit cheeses, exclude salty cheeses; sorrel, spinach, rhubarb, mushrooms, strawberries, pears, gooseberries, beans, salted vegetables, limit beets (in case of exacerbation), relatively limit carrots, onions, tomatoes; meat, mushroom and fish broths and sauces; salty snacks, smoked meats, canned food, caviar, pepper, mustard, horseradish; chocolate, figs; limit black currants, blueberries, sweets, jam, confectionery; cocoa, strong coffee; There is no need to strictly limit tomatoes, cabbage and other vegetables. Given that increased uric acid excretion increases the risk of oxalate stone formation, it is advisable to reduce the consumption of foods rich in purines. Eating foods rich in dietary fiber, which is the non-metabolized part of plant foods, helps bind minerals in the intestines, thereby reducing their absorption. This measure is especially important in patients with absorptive hypercalciuria. Considering that the formation of stones from calcium oxalate is a multifactorial process, increasing diuresis throughout the day is the most important metaphylactic measure. This is especially important for patients whose urine examination did not reveal any metabolic disorders. Dilution of urine and a decrease in the concentration of salts in it provides diuresis of about 2 - 2.5 liters of urine per day. Depending on the intensity of physical activity and the ambient temperature, the amount of liquid drunk should vary between 2.5 - 3 liters. This amount of liquid should be distributed evenly throughout the day. A very good habit is to drink extra fluid before each act of urination. It is very important to drink extra fluids before bed to avoid highly concentrated urine during sleep. Alkaline drinks are preferred because they increase urine pH and citric acid excretion. Suitable mineral water for this purpose is rich in bicarbonate ion and moderate calcium content (at least 1500 mg HCO3-/l; maximum 200 mg calcium/l. Drinks that do not cause changes in urine: kidney tea; fruit tea; mineral water with low mineral content. Drinks that should be limited: coffee and black tea are limited due to caffeine-dependent increase in uric acid excretion. Black tea also contains a significant amount of phosphorus and oxalate. Milk is limited due to the content of calcium, animal protein and phosphates. coffee 2 cups per day, black tea - 2 cups per day, milk - 2 glasses per day; drinks containing sugar increase the excretion of calcium; alcoholic drinks increase the excretion of uric acid and promote acidification of urine. high risk of recurrence. In this case, it is necessary to exclude obstruction of the urinary tract and pay special attention to urine dilution. This is achieved by drinking large amounts of fluid under the control of urine density. It is necessary to achieve a diuresis of at least 2.0 - 2.5 liters per day. To do this, you need to drink 2.5 - 3.0 liters of fluid per day and it is very important that the fluid intake is uniform throughout the day. It is recommended to develop the habit of drinking fluid before each urination and before going to bed at night. No less important is the question - what drinks to drink? Mineral waters with a low calcium and bicarbonate content (HCO3- maximum 500 mg/l and Ca2+ maximum 150 mg/l) are preferred. Cranberry juice also has an acidifying and bacteriostatic effect. However, cranberry juice consumption should be limited due to increased oxalate excretion. The daily volume of fluid should be supplemented with kidney tea, fruit tea, and apple juice. You should limit coffee, tea and milk (no more than two cups per day). You should not drink citrus juices, mineral waters rich in calcium and HCO3- ion, lemonades containing sugar and alcohol. You should avoid visiting a sauna, prolonged exposure to the sun or in hot climates, and excessive physical exertion due to fluid loss. The formation of calcium phosphate stones can sometimes be the result of prolonged immobilization. This occurs due to the resorption of calcium and phosphorus from the bones, urodynamic disturbances, and infection of the urinary tract. Physical activity in this case is a good metaphylactic measure. To monitor the effectiveness of metaphylaxis, it is recommended to monitor the serum levels of calcium, potassium and creatinine, and in the urine - the levels of pH, calcium, potassium, citric acid, and a nitrite test. With this type of urolithiasis, you need to follow a balanced diet. It is not recommended to follow a strict vegetarian diet. It is necessary to control calcium intake: avoid eating hard cheeses, replacing them with yogurt and cottage cheese. The acceptable level of protein consumption is 150 g per day in the form of meat, fish or sausages. With hyperphosphaturia, it is necessary to consume high fiber and low-calorie foods in small portions several times a day. The following products are recommended: meat, poultry, fish in any processing, including in the form of appetizers, soups and sauces; eggs in any preparation (1 time per day); fats: butter and vegetable oil, lard; cereals in any preparation, but without milk; bread, flour products in any form; vegetables: green peas, pumpkin; mushrooms; sour varieties of apples, cranberries, lingonberries, compotes, jelly and fruit drinks on them; honey, sugar, confectionery; weak tea and coffee (without milk), rosehip decoction. Exclude or limit: smoked meats, pickles; milk, fermented milk products: cottage cheese, cheese, sweet dishes made with milk and cream; meat and cooking fats; baked goods; potatoes and vegetables, except those mentioned above; vegetable salads, vinaigrettes, canned vegetables; spices, fruit, berry and vegetable juices.

Symptoms of kidney stones almost always vary from person to person, so describe your case in the comments, or write in the question and answer section.

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 are of 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 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 treatment necessary 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.

In case of 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 a urinary system infection and impaired urine outflow, is explained by the fact that the inflammatory process changes the pH of the urine and disrupts the integrity of the epithelial cover of the renal pelvis and calyces.

The amount of colloids secreted by the kidneys (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.