Urolithic disease – the widespread urological disease which is shown formation of stones in various departments of an urinary system, most often – in kidneys and a bladder. Tendency to the heavy recidivous course of an urolithic disease is quite often noted. The urolithic disease on clinical symptomatology, results of a radiological research, ultrasonography of kidneys and a bladder is diagnosed. The fundamental principles of treatment of an urolithic disease are: conservative kamnerastvoryayushchy therapy by tsitratny mixes, and at its not efficiency - carrying out a remote lithotripsy or surgical removal of concrements.
Urolithic disease – the widespread urological disease which is shown formation of stones in various departments of an urinary system, most often – in kidneys and a bladder. Tendency to the heavy recidivous course of an urolithic disease is quite often noted. The urolithic disease can arise at any age, but to a thicket affects people of 25-50 years. At children and elderly patients at an urolithic disease bladder stones are more often formed while persons of middle and young age, generally suffer from stones in kidneys and mochetochnik.
The disease is widespread. Increase in frequency of an urolithic disease as believe, connected with increase of influence of adverse factors of the external environment is noted. Now the reasons and the mechanism of development of an urolithic disease are not studied up to the end yet. The modern urology has a set of the theories explaining separate stages of formation of stones, but it is not possible to unite these theories yet and to fill missing intervals in a uniform picture of development of an urolithic disease.
The contributing factors
Allocate three groups of the contributing factors increasing risk of development of an urolithic disease.
- External factors
The probability of development of an urolithic disease increases if the person leads the inactive life leading to violation of phosphorus-calcium exchange. Developing of an urolithic disease features of food (excess of protein, the sour and spicy food increasing acidity of urine), properties of water (water with the increased content of salts of calcium) can provoke, a lack of vitamins of group B and vitamin A, harmful working conditions, reception of a number of medicines (large amounts of ascorbic acid, sulfanylamides).
- Local internal factors
The urolithic disease arises with anomalies of development of an urinary system more often (the only kidney, narrowings of urinary tract, a horseshoe kidney), inflammatory diseases of an uric path.
- General internal factors
The risk of developing of an urolithic disease increases at chronic gastrointestinal diseases, a long immovability owing to a disease or a trauma, dehydration at poisonings and infectious diseases, a metabolic disorder owing to deficiency of certain enzymes.
Men have an urolithic disease more often, but at women develop severe forms of MKB more often with formation of korallovidny stones which can occupy all cavity of a kidney.
Classification of stones at an urolithic disease
Stones of one look are formed approximately at a half of patients with an urolithic disease. At the same time in 70-80% of cases the stones consisting of inorganic compounds of calcium (carbonates, phosphates, oxalates) are formed. 5-10% of stones contain magnesium salts. About 15% of stones at an urolithic disease are formed by derivatives of uric acid. Proteinaceous stones are formed in 0,4-0,6% of cases (at violation of exchange of certain amino acids in an organism). At other patients with an urolithic disease polymineral stones are formed.
Etiology and pathogenesis of an urolithic disease
So far researchers only study various groups of factors, their interaction and a role in developing of an urolithic disease. Assume that there is a number of the constant contributing factors. At some point joins constant factors additional, becoming a push to formation of stones and development of an urolithic disease. Having made impact on the patient's organism, this factor can disappear subsequently.
The uric infection aggravates the course of an urolithic disease and is one of the major additional factors stimulating development and retsidivirovany MKB as a number of infectious agents in the course of activity influences composition of urine, promotes its alkalization, formation of crystals and formation of stones.
Symptoms of an urolithic disease
The disease proceeds differently. At one patients the urolithic disease remains a single unpleasant episode, at others accepts recidivous character and consists of a number of aggravations, at the third tendency to the long chronic course of an urolithic disease is noted.
Concrements at an urolithic disease can be localized both in right, and in the left kidney. At 15-30% of patients bilateral stones are observed. The clinic of an urolithic disease is defined by existence or lack of violations of an urodinamika, change of kidney functions and the joined infectious process in urinary tract.
At an urolithic disease there is pain which can be sharp or stupid, intermittiruyushchy or constant. Localization of pain depends on location and the sizes of a stone. The gematuriya, a piuriya (develops at accession of an infection), an anury (at an obturation). If there is no obstruction of urinary tract, the urolithic disease sometimes proceeds asymptomatically (13% of patients). Renal colic becomes the first display of an urolithic disease.
- Renal colic
At obstruction of a mochetochnik a stone pressure in a kidney lokhanka sharply increases. Stretching of a lokhanka in which wall there is a large number of pain receptors, causes severe pain. Stones less than 0,6 cm in size, as a rule, depart independently. During the narrowing of uric ways and stones of the big sizes obstruction is eliminated and cannot spontaneously cause damage and death of a kidney.
The patient with an urolithic disease suddenly has a severe pain in lumbar area which is not depending on position of a body. If the stone is localized in the lower departments of mochetochnik, there are pains in the bottom of a stomach irradiating to the inguinal area. Patients are uneasy, try to find position of a body at which pain will be less intensive. Perhaps speeded up urination, nausea, vomiting, intestines paresis, a reflex anury.
At fizikalny survey the positive symptom of Pasternatsky, morbidity in lumbar area and on the course of a mochetochnik comes to light. Laboratory the mikrogematuriya, a leykotsituriya, poorly expressed proteinuria, increase in SOE, decides on shift to the left.
If there is a simultaneous obstruction of two mochetochnik, at the patient with an urolithic disease the sharp renal failure develops.
At 92% of patients with an urolithic disease after renal colic the mikrogematuriya arising owing to injury of veins of fornikalny textures and revealed when carrying out laboratory researches is noted.
- Urolithic disease and the accompanying infectious process
The urolithic disease is complicated by infectious diseases of an urinary system at 60-70% of patients. Quite often in the anamnesis the chronic pyelonephritis which arose prior to the beginning of an urolithic disease is noted.
At development of complications of an urolithic disease the streptococcus, staphylococcus, colibacillus, vulgar proteas acts as the infectious agent. The piuriya is characteristic. The pyelonephritis accompanying an urolithic disease proceeds sharply or gains chronic character.
Sharp pyelonephritis at renal colic can immediately develop. The considerable hyperthermia, intoxication is noted. If adequate treatment is absent, bacterial shock is possible.
At some patients with an urolithic disease the big stones almost completely occupying cup system are formed. Such form of an urolithic disease is called the korallovidny nefrolitiaz (KN). The KN is inclined to a persistent recidivous current, causes gross violations of kidney functions and becomes frequent the reason of development of a renal failure.
Renal gripes for a korallovidny nefrolitiaz are uncharacteristic. In the beginning the disease proceeds almost asymptomatically. Patients can show nonspecific complaints (increased fatigue, weakness). Unsharp pains in lumbar area are possible. Further at all patients pyelonephritis develops. Gradually kidney functions decrease, the renal failure progresses.
Diagnosis of an urolithic disease
The diagnosis of MKB is based on anamnestichesky data (renal colic), frustration of an urination, characteristic pains, urine changes (a piuriya, a gematuriya), by otkhozhdeniya with urine of stones, these ultrasonic, radiological and tool researches.
In the course of diagnosis of an urolithic disease X-ray diagnostic methods of a research are widely applied. The majority of stones comes to light at survey urography. It is necessary to consider that soft proteinaceous and mochekisly stones of a rentgenonegativna and do not give a shadow in survey pictures.
At suspicion of an urolithic disease irrespective of whether shadows of concrements in survey pictures were found, the excretory urography by which define localization of concrements is carried out, estimate functional ability of kidneys and urinary tract. The Rengenkontrastny research at an urolithic disease gives the chance to reveal the X-ray negative stones which are displayed in the form of defect of filling.
If the excretory urography does not allow to estimate anatomic changes of kidneys and their functional state (at a pionefroza, a kalkulezny gidronefroz), carry out an isotope renografiya or a retrograde piyelografiya (it is strict according to indications). Before surgeries the kidney angiography is applied to assessment of a functional state and angioarkhitektonik of a kidney at a korallovidny nerolitiaz.
Use of ultrasonography expands possibilities of diagnosis of an urolithic disease. By means of this method of a research any X-ray positive and X-ray negative stones, regardless of their size and location come to light. Ultrasonography of kidneys allows to estimate influence of an urolithic disease on a state cup systems. Allows to reveal stones in underlying departments of an urinary system ultrasonography of a bladder. Ultrasonography after carrying out a remote lithotripsy is applied to dynamic observation of the course of litolitichesky therapy of an urolithic disease with X-ray negative stones.
Differential diagnosis of an urolithic disease
Modern techniques allow to reveal any kinds of stones therefore to carry out it is not required to differentiate an urolithic disease from other diseases usually. Need to carry out differential diagnostics can arise at a sharp state – renal colic.
Usually diagnosis of renal colic does not cause difficulties. At an atipichesky current and right-hand localization of the stone causing obstruction of urinary tract sometimes it is necessary to carry out differential diagnosis of renal colic at an urolithic disease with sharp cholecystitis or an acute appendicitis. The diagnosis is based on characteristic localization of pains, existence of the dizurichesky phenomena and changes of urine, lack of symptoms of irritation of a peritoneum.
Serious difficulties at differentiation of renal colic and heart attack of a kidney are possible. In that and in other case the gematuriya and the expressed pains in lumbar area is noted. It is worth to remember that the heart attack of kidneys usually is a consequence of cardiovascular diseases of which violations of a rhythm are characteristic (rheumatic heart diseases, atherosclerosis). The Dizurichesky phenomena at a heart attack of kidneys arise extremely seldom, pains are less expressed and almost never reach that intensity which is characteristic of renal colic at an urolithic disease.
Treatment of an urolithic disease
General principles of therapy of an urolithic disease
Are used both operational methods of treatment, and conservative therapy. Tactics of treatment is defined by the urologist depending on age and the general condition of the patient, localization and the size of a stone, the clinical course of an urolithic disease, existence of anatomic or physiological changes and a stage of a renal failure.
As a rule, for removal of stones at an urolithic disease it is necessary to carry out surgical treatment. An exception are the stones formed by derivatives of uric acid. Such stones often manage to be dissolved, carrying out conservative treatment of an urolithic disease by tsitratny mixes within 2-3 months. Stones of other structure do not give in to dissolution.
Otkhozhdeniye of stones from uric ways or surgical removal of stones does not exclude a possibility of a recurrence of an urolithic disease therefore it is necessary to carry out the preventive actions directed to prevention of a recurrence from a bladder or a kidney. The complex regulation of exchange violations including care of maintenance of water balance, a dietotherapy, a travolecheniye, medicamentous therapy, physiotherapy exercises, balneological and physiotherapeutic procedures, sanatorium treatment is shown to patients with an urolithic disease.
Choosing tactics of treatment of a korallovidny nefrolitiaz, are guided by violation of kidney functions. If function of a kidney is kept for 80% and more, conservative therapy is carried out if function is reduced by 20-50%, the remote lithotripsy is necessary. At further loss of kidney functions kidney operation for surgical removal of stones from kidneys is recommended.
Conservative therapy of an urolithic disease
Dietotherapy at an urolithic disease
The choice of a diet depends on structure of the found and remote stones. The general principles of a dietotherapy at an urolithic disease:
- various diet with restriction of total amount of food;
- restriction in a diet of the products containing a large amount of kamneobrazuyushchy substances;
- reception of enough liquid (it is necessary to provide a daily diuresis of 1,5-2,5 l.).
At an urolithic disease about calcium-oksalatnymi stones it is necessary to reduce the use of strong tea, coffee, milk, chocolate, cottage cheese, cheese, a citrus, bean, nuts, strawberry, blackcurrant, salad, spinach and a sorrel.
At an urolithic disease with uratny stones it is necessary to limit reception of proteinaceous food, alcohol, coffee, chocolate, hot and fat dishes, to exclude meat food and an offal (liverny sausages, pastes) in the evening.
At an urolithic disease with phosphorus-calcium stones exclude milk, hot dishes, spices, alkaline mineral waters, limit the use of sheep cheese, cheese, cottage cheese, green vegetables, berries, pumpkins, beans and potatoes. Sour cream, kefir, red currant cowberry, sauerkraut, vegetable fats, flour products, fat, pears, green apples, grapes, meat products is recommended.
Kamneobrazovaniye at an urolithic disease in no small measure depends on urine pH (normal – 5,8-6,2). Reception of these or those types of food changes concentration of ions of hydrogen in urine that allows to regulate urine pH independently. Vegetable and milk food alkalinizes urine, and animal products acidify. It is possible to check the level of acidity of urine by means of the special paper indicator strips which are freely on sale in drugstores.
If on ultrasonography there are no stones (existence of small crystals – microlitas is allowed) for washing of a cavity of kidneys it is possible to use "water blows". The patient accepts on an empty stomach 0,5-1 liter of liquid (low-mineralized mineral water, tea with milk, dried fruits decoction, fresh beer). In the absence of contraindications the procedure is repeated time in 7-10 days. In case there are contraindications, "water blows" can be replaced with reception of kaliysberegayushchy diuretic medicine or broth of diuretic herbs.
Phytotherapy at an urolithic disease
During therapy of an urolithic disease a number of medicines of a phytogenesis is applied. Officinal herbs apply to acceleration of an otkhozhdeniye of sand and fragments of stones after a remote lithotripsy, and also as prophylactic for improvement of a condition of an urinary system and normalization of exchange processes. Some medicines on the basis of herbs promote increase in concentration in urine of protective colloids which interfere with process of crystallization of salts and help to prevent a recurrence of an urolithic disease.
Treatment of infectious complications of an urolithic disease
At the accompanying pyelonephritis appoint antibacterial medicines. It is necessary to remember that complete elimination of an uric infection at an urolithic disease is possible only after elimination of the prime cause of this infection – a stone in a kidney or uric ways. The good effect at purpose of a norfloksatsin is noted. Appointing medicines to the patient with an urolithic disease, it is necessary to consider a functional condition of kidneys and expressiveness of a renal failure.
Normalization of exchange processes at an urolithic disease
Exchange violations are the major factor causing a recurrence of an urolithic disease. Apply to decrease in level of uric acid and . If acidity of urine does not manage to be normalized a diet, the listed medicines apply in a combination with tsitratny mixes. At prevention of oksalatny stones for normalization of shchavelevokisly exchange use B1 and B6 vitamins, and for prevention of crystallization of oxalate of calcium – magnesium oxide.
The antioxidants stabilizing function of cellular membranes – vitamins A and E are widely used. At increase in level of calcium in urine appoint a hydrochlorothiazide in a combination with the medicines containing potassium ( potassium). At violations of exchange of phosphorus and calcium long reception of diphosphonates is shown. The dose and duration of reception of all medicines is defined individually.
Therapy of an urolithic disease in the presence of stones in kidneys
If the tendency to an independent otkhozhdeniye of stones is noted, sick with an urolithic disease appoint the medicines from group of terpenes (extract of fruits of an amma tooth, etc.) possessing bakteriostatichesky, sedative and spazmolitichesky action.
Knocking over of renal colic is carried out by spazmolitikam (, sodium metamizol) in combination with thermal procedures (a hot-water bottle, a bathtub). At inefficiency appoint spazmolitik in combination with soothing medicines.
Surgical treatment of an urolithic disease
If the concrement at an urolithic disease does not depart spontaneously or as a result of conservative therapy, surgery is required. The indication to an urolithic disease operation is the expressed pain syndrome, a gematuriya, the attacks of pyelonephritis, hydronephrotic transformation. Choosing a method of surgical treatment of an urolithic disease, it is necessary to give preference to the least traumatic technique.
Open surgeries at an urolithic disease
In the past open operation was the only way allowing to remove a stone from uric ways. Quite often during such surgery there was a need of removal of a kidney. Today the list of indications to open an urolithic disease operation was considerably reduced, and the advanced surgical equipment and new operational techniques practically always allow to keep a kidney.
Indications to open an urolithic disease operation:
- stones of the big size;
- the developing renal failure in case other methods surgical are contraindicated or inaccessible to an urolithic disease;
- localization of a stone in a kidney and the accompanying purulent pyelonephritis.
The type of open surgical intervention at an urolithic disease is defined by localization of a stone.
Types of operations:
- piyelolitotomiya. It is carried out if the concrement is in a lokhanka. There are several techniques of operation. As a rule, the back piyelolitotomiya is carried out. Sometimes, in connection with anatomic features of the patient with an urolithic disease, an optimal variant there is a forward or lower piyelolitotomiya.
- nefrolitotomiya. Operation is shown at stones of especially large size which cannot be taken through a section in a lokhanka. The section is carried out through a kidney parenchyma;
- ureterolitotomiya. It is carried out if the stone is localized in a mochetochnik. Today it is applied seldom.
Rentgenendoskopichesky an urolithic disease operations
Operation is performed by means of the cystoscope. Small stones delete entirely. In the presence of large concrements operation is carried out in two steps: crushing of a stone (transurethral uretrolitotripsiiya) and its extraction (litoekstraktion). The stone is destroyed in the pneumatic, electrohydraulic, ultrasonic or laser way.
Prostate adenoma can become a contraindication to this surgery (because of impossibility to enter the endoscope), infections of uric ways and a number of diseases of musculoskeletal system at which the patient with an urolithic disease cannot be laid on the operating table correctly.
In certain cases (localization of concrements in a cup lokhanochnoy to system and existence of contraindications to other methods of treatment) to treatment of an urolithic disease the chrezkozhny litoekstraktion is applied.
Shock and wave remote lithotripsy at an urolithic disease
Crushing is made by means of the reflector which is letting out electrohydraulic waves. The remote lithotripsy allows to lower percent of postoperative complications and to reduce a travmatization of the patient having an urolithic disease. This intervention is contraindicated at pregnancy, violations of coagulability of blood, violations of warm activity (warm and pulmonary insufficiency, the artificial driver of a rhythm, vibrating arrhythmia), actively current pyelonephritis, excessive weight of the patient (over 120 kg), impossibility to remove a concrement in focus of a shock wave.
After crushing sand and fragments of stones depart with urine. In some cases process is followed by easily stopped renal colic.
Any type of expeditious treatment does not exclude a retsidivirovaniye of an urolithic disease. For prevention of a recurrence it is necessary to carry out long, complex therapy. After removal of concrements patients with an urolithic disease have to be observed within several years at the urologist.