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Overview |
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Definition |
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Also called nephrolithiasis or kidney stones, urolithiasis is the presence of
calculi in the urinary tract. The male-to-female incidence ratio is 4:1, with
240,000 to 720,000 Americans affected yearly. Eighty percent of calculi are
composed of calcium (either oxalate or phosphate), with others composed of
struvite, uric acid, or cystine. |
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Etiology |
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Type of stone indicates cause.
- Calcium type I—increased small bowel
absorption of calcium unrelated to intake
- Calcium type II—increased dietary calcium
intake
- Calcium type III—increased vitamin D
synthesis (secondary to renal phosphate loss)
- Calcium oxalate—idiopathic in origin, or
through primary intestinal disorders, chronic diarrhea with inflammatory bowel
disease or steatorrhea
- Struvite (magnesium ammonium
phosphate)—mainly in women and can be large, stag's
horn shape; secondary to infection with urease-producing organisms (Proteus,
Pseudomonas, Providencia, and less commonly Klebsiella)
- Uric acid—metabolic defects or dietary
excess of uric acid; bowel disease or chemotherapy
- Cystine—secondary to chronic diarrhea, type
I renal tubular acidosis, chronic hydrochlorothiazide treatment,
idiopathic
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Risk Factors |
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- Excess intake of calcium, oxalate, or purines in predisposed
individuals
- Inadequate fluid intake
- Sedentary occupation
- Area of high humidity, elevated temperatures (summer)
- Hyperparathyroidism
- Renal tubule defects (renal tubule acidosis)
- Bowel disease
- Ileal bypass for obesity
- Genetics—cystinuria is an autosomal
recessive disorder and homozygous type has markedly increased cystine
excretion
- Excessive intake of certain vitamins and minerals
- Gout
- Use of certain diuretics
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Signs and Symptoms |
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May be asymptomatic, but the following are usually seen.
- Sudden onset of severe flank pain
- Nausea and vomiting
- Patient in constant motion in attempt to lessen the pain
- Pain referred to testes or labium as the stone moves
- Fever and chills (infection)
- Pain radiating anteriorly over the
abdomen
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Differential
Diagnosis |
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- Urinary tract infection
- Pyelonephritis
- Diverticulitis
- Pelvic inflammatory disease
- Ovarian pathology
- Drug addiction
- Appendicitis
- Small bowel obstruction
- Ectopic pregnancy
- Cadmium toxicity
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Diagnosis |
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Physical Examination |
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Patient is in extreme pain and constantly moving. Pain occurs episodically as
the stone moves down the ureter and may be referred. Severity of symptoms does
not reflect stone size. Patient may be asymptomatic, with stone found
incidentally on plain film. |
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Laboratory Tests |
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- Urinalysis—Possibly microscopic or gross
hematuria, but absence does not exclude stones. Exclude infection.
- Urine pH—Persistent urinary pH <5.0
indicates uric acid or cystine stone; persistent urinary pH >7.5 indicates
struvite stone.
- Urine culture and sensitivity tests
- Serum chemistries for calcium, electrolytes, phosphate, and uric
acid
- 24-hour urine collection for calcium, uric acid, phosphate, oxalate,
citrate excretion (recurrent cases only), and to collect stones for
analysis
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Pathology/Pathophysiology |
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Analysis of stone to determine type—60% to 80% are
calcium, 15% to 20% struvite, 5% uric acid, and 1% to 3%
cystine. |
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Imaging |
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- Plain abdominal film and renal
ultrasound—radiopaque stones
- Ultrasound with a full bladder—to confirm
stone in the ureterovesical junction
- Intravenous urography—to confirm
diagnosis
- Intravenous pyelogram—to determine size and
location of stone and degree of obstruction
- Unenhanced helical CT scan—rim sign or halo
of the calculus
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Other Diagnostic
Procedures |
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Metabolic evaluation for recurrent stone formation:
- 24-hour urine collection to check volume, urinary pH, calcium, uric
acid, oxalate, and citrate excretion
- Second collection on restricted calcium (400 mg/day), sodium (100
mEq/day), and oxalate diet
- Serum parathyroid hormone and calcium load tests at third
visit
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Treatment Options |
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Treatment Strategy |
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Usually conservative management eventually results in stone passage.
Treatment depends on type of stone, ability or inability to pass, and presence
of complications. All patients should drink at least six to eight glasses of
water daily plus one at bedtime and one during the night. For calcium type II
stones, follow a low-calcium diet, restrict sodium to 1 g/kg daily, and increase
bran intake. |
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Surgical Procedures |
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Surgery is recommended for patients with severe pain unresponsive to
medications, serious bleeding, and persistent fever, nausea, or significant
urinary obstruction. If no medical treatment is provided after surgery, stones
recur in 50% of patients within five years.
- Extracorporeal shock wave lithotripsy
(ESWL)— outpatient procedure that shatters stones under
2 cm and without complications
- Urethroscopy for stones in lower third of ureter
- Percutaneous nephrolithotomy when in upper two-thirds of ureter and
greater than 2 cm in size
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Drug Therapies |
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- Narcotics—as needed to control acute severe
pain
- Allopurinol—for uric acid calculi; 100 to
300 mg/day to control hyperuricemia
- Potassium citrate—for uric acid calculi; 100
mEq tablets bid to raise urinary pH
- Hydrochlorothiazide—for calcium type I
stones; 25 to 50 mg/day.
- Cellulose phosphate—for calcium type I
stones; 10 g/day to decrease bowel absorption
- Orthophosphates—for calcium type III stones;
to inhibit vitamin B synthesis
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Complementary and Alternative
Therapies |
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Symptomatic urolithiasis requires medical attention. Alternative therapies
aid in preventing recurrent episodes and increasing the overall vitality of the
urogenital system. Start with nutritional guidelines for prevention of
recurrence. Herbs and homeopathics can be used for acute pain relief and
long-term tonification of the urinary tract. |
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Nutrition |
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- Reduce intake of sugar, refined foods, animal products (meats and
dairy), caffeine, alcohol, soft drinks, and salt.
- Increase intake of water, fiber, vegetables, whole grains, and
vegetable proteins.
- Minimize oxalate-containing foods such as spinach, rhubarb, beets,
nuts, chocolate, black tea, wheat bran, strawberries, and beans.
- Include foods rich in magnesium and low in calcium, such as barley,
bran, corn, rye, oats, soy, brown rice, avocado, banana, and potato.
- Magnesium citrate (200 to 400 mg/day)—may
increase the solubility of calcium oxalate and calcium phosphate.
- Pyridoxine (B6, 10 to 100 mg/day)—is
essential for the metabolism of oxalic acid.
- Folic acid (5 mg/day)—for uric acid
stones.
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Herbs |
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Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites, or tinctures (alcohol extracts). Unless otherwise indicated, teas
should be made with 1 tsp. herb per cup of hot water. Steep covered 10 to 20
minutes and drink 2 to 4 cups/day. Tinctures may be used singly or in
combination as noted.
- For acute pain relief, combine tinctures of wild yam (Dioscorea
villosa), cramp bark (Viburnum opulus), kava (Piper methysticum),
and Jamaica dogwood (Piscidia piscipula). Take 15 drops every 15
minutes for up to 8 doses.
- Drink an infusion of equal parts of gravel root (Eupatorium
purpureum), corn silk (Zea mays), pipissewa (Chimaphila
umbellata), and kava 1 tsp./cup, 3 to 4
cups/day.
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency. For acute
prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours
until acute symptoms resolve.
Remedies that may be considered for acute pain relief include the
following.
- Berberis—for sharp, stitching pains
that radiate to groin
- Colocynthis—for restlessness with
pains that feel better bending forward
- Ocimum—for nausea and vomiting from
the pain
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Physical Medicine |
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Castor oil pack. Used externally, castor oil is a powerful anti-inflammatory.
Apply oil directly to skin, cover with a clean soft cloth (e.g., flannel) and
plastic wrap. Place a heat source (hot water bottle or heating pad) over the
pack and let sit for 30 to 60 minutes. For best results, use for three
consecutive days. |
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Patient Monitoring |
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Fifty percent of patients pass the stone within 48 hours. For complications
or recurrences, refer patient to a urologist. Admit patients to the hospital
when they have persistent vomiting, suspected urinary tract infection, pain
unresponsive to oral analgesics, or obstructing calculus with a solitary
kidney. |
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Other
Considerations |
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Prevention |
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Maintain proper hydration and dietary restrictions to avoid future
development of stones. Determine and treat underlying cause. Alkalinize urine
(maintain pH >7.5 with cautious use of penicillamine) in patients with
recurrent cystine stones. |
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Complications/Sequelae |
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Urinary tract infection and obstruction can result in extensive kidney
damage. |
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Prognosis |
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Annual rate of recurrence after first stone is 3%, after second stone 6%.
This condition is painful but usually produces no permanent damage. Majority of
patients will pass the stone within 48 to 72 hours of onset of
symptoms. |
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Pregnancy |
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Do not perform ESWL on women of childbearing age who have a stone in the
lower ureter; the effect on the ovary is not known. Rule out ectopic pregnancy
and/or ruptured ovarian cyst. |
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References |
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The Burton Goldberg Group, compilers. Alternative medicine: The Definitive
Guide. Tiburon, Calif: Future Medicine Publishing; 1997.
Ferri FF. Ferri's Clinical Advisor: Instant Diagnosis and Treatment.
St Louis, Mo: Mosby-Year Book; 1999.
Grases F, et al. Urolithiasis and phytotherapy. Int Urol Nephrol.
1994;26:507-511.
Larson DE, ed. Mayo Clinic Family Health Book. 2nd ed. New York, NY:
William Morrow and Company; 1996.
Scalzo R. Naturopathic Handbook of Herbal Formulas. Durango, Colo: 2nd
ed. Kivaki Press; 1994.
Tierney LM Jr, McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis and
Treatment 1994. Norwalk, Conn: Appleton & Lange;
1994. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |