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.

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

• 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

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

• Urinary tract infection
• Pyelonephritis
• Diverticulitis
• Pelvic inflammatory disease
• Ovarian pathology
• Drug addiction
• Appendicitis
• Small bowel obstruction
• Ectopic pregnancy
• Cadmium toxicity

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.

• 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

Analysis of stone to determine type—60% to 80% are calcium, 15% to 20% struvite, 5% uric acid, and 1% to 3% cystine.

• 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

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

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.

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

• 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

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.

• 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.

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.

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

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.

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.

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.

Urinary tract infection and obstruction can result in extensive kidney damage.

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.

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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Scalzo R. Naturopathic Handbook of Herbal Formulas. Durango, Colo: 2nd ed. Kivaki Press; 1994.

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