Urinary Stone Diseases

History of Urinary Stone Disease

Urinary stones have affected mankind since time immemorial. It would be fascinating to know that the first evidence of urinary stones dates back to 4800 B.C., when a bladder stone was discovered in Egyptian mummy at E1 Amrah Egypt. Information about urinary stone disease can also be found in ancient Sanskrit literature in India.

A simple mechanism to understand stone formation

Imagine a glass of water containing little salt .If you add some more salt, it dissolves. When you add more and more salt, a stage is reached when the water is no longer able to dissolve the salt added to it. This is because the solution is supersaturated with the salt.Above this point , any little amount of salt added to the solution will start precipitating.

This is exactly the mechanism by which stones form except that the solution is urine and the chemical composition of the salt is different. There are 3 main ways by which stones form in the urinary tract.
First a crystal has to form, then it has to grow and then a large number of such grown – up crystals has to aggregate to each other before it becomes large enough to block the urinary passage.

It would be comforting to know that nature has it own protective mechanisms to prevent stone formation. Yes ! there are certain substances in urine which interfere with the growth and aggregation of crystals which are responsible for stone formation.It is because of the presence of these substances in urine that most of us do not form stones. The stone forming substances are kept in a dissolved state in our urine.

Types of Renal Stones

There are various types of urinary stones, but the most common ones are calcium oxalate, uric acid, struvite and cystine stones.

Symptoms of stone in the kidney or ureter Stones in the kidney or ureter do not cause any symptoms until and unless they obstruct the urinary passage. The nature and the location of the pain can vary from person to person depending upon the size of the stone, the position of the stone within the urinary tract, and the damage it causes to the urinary system.

It should be however remembered that the size of the stone does not interfere with the severity of the pain. For example even very small stones in the ureter can cause lot of pain whereas large stones which develop in the kidney or urinary bladder may not produce pain at all, or may be associated with a dull ache only.
Stones in the kidney may produce a deep, dull ache in the loin or back which might be mild, moderate or severe. Some stones may cause a dull or sharp pain in the abdomen below the ribs. It may be present throughtout the day and it is difficult to be ignored.

Stones which move down into the ureter (ie) the tube which carries urine away from the kidney cause lot of pain. The pain is usually sudden and might be so severe that the patient is not able to stay in one place for a short time. They move about from one place to another place in an attempt to feel comfortable. The pain may radiate from the loin to the groin. It might be associated with nausea or vomiting. The pain may also be felt in the testicle in males or vulva in females. Stones which are in the lower portion of the ureter may be associated with an increase in urinary frequency (ie) the patient has to visit the toilet to empty urine very frequently. It may also be associated with a sudden and intense desire to urinate where the patient has to rush to the toilet to pass urine. Burning sensation or pain accompanying urination is frequently present. If the stone is sharp, it might produce Haematuria (ie). blood in the urine . Most patients get alarmed by this and it is the reason why the patient comes for consultation to the doctor.

If urinary tract infection is present, there might be intermittent attacks of fever associated with pain.In some cases, the patient may not have any symptoms at all. They might be diagnosed to have a urinary stone when getting a routine health check up done.

Q.What are the tests to be done ?

A through physical examination is very important to understand the site and nature of the pain. It would also give the doctor an idea as to whether the pain is likely due to a stone within the urinary system or due to other reason.

A routine blood test and a urine test has to be done. The urine test will he helpful to know if there is blood in the urine, or if infection is present. It would be surprising to know that the doctor can make our if you are drinking adequate amount of fluids from the urine examination itself.

A special urine test in the form of urine culture has to be done to look for the presence of urinary tract infection . If it is present, it has to be treated with suitable anti-biotics for a specified time.

A blood test to measure the functioning of your kidney has to be done to know how your kidney is affected because of the urinary stone. Other metabolic tests may have to be done to look for any defects in your body which may be responsible for stone formation.This is very important as it is not only sufficient to treat for the stone but to find out why you formed the stone. So an appropriate treatment can be given so that you don’t form a stone again.

An ultra-sound examination is the first choice and it is very useful. It does not involve any intervention and is very safe. Even very small stones which cannot be seen on the X-Ray can be seen on an ultrasound. The presence of any abnormality in other organs in the abdomen can also be made out.

A X-Ray film is usually needed. It should be taken after proper bowel preparation. You may be asked to take some medicines which help in the easy passage of stools so that proper information can be obtained.

Depending upon the X-Ray and the ultra-sound findings a I.V.P. test has to be done. It is a special X- Ray test and involves the injection of a contrast agent intra-venously and taking a series of X-Ray films. Some people might be allergic to this contrast if this the case, then this test cannot be done. This is a very useful test which gives a lot of information about the kidneys ,ureter and bladder. Since this test involves the use of X-Ray which are damaging to the fetus, you have to inform your doctor if you have missed your periods or if you are pregnant.

A CT scan may have to done in some cases. It is now being increasingly used by the doctors. It is done quickly and the cost is also is comparatively less.If adequate information cannot be obtained from the above mentioned tests, then additional interventional radiological tests may have to be done.

Treatment of Urinary Stones

	1. CONSERVATIVE MANAGEMENT It is usually the treatment of choice for small stones in the kidney and ureter. Most of such stones pass spontaneously in the urine without any need for intervention. The probability of a stone passing down spontaneously will depend upon the size of a stone, it�s location, shape etc. Such patients can be treated with anti-biotics and analgesics to feel symptomatically better. Oral dissolution agents can also be given for a considerable length of time. The patient is generally instructed to maintain a high fluid intake ranging from 2 to 3.5 litres/day. If a patient has severe abdominal pain associated with vomiting and fever, then admission is usually required and intra-venous fluids may have to be given. If this does not help, then the stone may have to be removed by endoscopy. Some cases where the stone causes severe obstruction and infection then a procedure called DJ stenting has to be done to receiver obstruction. DJ stenting ie the process of inserting a synthetic tube between the kidney and the ureter. If this does not help a tube has to be passed directly into the kidney to drain the infected urine.
	2. EXTRA CORPOREAL SHOCK WAVE LITHOTRIPSY Extracorporeal Shock Wave Lithotripsy Advanced technique in stone removal Extracorporeal shock wave lithotripsy is recognized world wide as the most effective mode of treatment for kidney and ureteric stones.It is a highly scientific technique employing focused shock waves for breaking urinary stones into fine particles.This technique was introduced in 1980 by a German company. Ever since the introduction,of this technique,it has been successfully used by Doctors in USA,Europe and other areas of the world ,for the treatment of urinary stones. It is a non operative technique with no necessity for anaesthesia and involves minimal pain.Unlike the earlier open operation treatment, ESWL does not involve any cutting of tissues and no scars are left after the procedure. The ESWL procedure usually lasts for about 40 minutes.But depending on the size and number of stones,more than one session may be required for proper breaking of the stones. Patients may be required to remain in the hospital for a day for observation. After the procedure the patient is advised to drink plenty of fluids.This helps in the passage of stone fragments in the urine.In some cases, certain other procedures may have to be adopted to facilitate full removal of the stone fragments.
	3. URETEROSCOPIC STONE REMOVAL It is ideally suited for stones in the lower portion of the ureter. It involves the passage of an instrument namely ureteroscope through your urinary passage. The instrument is as thick as a pen and is about 40 cm long. You may have to be admitted in the hospital for a few days (2-3 days) for this procedure and it has to be done under anesthesia. A variety of other instruments can be passed in through the scope which can be used to break the stones and remove them. Very rarely it may so happen that the stone cannot be removed by this method in which case open surgery may be needed.
	4. PERCUTANEOUS NEPHROLITHOTRIPSY This procedure is ideally suited for very large calculi within the kidney and the upper ureter. In this procedure, a puncture is directly made on to the kidney, the stone is seen with a telescope, broken into fragments and the fragments removed. In some cases, it may not be possible to remove the entire stone. So a combination of other procedures like ESWL has to be done to ensure that the stone is completely removed.
	5. OPEN SURGERY With the advent of new technologies to treat stone disease, the need for open surgery has been drastically reduced. But in some cases it might be required. The type of open surgery will depend upon the site and size of the stone within the urinary tract.