Dr. Manu Gupta

MBBS, MS, DNB, MNAMS, M.Ch. (Urology)
Sanjay Gandhi Institute of Medical Sciences, Lucknow

Dr. Manu Gupta is an eminent urologist presently working as Senior Consultant, Department of Urology, Sir Ganga Ram Hospital, New Delhi. He is actively involved in academic activities.

 

Introduction

Kidney Stones are an extremely common problem in our society. You would have frequently come across a friend, relative, neighbor, or colleague who has had them. This article is about all stones in the urinary system.

The kidneys serve the purpose of filtering waste substances from blood and thus keep the body healthy. These substances, and the filtrate produced, are passed out as urine. A number of crystals are also excreted like calcium, oxalate, and phosphates. In fact, there is a fine equilibrium between these molecules, and a chemical imbalance leads to their aggregation and the formation of stones. Some people are stone formers in whom this balance is chronically disturbed whereas others never have stones. Usually, these stones are made of calcium and oxalate. Occasionally there are some diseases present from birth in which the person forms stones throughout their lives. These patients need special workup and regular medicines. Thankfully these conditions are very rare.

Causes

A number of factors exist in helping stone formation. Staying in a dry, hot area leads to dehydration and supersaturation of urine causing stone formation. Area such as Gujarat, Rajasthan, Delhi, and Western Uttar Pradesh is considered in the stone belt of India. The hardness of water is another factor. Lack of physical activity, excessive intake of fizzy drinks and coffee, junk food all contribute to stone formation. Increased protein intake is also a causative factor.

How does the patient present.

Usually, patients present with pain at either right or left side of the abdomen which is radiating towards the urinary passage. There may be accompanying nausea and vomiting. Some people may have blood in the urine. The best thing to do at that time is to reach the emergency ward of any health facility and get evaluated. After giving you a pain-relieving medicine, the doctors will do simple tests like an ultrasound and some blood and urine tests. An ultrasound of the abdomen is a useful screening test to find out whether the stones are in the kidneys or dropped into the ureters (tubes that bring urine from kidneys to the urinary bladder). A CT scan may also be done for more information regarding stone size, shape, location, and hardness.

Stones can be present in the kidneys, ureters, urinary bladder, or urinary passage. All these may present differently and are treated accordingly.

Stones in the kidney usually present with a dull ache, rarely with severe pain. Small stones up to 5mm do not usually bother but larger stones cause discomfort and bleeding in the urine. Kidney stones smaller than 1.5 cm can be broken down with a procedure called lithotripsy. This is a 30 minute, non-invasive office procedure where shock waves are focused on the stone, and stone fragmentation is done. Sometimes multiple sittings of lithotripsy are required.

Broken small fragments pass out through the urinary passages subsequently. Lithotripsy is inexpensive and very safe and freely available in large multi-specialty hospitals.

Larger stones in the kidney sometimes take the shape of the kidney and are called staghorn stones. These stones need surgical removal. A Percutaneous Nephrolithotomy (PCNL) is a procedure done under anesthesia wherein the kidney is approached through a small opening in the back, the stone fragmented using a laser machine, and all fragments are removed.

Stones in the ureters are more painful as they block the flow of urine and cause back pressure to the kidneys. Our ureters are not rigid and are rather distensible tubes with diameters ranging from 3-8 mm. This means that stones that are smaller than 8 mm can pass out, the smaller the stone the better chance of passing them out. 90% of stones less than 5 mm in size pass out on their own requiring no medicines.

Once the stones pass from the ureters into the urinary bladder, they come out on their own. This is because the urinary passage (urethra) both in men and women is much wider than the ureters.

The key to treatment of stones in the ureters is to drink plenty of oral fluids, and taking medicines as prescribed. These medicines relax the lower part of the ureters to help the stones to pass. Patience pays and usually small stones pass out within 3-4 weeks.

However if the stones persist and the patient continues to have pain, there is no point in waiting, and Ureteroscopic removal is advised. This is a short procedure under anesthesia, in which the stone is broken down using lasers by inserting special endoscopes through the urinary passage . The patient can be discharged within one day of the procedure.

“Once a stone former, always a stone former”, is an old saying. It is partly true as patients who have formed a stone once have a 50% chance of forming a stone in the next 7 years. The question on everyone’s mind is about how to prevent stone formation. The answers are simple. Here is some advice.

1. Drinking adequate fluids to have a daily urine output of 2-2.5 liters.
2. Regular exercise.
3. Moderate intake of red meats.
4. Limit junk food and fizzy drinks.
5. Less salt intake.
6. Regular yearly ultrasound scans.

All foods can be had in moderation. The age-old advice of stopping eating oxalate rich tomatoes, spinach and vegetables with seeds is not correct. All of these can be had but in moderation. A very frequently asked question is about the role of milk and milk products intake in stone formation. A glass of milk or its equivalent milk product like curd/cheese is absolutely essential for maintaining a normal calcium level in the body. Do not stop drinking milk in anticipation that its consumption causes stone. It is a myth.

Water intake should be appropriate depending upon one’s work, environment, and physical activity. A good measure of adequate hydration is to look at one’s color of urine. Urine should be the lightest possible yellow color to suggest that water/fluid intake is adequate.

There is an increased reliance on the traditional Ayurvedic, Unani, and Homeopathic systems of medicines in our country. Although there are no scientific studies to support these treatments, many people follow them. It is prudent to use these medicines intelligently and consult a qualified doctor/Urologist at the earliest. Many a kidney has been damaged due to overzealous use of such treatments without proper documentation of stone sizes and location.

Stones in the urinary system are common but perfectly treatable problems. Timely intervention and correct guidance are all that is necessary. Changing one’s lifestyle, healthy eating habits and a regular health check-up goes a long way in managing the stone disease.

This information is for general guidance and reflects the opinions and experience of the author. It is not intended to replace specialist consultation or provide treatment advice for specific cases.

 

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