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Genitourinary Conditions / Kidney Stones
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Once the stone's location, size, shape, and composition have been established, and other medical complications, such as infection, have been identified, the course of treatment is determined.
The size of the stone is a major factor in determining treatment. Most kidney stones are less than 4 mm wide (about 3/16 of an inch) and pass without medical intervention.
If the stone is 4 mm or less in diameter, and if the patient's symptoms are not severe, the physician may recommend expectant treatment (i.e., observation). The patient is advised to drink plenty of water, 8 to 10 large glasses, to flush out the stone and prevent others from forming. A change in diet may also be recommended.
The physician may recommend a second round of x-rays or ultrasound 1 to 2 weeks after the stone is discovered to see if it is progressing through the urinary tract. If movement is detected, the treatment is be continued; if not, the patient's condition and treatment plan are reevaluated.
Despite discomfort, expectant treatment patients are advised to avoid becoming sedentary because physical activity, especially walking, can help move a stone. Patients who are employed where a sudden attack of pain could place them in danger such as construction workers, drivers, or heavy-equipment operators may be advised to stay home from work.
The use of a heating pad and/or an over-the-counter pain medication such as aspirin, acetaminophen, or ibuprofen may relieve pain or discomfort while waiting for a stone to pass.
Patients are asked to strain their urine through a fine mesh strainer or thin cloth to catch the stone when it passes and to give it to their physician for analysis. Patients may urinate into a glass jar - the stone can be seen at the bottom. Analysis of the stone’s chemical composition helps the physician determine what type of stone is being produced, which suggests dietary and lifestyle changes to prevent further stone formation.
Ureteroscopy is the technique of choice with smaller stones that lodge in the mid- and lower- sections of the ureter. A ureteroscope (flexible, fiberoptic instrument resembling a long, thin telescope) is inserted through the urethra and bladder to the stone. The urologist can locate the stone visually and remove it with a small basket-like device inserted through the ureteroscope. This procedure is called endoscopic basket extraction. A laser may be used to break the stone into smaller pieces, which can be passed by the patient. Ureteroscopy is performed under general or local anesthesia on an outpatient basis. The urologist often places a small silicone tube (stent) into the ureter to relieve swelling and facilitate healing.
A variety of nonsurgical techniques have been developed to crush or pulverize kidney stones. Lithotripsy uses a machine called a lithotripter to project shock waves or sonic pulses against the stone and break it into tiny particles that can pass naturally in the patient’s urine. This can be done in several ways, depending on the size and location of the stone.
Patients undergoing lithotripsy are given a sedative and a general or local anesthetic. Shock waves are focused on the kidney stone at a rate of approximately one per second and the therapy may last over an hour. Bruising may result from the shock waves and discomfort may be experienced as the crushed calculi are passed; but, most patients resume normal activity in a few days.
Lithotripsy is highly effective for stones in the kidney and upper ureter. More than one treatment may be required. Rarely, a catheter may be inserted through a small incision in the back to drain the kidney and remove the stone fragments. Patients with very large stones or complicating medical conditions may require different treatment.
Ultrasonic lithotripsy locates the stone using an optical scope and electronic probe, inserted into the ureter under epidural (spinal) anesthesia. High frequency ultrasound waves are directed at the stone and break it up. The fragments can be passed naturally by the patient or removed by forceps, basket extraction, or suction through the scope instrument. Ultrasonic lithotripsy can only be employed when there is a straight path to the stone.
This technique uses a probe to break small stones with shock waves generated by electricity. The physician positions the tip of the probe 1 mm from the stone through a flexible ureteroscope and projects electrically generated hydraulic shock waves at the stone. These fragments can be passed by the patient or removed by extraction methods. EHL requires general anesthesia and is generally not used in close proximity to the kidney because the shock waves can cause tissue damage. Fragments tend to scatter widely, making retrieval or extraction difficult.
Extracorporeal shock wave lithotripsy uses highly focused impulses projected from outside the body to pulverize kidney stones.
The patient is positioned on a cushion atop a table and may be given a sedative. Lithotripters are effective at crushing cystine stones and those in the lower ureter. The stone usually is reduced to granules that can be passed in the patient's urine.
Very large stones, those 3 centimeters (about one inch) or more in diameter, may require several ESWL treatments to break up completely or may produce such a large volume of fragments that they block the ureter. This condition is called "steinstrasse," (a German word meaning "street of stone")
Large struvite stones, because of their jagged shape, sometimes become lodged in positions or locations that make them difficult to treat effectively with shock waves.
ESWL also may be precluded if:
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The patient's kidney is functioning poorly because of disease or defect and shock waves present an unacceptable risk of further damage
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The patient has a life-threatening heart problem or a cardiac pacemaker
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The patient is pregnant or has a bleeding disorder
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The size, location, and number of stones requires excessive ESWL treatment
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The patient's ureters are structurally abnormal or malformed
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The patient's symptoms are acute and urgent treatment is necessary to prevent kidney damage
Percutaneous nephrolithotomy (PCN) is a surgical option. Percutaneous means "though the skin." The surgeon or urologist makes a 1- centimeter incision under local anesthesia through which a nephroscope is passed directly into the kidney and, if necessary, the ureter. Smaller stones may be manually extracted and large ones may be broken up with ultrasonic, electrohydraulic, or laser-tipped probes and extracted. A tube may be inserted into the kidney for drainage and this procedure usually requires hospitalization for several days. Most patients can resume normal activity within two weeks.
Certain types of kidney stones can be dissolved with chemicals (chemolysis). Uric acid stones can be dissolved with a solution of sodium bicarbonate in saline. Cystine stones may be treated with a combination of acetylcysteine and sodium bicarbonate in saline. Struvite and carbon apatite stones can be treated with an acidic solution of hemiacidrin.
The procedure involves infusing the chemical solution into the affected area through a ureteral catheter in a series of treatments, until the stone is dissolved. The patient's urine is cultured regularly during treatment to monitor for urinary infection and to prevent the build up of excessive chemical levels, which can cause other health problems.
Chemolysis may be used as a primary form of treatment or with percutaneous lithotripsy, surgical lithotomy, or ESWL. It does not work well with calcium stones.
Open nephrolithotomy is the most invasive procedure for removing kidney stones and is usually reserved for the most difficult cases. Deep anesthesia is required and the surgeon makes a large (10-20 centimeter) incision in the patient's back or abdomen, depending on where the stone is located. The ureter or the kidney is opened and the stone extracted. Most patients require prolonged hospitalization and recovery may take up to 2 months.
A kidney may be profoundly damaged by injury, disease, serious infection, or prolonged blockage. When a kidney's function drops below acceptable levels, radical surgery may be necessary to remove all or part of the organ. Nephrectomy is the removal of the entire kidney. Partial nephrectomy, in which part of the kidney is removed, is rare, but may be appropriate if the damage is confined to a portion of the organ.
Recurrent Stone Disease Treatment There are several forms of recurrent stone disease, each with particular underlying causes. The physician can often prescribe medication prevent the formation of new stones. These drugs control the chemical imbalances that lead to the formation of crystals in the urine
The following supplements are indicated:
The following reflexes will often be active:
These reflexes should be tested and treated with the proper supplementation. Take this preliminary to see if your condition could respond to treatment.
Not sure on your treatment options? For a limited time you can schedule a
to talk with a licensed doctor or clinician regarding your condition. A liver/gallbladder flush and intestinal detoxification program may also be recommended.
Changing your diet can dramatically reduce your risk of making more kidney stones. We recommend that patients perform a 24 hour urine collection to measure urinary minerals. Sometimes we uncover important metabolic abnormalities. Most commonly, however, a diet too rich in oxalate or purine and too poor in water or citrate is the culprit. Have a look at the lists of mineral concentrations in common foods. Maybe your last stone could have been avoided by eating less spinach or fewer peanuts.
- Reduce your intake of sugar, refined foods, animal products (meats and dairy), caffeine, alcohol, soda, and salt.
- Drink more water and eat more fiber, vegetables, whole grains, and vegetable proteins.
- Cut down on 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 lactate (see above 200 to 400 mg per day) may increase the solubility of calcium oxalate and calcium phosphate.
- Pyridoxine (B6, 10 to 100 mg per day) is essential for the metabolism of oxalic acid, a component of some stones.
- Folic acid (5 mg per day) helps break down uric acid stones.
Athletic and chronically dehydrated patients are common in our practice. We tell them to carry water, especially in Marin's semi-arid summer environment. The issue is not how much you drink, but the amount left over for urine after you sweat. Our endurance athletes who start drinking a quart per hour of exercise report improved exercise tolerance despite carrying the extra weight.
Calcium restriction is only occasionally appropriate and only after testing demonstrates that urinary calcium concentrations fall to normal levels on a restricted diet. Calcium supplements rarely lead to stone formation.
Oxalate, the other common factor in stones, however should be reduced when possible. Many of our patients take a lot of Vitamin C. Vitamin C over 200mg/day is converted into oxalate and excreted in the gut and urine. We ask our patients to stop taking Vitamin C and to reduce nuts, chocolate and green leafy vegetables in their diet.
Excessive sodium (table salt) in the diet predisposes to stones. This is primarily an issue for our single men who dine on prepared foods, which are loaded with salt. I have included a list of sodium rich foods.
Uric acid is a waste product from purines in food. You will notice that the foods highest in purines are luxury items. We may ask you to review your diet to see if you are eating these foods.
Citrate, an acid that complexes calcium, helps reduce stone production. It is commonly found in fruit juices, which we encourage.By the same token, increasing your magnesium intake may reduce stone production.
High oxalate foods
Calcium rich foods
High acid ash foods
Magnesium rich foods
Ionic composition of fruit juices
Sodium rich foods
Calcium restriction diet for testing
Chiropractic can help reduce pain and nerve interference involving the kidnesy. Go here for information regarding chiropractic treatment.
Take this preliminaryto see if your condition could respond to treatment.
Not sure on your treatment options? For a limited time you can schedule a
to talk with a licensed doctor or clinician regarding your condition. Use our NutritionLocator to find a doctor in your area.
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