Kidney stones, one of the most painful of the urologic disorders, have beset humans for centuries. Scientists have found evidence of kidney stones in a 7,000-year-old Egyptian mummy. Unfortunately, kidney stones are one of the most common disorders of the urinary tract. Each year, people make almost 3 million visits to health care providers and more than half a million people go to emergency rooms for kidney stone problems.
Most kidney stones pass out of the body without any intervention by a Urologist. Stones that cause lasting symptoms or other complications may be treated by various techniques, most of which do not involve major surgery. Also, research advances have led to a better understanding of the many factors that promote stone formation and thus better treatments for preventing stones.
Introduction to the Urinary Tract
The urinary tract, or system, consists of the kidneys, ureters, bladder, and urethra. The kidneys are two bean-shaped organs located below the ribs toward the middle of the back, one on each side of the spine. The kidneys remove extra water and wastes from the blood, producing urine. They also keep a stable balance of salts and other substances in the blood. The kidneys produce hormones that help build strong bones and form red blood cells.
Narrow tubes called ureters carry urine from the kidneys to the bladder, an oval-shaped chamber in the lower abdomen. Like a balloon, the bladder`s elastic walls stretch and expand to store urine. They flatten together when urine is emptied through the urethra to outside the body.
What is a kidney stone?
A kidney stone is a hard mass developed from crystals that separate from the urine within the urinary tract. Normally, urine contains chemicals that prevent or inhibit the crystals from forming. These inhibitors however, do not seem to work for everyone, so some people form stones. If the crystals remain tiny enough, they will travel through the urinary tract and pass out of the body in the urine without being noticed. Kidney stones may contain various combinations of chemicals.The most common type of stone contains calcium in combination with either oxalate or phosphate.
A less common type of stone is caused by infection in the urinary tract. This type of stone is called a struvite, infection or triple phosphate stones, as they are made up of magnesium, ammonium and phosphate. Another type of stone, uric acid stones, are a bit less common, and cystine stones are rare. These chemicals are part of a person`s normal diet and make up important parts of the body, such as bones and muscles.
Urolithiasis is the medical term used to describe stones occurring in the urinary tract. Other frequently used terms are urinary tract stone disease and nephrolithiasis. Urologist also use terms that describe the location of the stone in the urinary tract. For example, a ureteral stone-or ureterolithiasis-is a kidney stone found in the ureter. To keep things simple, the general term kidney stones is used throughout this fact sheet.
Gallstones and kidney stones are not related. They form in different areas of the body. Someone with a gallstone is not necessarily more likely to develop kidney stones.
Who gets kidney stones?
For unknown reasons, the number of people worldwide with kidney stones has been increasing over the past 30 years. In the late 1970s, less than 4 percent of the population had stone-forming disease. By the early 1990s, the portion of the population with the disease had increased to more than 5 percent. Caucasians are more prone to develop kidney stones than African Americans. Stones occur more frequently in men. The prevalence of kidney stones rises dramatically as men enter their 40s and continues to rise into their 70s. For women, the prevalence of kidney stones peaks in their 50s, however, in recent times, the peak age of stone formation in female appears to be falling. Now 13.1% of all male and 19.6% of all female stone-formers form their first stone before the age of 20 compared with 4.7% and 4.0% respectively in 1975. Once a person gets more than one stone, other stones are likely to develop.
What causes kidney stones?
Doctors do not always know what causes a stone to form. While certain foods and lifestyle may promote stone formation in people who are susceptible, scientists do not believe that eating any specific food causes stones to form in people who are not susceptible.
A person with a family history of kidney stones may be more likely to develop stones. Urinary tract infections, kidney disorders such as cystic kidney diseases, and certain metabolic disorders such as hyperparathyroidism are also linked to stone formation.
In addition, more than 70 percent of people with a rare hereditary disease called renal tubular acidosis develop kidney stones.
Cystinuria and hyperoxaluria are two other rare, inherited metabolic disorders that often cause kidney stones. In cystinuria, too much of the amino acid cystine, which does not dissolve in urine, is voided, leading to the formation of stones made of cystine. In patients with hyperoxaluria, the body produces too much oxalate, a salt. When the urine contains more oxalate than can be dissolved, the crystals settle out and form stones.
Hypercalciuria is inherited, and it may be the cause of stones in more than half of patients. Calcium is absorbed from food in excess and is lost into the urine. This high level of calcium in the urine causes crystals of calcium oxalate or calcium phosphate to form in the kidneys or elsewhere in the urinary tract.
Other causes of kidney stones are hyperuricosuria, which is a disorder of uric acid metabolism, gout, excess intake of vitamin D, urinary tract infections, and blockage of the urinary tract. Certain diuretics, commonly called water pills, and calcium-based antacids may increase the risk of forming kidney stones by increasing the amount of calcium in the urine.
Calcium oxalate stones may also form in people who have chronic inflammation of the bowel or who have had an intestinal bypass operation, or stoma surgery. As mentioned earlier, struvite stones can form in people who have had a urinary tract infection. People who take the protease inhibitor indinavir, a medicine used to treat HIV infection, may also be at increased risk of developing kidney stones.
Foods and Drinks Containing Oxalate
People prone to forming calcium oxalate stones may be asked by their doctor to limit or avoid certain foods if their urine contains an excess of oxalate.
Calcium Oxalate Stone Diet
High-oxalate foods-higher to lower
- swiss chard
- wheat germ
- soybean crackers
- black Indian tea
- sweet potatoes
Foods that have medium amounts of oxalate may be eaten in limited amounts.
Medium-oxalate foods-higher to lower
- green pepper
- red raspberries
- fruit cake
Does the consumption of certain juices help?
Orange juice is the most effective way to keep stones from forming. This is because it increases the alkalinity, and so the potassium and citrate content of the urine which helps prevent stone formation. Grapefruit, pineapple, and apple juice also help, but not quite as much as orange juice.
Cranberry and lemon juice does not increase the citrate content, although they may reduce the rate at which stones are formed. High level of Citrate in urine helps prevent stone formation. Also in France the consumption of mineral water (Vichy Celestins™) is strongly recommended for prevention and treatment of urinary stones.
What are the symptoms of kidney stones?
Kidney stones often do not cause any symptoms. Usually, the first symptom of a kidney stone is extreme pain, which begins suddenly when a stone moves in the urinary tract and blocks the flow of urine. Typically, a person feels a sharp, cramping pain in the back and side in the area of the kidney or in the lower abdomen, this is called renal colic. Sometimes nausea and vomiting occur. Later, pain may spread to the groin.
If the stone is too large to pass easily, pain continues as the muscles in the wall of the narrow ureter try to squeeze the stone into the bladder. As the stone moves and the body tries to push it out, blood may appear in the urine, making the urine pink.
As the stone moves down the ureter, closer to the bladder, a person may feel the need to urinate more often or feel a burning sensation during urination.
If fever and chills accompany any of these symptoms, an infection may be present. In this case, a person should contact a doctor immediately or see a urologist.
How are kidney stones diagnosed?
Sometimes "silent" stones-those that do not cause symptoms-are found on radiological imaging taken during a general health exam. If the stones are small, they will often pass out of the body unnoticed. Often, kidney stones are found on an x ray, ultrasound, computerized tomography (CT) [left] or intravenous urography (IVU) [right] taken of someone who complains of blood in the urine or sudden pain. These diagnostic images give the doctor valuable information about the stone`s size and location. Blood and urine tests help detect any abnormal substance that might promote stone formation.
The doctor may ask the patient to collect urine for 24 hours after a stone has passed or been removed. For a 24-hour urine collection, the patient is given a large container, which is to be refrigerated between trips to the bathroom. The collection is used to measure urine volume and levels of acidity, calcium, sodium, uric acid, oxalate, citrate, and creatinine-a product of muscle metabolism. The doctor will use this information to determine the cause of the stone. A second 24-hour urine collection may be needed to determine whether the prescribed treatment is working.Preventing Kidney Stones
A person who has had more than one kidney stone may be likely to form another, so, if possible, prevention is important. To help determine their cause, the doctor will order laboratory tests, including urine and blood tests. The doctor will also ask about the patient`s medical history, occupation, and eating habits. If a stone has been removed, or if the patient has passed a stone and saved it, a stone analysis by the laboratory may help the doctor in planning treatment.
How are kidney stones treated?
Fortunately, surgery is not usually necessary. Most kidney stones can pass through the urinary system with plenty of water-2 to 3 litres a day-to help move the stone along. Often, the patient can stay home during this process, drinking fluids and taking pain medication as needed. The doctor usually asks the patient to save the passed stone(s) for testing. It can be caught in a cup or tea strainer used only for this purpose.
A simple and most important lifestyle change to prevent stones is to drink more liquids-water is best. Someone who tends to form stones should try to drink enough liquids throughout the day to produce at least 2 litres of urine in every 24-hour period.
Regular exercise seems to benefit those that tend to have a sedentary lifestyle. This helps also to have a more balanced diet with less animal proteins and more vegetable fibers.
In the past, people who form calcium stones were told to avoid dairy products and other foods with high calcium content. Recent studies have shown that foods high in calcium, including dairy products, may help prevent calcium stones. Taking calcium in pill form, however, may increase the risk of developing stones.
Patients may be told to avoid food with added vitamin D and certain types of antacids that have a calcium base. Someone who has highly acidic urine may need to eat less meat, fish, and poultry. These foods increase the amount of acid in the urine.
To prevent cystine stones, a person should drink enough water each day to dilute the concentration of cystine that escapes into the urine, which may be difficult. More than four litres of water may be needed every 24 hours, and a third of that must be drunk during the night.
During the acute renal colic phase, pain killers including drugs such as non-steroidal anti-inflammatory drugs (NSAID) such as diclofenac or opiates are recommended.
A doctor may prescribe certain medications to help prevent calcium and uric acid stones. These medicines control the amount of acid or alkali in the urine, key factors in crystal formation. The medicine allopurinol may also be useful in some cases of hyperuricosuria.
Doctors usually try to control hypercalciuria, and thus prevent calcium stones, by prescribing certain diuretics, such as hydrochlorothiazide. These medicines decrease the amount of calcium released by the kidneys into the urine by favouring calcium retention in bone. They work best when sodium intake is low.
Rarely, patients with hypercalciuria are given the medicine sodium cellulose phosphate, which binds calcium in the intestines and prevents it from leaking into the urine.
If cystine stones cannot be controlled by drinking more fluids, a doctor may prescribe medicines such as Thiola and Cuprimine, which help reduce the amount of cystine in the urine.
For struvite stones that have been totally removed, the first line of prevention is to keep the urine free of bacteria that can cause infection. A patient`s urine will be tested regularly to ensure no bacteria are present.
If struvite stones cannot be removed, a doctor may prescribe a medicine called acetohydroxamic acid (AHA). AHA is used with long-term antibiotic medicines to prevent the infection that leads to stone growth.
People with hyperparathyroidism sometimes develop calcium stones. Treatment in these cases is usually surgery to remove the parathyroid glands, which are located in the neck. In most cases, only one of the glands is enlarged. Removing the glands cures the patient`s problem with hyperparathyroidism and kidney stones.
Medical expulsive therapy
A meta-analysis of 9 randomised controlled trials suggests that treatment with a calcium channel blocker or an alpha blocker improves the chance of spontaneous expulsion of small distal urinary stones, which would spare patients from surgery.
Surgery may be needed to remove a kidney stone if it
- does not pass after a reasonable period of time and causes constant pain
- is too large to pass on its own or is caught in a difficult place
- blocks the flow of urine
- causes an ongoing urinary tract infection
- damages kidney tissue or causes constant bleeding
- has grown larger, as seen on follow-up imaging
Until 20 years ago, open surgery was necessary to remove a stone. The surgery required a recovery time of 4 to 6 weeks. Today, treatment for these stones is greatly improved, and many options do not require major open surgery and can be performed using minimally invasive techniques requiring only a few hours hospital stay.
Extracorporeal Shock Wave Lithotripsy
Extracorporeal shock wave lithotripsy (ESWL) is the most frequently used procedure for the treatment of small kidney stones. In ESWL, shock waves that are created outside the body travel through the skin and body tissues and target the denser stones. The stones break down into small particles and are easily passed through the urinary tract in the urine.
Several types of ESWL devices exist. Most devices use either x rays or ultrasound to help the Urologist pinpoint the stone during treatment. For most types of ESWL procedures, anaesthesia is not required.
In many cases, ESWL may be done on an outpatient basis. Recovery time is relatively short, and most people can resume normal activities the next day. To see if your stones can be treated using ESWL, contact us to book an appointment.
Complications may occur with ESWL. Some patients have blood in their urine for a few days after treatment. Bruising and minor discomfort in the back or abdomen from the shock waves can occur. To reduce the risk of complications, we would usually tell patients to avoid taking aspirin and other medicines that affect blood clotting for two weeks before treatment.
Sometimes, the shattered stone particles cause minor blockage as they pass through the urinary tract and cause discomfort. In some cases, the doctor will insert a small tube called a stent through the bladder into the ureter under general anaesthetic to help the fragments pass. Sometimes the stone is not completely shattered with one treatment, and additional treatments may be needed.
As with any interventional, surgical procedure, potential risks and complications will be discussed with the urologist before making a treatment decision.
Sometimes a procedure called percutaneous nephrolithotomy (PCNL) is recommended to remove a kidney stone. This treatment is often used when the stone is quite large or in a location that does not allow effective use of ESWL or flexible ureterorenoscopy.
In this procedure, the urologist makes a tiny 1cm incision in the back and creates a tunnel directly into the kidney. Using an instrument called a nephroscope, the urologist locates and removes the stone. For large stones, the Swiss LithoClast® Master which produces simultaneous ultrasonic and pneumatic lithotripsy- may be needed to break the stone into small pieces. Often, patients stay in the hospital for several days and may have a small tube called a nephrostomy tube left in the kidney during the hospital stay.
A major advantage of percutaneous nephrolithotomy is that the Urologist can remove all of the stone fragments directly instead of relying solely on their natural passage from the kidney.
Ureteroscopic Stone Removal
Although some stones in the ureters can be treated with ESWL, ureteroscopy may be needed for mid- and lower-ureter stones and a flexible ureterorenoscopy for small kidney stones not amenable to ESWL. No incision is made in this procedure. Instead, the Urologist passes a small fiberoptic instrument called a ureteroscope through the urethra and bladder into the ureter. The Urologist then locates the stone and either removes it with a basket -like device or shatters it with Holmium laser, a special instrument that vaporizes the stone into sand particles with minimal trauma to the wall of the ureter or kidney.