Stones in the bladder: what to do, how to treat with surgery, crushing, folk methods

Normally, urine contains no more than 5% salts, but under certain conditions their concentration increases, and then calculi - stones in the bladder - can form on the basis of salt crystals. This process is called cystolithiasis, and the pathologies associated with it have the ICD-10 code - N21.0-21.9.

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Epidemiology

According to clinical statistics, 95% of patients with bladder stones are men over 45-50 years old, suffering from urinary stasis due to obstruction of the bladder outlet due to benign prostatic hypertrophy.

A family history of the pathology can be traced in 25-30% of cases of urinary bladder stones in men.

Experts from the World Journal of Urology note that dietary changes over the past decades have affected the frequency and chemical composition of stones, with calcium oxalate stones now the most common.

In countries with hot climates, compared to temperate climate zones, an increase in the number of patients with urolithiasis and a more frequent formation of bladder stones (especially urate and oxalate) has been recorded. This is explained by a lack of fluid in the body at high air temperatures and the specifics of the diet.

In developing countries, bladder stones are also common in children and adolescents due to urinary tract infections and lack of protein in food. Experts from the American Urological Association note that approximately 22% of stones occur in pediatric patients.

They are found in the urinary bladder, and the most common are oxalate, phosphate and struvite stones.

In Western Europe, the USA and Canada, the occurrence of bladder stones is recorded in 7-12% of cases of visits to urologists; the main causes of cystolithiasis are problems with the prostate and metabolic disorders (including diabetes and obesity).

According to the European Association of Urology, up to 98% of small stones (less than 5 mm in diameter) pass spontaneously in the urine within four weeks of the onset of symptoms. But larger stones (up to 10 mm in diameter) pass spontaneously from the bladder in only half of cases.

Causes bladder stones

The causes of bladder stones are an increase in urine concentration and crystallization of salts contained in it. The urine that accumulates in the bladder is periodically removed - during urination (micturition), but some of it may remain in the bladder, and in urology it is called residual urine.

The pathogenesis of cystolithiasis is caused by incomplete emptying of the bladder (infravesical obstruction), increased pressure in it and stagnation of residual urine. It is under such conditions that the specific content of salts increases many times, and at the first stage they turn into small crystals. This is the so-called "sand", which is partially excreted with urine (since it passes relatively easily through the ureter). However, some amount of tiny crystals settles on the wall of the bladder, and over time their number and size increase, which causes the formation of crystalline conglomerates of various compositions. This process is accelerated by insufficient fluid intake and deviations from the physiologically normal acid-base properties of urine.

But the causes of incomplete emptying of the bladder with the constant presence of residual urine in it in clinical urology are considered to be:

• chronic urological infections (in particular, recurrent cystitis creates conditions in which dystrophy of the muscular wall of the bladder develops, the volume of residual urine increases and stones begin to form in the bladder in women);
• enlargement of the prostate (benign prostatic hyperplasia or adenoma), most often causing bladder stones in men;
• prolapse of the bladder (cystocele), which provokes the onset of cystolithiasis in elderly women, as well as bladder stones during pregnancy, especially multiple pregnancies. In men, the bladder prolapses due to excess body weight or lifting weights;
• dysectasia (fibroelastosis) of the bladder neck;
• urethral strictures (narrowing of the lumen of the urethra) of various etiologies;
• the presence of a diverticulum in the bladder;
• bladder innervation disorders resulting from brain or spinal cord injuries, cauda equina syndrome, diabetes, heavy metal poisoning, etc., which lead to neurogenic detrusor overactivity (or reflex spinal bladder).

Problems with emptying the bladder accompany prolonged bed rest, bladder catheterization, and radiation therapy for tumors of the pelvic organs and lower intestines.

Finally, kidney and bladder stones appear simultaneously in the presence of urolithiasis, when a small stone formed in the renal pelvis moves through the ureter into the cavity of the bladder.

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Risk factors

Numerous studies indicate that the main risk factors for the development of both cystolithiasis and urolithiasis are the characteristics of the body's metabolism and the nature of a person's diet.

With a deficiency of some enzymes or disturbances in the intestinal absorption of calcium and ammonium salts of oxalic acid, their content in the urine increases - oxaluria develops; changes in the pH of urine towards increased acidity lead to the precipitation of these salts - oxalate-calcium crystalluria. In the bladder, oxalate stones are formed from them very quickly, especially in adherents of plant-based foods (vegetables, nuts). Read more - Oxalates in urine

When glomerular filtration of the kidneys is impaired, and there are also problems with the metabolism of purines and pyrimidines (which happens with increased meat consumption), the body cannot cope with the utilization of nitrogenous bases and uric acid: the content of urate salts in urine increases and uraturia with urate stones is noted. More information in the article - Urate in urine

And with phosphaturia, which is observed if the diet is dominated by dairy products, the urine contains high levels of calcium, magnesium or ammonium phosphates (phosphates).

By the way, these metabolic disorders – due to a congenital deficiency of certain hormones and enzymes – in a significant proportion of cases are a genetically determined predisposition, which in urology is defined as salt diathesis or uric acid diathesis.

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Symptoms bladder stones

Sometimes bladder stones do not cause any symptoms and are discovered by chance during an X-ray.

The first signs of the presence of stones may include a change in the color of urine (from almost colorless to abnormally dark) and discomfort when urinating.

With larger sizes of stones - due to irritation of the mucous membrane of the bladder and urethra - the following symptoms of bladder stones are observed:

• difficulty urinating (it takes longer) and interruption of urine flow due to insufficient contractility of the bladder muscle - the detrusor;
• acute urinary retention or enuresis;
• burning or pain when urinating;
• pollakiuria (significant increase in the daily number of urinations);
• discomfort or pain in the penis in men;
• sharp pains in the lower abdomen (above the pubic symphysis) radiating to the groin and perineum, as well as dull pains when walking, squatting and bending;
• hematuria (the presence of blood in the urine) of varying intensity.

Types and composition of bladder stones

Depending on the etiology, the types of bladder stones are divided into primary (which, as noted above, are formed from salts of concentrated bladder urine residue directly in the bladder cavity) and secondary, that is, kidney stones in the bladder (which continue to increase).

There may be one stone – solitary, or several stones may form at once. They differ in shape, size, and, of course, in their chemical composition. Concrements can be smooth and rough, hard and strong, soft and quite fragile. The range in which the size of stones in the bladder fluctuates: from crystalline particles, almost invisible to the naked eye, to medium, large and giant. The largest stone in the bladder, according to Guinness World Records, weighed 1.9 kg and was found in 2003 in a 62-year-old Brazilian.

Urologists determine the chemical types of stones by examining the composition of bladder stones.

Oxalic acid salts for oxalate stones are calcium oxalate monohydrate (weddellite) and calcium oxalate dihydrate (weddellite).

Urate stones in the bladder are formed by urates – salts of uric acid (urate potassium and sodium), which precipitate in the form of pleomorphic crystals in overacidified urine (pH <5.5).

Phosphate salts – calcium phosphate, magnesium phosphate (magnesia), ammonium phosphate and ammonium carbonate – are part of phosphate stones, the formation of which is facilitated by alkaline urine (with a pH> 7).

Struvite stones, composed of magnesium ammonium phosphates, form in recurrent urinary tract infections with alkalinization of the urine. They may arise ex novo or complicate renal lithiasis if pre-existing stones are colonized by urea-splitting Proteus mirabilis bacteria. According to clinical data, they account for about 2-3% of all cases.

In many cases, the stones combine oxalic and uric acid salts to form urate-oxalate stones.

Useful information on this issue is also contained in the publication - Chemical composition of urinary stones

Complications and consequences

If left untreated, the main consequences and complications of bladder stones or kidney stones include chronic dysuria in the form of frequent and painful urination. And if the stones completely block the flow of urine (obstruction of the urethra occurs), then patients suffer from almost unbearable pain.

In addition, bladder stones provoke recurring bacterial infections and inflammation of the urinary tract - cystitis or urethritis.

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Diagnostics bladder stones

When consulting a urologist with urination problems, the patient should understand that the anamnesis and symptoms are not enough to make a diagnosis. Standard diagnostics of bladder stones include urine tests (general, pH level, morning urine sediment, 24-hour biochemical, bacteriological) and blood tests (general, biochemical and uric acid and calcium levels).

Only instrumental diagnostics can detect the presence of stones, primarily, contrast fluoroscopy of the bladder in three projections. However, not all stones in the bladder can be visualized on an X-ray: oxalate and phosphate stones are clearly visible, but urate stones are not visible due to the lack of contrast in conventional X-rays. Therefore, it is necessary to do an ultrasound of the kidneys, bladder and urinary tract.

They can also use voiding cystography; endoscopic cystography; urethrocystoscopy; computed tomography (which makes it possible to identify very small stones that are not visible with other equipment) during the examination.

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Differential diagnosis

Differential diagnosis addresses the problem of distinguishing stones from diseases that may cause similar symptoms: recurrent bladder and urinary tract infections; chlamydia and vaginal candidiasis; overactive bladder; bladder tumors; endometriosis; epididymitis; diverticulitis; intervertebral disc prolapse with impaction to the spinal cord; pubic symphysis instability, etc.

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Treatment bladder stones

Increasing fluid intake may help small bladder stones pass. However, larger stones may require other treatments.

When treating bladder stones, you should eliminate the symptoms and also get rid of the stones.

Note that antibiotics for bladder stones are used in pyuria (the presence of pus in the urine) and the development of urethritis or cystitis. And also in the case of struvite stones, accompanying frequent inflammation of the bladder. In such cases, antibacterial drugs of the cephalosporin, fluoroquinolone or macrolide group are prescribed, read more - Antibiotics for cystitis

Is it necessary to remove bladder stones? According to urologists, if you have bladder stones, they must be removed as soon as possible, otherwise they will become larger. Small stones (up to 2 mm) can be removed by drinking plenty of water. However, it should be taken into account that the male urethra has a curved configuration and different internal diameters (with three zones of significant narrowing of the internal lumen), so it is unlikely that it will be possible to “wash out” a stone with a transverse size of more than 4-5 mm. But in women, this is possible, since the internal lumen of the urethra is larger and it is much shorter.

So, if the stones cannot be flushed out of the bladder naturally, they still need to be removed: dissolved by taking medications or removed by lithotripsy.

Read also – How to treat urolithiasis

Dissolution of bladder stones

Dissolution of bladder stones is carried out with the help of drugs that reduce the acidity of urine and make it more alkaline. This can be done with the help of sodium bicarbonate, that is, baking soda.

However, there is a risk of kidney calcification and increased sodium levels in the blood (hypernatremia), which results in general dehydration, weakness, increased drowsiness, and cramps. In addition, overly aggressive alkalization can lead to calcium phosphate deposition on the surface of an existing stone, making further drug therapy ineffective.

So, to reduce the acidity (alkalization) of urine, the following medications are used:

• Potassium citrate (potassium citrate), which can cause nausea, belching, heartburn, vomiting, diarrhea, and hyperkalemia with consequences such as muscle weakness, paresthesia, and cardiac arrhythmia, including heart block.
• Oxalite C (Blemaren, Soluran, Uralit U) – 3 g two to three times a day (after meals).
• The diuretic drug Diacarb (Acetazolamide, Dehydratine, Diluran, Neframid, Renamid and other trade names) increases diuresis and quickly makes urine alkaline (pH 6.5-7.). But it is used for no longer than five days, taking a tablet (250 mg) twice a day with an interval of 8-10 hours. The drug is contraindicated for patients with acute renal failure, diabetes mellitus and low potassium levels in the blood.

Medicines can help dissolve only urate (uric acid) stones and reduce the calcium content in the urine (so that it does not settle as crystals). Cystenal in the form of a solution (contains tincture of madder root and magnesium salicylate) - take three to five drops up to three times a day (30 minutes before meals); at the same time, you should drink more liquid (up to two liters per day).

Cystone is also a herbal remedy. It is used for oxalate stones smaller than 10 mm - two tablets three times a day (after meals), the course of treatment lasts three to four months.

The drug Rowatinex, containing terpene compounds, is used to dissolve calcium salts - three times a day, one or two capsules (for a month). Side effects are possible, which manifest themselves as a feeling of discomfort in the stomach and vomiting.

And the drug Allopurinol, which reduces the synthesis of uric acid, is intended to reduce the recurrence of the formation of kidney calcium stones in patients with elevated urate levels in the blood serum and urine.

For bladder and kidney stones, vitamins B1 and B6 are needed, as well as magnesium preparations (magnesium citrate, Solgar, Magne B6, Asparkam, etc.), since this microelement prevents the crystallization of calcium salts contained in urine.

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Removal of stones from the bladder

Modern methods of removing stones from the bladder used in urology are based on ultrasound and laser technologies and do not require open surgery.

Contact lithotripsy of bladder stones is performed endoscopically - by direct contact of the lithotripter with the stones. This method involves the use of different techniques provided by different equipment. In particular, lithotripsy or crushing of stones in the bladder with ultrasound allows to destroy stones into small (up to 1 mm in size) parts with their subsequent removal from the bladder cavity using forced diuresis. The procedure is performed under regional or general anesthesia.

In contact laser cystolitholapaxy, the crushing of a stone in the bladder with a laser is also performed endoscopically, but with transurethral access under general anesthesia. The holmium laser copes with the densest stones of any composition and significant size, turning them into dust-like particles, which are then washed out of the bladder.

A contactless method – remote lithotripsy of bladder stones (shock wave) – involves the action of ultrasound pulses directed at stones through the skin on the abdomen or lower back (the localization is specified and the entire process is controlled by ultrasound). The stones must be destroyed to the state of fine sand, which then comes out during urination, enhanced by the prescription of diuretics.

Among the contraindications for crushing stones, urologists name urethral stenosis, inflammation of the urinary tract, bleeding and malignant neoplasms in the pelvis.

Some stones are so large that they may require surgical treatment in the form of an open cystotomy. That is, an incision is made in the abdominal wall above the pubis and the bladder is cut, and the stones are removed manually. This surgical removal of bladder stones is performed under general anesthesia and requires catheterization of the bladder through the urethra. Possible side effects of this operation include bleeding, damage to the urethra with scarring, fever, and secondary infection.

Folk remedies

In most cases, folk treatment for bladder stones includes home remedies to prevent their formation. They recommend:

• drink orange and cranberry juice;
• After lunch, take a decoction of grape leaves (25 g per glass of water), adding 20-30 ml of grape juice to it;
• drink a tablespoon of fresh onion juice or juice from parsley root and black radish (mixed in equal proportions) every day on an empty stomach;
• every day drink a decoction of dried leaves, flowers and fruits of hawthorn with the addition of a teaspoon of lemon juice per 200 ml of decoction;
• For phosphate stones, take apple cider vinegar in the morning and evening (a tablespoon per half glass of water).

No studies have shown that herbal treatments can break down bladder stones. However, some medicinal plants are included in pharmaceuticals.

For phosphate stones, herbalists recommend using the root of madder in the form of a 10% alcohol tincture (20 drops twice a day, after meals). And if the stones are uric acid, they advise drinking a glass of calendula flower decoction once a day. The fruits (seeds) of the plant of the umbelliferous family, ammi dentaria (in the form of a decoction prepared from them), relieve spasms of the urinary tract, which facilitates the passage of small stones, but when using this plant, you should drink a lot of water (up to two liters per day).

Knotweed (bird's knotweed), due to the presence of silicon compounds in it, helps dissolve calcium in the composition of stones. The decoction is prepared at the rate of a tablespoon of dry grass per 200 ml of water; drink three times a day, 30-40 ml (before meals).

Diuretic herbs such as dandelion leaves, horsetail and stinging nettle are also used.

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Diet and nutrition

Since urine is a waste product of metabolism in the body, its composition can be adjusted by diet and nutrition with restrictions on the consumption of certain foods that increase the level of uric acid salts (urates), oxalates (oxalic acid salts) or phosphate salts (phosphates).

Read - Diet for urolithiasis

If the bladder stones consist of oxalates, you should reduce the consumption of all nightshade crops (potatoes, tomatoes, peppers, eggplants) and legumes, nuts. And it is better to completely refuse sorrel, spinach, rhubarb and celery. More information in the material - Diet for oxalates in urine

In the diet for uric acid stones, nutritionists recommend focusing on dairy and whole grain products and avoiding red meat, lard, offal and strong meat broths. It is animal proteins that ultimately produce nitrogenous bases and uric acid. It is healthier to replace meat with chicken, but it should be consumed a couple of times a week, in small quantities and preferably boiled. For more information, see - Diet for elevated uric acid

Dietary recommendations in case of phosphate stones concern products that contain a lot of phosphorus and calcium, since it is their combination (with an excess of both nutrients) that leads to the formation of insoluble calcium phosphate. So all dairy and sea fish, as well as lentils and soybeans, green peas and broccoli, sunflower and pumpkin seeds, pistachios and almonds are not for such patients. Although phosphorus is one of the substances used by our body to maintain normal pH levels.

Some vegetables and fruits promote diuresis, i.e. reduce the concentration of salts in the urine. These include citrus fruits, cucumbers, cabbage, beets, pumpkin, watermelon, grapes, cherries, peaches, leafy greens (parsley and cilantro), garlic, leeks and onions.

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Prevention

Bladder stones are caused by a number of diseases and metabolic conditions, and there are no specific ways to prevent them. However, if a person has any problems with urination – pain, discoloration of urine, blood in it, etc. – it is better to go to a urologist immediately.

The main preventive measure is considered to be sufficient water consumption – 1.5-2 liters per day. Water increases the volume of urine and reduces its saturation with salts.

For prevention purposes, spa treatment can be used - balneotherapy with mineral waters, which have diuretic properties, mechanically wash out all excess from the kidneys and help stabilize the pH of urine.

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Forecast

If the underlying disease is eliminated, the prognosis is favorable, otherwise recurrent stone formation is possible. Relapses are observed in 25% of patients with prostatic hyperplasia and in 40% of cases of neurogenic bladder.

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