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

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

[1], [2], [3], [4]

Epidemiology

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

A family history of pathology can be traced in 25-30% of cases of detection of bladder concrements in men.

Experts World Journal of Urology note: changes in diet over the past decades have affected the frequency and chemical composition of stones, and the concretions of calcium oxalate are currently the most common.

In countries with a hot climate - compared to temperate zones - there has been an increase in the number of patients with urolithiasis and more frequent formation of stones in the bladder (especially urate and oxalate). Explain this lack of fluid in the body at high air temperature and specific diet.

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

Are in the bladder, and the most common oxalate, phosphate and struvite stones.

In Western Europe, the United States and Canada, the appearance of stones in the bladder is recorded in 7-12% of cases of calls to urologists; the main causes of cystolithiasis - 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) spontaneously go urine within four weeks after the onset of symptoms. But larger concrements (up to 10 mm in diameter) leave the bladder themselves only half the time.

Causes of the stones in the bladder

The causes of the formation of stones in the bladder consist in increasing the concentration of urine and the crystallization of the salts contained in it. The urine accumulating in the urinary bladder is periodically removed - with urination (mictures), but some of it may remain in the bladder, and in urology it is called residual urine.

The pathogenesis of cystolithiasis is due to 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 multiplies many times, and in the first stage they turn into small crystals. This is the so-called "sand", which is partially excreted in the urine (as it passes relatively easily through the ureter). However, a certain amount of the smallest crystals settles on the wall of the bladder, and over time their number and size increase, which causes the formation of crystalline conglomerates of different composition. Accelerated by this process, insufficient fluid intake and deviation from the physiologically normal acid-alkaline properties of urine.

But the reasons for incomplete emptying of the bladder with a permanent presence of residual urine in clinical urology are:

• chronic urological infections (in particular, recurrent cystitis creates conditions in which the degeneration of the muscular wall of the bladder develops, the volume of residual urine increases and stones in the bladder begin to form in women);
• prostate enlargement (benign prostatic hyperplasia or adenoma), most commonly causing stones in the bladder in men;
• omission of the bladder  (cystocele), provoking the onset of cystolithiasis in elderly women, as well as stones in the bladder during pregnancy, especially multiple. In men, the bladder falls with excessive body weight or lifting weights;
• dysectasia (fibroelastosis) of the neck of the bladder;
• stricture of the urethra (narrowing of the urethral lumen) of various etiologies;
• presence of a diverticulum in the bladder;
• disturbances of innervation of the bladder resulting from trauma to the brain or spinal cord, horse tail syndrome, diabetes, heavy metal poisoning, etc., which lead to neurogenic detrusor hyperactivity (or reflex spinal bladder).

Problems with emptying the bladder are associated with prolonged bed rest, catheterization of the bladder, radiation therapy for pelvic organs and lower intestinal tract.

Finally, simultaneously stones in the kidneys and bladder appear in the presence of  urolithiasis, when a small stone, formed in the renal pelvis, moves along the ureter to the bladder cavity.

[5], [6]

Risk factors

Numerous studies indicate that the main risk factors for the development of both cystolithiasis and urolithiasis are the characteristics of metabolism in the body and the nature of human nutrition.

With the deficiency of some enzymes or violations of intestinal absorption of calcium and ammonium oxalic acid salts in the urine, their content increases - oxaluria develops; a change in urine pH towards acidity leads to the precipitation of these salts into the sediment - oxalate-calcium crystalluria. In the bladder, oxalate stones are formed very quickly from them, especially among the adherents of food of vegetable origin (vegetables, nuts). Read more -  Oxalates in the urine

When the glomerular filtration of the kidneys is broken, and there are problems with the exchange of purines and pyrimidines (which happens with increased consumption of meat), the body can not cope with the utilization of nitrogenous bases and uric acid: urine increases the content of urate salts and shows uraturia with uric acid concretes. More information in the article -  Urat in urine

And with phosphaturia, which is observed if the diet is dominated by dairy products, urine has a high level of phosphate salts of calcium, magnesium or ammonium (phosphates).

Incidentally, these metabolic disorders - due to the inherent deficiency of these or those hormones and enzyme substances - are in a significant proportion of cases a genetically determined predisposition, which in urology is defined as  saline diathesis  or  urine acid diathesis.

[7], [8], [9], [10], [11]

Symptoms of the stones in the bladder

Sometimes the stones of the bladder do not cause any symptoms and are detected by randomizing the X-ray.

And the first signs of the presence of stones can be manifested by a change in the color of urine (from almost colorless to abnormally dark) and discomfort when urinating.

At more significant sizes of concrements - due to irritation of the mucous membrane and urethra - such symptoms of stones in the bladder are noted, as:

• difficulty urinating (it takes more time) and interruption of urine output due to insufficient contractility of the bladder muscle - detrusor;
• acute retention of a micture or enuresis;
• burning or pain while urinating;
• pollakiuria (a significant increase in the daily number of mycoses);
• discomfort or pain in the penis in men;
• sharp pains in the lower abdomen (above the pubic symphysis) with irradiation in the groin and perineum, as well as dull pain in walking, squats and inclinations;
• 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 already noted above, are formed from the salts of the concentrated vesicle urine immediately in the bladder cavity) and secondary, that is, the kidney stones in the bladder (which continue to increase).

A stone can be one - solitary, and several stones can be formed at once. They differ in shape, size, and, of course, in their chemical composition. Concrements can be smooth and rough, firm and strong, soft and fragile enough. The range in which the size of the stones in the bladder varies: from crystalline particles that are virtually 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 discovered in 2003 by a 62-year-old Brazilian.

Chemical types of concrements urologists determine by considering the composition of the stones of the bladder.

Oxalic acid salts with oxalate stones - calcium oxalate monohydrate (lead) and calcium oxalate dihydrate (weddellite).

Urate stones in the urinary bladder form urates - salts of uric acid (urate potassium and sodium), dropping out in the form of pleomorphic crystals in acidified 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 favored by alkaline urine (pH> 7).

Struvite stones, consisting of magnesium and ammonium phosphates, are formed with repeated infections of the urinary tract with alkalinization of urine. They may occur ex novo or complicate renal lithiasis if previously existing stones are colonized by Proteus mirabilis bacteria that break down urea. According to clinical data, they make up about 2-3% of all cases.

In many cases, the stones combine oxalic and uric acid salts with the formation of urate oxalate stones.

Useful information on this issue also contains a publication -  Chemical composition of urinary stones

Complications and consequences

In the absence of treatment, the main consequences and complications of stones formed in the bladder, or the kidney stones that have entered it, include chronic dysuria in the form of frequent and painful urination. And if the concrements completely block the excretion of urine (urinary tract obstruction occurs), then patients suffer from almost intolerable pain.

In addition, repeated bladder infections and inflammation of the urinary tract - cystitis or urethritis - are provoked by bladder stones.

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Diagnostics of the stones in the bladder

Referring to the urologist with urinary problems, the patient should understand that the history and symptoms for diagnosis are not enough. Standard diagnosis of stones in the bladder includes urinalysis (total, pH, morning urine for sediment, 24-hour biochemical, bacteriological) and blood (total, biochemical and uric acid and calcium levels).

Identify the presence of stones can only instrumental diagnostics, in the first place, contrast fluoroscopy of the bladder in three projections. However, not all stones in the bladder on the X-ray are amenable to visualization: oxalate and phosphate stones are visible clearly, but urate stones are not visible because of the lack of contrast in conventional X-rays. Therefore, you need to do ultrasound of the kidneys, bladder and urinary tract.

Migratory cystography can also be used in the survey; endoscopic cystography; urethrocystoscopy; computer tomography (which makes it possible to identify very small stones that were not noticed by other equipment).

[15], [16], [17], [18]

Differential diagnosis

Differential diagnosis solves the problem of distinguishing stones from diseases that can cause similar symptoms: recurrent infections of the bladder and urinary tract; chlamydia and vaginal candidiasis; hyperactive bladder; neoplasms of the bladder; endometriosis; epididymitis; diverticulitis; prolapse of the intervertebral disc with a blow to the spinal cord; instability of the pubic symphysis, etc.

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Treatment of the stones in the bladder

Increased fluid intake may help pass small bladder stones. However, for larger stones, other methods of treatment may be required.

When treating stones in the bladder, you should remove the symptoms, as well as get rid of the stones.

Note that antibiotics for bladder stones are used for 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 preparations of the group of cephalosporins, fluoroquinolones or macrolides are prescribed, read more -  Antibiotics for cystitis

Is it necessary to remove stones in the bladder? According to urologists, if you have bladder stones, they should be removed as soon as possible, otherwise they will become larger. Small stones (up to 2 mm) can be eliminated by consuming large amounts of water. However, one should take into account the fact that the male urethra has a curved configuration and a different internal diameter (with three zones of significant narrowing of the internal lumen), so it is unlikely to "wash" a stone with a transverse dimension of more than 4-5 mm. But in women it is possible, because the internal lumen of the urethra is larger, and it is much shorter.

So, if the stones can not be washed out of the bladder naturally, they still need to get rid of: dissolve, take medication, or remove with lithotripsy.

Read also -  How urolithiasis is treated

Dissolution of stones in the bladder

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

However, there is a risk of formation of calcification in the kidneys, as well as an increase in the sodium content in the blood (hypernatremia), which is manifested by general dehydration, weakness, increased drowsiness and convulsions. In addition, overly aggressive alkalinization can lead to precipitation of calcium phosphate on the surface of an already existing stone, making further drug therapy ineffective.

So, to reduce the acidity (alkalinization) of urine, drugs such as:

• Potassium citrate (potassium citrate), which can cause nausea, eructation, heartburn, vomiting, diarrhea, as well as hyperkalemia with such consequences as muscle weakness, paresthesia and cardiac arrhythmia right up to the heart block.
• Oxalite C (Blomaren, Soluran, Uralit U) - 3 grams two or three times a day (after meals).
• diuretic diacarb (Acetazolamide, Dehydratin, Diluran, Nephramid, Renamid and other trade names) increases diuresis and quickly makes urine alkaline (pH 6.5-7.). But it is used no longer than five days, taking a tablet (250 mg) twice a day with an interval of 8-10 hours. The drug is contraindicated in patients with acute form of renal insufficiency, diabetes mellitus and a low level of potassium in the blood.

Drugs can help dissolve only urate (uric acid) stones and reduce the calcium in the urine (so that it does not settle with crystals). Cystenal in the form of a solution (contains tincture of the root of the madder dye and magnesium salicylate) - takes three to five drops 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 also refers to herbal remedies. It is used with oxalate stones measuring less than 10 mm - two tablets three times a day (after a meal), the course of treatment lasts three to four months.

The drug Rovatinex, containing terpenic compounds, is used to dissolve calcium salts - three times a day for one or two capsules (within a month). Possible side effects, which are manifested by a feeling of discomfort in the stomach and vomiting.

And the drug Allopurinol, which reduces the synthesis of uric acid, is designed to reduce the recurrence of formation of renal calculous stones in patients with elevated urate content in serum and urine.

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

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Removal of stones from the bladder

Used in urology, modern methods of removing stones from the bladder are based on ultrasonic and laser technologies and do not require open surgical intervention.

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

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

The contactless method - remote lithotripsy of stones in the bladder (shock wave) - consists in the impact of ultrasonic pulses directed to the stones through the skin on the abdomen or lower back (localization is refined and the entire process is monitored by ultrasound). The stones should be destroyed to the state of fine sand, which then comes out with urination, enhanced by the appointment of diuretics.

Among the contraindications for the fragmentation of stones, urologists call stenosis of the urethra, inflammation of the urinary tract, bleeding and malignant neoplasms in the small pelvis.

Some stones are so large that surgical treatment in the form of open cystotomy may be required. That is, a cut of the abdominal wall is made above the pubis and the bladder is dissected, and the stones are removed manually. Such surgical removal of stones from the bladder is carried out under general anesthesia and requires a catheterization of the bladder through the urethra. Possible side effects of this operation: bleeding, damage to the urethra with scarring, fever, attachment of a secondary infection.

Alternative treatment

In most cases, alternative treatment of bladder stones includes home remedies to prevent their formation. Recommend:

• drink orange and cranberry juice;
• take after dinner a decoction of leaves of grapes (25 grams per glass of water), with the addition of 20-30 ml of grape juice;
• daily on an empty stomach to drink a tablespoon of fresh onion juice or juice from the root of parsley and black radish (mixed in equal proportions);
• every day to drink a decoction of dried leaves, flowers and fruits of hawthorn prickly with the addition of a teaspoon of lemon juice for 200 ml of broth;
• at phosphate concrements in the morning and in the evening take apple cider vinegar (a tablespoon for half a cup of water).

No studies have confirmed that herbal treatment can destroy bladder stones. However, some medicinal plants are part of the pharmaceuticals.

With phosphate stones, phytotherapists recommend using a madder root dye in the form of 10% alcohol tincture (20 drops twice a day, after meals). And if stones are uro-acid, advise once a day to drink a glass of decoction from the flowers of calendula. Fruits (seeds) of the plant of the umbrella ammoni family (in the form of a decoction prepared from them) relieve spasms of the urinary tract, which facilitates the escape of small stones, but using this plant, one should drink plenty of water (up to two liters a day).

Sporish (mountain bird bird), due to the presence of silicon compounds in it, helps dissolve calcium in the composition of stones. Decoction is prepared from the calculation - a tablespoon of dry herbs for 200 ml of water; Drink three times a day for 30-40 ml (before eating).

Use and diuretic herbs, such as dandelion leaves, horsetail and nettle dioecious.

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Diet and nutrition

Since urine is a waste of metabolism in the body, diet and nutrition can be adjusted to restrict its composition, limiting the use of certain foods that increase the level of urate salts (urates), oxalates (oxalic acid salts) or phosphate salts (phosphates).

Read -  Diet with urolithiasis

If stones in the bladder consist of oxalates, you should reduce the use of all solanaceous cultures (potatoes, tomatoes, peppers, eggplants) and legumes, nuts. And from sorrel, spinach, rhubarb and celery is better to give up altogether. More information in the material -  Diet with oxalate in urine

In nutrition with stones from salts of uric acid, nutritionists recommend focusing on dairy and wholemeal products and refusing to eat red meat, fat, offal and strong meat broths. It is animal proteins that result in nitrogenous bases and uric acid. It is more useful to replace meat with chicken, but it should be consumed a couple of times a week, in small amounts and better in boiled form. For more information, see -  Diet with increased uric acid

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

Some vegetables and fruits contribute to diuresis, that is, reduce the concentration of salts in the urine. They include citrus fruits, cucumbers, cabbage, beetroot, pumpkin, watermelons, grapes, cherries, peaches, leafy greens (parsley and coriander), garlic, leek and onions.

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Prevention

Stones in the bladder are caused by a number of diseases and the state of metabolism, there are no specific ways to prevent them. However, if a person has any problems with urination - pain, a change in the color of urine, the admixture of blood in it, etc. - it is better to go to the urologist immediately.

And the main preventive means is sufficient water intake - 1,5-2 liters per day, water increases the amount of urine and reduces its saturation with salts.

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

[30], [31], [32], [33]

Forecast

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

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