Dr Lizme Ajith
Renal calculi or renal stones consist of aggregates of crystals and small amounts of proteins and glycoproteins. Different types of stones occur in different parts of the world. Studies have shown that 4% of the total population has stones in the urinary tract.
The exact aetiology is unknown, the various predisposing factors may be
1) Dietary Factors – Diet rich in red meat, fish, eggs can give rise to aciduria. Diet rich in calcium – milk, spinach, rhubarb etc produce calcium oxalate stones. Diet lacking in vitamin A causes desquamation of renal epithelium and the cells form a nidus around which the stone is deposited.
2) Renal Infection – Organisms such as streptococci, staphylococci, proteus, pseudomonas, klebsiella & E.coli produce recurrent urinary tract infection, producing urea which causes stasis of urine precipitates calcium formation.
3) Metabolic Causes – a) HYPERPARATHYROIDISM – increases the calcium levels resulting in hypercalcaemia and hypercalciuria producing calcium stones.
b) GOUT – increases the uric acid levels and cause multiple uric acid stones.
4) Prolonged Immobilisation – from any cause, eg: paraplegia is liable to result in skeletal decalcification with increase in urinary calcium favouring the formation of calcium phosphate calculi.
5) Inadequate Urinary Drainage – as in cases of horse shoe kidney, undescended kidneys are more vulnerable for development of stones due to stasis.
6) Altered Urinary Solutes & Colloids – Dehydration leads to an increased concentration of urinary solutes and tends to cause them to precipitate.
7) Decreased Urinary Citrate – The presence of citrate in urine as citric acid, tends to keep otherwise relatively insoluble calcium phosphate in solution. When citrate level decreases, it precipitates the urinary calcium.
8) HOT CLIMATES – cause increase in concentration of solutes by excessive sweating resulting in precipitation of calcium.
9) RANDALL’S PLAQUE – Randall suggested that initially a small erosion or an ulcer develops on the tip of renal papilla on which minute concretions or minor calcium particles or microlith get deposited and give rise to stone formation.
Types Of Renal Calculus
Oxalate Calculus (CALCIUM OXALATE )
The commonest type of stone, called as mulberry calculi. Irregular in shape, covered with sharp projections which tends to cause bleeding. Produces haematuria very early, resulting in deposition of blood over the stone giving a dark colour to it. Hard and single, occurs in infected urine. Can be visualized radiologically.
Phosphate Calculus (usually CALCIUM PHOSPHATE or rarely as MAGNESIUM AMMONIUM PHOSPHATE or STRUVITE)
Smooth, round, dirty white to yellow in colour. Commonly occurs in renal pelvis & tend to grow in alkaline urine especially when proteus organisms are present. As it enlarges in the pelvis, it grows & fills the major & minor calyces & slowly forms a STAG HORN CALCULUS. This produces recurrent urinary infections & haematuria. As they are large, they are usually easy to see on radiographs.
Uric Acid Calculus
Multiple, small, hexagonal, multifaceted. Colour varies from yellow to reddish brown. Occur in acidic urine. Pure urate stones are radiolucent, unless contaminated with calcium salts.
They appear in the urinary tract of patients with a congenital error of metabolism that leads to cystinuria or due to decreased resorption of cystine from renal tubules. They are hexagonal, multiple, pink or yellow. Occur in acidic urine. Seen in young girls at puberty. They are radio opaque due to sulphur content.
Extremely rare. They are smooth and round, brick red in colour and show lamellation on cross section.
Conditions Associated With Hypercalciuria High dietary intake of calcium, chronic pyelonephritis, hyperparathyroidism, vitamin D poisoning, sarcoidosis, cushing’s syndrome, myelomatosis, renal tubular acidosis, prolonged immobilization, idiopathic hypercalciuria – a) excessive absorption of calcium from gut. b) reduced renal tubular absorption of filtered calcium.
Conditions associated with hyperoxaluria
High dietary intake of oxalates – fruits, vegetables, strawberries, plums, spinach, rhubarb, asparagus, tomatoes etc. Increased absorption of oxalates from gut – a) ileal diseases b) low calcium diet
Conditions Associated With Hyperuricosuria
Metabolic disorders like gout, myeloproliferative disorders, high dietary intake of urates – red meat, fish rich in purines, offal.
In all cases the basic initiating factor is super saturation of urine which leads to crystallization. The crystals get deposited on a nidus and when the conditions are favourable, the stone grows.
Fifty percent of patients present between the ages of 30 & 50 years. The male to female ratio is 4: 3.
These vary according to the size, shape & position of the stone & the nature of the underlying condition. Renal calculi may be present for years without giving rise to symptoms & may be discovered during radiological examination for another disease. These are called SILENT CALCULI.
The leading symptoms in 75% of people include –
1) RENAL PAIN – located posteriorly in the renal angle or anteriorly in the hypochondrium in costal margin or in both. It may be worse on movement, particularly on climbing stairs. It is described as FIXED RENAL PAIN or COSTOVERTEBRAL PAIN.
2) URETERIC COLIC – When the stone is impacted in the pelviureteric junction or anywhere in the ureter, it results in severe colicky pain radiating from the loin to the groin. It may also extend to the testicles, vulva & medial side of thigh. This may be associated with strangury, the painful passage of a few drops of urine, with pallor, sweating & vomiting & he groans in agony.
3) HAEMATURIA – is common with oxalate stones. The quantity of blood lost is small, but it is fresh blood.
4) URINARY TRACT INFECTION – fever with chills & rigors, pyuria, burning micturition & increased frequency of micturition may occur. In severe cases, even septicaemia can quickly develop.
5) RIGIDITY & GUARDING – abdominal examination during an attack reveals rigidity of the lateral abdominal muscles & of the rectus abdominis. Percussion over the kidney produces a stab of pain & there may be tenderness on gentle deep palpation.
CALCULOUS HYDRONEPHROSIS – occurs due to back pressure producing renal enlargement. Due to the stretching of the renal capsule, it results in pain in the loin & an associated palpable kidney mass suggests hydronephrosis.
CALCULOUS PYONEPHROSIS – The kidney is converted into a bag of pus when hydronephrosis becomes infected.
RENAL FAILURE – Bilateral staghorn calculi may be asymptomatic until they present with uraemia.
1) RADIOGRAPHY – plain x-ray (KUB) helps to diagnose 90% of renal stones. It can be visualized as an opacity which overlies the urinary tract and keeps a relatively constant position during respiration. Enlarged renal shadow can also be made out.
2) INTRAVENOUS PYELOGRAPHY OR EXCRETORY UROGRAPHY – This helps to locate the stone exactly in relation to kidney & ureter & to assess renal function. A radiolucent stone can be seen as a filling defect. Hydronephrosis can also be made out.
3) ULTRASONOGRAPHY – is the most valuable to diagnose the stone, its size & exact location. It also confirms the enlarged kidney.
4) URINE CULTURE & SENSITIVITY – Examination of urine for protein, R.B.C, W.B.C, micro organisms reveals abnormalities of urinary tract, infection etc.
5) INVESTIGATION OF RENAL FUNCTION – Blood examination for urea, creatinine, creatinine clearance etc to rule out renal failure.
6) INVESTIGATION TO DETERMINE UNDERLYING CA– USES – plasma calcium, phosphate, parathormone, plasma urate, 24 hour urine urate, cystine & oxalate & calcium.
7) STONE ANALYSIS – analysis of any stone that has been passed.
DIETARY ADVICE – They should drink plenty to keep their urine dilute. Fluid intake should be therefore 3 litres per day, more if the climate or patient’s occupation causes much sweating. In persons with hypercalciuria, intake of milk, cheese & other dairy products should be avoided. Persons with oxalate stones should avoid spinach, rhubarb, strawberries, plums & asparagus. Persons with hyperuricaemia should avoid redmeats, offal & fish rich in purines. Eggs, meat & fish are high in sulphur containing proteins & should be restricted in those with cystinuria.
Non Operative Treatment
Small stones less than 5 mm in size pass off with intake of copious amount of fluids & at times forced diuresis. Intravenous hydration may help pass the stones spontaneously.
Extracorporeal Shock Wave Lithotripsy – here the calculus is bombarded with shock waves of sufficient energy so that it will disintegrate into fragments using lithotriptors. The fragments then pass down the ureter & are cleared out.
- Percutaneous Nephrolithotomy
- Partial Nephrectomy
- Treatment Of Bilateral Calculi – Kidney with better function has to be operated first. 1-2 months later, the opposite side can be operated.
Renal colic < left side. Stitching, cutting pain from left kidney following course of ureter into bladder & urethra. Burning & soreness in region of kidneys. Pain in small of back, very sensitive to touch in renal region <when sitting & lying, from jar, fatigue. Numbness, stiffness & lameness with painful pressure in renal & lumbar regions. Bubbling sensation in kidneys. Urine greenish, blood red, with thick, slimy mucus, transparent, reddish or jelly like sediment. Rheumatic & gouty complaints with urinary diseases. < motion, any sudden jarring movement, walking, carriage riding.
Constant urging to urinate, passing but a few drops at a time, which is mixed with blood. Intolerable urging before, during & after urination. Violent paroxysms of cutting & burning in whole renal region. Violent tenesmus & strangury. Urine scalds him & is passed drop by drop. Membranous scales looking like bran in water. Urine jelly like, shredy. Pain raw, sore, burning in every part, internally & externally. Over sensitiveness of all parts. Drinking even small quantities of water increases pain in bladder.
Renal colic, right sided. Pain shooting across lower abdomen from right to left. Pain in back relieved by urinating. Urine slow in coming, must strain. Retension. Polyuria during night. Red sand in urine. Uric acid diathesis. Child cries before urinating. Pains drawing, aching < 4-8 pm. Upper part of the body emaciated, lower part semidropsical. Ailments from fright, anger, mortification, reserved displeasure. Avaricious, greedy, miserly, malicious, pussilanimous. Excessive accumulation of flatulence, lower abdomen. > warm food & drinks.
Passage of small calculi or gravel, renal colic, stone in the bladder. Excruciating pains from right kidney downwards. Severe almost unbearable pain at conclusion of urination. Urine bloody, scanty, slimy, flaky, sandy, copious, passed without sensation, deposits white sand. Painful distension & tenderness in bladder, urine dribbles while sitting, passes freely when standing. Air passes from urethra, child screams before & while passing urine.
Renal colic, violent spasmodic pains along ureter, left side. With deathly nausea & vomiting. Vomiting violent, with cold sweat, on least motion, with faintness > open air. Nausea incessant as if seasick > in fresh cold air. Vertigo, death like pallor, on opening the eyes. Face pale, blue, pinched, sunken, collapsed. Terrible, faint, sinking feeling at the pit of stomach. Icy coldness of surfaces.
Renal colic, right sided. Pain extends to the right thigh & to the genitals. Frequent ineffectual urge for urination with dribbling of urine. Haematuria, strangury. While urinating, itching in urethra & pain in neck of bladder. Backache, must sit up or turn over in bed. Adapted to thin, irritable, zealous, nervous, literary, studious, responsible persons. Bad effects of coffee, tobacco, alcohol, highly spiced food, overeating, long continued mental exertion. Over sensitiveness to all external impressions. Frequent ineffectual urging for stool.
Renal colic, right sided. Uric acid diathesis. Red sand in urine. High acidity, formation of spike crystals of uric acid. Turbid, thick, purulent, bloody, brick dust red or yellow sediment. Odour of musk. Pain in ureters, cramps in kidneys.
Violent spasmodic pains in kidney region especially of the right side. Pain comes suddenly, last indefinitely & cease suddenly. Pains usually in short attacks. Redness of eyes & face, throbbing of brain & carotids. Abdomen tender, distended, < least jar, even of the bed, slight noise, light, lying down. > pressure, tight bandaging, wrapping up. Bilious lymphatic plethoric constitutions.
Insupportable pains in loins & hips. Pains seem unendurable, drives to despair < by heat, evening before midnight, with heat, thirst & fainting with numbness of affected parts, eructations <. Violent pains, drive him out of bed, compels to walk about. Over sensitive to pain, to open air. Cannot endure anyone near him, is cross, irritable, easily angered.
Pains on urinating over whole abdomen. Vesical catarrh, discharge like fresh white of egg. Red hard crystals. Renal colic < left side. Agonising pain in abdomen causing patient to bend double, with restlessness, twisting & turning to obtain relief. > hard pressure. Pains < eating & drinking > warm application. Shooting pains like electric shocks. Complaints from anger, indignation, mortification.
Renal colic with pains radiating to the extremities. Colic pains < bending forward & while lying. > on standing erect or bending backwards. Violent twisting colic, occurring in regular paroxysms as if abdomen were grasped & twisted by a powerful hand. Pain suddenly shift to different parts, appear in remote localities as fingers & toes.
Renal calculi, gravel, profuse deposit of white amorphous salts in urine. Renal colic, sharp pain in loins, especially left. Burning in urethra & frequent desire. Urine hard to start. Bloody urine, heavy deposit of mucus. Great thirst with abdominal symptoms & enlarged prostate.
Renal colic, pain going down the thighs. Neuralgic pain in the anterior crural region. Constant urging, great straining. Can emit urine only when he goes on his knees, pressing head firmly against floor. Black, bloody, thick mucus urine. Dribbling after micturition. Urethritis, prostatitis.
Fabiana Imbricata ( Pichi )
Excoriating urine & calculi. Uric acid diathesis. A terebinthine diuretic. Vesical tenesmus & burning after urination. Dysuria, cystitis, prostatitis, gonorrhea. Cholelithiasis & liver affections.
Dull burning pain over left kidney. Pain along left ureter. Dragging pain from kidney to bladder. Red sand in urine. Frequent urging, cutting pains. Frequent intense desire to urinate & inability to retain urine for more than few minutes, better urinating.
Renal calculi, gravel, uric acid deposits. Fine sand in urine of a brown colour. Dysuria, tenesmus after urination. Burning in neck of bladder while urinating. Chronic cystitis, mucopus, pyelitis, incontinence of urine.
Renal colic. Pain behind pubes. Congestion of kidneys with dull pain in back, running down the ureters & limbs. Difficult & frequent micturition. Strangury with nervous erethism. Tenesmus of bladder & urethra. Thick yellow mucus discharges.
Deep dull pain in kidneys. Dysuria, haematuria, strangury. Boring in bladder & urethra on urinating. Vesical irritability in women. Insufficient flow, milky. Albuminuria, dropsy, diabetes, enlarged prostate.
Renal colic. Accumulation of gravel. Brick dust sediment. Urine heavy, phosphatic. Dysuria & spasmodic retension. Uric acid diathesis. Renal & vesical irritation. Urethritis, urine runs away in little jets. Haematuria & albuminuria.
Vesical calculi. Irritation at neck of bladder. Urine suppressed. Dropsy. Deranged portal circulation. Prostatic enlargement.
Urine scanty, reddish brown, thick sediment, dysuria, gravel. Pain in kidneys extends forward to abdomen & bladder. Urine difficult & scanty, albumen, blood & slime. Kidneys sensitive to pressure. Backache of congested kidneys.
Renal calculi. Night mares, patient dreams of being buried alive.
Stigmata Maydis (Zea)
Renal lithiasis, nephritic colic. Blood & red sand in urine. Suppression & retension of urine. Dysuria, tenesmus after urinating. Uric & phosphatic gonorrhea. Urinary symptoms associated with organic heart disease.
Renal colic, aching in small of back & extremities. Pain in left lumbar muscles on stooping. Aching in top of right shoulder.
Smarting, burning sensation along urethra & bladder with frequent desire to void urine often with strangury. Cystitis, irritable bladder.
Severe pain in kidneys, cystitis & gravel. Pain from ureter to bladder & testicles. Pain in small of back returns from least chill or damp.
Calculous inflammation. Chronic vesical irritation with pain, tenesmus & catarrhal discharges. Burning after the discharge of slimy urine. Frequent urging with severe spasms of the bladder. Urine contains blood, pus & much tenacious mucus, with clots in large masses. Painful dysuria. Involuntary green urine. Cystitis with bloody urine.
Urinary calculi, urates & uric acid. Brick red sediment. Haematuria. Deep coloured thick urine. Dysuria, urging to urinate. Lancinating pains from kidneys to bladder. Chronic bronchitis complicated with gravel.
Small amount of urea & phosphoric acid with excess of uric acid & abundance of chlorides. Bloody urine. Albuminuria. Chronic interstitial nephritis. Turbid, slimy, clay coloured, greasy sediment. Complaints from suppressed malaria.
Excess of uric acid in urine. Urine high coloured, urinous odour highly intensified. Dark brown, highly offensive. Gonorrheal & syphilitic patients. Pain suddenly change their locality. Rheumatism & gout.
Cloudy phosphatic urine. Scanty, dark, offensive, smells like horse’s urine. Urine bloody, albuminous, turbid, looks like remains of cider barrel, cold on passing. Pricking splinter like pains. Complaints after continued loss of sleep, over exertion of mind & body.
Renal colic. Painful tenesmus when urinating. Severe pain in renal region > by profuse urination. Intense pain in ureters, with sensation of passing of calculus. Urine flows very slowly. Ailments from suppressed gonorrhea. Women with chronic pelvic disorders. < thinking of ailments, day time. > lying on abdomen.
Red adhesive sand in urine. Chronic cystitis, slow micturition with bearing down sensation above pubes. > by violent exercise, warm application. Involuntary urination during first sleep. Urine highly offensive, must be removed from the room. Pains from other parts to back, attended with shuddering. Sensation of ball in inner parts. Weeps easily, indifference to those loved best.
Urine loaded with ropy, mucopurulent sediment. Urine turbid, offensive, scanty. Burning & scalding. Must strain before flow comes. Unable to urinate without standing with feet wide apart & body inclined forward. Prostatic enlargements.
Renal colic, great heat & constant urging. Nephritis. Scanty, high coloured, bloody with much mucus & tenesmus. Irritable bladder with headache. Backache of congested kidneys. Functional amenorrhea.
Gravel & renal calculi.
Urinary calculi, uric acid diathesis. Constant backache. Urine scanty. Rheumatic urethritis.
Pains of nephritic colic, lancinating pain along spine. Suppurative nephritis. Aching pain in hips & loins.
Renal colic & calculi.
Gravel. Oxaluria, almost a specific. Urine cloudy, burning in urethra. < eating meat, alcohol.
Gravel. Irritable bladder with vesical catarrh. Mucopurulent discharges
Dr.Lizme Ajith MD(Hom)
Tutor, Department of Practice of Medicine
Govt. Homeopathic Medical College. Calicut. Kerala
Email: [email protected]