Understanding urolithiasis and its homoeopathic management

Dr. Ashok Yadav1, Dr. Kanika Agarwal2,Dr Shradha Sharma

ABSTRACT
The formation of stone in the urinary system, i.e. in the kidney, ureter, and urinary bladder or in the urethra is called urolithiasis.  It is an increasing urological disorder of human health and given its high rate of recurrence and the inability to predict stone events, urolithiasis has long been recognized as a chronic condition and is related with a decrease in health-related quality of life. This article on urolithiasis provides a comprehensive understanding of this disorder and its homoepathic management.

KEYWORDS – Urolithiasis, Renal calculi , Homoeopathy, repertory, homoeopathy medicine

INTRODUCTION
Kidney stone disease has been a well-known entity for centuries. This has been markedly established by different archeological findings, as well as by writings about painful stone colic and therapeutic trials for stone removal. In ancient centuries urolithiasis was often a disastrous disease, with a catastrophic outcome all too often leading to the patient’s death.[1]

EPIDEMIOLOGY
Urolithiasis is an increasing urological disorder of human health, affecting about 12% of the world population. In Asia, about 1%-19.1% of the population suffer from urolithiasis. However, due to variations in socio-economic status and geographic locations, the prevalence and incidence have changed in different countries or regions over the years.. In India and Malaysia, the incidence was lower than 40/100 000 in 1960s, but three decades later, it grew dramatically to 930/100 000 and 442.7/100 000, respectively.The “stones belt” concerns parts of Gujarat, Rajasthan, Maharashtra, Punjab, Haryana, Delhi and states of north-east.

There is no evident difference in recurrence rate of urolithiasis among Asian countries, which is about 6%-17% after 1 year, 21%-53% after 3-5 years, and the lifetime risk of recurrence is estimated to be 60%-80% . When it comes to gender, the recurrence rate of urolithiasis in male is twice than that in female. [2,3,4]

CLASSIFICATION

Classification on the basis of of location of calculi

 kidney nephrolithiasis
 ureter ureterolithiasis
 Urinary bladder cystolithiasis

Classification on the basis of chemical composition –

  • calcium  oxalate
  • calcium phosphate
  • magnesium ammonium phosphate (struvite)
  • uric acid
  • cystic or other compounds

 The size of a stone is usually given in millimetres (mm), using one or two-dimensional measures. Stones can be stratified further into those measuring up to 5 mm, > 5-10 mm, > 10-20 mm, and > 20 mm. [3]

Risk Factors

  1. Lifestyle habits and dietary/nutritional factors: such as excessive intake of animal proteins and salt and delciecies of chelating agents like citrate, Iber, and alkali foods
  2. Metabolic disorders: such as hypercalciuria, hypocitraturia, hyperoxaluria, hyperuricosuria, and history of gout (defective metabolism of uric acid)
  3. Hypercalcemic disorders: primary hyperparathyroidism and other disturbances of calcium metabolism
  4. Urine composition: excessive excretion of promoters of urinary crystallization and reduced excretion of  inhibitors 
  5. Low urine volume: inadequate water intake (dehydration and supersaturated urine)
  6. Recurrent urinary tract infections: abnormalities of urinary pH and alkalinization of urine by bacterial urease (such as Proteus mirabilis)
  7. Genetic predisposition/inherited disorders: family history of stones (genetic susceptibility); genetic monogenic diseases (single abnormal gene disorders on the autosomes); renal tubular acidosis
  8. Anatomical abnormalities: factors such as defects in medullary sponge kidney, ureteropelvic junction stenosis, pyeloureteral duplication, polycystic renal disease, and horseshoe kidney
  9. Hypertension
  10. Obesity 
  11. Climate change (global warming), occupation, geographic conditions, and seasonal variations (higher in summer than winter) 
  12. Inflammatory bowel disease and other intestinal malabsorption or associated disease states
  13. Absence of intestinal oxalate-degrading bacteria
  14. Lithogenic drugs: such as indinavir (Crixivan), a protease inhibitor, sulfonamides (sulfadiazine), uricosuric agents, which have low solubility andpromotes the formation of calculi, and ceftriaxone (high dose on long terms)[4]

Mechanisms of Renal Stone Formation
Pathogenesis of kidney stone or biomineralization is a complex biochemical process which remains incompletely understood . Renal stone formation is a biological process that involves physiochemical changes and supersaturation of urine which refers to a solution that contains more of dissolved material than could be dissolved by the solvent under normal circumstances. As a result of supersaturation, solutes precipitate in urine leading to nucleation and then crystal concretions are formed.[4]

Signs and symptoms
Symptoms of urolithiasis are related to their location whether it is in the kidney, ureter, or urinary bladder.  Initially, stone formation does not cause any symptom. Later, signs and symptoms of the stone disease consist of renal colic , flank pain (pain in the back side), hematuria (bloody urine),  urinary tract infections, blockage of urine flow, and hydronephrosis (dilation of the kidney). These conditions may result in nausea and vomiting with associated suffering from the stone event .[4]

The physical examination of patient may reveal-

a) Rigidity of lateral abdominal wall,

b) Tenderness over renal angle/ kidney region

INVESTIGATIONS
Investigations depend on whether patient presents with first stone episode or has recurrent history of renal calculi. Investigations include –

  • Stone chemical composition ( if stone can be obtained)
  • Blood for calcium, phosphate, uric acid, urea and electrolytes, Bicarbonate, parathyroid hormone
  • Urine investigations for protein, blood, glucose, amino acids
  • 24 hour urine for urea, creatinine clearance, sodium, calcium, oxalate, uric acid[5]

Management:
Around 90% of stones of less than 4mm pass spontaneously and stones bigger than 6 mm require surgical intervention.There are a number of practices for treatment of urinary calculi, including surgery, and endoscopic procedures such as percutaneous nephlithotomy and extracorporeal shock wave lithotripsy. 

General management include-

  • Approximately 3-4 litre fluid intake distributed throughout the day to achieve at least 2 litre output per day
  • Restricted intake of sodium, moderate intake of protein
  • Good intake of  dietary calcium as calcium forms and insoluble salt with dietary oxalate; avoid calcium supplements separated from meal
  • Avoid food rich in oxalate. [3][5]

Homoeopathic View:
Homoeopathy considers urolithiasis as chronic disease of miasmatic origin.In Aphorism 80, Master Hahnemann mentions that the chronic miasm of psora is the real fundamental cause and producer of innumerable forms of disease,among which he included urinary calculi.[6] However,in urolithiasis there is deposition of crystals due to supersaturation of urine with insoluble materials, crystals may grow and aggregate to form stone. Since“The accentuation of psora is function; the accentuation of the syphilitic taint is ulcerative; the accentuation of sycosis is infiltration and deposits.”[7] So it can be said that sycosis is the dominating misam in the formation of urolithiasis.

Homoeopathic Management:
Homoeopathy has been proved to be a boon for patients in whom surgery is a risky affair such as aged ones, hypertensive and diabetics or those who are in search of an alternative to surgery.  The most appropriate treatment protocol is based on the simila principle along with general management to prevent stone formation. The homoeopathic practice that is arriving at similimum, is an application of logic to find the most similar remedy from the group of apparently similar remedy. 

RECENT RESEARCHES

  1. A prospective, multicentre observational study was conducted by Central Council for Research in Homoeopathy (CCRH) from October 2005 to January 2010 to find the usefulness of homoeopathic medicines in cases of Urolithiasis. Out of 220 cases, there was expulsion of calculi in 106 cases (single calculus in 76 cases, multiple calculi in 30 cases) and in 114 cases, calculi remained but the symptom score reduced, indicating improvement in the case. The symptom score at baseline and after treatment was analysed and found statistically significant (P<0.0050). Treatment with homoeopathic medicines showed positive response in dissolution/expulsion of calculi.[8]
  2. Central Council for Research in Homoeopathy (CCRH) conducted a to explore the utility of Lycopodium Clavatum in urinary calculi from 2005-2010. Results of this study in calculi: Fourty one(45.6%) patients showed marked improvement, 6(6.7%) patients showed moderate improvement, 31(34.4%) patients showed mild improvement,in 11(12.2%) patients there was no significant improvement and 1(1.1%) patient did not improve [9].
  3. A multicentric, randomised, double-blind, placebo-controlled trial was conducted between July 2012 and March 2015 to evaluate the efficacy of Lycopodium clavatum in the management of urolithiasis. Patients having symptomatology like Lycopodium clavatum were enrolled. There was no statistical significance between the groups (P = 0.31) in reference to the number of cases in which stones expelled during the trial. The mean size of single stone expelled was 9.4 ± 4.9 and 13.9 ± 2.2 in Verum and Placebo groups, respectively (P= 0.12). There was also no significant difference in the mean size of multiple stones; in Verum group (10.1 ± 5.3) and Placebo group (16.1 ± 9.1) (P = 0.11). For assessment of pain and dysuria, Visual Analogue Scale was used, and a statistically significant difference was found between the groups (P = 0.039) for pain, and positive trend for Homoeopathy was noted for dysuria. [10]

REPRESENTATION OF RELATED RUBRICS IN REPERTORIES

  • Knerr Repertory of Hering Guiding Symptoms[11]
Chapter Rubric/Subrubric
URINARY ORGANS -KIDNEY Calculi Act-sp., Apoc., Arn., Chin-s., Eup-pur., Ipom., LYC.SARS., Sep., Sil., Tab., ¤ Ter., Uva.
Colic, with renal, during passage Chlf.
Congestive and inflammatory symptoms, with purulent chalky, or sandy sediment Phos.
Nephritis, caused Nux-v.
Passage, with writhing, twitching, crampy pain Dios.
URINARY ORGANS -BLADDER Calculi Ant-c., Apoc., Arg-n., Ars., Aspar., Bell., Benz-ac., BERB.Cact., CALC., Cann i. , CANTH.Carb-v., Card-m., Chin., Coc-c., Coch., Coff-t., Colch., Coloc., Cupr., Dig., Equis., Eup-pur., Graph., Kreos., Lach., Lith-c., LYC.Mez., Naja, Nat-m., Nat-s., Nit-ac., Nux-m., Nux-v., Pall., Pareir., Petr., Phos., Puls., Ruta, SARS.SEP., Sil., Thuj., Uva.
Colic, cause Ter.
Concretions of urate of ammonia Benz-ac.
Disposition to, in cystitis LYC.
Gout, in BENZ-AC.
Gravel Anag., Benz-ac., Chim., Chin., Coc-c., Coch., Coff-t., Con., Eup-pur., Hydr., Lith-c., LYC.Mag-p., Nat-s., Phos., Raph., Ruta, Sars., Sil., Urt-u., Uva, Zinc.
Gravel, with chronic bronchitis Coc-c.
Gravel, in children SARS.
Gravel, with hæmaturia Lyc.
Gravel, with pain in back Ipom.
Gravel, periodical discharge Lyc.
Gravel, in subacute pleuritis Arg-n.
Gravel, passes small quantities of fine red sand Lyc.
Gravel, in small quantities, when urinating Aspar.
Pain and spasm during passage Nux-v.
Prismatic crystal of triple phosphate, one (Bright’s disease) Kalm.
Stone, discharge of a porous, as large as half a bean, with much sand and sediment (renal colic Lyc.
Small, passes frequently, crystals of uric acid Pareir.
Small, passed several times (nephritic colic) Pareir.
Small, pass away Dol.
Small, round and rough, with hæmaturia Lyc.
Ulceration, causing, of bladder All-s.
  • Kent Repertory of homeopathic material medica[12]
Chapter Rubric/subrubric
URINARY ORGANS-URINE Sediment, renal calculi Bell., Benz-ac.berb., Calc.canth., coc-c., coloc., equis., hydrang., Lith.Lyc., mill., oci., Pareir.phos., Sars.sil.
  • The Prescriber[13]
Rubric/subrubric Indication Medicine
Calculus- RENAL,PASSAGE OF Agonising pain, twists about, screams and groans ; red urine with brick-dust sediment  Oc. can.
Writhing with crampy pains, must move about Diosc.
Violent sticking pains in bladder, extending from kidneys into urethra, with urging to urinate Berberis
Should this fail  Pareira brava
Calculus – PREVENTION Gravelly urine, pain in back and loins Berb
Tendency to store uric acid in the tissues ; gouty subjects Urt. ur.
Gravel Red sandy sediment with flatulence in the abdomen and constipation Lyc.
Should this fail Urtica ur.,Cocc.cact.
White phosphatic sediment Phos. Ac.
White sediment after standing, acrid sourish odour Graph.
Turbid urine, white sediment ; red (bloody) urine, with brick-dust sediment, Ocim can.
Brick-dust or straw-yellow granular deposit Chinin. Sulph.
White or whitish-grey, and later, mealy reddish sediment ; pain in the ureters, Berb.
Pasty sediment, reddish or white Sep.
Oxalate of lime deposit Nitr. Mur. Ac. , Oxal. ac.
Turbid immediately after passing, like clay water, much pain at end of urinating ; white sand, scanty, slimy, flaky urine, tenesmus of bladder Sarsa.

SYMPTOMATIC INDICATIONS OF SOME HOMOEOPATHIC MEDICINES-

  1. Benzoicum Acidum – fleeting pains in bladder,not when urinating, but at other times, visceral catarrh from supressed gonorrhoea, calculi or gout; Urinous odour highly intensified like horse’s urine[14]
  2. Berberis Vulgaris   renal colic  aggravation left side;  stitching, cutting pain from left kidney following the course of ureters into bladder and urethra;  burning and soreness in region of kidney[15]
  3. Calcarea Carbonica – Renal colic; urine dark brown, sour,foul or of strong odour; white urinary sediment with milky urine[16,17]
  4. Calcarea Renalis  after berberis in Renal calculi cases; gravel and renal calculi. Recurrent stone formation, in a calcarea carb constitution, remove the tendency[19]
  5. Cantharis  cantharis is valuable remedy in passage of renal calculi when the pains are very violent. Indicated in gravel in children when they have this irritation extending down the penis, with almost constant pulling at the organ; intolerable, constant urge to urinate is most characteristic.[17,18] 
  6. Chimaphila   catarrah of bladder caused by stones.  It produces frequent urination at night with increased debility and smarting pain extending from the neck of bladder to the end of urethra [18]
  7. Eryngium Aquaticum   renal colic.  Congestion of kidney with dull pain in back, running down the ureters and limbs; tenesmus of bladder and urethra, difficult and frequent micturation[17]
  8. Hedeoma   red sand in urine.  Frequent urging, cutting pains. Pain along left ureter.  Dragging pain from kidney to bladder. Dull burning pain over left kidney. Burning irritation at neck of bladder causing frequent intense desire to urinate and  inability to retain urine for more than few minutes,better urinating[18]
  9. Hydrangea   calculus, renal colic.  Sharp pain in loins,  especially left. [17]
  10. Ipomoea –  in calculi  which severe cutting pain in other renal region extending down the ureter on the corresponding side.  The distinctive feature with separate it from other remedies is that these pains excite nausea.[18]
  11. Lycopodium Clavatum  right sided renal colic;  red sand in urine on child diaper. Child cries before urinating; pain in back relieved by urinating[15]
  12. Medorrhinum   renal colic, intense pain in ureters, which sensation of passing of calculus. Severe pain (backache)  in renal region ameliorated by profuse urination [14]
  13. Nux Vomica –  renal colic extending to genitals,  with dribbling urine.  While urinating,  itching in urethra and pain in neck of bladder. [17]
  14. Occimum Canum –  renal colic,  favours right side.  Indicated when there is considerable hemorrhage; when the urine may not only has a brick red sediment, as under Pareira brava, but contains considerable blood.[18]
  15. Oxydendron Arboreum – Visceral calculi. Iritation of neck of bladder. [17]
  16. Pareria Brava  excellent drug in gravel and in cystc calculus, when the patient has to get down on all fours to urinate.  The tenesmus is great; urine passes in drops; Pain shoot from the kidney down the thighs, and even in the feet; the urine deposits a copious uric acid sediment and also blood [18]
  17. Pichi – Excoriating urine and urinary calculi. Inflammation of whole uretheral tract, must pass water frequently. Acute chronic cystitis caused by gravel. [14] 
  18. Sarsaparilla –  Neuralgia or renal colic;  excruciating pain from right kidney downwards.   Sand in urine or on diaper;  child screams before and while passing it,severe almost unbearable pain at conclusion of urination. [15]
  19. Solidago   pain in kidney extend forward to abdomen and bladder. Scanty,  reddish brown, thick sediment , dysuria, gravel. [17]  
  20. Tabacum   renal colic: violent spasmodic pain along ureter,  left side; deathly nausea and cold perspiration[15]
  21. Uva Ursi   cystic and urethral symptoms referable to stone in bladder.  Burning, scalding urination;  the flow of urine stops suddenly as if a stone has rolled in front of the internal orifice of the urethra.  The drug seems to diminish inflammatory thickening of  the cystic walls,  and relieve suffering until the stone can be removed by operation. [18]

REFERENCES

  1. López M, Hoppe B. History, epidemiology and regional diversities of urolithiasis. Pediatric nephrology. 2010 Jan 1;25(1):49-59.https://doi.org/10.1007/s00467-008-0960-5
  2. Liu Y, Chen Y, Liao B, Luo D, Wang K, Li H, Zeng G. Epidemiology of urolithiasis in Asia. Asian journal of urology. 2018 September 6; 5(4):205-214. Doi: https://doi.org/10.1016/j.ajur.2018.08.007
  3. Jayaraman UC, Gurusamy A. Review on Uro-Lithiasis Pathophysiology and Aesculapian Discussion. IOSR Journal of Pharmacy.  2018 February; 8(2):30-42.Available from: https://www.semanticscholar.org/paper/on-Uro-lithiasis-pathophysiology-and-aesculapian-Jayaraman-Gurusamy/90f5068d8da0af943f65922a54ad31dce445de5d
  4. Alelign T, Petros B. Kidney stone disease: an update on current concepts. Advances in urology. 2018;2018. Doi: https://doi.org/10.1155/2018/3068365
  5. Walker, B., Colledge, N., Ralston, S. and Penman, I.. Davidson’s Pinciples & Practice of Medicine. 22nd ed. China: Elsevier Limited;2014
  6. Sarkar BK. Organon of Medicine by Samuel Hahnemann.14th ed.Delhi : Birla Publications Pvt.Ltd;2013. 
  7. Roberts Herbert A. The Principles and Art of Cure by Homoeopathy.Low price edition. Noida: B Jain Publishers Pvt. Ltd;2002. 
  8. Siddiqui VA, Singh H, Gupta J et al.A multicentre observational study to ascertain the role of homoeopathic therapy in Urolithiasis. Indian Journal of Research in Homoeopathy.2011[cited 2020 June 17] ;5(2) [Internet] Available from: http://aohindia.in/jspui/bitstream/123456789/1336/1/Clinical%20Research.pdf
  9. Siddiqui VA. To explore the utility of Homoeopathic medicine Lycopodium Clavatum in Urinary Calculi. Indian Journal of Research in Homoeopathy.[internet]2010:4(3),34-43 Available from: http://ayushportal.nic.in/ShowDefault.aspx?IDD=13328/.
  10. Bhalerao R, Oberai P, Mehra P, Rai Y, Choubey G, Sahoo AR, Majumder A K, Sah M, Gupta A K, Tyagi A K, Siddiqui V A, Kumar A, Manchanda RK. Lycopodium clavatum for the management of urolithiasis: A randomised double blind placebo controlled trial. Indian J Res Homoeopathy [serial online] 2019 [cited 2020 Jun 29];13:139-49. Available from: http://www.ijrh.org/text.asp?2019/13/3/139/268517
  11. Knerr CB. Repertory of Hering’s Guiding Symptoms of our Materia Medica. Available from: http://www.homeoint.org/hering/nose-lr.htm
  12. Kent JT. Repertory of Homeopathic Materia Medica. Reprint Edition. New Delhi: B. Jain Publishers (P) Ltd.; 2007.
  13. Clarke JH. The Prescriber. Reprint ed.New Delhi: B Jain Publishers Pvt. Ltd;1991
  14. Clarke JH. A Dictionary of Practical Materia Medica. Available from: http://www.homeoint.org/clarke/index.htm
  15. Allen H.C.  Keynotes Rearranged And Classified  With Leading Remedies Of Material Medica added with other Leading Nosodes and Bowel Nosodes. New Delhi. Indian books and periodicals Publishers;2011
  16. Phatak SR. Materia Medica of Homoeopathic Medicines. New Delhi: B Jain Publishers;2007
  17. Boericke W. New Manual of Homoeopathic Materia Medica and Repertory. Reprint Edition  New Delhi: B. Jain Publishers(P)Ltd. 2011.
  18. Farrington EA.Clinical Materia Medica. Low price ed. New Delhi: B Jain Publishers Pvt. Ltd;2002
  19. Banerjea SK.Success of Homoeopathy – Authentic cures. Nw Delhi: B Jain Publishers;2010

Dr. Ashok Yadav1, Dr. Kanika Agarwal2,Dr Shradha Sharma2

1 Professor & Head of Department, Department of Practice of Medicine, Dr. MPK Homoeopathic Medical College, Hospital & Research Centre (under Homoeopathy University), Jaipur, Rajasthan, India

2 PG Scholar, Dr. MPK Homoeopathic Medical College, Hospital & Research Centre (under Homoeopathy University), Jaipur, Rajasthan, India. E mail : drkanikaagarwal18@gmail.com,sharmashradha72@gmail.com

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