FOCUS ON URINARY STONES
Global Healthcare Patient Education Fact Sheet

What are urinary stones?
Urinary stones are stones in the urinary tract (either in the kidney, ureter or urinary bladder) which develop when crystal formation occurs from the salt and mineral substances in the urine. These crystals combine together and grow in size. Usually, the crystals are removed from the body through the urine. However, they sometimes stick to the lining of the kidney or settle in places that the urine cannot carry them out. The stones can range in size from a grain of salt to a golf ball and can become very painful. Some of the stones may move to other parts of the urinary system including the ureter or bladder.

Why do people develop urinary stones?
Doctors do not know for sure what causes a kidney stone to form in all cases. They have found that certain people are more likely to develop kidney stones. The most common predisposing cause is a relative low intake of water. The resultant highly concentrated urine allows certain chemicals in the urine to 'crystallize', thus setting the stage for stone formation.

Other risk factors include:
1. Previous history of urinary stones or urinary infection.
2. Family history of urinary stones.
3. Gout.
4. High intake of calcium-rich foods (e.g. dairy products), or oxalate- rich foods (e.g. chocolates,     colas, peanuts, tea)
5. Age (more common during middle age)
6. Gender (three times more common in men than in women)
7. Activity level (more common in people who are immobilized or after excessive fluid loss     through sweating)
8. Climate (more common in hot climates or during summer months)
9. Urinary tract infections, kidney disorders and metabolic disorders such ashyperparathyroidism     are also linked to kidney stones.

How do I know that I have urinary stones?
Many kidney stones are called “silent stones” because they do not cause symptoms. The most common symptom of kidney stones is blood in the urine. Urine may look rusty or smokey red.

Other symptoms include:
• Pain along the area of the kidney; pain may extend over the abdomen and to the groin (Pain    may be severe and come and go), commonly called colic.
• Lower back pain
• Feeling the need to urinate often
• Inability to urinate (when a stone blocks the urinary tract)
• Nausea
• Vomiting

Cloudy, foul smelling urine, fever, chills or weak-ness may be a sign of a serious infection.

What does it feel like to pass a kidney stone?
You may have severe pain that can last minutes to hours as the stone moves and irritates the lining of the urinary tract or blocks the flow of urine. This pain may be followed by long periods of relief. There may be a period of nausea and vomiting with the pain. The pain may start in the kidneys or lower abdomen and then later move to the groin. As the stone moves toward the bladder, you may feel an increased need to urinate.

What tests will my doctor do to confirm the diagnosis?
Besides a detailed history and examination, the most common tests would include a simple X ray (called a KUB or Kidneys, Ureters and Bladder film); and a urine test. Nowadays, a bedside ultrasound when available can also diagnose urinary stones easily. If your doctor strongly suspects a urinary stone as the cause of your problems, the 'Gold Standard' test is the Intravenous Pyelogram or IVP. (Commonly called “Coloured X-ray.”)

The IVP is a specialized form of X-ray; it will require you to fast for a 4 to 6 hours before the test, and would involve an injection of contrast (dye). Although it is a commonly performed test that generally carries minimal complication, you must highlight to the doctor if:

1. You have any form of Allergy
2. You suffer from Asthma
3. You are on Diabetic medication

Of course, pregnancy will exclude any form of x-ray investigations. In such situations, ultrasound examination would be the alternative.

What are the treatment options for urinary stones?
Most urinary stones, especially if they are small, can be treated expectantly i.e. they can be left alone as they may pass out in the urine by themselves. The pain that might occur during stone passage can usually be controlled with oral analgesics. Occasionally, you might require an injection for pain control during the acute attack; in which case you will need to be seen at a clinic or the Accident and Emergency Department. To help 'propel' the stone or to facilitate its passage, you are encouraged to consume 10 - 12 glasses of water a day, and to avoid agents like coffee and alcohol. 90% of all kidney stones pass on their own, within 3-6 weeks.

Occasionally, your doctor might prescribe medication to help 'dissolve' the stone, which is only applicable for some specific type of stone (e.g. uric acid stone which accounts for 5-10% of stones). In general, a Surgeon or Urologist should review you, especially if complications including infection and kidney 'swelling' are present.

What treatment can the Surgeon or Urologist provide?
The following treatment options are available for complicated urinary stone diseases:

1. Extracorporeal Shock Wave Lithotripsy (ESWL)
This is the commonest form of stone treatment presently (up to 80-90% of cases). If the stone does no pass, energy waves may be used to break up the stones (a procedure known as ESWL). A strong analgesia with sedative effects will be given intravenously before commencement of treatment. During the treatment itself, many patients are asleep. If you are still aware, you may feel a tapping sensation as the shock waves pass harmlessly through your body. The procedure is usually well tolerated. The treatment will last between 45 minutes to an hour.

After treatment, you will rest at the treatment centre for an hour or two. It is advisable for you to be accompanied by someone as you return home, and to avoid driving immediately after treatment.

You will be advised accordingly after treatment. Occasionally, you may have to return for repeat sessions of ESWL treatment.

2. Percutaneous Nephrolithotripsy (PCNL)
This is a specialized form of Minimally Invasive Surgery, and is required in selected cases only. Under general anaesthesia, a small hole (1-2 cm) is made in the loin to allow a kidney-scope to pass into the kidney. The stone is broken up and removed through this tract. Hospitalization for about 2-3 days on average is required.

3. Uretero-renoscopy (URS)
This is another specialized procedure requiring general or spinal anaesthesia. There is no cutting on the skin; instead, a small tube called an Uretero-renoscope is passed from the external urine passage up through the bladder and into the ureters and kidneys. The stone is broken up and removed. Hospitalization is for about 1day on an average.

4. Holmium Laser
Flexible ureteroscopy with Holmium laser lithotripsy provides a reasonable alternative for the management of stones inpatients who are prone repeated percutaneous procedures. Although it is time consuming, but it gives complete stone fragmentation along with clearance of fragments in the majority of patients of ureteral and even intravesical calculi.

5. Laparoscopic Surgical removal
This is a specialized minimal access surgery procedure which while maintaining the efficacy of conventional open surgery, provides you all the benefits of minimal access surgery (namely minimal scar, less pain, faster recovery and return to normal activity). Thus it is slowly replacing “Open Surgery.”

Interestingly and fortunately laparoscopic procedures to remove stones from the urinary tract are being employed in almost all special conditions where a urinary stone can co-exist. These are conditions such as – calyceal divertuculae (including complex calyceal diverticulae, where marsupalisation/ laparoscopic partial nephrectomy/ laparoscopic-facilitated PCNL are utilised), pelvi-ureteric junction obstruction (where a laparoscopic pyeloplasty is performed simultaneously), ectopic kidneys, large stones (where laparoscopic pyelolithotomy may be given preference over PCNL) and staghorn calculi with poorly functioning kidney (where laparoscopic nephrectomy is considered). Experts forsee the universal application of the laparoscopic approach to all reconstructive renal operations in the future. The average hospital stay is about 2-3 days.

6. Open Surgical removal
This conventional method involves 'cutting' and thus a wound of about 6 inches, but is rarely required nowadays. The average hospital stay is about 4 - 5 days.

How do I prevent further recurrence of Urinary Stones?
You can prevent recurrences by:
1. Drinking lots of water. 8-10 glasses a day are a rough guide.
2. Following any prescribed medication or diet by your doctor
3. Having your condition monitored regularly

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