Internal Medicine

Therapy of kidney stones

Guidelines

Pain that is acutely caused by kidney stones (so-called "colic") requires a direct drug therapy.

Depending on the pain assessment, which with the so-called Pain scale can take place, different drugs are used, according to the so-called level scheme.

It is also possible to treat with certain drugs during pregnancy.

It is also possible to use medication to prevent recurrent colic.

For newly diagnosed ureteral stones that smaller than 5mm are big, we can wait. One hopes for one under regular control Spontaneous departure of the stones. Otherwise you can with conservative therapies (Change in diet, home remedies, etc.).

However, there are also patients with kidney stones who have no symptoms. Here is one active monitoring indexed. The patient is clinically examined annually and imaging procedures are used, such as ultrasound, an empty kidney scan or CT.

In the case of colic that cannot be controlled with medication, you can try to drain the urine, which was blocked by the stones, with a ureteral splint. From a kidney stone size of 5mm you should try to remove the stones surgically.

1. Conservative therapy

1.1 Drug therapy for renal colic

The pain from kidney stones can be divided with the Numerical pain scale (NRS). There are target values under 3 in the rest interval and during Colic episodes less than 5 to strive for.

Medication like Metamizole (Trade name Novalgin) and Indomethacin lower the pressure in the lumen (cause of colic pain). They work in addition antispasmodic and pain relieving.

NSAIDs such as Ibuprofen or Diclofenac should not be used in pre-stressed people who suffer from chronic kidney disease, for example. Otherwise, they, especially diclofenac, are well suited for acute renal colic. Mostly it is in the form of Suppository anal administered.

Paracetamol and Morphine can as an alternative to metamizole and at too in pregnant women be used.

Opioids (like morphine) have many side effects and are only given in addition to the so-called non-opioids like metamizole or the NSAIDs.

Antispasmodic Medication do not affect them ureter, are therefore not to be administered. Morphine is used in therapy Kidney stones also discouraged as they use the Increase the tendency to vomit and affect the already disturbed bowel movements even more.

At lighter pain often helps hot full bath or moist - warm envelopes (Warmth relaxes and relaxes).

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1.2 Homeopathy for the treatment of kidney stones

With kidney stones, the following can occur homeopathic remedies be applied:

Adlumia
Berberis aquifolium
Berberis
Coccus cacti
Equisetum hiemale
Lycopodium clavatum
Solidago

The best way to find a suitable remedy is to read through the respective descriptions and compare them with the individual situation. It is best to only use one remedy. The potencies D6 to D12 (low potencies) are usually the best choice here.

1.3 Non-operative therapy in the colic-free period

Kidney stones that less than 5 mm are can still get away from solve alone and leave. It is recommended that you exercise a lot and drink plenty of fluids to flush out the kidney stones. About 80% of urinary stones go away on their own again.

If another colic occurs or even fever on, a doctor should urgently be consulted because one Urosepsis (Blood poisoning with urine components).
Further information on this topic can be found at: Urosepsis

1.4 Home remedies for the therapy of kidney stones

Generally, it should be noted that you are low in salt nourished because kidney stones calcium rich are. Preferably waived one on Ready meals and coffee, as the latter can also increase the calcium level in the urine, and drinks much water.

Good home remedies for kidney stones are also Cranberry juice, Dandelion tea and Book herb tea. Furthermore, a magnesium-rich diet be conducive and used prophylactically. There is a lot of magnesium in Seafood, Cashew nuts, Almonds, Peanuts and Soy products.

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2. operative therapy

2.1 Extracorporeal shock wave lithotripsy (ESWL) = shatter kidney stones

Kidney stones can be generated by outside of the body Shock waves be crushed without damaging the surrounding tissue.
The shock waves are generated in different ways: either by underwater spark discharge, pulsed laser beams or by converting electromagnetic energy.

The resulting shock waves must be focused so that the highest effectiveness is achieved in the area of the stone (Shock wave therapy). This breaks down through tensile and compressive forces acting on it into individual parts the size of a grain of sand, which can be excreted with the urine without problems.
The ESWL can destroy urinary stones up to 2.5 cm in size, regardless of their location. First of all, the exact location must be through previous Ultrasonic- or X-ray examinations be known. This moves the stone into the focus of the shock waves. A water bath or water or gel pillow serve as a mediator between shock waves and the body.

Occasionally, a light local anesthetic is necessary, as some patients perceive the incoming shock waves as a "blow in the back".

If you weigh more than 145 kg or if you are too small (<120 cm), the ESWL reaches its technical limits.

Under no circumstances should shock wave therapy be carried out if:

untreated or untreatable Bleeding disorder
pregnancy
untreated urinary tract infection
Aneurysms (Bulging of the blood vessels)

Complications are rare. Larger urinary stones in particular can become so-called after they have been broken up. Stone streets that must be removed endoscopically. There may be bruises in the area kidney come, which usually improve on their own. It may only be necessary to clear out extremely large bruises in the kidney capsule. Parts of the broken stones can become trapped in the ureter and cause colic. A ureteral splint can be inserted as a preventive measure to prevent the urine from building up. Urinary tract infections can occur after ESWT, often when the stones are so-called infection stones with bacteria trapped inside. A preventive one Administration of antibiotics can possibly prevent this.

Anticoagulant drugs such as B. ASA should be discontinued 8 days in advance in order to avoid bleeding-related complications (see above).

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For more information on the ESWL / ESWT procedure, please visit: Shock wave

2.2 Percutaneous nephrolitholapaxy (PNL)

In the percutaneous Therapy (through the skin) The destruction of kidney stones is carried out under ultrasound or X-ray control through the skin of the abdomen Renal pelvis dotted. After the puncture channel has been stretched a little, an endoscope can be passed through. Either the kidney stone can then be removed with the help of a recovery forceps, or it is too big for it, which makes it necessary to use forceps or something similar to crush it. The fragments are then removed individually. In principle, kidney stones of any size can be treated in this way, with stones that almost or completely fill the kidney pelvis (so-called. Pouring stones), however, a combination of ESWL and PNL therapy.

The procedure is performed under local anesthesia in the prone or side position. When the procedure is complete, a Urinary catheter be introduced to secure the urine flow.
The complication rate of this therapy is very low. A perforation of the renal pelvis, bleeding, infection or fistula formation (connection of the urinary drainage system to the intestine or the skin, for example) are possible.

Laser lithotripsy

In a brief anesthetic, a laser probe is placed in front of the stone with the help of an endoscope, which then passes through high-energy light pulses is smashed (so-called Laser lithotripsy). Then the remains are rinsed out or taken out with pliers. Sometimes it is necessary to install a ureteral splint afterwards.

2.3 Removal of kidney stones by ureterenoscopy

With this therapy, the kidney stone / urinary stone is removed in the course of an endoscopic (tube camera) examination.

To do this, the patient is placed on his back with his legs apart (so-called lithotomy position). Then the endoscope is over the urethra in the bladder advanced. Now the openings of the ureters are found and, if necessary, initially expanded using a ureteral catheter or guide wire. Next, the ureters are searched for the kidney stone. Once this has been found, there are several possible approaches. The stone can either be broken up using sound waves and then suctioned off, or crushed using impact waves (e.g. using a laser) and then removed with grasping forceps. It is an alternative to the ESWLwhich offers the possibility, e.g. B. to expand existing constrictions of the ureter and thus eliminate future sources of problems.

This method is recommended for kidney stones / urinary stones larger than 5 mm, violent, uncontrollable colic or kidney stones that do not go away despite conservative therapy.It is also used when urinary congestion increases or a urinary tract infection is present. Deep and very stuck urinary stones can also be removed in this way or pushed back into the renal pelvis in order to subsequently remove them using ESWL.
Complications such as urinary tract infections, perforation of the ureter or bleeding are rare.

2.4 Urinary diversion using a ureteral splint

A urinary diversion makes sense when colic not controllable with medication are. One can use ureteral splints for this, too Double J catheter or Ureteral stent called to keep the ureter open.

These are plastic tubes that are J-shaped, like a curly tail. This can do that Tubes held in the bladder and renal pelvis become. It can be advanced into the renal pelvis during a cystoscopy. However, rails are usually only for one short time used. With permanent use they should changed every 3-6 months become.

2.5 Removal of kidney stones via the ureter loop

Another therapy to remove kidney stones is that Using a slingwhich penetrates through the urethra and bladder to the renal pelvis and then the To get stones out. However, this method is no longer used frequently because of a increased risk of injury to the ureters consists. In exceptional cases, the method is used for stones in the lower third of the ureter used.

Which therapy for which stone?

Kidney calyx usually does not require treatment if there are no symptoms, urinary congestion or infection. At Blood in the urine and non-treatable infection, as well as in certain professional groups (pilots, professional drivers) ESWL

Renal pelvis stone
In the case of stones that can no longer be removed spontaneously (> 5 mm) ESWL or PNL.

Pouring stone
Usually there are no symptoms, but chronic inflammation of the kidneys (pyelonephritis) with subsequent kidney failure and death can threaten. Therefore, one should be operative: ESWL, PNL or a combination of both. Afterwards, a so-called stone road can emerge through outgoing rubble, which must be surgically removed.

High ureteral stone
If there is significant urinary stasis, a spontaneous discharge can be excluded. ESWL or endoscopic removal (mechanical removal) are favorable.

Deep ureteral stone
It can disappear spontaneously up to a size of 5 mm. If the kidney function continues to be normal, non-surgical measures can be used.

Bladder stone
The stone should be smashed and then vacuumed with the suction pump. Then the underlying condition (e.g. enlarged prostate) should be addressed.

Duration of treatment

Depending on the type of therapy varies the duration of treatment. The kidney stones are removed by conservative therapy, so without surgery, the Time span cannot be specified precisely. It is more like over months ongoing therapeutic measures (change in diet, use of budget funds, homeopathic remedies or medication). After a contact-free stone fragmentation using extracorporeal shock wave lithotripsy (ESWL), the inpatient stay is only 1-2 days.

When the stone larger than 5mm surgery is indicated. When a percutaneous nephrolitholapaxy (PCNL) has taken place, i.e. a direct removal of the kidney stones through a puncture through the skin with the help of an endoscope, is an inpatient stay of 4-5 days to count and one physical rest for about 2 weeks after hospitalization.

After a ureter renoscopy, one Ureteroscopy and Removal of the stones with pliers, the inpatient stay lasts 2-4 days. The duration of a hospital stay after inserting a ureter splint to keep the ureter open is approx. 2 days and the splint usually only stays in place for 1 week. However, it may only remain there for a maximum of 3 months.

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