Ureterolithiasis

Description:

Stones in an ureter (ureterolithiasis) in comparison with concrements of other localizations (stones of a bladder, an urethra, kidneys) are dangerous by the heaviest and serious complications. The concrements breaking an urine passage cause a loosening mucous an ureter, hemorrhage in its submucosal layer, a hypertrophy of a muscular wall. Over time the progressing changes lead to an atrophy of muscle and nerve fibrils of an ureter, sharp decrease in its tone, ureteroektaziya and a gidroureteronefroz. At infectious process in anatomically the changed ureter the ascending pyelonephritis, the descending cystitis, an inflammation of surrounding cellulose - a periureteritis quickly develops and peripiyelit. It is on site long the stone which is in an ureter decubituses, strictures, perforation of a wall can form.

Ureterolithiasis reasons:

The most part of concrements of ureters which the practical urology faces are the stones of kidneys displaced from a pelvis. They can have the various form and size. More often in an ureter single concrements get stuck, however also multiple stones of an ureter meet. Usually the concrement is late in zones of physiological narrowing of an ureter – a lokhanochno-ureteric segment, in the field of decussation with ileal vessels or a vesicoureteral segment. For a delay in an ureter diameter of a stone has to exceed 2 mm.

Lokhanochno-mochetochnikovy the segment is a place of transition of a renal pelvis of bigger diameter to an ureter with a gleam 2-3 mm. After a lokhanochno-ureteric segment the gleam of an ureter extends to 10 mm therefore the small stone can be displaced distalny – before the second physiological narrowing at the level of ileal vessels. In this place the ureter crosses the upper bound of an entrance to a basin and again is narrowed to diameter of 4 mm. The third physiological narrowing of an ureter is the vesicoureteral segment where diameter of an ureter makes 1-5 mm.

In an upper third of an ureter about 25% of stones, in average – about 45%, in lower – to 70% get stuck. Primary stones in an ureter meet seldom. Their initial education in an ureter can be promoted an ureterotsela, a tumor, by an ectopia of an ureter, a stricture, foreign bodys (ligatures, etc.). Stones of the left and right ureter come to light equally often.

In genesis of an urolithiasis a certain role belongs to geographical and climatic factors. So, in the basin of Don and Volga, in the Caucasus, in Central Asia, Bavaria and Dalmatia the urolithiasis meets especially often. The lithogenesis in urinary tract is promoted by alimentary factors – feeding habits and quality of drinking water.

As formation of stones disturbance phosphate, oxalate, urate, etc. is the cornerstone of types of a metabolism, the frequency of an urolithiasis correlates with gout, a hyperparathyreosis, osteoporosis, fractures of bones.

In a lithogenesis pathogeny paramount value plays change рН urine, disturbance of its colloidal state and decrease in dissolving capacity. Such changes can develop under the influence of an infection, first of all, of pyelonephritis. The known part is assigned to the factors leading to an urinary stasis here - to the wrong structure of cups and a pelvis, strictures and valves of an ureter, incomplete bladder emptying at an urethra stricture, prostate adenoma, diverticulums of urinary tract, vertebral and spinal injuries etc.

Urolithiasis symptoms:

Clinical manifestations of stones of an ureter develop at a partial or total block of outflow of urine from a kidney. Therefore at 90 — 95% of patients stones in an ureter come to light only at development of renal colic.

At partial overlapping of a gleam of an ureter a stone dull aches, with localization in the corresponding costovertebral corner. In case of full obturation of an ureter sudden disturbance of outflow of urine from a kidney, restretching of a pelvis and increase in intrapelvic pressure develops. Disturbance of microcirculation in renal fabric and irritation of nerve terminations causes the strongest attack of pains - renal colic.

The bad painful attack at a stone in an ureter develops suddenly and is more often connected with the physical tension, bystry walking, jolty driving or plentiful reception of liquid. Pains are localized in a waist and hypochondrium, irradiate on the ureter course in a scrotum or vulvar lips. The acute pain forces the patient to change continuously situation that, however, does not give relief. Renal colic can proceed several hours or days, periodically abating and renewing again.

The painful attack at a stone in an ureter is followed by reflex disorders of activity of a GIT – nausea and vomiting, a meteorism, a chair delay, a muscle tension of a front abdominal wall. It is connected with irritation of nerve terminations adjacent to the blocked kidney of a parietal peritoneum.

Dysuric frustration at a stone in an ureter depend on the location of a concrement. At localization of a stone in a lower part of an ureter continuous painful desires on an urination, feelings of strong pressure in suprapubic area caused by irritation of receptors of walls of a bladder develop.

Sometimes at ureter obturation the stone observes an oliguria in view of impossibility of removal of urine from a kidney or the general dehydration at severe vomiting. At stones in an ureter in 80 — 90% of cases the gross hematuria which often precedes a painful attack is noted. Long finding of a stone in an ureter leads to accession of a leukocyturia and pyuria.

Renal colic is accompanied by sharp deterioration in the general state – a headache, a fever, weakness, dryness in a mouth, etc. At a small stone in an ureter renal colic can end with a spontaneous otkhozhdeniye of a concrement. Otherwise the bad attack of ureteric pain will surely repeat.

As the most probable complications of stones in an ureter serve obstructive pyelonephritis, a hydronephrosis, development of a renal failure (at a bilateral ureterolithiasis or concrements of the only kidney). At a part of patients with stones of ureters the disease is burdened by accession of an infection - colibacillus, vulgar a protea, staphylococcus that is shown by acute and chronic pyelonephritis, an urethritis, a pyonephrosis, an urosepsis.

Diagnosis:

The clinic of renal colic with high degree of probability forces the urologist to assume existence of stones in an ureter. The palpation of a projection of kidneys is extremely painful, reaction to a symptom pokolachivy – sharply positive. After stopping of renal colic at a palpation of points of the Tour corresponding to places of anatomic narrowing of ureters morbidity remains.

Urine researches at a stone in an ureter (the general analysis, a biochemical research, definition of pH, bacteriological crops) can give valuable information on availability of impurity in urine (erythrocytes, leukocytes, protein, salts, pus), chemical structure of stones, contagiums etc.

For visualization of a stone in an ureter, definitions of their localization, the sizes and a form the comprehensive radiological, endoscopic and ekhografichesky examination including a survey X-ray analysis of an abdominal cavity, survey urography, excretory urography, KT of kidneys, an ureteroskopiya, radio isotope diagnosis, ultrasonography of kidneys and ureters is carried out. On the basis of a complex of data medical tactics concerning a stone in an ureter is planned.

Treatment of an urolithiasis:

Conservative and waiting tactics at a stone in an ureter is proved in case of the small size of a concrement (to 2-3 mm). In this case spasmolysants, water loading (more than 2 l a day), drugs-urolitiki (cystenal, Avisanum, Soluranum, Blemarenum, etc.), antibiotics, LFK, physical therapy (a diathermy, diadynamic currents, subaqual bathtubs) are appointed. At development of renal colic urgent measures for its stopping by means of narcotic analgetics, blockade, spasmolysants are taken.

Introduction to a gleam of an ureter of the special drugs (glycerin, papaverine, novocaine) strengthening a peristaltics and facilitating advance of a concrement or carrying out electric stimulation of uric ways through catheters electrodes is among endovesical methods of a removing calculus.

In some cases for extraction of stones from an ureter resort to endourological intervention – an ureterolitoekstraktion – removal of concrements by means of special loops traps via the channel of the ureteroskop entered into an ureter gleam. At infringement of a stone in the mouth of an ureter resort to its section facilitating extraction or an otkhozhdeniya of a concrement. After extraction of a stone stenting of an ureter is made for the best otkhozhdeniye of urine, sand and microscopic fragments of a concrement.

Concrements with a diameter more than 6 mm before extraction demand fragmentation which is reached by carrying out an ultrasonic, laser or electrohydraulic lithotripsy (crushing). At a stone in an ureter apply a remote ureterolitotripsiya, transdermal contact ureterolitotripsiya, an endoscopic ureterolitotripsiya.

The open or laparoscopic ureterolithotomy is shown at a stone in an ureter more than 1 cm; the infections which are not giving in to antimicrobic therapy; to the heavy, not stopped colic; not moving ahead concrement; obstructions of the only kidney; inefficiencies of UVL or endourological methods.

Prevention:

Prevention and the prevention of a recurrence of formation of stones in ureters demands treatment of disturbances of exchange, pyelonephritis, an urinary stasis. After removal of a stone and recovery of a passage of urine elimination of the anatomic reason of obstruction is necessary (strictures and valves of ureters, a prostate hyperplasia, etc.).

The dietotherapy (restriction of table salt, fats), daily primas not less than 1,5-2 l of liquid, special phytocollecting, resort rehabilitation is recommended to the patient with this or that form of an urolithiasis.