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Bladder stones

Bladder stones: description

In general, a urinary stone is a solid, stone-like structure (concrement) in the urinary tract. If there is a urinary stone in the bladder, this concrement is called a bladder stone. The urinary bladder collects the urine as a reservoir and, thanks to special muscles, enables it to be released at will. Bladder stones can either form in the urinary bladder itself (primary bladder stones) or they arise in the kidneys or ureters and eventually get into the bladder with the steady flow of urine (secondary bladder stones). The urinary stone symptoms are the same for both types.

A bladder stone occurs when certain stone-forming salts crystallize in the urine. This usually happens when the concentration of the salt in question is too high in the urine and thus exceeds the solubility threshold. If the salt forms a solid crystal (concrement), more and more layers are deposited on it over time, so that the initially small concrement becomes an increasingly larger urinary stone.

Depending on the type of salt from which the stone is made, doctors distinguish:

  • Calcium oxalate stones (75 percent of all urinary stones)
  • "Struvite stones" made from magnesium ammonium phosphate (10 percent)
  • Urate stones from uric acid (5 percent)
  • Calcium phosphate stones (5 percent)
  • Cystine stones (rare)
  • Xanthine stones (rare)

The distinction between the different types of stone is not only made for purely scientific reasons. Rather, the different types of stone differ in terms of their causes, diagnosis and treatment. For example, only the calcium-rich, "radiopaque" stones can be recognized on the X-ray or only certain urinary stones with an alkalinization of the urine can be dissolved again.

Bladder stones can appear in people of all ages. However, older and overweight people are more prone to bladder stones. Men and women are equally affected. In men, the most common cause of bladder stones is benign enlargement of the prostate (BPH).

In many cases, bladder stones do not cause any symptoms and are flushed out of the body with the urine on their own. However, if the urinary stones block the exit to the urethra or are too large to pass through the urethra on their own, a medical urinary stone removal is necessary. Urinary stones can be crushed during a cystoscopy with forceps or using what is known as shock wave therapy (ESWL). The resulting lumps are then small enough to be flushed out with the urine stream. Correct operation is only necessary in a few cases for very large bladder stones. In addition to removal, it is especially important to eliminate the cause in order to prevent new bladder stones.

Bladder stones: symptoms

People with bladder stones often have no symptoms whatsoever. Whether the bladder stones cause symptoms primarily depends on exactly where the stone is and how big it is. If it is free in the bladder, the urine can flow unhindered through the urethra (urethra). There are no special symptoms in this case. If, on the other hand, it sits firmly on the lower bladder wall and blocks the urinary bladder outlet to the urethra due to its size, symptoms develop. The symptoms arise, on the one hand, from irritation of the mucous membrane caused by the often sharp-edged bladder stone and, on the other hand, from the urine that often builds up to the kidneys. Typical bladder stone symptoms are sudden, colicky pelvic pain that can radiate into the flanks. You may also experience pain when urinating, the urine stream may suddenly stop, and the urine may be bloody. Frequently there is also a constant urge to urinate, combined with a small amount of urine when urinating (pollakiuria).

How severe the symptoms are depends on the size of the bladder stone. Smaller urinary stones usually only partially obstruct the opening to the urethra and still allow a certain amount of urine to pass through. With larger stones, less and less urine can escape through the urethra, so that the symptoms usually increase with the size of the stone. If the urethra is completely blocked, urine will build up in the bladder, which can reach the kidneys via the ureters. This situation, in which it is no longer possible to pass urine, is called urinary retention or ischuria by doctors.

In addition to these symptoms, many sufferers show increasing restlessness of movement. This is mainly due to the fact that those affected unconsciously search for a body position in which the pain subsides. Thus, they constantly change from lying to a standing position or walk around. The pain can also lead to nausea and even vomiting.

If you notice pain when urinating or unusual, cramp-like pain in the lower abdomen, you should consult a doctor immediately and have the cause clarified. If the urine builds up to the kidneys, it can cause permanent damage to the kidneys.

Bladder stones: causes and risk factors

Bladder stones consist of mineral salts that are normally dissolved in the urine and are flushed out of the body with it. Under certain circumstances, these mineral salts can be released from the urine (they are “precipitated”) and settle in the urinary bladder. At the beginning of development, bladder stones are very small, crystal-like structures. They often continue to grow due to the addition of additional salts.

Doctors differentiate primary and secondary bladder stones. Primary bladder stones arise in the urinary bladder itself, secondary bladder stones arise in the upper urinary organs such as the kidneys or ureters and are flushed into the bladder with the urine. Primary bladder stones, however, are much more common than secondary bladder stones. If the urinary stones become detached from the kidney or ureter, they are usually so small that they can be excreted without any problems and do not get stuck in the bladder.

Most bladder stones develop when the flow of urine from the bladder is obstructed (primary bladder stones). This causes the urine to remain in the bladder for an excessive amount of time, causing the mineral salts to precipitate and thus causing urinary stones. Often, this also causes inflammation of the urinary tract, which in turn promotes the formation of bladder stones.

The typical causes of urinary outflow disorder include prostate enlargement or neurogenic bladder emptying disorder: Benign enlargement of the prostate (BPH) is a very common finding in older men. Even with neurological diseases such as multiple sclerosis or paraplegia, drainage disorders can lead to the formation of bladder stones. In these diseases, the contraction of the bladder muscles and thus urination (micturition) is often impaired.

In the case of a urinary tract infection, the bacteria can change the chemical composition of the urine and increase the risk of certain substances precipitating. The formation of struvite stones consisting of magnesium ammonium phosphate is attributed to urinary tract infections with certain bacteria.

In Germany, an unfavorable diet with a lot of animal fats, proteins and foods containing oxalic acid is seen as a risk factor for the development of bladder stones. Oxalic acid is found in nuts, coffee, cocoa, rhubarb, beetroot and spinach, for example. Stone-forming substances such as oxalate, calcium, phosphate, ammonium and uric acid (urate) can only be dissolved in the urine in a certain amount and then transported out of the body. If the amount ingested with food exceeds a certain limit, this can also lead to the precipitation of certain substances.

Foreign bodies in the bladder, such as urinary catheters or surgical sutures, are also risk factors for bladder stones. Bacteria can easily adhere to foreign bodies and thus trigger a urinary tract infection. The infection in turn increases the risk of bladder stones.

Other risk factors for bladder stones are:

  • Insufficient fluid intake (concentrated urine)
  • one-sided diet with too much meat and dairy products
  • increased intake of vitamin D3 (e.g. vitamin capsules)
  • Deficiency of vitamin B6 and vitamin A.
  • Osteoporosis in which calcium is released from the bones into the blood
  • Overactive parathyroid glands (hyperparathyroidism) due to the increased level of calcium in the blood associated with this condition
  • excessive magnesium intake

Bladder stones: examinations and diagnosis

If you suspect bladder stones, a specialist in urinary tract disorders (urologist) is the right contact. In large cities there are also resident urologists with their own practice, in rural areas urologists can usually only be found in hospitals. First, the attending physician will take the medical history (anamnese) raise. You describe your current symptoms and any previous illnesses to the doctor. The doctor then asks further questions in order to be able to go into more detail about your personal case. These can be questions like:

  • Where exactly are you in pain?
  • Are you currently having problems urinating?
  • Did you have problems urinating before the symptoms began?
  • Do you (men) have an enlarged prostate?
  • Have you noticed blood in your urine?
  • Do you take any medicine?

The anamnesis is followed by the physical examination. For example, the doctor listens to the stomach with the stethoscope and then carefully feels it. The physical examination enables the doctor to better assess the possible causes of the pain in the abdomen and which further examinations are necessary for the clarification.

Further investigations:

If bladder stones are suspected, further examinations are usually necessary. To do this, if the patient is able to urinate despite the bladder stone, the urine is examined in the laboratory for crystals, blood and bacteria. In addition, a blood sample is taken with which the kidney function can be assessed and the uric acid level can be determined. A blood count and blood clotting indicate possible accompanying inflammations in the urinary bladder. When there is inflammation in the body, the level of white blood cells (leukocytes) and the so-called C-reactive protein (CRP) in the blood are greatly increased.

Urinary stones can be made visible through an X-ray or ultrasound examination (sonography). In the X-ray image, however, only the so-called "radiopaque" (calcium-containing) stones are clearly visible. Urography is another way of showing radiolucent stones. A contrast agent is injected into a vein. This is distributed in the body and makes it possible to make the kidney and the urinary tract visible with possible stones. In the meantime, however, urography has largely been replaced by computed tomography (CT). With a computed tomography, all types of stone and any urine stagnation can be recognized quickly and safely.

Another examination method is a cystoscopy. A rod-like or catheter-like instrument with an integrated camera (endoscope) is inserted into the bladder. In this way, stones can be recognized directly on the transmitted live images. The advantage of cystoscopy is that smaller stones can be nicely removed during the examination. In addition, other causes of a blockage in the flow of urine from the bladder, such as tumors, can also be identified.

Read more about the examinations

Find out here which examinations can be useful for this disease:

Bladder stones: treatment

If pain persists, the first step in treatment is giving a pain reliever. In many cases, a thorough examination is only possible with the previous pain relief. Symptom-free bladder stones that happen to be discovered during a routine ultrasound should also be treated as they can grow in size over time and cause discomfort.

It primarily depends on the size and location of the bladder stone whether you have to remove it or wait for it to pass spontaneously. In most cases, a bladder stone does not require any special treatment. Small (≤ 5 mm) stones lying freely in the urinary bladder are flushed out by themselves via the urethra in around 90 percent of cases. Certain medications (such as tamsulosin) can facilitate flushing out if, for example, an enlarged prostate is constricting the urethra. With some stones (urate stones, cystine stones) an attempt can also be made to dissolve the urinary stones by means of a chemical reaction, or to reduce them (chemolitholysis).

In any case, it is important that you drink a lot to make it easier to remove stones. If pain occurs (which often happens when the urinary stone slides through the urinary tract), pain relievers such as diclofenac can help.

If the stone is too large to pass spontaneously, the stone blocks the urethra and there is thus a congestion of urine, as well as if there are indications of a severe infection (urosepsis), the stone must be surgically removed. The doctor can use pliers to crush smaller stones during a cystoscopy or remove them directly. For adult cystoscopy, only local anesthesia is required so that you can follow the procedure yourself on a monitor. In children, the procedure is performed under general anesthesia. After a bladder mirror, you can either go home on the same day or within the next two to three days.

How long you have to stay in the hospital after the treatment depends on the size of the stone removed and whether there were any complications during the procedure. As with any surgical procedure, cystoscopy involves risks. In general, there is a risk that the instruments could introduce germs into the urinary bladder and cause it to become inflamed. Organ walls can also be injured or even pierced with the instrument. Such incidents are very rare.

For some years now, the majority of all interventions have used pressure waves to break stones up. This procedure is known as extracorporeal shock wave lithotripsy (ESWL). In ESWL, larger stones are destroyed by shock waves, so that the debris (now much smaller) can simply be excreted in the urine. If the pain persists after the stone has been removed, this may be an indication of inflammation of the urinary bladder (cystitis). This may be treated with antibiotics.

An open surgical method is only used in very rare cases today. It is necessary, for example, if the doctor cannot get into the bladder during a cystoscopy with the endoscope because the stone or other structure is blocking the urethra or the entrance to the bladder. For example, tumors can sometimes also look like urinary stones on the computed tomography image. However, tumors generally require a completely different treatment method, so that in case of doubt, surgery is more likely to be open.

If the bladder stones were caused by a disorder in the emptying of the bladder, after the stone has been removed, the main focus is on treating the cause. In men, an enlarged prostate often leads to urethral drainage disorders and subsequent stone formation. In such a case, one can first try to treat the enlarged prostate with medication. In the case of a greatly enlarged prostate or recurring urinary stones, however, surgical intervention is advised in order to switch off the trigger for stone formation. A so-called transurethral prostate resection (TURP) is usually recommended. During this procedure, the prostate is removed through the urethra.

Read more about the therapies

Read more about therapies that can help here:

Bladder stones: disease course and prognosis

About 90 percent of bladder stones that are ≤ 5 millimeters are flushed out with the urine on their own. During this time, however, severe pain can occur if the bladder stone "wanders" through the urethra. As a rule, all urinary stones that do not come off on their own can be removed with an interventional or surgical procedure. Basically, one tries to wait for a spontaneous stone loss before considering an intervention.

Consequential damage from bladder stones is rare, for example if a sharp-edged bladder stone injures the bladder wall or the urethra. When the stone moves through the urethra, it can literally "slit" the wall of the urethra. This can lead to scarring of the urethra and permanent urination problems.

Successful bladder stone removal does not guarantee that urinary stones will never appear again. Doctors repeatedly point out that urinary stones have a high recurrence rate.This means that people who have had bladder stones are at risk of developing them again.

You can reduce the risk of bladder stones by getting regular exercise and eating a balanced diet that is high in fiber and low in animal protein. Especially if you have already had bladder stones, you should only consume small amounts of foods containing purine and oxalic acid. These foods include, for example, meat (especially offal), fish and seafood, legumes (beans, lentils, peas), black tea and coffee, rhubarb, spinach and chard. In addition, you should make sure to drink at least 2.5 liters per day, as this flushes the urinary tract well and thus reduces the risk of mineral salts settling. A safe way to Bladder stones However, there is no general avoidance.

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