Physiotherapy for urolithiasis. Treatment of urolithiasis: pain relief, lithokinetic therapy, physiotherapy, metaphylaxis

In the complex conservative treatment of patients with ICD includes the appointment of various physiotherapeutic methods:

o sinusoidal modulated currents;

o dynamic amplipulse therapy;

o ultrasound;

o laser therapy;

o inductothermy.

In the case of physiotherapy in patients ICD complicated by urinary tract infection, it is necessary to take into account the phases inflammatory process(shown in latent course and in remission).

Sanatorium-resort treatment for urolithiasis

Sanatorium-resort treatment is indicated for ICD both during the absence of a stone (after its removal or independent discharge), and in the presence of a calculus. It is effective for kidney stones, the size and shape of which, as well as the condition of the urinary tract, allow us to hope for their independent discharge under the influence of a diuretic action. mineral waters.

Patients with uric acid and calcium oxalate urolithiasis are treated at resorts with low-mineralized alkaline mineral waters:

o Zheleznovodsk (Slavyanovskaya, Smirnovskaya);

o Essentuki (Essentuki No. 4, 17);

o Pyatigorsk, Kislovodsk (Narzan).

With calcium-oxalate urolithiasis, treatment can also be indicated at the Truskavets (Naftusya) resort, where mineral water is slightly acidic and low-mineralized.

Treatment at the resorts is possible at any time of the year. The use of similar bottled mineral waters does not replace a spa stay.

Reception of the above mineral waters, as well as mineral water "Tib-2" (North Ossetia) for therapeutic and prophylactic purposes is possible in an amount of not more than 0.5 l / day under strict laboratory control of indicators of the exchange of stone-forming substances.

Treatment of uric acid stones

With medical treatment ICD

At ICD

The following are used in the treatment of uric acid stones: medicines:

1. Allopurinol (Allupol, Purinol) - up to 1 month;
2. Blemaren - 1-3 months.

Treatment of calcium oxalate stones

With medical treatment ICD The doctor sets himself the following goals:

o prevention of recurrence of stone formation;

o prevention of the growth of the calculus itself (if it already exists);

o dissolution of stones (litholysis).

At ICD stepwise treatment is possible: if diet therapy is ineffective, it is necessary to additionally prescribe medications.

One course of treatment is usually 1 month. Depending on the results of the examination, treatment may be resumed.

The following drugs are used in the treatment of calcium oxalate stones:

1. Pyridoxine (vitamin B 6) - up to 1 month;
2. Hypothiazid - up to 1 month;
3. Blemaren - up to 1 month.

Treatment of calcium phosphate stones

With medical treatment ICD The doctor sets himself the following goals:

o prevention of recurrence of stone formation;

o prevention of the growth of the calculus itself (if it already exists);

o dissolution of stones (litholysis).

At ICD stepwise treatment is possible: if diet therapy is ineffective, it is necessary to additionally prescribe medications.

One course of treatment is usually 1 month. Depending on the results of the examination, treatment may be resumed.

In the treatment of calcium phosphate stones, the following drugs are used:

1. Antibacterial treatment- in the presence of an infection;
2. Magnesium oxide or asparaginate - up to 1 month;
3. Hypothiazid - up to 1 month;
4. Phytopreparations (plant extracts) - up to 1 month;
5. Boric acid - up to 1 month;
6. Methionine - up to 1 month.

The complex conservative treatment of patients with urolithiasis includes the appointment of various physiotherapeutic methods: sinusoidal modulated currents; dynamic ampl pulse - therapy; ultrasound; laser therapy; inductothermy.

In the case of the use of physiotherapy in patients with urolithiasis complicated by urinary tract infection, it is necessary to take into account the phases of the inflammatory process (shown in the latent course and in remission).

Rehabilitation therapy for patients with urolithiasis

The goal of treatment of patients with urolithiasis (UCD) is to restore impaired metabolism and prevent the precipitation of salts in the urine.

Comprehensive prevention of patients with KSD and urolithiasis consists of a combination of the following therapeutic factors: internal and external applications of mineral waters; appointment of therapeutic mud, therapeutic nutrition, therapeutic physical culture, therapeutic regimen, apparatus physiotherapy. Several groups of patients can be distinguished rehabilitation treatment: patients who underwent surgical removal of stones from the kidneys and ureters or their extraction or remote shock wave lithotripsy, patients with small stones in the kidneys and ureters, which, judging by their size and the anatomical and functional state of the kidneys and urinary tract, can move away on their own . The maximum size of the calculus should not exceed 8 mm in the absence of an active phase of chronic pyelonephritis in these patients, patients with unilateral or bilateral staghorn stones, in which surgical treatment is either not indicated at the moment or is impossible, patients with stones of a single kidney, if they are not obturating or migrating, preoperative preparation of patients with urolithiasis. Thus, the main tasks of restorative therapy of patients with KSD and urolithic diathesis are the following: elimination of small calculi; removal from the urinary tract of salts, mucus, decay products of tissues, bacteria; anti-inflammatory therapy; normalization of impaired mineral metabolism and urodynamics of the upper urinary tract. Therefore, the strategic goal of spa therapy is primary and secondary prevention of urolithiasis.

Contraindications: the presence of urostasis caused by a calculus or anatomical features of the upper urinary tract, chronic pyelonephritis in the phase of active inflammation, patients with large, long-term ureteral and kidney stones in one place, patients with staghorn stones and stones of the only kidney against the background of progressive chronic kidney failure(CRF) - intermittent and terminal stages. The remaining contraindications for the treatment of patients with urolithiasis are common and are associated mainly with cardiovascular and cardiopulmonary insufficiency.

COURSE WORK

Methods of physical rehabilitation of urolithiasis

Introduction

urolithiasis massage therapeutic exercise

The relevance of research.Urolithiasis has been known since ancient times. Urinary stones were found in Egyptian mummies of people who died and were buried before our era. Information about urolithiasis can also be found in ancient Sanskrit literature in India.

At the end of the 17th century, data on the structure of urinary stones and their crystals were published. The second half of the 19th century is characterized by the development of manatomic-topographic, laboratory, radiological ideas about the ICD, which made it possible to give a scientific justification for this process.

In Russia, the first operation for the ICD was performed by N.V. Sklifosovsky in 1882.

Recently, there has been a clear increase in this pathology in all regions of the world. Urolithiasis is diagnosed in 32-40% of cases of all urological diseases. According to many leading experts, the trend will continue in the future. This is facilitated by the deterioration of the ecological situation on the planet, poor nutrition, poor socio-economic conditions.

Purpose of the study

To study the current state of the problem of methods of physical rehabilitation of patients with urolithiasis, the use of therapeutic exercises

Research objectives

The first task is to investigate the etiology, clinic, diagnosis, classification of urolithiasis;

The second task is to determine the most effective methods of rehabilitation of patients with urolithiasis.

1. Urolithiasis

.1 Etiology of urolithiasis

Urolithiasis is a polyetiological disease. There are several theories explaining the formation of stones. Currently, there is no unified theory of the causes of the development of ICD. Urolithiasis is a multifactorial disease that has complex, diverse mechanisms of development and various chemical forms. According to the chemical structure, different stones are distinguished - urates, phosphates, oxalates and others. However, even if there is a congenital predisposition to urolithiasis, it will not develop if there are no predisposing factors.

The following metabolic disorders are the basis for the formation of urinary stones: hyperuricemia (increased levels of uric acid in the blood), hyperuricuria (increased levels of uric acid in the urine), hyperoxaluria (increased levels of oxalate salts in the urine), hypercalciuria (increased levels of calcium salts in the urine), hyperphosphaturia (increased levels of phosphate salts in the urine); change in the acidity of urine.

In the occurrence of these metabolic shifts, some authors prefer the effects of the external environment (exogenous factors), others prefer endogenous causes, although their interaction is often observed.

Exogenous causes of KSD:

climate, geological structure of the soil, chemical composition of water and flora, food and drinking regime, living conditions (monotonous, sedentary lifestyle and recreation), working conditions (harmful industries, hot shops, hard physical labor, and others).

The food and drinking regimes of the population - the total calorie content of food, the abuse of animal protein, salt, products containing in large numbers calcium, oxalic and ascorbic acids, lack of vitamins A and group B in the body play a significant role in the development of KSD.

Endogenous causes:

infections, both of the urinary tract and outside the urinary system (tonsillitis, furunculosis, osteomyelitis, salpingo-oophoritis), metabolic diseases (gout, hyperparathyroidism), deficiency, absence or hyperactivity of a number of enzymes, severe injuries or diseases associated with prolonged immobilization of the patient, diseases digestive tract, liver and biliary tract, hereditary predisposition to urolithiasis.

A certain role in the genesis of KSD is played by such factors as gender and age: men get sick 3 times more often than women. Along with common causes endogenous and exogenous in the formation of urinary stones, local changes in the urinary tract (developmental anomalies, additional vessels, narrowing, and others) that cause a violation of their function are of undeniable importance.

Symptoms

The most characteristic symptoms of urolithiasis are: pain in the lumbar region - can be constant or intermittent, dull or acute. The intensity, localization and irradiation of pain depend on the location and size of the stone, the degree and severity of the obstruction, as well as the individual structural features of the urinary tract. Large pelvic stones and staghorn kidney stones are inactive and cause dull pain, often permanent, in the lumbar region. Urolithiasis is characterized by the connection of pain with movement, shaking, driving, heavy physical activity.

For small stones, attacks of renal colic are most characteristic, which is associated with their migration and a sharp violation of the outflow of urine from the calyx or pelvis. Pain in the lumbar region often radiates along the ureter, into the iliac region. When the stones move into the lower third of the ureter, the irradiation of pain changes, they begin to spread lower to the inguinal region, to the testicle, the glans penis in men and the labia in women. There are imperative urge to urinate, frequent urination, dysuria.

Renal colic - paroxysmal pain caused by a stone, occurs suddenly after driving, shaking, drinking plenty of fluids, alcohol. Patients constantly change position, do not find a place for themselves, often groan and even scream. This characteristic behavior of the patient often makes it possible to establish a diagnosis "at a distance". The pains continue, sometimes for several hours and even days, periodically subsiding. The cause of renal colic is a sudden obstruction of the outflow of urine from the calyces or pelvis, caused by occlusion (of the upper urinary tract) by a stone. Quite often, an attack of renal colic may be accompanied by chills, fever, leukocytosis, nausea, vomiting, bloating, abdominal muscle tension, hematuria, pyuria, dysuria - symptoms often associated with renal colic; independent stone passage is extremely rare - obstructive anuria (with a single kidney and bilateral ureteral stones). In children, none of these symptoms are typical for urolithiasis.

Stones of the renal calyx

Calyx stones can be the cause of obstruction and renal colic. With small stones, pain usually occurs intermittently at the time of transient obstruction. The pain is dull in nature, of varying intensity, and is felt deep in the lower back. It can be aggravated after heavy drinking. In addition to obstruction, the cause of pain may be inflammation of the renal calyx due to infection or the accumulation of tiny crystals of calcium salts. Calyx stones are usually multiple, but small, so they should pass spontaneously. If, the stone is retained in the renal calyx, despite the flow of urine, then the likelihood of obstruction is very high. Pain caused by small calyx stones usually disappears after extracorporeal lithotripsy.

Stones of the renal pelvis

Stones of the renal pelvis with a diameter of more than 10 millimeters. usually cause obstruction of the ureteropelvic segment. In this case, there is severe pain in the costovertebral angle below the XII rib. By nature, the pain is different, from dull to excruciatingly acute, its intensity is usually constant. The pain often radiates to the side of the abdomen and hypochondrium. It is often accompanied by nausea and vomiting.

A staghorn stone occupying all or part of the renal pelvis does not always cause urinary tract obstruction. Clinical manifestations are often poor. Only mild back pain is possible. In this regard, staghorn stones are a finding when examining recurrent urinary tract infections. Left untreated, they can lead to serious complications.

Upper and middle ureteral stones

Stones in the upper or middle third of the ureter often cause severe sharp pain in the waist. If the stone moves along the ureter, periodically causing obstruction, the pain is intermittent, but more intense.

If the stone is immobile, the pain is less intense, especially with partial obstruction. With immobile stones that cause severe obstruction, compensatory mechanisms are activated that reduce pressure on the kidney, thereby reducing pain.

With a stone in the upper third of the ureter, pain radiates to the lateral sections of the abdomen, with a stone in the middle third - in the iliac region, in the direction from the lower edge of the ribs to the inguinal ligament.

Stones in the lower ureter

Pain at the stone lower third ureter often radiates to the scrotum or vulva. The clinical picture may resemble testicular torsion or acute epididymitis. A stone located in the intramural ureter (at the level of the entrance to the bladder) clinically resembles acute cystitis, acute urethritis or acute prostatitis, since it can cause pain in the suprapubic region, frequent, painful and difficult urination, imperative urges, gross hematuria, and in men, pain in the region of the external opening of the urethra.

Bladder stones

Bladder stones are mainly manifested by pain in the lower abdomen and suprapubic region, which can radiate to the perineum, genitals. The pain appears when moving and when urinating.

Another manifestation of bladder stones is frequent urination. Sharp causeless urges appear when walking, shaking, physical activity. During urination, the so-called "stuffing" symptom may be noted - suddenly the urine stream is interrupted, although the patient feels that the bladder is not completely emptied, and urination resumes only after a change in body position.

In severe cases, with very large stones, patients can only urinate while lying down.

1.2 Pathogenesis of urolithiasis

The hypothesis put forward by L.S. Coe et al., is that a low concentration of calcium in the lumen small intestine causes a secondary increase in the content of oxalates in the urine due to a decrease in the binding of oxalates to calcium in the gastrointestinal tract. A.T. Carhan et al showed that the lower the calcium intake, the more often urolithiasis developed. Absorptive and renal hypercalciuria are the two extremes of dysregulation of vitamin D metabolism.

Many researchers note bone loss in patients with hypercalciuria. It has been suggested that a high intake of animal protein and sodium is also an additional risk factor. It should be borne in mind that calcium excretion is affected not only by its intake, but also by the intake of other nutrients, such as animal protein, sodium, oxalates and potassium.

The rationale for limiting oxalate intake is the fact that calcium oxalate is the main component of most urinary stones and that the molarity of urinary oxalate is less than the molarity of calcium (calcium-oxalate ratio - CaOx - is 5:1). This means that small changes in oxalate concentration have a much greater effect on CaOx crystallization than large changes in calcium concentration.

High animal protein intake causes hyperuricosuria due to purine overload, hyperoxaluria due to increased oxalate synthesis, and hypercitraturia due to increased citrate reabsorption. In addition, protein-induced hypercalciuria can cause bone resorption and decreased tubular calcium reabsorption to compensate for acid loading, as well as by increasing calcium filtration load and by the presence of non-reabsorbable calcium sulfate in the tubular lumen. Moderate acute protein restriction reduces urinary oxalate, phosphate, hydroxyproline, calcium, and uric acid and increases citrate excretion.

Epidemiological studies have shown that low potassium intake (below 74 m/mol/day) increases the relative risk of stone formation. This effect may be attributed to the increase in urinary calcium and the decrease in citrate excretion caused by low potassium intake.

An increase in dietary sodium for every 100 m/mol increases urinary calcium excretion by 25 mg. High intake of NaCl also reduces the excretion of citrate. Pathological changes in urolithiasis largely depend on the localization of the stone. In the presence of a stone in the calyx, the outflow of urine from a small area of ​​the kidney is disturbed. Much, Big changes come, with the localization of stones in the pelvis and ureter. An increase inside the pelvic pressure, even with "aseptic" stones, leads to an expansion of the tubules, their epithelium loses its function, the interstitial tissue of the kidney is saturated with urine, which leads to sclerotic processes and wrinkling of the kidney. Accession of infection causes the occurrence acute pyelonephritis, kidney abscesses, papillary necrosis occurs and, as a result of inflammation, pyonephrosis develops. In parallel with this, cicatricial-sclerotic changes occur around the kidney and ureter, paranephritis, periurethritis develops, which further disrupts kidney function.

Thus, clinicians distinguish three main types of stone formation: calcium, which accounts for up to 70% of patients with KSD, metabolic (uric acid) - 12% and infected - 15%; a small group (2-3%) are patients with cystine stones.

1.3 Urolithiasis, clinical manifestations and localization of stones

Urolithiasis is a metabolic disease caused by various reasons, often of a hereditary nature, characterized by the formation of stones in the urinary system (kidneys, ureters, bladder or urethra). Stones can form at any level of the urinary tract, ranging from the renal parenchyma, in the ureters, in the bladder, to the urethra.

The disease can be asymptomatic or manifested by pain in the lower back, blood may appear in the urine, and independent discharge of stones in the urine is possible. The pains are dull, aching in nature, but can be sharp. More often the pain is on the one hand. If there are stones in both kidneys, then the pain will occur simultaneously or alternately on both sides. The connection of pain with movement, change in body position is characteristic.

Blood in the urine usually appears after severe pain or after physical exertion, walking. After a severe attack of pain, stones can also move away. Moving from the kidney, the stone enters the ureter. The pain in this case passes from the lower back to the groin, lower abdomen, genitals, thigh.

If the stone is located in the lower part of the ureter, then the patient experiences frequent causeless urge to urinate.

If the stone completely blocked the lumen of the ureter, then urine accumulates in the kidney, which causes an attack of renal colic. It is manifested by sharp cramping pains in the lower back, which quickly spread to the corresponding half of the abdomen. The pain can last for several hours or even days, periodically subsiding and resuming. The patient at the same time behaves uneasily, cannot find a comfortable position. The attack ends when the stone changes its position or leaves the ureter. If, after an attack of colic, the stone has not moved away, then the attack may repeat. Usually, at the end of the attack, blood appears in the urine. The main manifestation of bladder stones is pain in the lower abdomen, which can radiate to the perineum, genitals. Pain occurs when moving and when urinating.

Another manifestation of bladder stones is frequent urination. Sharp causeless urges appear when walking, shaking, physical activity. During urination, the so-called "stuffing" symptom may be noted - suddenly the urine stream is interrupted, although the patient feels that the bladder is not completely emptied, and urination resumes only after a change in body position. In severe cases, with very large stone sizes, patients can only urinate while lying down. Kidney and ureter stones will eventually lead to the development of acute or chronic pyelonephritis. In cases where the stone disrupts the outflow of urine for a long time, calculous (secondary) hydronephrosis develops. The outcome of acute and chronic pyelonephritis may be calculous pyonephrosis, acute renal failure, and with a long course of pyelonephritis, chronic renal failure gradually develops. One of the complications of urolithiasis may be subrenal anuria, which occurs when the urinary tract is occluded by both kidneys or one functioning kidney. A relatively rare complication of urolithiasis is peritonitis, which occurs as a result of a breakthrough of the kidney abscess into the abdominal cavity. Bladder stones can provoke the development of acute cystitis with severe manifestations.

1.4 Diagnostics. Differential diagnosis of urolithiasis

Modern techniques make it possible to detect any type of stones, so it is usually not required to differentiate urolithiasis from other diseases. The need for differential diagnosis may arise in an acute condition - renal colic.

Usually, the diagnosis of renal colic is not difficult. With an atypical course and right-sided localization of a stone that causes urinary tract obstruction, it is sometimes necessary to carry out a differential diagnosis of renal colic in urolithiasis with acute cholecystitis or acute appendicitis. The diagnosis is based on the characteristic localization of pain, the presence of dysuric phenomena and changes in urine, the absence of symptoms of peritoneal irritation.

Serious difficulties are possible in the differentiation of renal colic and kidney infarction. In both cases, there is hematuria and severe pain in the lumbar region. It should not be forgotten that renal infarction is usually the result of cardiovascular disease, which are characterized by rhythm disturbances (rheumatic heart disease, atherosclerosis). Dysuric phenomena in renal infarction are extremely rare, pain is less pronounced and almost never reaches the intensity that is characteristic of renal colic in urolithiasis.

During a physical examination, it is very important to diagnose the location and nature of the pain. Also, the doctor, during examination and questioning, will try to differentiate the pain syndrome.

Routine clinical blood and urine tests must be performed. Clinical Analysis urine test allows you to evaluate the urine for the presence of hematuria and infection. Up to 85% of patients with urinary tract stones may have macroscopic (visible to the naked eye) or microscopic (visible only under a microscope) hematuria (blood in the urine). The absence of hematuria does not exclude the presence of urinary stones, so approximately 15% of patients with urolithiasis do not have hematuria (blood in the urine). By analyzing urine, you can determine the density of urine, by which you can determine the amount of fluid you drink. With a low concentration of urine, there is a high risk of stone formation.

General analysis blood - determination of the number of red blood cells (erythrocytes) and white blood cells (leukocytes). If you have nephrolithiasis (kidney stones), elevated level leukocytes, indicates a renal or systemic infection.

A reduced number of red blood cells (the presence of anemia) indicates a chronic course of the disease or a severe degree of hematuria.

Biochemical blood test to determine the level of electrolytes, creatinine, calcium, phosphorus, uric acid, parathyroid hormone (parathormone). These biochemical blood parameters allow assessing the functional state of the kidneys, as well as assessing the metabolic risk of stone formation in the kidneys and other organs of the urinary system.

Urinalysis for metabolic disorders (daily amount of urine to determine the level of pH (acidity), calcium, oxalates, uric acid salts, sodium, phosphates, citrates, magnesium, creatinine, and overall urine volume). The study of urine collected during the day, allows you to obtain information about the chemical composition of urine, thereby determining the nature of the stones. This information is useful not only for the selection of specific and effective therapy to prevent the formation of stones in the urinary system, but also to identify patients with urolithiasis who may have other severe comorbidities. In addition, daily urine can identify not only patients with urolithiasis, but also patients who have a high risk of stone formation.

Ultrasound examination (ultrasound) of the urinary system is an effective method in the diagnosis of urolithiasis. Ultrasound of the kidneys is used as a routine diagnostic method for all patients with urolithiasis. Ultrasound of the kidneys can reveal signs of hydronephrosis or dilatation of the ureter due to a urinary tract stone.

In the case of x-ray negative stones of the genitourinary system (urate, cystine stones), stones are well visualized with ultrasound of the kidneys.

X-rays are recommended for diagnosing urolithiasis. abdominal cavity. Plain radiography of the abdominal cavity (also known as plain urography) allows you to detect stones in the genitourinary system, their location, size, shape in some patients. In some rare cases, survey urography allows you to evaluate the dynamics of urolithiasis (stone growth, or, conversely, its discharge) without the use of other diagnostic methods.

When using other diagnostic methods, such as ultrasound of the kidneys, or CT of the kidneys, plain abdominal radiography is an assistant in determining the size, shape, localization, orientation, composition of urinary stones detected by other diagnostic methods. Plain radiography is also an effective diagnostic method in planning surgical treatment and in the postoperative period for monitoring (managing) patients.

Intravenous urography, also known as intravenous pyelography, has recently become the standard method in diagnosing the size and location of urinary stones. Intravenous urography (pyelography) is a source of both anatomical and functional information. When performing intravenous urography in the presence of urinary tract obstruction, the contrast agent slowly passes through the collection system. Therefore, when taking a picture, an accumulation of a contrast agent in the projection of the kidney parenchyma can be observed. In this case, the picture looks like a nephrogram, this is one of hallmarks acute obstruction of the urinary tract.

In some cases, with urolithiasis, CT of the kidneys and abdominal cavity is performed. Nowadays, CT scans are increasingly recommended by physicians. Helical CT of the kidneys without contrast enhancement is the most sensitive method for diagnosing urolithiasis. All X-ray positive and even X-ray negative (except for indinavir-induced) urinary tract stones are well visualized on renal CT. In many institutions, renal CT is the method of choice in cases of suspected acute renal colic.

1.5 Prevalence of urolithiasis

The incidence of urolithiasis varies greatly in different countries of the world, averaging: 1-5% in Asia, 5-9% in Europe, 13% in North America and up to 20% in Saudi Arabia. In various countries of the world, out of 10 million people, 400 thousand suffer from urolithiasis. Over the past 4 years, the incidence of KSD in our country has increased from 405.2 to 460.3 per 100,000 of the adult population. Afghanistan, Pakistan, Iran, Iraq, Syria are the countries where ICD is most often observed. On the contrary, aboriginal blacks do not have ICD, and blacks living in the USA and European countries suffer from it quite often. This is probably due to the peculiarities of nutrition, climate, and so on. KSD occupies one of the first places among urological diseases, accounting for an average of 34.2% in Russia. The endemicity of the regions of Russia has been proven, not only in terms of frequency, but also in terms of the type of urinary stones formed. So, in the Southern regions, stones from uric acid compounds dominate, and in the Moscow region - oxalates. In most patients, KSD is detected at the most able-bodied age of 30-50 years. In Russia, the highest incidence of KSD is observed in the Volga region, which can be explained by the high content of calcium salts in the Volga.

2. Methods of physical rehabilitation for urolithiasis

2.1 Massage for urolithiasis

A known role in the etiology of urolithiasis is played by a violation of uric acid, phosphate and oxalic acid metabolism, infection, urinary stasis, slowing of renal blood flow. The latter causes a violation of the secretory and reabsorption functions of the renal epithelium, followed by the release of pathological proteins, from which an organic matrix is ​​formed - the bed of the future stone.

With urolithiasis, the tone of arterioles increases (in which there is a narrowing of the afferent and efferent arterioles).

Massage tasks: improvement of blood and lymph flow, metabolic processes, tissue metabolism and others.

Massage technique :

Conduct a general massage; when massaged in a sauna (bath), a plentiful drink is shown (tea, alkaline water, kvass and others). During the massage, they affect the paravertebral regions, rub the costovertebral angle, and also massage the stomach and thighs. Massage is carried out with ointments that cause hyperemia (or heated oils). The duration of the massage is 10-15 minutes. Course 20-25 procedures. 3-4 courses per year.

Reflex-segmental massage

Segmental massage gives a positive effect in the treatment of nephritis, nephrosis, nephrolithiasis, oliguria.

Segmental massage is not performed for kidney infarction, kidney diabetes, kidney tuberculosis and acute stages of diseases.

The main reflex changes as a result of segmental massage are observed in segments L4-1 and D12-9 located on the affected side.

muscle changes occur: on the right side of the rhomboid major muscle (D4), in the iliopsoas muscle (D12-11), on the right side of the latissimus dorsi muscle (L1), in the sacrospinous muscle (D12-11). Changes in the skin are observed: in the region of the rectus abdominis on the right side (D12-11), to the right of the spinal column (D11-7), in the central region above the pubic symphysis (S).

Changes in the connective tissue are localized: to the right of the spine (D11-7), in the upper region of the gluteal muscles and in the area of ​​fixation of the right thigh (81, L3-2), in the upper part of the sacral region (S3-1), above the right clavicle (C4 ), to the right of the inguinal region (L1), in the area right foot above the knee (L4-3).

Changes in the periosteum are observed: in the area of ​​the pubic joint, in the area of ​​the sacrum, in the area of ​​the right outer part ilium, in the region of the lower ribs on the right side.

The maximum points are located: on the sacrum, in the connective tissue, in the lumbar (shen-shu point), in the region of the patella of the right leg with the affected right kidney, and the left leg with damage to the left kidney.

Massage in the area of ​​the ischial tuberosity can lead to backaches, which are relieved by exposure to lumbar regions.

In order to avoid various side effects during each session, it is recommended to massage the anterior abdominal wall with increased pressure on the area above the pubic joint.

The procedure for conducting segmental massage in the treatment of kidney diseases.

The patient lies on his stomach, and the masseur begins to work on the surface of the back with the help of: planar stroking, increasing pressure on the affected side (7-8 movements), belt segmental stroking with increasing pressure on the affected area (4-6 movements), the first method of "drilling "on the affected side (7-8 movements), planar stroking the entire surface of the back (4-6 movements), influencing the spaces between the spinous processes of the vertebrae (10-12 movements), "sawing" on the affected side (10-12 movements), movements from the same side (8-10 movements), waist segmental stroking with increased pressure on the affected side (4-6 movements).

Note: to provide a calming effect after the impact on the gaps between the spinous processes of the vertebrae and "sawing", it is recommended to apply flat stroking of the entire surface of the back (4-6 movements). Then the area of ​​the pelvis, sacrum, iliac crest is massaged using all the methods of classical massage in combination with separate methods of connective tissue and periosteal massage. After that, the patient lies on his back, and the massage therapist begins to act on the front surface. chest, abdomen, anterior and posterior surfaces lower limb with increased pressure on the thigh and knee joint. At the same time, he uses all the techniques of classical massage, separate techniques of connective tissue massage, and performs periosteal massage on the periosteum with an emphasis on the patella. The massage ends with hip joint through passive movements, shaking and stroking.

The course of treatment for kidney diseases is 10-15 sessions, carried out every day or every other day. The duration of one session is 25-30 minutes.

Notes: If during the massage the patient feels worse, then the procedures should be carried out less often - 2 times a week; a second course of massage can be carried out only 1.5 months after the previous one and in combination with other types of treatment.

2.2 Physiotherapy with urolithiasis

With urolithiasis, various methods of therapeutic physical culture are widely used, which contribute to the expulsion of the stone. In addition, physical exercises are aimed at improving the urinary function of the kidneys and the outflow of urine, stimulating metabolism, and general strengthening of the body. Physical exercises cause fluctuations in intra-abdominal pressure and capacity of the abdominal cavity, stimulation of ureteral motility, concussion and some movement of the abdominal organs, stretching of the ureters and thereby contribute to the reduction of the stone. In addition to the mechanical action, a large role belongs to motor-visceral reflexes that change the tone of the smooth muscles of the ureter. The main form of training is therapeutic gymnastics. Against the background of general developmental exercises, special exercises for the abdominal muscles, various inclinations, bendings and turns of the body, movements with a sharp change in body position, running, jumping, jumping off the shells are widely used. These exercises alternate with muscle relaxation and breathing exercises (diaphragmatic breathing). The peculiarity of the technique lies in the frequent change of starting positions (standing, sitting, lying on your back, on your side, on your stomach, emphasis on your knees, kneeling). The duration of the lesson is 30-45 minutes.

In addition to therapeutic exercises, it is recommended to independently perform well-learned special exercises many times throughout the day, as well as morning hygienic exercises, including 2-3 special exercises, therapeutic walking (normal, with accelerations), jumping off the stairs. It is necessary to carefully individualize physical activity depending on the state of the cardiovascular system, age, gender, level of physical fitness of patients and clinical data. With various concomitant diseases, poor physical fitness of the patient, the load should be reduced by facilitating exercises, reducing dosage, introducing pauses between exercises, and the like. An indication for the appointment of therapeutic exercises is the presence of a stone in any of the sections of the ureter, if, judging by the shape and size of the stone, it can be removed naturally (the largest size in diameter is up to 1 millimeter). A contraindication is an exacerbation of urolithiasis, accompanied by fever and sharp pains, renal failure, insufficiency of the cardiovascular system. This technique cannot be used if the stone is in the calyx or in the pelvis.

Exercise therapy must be combined with the introduction of medications that relieve reflex spasm of the walls of the ureter, and painkillers. Remedial gymnastics should be prescribed after taking diuretics and a large amount of fluid.

Tasks of exercise therapy:

improvement of the urinary function of the kidneys and the outflow of urine;

promoting the passage of stones;

general strengthening of the body and improvement of metabolism.

LFK technique.

In urolithiasis, physical exercise causes fluctuations in intra-abdominal pressure and volume of the abdominal cavity, stimulation of intestinal motility, concussion and stretching of the ureters and thereby contributes to the removal of stones. Special exercises for the abdominal muscles, muscles of the back and small pelvis also reduce the tone of the smooth muscles of the ureters by the mechanism of motor-visceral reflexes and contribute to the passage of the stone. Such exercises include various tilts and turns of the body, sudden changes in body position, running, jumping, jumping off the shells and others. These exercises alternate with muscle relaxation and breathing exercises with diaphragmatic breathing. An important feature of exercise therapy is the frequent change of starting positions (standing, sitting; standing on all fours, kneeling; lying on the stomach, on the back, on the side, and others). The duration of the therapeutic gymnastics class is 30-45 minutes.

.3 Prevention of urolithiasis

Preventive therapy aimed at correcting metabolic disorders is prescribed according to indications based on the patient's examination data. The number of courses of treatment during the year is set individually under medical and laboratory control.

Without prophylaxis for 5 years, half of the patients who got rid of stones with one of the methods of treatment, urinary stones form again. Patient education and proper prevention are best started immediately after spontaneous passage or surgical removal of the stone.

Lifestyle: fitness and sports (especially for professions with low physical activity), however, excessive exercise should be avoided in untrained people, alcohol should be avoided, emotional stress should be avoided, KSD is often found in obese patients, Weight loss by reducing the intake of high-calorie foods reduces the risk of disease.

Increasing fluid intake:

It is shown to all patients with urolithiasis. In patients with a urine density of less than 1.015 g / liter, stones are formed much less frequently. Active diuresis promotes the discharge of small fragments and sand. Optimal diuresis is considered in the presence of 1.5 liters of urine per day, but in patients with urolithiasis it should be more than 2 liters per day.

Calcium intake:

Indications: Calcium oxalate stones. High calcium intake reduces oxalate excretion.

Fiber intake:

Indications: Calcium oxalate stones. You should eat vegetables, fruits, avoiding those that are rich in oxalate.

Oxalate Retention:

Low dietary calcium levels increase oxalate absorption. When dietary calcium levels increased to 15–20 mmol per day, urinary oxalate levels decreased. Ascorbic acid and vitamin D may contribute to increased oxalate excretion.

Indications: hyperoxaluria (urine oxalate concentration more than 0.45 mmol/day). Reducing oxalate intake may be beneficial in patients with hyperoxaluria, but in these patients, oxalate retention should be combined with other treatments. Limiting the intake of oxalate-rich foods for calcium oxalate stones.

Oxalate rich foods: rhubarb 530mg/100g, sorrel, spinach 570mg/100g, cocoa 625mg/100g, tea leaves 375-1450mg/100g, nuts, vitamin C intake: Vitamin C intake up to 4g per day can occur without the risk of calculus formation. Higher doses promote endogenous metabolism of ascorbic acid to oxalic acid. This increases the excretion of oxalic acid by the kidneys; Reduced protein intake: Animal protein is considered one of the important risk factors for stone formation. Excessive intake may increase calcium and oxalate excretion and decrease citrate excretion and urinary pH.

2.4 Surgical methods. Remote shock wave lithotripsy and its types

External lithotripsy (EBLT) is a new method of surgical, but non-surgical treatment of kidney and ureteral stones, which is widely used in the world. EBRT has largely supplanted the surgical removal of urinary stones, freed thousands of patients from the severity of the operation and postoperative period from operational complications. The number of operations for nephrolithiasis has now decreased to 25% due to the widespread use of external and contact lithotripsy. Despite the existing shortcomings of lithotripsy, the method has taken a worthy leading place in the surgical treatment of urolithiasis among the following methods and types: symptomatic treatment (more often acceptable for renal colic), the use of non-surgical methods of treatment for the passage of stones, medicinal litholysis (descending), "local litholysis" (ascending), percutaneous nephrostomy in combination with mechanical destruction of the stone or its intracorporeal crushing, instrumental removal of stones descended into the ureter, percutaneous removal of kidney stones by extraction or litholapaxy, contact ureteroscopic destruction of the stone, non-contact (remote) shock wave lithotripsy. General indications The choice of one or another method of treatment depends on a number of factors, including the size, shape, density and localization of the stone, complications of urolithiasis, the state of urodynamics and kidney function, technical equipment and the capabilities of the medical institution.

For a long time, open and maximally invasive surgery dominated, which posed many problems for the patient and the surgeon. Open surgery is traumatic, and after the removal of the stone, the consequences surgical intervention sometimes they become very tense due to complications (pneumonia, bleeding, thromboembolism, and others) and even deaths. Frequently occurring relapses are forced to resort to repeated interventions in already more difficult conditions.

These problems, as well as the lack of effective litholytic agents, often resulting in disability of patients due to multiple surgical interventions for recurrent urolithiasis, multiple and staghorn stones, encourage urologists to search for new, gentle methods of treating this disease.

One of the most modern methods treatment of urolithiasis is extracorporeal shock wave lithotripsy (ESWL), also called external shock wave lithotripsy (ESWL), and sometimes more briefly: external lithotripsy (ESWL), which in recent years has become an alternative to traditional methods of treating urolithiasis.

As early as the 19th century, the idea of ​​the possibility of in situ disintegration of stones appeared and the development of mechanical tools for this purpose was carried out. The first real steps in the destruction of urinary stones were made in Russia in the 1950s.

In 1955 L.A. Yutkin in our country proposed the theory of the electrohydraulic effect. Using the idea associated with the technology of electro-hydraulic waves used in mining by mine surveyors of the Leningrad Mining Institute, Yu.G. United and L.A. Yutkin in 1969 created the apparatus "Urat-1" and "Urat-2" for the destruction of stones in the bladder using hydraulic shock in order to use it in medicine. In a patent submitted by L.A. Yutkin, provides not only a description of the principle of this method, but also specific ways of execution, taking into account the parameters and regime used in subsequent research: generation of an elastic pulse using an electric discharge occurring between two electrodes in a liquid medium, wave focusing with an ellipsoidal mirror, and stone localization x-ray machine in two projections. As a result of the generation of a shock wave in the stone zone, it collapses into small particles. Based on the same theory, German specialists in the clinic of the University of Munich used an apparatus of their own design. Lithotripsy - in the experiment they began to be carried out since 1976, and since 1980 - in the clinic (Chhaussy Ch. et al., 1980) using the apparatus of the West German company Dornier (model HM-1). The shock waves in this apparatus are generated by a spark discharge underwater and are focused by an ellipsoidal reflector to disintegrate kidney stones. Stones are located using two videographic systems with intersecting projections. By 1986, about 150 thousand lithotripsy had already been produced in 175 centers of the world.

Since 1983, experimental studies have been carried out to develop and then introduce ESWL into clinical practice in our country using domestic equipment. The domestic lithotripter "Urat-P" made it possible to obtain fairly good results and began to be widely used in various medical institutions Russia.

Since the introduction of ESWL into medical practice, this method has earned a reputation as a well-proven and effective way to treat kidney and ureteral stones. The main challenge facing ESWL is to ensure rapid, reliable, safe and atraumatic destruction of kidney and ureteral stones.

Two concepts of ESWL therapy for urolithiasis are fundamentally distinguished: preliminary retrograde movement of the stone into the renal pelvis followed by lithotripsy and in situ ESWL. The main advantage of ESWL after retrograde displacement of a stone into the renal cavitary system is effective disintegration in 95% of cases, which requires fewer shock pulses and significantly fewer repeated procedures compared to in situ lithotripsy. ESWL in situ provides effective disintegration of ureteral stones in 80% of cases. In situ procedures require more shocks and increased generator voltage, which in turn leads to an increase in repeat sessions of about 10% compared with the procedure after retrograde assistance.

Physical basis of lithotripsy.

It is known from the theory of acoustics that sound propagates in the form of waves formed in the process of alternating compression and rarefaction. As a result of wave motion in some medium, a shock front or a moving shock arises, which has a certain duration and amplitude and is characterized by a sharp increase in pressure and density.

A complex acoustic pulse is formed by the sum of many sinusoidal waves of different frequencies. A typical lithotriptor pulse is characterized by energy, most of which is at or above the frequency corresponding to the pulse decay time (from several hundred kHz to tens of MHz).

In the process of concentrating the shock wave in its geometric focus, its shape changes. The final pressure distribution at the focus depends on the shape and size of the focused system, energy and pressure characteristics of the unfocused wave. Propagating in water and soft tissues, acoustic waves lose energy, mainly due to absorption and reflection. Absorption is understood as the process of transformation of acoustic wave energy into thermal energy in the propagation medium. Absorption is higher in soft tissues than in water. Part of the wave energy is reflected under the influence of changes in acoustic impedance, the magnitude of which is equal to the product of the density and the speed of sound. The relative difference in the impedance values ​​at the interface determines the fraction of the reflected energy. As a result of reflection at the impedance interfaces, acoustic waves can change direction, requiring focusing.

From a physical point of view, water is the best conductor for ultrasound and a good medium for transmitting shock waves to the human body. The temperature of the water should provide comfortable conditions for the patient and is usually 37°C. Since water has an acoustic impedance similar to soft tissue, it can serve as a contact medium for the transmission of shock waves from the generator to the tissue, unlike air, which has a completely different impedance. In this regard, air is removed from ESWL devices by degassing. This allows you to reduce the energy loss in the water to a minimum. The resulting air bubbles directly on the patient's skin can lead to redness. They can be removed by hand. Bursting and negative pressure decrease as the density of the propagation medium decreases. When the shock front is reflected from the interfaces in soft tissues, the compression pressure pulse turns into a discontinuous one and vice versa. The burst pressure can be generated by shock wave generators. With sufficiently large rupture forces, they can exceed the strength of the medium at one point or another. If this happens in a liquid, then as a result it breaks and a bubble is formed. This phenomenon is called cavitation. In solids, rupture forces create a concentration of deformation around the existing microcracks or at the interfaces in the composition of the substance. The tendency of solids to deform creates rupture forces, resulting in splitting.

The interaction of shock waves with stones obeys strict physical laws. Density and speed of sound in stone differ from those in soft tissues. A certain amount of energy reflected when the shock wave collides with the surface of the stone creates a compressive force on its front surface. And on its lateral surfaces, stress is created due to the faster passage of the compression pulse than its original shock front. On the back surface of the stone, a rupture impulse is created from the reflected compression impulse, which returns back through the stone. Acting on the inhomogeneous structure of the stone, complex stress fields cause the appearance of cracks, and due to cavitation, its surface is destroyed.

The waveform of the pressure signal that is generated in ESWL devices is significantly distorted compared to conventional sinusoidally oscillating pressure. It depends on a number of factors, including the power of the emitter and the distance that the wave needs to travel from this emitter. At high pressures, the leading edge of the positive pressure half-cycle becomes almost abrupt. It is this property that makes it possible to call the shock wave and use it for the disintegration of stones. In most devices, the main frequency of the shock wave is about 0.5 MHz.

Various models of devices are currently used for remote lithotripsy. The list of the most commonly used lithotripters in the world can be presented as follows.

Models of lithotriptors, whose operation is based on the principle of electrohydraulic generation of shock waves: NM-3, Dornier, (Germany); MFL-5000, Dornier, (Germany); MPD-9000, Dornier, (Germany); Compact, Dornier (Germany); SonolithTechnomed (France); Medstone-1000, Medstone (USA); SD-3, Monaghom (USA); Breakstone 130/135, Breakthzrough (USA - Netherlands); Tripter XI, Medirex (Israel); Urat-N (Russia).

Lithotripters with electromagnetic principle of shock wave generation: Modulith SL 10/20, Sforz (Germany): Lithostar, Siemens, (Germany); Lithostar-Plus, Siemens (Germany); Multiline-3B.

Lithotripters with the piezoelectric principle of shock wave generation: Piezolith 2300, Wolf (Germany); Piezolith 2500.10, Wolf (Germany); LT-01, Edap (France). Micro explosive principle of wave generation of Yashigoda SZ-1 apparatus, Yashigoda, (Japan); laser - from Lazertripter, Paramedic (USA).

Lithotripsy is based on a shock wave focused on a stone, and various options for generating and transmitting shock waves are currently used. On many models of lithotriptors, X-ray location and focusing of the calculus is supplemented by ultrasonic guidance. Apparatus for lithotripsy differ from each other in the following parameters: energy source - electric spark gap: - piezoelectric system - electromagnetic membrane; focusing system - ellipsoid reflector: - profile system, - lens.

Either x-ray or ultrasound systems are used to localize and position stones in focus.

For remote shock wave lithotripsy, in principle, any physical mechanism for converting energy into acoustic waves can be used.

The electric spark gap is represented by two underwater metal electrodes connected in series with a capacitor charged to a high voltage. As a result of the discharge of the electrical energy of the capacitor into the water, the temperature of the water rises sharply until steam is formed, and then plasma. There is a compression pressure pulse, then a negative pressure pulse. Discharge efficiency is related to the gap size and voltage. It should be noted that due to high temperature erosion of the electrodes leads to the need for their periodic replacement.

Piezoelectric source . The principle of operation of devices with a piezoelectric system is based in the physical sense on piezoceramics, which is represented by materials based on lead-zirconium titanate or barium titanate. The piezoelectric effect is characterized by the fact that after the polarization of the piezoceramic material and the application of voltage to it, it expands by an amount that depends on the size and direction of the voltage. As a result, pressure waves are created in a spherical thicket, where a large number of piezoelectric elements are located. The shock wave in the piezo system works like a chisel, beating off small particles with each impact, due to the fact that in this case, low energy creates high pressure impulses. The shock wave is created by moving a crystal of a piezoelectric material used as acoustic radiation in ultrasound diagnostic systems. The mechanical resistance, which determines the service life of the crystal, is affected by the formation of acoustic waves and electrical breakdowns of the insulation of crystals.

electromagnetic source. The electromagnetic field generated by the passage of electric current through the wire is used. Being attracted or repelled by an electromagnetic field, magnetic materials convert electrical energy into mechanical and acoustic.

Focusing is carried out in the form of: homing, when the emitter itself concentrates energy in focus, using a lens, then it is determined by the difference in the acoustic properties of water and the lens and the shape of the lens, reflective focusing, while the emitter is in the same focus of the ellipsoid reflector, and the rays outgoing from one focus of the ellipsoid, converge at the second.

Localization . Accurate location in ESWL is no less important than the shock wave generation system. Regardless of the method of focusing on the stone (X-ray or ultrasound), the criterion for the operation of localization systems is adequate visualization of the stone for control during the procedure and accurate matching of the stone image and the focus of the shock wave. However, even with complete coincidence of shock wave foci and visualization systems in water, the focus of the shock wave can be shifted by non-linear effects in the human body.

Indications for remote shock wave lithotripsy.

ON THE. Lopatkin and co-author (1988) O.L. Tiktinsky, (1990) and others believe that the indications for extracorporeal lithotripsy are: - the presence of a stone in the kidney, the possibility of focusing the stone (by X-ray, ultrasound), the absence of disturbances in the outflow of urine from the kidney below the stone.

External shock wave lithotripsy is effective and less invasive, especially for stones up to 3 cm in size, and is the method of choice in the treatment of urolithiasis.

Special classifications of nephrolithiasis have been developed, taking into account the size, location, shape of the stone and the functional state of the kidneys and urinary tract.

When determining indications and contraindications for external lithotripsy, A.A. Naumenko and P.I. Chumakov (1996) proceed from the concept of the process of primary stone formation: the cause of stone formation (stage I), stone formation (stage II), stone growth (stage III), destruction of the urinary tract and kidney by the stone (stage IV), kidney death (stage V ). The authors believe that in case of kidney death (stage V), external lithotripsy is not only inappropriate, but also dangerous. The effect of DLT at stage IV is achieved in 77% of patients, at stage III - in 93%. At the same time, at the stage of stone formation, one hundred percent discharge of fragments is observed. This leads to an important organizational conclusion about the need for preventive ultrasound examinations for the purpose of early detection of a preclinical form of urolithiasis that is most suitable for lithotripsy.

Over time, views on the indications for lithotripsy have undergone significant changes. Initially, OIL was used for isolated kidney and ureteral stones. CM. Javad-Zadeh (1996) divides stone sizes into 3 groups when determining indications for ESWL: up to 10 mm, up to 15 mm, 20 mm and more. According to F. Eisenberger and co-author (1986), J. Simon and co-author (1988), a stone with a diameter of no more than 15 mm is ideal for indications for lithotripsy. A digital method for predicting the effectiveness of ESWL has been proposed: a previous operation on the ESWL side, the duration of the calculus in the urinary tract, anti-inflammatory therapy before lithotripsy, increased fullness, calculus size, presence of urinary tract obstruction and hydronephrotic transformation, calculus composition. With a score of up to 10, lithotripsy was effective in 97.1% of patients, and with an increase to 20, the efficiency decreased to 24.4%. The gradual effect of ESWL extended to staghorn and multiple stones. At the same time, it was agreed that the total volume of multiple stones should not exceed 5 cm. 3(Fisenberger F., Rassweiler J., 1986). Localization of the stone in the lower group of cups is unfavorable for shock wave lithotripsy. In such a situation, it is recommended to resolve the issue in favor of percutaneous nephrolithotomy.

ON THE. Lopatkin and N.K. Dzeranov (1996) note that the size of the stone is not an absolute criterion of proof for extracorporeal lithotripsy. L.V. Shaplygin (1995) believes that the effectiveness of the destruction of urinary stones by focused shock waves does not depend on the method of generation of the shock wave, but is related to the pressure at the focus, the pulse length, the frequency of sending shock wave packets, the chemical composition of the stone and its location.

Contraindications to external shock wave lithotripsy.

Contraindications to ESWL are divided into technical, general and urological:

Technical : the patient's height is more than 200 centimeters and less than 100 centimeters, body weight is more than 130 kilograms (the kidney lies deep from the skin surface, X-ray negative stones (impossibility of visualizing them), if the device has only X-ray guidance, deformation of the musculoskeletal system that prevents the patient from laying down and bringing the stone into the focus of the shock wave.

General : disorders of the blood coagulation system, pregnancy.

It has an active preoperative preparation (antibacterial therapy, improvement of the microcirculation of the kidney vessels, antioxidant, detoxification therapy), which allows you to largely protect the only kidney from the traumatic effect of the shock wave. In case of obstruction of the only or only functioning kidney, as well as in the case of the recurrent nature of the stone, its large size, the issue of preliminary drainage of the kidney (ureteral catheter, stent) should be considered, and with more favorable conditions monotherapy can be used. Under our supervision (Aleksandrov V.P. et al., 1996) there were 11 patients with staghorn recurrent stones of the only functioning kidney. Nephrectomy was transferred by 8 people, 6 of them - secondary. 3 patients had a non-functioning contralateral kidney. All patients had previously been operated on a single kidney. In 9 out of 11 patients, chronic renal failure was detected in the latent phase. Chronic pyelonephritis was in all patients. Remote lithotripsy was carried out on the apparatus "Urat-P" in the second mode and 4000 strokes. Complete disintegration (at 3-4 sessions) occurred in 7, partial - in 4 patients. In connection with the active phase of pyelonephritis after lithotripsy (moderate in most cases) and the presence of CRF, in the postoperative period, patients were prescribed retobolil, lespenephril, sorbents, sodium bicarbonate, and intensive antibiotic therapy continued. Improvements were achieved in all patients. Our observations suggest that the tactics of using ESWL for the disintegration of the pelvic fragment of the staghorn stone of the only functioning or remaining kidney is surgical treatment choice.

Remote lithotripsy is used with good effect and in patients with abnormal kidneys. J.E. Smith et al. (1989) report, in particular, the results of lithotripsy for horseshoe kidney stones. V.A. Kozlov et al (1992, 1993) performed lithotripsy in 54 patients with abnormally developed kidneys. 19 of them had a horseshoe kidney, 12 had a double kidney, 9 had a dystopic kidney, 3 had an L-shaped kidney, and so on. The very fact of the anomaly is not a contraindication for lithotripsy. In the presence of a spongy kidney, it is advisable to use this method only for stones localized in the pelvis or calyces, since attempts at lithotripsy of parenchymal calculi are accompanied by intense hematuria and attacks of pyelonephritis.

The greatest risk factor for stone formation is in patients with fused, horseshoe-shaped kidneys. Over the past 20 years, we have observed 78 patients with a horseshoe-shaped kidney and stones complicated by pyelonephritis. Proteus flora (Pr. rettgeri and Pr. mirabilis) was detected in 42.6% of these patients. Out of 78 patients, indications for surgical treatment arose in 44 cases. They were mainly associated with pyelonephritis, acute or often exacerbated, especially with proteus infection. True relapses occurred in 37 patients. 29 of them were reoperated, 3-4 times and more than 3 more patients. In one observation (a 22-year-old girl) there were 5 surgical interventions.

Analyzing this group of patients, we came to the conclusion that due to a pronounced pathogenetic factor - a violation of the outflow of urine through the ureter when isthmotomy is impossible, when the kidney is a single organ, it is advisable not to operate on such patients if possible. With the advent of EBRT, it became possible to successfully treat such patients.

The technical features of DLT in urolithiasis of abnormal kidneys are associated with the often accompanying malformations of the upper and lower urinary tract, a greater predisposition to the development of chronic pyelonephritis. This also applies to the issue of laying the patient, depending on the depth of the stone, pre-and postoperative drainage of the kidney. Small cysts (up to 2-3 cm in diameter) located outside the projection of the shock wave are not an obstacle to in situ EBRT. For large cysts (more than 5.0 centimeters), projected to coincide with the direction of the shock wave, a two-stage treatment is indicated with the initial puncture of the cyst.

M.F. Trapeznikova (1996) reported the results of successful extracorporeal lithotripsy in the treatment of urolithiasis in transplanted kidneys.

Remote lithotripsy in urgent urology for the treatment of renal colic and at the same time for the radical removal of ureteral stones was used by many authors with different localization of calculi. 85.3-90% of them achieved positive results both due to the destruction of stones and the dispersal of a finely dispersed path (Volkov I.N., 1998, and others). This tactic is quite effective, however, as monotherapy for stones in the upper third of the ureter and ureteropelvic anastomosis, it should be treated with caution due to the high probability of getting into the shock wave zone of the renal parenchyma, the length of the path, the unpredictability of the movement of fragments and the threat of developing purulent pyelonephritis.

Our clinical observations cover 52 patients with obturating stones of the pelvic-ureteral anastomosis and ureter aged from 17 to 69 years. 39 of them had no signs of attack of pyelonephritis, and in 13 the disease was complicated by acute serous pyelonephritis. When planning remote lithotripsy, we counted not so much on the effect of complete disintegration of the stone, but at least on a partial split of the stone, which should have led to leakage of urine and a decrease in intrapelvic pressure. In the first of these groups, after a single session of lithotripsy, renal colic was arrested in 28 patients, in 4 more patients its intensity decreased significantly, in the rest, relief of colic occurred after the second session of EBLT.

Stone crushing was carried out on the 2nd mode, up to 3500-4000 blows. Complete disintegration and passage of stones in half of the patients in this group occurred after the first session, in the rest - after 2-3 (rarely 4) sessions of EBRT.

In patients with acute serous pyelonephritis, lithotripsy was performed against the background of intensive antibiotic therapy. Ureter catheterization was required only in 3 cases in this group.

External shock wave lithotripsy for ureteral stones

In the early stages of the introduction of lithotripsy, a significant number of patients with ureteral stones dropped out of the contingent who were indicated for the use of ESWL. This was due primarily to the fact that with such a localization of the stone there is no liquid around it, as well as the often occurring coincidence of the projection of the stone with the skeletal system, and others.

Remote lithotripsy in patients with ureteral stones is performed in various ways. The most common are options with prior retrograde ureteral catheterization. In some cases, an attempt is made to grab the stone with the Dormia loop, the tactic of moving the stone into the pelvis, and others.

However, in recent years, no significant correlation has been found between the efficiency of stone destruction and the above-mentioned manipulations. The algorithm for the treatment of patients with proximal ureteral stones considers EBRT as a first-line, less invasive method of treatment. Repeated lithotripsy is indicated when obvious, partial disintegration of the stone is achieved. This allows to achieve the destruction of stones in 60-80% of patients (Trapeznikova M.F., Dutov V.V., 1998).

Indications for catheterization of the ureter during EBRT - monotherapy for proximal stones can be presented as follows: emergency indications (non-stopping renal colic, obstruction, and so on), exacerbation of obstructive pyelonephritis (if a stent cannot be installed), long-term (more than 6-8 weeks ) finding a stone with signs of endo - and periureteritis, ex-visit cases of large stones (more than 2.5-3.0 centimeters to the original).

It is possible to use external drainage of the pelvis, percutaneous nephrostomy, as well as retroperitoneal endoscopic surgical technologies.

With localization in the terminal ureter, spontaneous passage of stones up to 5 mm in diameter should be expected in 90% of patients. DLT is prescribed for: intractable renal colic, solitary kidney, more than 30% impaired renal secretory function, refusal of the patient from endoscopic methods of treatment.

In women of childbearing age and girls of puberty, indications for RT for stones in the lower third of the ureter are limited.

A reasonable combination of contact endoscopic ureterolithotripsy and remote shock wave lithotripsy can successfully treat up to 95% of patients with urethrolithiasis. For contact destruction of urinary stones, as a rule, ultrasonic and electrohydraulic effects are used: long-term (more than 6-8 weeks) presence of a stone with signs of endo- and periureteritis, exclusive cases of large stones (more than 2.5-3.0 centimeters to the original).

Remote shock wave lithotripsy for large staghorn stones

Currently, views have changed regarding the possibility of lithotripsy for large (exceeding 3 centimeters) and coral-like stones. The tactics of a combined approach to treatment with the use of percutaneous nephrolithotomy, the introduction of a stent before lithotripsy, repeated crushing sessions made it possible to significantly expand the range of indications for the treatment of such forms of urolithiasis (Lopatkin N.A. and others, 1990; Tiktinsky O.L. and others, 1992; Yanenko E.K. and others, 1994). Features of the approach to lithotripsy for large and coral-like stones N.A. Lopatkin et al. (1988) consider: the need for more impulses. This increases the likelihood of disintegration of a large stone. On the other hand, in this case, negative effects of shock waves on the kidney and neighboring organs are possible; the larger the stone, the more fragments are formed and the risk of blockage of the ureter increases, which may require endo-urological intervention, as a result of the destruction of large stones, a large number of bacteria contained in the stone are released, which causes the risk of septic complications.

For the destruction of partially coral-like stone, the method of fractional crushing is used. They start it in the first session from the cup section. At the same time, N.A. Lopatkin et al. (1990) are rather reserved about expanding the use of DLT in staghorn nephrolithiasis. The main arguments for such a conclusion are the deep and not yet fully understood effects of the impact of the shock wave on the already altered microstructure of the kidney, as well as the presence of significant changes associated with severe pyelonephritis and impaired renal function. The unpredictability of the functional results of the operation, noted by many authors, should, according to N.A. Lopatkina and co-author, to orient urologists to the solution of the issue of removal of coral stone only in the case of an increase in secretory deficiency. The optimal approach in the treatment of staghorn kidney stones is considered to be an approach that involves a combination of an “open” operation with remote shock wave lithotripsy in situations where the stone occupies the entire pyelocaliceal system and when there is no possibility of performing percutaneous nephrolithotripsy (Trapeznikova M.F., Dutov V.V., 1999; Alexandrov V.P. and others, 1999, and others). Supporters of the use of internal stents believe that this tactic increases the efficiency and expands the possibilities of external lithotripsy in coral stones (Tkachuk V.N. and others, 1991; Preminger G., 1989, and others). Removal of the stent is advisable only after the departure of most of the fragments.

Depending on the specific situation, both monolithotripsy and the combination of ESWL with percutaneous puncture nephrostomy (PPN), percutaneous puncture nephrolithotripsy, and the use of a ureteral stent can be used. The use of external lithotripsy as the only method of treating staghorn urolithiasis makes it possible to destroy the stone in only half of the patients.

General rule for DLT-monotherapy, it is possible to conduct each subsequent lithotripsy session only after the complete discharge of the fragments formed during the previous one (Trapeznikova M.F., Dutov V.V., 1998). Fragmentation is considered complete when the size of the parts of the destroyed stone does not exceed 3-4 mm M.F. Trapeznikova et al. (1995) consider that the indications for lithotripsy as a monotherapy for large and staghorn stones are: the recurrent nature of the stone, complete filling of the calyces and pelvis inside the renal type, the presence of preserved kidney function and the absence of calyx ectasia. Here, open surgery is difficult and highly traumatic, and intrarenal contact lithotripsy is technically extremely difficult. As a method of choice for staghorn nephrolithiasis, combined (“sandwich”) therapy is used, which includes percutaneous nephrolithotripsy followed by EBRT of residual stones. The first stage - nephrostomy and removal of fragments - involves the creation of 2-3 accesses. After 7-10 days, the second stage is performed with an additional prophylactic installation of an occluding ureteral balloon catheter. According to M.F. Trapeznikova and V.V. Dutova (1999), the use of percutaneous nephrolithotripsy and EBRT as monotherapy should be limited to small (less than 200 m) 3) with a low density of (mainly struvite) staghorn stones, in an anatomically normal collecting system of the kidney.

.5 Surgical treatment of nephrolithiasis

Surgery is needed if the kidney stone causes pain; depriving the patient of ability to work; in violation of the outflow of urine, leading to pyelonephritis, hydronephrotic transformation; with dysfunction, hematuria.

Operations on the kidney in patients with nephrolithiasis can be organ-removing (nephrectomy) and organ-preserving (pyelolithotomy, calicolithotomy, nephrolithotomy, kidney resection, and others).

Contraindications to surgical treatment are organic diseases of the cardiovascular system with symptoms of decompensation, cachexia, cerebrovascular accident.

You should not resort to surgery for small calyx stones (parenchymal), no or mild infection, when there is no severe pain, hydronephrotic transformation and recurrent gross hematuria.

Preoperative preparation of patients with nephrolithiasis is carried out taking into account age, activity of pyelonephritis, impaired renal function.

It is advisable to prescribe anti-inflammatory treatment, given the type of pathogen and its sensitivity to antibiotics and chemotherapy. Antibiotics are prescribed in sufficient doses for a long time.

The main factors in preparing patients for surgical removal of stones are the use of all means of determining the etiology of the disease and the use of all methods for preventing recurrence of stone formation. These include the correction of water-salt disorders in the body and the removal of the parathyroid glands in primary and even secondary hyperparathyroidism.

In the presence of signs of renal failure, preoperative treatment includes vitamin therapy (vitamins of groups B, C, A, E), oxygen therapy, antihistamines and sedatives. Widely applied intravenous administration cardiac glycosides, cocarboxylase, ATP.

Great importance in complex treatment late stages of chronic renal failure has the use of hemodialysis if necessary.

Types of surgical intervention methods .

For the production of operations for nephrolithiasis, extraperitoneal and through the peritoneal access to the kidney are proposed. The extraperitoneal lumbar incisions of Simon, Czerny, Pean, Bergman-Israel, S.P. Fedorov, which give good access to the kidney. The most commonly used oblique lumbo-abdominal incision of Fedorov and the oblique lumbar incision of Bergman-Israel. These accesses allow you to perform all interventions for kidney stones.

To remove single stones A.P. Frumkin and I.P. Pogorelko proposed a number of intermuscular approaches: posterolateral, posteromedial, posterior oblique-transverse with intersection of the broad back muscle and anterior.

With posterolateral access, the patient is in a position on a healthy side. The incision is made from the end of the XII rib downwards towards the Petit triangle. The latissimus dorsi and external oblique muscles of the abdomen are bluntly pushed apart, exposing the internal oblique muscle of the abdomen.

To penetrate into the retroperitoneal space, along the course of the muscle fibers, the internal oblique is pulled apart and then, in depth, the transverse abdominal muscle. The wound is bluntly expanded with hooks, the outer edge of the kidney is exposed after opening behind the renal fascia and parenteral fatty tissue.

The posterior medial intermuscular access is used by laying the patient on the stomach, placing a roller under its upper half. The skin incision is made from the middle of the XII rib obliquely downwards and medially towards the depression between the iliac crest and the spine. The latissimus dorsi muscle is stratified longitudinally, the oblique muscles of the abdomen push the lateral, long flexor of the back and the posterior superior serratus muscle - medial to the spine. The transverse abdominal muscle with its aponeurosis that has appeared is stratified stupidly along the fibers and the retroperitoneal space is exposed. After dissection of the retrorenal fascia, the perirenal fatty tissue is pushed up and down, exposing the posterior surface of the kidney.

The posterior oblique transverse approach with the intersection of the latissimus dorsi muscle is used when the patient is in the prone position. The skin incision is made from the costovertebral angle 2 cm below the XII rib and parallel to it from back to front. This access, in principle, is no different from conventional oblique incisions with the intersection of muscles. The muscles of the posterior wall of the abdomen, the latissimus dorsi and partially posterior serratus muscles are dissected in layers. Then the external and internal oblique muscles are dissected and the transverse abdominal muscle is dissected. Along the lateral edge of the square muscle lies the first fatty layer of the retroperitoneal space. The paranephrium is opened and the posterior surface of the kidney is exposed.

With anterior intermuscular access, a skin incision 8–10 centimeters long is made from the XII rib obliquely downward anteriorly. After opening the fascia of the external oblique abdominal muscle, its fibers are bluntly stratified. The fibers of the internal oblique and transverse abdominal muscles are also pushed apart. The peritoneum and adipose tissue are moved medially. Then a leaf of the perirenal fibrous capsule is opened and the pelvis is exposed in front.

Through the peritoneal access for kidney surgery for nephrolithiasis in the clinic is not used. Most often, in all operations for kidney stones, including nephrectomy, Fedorov's lumbotomy is used.

The method of choice for surgical intervention for nephrolithiasis is pyelolithotomy, which is performed in various modifications: posterior, anterior, superior, inferior, subcapsular, subcortical. Nephrolithotomy is often performed, which can be radial, transverse, sectional. When indicated, nephrostomy, pyelostomy, kidney resection, nephrectomy are taken.

When performing any of these operations, various options are possible, which depend on the location, shape, size and number of stones, on the state of the renal parenchyma, the shape and location of the renal pelvis, and the branching of the kidney vessels.

Possible complications and their prevention .

Surgical treatment of patients with kidney stones is sometimes difficult for surgeons and difficult for patients. Pyelonephritis, which has joined the course of urolithiasis, is accompanied by sclerosing paranephritis, which involves the tissues surrounding the kidney, and often the adrenal gland, in the process. duodenum, large intestine, diaphragm, large vessels.

The most common complication - bleeding from the kidney, especially with large staghorn stones - significantly decreased after the introduction of the practice of clamping the renal artery during the production of nephrotomy.

During repeated operations, damage to the peritoneum, pleura, adrenal gland is possible, which are eliminated during the operation. Sometimes there are colonic fistulas, the early ones are the result of an unnoticed injury, the later ones are the result of necrosis of the intestinal wall due to thrombosis of the vessel branch.

The basis for the prevention of all these complications is the most careful and extremely careful isolation of the kidney from the surrounding tissues.

In preparation for surgery in patients with nephrolithiasis complicated by CRF in the intermittent or terminal stage, in the complex conservative treatment it is necessary to include the use of hemodialysis.

Postoperative management of patients operated on for nephrolithiasis has a number of features. Patients after surgery are placed in the intensive care unit, equipped with modern equipment. The age of operated patients varies over a wide range, the degree of impairment of the functional state of the kidneys is variable, comorbidities are heterogeneous, surgical interventions are extremely different, both in terms of the severity of the injury to the kidney, the amount of blood lost during the operation, and the duration of the operation and the administration of anesthesia. Each of these factors is the basis for the occurrence of certain complications. All this requires maximum attention to the patient and correction of complications in the initial stage of their manifestations.

Operations on the kidney, as a rule, cause an exacerbation of chronic pyelonephritis and a change in kidney function. These changes are accompanied by fever, leukocytosis, increased ESR, changes in osmolarity and urine pH. It is necessary to monitor the function of the drainage tube, the amount and nature of urine. A good outflow of urine from the operated kidney is necessary condition, accelerating the regenerative processes in the kidney, prevents exacerbation of pyelonephritis and recurrence of stone formation. Urine should not be allowed to seep into the wound, as this impairs its healing and leads to skin maceration. The term of drainage of the kidney is determined by the nature of the surgical intervention and the course of the postoperative period.

During the first 2-3 days, some oliguria is noted, which is especially common in patients who have undergone nephrectomy. Therefore, it is necessary to monitor the state of the function of the remaining kidney.

To eliminate respiratory failure, oxygen therapy and painkillers (promedol, baralgin) are prescribed. It is necessary to correct the metabolic balance, which is carried out by the regulation of BCC, water-electrolyte balance, acid-base state. Conservative therapy includes intravenous administration of 300-500 ml of 20% glucose solution with 20-30 units of insulin, 20 ml of 10% chloride solution or calcium gluconate. According to the indications, polyglucin, reopoliglyukin, hemodez, plasma, blood are administered. With hypokalemia against the background of acidosis, potassium citrate or potassium gluconate is prescribed. Antibacterial treatment is carried out by all modern means and is controlled by the results of urine cultures and the sensitivity of the flora. With a decrease in kidney function, lasix, beckons, anabolic hormones, flavin drugs (lespenefril, flavonin, soledoflane) are prescribed.

Patients operated on for staghorn nephrolithiasis in the intermittent stage of CRF with worsening general condition and an increase in renal failure, hemodialysis is included in the complex of conservative treatment.

There is no consensus regarding the timing of removal of the drainage tube from the kidney during temporary nephrostomy. Some authors suggest removing the tube on the 8th - 15th day after the operation.

The term of drainage of the kidney is determined by the nature of the surgical intervention, the course of the postoperative period, the severity of the inflammatory process in the kidney and the patency of the urinary tract. The patency of the urinary tract is determined by the introduction of 10 ml of a sterile 0.4% solution of indigo carmine through a nephrostomy tube into the renal pelvis, which, with good patency of the urinary tract, quickly appears in the bladder.

If the nephrostomy is applied for a long time, then periodically once a month it is necessary to change the drainage tube in the kidney.

Patients who have a nephrostomy or pyelostomy require special care. It is necessary to monitor the operation of the drain tube. Patients are prescribed peros oxidizing urine agents and an appropriate drinking regimen.

.6 Diet for urolithiasis

In the case of urolithiasis, treatment without following a certain diet is impossible. Limiting certain foods in the diet slows down the growth of existing stones or the appearance of new ones, because it deprives them of "building material". Careful selection of foods changes the acidity of the urine, which also contributes to the dissolution of stones, and a large amount of fluid recommended in the diet contributes to the rapid removal of small stones and sand from the kidneys.

It must be borne in mind that different types Stones require completely different diets because different stones grow in different conditions. For the same reason, long-term use of a strict diet is not recommended, since the one-sided composition of the diet will create an opportunity for the formation of stones of a different type. Diet therapy, as a rule, is used during the period of active treatment and its duration should not be more than six months. Over time, the diet should be gradually expanded.

Diet for the deposition of urate stones

Urate stones are formed in the kidneys when there is a high concentration of uric acid and when the urine is acidic. The task of the diet is to reduce the intake of purine bases, which are the source of uric acid formation, and to shift the urine reaction to the alkaline side. For such cases, official medicine has developed dietary table No. 6.

Foods containing a large amount of purines are sharply limited or prohibited for use: veal, young lamb, broths, smoked meats, canned food, sausage, salted cheese and fish, offal, tea, coffee, cocoa, chocolate, solid animal fats.

The list of allowed foods is approximately the following: fruits and vegetables (pears, apples, watermelons, apricots, peaches, cucumbers, beets, potatoes), vegetarian soups, okroshka, beetroot, botvinya, borscht - care must be taken that vegetables are the main component of the soup, not meat. On the second: vegetable stew, squash, eggplant caviar, vegetarian zrazy, potato pancakes, potato casserole, vegetarian pilaf and cabbage rolls stuffed with cereals, cheesecakes, pudding. You can use spices in small quantities.

Meals should be fractional and frequent 5-6 times a day in small portions. Between meals, drink plenty of fluids - at least 2 liters per day. Alcohol is completely excluded. Starvation is also highly undesirable. You can arrange fasting days.

Diet for the deposition of phosphate stones

We can say that this is the exact opposite diet. official medicine developed dietary table No. 14 for patients with phosphate stones. The task of the diet is to achieve "acidification" of urine, since phosphates are formed in an alkaline environment.

The list of undesirable foods includes: milk, fruits, vegetables, dairy products, cheese, cottage cheese, cereals with milk, milk soups, juices, ice cream, smoked meats, pickles, marinades.

But meat, fish, poultry, canned food, green peas, pumpkin, mushrooms, sweets are allowed.

Meals should be fractional and frequent 5-6 times a day in small portions. Between meals, drink plenty of fluids - at least 2 liters per day. Alcohol is highly discouraged.

When applying any diet, a reasonable approach is needed - no need to go to extremes and take everything literally. If a patient with phosphate stones still suffers from obesity and atherosclerosis, you should not get carried away with fatty meats and fish.

Diet for the deposition of oxalate stones

Oxalate stones form when there is too much oxalic acid in the body. For this case, a specific diet has not been developed, but general recommendations exist.

To limit the intake of oxalic acid in the body, the following are completely excluded: sorrel, spinach, parsley, rhubarb, chocolate, black and red currants, gooseberries, exotic fruits, carrots, beets, potatoes, tomatoes, green onions.

To exclude the possibility of excessive formation of oxalic acid in the body, limit the consumption of: gelatin, easily digestible carbohydrates. The diet includes buckwheat, wheat bran, oatmeal porridge rich in magnesium and vitamin B6.

To improve the excretion of excess oxalic acid from the body, it is recommended: pears, apples, plums, grapes, dogwood.

You also need to drink plenty of water.

Diet for the deposition of cystine stones.

This pathology develops with a congenital defect in the metabolism of amino acids and their excretion through the kidneys. In this case, an elimination diet is used, which excludes foods containing a certain substance from the diet. All day there should be a vegetarian table, animal products can be consumed only in the morning for breakfast, combining them with taking a large amount of vitamin C, which will avoid an increase in the cystine content in the urine at night, when urine is most concentrated and stones are most easily formed. It is necessary to take a large amount of liquid. Salt should not be limited, since a large amount of sodium contributes to the normalization of kidney function in relation to amino acids.

2.7 Physiotherapy for urolithiasis

The complex conservative treatment of patients with urolithiasis includes the appointment of various physiotherapeutic methods: sinusoidal modulated currents; dynamic ampl pulse - therapy; ultrasound; laser therapy; inductothermy.

In the case of the use of physiotherapy in patients with urolithiasis complicated by urinary tract infection, it is necessary to take into account the phases of the inflammatory process (shown in the latent course and in remission).

Rehabilitation therapy for patients with urolithiasis

The goal of treatment of patients with urolithiasis (UCD) is to restore impaired metabolism and prevent the precipitation of salts in the urine.

Comprehensive prevention of patients with KSD and urolithiasis consists of a combination of the following therapeutic factors: internal and external applications of mineral waters; appointment of therapeutic mud, therapeutic nutrition, therapeutic physical culture, therapeutic regimen, apparatus physiotherapy. There are several groups of patients subject to rehabilitation treatment: patients who underwent surgical removal of calculi from the kidneys and ureters or their extraction or extracorporeal shock wave lithotripsy, patients with small calculi in the kidneys and ureters, which, judging by their size and anatomical and functional condition of the kidneys and urinary tract, can move away on their own. The maximum size of the calculus should not exceed 8 mm in the absence of an active phase of chronic pyelonephritis in these patients, patients with unilateral or bilateral staghorn stones, in which surgical treatment is either not indicated at the moment or is impossible, patients with stones of a single kidney, if they are not obturating or migrating, preoperative preparation of patients with urolithiasis. Thus, the main tasks of restorative therapy of patients with KSD and urolithic diathesis are the following: elimination of small calculi; removal from the urinary tract of salts, mucus, decay products of tissues, bacteria; anti-inflammatory therapy; normalization of impaired mineral metabolism and urodynamics of the upper urinary tract. Therefore, the strategic goal of spa therapy is primary and secondary prevention of urolithiasis.

Contraindications: the presence of urostasis caused by a calculus or anatomical features of the upper urinary tract, chronic pyelonephritis in the phase of active inflammation, patients with large, long-term ureteral and kidney stones in one place, patients with staghorn stones and stones of the only kidney against the background of progressive chronic renal failure ( CRF) - intermittent and terminal stages. The remaining contraindications for the treatment of patients with urolithiasis are common and are associated mainly with cardiovascular and cardiopulmonary insufficiency.

Drinking mineral water.

The main natural factor used for the prevention and treatment of patients with KSD is drinking mineral water. The intake of water from mineral springs leads to the restoration of violations of mineral metabolism. At the same time, the production of protective colloids increases, the solubility of salts in the urine increases and their precipitation stops. Consequently, one of the conditions for stone formation or further growth of existing stones is eliminated.

In addition, mineral waters dissolve and wash out mucus, pus, and pathogens that have accumulated in the urinary tract. As a result, the size of the calculus surrounded by mucus and salt deposits decreases. However, it should be noted that stones of the kidneys and urinary tract cannot be dissolved by any mineral waters. Restorative therapy only contributes to a faster independent discharge of a stone from the pyelocaliceal system (PCS) and the ureter if it can be removed in its shape and size without additional surgical or instrumental intervention.

Drinking mineral waters used for the prevention and treatment of patients with urolithiasis should have the following properties. First, to have a pronounced diuretic effect. Secondly, to have an anti-inflammatory and mucus-dissolving action. Thirdly, to have an antispasmodic effect in case of pathological spasm of the smooth muscles of the PCS and ureters and an analgesic effect. Fourth, drinking mineral water should affect the pH of the urine, which is especially important in the treatment of patients. Fifth, to have a tonic effect on the smooth muscles of the upper urinary tract. Sixth, increase renal plasma flow and urine filtration in the renal glomeruli. The therapeutic effect of mineral waters is due to the variety of their physical and chemical properties, as well as their chemical composition.

The physical properties of mineral waters include: temperature, radioactivity, pH value.

Chemical properties determined by the content of minerals, gases, specific biologically active substances.

The chemical composition of mineral water is one of the most important characteristics and is of great importance in assessing its physiological and therapeutic effects. In mineral water, there are not salts themselves, but complexes of ions (anions and cations), which constantly combine and separate, forming complex composition. The main anions of mineral waters are bicarbonate (НСО3-), sulfate (SO42-) and chlorine (Сl-). The leading cations are sodium, calcium and magnesium. It is from the main ions found in mineral water that the water gets its name. Ions such as sodium, potassium, calcium, magnesium, bicarbonate, chlorine are contained in mineral waters in large quantities and are involved in the most important metabolic processes, including maintaining acid-base balance.

Mineral waters also contain trace elements (iodine, bromine, iron, fluorine, silicon, arsenic, boron) and organic substances (humins, naphthenes, bitumens).

Mineral waters, depending on temperature, are divided into: cold (below 20°C), subthermal (20-36°C), thermal (37-42°C), hyperthermal (above 42°C).

The temperature of the human body is chosen as the boundary between subthermal and thermal waters.

The diuretic effect mainly depends on the hypotonicity of mineral waters, to a lesser extent - on its mineral composition and temperature. If it is necessary to increase diuresis, mineral water of a lower temperature is prescribed. Hypertonic water for drinking treatment of patients with urolithiasis is practically not used.

Each of the chemicals that make up mineral waters has a certain effect on the body as a whole and on the urinary system in particular.

Carbon dioxide (CO2) is contained in almost all medicinal waters in fairly significant quantities (from 0.8 to 1.52 grams per 1 liter). Medicinal water containing CO2 is absorbed in the body much faster than water that does not contain it. This contributes to its faster excretion by the kidneys, which is one of the reasons for the diuretic effect. In addition, carbon dioxide increases blood flow and water filtration in the renal glomeruli, while calcium and magnesium salts absorb excess fluid during tissue metabolism and increase its excretion from the body. As a result, diuresis increases and the hydrodynamic effect in the PCL of the kidneys and ureters increases. At the same time, CO2 when drinking carbonic water has a beneficial effect on the nervous system, stimulating and toning it; excites taste buds in the mouth, increasing appetite; enhances gastric secretion and motility of the stomach and intestines.

Calcium ions have an anti-inflammatory effect due to the astringent and sealing effect on the cell wall. This is extremely important in the treatment of patients with KSD and in the presence of concomitant pyelonephritis. At the same time, calcium salts increase blood clotting, helping to stop bleeding, which has a positive effect on hematuria. Calcium also increases the solubility of uric acid in the urine, which explains the effectiveness of treatment for uric acid diathesis.

The anti-inflammatory effect of a number of mineral springs is enhanced by the presence of sulfur compounds in their composition, which are not necessarily volatile. Potassium ions have a stimulating effect on the smooth muscles of the urinary tract, increasing motor function PLS of the kidneys and ureters, and improve urodynamics, which contributes to the promotion of urinary sand and small stones and their removal with urine from the urinary tract.

A significant content of sulfate anion, carbon dioxide and calcium salts is due to the shift of ionic equilibrium towards oxidation. The ability of mineral waters to change the degree of acidity of urine and thereby create unfavorable conditions for the development of microbes is of great importance for the effective treatment of inflammatory processes in the urinary tract.

It should be remembered that when drinking mineral waters, the pH of urine changes faster than when prescribing an appropriate diet. With urinary tract infections, urine pH should be adjusted according to the chemical composition of urinary salts and stones. In the presence of hyperuricuria and uraturia, oxaluria and oxalates, alkalization of urine with slightly alkaline mineral drinking water is necessary. In the presence of phosphaturia and phosphate stones, acidic mineral drinking water should be recommended. The presence of magnesium ions in mineral waters is useful for patients with oxaluria and oxalate stones due to their inhibitory effect on the formation of urinary stones. Some trace elements in mineral waters (copper, iron, tungsten) contribute to the dissolution of oxalate and phosphate salts.

The diuretic property of mineral waters means not only the removal of water from the body, but also the removal, together with water, of minerals and products of nitrogen metabolism that are unnecessary for the body. Hot springs increase the excretion of urine with a high content of salt in it. When taking such mineral waters, the water content in the blood temporarily increases, followed by its excretion in the urine.

Medicinal mineral waters are not a simple solution of various salts: salts are in a state electrolytic dissociation. This means that some of the molecules of these salts decompose into ions - cations and anions. The ratio between the number of cations, anions and molecules that have not decomposed into ions can change under different conditions, as a result of which the properties of water also change. Therefore, it is recommended to drink mineral water directly at the source, where special pump rooms are arranged.

It is recommended that patients with ICD take mineral water 4-6 times a day, 200-300 milliliters once, 30-40 minutes before meals and 2-3 hours after meals. This allows you to maintain diuresis at a constantly high level throughout the day.

The temperature of the received mineral water can vary from 24 to 45°C, depending on the desired effect. If necessary, sharply increase diuresis, take subthermal mineral water. With concomitant chronic pyelonephritis, as well as, if necessary, to relieve spasm of the upper urinary tract and pain, it is recommended to take thermal and hyperthermal mineral waters.

Medicinal mineral water is usually drunk slowly, slowly, in small sips. It is usually recommended to walk while drinking water, as this contributes to its better absorption. In view of the fact that when drinking water slowly, its temperature may decrease, then in cases where drinking hot water is prescribed, after drinking part of the contents of the glass, replace the rest with a new portion of hot water and continue drinking without exceeding the prescribed single dose.

The duration of treatment with mineral waters in drinking resorts according to the classical method is usually 4 weeks.

Thus, drinking therapeutic mineral waters is an important specific natural factor of paramount importance in the prevention and treatment of patients with urolithiasis.

External use of mineral waters.

The external use of mineral waters in the form of therapeutic baths is not of paramount importance in the prevention and treatment of patients with KSD. However, in complex therapy, including drinking mineral water, diet therapy, therapeutic physical culture, apparatus physiotherapy, the role of therapeutic mineral baths is quite significant.

The action of mineral baths is based on a complex and interrelated influence on the body of mechanical, chemical and temperature factors. A large role, apparently, belongs to the temperature factor.

The mechanical effect of general mineral baths on the human body should be considered from several positions. One side, mechanical pressure when taking mineral baths, it serves as a source of irritation of mechanoreceptors of the skin and reflexively influences the formation of the general response of the body. On the other hand, causing compression of the venous vessels, the mechanical factor affects microcirculation and hemodynamics, blood distribution in the body, heart function and lymph circulation. In addition, the mechanical factor has a certain significance in the transfer of heat into the depths of tissues.

Chemical substances contained in therapeutic baths (cations and anions of mineral salts, trace elements, organic compounds, gases, radioactive substances, etc.) can act on the body in various ways: directly on the skin and its structures, reflexively due to chemical irritation of the extero- and interoreceptors of the skin, humoral through the penetration of mineral water components through the skin barrier and their circulation in the blood.

An important factor for the chemical action of the mineral water component is skin permeability. The passage of substances through the skin is carried out either transepidermally or through the pores and appendages of the skin. Substances that are soluble in both water and lipids have the greatest penetrating power. Many gases diffuse fairly easily through the skin.

Iodine, bromine and arsenic ions, hydrogen sulfide, carbon dioxide, oxygen and others penetrate into the body from mineral baths. Iodine that has penetrated into the body accumulates intensively in the thyroid gland, and bromine - in various structures of the brain. Thanks to these iodine ions, bromine baths have a specific effect on metabolism, functions thyroid gland and the pituitary gland, the nervous system.

The specificity of the action of radon baths is largely due to the entry into the body of radon, its daughter products, as well as the formation of active plaque on human skin. The radiation that occurs in the body causes the ionization of water and the organization of molecules, promotes the formation of various peroxides, which significantly affects the biochemical and biophysical processes in cells and tissues.

Therefore, the peculiarity of the action of various mineral waters is to a certain extent due to the pharmacokinetics and pharmacodynamics of their chemical ingredients that have penetrated into the body during the procedure.

The action of the chemical factor of mineral waters can also manifest itself in a way that does not require the entry of their components into the internal environment of the body. Without penetrating the skin barrier, salts and other chemical compounds form a kind of chemical mantle, impregnate the surface layers of the skin, enter the skin glands and hair follicles. At the same time, they serve as a source of long-term chemical irritation, which by a reflex way corrects the thermal regulatory reflex and the reactions associated with it. Along with this, the chemical components of mineral waters have a direct effect on the skin, which is actively involved in metabolic processes, reactivity and immunobiological reactions of the body. In the mechanism of action of mineral waters, a certain role is played by the formation of physiologically active substances in the skin, which, entering the bloodstream, affect various organs and systems, including the nervous, endocrine and immune systems. Mineral waters can affect the production of antibodies, change the response of immunocompetent organs, limit the development allergic reactions immediate and delayed types, affect a variety of indicators of nonspecific immunity, stimulate the activity of the reticuloendothelial system.

Thus, the chemical components of mineral waters have a direct or indirect effect on various organs and systems of the body.

The temperature (thermal) factor has a variety of effects on the body and plays an important role in the mechanism of action of mineral baths. The consequence of the direct action of the temperature factor is an increase in the activity of enzymes and the rate of biological reactions catalyzed by them, an increase in local metabolic processes. One of the manifestations of such processes can be considered the acceleration of tissue regeneration (epithelial, connective, nervous, and others). An increase in skin temperature can lead to the release and enhancement of the synthesis of biologically active substances, the appearance of products of autolytic cell decay. All this can also contribute to the stimulation of reparative and regenerative processes.

An increase in temperature is simultaneously accompanied by an increase in the permeability of histohematic barriers and activation of diffuse processes. As a result of tissue heating, pain decreases or disappears, muscle tension is relieved.

The excitability of peripheral receptors and the bioelectrical activity of the hypothalamus under the influence of baths of various chemical compositions change in the same direction. Along with a change in the bioelectrical activity in these nerve formations involved in the regulation critical processes the vital activity of the body and thermoregulation, in particular, metabolic processes, including neurosecretion in the hypothalamus, also change significantly.

The reflex reaction that occurs as a result of thermal stimulation of the body with mineral baths is characterized primarily by the mobilization of the term of the regulatory activity of the nervous system and peripheral apparatus, which manifests itself in pronounced hemodynamic shifts, changes in the activity of the heart and lungs, metabolism, and others.

So, the body responds to the temperature irritation produced by mineral baths with a complex adaptive reaction, the basis of which is the thermal regulatory reflex.

Thus, the action of mineral baths on the human body is based on local shifts caused by the direct influence of mechanical, chemical and temperature factors on skin, and a complex adaptive reaction that develops according to neuro-reflex and humoral mechanisms due to irritation of baro-, mechano-, chemo- and thermoreceptors and the formation of biologically active substances. Ultimately, due to these mechanisms, pathological changes are weakened, painful phenomena disappear or decrease, compensatory reactions are stimulated, the adaptive capabilities of the body increase and impaired functions are restored.

For the prevention and treatment of patients with KSD, sodium chloride, iodine, bromine and radon baths are most widely used.

Sodium chloride baths have a regulatory effect on the functional state of the central nervous system, cause immunological changes in the body, significantly change the course of metabolic processes, and so on. Analgesic, anti-inflammatory, antispasmodic and desensitizing effects have been identified. Sodium chloride baths are used at a temperature of 36-38°C, the duration of the procedure is 10-15 minutes, daily or 2 days in a row with a break on the 3rd day. The course of treatment is prescribed 12-15 procedures.

Iodine-bromine baths affect the leading physiological systems of the body (nervous, cardiovascular, sympathetic-adrenal and pituitary-adrenal), resulting in conditions for the formation of compensatory-adaptive and regenerative reactions of the body, which contributes to a significant change in the course of the pathological process in many diseases , the basis of the pathogenesis of which is a violation of the function of the central nervous system, metabolic processes, thyroid function, and others.

Iodine-bromine baths are a "mild" irritant. Apply at a temperature of 36-38 ° C, the duration of the procedure is 10-15 minutes, daily or 2 days in a row with a rest on the 3rd day. The course of treatment is prescribed 15-20 baths.

Radon baths normalize peripheral circulation and heart function, stabilize blood pressure, and improve blood composition. Radon baths stimulate the motor and secretory functions of the stomach, liver and pancreas, improve blood circulation in the liver, and also stimulate the contractile function of the upper urinary tract. They reduce the increased function of the thyroid gland and ovaries, normalize the work of the pituitary gland, the medulla and cortical layer of the adrenal glands. Radon procedures have a beneficial effect on basal metabolism, on certain aspects of carbohydrate and mineral metabolism, and on cholesterol metabolism. Radon baths stimulate immunological reactions body, have analgesic, antipruritic, antispasmodic, enhancing the contractile function of the upper urinary tract, anti-inflammatory and desensitizing effects. Radon baths have a calming effect on the central nervous system, and an anesthetic effect on the peripheral nervous system. Natural radon baths are used in concentrations from several units to several hundred nCi/l. Radon baths are used at a concentration of 40-120 nCi / l at a water temperature of 35-37 ° C, lasting from 5 to 15 minutes, daily or 2 days in a row with rest on the 3rd day. The course of treatment is prescribed 12-15 procedures.

Thus, mineral baths used to treat patients with KSD have an antispasmodic effect on the smooth muscles of the upper urinary tract, which contributes to a faster discharge of small stones, salts, mucus, bacteria, and the like; normalize metabolism, including mineral; have anti-inflammatory and immunomodulatory effects.

Therapeutic effect mineral baths in ICD is especially pronounced in their complex application with drinking mineral water, diet therapy, exercise therapy, hardware physiotherapy.

When taking a mineral bath, the patient must observe the following rules: lie in the bath calmly and in such a position that the upper part of the chest, starting from the nipples and above, is not covered with water; after the bath, you must rest in a special room for 30-40 minutes; a bath not on an empty stomach, but after a light breakfast; you should take a bath 1-1.5 hours after eating, on the day of taking a bath, do not take long walks and do not take several tedious procedures at once (mud therapy).

Mud cure.

Mud therapy is not a specific natural factor used in the prevention and treatment of patients with KSD.

Basically, mud therapy for KSD is used in combination with drinking mineral water and mineral baths with concomitant chronic pyelonephritis in the phase of remission or latent inflammation.

Therapeutic muds are natural organomineral colloidal formations (silt, peat, knoll, sapropel) with high heat capacity and heat-retaining capacity, containing, as a rule, therapeutically active substances (salts, gases, biostimulants, etc.) and living microorganisms.

The action of therapeutic muds as environmental irritants is based on general physiological mechanisms that determine the body's response. These general patterns are based on ideas about the integrity of the body, provided by nervous and humoral regulatory mechanisms, and their interaction.

The reaction of the body to the impact of therapeutic mud is due to irritation of a large number of sensitive nerve endings of the skin and mucous membranes, followed by the flow of impulses into the central nervous system and the development of reflex reactions. Therefore, the general physiological mechanism of influence on the body of mud procedures is primarily a reflex pathway of influence, including humoral links.

In the mechanism of action of mud, a certain role belongs to the activation of the pituitary - adrenal cortex system. At the same time, a two-phase reaction of this system is revealed: the initial restriction is replaced (by the end of the course of treatment, increased activity.

Thus, their anti-inflammatory activity, which is important in the therapeutic effect of mud, manifests itself only with preserved neuro-humoral regulatory mechanisms, including the adrenal cortex, thyroid gland and pituitary. In addition, mud therapy causes an intensification of carbohydrate, phosphorus, lipid and protein metabolism. Mud procedures are accompanied by increased mobilization of sugar from liver glycogen, increased activity of proteolytic enzymes with increased protein breakdown and an increase in the level of residual nitrogen in the blood. Under the influence of mud applications, the activity of cellular respiration enzymes increases and tissue respiration increases, which ultimately mobilizes the compensatory-adaptive reactions of the body. In the action of therapeutic mud on the body, the significance of their properties as heat carriers is taken into account. There is a point of view that the thermal factor is the leading and determining therapeutic effect of mud. With an increase in the temperature of the mud within certain limits, the reaction of the cardiovascular system intensifies, the mass of circulating blood increases, and excitation processes begin to predominate in nervous system, skeletal muscle chronaxia lengthens, the permeability of vascular tissue structures increases, gas exchange increases, changes in catecholamine metabolism increase, the activity of cellular respiration enzymes, motor and secretory activity of the stomach, clinically pronounced balneological reactions and exacerbations of inflammatory processes occur more often.

At the same time, it has been shown that a favorable clinical effect is achieved in the case of mud applications at a temperature close to body temperature, the so-called cold mud.

Therefore, the effect of therapeutic mud depends not only on the thermal factor. It is essential that in order to achieve one or another physiological effect at a higher temperature of therapeutic mud, a smaller exposure of the application is required, and at a low temperature, a larger one. This is due to the need for a certain time for the absorption of the chemical components of the mud. The studies carried out in this direction made it possible to prove the important role of the chemical factor in the mechanism of the anti-inflammatory action of therapeutic mud. The importance of the chemical factor in the action of therapeutic mud is also confirmed by the fact that chemically indifferent, but similar in thermal properties, substances (sand, clay) of the same temperature as native mud turned out to be largely devoid of its inherent action. With all the variety of the general effect of therapeutic mud on the body important feature- the predominant effect of this factor on the processes, in one way or another, related to the development of inflammation in the broadest sense, as well as to its consequences. The influence of mud on the reactivity of the body, including immunological, is accompanied by an anti-inflammatory effect in allergic and infectious-allergic diseases.

Therapeutic mud procedures have a variety of effects on the body: a mechanical effect due to the pressure of the mud mass on the body and friction between the surface of the body and mud particles, a chemical effect due to the absorption of gases and volatile substances through the skin, the action of biologically active substances contained in the mud, the action of a relatively high temperature .

Mud applications in the form of “panties” are used to treat patients with KSD, when mud is applied to the lower abdomen, lower back, buttocks and thighs. The temperature of the mud “underpants” is 40-42°C. The course of treatment consists of 10-12 procedures carried out either every other day or 2 days in a row with a rest on the 3rd day. At the end of the procedure, the dirt is washed off under a warm shower, after which the patient rests for 40-45 minutes.

Mud therapy for ICD with concomitant chronic pyelonephritis is especially effective in alternation with mineral baths.

2.8 Triar massage for urolithiasis

Currently, we know more than 200 massage techniques. Despite the ancient traditions of massage, new institutions, schools and trends are emerging that allow us to most effectively solve the problems of restoring health, youth and beauty.

Holistic or integral massages are becoming more and more widespread, in which the physical, mental and social factors affecting the patient are taken into account to a greater extent than a simple diagnosis of the disease he has. TRIAR massage is the best combination of the latest technology and ancient techniques healing, TRIAR-massage (3R - Relax, Release, Rehabilitaton, or Relaxation, Release, Recovery (health) - an integrated massage technique that comprehensively solves a wide range of specific problems of an aesthetic and physiological nature (disease prevention and health maintenance, improved adaptation to the environment and others).

The work algorithm proposed by TRIAR-massage allows you to combine and vary, depending on the indications, the techniques of Swedish massage, soft manual methods and therapeutic exercises in such a way that positive impact these techniques are enhanced. Each technique has its own individual characteristics performance and impact on certain layers of tissues, has its main specific physiological effect for this technique, as well as associated physiological effects both on individual systems and on the body as a whole. As a result - the removal of pain, improved mobility in the joints, improved muscle contractility and increased overall tone and turgor of tissues, slowing down the aging process. - Relaxation

This type of massage technique is aimed at deep relaxation, relieving tension and stress. It has a calming effect, restoring energy balance and peace of mind. Relax massage is an excellent wellness procedure that quickly relieves fatigue and restores working capacity, prevents overwork, and creates a good mood; it is not only a pleasure, but also a very effective method treatment and prevention of many diseases.

This technique is based on the Swedish P.H. massage. Linga. The main effects of Swedish massage are the activation of blood and lymph circulation both in the treated anatomical area and throughout the body, and, as a result, the acceleration of the overall metabolism. Thanks to the reflex effect of massage techniques, you can adjust the activity internal organs. In addition, Swedish massage techniques, performed in a certain way, affect the functional state of the cerebral cortex, increasing or decreasing the excitability of the central nervous system. The complex of massage and gymnastics (Ling complex) is rightfully considered a powerful therapeutic and prophylactic tool that allows you to prepare the body for physical exertion or for medical procedures.

Releasing is a branch of alternative medicine that involves identifying structural changes and applying specific massage techniques to stretch the fascia and eliminate possible knots of tension that occur between the fascia, muscles and bones. This technique has been successfully used to relieve pain, release tension and restore balance to the body. Its main components are soft manual techniques (MMT) of the functional direction, which belong to the progressive direction of modern manual therapy. They are devoid of the shortcomings of direct manipulations used in classical manual techniques. Therefore, they were adopted by massage therapists and are a huge success.

The essence of the method is in a soft layer-by-layer effect on tissues in order to eliminate tension and displacement of internal organs, increase blood flow and lymph flow. At the same time, the functioning of organs is significantly improved, many diseases are eliminated without the use of medications. The impact of releasing techniques is very mild, and this makes it possible to work with wrinkles on the face, and with mimic muscles, and with seams and scars, neck muscles (injuries are completely excluded) - in a word, with any muscles and fascia to the full depth soft tissue up to the periosteum. In this case, the patient does not experience pain and most often sleeps.

The main types of release techniques:

myofascial release;

work with trigger points;

post-isometric relaxation.

Myofascial release technique is based on the idea of ​​the unity and integrity of the body's fascial system. Fascia are interconnected and form a single tissue system. They are part of the so-called soft skeleton, perform supporting and trophic functions. Violation of the fascial structure leads to disruption of the normal functioning of the muscles, which, in turn, can cause pain. Myofascial release is a technique that includes the identification of structural changes in the fascia and the use of special massage techniques to eliminate these disorders.

Trigger points (or myofascial trigger points) are supersensitively palpable hardened areas in a muscle or its fascia. AT propulsion system such points can cause functional disorders or be their consequence. There is practically no muscle in which, under certain conditions, such a violation could not develop. In TRIAR massage, for medical reasons, exposure to trigger points may be included.

The purpose of post-isometric relaxation (PIR) used in TRIAR massage is to relax muscle clamps. This is achieved by combining short-term voluntary isometric muscle tension with its subsequent slow passive stretching. As a result, functional hypertonicity of the muscles is eliminated and, as a result, muscle and joint pain, excessive tension of the ligaments, joint capsules, compression of blood vessels and nerves. - Recovery (improvement)

Rehabilitation massage techniques are most effective for functional treatment and restoration of the patient's physical performance, especially after surgical interventions (removal of the menisci, surgery on the Achilles tendon, and others). Such techniques are carried out in combination with therapeutic exercises and soft manual techniques. A session of general rehabilitation massage is recommended 2-3 times a week, and local - daily. In case of injuries, massage begins to be used as early as possible, since it helps to normalize blood and lymph flow, relieve pain, resolve edema, hematoma, and normalize redox processes in the body. With the help of rehabilitation massage, the following tasks are solved:

.General tonic effect - by enhancing blood and lymph circulation, as well as non-specific stimulation of exteroceptive and proprioceptive sensitivity (Swedish massage + myofascial release).

Regional tonic effect on flaccidly paretic muscles - is achieved by applying various techniques of Swedish massage in large volume, with sufficient strength, with exteroceptive relief, due to longitudinal rubbing and kneading of the muscle abdomen in its various states (relaxation or varying degrees of tension) and subsequent shaking, small-point vibration and short-term, up to pain, pressing the muscle.

Relaxing effect on rigid, spastic and locally spasmodic muscles, carried out with the help of general relaxing techniques of soft manual techniques, performed at a slow pace with obligatory pauses between techniques. The analgesic effect is achieved by the reflex effect of the technique of exposure to trigger points.

A feature of the TRIAR complex is the use of the elements of the above methods not only as manual therapy (only to eliminate dysfunctions), but as a system for increasing joint mobility, improving or restoring spinal mobility at any age. At the same time, the body's capabilities for self-correction and restoration of partially lost functions are used.

All methods of restorative massage should be combined with passive and active gymnastics. The therapeutic effect from the use of the manual rehabilitation complex is significant and persists for a long time during physical activity. The rehabilitation program is compiled individually each time. It can be used for athletes during rest and recovery and for healthy people for the purpose of recovery and prevention.

Conclusion

In the course of the work done, the relevance and severity of the problem of urolithiasis among the population was revealed. All the tasks were completed: we studied the pathogenesis and etiology of the disease urolithiasis (UCD), considered the main methods of rehabilitation in urolithiasis, outlined the main directions and methods of treating this pathology, examined in detail the main group of drugs for the treatment of urolithiasis - antispasmodics, described the role of herbal medicine and the resort treatment in the treatment of the pathology under study, revealed the main pharmacological indicators of drugs in the treatment of urolithiasis, and also considered non-traditional methods of treating KSD. Although urolithiasis is a multi-causal disease, but, in my opinion, nutrition plays a big role in the appearance of such a disease. Nutritionists say that a person is what he eats. There is some truth in this humorous phrase. The state of human health is largely determined by nutrition. Eating disorders cause serious health problems. Therefore, the main commandment of health should sound like this: “Eat wisely! Identify and correct your eating errors.

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Even in ancient times, people noticed the healing power of the surrounding world - air, sun, sea ​​water… The thousand-year experience of many cultures confirms that the wise use of the gifts of nature can improve health, treat and prevent many diseases. Of course, this will not completely replace drug therapy, but will help reduce the amount of medication used. For example, herbal medicine for urolithiasis can not only treat, but also help prevent the early development of the disease.
Climatic resorts are very diverse and each of them favorably affects people with various diseases.

Article content:

Factors of selection of patients for sanatorium treatment

When selecting patients with urolithiasis for sanatorium treatment, the following factors are taken into account:

• Size of calculi (stones). Patients with small calculi that do not require surgical intervention and with possible spontaneous discharge of the calculus can be referred for sanatorium treatment. Most often, such stones are located in the pelvis, bladder or ureters. If the calculus is larger than 6-10 mm in diameter, spa treatment of urolithiasis is possible only after surgical removal of the stone. As an alternative, crushing can also be used, after which rehabilitation is also necessary.

In addition, staghorn calculi, which after spa treatment often increase in size and contribute to the deterioration of kidney function, are of particular concern. Sanatorium treatment for such people is recommended after surgery, after one and a half to two months.

• inflammation activity. In half of the people, urolithiasis can be complicated by chronic pyelonephritis. With calculous pyelonephritis, sanatorium treatment is recommended only during remission. During an active inflammatory process, when the release of leukocytes is more than 25,000 in 1 ml of urine, the release of bacteria is over 1,000,000 in 1 ml of urine, spa therapy is prohibited.

Urolithiasis disease in some cases amenable to conservative treatment. Stone expulsion therapy is indicated for small kidney stones, uncomplicated ureteral calculi that can move away on their own, and also after extracorporeal lithotripsy. Therapy of urolithiasis is aimed at preventing the recurrence of stone formation and growth of the calculus, as well as at the dissolution of stones (litholysis). Non-surgical treatment of urolithiasis includes the following necessary measures:

1. Pharmacotherapy (drug therapy) for kidney stones

Medical treatment urolithiasis of the kidneys includes:

• measures to prevent stone formation;
• treatment of concomitant urinary tract infections that often occur with urolithiasis;
• relief of attacks of renal colic with antispasmodic drugs;
• litholysis (dissolution) of existing stones with special preparations and herbs.

Purpose antibacterial drugs taking into account the data of bacteriological examination of urine and clearance of endogenous creatinine, it is indicated in case of infection.

1.1. Treatment for urate kidney stones

At urate stones kidneys for litholysis of uric acid stones use the drug Blemaren, which promotes alkalization of urine and the dissolution of uric acid crystals. The dose of the drug is selected individually to achieve the pH range of urine 6.2–7.0.

In case of disorders of purine metabolism (hyperuricemia, hyperuricuria) and in order to prevent the formation of uric acid stones, Allopurinol is prescribed 100 mg 4 times a day for 1 month. Allopurinol, inhibiting xanthine oxidase, prevents the transition of hypoxanthine to xanthine and the formation of uric acid from it, reduces the concentration of uric acid and its salts in body fluids, helps dissolve existing urate deposits, and prevents their formation in tissues and kidneys.

1.2. Treatment for calcium oxalate and calcium phosphate kidney stones

At calcium oxalate and calcium phosphate stones are used pyridoxine , magnesium preparations, hydrochlorothiazide (reduces the severity of hypercalciuria), as well as etidronic acid (Xidiphone).

Xidifon is an inhibitor of osteoclastic bone resorption. The drug prevents the release of ionized calcium from the bones, pathological calcification of soft tissues, crystal formation, growth and aggregation of calcium oxalate and calcium phosphate crystals in the urine. Maintaining Ca2+ in a dissolved state reduces the possibility of formation of insoluble Ca2+ compounds with oxalates, mucopolysaccharides and phosphates, thereby preventing recurrence of stone formation. Xidifon is administered orally as a 2% solution, which is obtained by adding 9 parts of distilled or boiled water to 1 part of a 20% solution. The drug is taken 15 ml 3 times a day 30 minutes before meals. The initial course of treatment is 14 days. With crystalluria and the presence of stones in the kidneys, 5-6 courses are carried out with 3-week breaks for 1-2 years. To prevent stone formation, Xidifon therapy is continued for 2-6 months.

In addition, at calcium phosphate stones are used to acidify urine boric acid or methionine .

2. Diet therapy for urolithiasis of the kidneys

The diet of patients with KSD includes:

• drinking at least 2 liters of fluid per day;
• depending on the identified metabolic disorders and the chemical composition of the stone, it is recommended to limit the intake of animal protein, table salt, products containing large amounts of calcium, purine bases, oxalic acid;
• The consumption of foods rich in fiber has a positive effect on the state of metabolism.

3. Physiotherapy of urolithiasis of the kidneys

As part of the complex conservative treatment of patients with KSD, various physiotherapeutic methods are used, aimed both at accelerating the passage of the stone from the ureter and at treating concomitant pyelonephritis:

• amplipulse therapy (a method of electrotherapy in which the patient is affected by alternating sinusoidal modulated currents of low strength);
• laser magnetic therapy (hardware exposure under the influence of laser radiation in the infrared spectrum penetrating to a depth of 6 cm);
• ultrasound therapy (the use of mechanical vibrations of ultra-high frequency of 800-3000 kHz, called ultrasound, for therapeutic and prophylactic purposes).

4. Sanatorium treatment of urolithiasis

Sanatorium-and-spa treatment is indicated for ICD both in the period of the absence of a stone (after its removal or independent discharge), and in the presence of a calculus. It is effective for kidney stones, the size and shape of which, as well as the condition of the upper urinary tract, allow us to hope for their independent discharge under the influence of the diuretic action of mineral waters.

Patients with urate and calcium oxalate urolithiasis shows treatment at resorts with low-mineralized alkaline mineral waters, such as Zheleznovodsk (Slavyanovskaya, Smirnovskaya); Essentuki (Essentuki No. 4, 17); Pyatigorsk, Kislovodsk (Narzan). At calcium oxalate urolithiasis can also be treated at the resort of Truskavets (Naftusya), where mineral water is slightly acidic and low-mineralized.

Reception of the above mineral waters for therapeutic and prophylactic purposes is possible in an amount of not more than 0.5 l / day under strict laboratory control of indicators of the exchange of stone-forming substances. The use of similar bottled mineral waters does not replace a spa stay.