156

Practical Urology: EssEntial PrinciPlEs and PracticE

A liquid preparation of potassium citrate with a

pH to 6.5–7.0. When this conservative program

frequent dosage schedule (three to four times/

is ineffective d-penicillamine or alpha-mercap-

day) is recommended in chronic diarrheal states.

topropionylglycine (approximately 1–2 g/day in

In other conditions, a solid preparation given

divided doses) has been used. Penicillamine has

on a twice daily schedule is generally well

been associated with frequent side effects includ-

tolerated.

ing nephrotic syndrome, dermatitis, and pancy-

topenia. This side effect profile appears to be less

Hypomagnesiuric Calcium Nephrolithiasis

marked with alpha-mercaptopropionylglycine.

Hypomagnesiuric calcium nephrolithiasis is

characterized by low urinary magnesium, hyp-

Infection Lithiasis

ocitraturia, and low urine volume. Therefore,

management might include restoration of uri-

If long-standing effective control of infection

nary magnesium levels with either magnesium

with urea-splitting organisms can be achieved,

oxide or magnesium hydroxide as well as cor-

new stone formation may be averted and some

rection of the hypocitraturia with potassium

dissolution of existing stones may be achieved.

citrate.

Unfortunately, such control is difficult to obtain

with antibiotic therapy. If there is an existing

Gouty Diathesis

struvite stone, it is often difficult to completely

The major goal in the management of gouty

eradicate the infection because the stone often

harbors the organism within its interstices. For

diathesis is to increase the urinary pH above pH

this reason, surgical removal of struvite stones

5.5., preferably between 6.5 and 7.0. In the past,

is usually recommended.

urine alkalinization has been accomplished

Acetohydroxamic acid (AHA), a urease inhi-

with either sodium bicarbonate or various

bitor, may reduce the urinary saturation of

combinations of sodium and potassium alkali

struvite and to retard stone formation. When

therapy. While sodium alkali may enhance dis-

given at a dose of 250 mg three times/day, AHA

sociation of uric acid and inhibit uric stone acid

has been shown to prevent recurrence of new

formation by raising urinary pH, this medica-

stones and inhibit the growth of stones in

tion may be complicated by the development of

patients with chronic urea-splitting infections.

calcium-containing stones (calcium phosphate

In addition, in a limited number of patients,

and/or calcium oxalate). Potassium citrate is

AHA has caused dissolution of existing stru-

advantageous because it is not only a good alka-

vite calculi. However, 30% of patients receiving

linizing agent, but it appears to be devoid of

chronic AHA therapy have experienced minor

complication of calcium stones. It should be

side effects and 15% developed deep venous

given at dose sufficient to maintain urinary pH

thrombosis.

at approximately 6.5 (30–60 mEq/day in 2–3

divided doses). Attempts at alkalinizing the

urine to a pH of greater than 7.0 should be

Summary

avoided. At a higher pH, there is a danger of

increasing the risk of calcium stone formation.

If the urinary uric acid excretion is elevated or

Stone disease appears to be an increasing prob-

hyperuricemia exists, allopurinol (300 mg/day)

lem as a consequence of climate and dietary

is recommended.

changes, as well as lifestyle associated risk fac-

tors. The key role for proper management of

Cystinuria

stone disease is obtaining control of its under-

lying source. This goal can be easily achieved

The object of treatment for cystinuria is to reduce

provided there is good patient-physician com-

the urinary concentration of cystine to below its

munication and both sides adhere to simple

solubility limit (200–300 mg/L). The initial treat-

rules. Only in selected cases should further

ment program includes a high fluid intake and

regimens be added to the equation, while assur-

oral administration of soluble alkali (potassium

ing patient tolerance and compliance (see

citrate) at a dose sufficient to raise the urinary

Fig. 11.1).

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