Conservative treatment of urinary tract stones
INTRODUCTION
Urinary tract stones remain one of the most common problems addressed by urologists. According to the latest data, the frequency of urinary tract stones worldwide ranges from 1 to 20 percent. Even in developed countries such as Sweden, Canada, or the United States, the prevalence of kidney stones exceeds 10 percent. [1].
Stones cause problems in various parts of the urinary tract: kidneys, ureters, bladder. Urinary tract stones causing symptoms are very common. Up to 68 percent of urinary tract stones up to 5 mm in size pass spontaneously, but sometimes prolonged passage can lead to dangerous complications. In the absence of indications for surgical treatment of urinary tract stones, the European Association of Urology recommends actively monitoring the patient and prescribing medications to reduce pain and accelerate stone passage [2].
CONSERVATIVE TREATMENT OF URINARY TRACT STONES
Many factors determine the choice of treatment tactics for urinary tract stones: stone size, location and number, presence of infection, previous urological procedures, and, of course, the patient's opinion. Advancements in modern technologies in urology have enabled the selection of various invasive treatment methods: endoscopic, laparoscopic, or open surgeries, extracorporeal shock wave lithotripsy (ESWL). However, the risk of possible complications often leads to choosing a conservative treatment method, especially in uncomplicated cases of urinary tract stones.
Conservative Treatment and Phytotherapy
As mentioned, up to 68 percent of urinary tract stones up to 5 mm in size pass spontaneously, but prolonged passage can lead to dangerous infectious complications. Other authors claim that even 95 percent of urinary tract stones up to 4 mm in size pass spontaneously [2].
The latest recommendations advise using various analgesics, nonsteroidal anti-inflammatory drugs, alpha-adrenoreceptors, and calcium channel blockers (CCBs) for the conservative treatment of urinary tract stones. However, plant-based remedies with fewer side effects are gaining popularity. Preparations containing terpenes, for example, have shown effectiveness in numerous studies.
Benefits of Alpha-Adrenoreceptor Blockers and CCBs
Patients suffering from urinary tract stones may recover faster and experience fewer pain episodes when prescribed alpha-adrenoreceptor blocking drugs like tamsulosin or CCBs such as nifedipine [3–4]. Both of these medications are effective, but research indicates that tamsulosin is significantly more effective than nifedipine. It reduces the frequency and intensity of pain attacks and accelerates the spontaneous passage of stones [5–6].
Increasing Popularity of Phytotherapy
The increasing popularity of phytotherapy and the demand for more natural medicine have led to the search for an alternative conservative treatment method. A mixture of terpenes, known in Europe as Rowatinex®, has anti-inflammatory, muscle-relaxing, antibacterial, and pain-relieving effects. The first terpene-containing preparations have been mentioned since 1950 [7].
Efficacy of Terpene Mixtures
Over the past 20 years, researchers have conducted numerous studies investigating the effects of terpene mixtures. These studies have explored their effectiveness in treating not only urinary tract stones but also urinary tract infections and chronic prostatitis [8]. The effect of Rowatinex® is very versatile, which is why this preparation is used in treating urinary tract stones. Terpenes inhibit the formation of calcium oxalate aggregates, which constitute a large part of urinary tract stones. The anti-inflammatory and pain-relieving effects are beneficial for reducing the pain, inflammation, and muscle spasms caused by stones. It also promotes urine production in the kidneys, as terpene preparations enhance kidney blood circulation. All these properties are highly valuable for patients suffering from various urinary tract conditions.
Meta-Analysis of Terpene Efficacy
In one of the more recent, extensive meta-analyses conducted by Michaelis Erlano Chua and colleagues, analyzing various clinical trials related to the use of terpene preparations for removing urinary tract stones [9], out of 117 possible sources, they rejected 96 that they deemed unreliable and unsuitable. The researchers revealed that patients treated with terpene preparations recovered significantly more often from urinary tract stones compared to patients in the placebo group who did not receive these preparations. A total of 344 patients were evaluated.
Comparing Terpenes and Alpha-Adrenergic Blockers
Subgroup analysis comparing the effectiveness of terpenes and alpha-adrenergic blockers did not show a significant difference between these groups. The effectiveness of terpenes increased with increasing dose. Studies have shown a positive correlation between the dose of terpene preparations and the likelihood of stone passage. Additionally, terpene preparations successfully reduce the need for analgesics in treating stone disease, thereby providing a more comprehensive and less invasive treatment option for patients. It is important to mention that most stones, when treated conservatively, passed within 2 weeks.
Optimal Duration for Conservative Treatment
After 14 days, the possibility of spontaneous stone passage clearly decreases. Based on this, the authors emphasized that conservative treatment of urinary tract stones should be applied for at least 2 weeks [9]. The European Association of Urology recommends conservative treatment of urinary tract stones for up to 30 days [2].
Rowatinex® Post-ESBL Treatment
Previous studies have investigated the effectiveness of treating urinary lithiasis with terpenes, but in recent years, studies have emerged examining the effects of Rowatinex® after ESBL. This non-invasive treatment method has become very popular since 1980 due to its simplicity. This procedure does not require anesthesia, and long-term hospitalization is unnecessary. However, the drawback is that stone fragments typically eliminate gradually over approximately 30 days. Any remaining fragments can cause pain, urinary tract obstruction, infection, or the formation of new stones [10].
Clinical Studies on Terpene Effectiveness
In a study conducted in Korea, the effectiveness of terpene preparations after ESBL was analyzed. The study involved 499 patients who underwent ESBL for urinary lithiasis (stones larger than 4 mm), with one group receiving analgesics, tamsulosin, and Rowatinex®, while the other group received only analgesics and tamsulosin. After 2 weeks of treatment, a comparable number of patients in both groups experienced stone elimination, with 37.4% in the first group and 35.5% in the second group (p=0.684). However, after 4 weeks, a statistically significant difference emerged, with 72.2% of stones eliminated in the first group compared to 61.1% in the second group (p=0.022).
Safety and Efficacy of Rowatinex®
The duration of treatment, frequency of complications, and the need for ureteroscopy were similar between the groups. No adverse drug effects (e.g., diarrhea, nausea, vomiting) were observed in the subjects. The study results demonstrated that Rowatinex® increases the likelihood of stone elimination after ESBL, especially when administered for at least 4 weeks. Up to 72.2% of stones were eliminated without an increased risk of complications, making the drug not only effective but also safe [11].
Conclusive Evidence of Rowatinex®
In a randomized, double-blind study conducted in Hungary, 222 patients with kidney or urinary lithiasis after ESBL were treated and monitored for 14 weeks. The first group of patients received Rowatinex® at a dose of 2 capsules 3 times a day, while the second group received a placebo. After 14 weeks, spontaneous lithotripsy occurred in 67.9% of patients in the first group, compared to 50% in the second group (p=0.009). Additionally, spontaneous lithotripsy occurred faster in the Rowatinex® group: an average of 49.5 days in the first group versus 85 days in the second group. The authors concluded that Rowatinex® is an effective, safe, and well-tolerated drug that facilitates stone elimination after ESBL [12].
SUMMARY
The multifaceted effects of terpene-containing preparations like Rowatinex® (anti-inflammatory, pain-relieving, muscle relaxant, and diuretic) are beneficial in treating urinary lithiasis. These drugs expedite stone elimination and reduce the need for analgesics.
Doctors can use Rowatinex® not only as a primary treatment for urinary lithiasis but also after ESBL procedures.
Prescribing terpene preparations after ESBL increases the likelihood of spontaneous stone elimination and shortens the time for stone elimination. This approach reduces the duration of treatment and patient discomfort. Observations indicate that the effectiveness of Rowatinex® improves with higher doses, recommending up to 2 capsules 3 times a day.
The drug's effectiveness particularly improves when taken for at least 4 weeks, while the risk of adverse effects remains low.
APPENDIX OF JOURNAL "INTERNIST" UROLOGY No. 1 (9)
