AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS CLIENT RESPONSES Onset When did the symptoms start? The symptoms have been happening for the past few months. They go away for a while but come back again. Exacerbating factors What do you think makes it worse? The main thing is it keeps coming back after having sex. Relieving factors What makes it better? Antibiotics make it better and sometimes Ural helps too.

TABLE 9.2 CONTEXT

Analogy: Flesh of the apple	Context: Put the presenting complaint into context to understand the disease
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Occupational toxins and hazards
What kind of chemicals do you use in your work?	Mostly hair colouring and perming solutions. I always wear gloves to protect myself from the chemicals.
Functional disease
Were you doing any horseback or bike riding when you developed the symptoms of the stinging sensation on urination and vaginal discharge? (mechanical urethritis)	No, I am not that fit!
Infection and inflammation
Is the stinging and burning sensation on urination worse at the end of the urine stream? (cystitis) Are the symptoms of burning pain and increased frequency of urination pain better for a hot bath? (cystitis) Do you experience any pain or blood during or after sexual intercourse?(STD, cancer/infection)

Yes, definitely.

Yes, I do like to have a bath when the symptoms are bad, I think it relaxes me too.

No blood and pain when having sex but I notice the symptoms are bad afterwards.

Supplements and side effects of medications Has taking antibiotics led to any problems? I got thrush a couple of times, but I’m OK at the moment. Endocrine/reproductive

Can you tell me about your menstrual cycle?

Tell me about the vaginal discharge and pelvic discomfort.

Marion reports a 28-day cycle with normal bleed pattern and duration. She is not currently taking the oral contraceptive pill.

Marion notices she sometimes gets increased vaginal discharge, particularly after taking antibiotics which she thinks is thrush. The pelvic discomfort usually happens when she has cystitis.

Eating habits and energy

Tell me about your diet and

energy levels.

Marion describes her diet. It is high in refined carbohydrates and she drinks at least 4 cups of coffee daily. Sometimes she misses out on lunch if the salon is very busy. She tries to eat healthy food most nights.

She usually has lots of energy, but when she has cystitis she feels tired.

TABLE 9.3 CORE

Analogy: Core of the apple with the seed of ill health	Core: Holistic assessment to understand the client
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Daily activities
Tell me about your daily routine.	I get up at 6.30 am, have breakfast and get to work by 7.30 am. I finish about 5.30 pm or 6 pm and then go home. Dinner is about 7 pm and then I either go out with Sean or we stay home. I usually go to bed by 11 pm.
Occupation
Do you enjoy your work?	I love it, although standing on my feet all day can be tiring.
Family and friends Do you have much contact with family and friends?	Not as much as I did before I started going out with Sean. I try to see my parents every couple of weeks and sometimes Sean and I go out with friends.
Education and learning Do you understand why your cystitis keeps returning?	Not really, but I think it must have something to do with sex.
Action needed to heal
What do you think you need to do to get better?	Hopefully not stop having sex! Maybe I need to go to the toilet more during the day and drink more water.

TABLE 9.4 MARION’S SIGNS AND SYMPTOMS [1–3, 13]

Pulse	85 bpm
Blood pressure	120/80
Temperature	38°C
Respiratory rate	14 resp/min
Body mass index	22
Waist circumference	77 cm
Face	Pale
Urinalysis	Cloudy colour; foul odour; alkaline pH; leukocytes detected; microscopic blood detected; positive nitrites; increased specific gravity

TABLE 9.5 RESULTS OF MEDICAL INVESTIGATIONS

Marion has not been consistent with contraception recently and had these tests
TEST	RESULT
Home urine HGC pregnancy test	Negative
Follow up blood HGC pregnancy test	Negative

TABLE 9.6 UNLIKELY DIAGNOSTIC CONSIDERATIONS [3–8]

CONDITIONS AND CAUSES	WHY UNLIKELY
CANCER AND HEART DISEASE
Congestive heart failure	No protein in Marion’s urine; she does not have high blood pressure, extreme tachycardia or shortness of breath
TRAUMA AND PRE-EXISTING ILLNESS
Renal failure	No protein in Marion’s urine
OBSTRUCTION AND FOREIGN BODY
Renal calculi: primary hyperoxaluria (oxalate stones); hyperuricaemia and hyperuriosuria (uric acid stones); cysteinuria (results in cystine stones)	Usually presents with acidic urine
FUNCTIONAL DISEASE
Female urethral syndrome: irritative bladder symptoms in absence of urologic findings; pain in the urethra; can be a component of interstitial cystitis; pain on urination, increased frequency, pelvic pain, sexually active [43]	Onset of symptoms occurred more than 2–7 days ago; usually does not present with blood in the urine; no bacteria usually detected by urinalysis; level of urinary urgency not noted yet in Marion’s history; usually no fever presents; does not necessarily have nocturia as a symptom
INFECTION AND INFLAMMATION
Trigonitis: inflammation of the mouth of bladder; increased urination, pelvic pain	Usually normal urinalysis results
Glomerulonephritis (advanced kidney infection)	Would show protein in urine and possible macrocytic blood; low specific gravity
ENDOCRINE/REPRODUCTIVE
Causal factor: Ectopic pregnancy	Blood and urine HGC tests negative
Causal factor: Pregnancy	Blood and urine HGC tests negative
Diabetes: nocturia	No glucose in urinalysis

Case analysis

TABLE 9.7 POSSIBLE DIFFERENTIAL DIAGNOSIS

Not ruled out by tests/investigations already done [2–9, 44, 47]
CONDITIONS AND CAUSES	WHY POSSIBLE	WHY UNLIKELY
CANCER AND HEART DISEASE
Bladder carcinoma	Blood in urine; pelvic discomfort; increased frequency of urination (need to determine if the volume is decreased)	Pain on urination is not a common symptom
Cervical cancer	Vaginal discharge, symptoms worse with sexual intercourse	Need to determine if pain/blood is experienced on intercourse
TRAUMA AND PRE-EXISTING ILLNESS
Causal factor: Mechanical urethritis/honeymoon cystitis/trauma	Pain on urination, increased frequency; sexually active	Urine is usually sterile and urinalysis does not indicate the presence of bacteria or other abnormalities
OBSTRUCTION AND FOREIGN BODY
Renal calculi/kidney stones/bladder obstruction/ stones (hypercalcaemia/hypercalciuria)

Blood in the urine; pelvic discomfort noted (need to determine whether discomfort occurs at the end of urination); alkaline pH No back pain (predominant symptom); normal appetite FUNCTIONAL DISEASE Causal factor: Stress incontinence Can be associated with pain on urination, increased frequency of urination and urgency Usually no nocturia in stress incontinence Nocturnal polyuria syndrome Nocturia, increased volume of urine Usually occurs in the elderly from conditions such as diabetes, heart disease and from certain medications DEGENERATIVE AND DEFICIENCY Osteoporosis (hypercalcaemia) Alkaline urine, pelvic pain No family history reported yet; Marion is not in the common age group Anaemia Marion’s face looks pale Need more information about Marion’s diet and gastrointestinal function INFECTION AND INFLAMMATION

Urinary tract infections (UTIs): can affect anywhere along the whole urinary tract

Recurrent cystitis: lower urinary tract infection/bladder infection [42, 47]

Increased urination during the day and at night; passing urine is painful, high temperature, urine contains blood, has strong odour and the condition is worsened by sexual intercourse; symptoms develop quickly; recurrence of the same symptoms; urinalysis detected nitrates, leukocytes (pyuria), blood, foul odour and increased pH; pain on urination with pus (pyuria) in urine is diagnostic for cystitis; common in women of this age group Pyelonephritis (upper UTI in the kidneys) White blood cells in urine (pyuria), pelvic pain, raised temperature No anorexia, severe abdominal pain, back pain, headache, fatigue, chills or vomiting reported Interstitial cystitis: painful bladder syndrome Marion is in the age group most commonly affected, recurrent pain on urination, pelvic pain, marked frequency, nocturia Level of urinary urgency not noted yet in Marion’s history; need to determine whether pain is relieved when voiding urine; usually no pus is present (leukocytes in urine) Reiter’s syndrome: can begin with gonorrhoeal urethritis Pain on urination and increased discharge; urinary symptoms that begin after sexual intercourse; syndrome can be asymptomatic No conjunctivitis or arthritis or skin lesions reported ENDOCRINE/REPRODUCTIVE Hyperthyroidism/hyperparathyroidism (hyercalcaemia) Nocturia, alkaline urine, increased urination Need more information about thirst, appetite, weight and energy levels Pelvic inflammatory disease/salpingitis Pelvic pain, vaginal discharge, fever, sexually active, unsure about contraceptive use Periods are regular, unsure whether vaginal discharge is purulent and offensive, no significant backache or lower abdominal pain reported; no period pain; unsure at this stage of severity of Marion’s pelvic pain Vaginitis: Candida albicans, Trichomonas, chemical reaction to vaginal sprays, douches or bubble baths Vaginal discharge, pain on urination (need to determine if external pain) No vaginal itching reported; pyuria not commonly detected in urinalysis (leukocytes) Urethritis: Chlamydia trachomatis, Mycoplasma, D streptococci, Trichomonas, Candida albicans, gonorrhoeal, herpes urethritis, masturbation, foreign body, horseback or bike riding [48] Vaginal discharge, Marion is sexually active and has a new partner; the form of contraception Marion and her partner are currently using is unclear; Marion is experiencing pain on urination (need to determine whether it is internal pain) Less common in women to have blood in urine with urethritis; pyuria not commonly detected in urinalysis (leukocytes) STRESS AND NEUROLOGICAL DISEASE Neurologic disease: multiple sclerosis (MS), spinal cord injury, cauda equina syndrome Lower urinary tract symptoms; more common in women; increased urination, nocturia Usually occurs in advanced stages of MS; no significant trauma or injury mentioned in health history so far; no lower back pain reported; no numbness, weakness or tingling in lower limbs

TABLE 9.8 DECISION TABLE FOR REFERRAL [1, 3–6, 8, 12]

COMPLAINT	CONTEXT	CORE
Referral for presenting complaint	Referral for all associated physical, dietary and lifestyle concerns	Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors
REFERRAL FLAGS	REFERRAL FLAGS	REFERRAL FLAGS
• Recurrent UTIs • Marion experiences persistent increase in urinary frequency	• Pelvic pain and vaginal discharge • Dehydration • Return of symptoms following sexual intercourse • Holds on to urine rather than going to the toilet when she needs to while at work • Unclear what form of contraception Marion and her partner are using	• Marion’s concerns about her condition affecting her relationship
ISSUES OF SIGNIFICANCE	ISSUES OF SIGNIFICANCE	ISSUES OF SIGNIFICANCE
Nil	• Recurrent antibiotic therapy	Nil
REFERRAL	REFERRAL	REFERRAL
• For medical assessment and definitive diagnosis • Second medical opinion on urinalysis result [45]	• Medical investigations to help rule out underlying pathologies (e.g. STD) [48] • Pap (cervical) smear check-up	• Women’s health centre or family planning to discuss contraception options and safe sex practice

TABLE 9.9 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [1–8, 42, 45]

TEST/INVESTIGATION	REASON FOR TEST/INVESTIGATION
FIRST-LINE INVESTIGATIONS:
Urinalysis – repeat test [42, 46, 49–51]	UTI, kidney infection, stones, diabetes, blood
Abdominal examination	Suprapubic tenderness on palpation and percussion
Pelvic examination	Appearance of labia, vulva, entire vagina, cervix, vaginal discharge should be inspected; cervical manipulation for masses or points of tenderness; scabies, contact dermatitis; bulky uterus indicates uterine cancer; vulval inflammation more often in Candida than in bacterial vaginosis; vaginal discharge visible with vaginitis
Pap smear (cervical smear) [42, 46]	Check for signs of STIs
Full blood count	Check for infections and/or anaemia
ESR/CRP blood test	Check for inflammation, tumour detection, bacteria and viral detection
Urea, creatinine and electrolytes (sodium, potassium, chloride, bicarbonate) blood test	Gives an indicator of renal excretory function as urea and blood creatinine is excreted entirely by the kidneys; this will show in renal abnormalities and diabetes
Gram stain and culture of urethral discharge [48]	Chlamydia and gonorrhoea
Potassium hyroxide/saline wet mount	Candida albicans, Trichomonas
Urine microscopy	To eliminate the possibility of renal disease; will give information about specific white blood cells (indicates an inflammatory reaction in urinary tract), red blood cells, casts (clumps of materials or cells and can indicate renal disease) and crystals (indicate renal stone formation is imminent)
IF NECESSARY:
Calcium, phosphate and serum alkaline phosphatase	Metabolic bone disease and renal calculi due to calcium excess, renal infarction; calcium excretion can be monitored
Thyroid function test TSH, T4, T3	TSH (thyroid-stimulating hormone) suppressed in hyperthyroidism; thyroid-specific antibodies, to confirm auto-immune cause of hyperthyroidism (Graves’)
Estimated glomerular filtration rate (eGFR)	Kidney function
Renal ultrasound/x-ray	If renal disease is suspected; ultrasound/x-ray will give information about renal size, failure, stones, mass formation, lesions
Pelvic x-ray	Osteoporosis
Cystoscopy: bladder	Direct visualisation of urethra and bladder; check for interstitial cystitis; evaluate blood in urine, bladder cancer, trigonitis
HLA-B27 antigen: human lymphocyte antigen B-27	Reiter’s syndrome

Confirmed diagnosis

Marion and recurrent chronic cystitis

Marion is a 34-year-old woman who has recently been experiencing increased urination during the night along with symptoms of burning and stinging on urination, pelvic discomfort, increased vaginal discharge, raised temperature and her urine has an unpleasant odour. Marion has experienced these symptoms in the past and has noticed the symptoms return after sexual intercourse. Marion has only recently entered into a new sexual relationship and is concerned this pattern of symptoms is beginning to have a negative impact on her relationship.

Marion’s symptom picture reflects recurrent cystitis that develops as a reinfection in an otherwise functionally normal urinary tract. This is a condition that requires attention as persistent infection may result in further upper UTIs.

Cystitis is a term used for urinary tract infection and is very common in women. Microbial transfer is more likely to happen due to the short urethra to the bladder in women compared with the longer urethra in males. Infection is most often due to the person’s own bowel flora and transfer to the urinary tract can be via the bloodstream or lymphatic system. Microbial transfer in women most commonly occurs via the transurethral route between the anus and the vagina. Bacteria can be further carried to the bladder by sexual intercourse. Infrequent and poor bladder emptying can predispose to infection.

It is important to define what kind of cystitis is presenting. There is both functionally normal urinary tract (persistent infection rarely results in kidney damage) and abnormal urinary tract (from such conditions as urinary stones or diabetes mellitus, which can cause kidney damage and can be made worse by a urinary infection).

Additionally the case history can help ascertain whether the cystitis is due to relapse (recurrence of the same bacterial infection within seven days of treatment implying failure to eradicate the infection and indicating kidney stones, scarred kidneys, polycystic disease of the kidneys) or reinfection (bacteria is absent after treatment for at least 14 days followed by a reoccurrence of infection with the same or different organism; 80 per cent of recurrent infections are due to this).

General references used in this diagnosis: 3, 5–7, 47

Prescribed medication

• Antibiotics for the current urinary infection [52]

TABLE 9.10 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)

COMPLAINT	CONTEXT	CORE
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Lifestyle recommendations to reduce the frequency and severity of symptoms • Dietary recommendations to improve immune function, inhibit the growth of pathogenic bacteria and reduce the frequency and severity of symptoms • Physical therapy recommendations to reduce frequency and severity of symptoms • Herbal tonic with antimicrobial, diuretic, immune-stimulating and mucous membrane tonic action to help reduce the severity of acute symptoms • Herbal tea with antiseptic, diuretic and demulcent action to help reduce the severity of acute symptoms • Nutritional supplements to improve immunity, inhibit growth of pathogenic bacteria, inhibit adherence of bacteria to the bladder wall and protect the bladder from damage • Lifestyle recommendations to alleviate the discomfort of symptoms of acute cystitis • Physical treatment recommendations to help alleviate the discomfort and severity of symptoms NB: Marion’s vitamin and mineral levels should be monitored to ensure she stays within normal range. Recommendation to reduce normal dose of vitamin A once symptom improvement has been achieved [16]

• Lifestyle recommendations to help prevent a recurrence of symptoms and improve urinary hygiene

• Physical therapy recommendations to help prevent a recurrence of symptoms

• Dietary recommendations to improve general health and immunity

• Dietary supplements to boost immunity, support bowel flora and prevent a recurrence of cystitis

• Herbal tea to help prevent a recurrence of cystitis

• Counselling regarding sexual health

• Recommendation for massage to help reduce stress

Lifestyle alterations/considerations

• Marion can improve urinary hygiene by emptying her bladder completely before going to bed [16] and by drinking at least 2½ L of water daily [14, 16, 17].

• Encourage Marion to should minimise exposure of the urethra to E. coli by ensuring she wipes from front to back when she has a bowel motion and wearing cotton underpants rather than nylon underpants and/or pantyhose [17].

• Encourage Marion to empty her bladder as soon as she feels the urge [17].

• Marion’s partner should wear condoms during intercourse [17] and avoid the use of spermicides [16].

• Encourage Marion to urinate after intercourse [14, 17] and can wash her labia and urethra with a strong tea of golden seal (2 tsp/cup) both before and after intercourse [14].

• During acute episodes of cystitis Marion can reduce the sensation of burning and stinging by pouring warm water over her labia and urethral opening while urinating to dilute the urine.

• Weekly vaginal insertion of a pessary containing Lactobacillus rhamnosus and Lactobacillus gasseri may be helpful to prevent recurrence [16, 28].

Dietary suggestions

• Encourage Marion to drink at least 2½ litres of water each day [14–18].

• Drinking 250 mL of unsweetened cranberry or fresh berry juice [14, 15, 33] and eating a cup of cranberries daily can help prevent recurrence [17, 21, 33].

• Barley water (30 g barley in 1 L of water, reduced by boiling it down to 500 mL) can help alleviate symptoms [16].

• Encourage Marion to avoid refined carbohydrates and simple sugars [14].

• Identify and manage food allergies or intolerances [14].

• Encourage Marion to consume of garlic and onions [14] and eat unsweetened yoghurt with live lactobacilli several times per week [14, 33].

• Encourage Marion to have an antioxidant and flavanoid-rich whole-food diet [30, 31].

Physical treatment suggestions

• Hydrotherapy: a hot shallow bath several times a day or hot foot baths in the acute stage [36]. Apply a hot Epsom salt compress on the bladder, covered with wool and kept warm by a heating pad/hot water bottle [37]. Alternate hot compress with neutral sitz bath [35, 37]. Note: ice packs or ice compresses are contraindicated over the bladder in cystitis.

• Myofascial trigger point therapy on pelvic floor trigger points may help alleviate symptoms of urgency and frequency [26].

• Acupuncture may help reduce the severity and frequency of symptoms [27].

• Marion may benefit from massage to help reduce stress [38, 39].

TABLE 9.11 ACUTE HERBAL FORMULA (1:2 LIQUID EXTRACTS)

HERB	FORMULA	RATIONALE
Bearberry Arctostaphylos uva-ursi

60 mL Urinary antiseptic [19, 23]; astringent [19]; anti-inflammatory [19]; urinary alkaliser [15]; indicated for use in recurrent cystitis [19]; particularly effective against E. coli [14]; in combination with other herbs can significantly reduce the recurrence of cystitis [20]

Echinacea root

Echinacea angustifolia/purpurea

60 mL Immunostimulant [19, 21]; anti-inflammatory [19, 21]; antioxidant [21]; increases resistance to infection [19]

Golden rod

Solidago virgaurea

40 mL Diuretic [21, 22]; anti-inflammatory [21, 22]; antibacterial [21]; the European Scientific Cooperative on Phytotherapy (ESCOP) indicates its use as an adjunctive treatment for bacterial UTIs [21]

Andrographis

Andrographis paniculata

40 mL Immunostimulant [19, 21]; antimicrobial [21] Supply: 200 mL Dose: 5 mL four times daily This formula is for short-term use in the management of an active UTI. Bearberry should not be taken continuously for longer than 1 month [23]

Cranberry

Vaccinium oxycoccus, Vaccinium macrocarpon

Cranberry is bacteriostatic [21]; antioxidant [21]; prevents bacterial adhesion [15, 23, 25] and deodorises urine [16]; an effective adjunctive treatment in UTI [21]. Cranberry may interfere with the action of bearberry [16], so should not be used in conjunction with it [16]; cranberry can be used when Marion is not taking the acute herbal tonic

Dose: 10,000 mg capsule or tablet 3–4 times daily [21] or 500 mL unsweetened juice daily [14, 17] in acute cystitis. One 10,000 mg capsule or 250 mL juice daily can be used as a preventative [21]; cranberry may be contraindicated if Marion has a history of oxalate kidney stones [21]

TABLE 9.12 HERBAL TEA

In addition to herbal liquid
HERB	FORMULA	RATIONALE
Buchu leaf Barosma betulina	1 part	Urinary tract disinfectant [19, 23]; mild diuretic [19]; traditional therapeutic use for UTIs [19]
Cornsilk Zea mays	1 part	Diuretic [22]; urinary demulcent [22]
Dandelion leaf Taraxacum officinale	1 part	Diuretic [16, 22, 23]; beneficial to reduce the risk of hypokalaemia and hypertension from long-term use of licorice in herbal tea [40]
Couch grass Agropyron repens	1 part	Soothing diuretic [22]; urinary demulcent [22]; indicated for use in cystitis with inflammation or irritation of the urinary tract [24]; may prevent bacterial adhesion [23]
Licorice root powder Glycyrrhiza glabra	½ part	Anti-inflammatory [19, 21]; mucoprotective [19, 21]; antibacterial [19, 21]; adrenal tonic [19, 21]; immunomodulator [19, 21]; demulcent [19, 21]; may help prevent bacterial adhesion to the bladder wall [41]

Infusion: 1 cup 3–4 times daily

This tea can be used during acute episodes of cystitis at a dose of 3–4 cups daily, and can also be consumed at a dose of 1–2 cups daily as a preventative and alternative to tea and coffee; using herbal teas in the management of cystitis provides additional benefits by helping increase fluid intake

TABLE 9.13 NUTRITIONAL SUPPLEMENTS

SUPPLEMENT AND DOSE	RATIONALE
Vitamin C 500 mg every 2 hours during the first day of infection [14, 15] then reduce dose to 500 mg twice daily [34]	4–12 g vitamin C daily acidifies urine and facilitates the formation of reactive nitrogen oxides which are toxic to E. coli and other microorganisms [17, 18]; antioxidant [18, 29]; immunostimulant [18, 29]
High-potency practitioner-strength probiotic supplement containing L. acidophilus [16], L. rhamnosus and L. reuteri [17] Dosage as recommended by the manufacturer	Probiotic supplementation is helpful in preventing recurrent UTIs in women [16, 17, 21]; immune stimulant [21]; may help prevent disruption to intestinal microflora following antibiotic therapy [21, 32]
High-potency practitioner-strength multivitamin, mineral and antioxidant supplement providing therapeutic doses of antioxidants and flavanoids [30, 31] including a daily dose of 30 mg elemental zinc and 10000 IU Vitamin A [16, 21] Dosage as recommended by the manufacturer to achieve recommended doses of specific nutrients Dose should be maintained until there is a consistent improvement in symptoms and then reviewed	Supplemental antioxidants and flavanoids may help prevent bladder damage [30, 31]; vitamin A and zinc are important antioxidants, essential for immune function and mucous membrane health [16, 21]; deficiency can result in impaired immunity [16, 21]
NB: Ensure Marion is using effective contraception while taking vitamin A at this dose. Vitamin A supplementation should be reviewed and reduced to no more than 2500 lU daily [16,21] once her symptoms improve

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[48] Shapiro T., Dalton M., Hammock J., et al. The prevalence of urinary tract infections and sexually transmitted disease in women with symptoms of a simple urinary tract infection stratified by low colony count. Acad Emerg Med. 2005;12:38–44.

[49] Medina-Bombardo D., Segui-Diaz M., Roca-Fusalba C., et al. What is the predictive value of urinary tract infection in women? Fam Pract. 2003;20:103–107.

[50] Bulloch B., Bausher J., Pomerantz W., et al. Can urine clarity exclude the diagnosis of urinary tract infection? Pediatrics. 2000;106:E60.

[51] Deville L., Yzermans J., Van Duijn N., et al. The urine dipstick test useful to rule out infections. A meta-analysis of the accuracy. BMC Urol. 2004;4:4.

[52] Fihn S.D. Acute uncomplicated urinary tract infection in women. N Engl J Med. 2003;349:259–266.

Kidney stones (renal calculi)

Case history

Max Costas is 60 years old and has come to the clinic for help with backache that has been bothering him for the past couple of weeks. Max describes his pain as dull and intermittent, travelling across his lower back, radiating around to his stomach, down the front of his abdomen and into his groin. The pain has been gradually worsening and in the past three or four days the pain in his lower back has become constant, and he finds himself moving around a lot to ease the discomfort. In the past two days he has experienced sharp pains across his lower back on a few occasions. He tells you the pain was much worse after a long day building a limestone block wall, a task that involved a lot of heavy lifting and physical stress.

Max explains that he owns a landscaping business and this last year has been particularly physically demanding. Over the past few months of summer he has been working long hours to make the most of the daylight, and often forgets to eat and drink properly until he finishes for the day. This is partly because he has so much work to get through but also because he hasn’t always been feeling well. Recently his gut has been bloated and he sometimes feels a bit nauseous. He mentions that when he gets home and tries to catch up on his water intake, the pain in his lower back seems to worsen.

When you ask Max about his diet he tells you he loves dairy food even though he doesn’t eat as much as he used to. He laughs when he tells you that his apprentice jokes that he thinks Max enjoys a glass of cold milk as much as a beer. Before he was diagnosed with gout four years ago Max used to drink red wine and eat much more red meat and dairy products than he does now. Now he and his wife eat more chicken and fresh fish as well as vegetables and salads. He tells you he particularly enjoys eating spinach and would happily eat it every day. He has also started craving chocolate in the evenings after work. He admits that he isn’t always as strict with his new healthier diet as he should be, but since the back pain has started his appetite has gone a bit off, particularly because he feels nauseous so often now. Max is a tea drinker and can consume quite a few cups during the day, particularly if he is working on a residential job and the homeowners offer him cups of tea.

Max and his wife have four children who are now grown up, and four grandchildren with another two on the way. He tells you being a grandfather is the best thing in the world and if he could he’d spend all day every day with the grandkids. He has thought about retiring and travelling around the country with his wife, but the thought of being away from the grandchildren for an extended period of time puts him off doing anything about it. He has been running his landscaping business for the past 25 years and it has become so busy that he has several staff and two apprentices to help him keep up with the workload. While he really enjoys landscaping, Max is aware that his body doesn’t cope as well with the physical demands of his work as it did 10 years ago.

Max’s doctor prescribed 200 mg Progout daily when he diagnosed Max with gout four years ago, and Max has been taking it consistently each day since then. When he recently saw his doctor to get a repeat prescription for Progout he told his doctor about the back pain and that he wasn’t feeling very well. The doctor did some blood tests that revealed Max has kidney stones. Max would now like to learn how he can manage his condition as naturally as possible and prevent this happening again. He thinks a massage may help his back pain and ease his tension.

TABLE 9.14 COMPLAINT

Analogy: Skin of the apple

Complaint: Define the presenting complaint and symptoms; understand the complaint

Kidney stones

AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS CLIENT RESPONSES Onset About two weeks. Understanding the cause (client) Max knows he has kidney stones because the doctor told him. Because he thinks massage might alleviate the pain, it is apparent he needs further information about his condition and how to manage it. Exacerbating factors When does your back pain feel worse? At the end of the day when I get home and drink lots of water. Relieving factors Is there anything that seems to make it better? Not that I can think of. I’m hoping a massage might help a bit. Location and radiation The pain started in Max’s lower back and radiates around to his stomach, down the abdomen and into his groin. Rating scale On a scale of 1 to 10, with 1 being no pain and 10 being the worst pain you have ever experienced how would you rate your back pain? At the moment it’s about a 5, but sometimes it gets worse and it’s about an 8. It seems to be getting worse.

TABLE 9.15 CONTEXT

Analogy: Flesh of the apple	Context: Put the presenting complaint into context to understand the disease
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Family health
Has anyone in your family ever had back pain or kidney stones?	My dad used to suffer from back pain when he was older and my brother has arthritis in his back. I don’t think anyone else has kidney stones.
Surgery and hospitalisation
Have you had surgery or been hospitalised in the last year or so?	No.
Occupational toxins and hazards
Are you exposed to any chemicals in your work? Do you think your work is contributing to your back pain?	Not really. I think work does have an effect on my back, I do some pretty heavy lifting although I try and leave most of that type of work to the younger blokes.
Functional disease
Does lying on your back with rest relieve your back pain? (acute lumbosacral strain/mechanical/disc syndrome) Is the back pain worse by coughing, laughing, passing a bowel motion, sneezing, sitting or bending? (disc syndrome)

No. I usually feel very restless and need to move around to ease the pain.

No. I haven’t noticed that.

Degenerative and deficiency

Did the doctor tell you if they found arthritis in your back when they did the tests?

Do you experience early-morning stiffness that wears off after a couple of hours of activity? (inflammatory arthritis)

Is the lower back pain associated with pain in other joints? (osteoarthritis)

No, I don’t remember them saying anything.

No. The pain can be there any time of the day.

No, the pain is just in the back area and radiates to the groin when it’s really bad.

Endocrine/reproductive Is your back pain associated with burning urination, difficulty urinating or fever? (prostatitis) No urine problems yet, but sometimes I notice the colour is darker than normal.

Supplements and side effects of medications

Are you taking any supplements or medications such as pain killers at the moment?

Yes, the doctor gave me some tablets to take for the pain when I needed them.

Max shows you a pack of paracetamol and codeine tablets.

Stress and neurological disease Do you experience upper arm, leg, shoulder weakness associated with muscle wasting? (motor neuron disease) No muscle weakness that I’ve really noticed. I can still lift things at work if this other pain is not irritating me.

TABLE 9.16 CORE

Analogy: Core of the apple with the seed of ill health	Core: Holistic assessment to understand the client
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Emotional health
You have been experiencing some physical setbacks recently; how is this affecting your moods?	I really like my work, but it’s getting harder on my body. I don’t usually get stressed, but I’ve been working really hard lately. I suppose I get a bit grumpy when I get stressed.
Daily activities
Apart from work, what do you do during the day?	At the moment it really is just work. I’m up at about 5.30 and get home about 6. Then it’s dinner and bed. I’m working most of the weekends at the moment too. Things should quieten down in the next month and I’ll have more time for my wife and family.
Family and friends
Tell me about your family and social life.	I really just live for the grandkids, they’re really great. If I could, I’d get out of the business and look after them all the time although the wife might have something to say about that! I haven’t spent much time with friends recently since work has been so busy. It usually eases off over winter so I should get some more time then.
Education and learning
Do you understand how kidney stones can cause a backache?	Not really. Will massage make it better?
Action needed to heal
What do you think will help you get better?	I don’t really know. The doctor said something about what I eat and to drink more water. He said I might have to have surgery if it doesn’t get better, so I’m here for something natural to help.

TABLE 9.17 MAX’S SIGNS AND SYMPTOMS [1–3]

Pulse	88 bpm
Blood pressure	140/90
Temperature	37.2°C
Respiratory rate	14 resp/min
Body mass index	23
Waist circumference	85.7 cm
Face	Sunburned
Urinalysis	Colour – brown/orange pH – low (acidic urine is associated with xanthine, cysteine, uric acid and calcium oxalate stones; if pH was high it would indicate presence of calcium carbonate, calcium phosphate and magnesium phosphate stones instead) Multiple crystals found in urinary sediment Specific gravity – high Blood present – small amount (microscopic)

TABLE 9.18 RESULTS OF MEDICAL INVESTIGATIONS [1–8, 37]

TEST	RESULTS
Abdominal inspection: guarding, rebound tenderness, palpation, abnormal pulsations (auscultation)	No sign of appendicitis, pancreatitis, enlarged liver, bowel obstruction, perforated ulcer; no positive Murphy’s sign for inflamed gall bladder; hiatus hernia signs, swallowed air; no middle epigastric tenderness in gastric and peptic ulcer; mild kidney discomfort on percussion
Urine microscopic investigation: define type of urine crystals and red blood cells [38] Radio-opacity of stone	Result: calcium oxalate – radio-opaque All types: Calcium stones – radio-opaque, cysteine stones radio-opaque, magnesium ammonium phosphate – moderately radio-opaque Ruled out: uric acid stones: radiolucent
Urinary calcium, oxalate and uric acid output: two 24-hour samples	High oxalate output
Estimated glomerula filtration rate (eGFR)	Kidney function: NAD
Electrolytes (sodium, potassium, chloride, bicarbonate blood test) urea and creatinine; signal muscle breakdown and tissue damage and gives an indicator for renal excretory function as urea and blood creatinine is excreted entirely by the kidneys; this will show in renal abnormalities	NAD
Full blood count: anaemia, infection	NAD
ESR/CRP: indication of infection, cancer, inflammation	NAD
Fasting blood glucose test: raised in pancreatic cancer, pancreatitis, drug therapy and acute stress response; diabetes; decreased levels, liver disease	NAD
Calcium, phosphate, serum alkaline phosphatase: metabolic bone disease such as osteomalacia, Paget’s disease and renal calculi due to calcium excess, renal infarction; calcium excretion can be monitored	NAD
Prostate-specific antigen: raised in prostatic cancer, benign prostatic hypertrophy, prostatitis	NAD
Liver function test: hepatitis, substance abuse	NAD
Plain abdominal x-ray: to rule out appendicitis, intestinal obstruction such as constipation and hiatus hernia; abdominal aneurysm	Detected urinary calculi on x-ray
Stool test: detect ova, parasites, bacteria and fat levels, and occult blood; if acidic stools are passed it indicates lactose intolerance	NAD

TABLE 9.19 UNLIKELY DIAGNOSTIC CONSIDERATIONS [2, 4–8]

CONDITIONS AND CAUSES	WHY UNLIKELY
ALLERGIES AND IRRITANTS
Causal factor: Lactose intolerance: abdominal pain, bloating, nausea; possible recurrent abdominal pain with onset of lactose ingestion	Usually significant diarrhoea; no acidic stools
CANCER AND HEART DISEASE
Prostate cancer: metastases into bone	Prostate specific antigen NAD; CRP within normal range
Neoplasms: kidney, stomach, pancreatic, intestinal, prostate	ESR/CRP not raised, abdominal x-ray did not detect, full blood count NAD
Hypertension	Blood pressure is within normal range, although in the higher range of normal
TRAUMA AND PRE-EXISTING ILLNESS
Causal factor: Trauma: (ruptured spleen, stomach, colon)	Abdominal x-ray did not detect
Abdominal aneurysm: deep pain in lumbosacral region; can cause acute pain if likely to rupture; steady pain; Max is in the age group in which this condition is likely to develop; pain relieved by changing positions	Abdominal x-ray did not detect
Kidney embolism/infarction: abdominal pain, steady aching in flank pain that can radiate to the groin; nausea often associated; microscopic blood in the urine usually present	Usually occurs in the elderly and over 60 years of age; most often protein and white blood cells are present in the urine; no advanced hypertension
Primary renal diseases: medullary sponge kidney, renal tubular acidoses	Electrolytes test NAD, urinalysis revealed no protein
OBSTRUCTION AND FOREIGN BODY
Renal calculi – hypercalcaemia: most common causes are hyperparathyroidism, vitamin D ingestion, sarcoidosis	Unlikely due to urinalysis detecting low pH (acidic reading); no excess serum calcium would usually present with alkaline urine (high pH)
Renal calculi – hypercalciuria: most common metabolic abnormality detected in calcium stone-formers; causes can be excess dietary intake of calcium, excess resorption of calcium from the skeleton in prolonged immobilisation, idiopathic reasons where there is an increased absorption of calcium from the gut	Unlikely due to urinalysis detecting low pH (acidic reading); no excess serum calcium would usually present with alkaline urine (high pH)
Hyperuricaemia and hyperuriosuria: uric acid stones comprise 3–5% of all kidney stones; uric acid is the endpoint of purine metabolism and hyperuricaemia can be a primary defect in gout and an end result of increased cell turn over in myeloproliferative disorders; dehydration alone can cause uric acid stones to form; some people with calcium stones also have increased uric acid levels; pH was low on urinalysis (acidic)	Unlikely while taking Progout, which reduces the formation and accumulation of uric acid in the body; uric acid stones are radiolucent
Cystinuria: results in formation of cystine stones, but only 1–2% fall into this category; cystinuria is a defective tubular reabsorption and jejunal absorption of cystine, lysine, ornithine and arginine; pH was low on urinalysis (acidic)	No family history mentioned for cysteine kidney stone formation; tests would have revealed radio-opaque cysteine stones
Polycystic kidney disease: symptoms can include some abdominal and loin pain, blood in urine and can result in kidney stones (often uric acid)	No family history yet revealed for polycystic kidney disease, which is often inherited Tests: no uric acid stones, no protein in urinalysis
DEGENERATIVE AND DEFICIENCY
Osteoporosis: lower back pain, rapid bone remodelling causing calcium excess	Unlikely due to urinalysis detecting low pH (acidic reading); no excess serum calcium; would usually present with alkaline urine (high pH)
Osteomalacia: buffering of H⁺ by Ca²⁺ in bone resulting in depletion of calcium from bone; excess calcium excretion can develop	Unlikely due to urinalysis detecting low pH (acidic reading); no excess serum calcium; would usually present with alkaline urine (high pH)
Paget’s disease: rapid bone remodelling causing calcium excess	Unlikely due to urinalysis detecting low pH (acidic reading); no excess serum calcium; would usually present with alkaline urine (high pH)
Peptic ulcer: dull constant pain and sharp pain, referred back pain, nausea, lack of appetite	No vomiting or weight change; pain not only at night; pain location usually located in middle of the abdomen and does not radiate; no abnormality with CRP reading in blood tests; not detected in abdominal x-ray
INFECTION AND INFLAMMATION
Appendicitis: referred back pain, nausea, lack of appetite	No fever; ESR/CRP not raised; full blood count NAD; abdominal x-ray did not detect; pain usually in midgut
Cholecystitis: referred pain, nausea	No fever; ESR/CRP not raised; full blood count NAD; abdominal x-ray did not detect; pain usually above the navel on the abdomen
Pancreatitis: abdominal pain, nausea, lower back pain	No fever; ESR/CRP not raised; full blood count NAD; abdominal x-ray did not detect; no glucose in urinalysis
Inflammatory bowel disease: Crohn’s disease, diverticulitis, ischaemic colitis, regional ileitis, amoebicolitis, autoimmune granulomatous colitis	ESR/CRP not raised; no fever; full blood count NAD; abdominal x-ray did not detect, stool test did not detect blood in stool
Kidney infection: pyelonephritis, perinephric abscess	No fever; ESR/CRP not raised; full blood count NAD
Prostatitis: lower back pain, urinary changes	Prostate-specific antigen NAD
Hepatitis: biliary disease can cause excess oxalate-containing foods	Liver function test NAD
Causal factor: Intestinal abscess	No raised ESR/CRP; full blood count NAD; no fever; abdominal x-ray did not detect
Causal factor: Septic infection causing back pain	ESR/CRP not raised; no fever; full blood count NAD
Urinary tract infection	No leukocytes or nitrates present in urinalysis or alkaline urine
Phlebitis of iliac veins and inferior vena cava	ESR/CRP not raised; abdominal x-ray did not detect; full blood count NAD
Causal factor: Inflammatory lower back pain: osteoarthritis, rheumatoid arthritis, fibromyositis, osteomyelitis, spinal, rectal abscess, myelitis, cystitis, ankylosing spondylitis, tuberculosis of spine	ESR/CRP not raised; full blood count NAD
SUPPLEMENTS AND SIDE EFFECTS MEDICATION AND DRUGS
Causal factor: Vitamin D intoxication: causes excess calcium levels due to producing excess bone resorption	Unlikely due to urinalysis detecting low pH (acidic reading); no excess serum calcium; would usually present with alkaline urine (high pH)
ENDOCRINE/REPRODUCTIVE
Diabetes	Fasting blood glucose test NAD
Benign prosatatic hyperplasia (enlargement): age, abdominal and loin pain; causes symptoms of urinary obstruction such as loin pain	Urinary stream changes not reported by Max as predominant symptoms in case history; prostate specific-antigen NAD
Primary parahyperthyroidism: caused by single or multiple adenomas or by hyperplasia of the parathyroid gland, or compensatory response due to renal failure or vitamin D deficiency	Unlikely due to urinalysis detecting low pH (acidic reading); would usually present with alkaline urine (high pH)
Hyperthyroidism: endocrine condition that can lead to excess calcium and kidney stones	Urinalysis showed acidic urine, no excess calcium; would usually present with alkaline urine (high pH)

Case analysis

TABLE 9.20 POSSIBLE FURTHER DIFFERENTIAL DIAGNOSIS

Not ruled out by tests/investigations already done [2–8]
CONDITIONS AND CAUSES	WHY POSSIBLE	WHY UNLIKELY
ALLERGIES AND IRRITANTS
Causal facotr: Food allergy: typically to cow’s milk, egg, soya, peanut, wheat and fish	Abdominal discomfort	Often presents with swelling of the lips and tongue, urticaria skin rash, conjunctivitis, rhinitis, anaphylaxis and difficulty breathing
TRAUMA AND PRE-EXISTING ILLNESS
Causal factor: Trauma (strains, sprains, tear, herniated disc, fracture, disc prolapse)	Work strain and lower back pain
Causal factor: Leg length discrepancy	Low back pain, restlessness	Has not experienced this kind of pain before
Causal factor: Congenital disorders: scoliosis	Lower back pain	Has not experienced this kind of pain before
FUNCTIONAL DISEASE
Irritable bowel syndrome	Bloating and pain	Pain not necessarily relieved by passing a bowel motion
Causal factor:Faulty posture	Strain for long periods of time at work
SUPPLEMENTS AND SIDE EFFECTS OF MEDICATIONS
Casual factor:Medication/supplementation: Analgesic abuse: causes calcified papillae that mimic kidney stones

Salicylate excess may predispose to uric acid stone formation; pH would be acidic in this case This would be prevented by taking Progout AUTOIMMUNE DISEASE Coeliac disease Abdominal pain, poor diet, diarrhoea More often upper abdominal pain with bloating; diarrhoea or constipation usually a prominent symptom EATING HABITS AND ENERGY Dehydration Working long hours, not drinking enough water causing kidney stones; drinking mostly tea which can be more dehydrating; pH was low on urinalysis (acidic) More often increases uric acid stones; this would be masked by taking Progout

TABLE 9.21 CONFIRMED DIAGNOSIS [1–8, 35]

CONDITION	RATIONALE
Kidney stones	Referred pain in the back that can be dull and constant; pain can be sharp when a kidney stone is dislodged, usually after physical exertion; kidney stones are more likely to develop with dehydration, physical exertion in warm environments, increased intake of calcium, high purine and oxalate-containing foods; small amount of blood present in the urine; reduced appetite; occasional nausea; drinking fluids makes the pain worse
Primary hyperoxaluria: Inherited disorder may cause errors in metabolism of glycoxalate that increase endogenous oxalate biosynthesis; calcium oxalate stones will form, which are the most common type (65%) of kidney stone; a more common cause for milder hyperoxaluria is the ingestion of high oxalate-containing foods, too much dietary calcium restriction causing compensatory reabsorption of oxalate, and dehydration	Max is consuming a lot of spinach, chocolate and tea and doesn’t drink enough water; he has recently reduced dairy products; pH was low on urinalysis (acidic); calcium oxalate stones can present at any urinary pH, unlike most calcium stones that will present at alkaline pH and uric acid stones will present as acid pH; urine microscopy revealed calcium oxalate stones as radio-opaque; high oxalate output in 24-hour urine samples
Tests: urine microscopy, urinalysis, abdominal x-ray	Uric acid – radiolucent detected with urine microscopic investigation; detected urinary calculi on x-ray; high oxalate output in two 24-hour urine samples

Working diagnosis

Max and kidney stones (renal calculi) common mild hyperoxaluria

Max is a 60-year-old man who enjoys owning and working in a landscaping business. His work requires him to expend physical energy for long hours, which could lead to strain and wear and tear of the musculoskeletal system. Max has previously been diagnosed with gout for which he is currently being prescribed the medication Progout, along with advice to reduce consumption of meat, dairy products and alcohol. Recently Max has experienced symptoms that mirror the development of kidney stones (renal calculi).

From the information provided in his case history it is most likely that Max has the most common type of kidney stone for men (65 per cent), which is composed of calcium oxalate (hyperoxaluria). Kidney stones develop when there is a chemical composition of urine that favours stone crystallisation, when there is production of concentrated urine and an impairment of inhibitors that prevent crystallisation. The pain of kidney stones can be acute, sharp, dull, wax and wane, or may present as a constant ache in the loin. Kidney stones should be considered when abdominal pain lasts for more than 12 hours, there is a loss of appetite, loin and renal tenderness and there is blood in the urine. Nausea and vomiting with a feeling of restlessness is also a symptom of renal calculi.

It is vital to confirm a diagnosis of renal calculi and the composition of kidney stones before proceeding with treatment. A common cause of mild hyperoxaluria is ingestion of high oxalate-containing foods or excessive dietary calcium restriction causing compensatory reabsorption of oxalate and dehydration [39]. Kidney stones can be a recurring problem with 50 per cent of people forming further stones. Along with alleviating initial acute symptoms of discomfort, preventative guidance is therefore essential.

General references used in this diagnosis: 2, 4–8, 36, 38, 39

TABLE 9.22 DECISION TABLE FOR TREATMENT PRIOR TO REFERRAL

COMPLAINT	CONTEXT	CORE
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Lifestyle recommendations to reduce the formation of kidney stones • Physical therapy recommendations to alleviate acute symptoms • Dietary recommendations to reduce stone formation and the risk of stone recurrence • Herbal tonic or tea to reduce stone formation and provide symptom relief • Nutritional supplements to reduce inflammation and the risk of stone formation

• Dietary recommendations to enhance general health and wellbeing

• Lifestyle recommendations to enhance general health and wellbeing

• Dietary and lifestyle recommendations to help reduce blood pressure

• Lifestyle recommendations to reduce stress levels

TABLE 9.23 DECISION TABLE FOR REFERRAL [2–8, 13]

COMPLAINT	CONTEXT	CORE
Referral for presenting complaint	Referral for all associated physical, dietary and lifestyle concerns	Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors
REFERRAL FLAGS	REFERRAL FLAGS	REFERRAL FLAGS
• Presence of microscopic blood in urine and acidic urine	• Dehydration risk when working long hours • Blood pressure on the high side of normal range • Physically demanding work	• Working long hours
ISSUES OF SIGNIFICANCE	ISSUES OF SIGNIFICANCE	ISSUES OF SIGNIFICANCE
• History of treatment for gout	• Nausea and bloating • Pain in lower back • Excess intake of dairy products in diet • Consistent intake of high oxalate-containing foods	• Worried about the business if his health suffers • Would like more time with the grandchildren
REFERRAL	REFERRAL	REFERRAL
• Stones need to be surgically removed [2, 16, 36] • Max’s case needs to be managed collaboratively with his GP [35]	• Refer for musculoskeletal examination and exercise therapy program to strengthen Max’s lower back • Dietary assessment for allergies or intolerances • Refer for thorough abdominal examination	• Regular massage for musculoskeletal support and stress release

TABLE 9.24 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [1–9]

TEST/INVESTIGATION	REASON FOR TEST/INVESTIGATION
FIRST-LINE INVESTIGATIONS:
Musculoskeletal examination	Flexion, extension, rotation, straight leg test will reveal physical signs of mechanical or inflammatory, compression or degeneration of spine
Elimination diets	Detect food intolerance
IF NECESSARY:
Renal helical CT scan/excretion urography/IV urography/retrograde pyelography [36–38]	Definitive diagnosis for renal calculi if there are any doubts; detects any urinary obstructive causes, renal infarction, polycystic kidney disease
Cystoscopy	Direct visualisation of urethra, bladder and prostate
Hydrogen breath test	To detect bacterial overgrowth; when bacteria is metabolised by lactose or glucose there is a production of hydrogen
Antigliadin antibodies	Check if antibodies to gluten are present in the blood
Colonoscopy and biopsy	Rule out bowel cancer, polyps, inflammatory bowel disease, diverticulitis or haemorrhoids
Back x-ray/radiography	Osteoarthritis, osteoporosis, herniated disc, cancer, Paget’s disease, bone cancer

Confirmed diagnosis

Kidney stones (renal calculi), common mild hyperoxaluria and faulty posture

Prescribed medication

• Paracetamol and codeine as required for pain

TABLE 9.25 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)

COMPLAINT	CONTEXT	CORE
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Continue with lifestyle recommendations to reduce the formation of kidney stones • Continue with physical therapy recommendations for the relief of back pain • Continue with dietary recommendations to reduce stone formation and the risk of stone recurrence • Continue with herbal tonic or tea and nutritional supplements NB: Max’s mineral levels should be monitored to ensure they stay within an acceptable range during supplementation; this should be done as part of the collaborative management of Max’s case with his GP

• Physical therapy recommendations to help improve muscle strength in Max’s lower back and to improve his posture

• Continue with lifestyle and dietary recommendations to enhance general health and wellbeing and to reduce blood pressure

• Recommendation to test for heavy metals if symptoms continue despite dietary and lifestyle measures; appropriate detoxification program if necessary

• Continue with lifestyle recommendations to reduce stress

• Recommendation for Max to participate in hobbies and other activities for pleasure to improve his work/home/social life balance

Lifestyle alterations/considerations

• Encourage Max to avoid consuming aluminium compounds and alkalis (antacids) [15, 17].

• Consider testing for heavy metal toxicity if Max continues to experience stones despite treatment. Many heavy metals are toxic to the kidneys, and cadmium exposure in particular can lead to renal tubular failure and is known to increase kidney stone formation. It tends to be concentrated in the kidney tissue [15, 17].

• If Max consistently sleeps on the same side, encourage him to change sleep position. Research has shown the side of the stone is the same as the side on which people sleep in 76 per cent of people studied [29].

• Kidney stone formation is more likely to occur with stress [28], so encourage Max to reduce his stress levels. This may involve delegating more of the physical work to his employees to reduce the physical stress on his body and/or taking on additional staff to reduce his workload, stress-management techniques, etc. Stress management can reduce his blood pressure [15, 16, 30].

• Encourage Max to take up some activities for pleasure rather than financial reward. He needs to get more balance between work and play in his life.

Dietary suggestions

• Encourage Max to should increase water consumption aiming for at least 2½–3 L daily [15, 17, 33].

• Encourage Max to should consume 120 mL of lemon juice in water daily. Lemon juice consumption increases citrate excretion in urolithiasis [17]. Lemon juice can be added to water and included in Max’s water intake.

• Encourage Max to increase his intake of fibre, complex carbohydrates and green leafy vegetables [15–17, 33] and reduce consumption of refined carbohydrates, sugar, fat and alcohol [15, 17, 33].

• Encourage Max to minimise his salt intake [15, 17, 33]. A high dietary intake of salt increases calcium excretion [11, 17] and can adversely affect blood pressure [15–17, 31, 32].

• Encourage Max to increase his intake of foods rich in vitamin K [15, 17].

• Encourage Max to reduce consumption of animal protein and particularly purine protein (meat, fish, poultry, yeast) [15, 17, 33] and limit his consumption of dairy foods [15, 17].

• Encourage Max to reduce consumption of foods high in oxalates (black tea, chocolate, carrots, cucumber, grapefruit, kale, peanuts, sweet potato, peppers, spinach, beet leaves, rhubarb, parsley and cranberry) [15, 17, 33].

• Encourage Max to reduce his consumption of caffeine. Caffeine consumption is associated with higher levels of urinary calcium [17]. Max will benefit from replacing black tea with herbal tea [33].

• Encourage Max to increase consumption of foods with a high magnesium-to-calcium ratio (barley, bran, corn, buckwheat, rye, soy, oats, brown rice, avocado, banana, lima beans, potato) [15–17].

Physical treatment suggestions

• Acupuncture may help to relieve pain as part of a holistic treatment program [14].

• Hydrotherapy suggestions: hot trunk wrap [34, 35].

• Constitutional hydrotherapy [34, 36, 37].

• Hot fomentations (5–10 minutes) with vinegar water alternating with cold (1–5 minutes) mitten frictions to abdomen and lower back [36, 37].

• Place a cold compress to the head and immerse the body in a hot half-full bath, massage the lower back while in the water [36].

• A hot towel roll massage; fomentation to the lumbar spine [34].

• Full-immersion warm bath [34].

• Swimming in a warm pool, underwater massage and mud baths are helpful for lower back pain [34].

• Hot sitz Epsom salt bath for lower back pain [35].

• Max is likely to benefit from a prescribed graduated activity exercise therapy program to improve lower back strength and reduce pain [38].

TABLE 9.26 HERBAL FORMULA (1:2 LIQUID EXTRACTS)

Made with ethanolic extract herbal liquids (alcohol removed)
HERB	FORMULA	RATIONALE
Crataeva Crataeva nurvala

80 mL Antilithic [19, 20]; anti-inflammatory [19, 20]

Gravel root

Eupatorium purpureum

30 mL Antilithic [18], diuretic [18], antirheumatic [18]; indicated for the treatment of renal calculi [18]

Hydrangea root

Hydrangea arborescens

30 mL Contains furanocoumarins that promote smooth muscle relaxation, relaxing the ureter and allowing stones to pass [15]; traditionally used for treating urinary calculi [18]

Bearberry

Arctostaphylos uva-ursi

60 mL Urinary system anti-inflammatory [18, 34]; diuretic [18]; indicated for urolithiasis [18] Supply: 200 mL Dose: 5 mL 3 times daily

TABLE 9.27 HERBAL TEA

Alternative to herbal liquid if Max prefers to drink a herbal tea rather than a tonic
HERB	FORMULA	RATIONALE
Corn silk Zea mays	1 part	Antilithic [18]; diuretic [18]
Gravel root Eupatorium purpureum	1 part	See above
Hydrangea Hydrangea arborescens	1 part	See above

Decoction: 1 tsp per cup – 1 cup 3 times daily

TABLE 9.28 NUTRITIONAL SUPPLEMENTS

SUPPLEMENT AND DOSE	RATIONALE
Magnesium citrate supplement Providing 480 mg elemental magnesium [17] and 25 mg vitamin B6 daily [15, 17]	Increases calcium oxalate solubility in the urine [15, 17, 33] and inhibits precipitation of calcium phosphate and calcium oxalate [15, 22]; low urinary magnesium:calcium ratio is a risk factor for development of kidney stones [15]; supplemental magnesium is effective in preventing recurrence of kidney stones [15, 17, 33]; the citrate form of magnesium has been shown to be successful in preventing kidney stone recurrence [17]; combining magnesium with B6 is more effective in prevention of kidney stone recurrence than supplementing with magnesium alone [15, 24]; vitamin B6 reduces endogenous production and excretion of oxalates [15]; supplementation decreases oxalate formation [23, 33]
Calcium citrate 500 mg daily [17, 33]	Supplementation with calcium citrate can decrease oxalate absorption [17] and reduce urinary oxalate levels [21]; calcium supplementation is preventative for oxalate stones [16, 33]
Vitamin K 2 mg daily [15, 17]	Necessary for carboxylation of glutamic acid to gamma-carboxyglutamic acid [17]; gamma-carboxyglutamic acid inhibits growth of calcium oxalate monohydrate and therefore stone formation [17, 25]
Omega-3 fish oil 10,000 mg daily in divided doses [17]	Anti-inflammatory [17, 33]; decreases transmembrane oxalate exchange [17]; urinary calcium excretion is positively correlated with plasma arachidonic acid levels [26]; can reduce the risk of stone formation [33]
High-potency practitioner-strength probiotic containing human strain lactobacillus and bifidobacterium organisms, and specifically containing Oxalobacter formigenes [27] Dosage as per the manufacturer’s instructions NB: probiotic supplements containing Oxalobacter formigenes may be difficult to obtain in some locations	To support normal digestive function and synthesis of vitamin K in the gut [15]; people with low levels of Oxalobacter formigenes are more likely to form calcium oxalate stones [27]; supplementation with Oxalobacter formigenes may reduce the incidence of calcium oxalate stones [15, 27]