In my 25 years of working with stone formers, as a nurse in residence at Litholink Corporation and in my own practice, the number one question has always been: ‘How much water do I really need to drink?’ Maybe as important is: ‘How Do I Do It?’
Tread Slowly
Many patients leave their doctor’s office with the vague instruction to increase their water input. How much are you supposed to drink to reduce your stone risk?
Even more, patients are told to go home and start drinking a gallon of water a day. If you don’t drink more than a couple of glasses per day now, how are you supposed to drink a gallon tomorrow?
Drinking more water is a simple way to reduce your stone risk, but simple does not mean easy. Most of you find this task extremely hard. I tell everyone to start out slowly. If you drink one glass per day now, then drink two tomorrow. Set new goals to increase your water consumption each week. I have seen people go from 1 glass per day to 10 glasses per day within a month.
Spend Time to Avoid Pain
I can hear you saying now; “I don’t have enough time in the day to spend it in the washroom”.
This is a legitimate response and one I have heard many times throughout my career. I will not lie. You will spend more time in the bathroom, but you will get accustomed to your more frequent bathroom visits. The bigger picture is the one to focus on. Better hydration means you will be less likely to form more stones; this means that water can reduce ER and doctor visits, and lost time away from work. What is going to the bathroom a few more times a day compared to all of the pain, suffering, and expense you will endure if you don’t drink more water?
Be Willful
I have seen my share of pilots, teachers, surgeons, nurses, and traveling salesman all increase water intake despite the time constraints of their occupations. The one thing they all do is make the time.
I have worked with surgeons and surgical nurses before and it is true that they cannot leave the OR to use the bathroom during an 8 hour open heart surgery. Intermittent dehydration can be a real problem in this case. My clients who work in the OR do their best to drink for the rest of the day to try and make up for the loss. Sometimes there is really no choice. Thankfully this is the exception, not the rule.
Once you make up your mind that you do not want to suffer with the severe consequences that kidney stones bring to your life, you will find a way to incorporate more water into your daily routine. It is your choice, your commitment to your health that creates a one day at a time habit of drinking more water.
How Much?
Under the usual conditions of life, 3 – 4 liters of fluids a day will provide 2.5 to 3 liters of urine volume, and this is enough. The average healthy adult bladder holds about 1/2 liter, so this means 7 – 9 bathroom trips in 24 hours.
Input Doesn’t Always Equal Output
Four factors make the answer harder to come by: sodium intake, geographical location, occupation, and exercise.
Sodium intake
High sodium intake can confuse people. It is does not by itself change how much you need to drink, but salt intake can shift the timing of water loss so you think you are not increasing your urine volume even though you are drinking. It does something more. It increases urine calcium losses, a matter we will come back to at a later time.
When you eat a meal that is high in salt, you can count on it decreasing your urine output. I have clients tell me that they drink “a ton” of water but they never have to use the bathroom. The reason is that water is retained with the excess sodium. High sodium meals will decrease urine output that day and even that night, thus causing bloating, worsened hypertension, and higher risk for stones because of higher urine calcium.
But a steady high sodium intake, not just the effects of one meal, will cause a steady water retention and stable weight gain so after a while the extra water you drink will appear in the urine. In fact, when people lower their salt intake they become less thirsty so they have to focus more on drinking or they will ‘forget’.
Even so, keeping your water intake high and lowering your sodium consumption is best. Stone formers who have no medical contraindications to lower salt diets should be aiming for about 1500 mg of sodium per day. People become accustomed to high water intake and low sodium intake, and can benefit not only from the stone prevention but often from a lower blood pressure. How you lower your sodium intake to this number will be discussed in a future post.
Geographical location
There are actually places on the map that we who deal with kidney stones call the “stone belt”. Basically these are the states that are consistently hot and humid or hot and dry. Why is where you live a problem? Simply put, you sweat more. If you sweat more, you run the risk of becoming dehydrated, and being dehydrated reduces your urine volume and makes you more prone to form a stone. If you live in a hot, humid or dry state, you need to drink more to compensate.
Occupation
Are you working construction in the summer in Texas? Are you a camp counselor in Arizona? Do you wash windows for a living in Florida? Your occupation can be the increased risk factor for your stone disease. The reason is the same as above. You are sweating more and need to drink more than the office worker seated in the air conditioned office whose windows you are washing.
Exercise
I am very proud of you that you are doing your daily exercise. We all know how important that is to maintain good health. Exercise plays an important part in stone prevention so make sure you do it. Just remember to hydrate before, during, and after to balance the water lost from sweating!
Tricks
Here are few ways to make water drinking more enjoyable.
Stylish water bottle
Find a water bottle http://www.zazzle.com/fun+water+bottles that you really like carrying around. Seems like such a silly thing, but it really does help. I like big ones so I don’t have to keep getting up to fill it and it makes me very proud to see it empty. You may find smaller ones keep you inspired and you can easily go refill it as you make your bathroom pit stop. Here is an awesome water bottle I have found to help http://www.amazon.com/Basily-Infuser-Bottle-Around-Hydrated/dp/B00M1UOF3K/ref=dp_ob_title_sports
Make Tasty
Add fruit to your water. Adding lemons to your water has the added benefit of increasing your citrate level which is a natural inhibitor of stones, but use fruit that makes you smile most.
Using the product Mio http://www.makeitmio.com/ has helped many patients who constantly tell me that water is BORING. My reply is always, “better boring water than excruciating stones”. It is at that point that they take another sip.
Water is the most benign way to increase fluid intake, but don’t forget to include other beverages in your daily intake: Green tea, lemonade (no sugar), flavored waters, even fruit like watermelon, grapes, etc. will be helpful.
Be Techy
If you’re a phone app geek like me, download this app and track your progress https://itunes.apple.com/us/app/waterlogged-drink-more-water/id352199775?mt=8
Treats
Eat Your Water
Here is a list of foods that are made up of at least 90% water. Be careful. Some of them are high in oxalate and for those of you who need to limit your oxalate intake I have asterisked them: cucumbers, radishes, iceberg lettuce celery*, tomato*, green peppers, cauliflower, spinach*, starfruit, strawberries, broccoli, grapefruit, baby carrots*, and watermelon.
Channel Your Inner Child
I have straws on my counter top in a cute container. They add color, fun, and make drinking water a much more whimsical experience. They also makes the water go down a bit faster. I find myself downing a glass with ease when I have a straw. My son likes it too. No matter what your age or disposition, straws add fun to an otherwise boring activity.
If you are enjoying some grape or apple juice, dilute it with half water. You will cut down on your sugar and increase your water intake. This is a win-win.
A neat way to add color and zest to your water without added calories or artificial flavors: Freeze grapes, or lemon, lime, or orange peels, and add to your water instead of boring ‘ole ice cubes.
Make new habits
Every time you reach for a diet soda, replace it with water. Soon you will just reach for water and your old diet soda will be a long forgotten bad habit.
Upon waking, drink a glass or two of water with lemon. This helps keep your urine alkaline and gets you feeling ready for the day.
In winter, get some hot water, lemon and honey. It will warm you up on a cold day.
Green tea (yes, low in oxalate).
Le Croix. For those of you who are addicted to bubbles. Try this no calorie, carbonated water. It comes in many flavors and has been a staple in my house for the past year. There are generic versions of it for budget conscience stone formers.
Drink a glass of water before and after a meal. Drink water. Eat less. Yet another win, win. Who knew it would be this fun?
Be Patient and Persist
I want you to know that incorporating large amounts of water into your life takes a bit of time. New habits are built with commitment, patience, and an understanding that you are not perfect. You will have days that you cannot get in the amount of water that you would like to. It is ok. Your goal is to do your best on more days than not. And when you don’t, you can get back on track the next day.
Drinking more water is the number one thing you can do to help prevent further stone formation. It also has no bad side effects. So what do you say? Let’s raise a glass, a refreshing, ice cold glass of water. It might just save you from your next ER visit.
A Reservation
Water is always the first line of treatment for stones.The most important thing to do about supersaturation is lower it, and water will do just that. In relation to kidney stone prevention, more is better. In a perfectly healthy younger (below age 50) person taking no medications, up to 5 or even 6 liters a day is safe provided it is consumed over the whole day and never all at once. But if you have heart disease, kidney disease, or liver disease, or are elderly, great caution is important and the amount of water needs to be determined individually for you. When diuretic drugs are being used, to lower urine calcium excretion for stone prevention or for blood pressure control, water intake needs to be no more than 3-4 liters a day and testing is necessary at intervals to be sure blood sodium levels have not fallen. Many other medications interfere with water excretion; psychoactive drugs can do this, for example. All drugs in use must be reviewed with your physician before drinking large volumes of water, above 2.5 liters daily. It is true that most people can easily and safely drink the extra water needed for stone prevention, but the reservations are important, always.
I have recently put together a private FB page called THE Kidney Stone Diet. It is a group that helps educate you on your physician prescribed treatment plans. I moderate it to keep it clinically sound. Come on over and join the discussion!
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So interesting!!
Hi.I have kidney stone of 4mm in both the kidneys.IN THE MORNING AFTER I WAKE UP AND PASS THE URINE I HAVE A SEVERE PAIN IN MY RIGHT KIDNEY. I FEEL PAIN BACK SIDE. IT IS VERY SEVERE FOR FEW MINUTES I HAVE TO SIT AND REST.
I ALSO SUFFER FROM URINE INFECTION.CAN YOU PLEASE SUGGEST THAT HOW MUCH AMOUNT OF WATER SHOULD I DRINK?
AND MOST IMPORTANTLY HOW CAN I GET RID OF THE PAIN AFTER DOING PEEP AS I WAKE UP IN MORNING??
Hi S v, You need your urologist to determine what is best for you, and right now things do not seem ideal. Are your stones causing pain? IF so, are they infected or obstructing some portions of the kidneys. Drinking water will not help with the pain problem, it is for your physicians to do this. I would suggest you ask for management of the pain and also consider how to prevent more stones. For the latter, here is a good reference for you. Regards, Fred Coe
You need to act immediately so you don’t permanently damage your kidneys. Large stones usually have to be removed surgically. I am not a physician but I have had stones. 4mm will probably not pass on its own. The blockage (kidney stone) can cause very high pressure in your kidney and permanent damage. I hope you will make an urgent visit to see a urologist, (a surgeon). You will probably need to schedule surgery as soon as possible.
Hi! I just want to know about 2+ Protein in my Urine. Negative in Glucose. My creatinine test was not yet released.
I do some research about it and I’m worried because it talks about kidney problem. I have a moderation intake in salt/sodium. I’m a water person not into sodas. Help me to know better. Is protein in urine curable by only taking water and lessen of sodium intake? What are other options?
Protein was found after I’m cleared from my 1st pre-existing condition Urinary Tract Infection.
Thanks for the response.
Hi POPS, Protein can reflect bleeding – check if the blood test in urine was negative. If so, the protein can reflect some kidney issue. Common ones include diabetes and hypertension. You are correct in that your physicians need to track down the cause and take steps to offset more kidney injury. I imagine they plan to do this. Regards, Fred Coe
Very very helpful. Thank You
I drink apple cider vinegar with a glass of water and lemon whenever I am passing stones; The high acid levels seems to break the stones down. I am wondering what your thoughts are on this?
Hi Kevin,
If your stones are uric acid this could be true. It will not work for any other type of stone.
Best, Jill
Hi! I have stone kidney on both sides.in right side 1cm and In left side 0.44mm.how can removes my right side kidney stone.if any suggestion help me .I have more pain in my right side.
Hi Wasington, the larger stone can be removed by ureteroscopy in most cases. Your urologist ultimately determines what will be done, however. Regards, Fred Coe
I had a 10×7 mm kidney stone. Had lipotipsy to blast them. How much water to drink
Hi Margaret, The stone needs analysis – makes a big difference. You need a proper evaluation as for cause. Treatment depends on the stone type and the results of testing.
I am a coffee drinker. Can I count the cups of coffee I drink as part of my fluid intake? Also, what is the least harmful artificial sweetener I can use in my lemon/water?
Hi B, Coffee counts. Sweeteners other than sugar and Stevia from plants. Fred
Spinach should not be on the list of items to consume as it is very high in oxalates which causes kidney stones.
Hi Daniel, It is indeed at the top of our list of highest risk foods, and we hope that dissuades all from using it. Fred
Hi, I drink a lot of water but recently I noticed that very small pieces of stone are being released. They are tiny and it doesn’t even pain but I’m still worried as it causes bad odour around the part of my genitals on my pants pls help
Hi Abhi, These need to be analyzed as they are stone crystals and may be infected – especially if the odor is like ammonia. Ask your physicians to do that now. Regards, Fred Coe
But it has disappeared or totally released from my body ever since that comment and it didn’t pain any time
Hi Abhi, I am afraid I cannot place to what this comment pertains. Fred
Do you think your suggestions are useful for someone like me who has a hyper parathyroid gland that near heart that cannot be pinpointed for removal and that causes higher levels of calcium than desired – probably causing the stones? Have had 6.
Hi Tom, Here is my clinical article on your disease. Here is a more detailed one. Mediastinal glands are not rare, and need removal. If your physicians are having some uncertainties about locating the removing the gland they need to refer you to a center that specializes in this rather intricate and difficult surgery. Surgery cured this disease in almost all cases, and if left alone the disease can cause very serious systemic disease beside stones. Regards, Fred Coe
I have kidney stones .7mm and 11 mm .can it be removed through 2.5 liter water per day . Which includes lemon water , turmeric water ,and apple cider vinegar and plain water ? And regarding pain I have little very little bit
Hi Rahul,
Drinking water ( you do not need the other items and tumeric is high in oxalate so I would limit it). You may or may not pass the stone. Make sure to get advice from you doctor to see what type of treatment is best for you.
Best, Jill
If you know the size of your stone your urologist should give you an opinion. I don’t think an 11 mm will pass on its own. Failing to pass it can result in dilation in kidney and ureter. I just had 2 9mm stones lasered. Please don’t delay getting treatment.
Hi Leisa, I agree with your advice. Here is an article to back you up. Regards, Fred Coe
I have 3mm kidney stone… how many days does it take to pass and how many litres of water should I drink per a day ?
Hi Radha, It can be days to weeks. I believe 3 weeks is the longest reasonable interval before your surgeon just removes it. Regards, Fred Coe
Water we choose should always be given high priority because it helps us to maintain good health and fitness.
Generally how long does it take for a calcium Oxalate stone of significant size ( 2mm or more) to form if a person drinks less water and consumes high risk foods ?.
Hi Arjun, I do not know for sure – my best guess would be months. Fred
Do you see anything wrong with this type of drink ?
https://lemonperfect.com/products/peach-raspberry
Hi Terry,
Nothing that will bother stone makers unless you are drinking many bottles per day. It does have Vitamin C in it and vitamin C in excess can covert to oxalate. So know that. There is also nothing in it that will help stone disease either.
Jill
I have been to the doctor three times with hematuria- never passed a stone. I am a nurse, so not the best in the H20 intake at work but I drink 2-3 bottles on the way home and I have 1 down before I come to work. Do stones cause you to have hematuria if you don’t have much flank pain and haven’t passed one or is this something that I need to press to have more tests done. I don’t have any increase WBC so no infection of any sort. I am worried that it is not truly a stone but something more nefarious. Thank you.
Hi Dawn, Crystals can do it, and disappear. But – that word! – I would get a CT as there are other possibilities. If the CT is negative, a likely probability, Urology guidelines call for a diagnostic cysto unless an obvious cause is – well – obvious. Fred
Hi Dawn,
I recently had a kidney stone surgery to remove 9mm stone that was in my left kidney. I never had the slightest of pain to suggest kidney stone. I visited the doctor three times for hematuria, was passing blood in urine for three days straight. I had an ultrasound done but the stone was not detected in the ultrasound. The urologist decided to do cysto-uroscopy to check if blood was dripping from my bladder but even that was normal. Finally I did a CT scan that showed a 9mm Calcium oxalate stone sitting near the kidney. The doctor was surprised to see I did not experience any pain despite such a big stone . Finally the stone was removed after laser lithotripsy with Stent placement. It took me a week to recover after a surgery and that one week was one of the worse time but the doctor said that the recovery pain is far less that what people experience when passing a big stone. I would suggest to get a ultrasound done, if no stone is found in ultrasound you can think of getting CTscan
Dear Tan, It is not rare for a large stone to obstruct without pain and be invisible except on CT. Fred
Hello;
First, Thank You Soooo Much for your Low Oxalate diet article. As a person with Medullary Sponge Kidney finding not only the University of Chicago information about MSK but finding your oxalate diet articles was such a relief that I cried happy happy tears. I have struggled for 10 years when it came to diet due to so much scattered and lack of information.
So my questions are: I noticed in the comments section here that yourself and Fred answered questions and you say that excessive vitamin C can convert to oxalates but you do not state what the Amount of vitamin C is considered excessive. What is the amount please?
Next question: you answered that Turmeric is high in oxalate but I do not see it on the low oxalate diet list. How high is it? I have been taking a Turmeric capsule every day for some time now as it is recommended to help reduce inflammation.
Last question: you spoke of quinoa and that you did not know if it contains oxalates. Have you found new information since then? Is there another way I can find out? I do Love quinoa and hope I don’t have to give it up.
Thank you for taking the time to read through my questions and I hope to hear back from you.
Happy New Year 🙂
Hi Faye, The amount of vitamin C is much above that in a common vitamin and varies between people. I would stay with a routine vitamin level. We now know for sure that vitamin C is converted to oxalate by the liver. Turmeric is indeed able to raise urine oxalate – here is a decent article about it. The turmeric and cinnamon each containing 62 mg of oxalate but only the turmeric raised urine oxalate because its oxalate was water soluble. So, avoid it. We have written about quinoa and noted it has modest amounts of oxalate. This rather fancy article about quinoa and the world points to its oxalate as a drawback – among many.It is apparently bad for Bolivia. Regards, Fred Coe
I just had a cystolathosopy done to remove stones from my bladder due to urine retention. It has been nearly 48 hours and I’m still passing Cranberry Juice colored blood, and small clots and stone fragments. The Dr also said he removed some prostate chops. I’m drinking 2-3 liters water a day and usually a cup of coffee when I wake up. Thanks.
Hi Noel, Bladder stones are indeed due to obstruction. It is worth getting the stones analyzed to be sure what crystals they are made of in case you form more. Regards, Fred Coe
Thank you Dr Coe I’m sure my Dr is doing that. Had the 24hr/day catheter removed to day but he still wants me to self catheterize up to 4 times a day to make sure I’m voiding everything. I need to have my right kidney removed due to a 5cm+ tumor in it, and I guess he doesn’t want any other complications.
I want to thank you so much for this website. I downloaded a water app – so I really know how much fluid I take in and set my minimum 2 liters/day. Since 5/5 I have taken in between 2 – 3 liters every day and passed one small stone and one 7mm that had been sitting at the UV junction and creating much discomfort. I’m waiting to do the 24 hr urine collection that I suggested to my urologist (after reading your site) but need to finish a round of antibiotics for a kidney infection that was concurrent with the last stone episode. (with me thinking my symptoms were all stone related) How long should I wait to be off the antibiotics before collection? Does it matter – or if I’m doing my regular eating and drinking I can do it even while on antibiotics? (Keflex) Thank you in advance if you read this – and no matter what – you have made a difference in my health already. with gratitude, Deborah
Hi Deborah, I would wait until the infection is cured as evidenced by negative culture. Be aware that UV stones can cause the exact symptoms of a UTI so antibiotics needs be given for a positive culture. By all means do the urine collections eating and drinking as you will be doing and are doing as it is one picture out of a movie running life long. Regards, Fred Coe
I recently had my first kidney stone removed. 2 things:
– I eat a lot of vegetables (and some fruits), so there is a lot of hydration I already get from here – enough so that I don’t usually feel thirsty and urine color is pale yellow
– I have an enlarged prostate, so drinking lots of water
a) wakes me up to pee at night
b) doesn’t seem necessary if my urine color is fine and I’m not getting dehydrated much
So I’m trying to find the right balance to avoid future stone formation, AND minimize trips to the bathroom at night. I already try to drink more of my water earlier in the day. What might be a good target to shoot for in terms of daily urine output, 2 liters?
Hi Dan,
We like output to be 2.5 liters and up. Of course, it is challenging to drink all night right up to bedtime. Sleep is important, too, and not getting enough can lead to making poor food choices and less activity the next day. Drink enough that you produce 2.5 liters and above each day but not too much where it bothers your nightly sleep requirement. An enlarged prostate will add to the getting up all night long. I typically get up 3 times a night but also have the added luxury of falling right back to sleep. If you do not cut off your fluids enough but not too much. This might be different for each of us. Perhaps just take sips here and there 2 hours before bed. See if that helps and let us know-
Jill
Information was very helpful, thanks.
Nice.
Keep up the good works!
Best regards and wishes!
G3
Thank you, Fred Coe
What should I drink after one kidney removal from cancer
Hi Sue, If you are not a stone former, just one kidney does not – that I know of – raise stone risk. But if more water is not too much of a trial I would consider 3 liters daily. No more. If you had stones, that is a different matter. Regards, Fred Coe
Thanks for this excellent website and the treasure trove of info. I had a kidney stone attack in September 2022 (and one prior, about 5 years ago). I had significant issues with heat intolerance in the summer of 2022. Based on your writing about heat / sweating / dehydration, would it be correct to assume that the kidney stone and heat intolerance are related?
Hi Sally Lee, NO. I would get evaluated fully in case there is more, because whatever is a cause can be corrected.I would also avoid dehydration, of course. Regards, Fred Coe
Hi,
Thanks for this great site and information. I am a 30 yr old female. I recently had a kidney stone attack in September 2022, my second after a 5 year period. I had a very difficult summer 2022 struggling with heat intolerance. Based on your writing about drinking/sweating/dehydration, am I correct to assume that my issues with heat intolerance and my stone attack can be related? If yes, is there anything different I can do for the future to prevent another attack? I force myself to drink water but it is difficult for me – can I use other drinks in large quantities to get to the recommended intake amount? (Based on 24 hr testing, my stones are calcium-oxalate). Thanks for your help!
Hi Sally Lee, I believe I answered you in another location. You should find out all causes of your stone to avoid recurrence. High fluids alone are a very weak and cumbersome alternative. Regards, Fred Coe
I just had a CT scan of my kidneys on May 3. It showed both sides have stones “too numerous to count”. I am waiting for a urologist appointment to have my images reviewed and then devise a treatment plan. I passed 2 stones in March. I took one in for testing and it was calcium oxalate monohydrate (50%), calcium oxalate dihydrate (10%), and calcium phosphate (hydroxyl) (40%). It was 8×5 mm. Until I get treated, I was told to urinate half a gallon a day. My questions: How much liquid do I need to consume in order to do that? How do I know how much I urinate each day? Do I need to capture it each time to get an idea of how much I pass each time I go? Also is your FB page still active? I know dark sodas and sweet tea are no-nos, but what else am I not supposed to eat knowing I am a kidney stone factory?
Hi Michelle,
Given multitudes of stones and their high phosphate content (40% HA) you would be best served by a full evaluation. I would expect high urine calcium and pH together. Fluids alone are a weak treatment although they do help. You might need a lot more to prevent more stones. Regards, Fred Coe
Hello. When increasing fluids to help reduce or flush kidney stones, does coffee count towards your daily fluid intake? I am guessing yes, but is there any negatives to coffee? (I drink three cups before Noon every day and then stop and change to plain water for rest of the day).
Thanks, Mike
Hi Mike, Coffee counts. Fred