Urolithiasis Symptoms and Risk Factors Among the General Population of Alahsa, Saudi Arabia

Objective: This study aims to assess the awareness and attitudes about urolithiasis among the general population of Alahsa, Saudi Arabia. Methodology: A cross-sectional study was conducted in September 2022 in Alahsa, Saudi Arabia, using a validated questionnaire that was distributed to the general population. Inclusion criteria include male and female citizens of Saudi Arabia who were living in Alahsa, older than 18 years old, and willing to participate in the study. Exclusion criteria include non-Saudi citizens or Saudi citizens who did not live in Alahsa. Data were analyzed using SPSS Statistics. Result: The results showed there were 1023 participants. The results showed the awareness level of symptoms associated with kidney stones at 29%, complications at 34%, diagnosis at 51%, and treatment at 16%. The results showed there was a significant association between a history of kidney stones and having no complications (p-value = 0.002) or inflammation (p-value = 0.009). However, there was no significant association between kidney stone symptoms and the participants' comorbidities. Conclusion: According to our findings, there was a low level of knowledge about the condition and the methods to prevent it, like dietary and lifestyle modifications. Regardless of the low level of general knowledge, there was some awareness of urolithiasis in some elements. Therefore, it is advised to increase health awareness campaigns.


Introduction
The term "urolithiasis" refers to the formation of stones or calculi in the urinary tract, mostly in the kidneys and ureters, although it may also affect the bladder or urethra. There are many classifications according to their chemical composition, such as calcium, cystine, struvite, uric acid, and other rare types of stones [1].
It is one of the most common urological conditions, and its incidence is rising worldwide. It represents a significant health problem affecting diverse age groups, with a high prevalence in Saudi Arabia and a lifetime risk of 20%. It is more common among men than women, with a ratio of (3.2:1) [2]. The high incidence and prevalence can be linked to the hot climate of Saudi Arabia, which led to an increase in perspiration, which will lead to dehydration, as well as some local dietary habits, like decreased fluid intake, increased intake of animal proteins, high salt intake, decreased calcium intake, and genetic factors increasing crystallization and stone formation [3][4][5]. Urolithiasis patients are usually asymptomatic. Some patients, however, may experience loin pain, dysuria, hematuria, sweating, pallor, vomiting, restlessness, and urinary tract infection or obstruction [6]. Nowadays, with conservative management, most stones pass, and the rest are managed with minimal surgical interventions [7].
A study conducted in Malaysia showed that there are low levels of awareness about risk factors and symptoms of renal stones, and there is a lack of sufficient knowledge about the role of diet in the medical management of renal stones [8]. Another study conducted in Saudi Arabia showed the level of awareness about risk factors and prevention among communities. However, it seems that few Saudis, particularly those outside the medical profession, are familiar with these risk factors [9]. This raises the importance of awareness of urolithiasis to prevent such complications. Our study aims to assess the awareness and attitudes toward urolithiasis symptoms and the proper diet for this disease among the general population of Alahsa, Saudi Arabia. A cross-sectional study was conducted in Alahsa, Saudi Arabia, using a validated questionnaire. Inclusion criteria include male and female Saudi Arabian citizens living in Alahsa, older than 18 years old, and willing to participate in the study. Exclusion criteria include non-Saudi citizens or Saudi citizens who did not live in Alahsa and who had refused to participate or had not completed the entire questionnaire.

Questionnaire
The questionnaire was distributed via social media networks including WhatsApp, Telegram, and Twitter to the general population. It was distributed between November 2022 and December 2022 in Arabic via social media networks including WhatsApp, Telegram, and Twitter. The questionnaire might take approximately four minutes to be completed. The questionnaire was divided into three sections. The first section included informed consent and demographic data such as age, gender, marital status, educational level, and occupational status. The second section included questions regarding the awareness of the prevalence of urolithiasis. The final section included questions that assess one's attitude toward urolithiasis. The knowledge and awareness level was calculated by giving the correct answer a score of 1 and the wrong answer a score of 0.

Ethical consideration
The participants' confidentiality and the privacy of their data were the priorities. Nothing leads to any ethical issue being used, such as the names of participants or consent obtained through a direct question before completing the questionnaire. The approval was obtained from the Ethics Committee of King Faisal University. The code of approval is (KFU-REC-2022-OCT-ETHICS225).

TABLE 3: Chronic diseases
The results showed there was a significant association between a history of kidney stones and side and back pain (p-value = 0.026), sweating (p-value = 0.002), and chills (p-value = 0.027), but there was no significant association with red or brown urine with blood, pain or burning during urination, nausea, fever, vomiting, and urine retention (

TABLE 4: Symptoms that may be associated with kidney stones
The results showed there was a significant association between kidney stone prevention and drinking fluids (p-value = 0.039). Red meat increases the risk of developing kidney stones (p-value 0.01), tea and coffee help in the formation of kidney stones (p-value 0.01), and boiled parsley water helps prevent kidney stones (pvalue 0.01). If a family member had kidney stones, this increases your risk of developing kidney stones (pvalue = 0.002), but there was no significant association between kidney stone formation and urinary tract infections, sedentary lifestyle, excess calcium and uric acid in the blood, endocrine diseases, or drinking adequate amounts of water as prevention of stone formation ( Table 5).

TABLE 5: Awareness of risk factors and prevention
The results showed there was a significant association between kidney stones and having no complications (p-value = 0.002) and inflammation (p-value = 0.009) but no significant association with urethral obstruction, renal failure, diabetes, weakness in urination, or heart disease ( Table 6).

TABLE 6: Expected complications of kidney stones
The results showed there was a significant association between kidney stones and X-ray examination as a tool for diagnosis (p-value 0.01) but no significant association with kidney biopsy, urinalysis, blood tests, and stool examination ( Table 7).

TABLE 7: Tests that help diagnose kidney stones
The results showed that surgical intervention, parsley water, diuretic drugs, drinking milk daily, drinking barley, using medical therapy, drinking more water, and laser Lithotripsy and ultrasound lithotripsy had no role in the treatment of kidney stones ( Table 8).
Have you had kidney stones before?

TABLE 9: Awareness level of kidney stones
The results showed there was a significant association between kidney stone formation and a family history of stones (p-value = 0.008), the most appropriate amount of water to be taken daily (p-value = 0.002), and attending awareness campaigns about kidney stones in public places such as complexes or parks or via the Internet (p-value = 0.01). However, there was no significant association between kidney stones and the type of kidney stones that were most common or the amount of water you drink daily (

Discussion
This study aims to investigate awareness and attitudes regarding urolithiasis symptoms among the general population of Alahsa, Saudi Arabia. The study assessed the awareness of 491 male (48%) and 532 female (52%) participants with a prevalence of 10% who were diagnosed with urolithiasis, the majority of whom were 49 (50%) among those 35-50 years of age, more commonly in males 63 (64%). There are studies that suggested a prevalence of 10-15% globally and up to 20% among Saudis. On the other hand, our study showed a 10% prevalence among the Alahsa population [8][9][10]. Our study found a higher incidence among those aged 35 to 50, which is consistent with many other studies [8,10,11].
The results showed that there was an increase in kidney stone incidences among males, making females less prone to develop kidney stones as has been widely reported in several studies [12][13][14].
Family history was significant for the individuals who were diagnosed with urolithiasis, with 63% of them having a relative who was also diagnosed; this association is seen among many other studies. Thus, it could be a genetic predisposition or due to the same dietary and lifestyle habits, but it was a significant point that should be taken into consideration since there are well-known familial causes of renal stones [11].
The results showed that some symptoms (nausea, vomiting, sweating, and chills) were poorly understood by the responders; however, flank pain, hematuria, and dysuria were better understood. A similar conclusion was reached in the study by Alghamdi et al. [3]. It could be due to a lack of knowledge or to the fact that these symptoms occur less frequently than flank pain, hematuria, and dysuria, which were found to be common in the study by Safdar et al. [11][12].
The findings revealed that the most identifiable risk factors associated with kidney stones were decreased fluid intake, red meat increased risk, and tea and coffee increased risk. While the two major factors promoting the development of urinary stones in the study by Baatiah et al. were low fluid consumption and daily caffeine consumption, and few participants mentioned obesity or family history as urolithiasis risk factors [15][16][17].
The results showed that the participants believed that X-rays were considered a tool for diagnosis while kidney biopsy, urinalysis, blood tests, and stool examination were not. It was in line with the study by Almuhanna et al. [9]. It is because several of the participants have a family member who has had a kidney stone.
The results showed that 29% of people were aware of the symptoms of kidney stones, 34% were aware of the complications, 51% were aware of the diagnosis, and 16% were aware of the treatment. Participants in the study by Baatiah et al. with similar findings had awareness levels that ranged from low (64.1%) to medium (35.3%) to high (0.6%) [17].
This study has some strengths in different aspects. The first strong point is the large sample size which reduces errors and biases. There is another point that makes the sample much better. There is a diversity of responses according to age, gender, and educational level. Accessibility to the questionnaire with the privacy of personal data makes the participants more open to participating. All of that ensures the external validity of the study result. The benefits of the study will be shown if it was conducted in a suitable area like in this study. Saudi Arabia has a high prevalence of urinary tract stones, and this is why it is important to make the community aware of the problem. This study was conducted in a limited region of Saudi Arabia, which is Alahsa. The exclusion criteria exclude non-Saudi Arabia citizens. The questionnaire focused on symptoms and risk factor awareness of kidney stones, and it did not include any questions regarding management awareness.

Conclusions
We found that there was a low level of awareness of the disease and how to prevent it by making some alterations to lifestyle and dietary habits. Also, there was a strong association between the history of urolithiasis and age, gender, some chronic diseases, and some habits, like insufficient water intake, especially in a hot area like Saudi Arabia. This leads us to try to increase awareness by doing more studies and more health campaigns about urinary tract stones in Saudi Arabia. We recommend conducting a study with multiple regions with a larger sample size. The method of collection should be a personal interview rather than an online questionnaire.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Ethics Committee of King Faisal University issued approval KFU-REC-2022-OCT-ETHICS225. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.