Tofusi with gout
Interstitial foci of compaction in the form of petiolate nodes of various sizes with deposition of crystallized uric acid and its salts in rheumatology are defined as tophi in gout. They are one of the clinical manifestations of chronically occurring gout and occur at any stage of the disease with a frequency of up to 25%.
Pathologies are assigned code for the ICD 10 - M10, class XIII( diseases of the musculoskeletal system and connective tissue).
Causes of tofus in case of gout
The pathogenesis of tofus, like the gout proper, has a systemic exchange character and is associated with hyperuricemia - an excess of the blood in the blood constantly forming during the metabolism of the nitrogenous bases of uric acid. When the levels of free uric acid in the blood plasma are too long( at a rate of 1-1.2 mg / dl) for a long time, and the acidity( pH) of the blood is also increased, the formation of crystals occurs not only in the synovial fluid of the joints, articular bags) and the surrounding joints of the fibrillar tissues of the cartilage and tendons, but also in other tissues, primarily the dermal ones.
That is, the key causes of tofus in gout is the local accumulation of the products of the abnormal altered cycle of uric acid in the body brought by the bloodstream. The smallest insoluble crystals of uric acid and sodium monoaurate by infiltration or diffusion( finally not yet clarified) fall into the intercellular space of peripheral tissues and disrupt their structure in separate areas where bulk pathological clusters appear over time. The mechanism of tofus formation resembles epithelioid cell granulomatosis, since in addition to concentrated urate crystals in tofus there is granulomatous tissue with giant multinucleate cells and dead macrophages.
Tofuses with gout are of different sizes and different to the touch( most often tight and dense enough);have clear boundaries, since the undamaged tissues are separated by a layer of fibrous fibers. They have the appearance of protruding "cones" above the surface of the skin. Over time, their calcification( calcification) or heterotopic ossification( ossification) can be noted.
The most characteristic places for the appearance of tophi are the fingers and toes, feet, elbows( near the elbow), the knees, the ears - that is, the colder parts of the body where there are no large blood vessels, and the temperature drops in the direction of lowering contribute to the process of precipitation of crystals. However, tofus can occur in bone tissues, and in the tissues of internal organs( most often the kidneys).
Symptoms of tofus with gout
Gout patients may not notice the first signs of the appearance of a toffee form of the disease, since at the initial stage the accumulation of crystals can take place in deeper layers of subcutaneous tissue. If you look closely, you can see whitish spots - when tofus grows closer to the surface of the skin, which gradually becomes more pale in this place.
Obvious symptoms of tofus in gout are expressed in small, medium or rather large yellowish or white nodes under the skin - on the fingers, toes, flexion part of the elbows, around the heels( in the Achilles tendon zone) or the ankles and around the outer edge of the ear. In most clinical cases, tofus do not cause pain, or these feelings are minor. But as the size increases, the tofus begin to exert mechanical pressure, which makes the pain worse.
Tofuses can break through the epithelium and the subepithelial layer of the skin, and a fistula( fistula) is formed. The contents of tofus pasty or granular consistency outward, and in place of the fistula on the skin remains ulcer.
The liquid contents of tofusa speaks about an inflammatory process, however, as rheumatologists note, the inflammation inside the unopened tofus does not usually develop.
Tofuses with gout, especially large ones, cause complications, deforming the joints. And the most serious consequences of the deposition of uric acid crystals in tissues are destruction of cartilage and erosive defects of bones.
Diagnosis of tofus with gout
The diagnosis of tofus begins with gout with their visual examination by a rheumatologist. Then you need to pass the tests:
- clinical blood test;
- biochemical blood test with determination of uric acid level;
- 24-hour urine test.
Instrumental diagnosis is performed using an X-ray or, if necessary, ultrasound.
Gouty tophi can be mistaken for tumor calcification in basal cell carcinoma or sarcoidosis, pseudogout( with the crystallization of calcium pyrophosphate), spondyloarthritis or ostearthrosis, as well as Kaposi's sarcoma, neurofibrosarcoma, dermoid cyst or - for localization in the auricle - for nodal cartilage dyskinesia cartilageear curl. Therefore, differential diagnosis should be carried out. The final diagnosis of gouty tophi is established by the detection of crystallized monosodium urates in tofus or nearby joints, for which purpose fine needle aspiration is conducted and the sample is studied using polarization microscopy to see crystals of uric acid or its salts. And to exclude tumors, the doctor prescribes a biopsy with histology.
Treatment of tofus with gout
How to remove tophi with gout? It is necessary to have a long but effective medication for tofus with gout with uricosuric drugs, which reduce the uric acid content in the blood.
Reduce the size of tofus help drugs that affect the cycle of uric acid - due to more intensive excretion through the kidneys:
- Benziodarone is prescribed in a daily dose of 100 to 300 mg.
- Benzbromarone( an analogue of Benziodarone, differs by the presence of bromine in the composition);is taken once a day, the minimum dose is 0.05 g, the maximum dose is 2 g.
- Probenecid( other trade names are Benedom, Santuril), is prescribed 0.25-0.5 g twice daily.
- Etamide( Etabenecid) is a remedy similar to Probenecid. The standard daily dose is 1-1.4 g( in four divided doses);It is accepted by courses for 10 days with weekly breaks.
- Sulfinpirazone( Sulfazon, Anturan, Enturan) - should take one tablet( 0.1 g) three times a day( after eating, squeezed milk).
But the action of the drug Allopurinol( Alloprim, Allogexal, Ziloprim, Zilorik, Milurit, Purinol) is based on the maximum decrease in the participation in the metabolism of uric acid enzyme xanthine oxidase. As a result, the synthesis of uric acid decreases and, accordingly, its entry into the blood. The usual dose is 1-3 g per day( individual dosage is determined by the doctor according to the results of the blood test).The use of this drug requires an increase in the daily volume of fluid consumed to two liters.
Experts consider operative treatment of gouty tofusis justifiable if tofusi: destroy joints or negatively affect the function of tendons;threaten to cause skin necrosis and ulcers;accompanied by suppuration;squeezing nerves and hurting;have an unsightly appearance. Surgical intervention is also carried out in cases when the total volume of urate in the body can be reduced by removing easily accessible tofuses of large sizes.
Traditional treatment of tofus with gout is to lubricate the cones with alcoholic iodine solution, in which it is recommended to add several powdered acetylsalicylic acid tablets. Can help warm baths with English salt( tablespoon per glass of water).
You can also try and treat herbs: take in the water infusions of medicinal plants such as nettle, black elderberry( flower), stigmas corn, cowberry( leaves), etc.
Among the remedies recommended for tophi homeopathy are Ledum LedumPalustre and Lycopodium clavatum( with clown-shaped plaques).
Prevention is the key to reducing the risk of gouty cones. And to reduce the level of uric acid there is a special diet, for more details see - Diet for gout. Be sure to drink enough clean water( at least 5-6 glasses a day).
Prognosis in the absence of treatment: tofusi are a source of uric acid, which can return to the bloodstream, which will increase its concentration and increase the chances of further attacks of gouty rheumatism. In addition, tofusi with gout can destroy the skin, tendons, ligaments and skeletal structures, and this ultimately limits the ability of the musculoskeletal system and leads to disability.
Gout( gouty arthritis): what is it, the symptoms and treatment of
Gout( gouty arthritis) is a disease in which an excess of uric acid salts( urates) accumulates in the body.
This disease manifests itself in that from time to time the patient develops acute attacks of gouty arthritis.
In addition, near the joints are formed special nodules - tofus.
Who most often develops the disease?
Gout is predominantly a male disease: in the stronger sex it is more common than in women.
gout attack: salt crystals injure tissues
On average, for one ill gout woman there are from 3 to 7 men who are affected by this ailment.
Mostly mature people and older people are ill: most often gout manifests in men after the age of 40-45 years, and in women - after 55-60 years.
This is due to the fact that female sex hormones( estrogens) have a positive effect on the exchange of uric acid in the body. When the climacterium content of estrogen decreases dramatically, then the likelihood of becoming ill with gout is significantly higher.
In addition, it is considered that there is a hereditary predisposition to arthritic arthritis: if someone from your relatives had a gout, chances are that it will arise from you( especially if you are a man) is much higher, and you arein the risk group for the development of this disease.
In addition, factors such as overweight, as well as alcohol abuse, also increase the risk of developing this disease.
In general, in the world, according to statistics, gouty arthritis suffers from 2-3% of the population( data for the United States), but for men after 40-50 years this figure grows to 5-6%.In Russia, the incidence of gout is about 0.1-0.2%.
Why does this disease occur
how does the gout originate( schema)
Because gouty arthritis is a metabolic disease, then it arises in those people who have either increased the intake of substances containing purines, or their excretion due to whichit's a disease.
Which products contain many purines? This is primarily meat and by-products( not for nothing, gout is also called "meat-eating disease"), as well as legumes, tea, cocoa, some fish, and especially alcohol, including beer and red wine.
People who have a lot of such foods in their diet have a high risk of getting gouty arthritis.
And when the removal of purines from the body can be difficult? Most often - because of concomitant kidney diseases, as a result of which renal filtration is reduced, and therefore - the body retains more uric acid salts than necessary, and it begins to be deposited in various tissues - both in the joint region and in the renal themselvestubules.
In addition, an additional risk factor for gout is arterial hypertension, as well as taking certain serious medicines for serious illnesses.
Symptoms of gout
The main and main sign of gout is an acute attack of gouty arthritis, which is also called a gout attack.
Inflammation of the big toe - the main sign of gout
Often such an attack is observed after a plentiful meal with alcohol. Suddenly, more often in the evening or at night, acute pains appear in one of the joints.
Most often, when an attack of gouty arthritis is somehow affected by a big toe, but it can be another joint - for example the knee or elbow.
The joint starts to ache badly - so it can even be painful to touch the affected area( for good reason "gout" is literally translated from ancient Greek as a "trap for the leg").The joint swells, the skin around it due to swelling acquires a purple-red hue, and the skin temperature in this area rises.
This condition( attack), if left untreated, can last up to several days and longer. But usually a patient and his relatives quickly turn to doctors who, with the help of medicines for gout, more or less successfully relieve an attack.
The heavier the course of gout, the more likely these seizures may occur. Conversely, if all the conditions are met to ensure that uric acid and its products do not accumulate in the body, then attacks of the disease can be avoided altogether.
Tofusi with gout
tofusi( photo) with gout
If a gout attack with joint inflammation and pains in it can be considered acute manifestations of this disease, tofusi is a sign of a chronic disease.
Because gout accumulates an excessive amount of uric acid salts, it is clear that these salts should be deposited somewhere. They also are postponed - in the field of various joints( at some point causing a gouty attack), in the skin in the region of the elbows, heels, and also in the area of the cartilage of the auricles.
Collecting in these places, crystalline salts gradually turn into small nodules of white color, which can be palpated in the area of small joints on the hands and feet. These nodules are called tofusi in case of arthritis arthritis.
No special damage to the body by tofus is directly applied - it only signals to the person himself, as well as to his doctor, that there is an excess of uric acid salts in the body - which means that you need to pay attention and take the necessary measures. But we will talk about this in the treatment and prevention of gout.
We offer to watch an interesting video about what is gout and gouty arthritis, and how dangerous this disease is:
disease Treatment of gout can be conditionally divided into two tasks:
- cupping( interruption) of an acute attack;
- normalization of metabolism in the body, that is, treatment and prevention of the disease outside seizures.
Treatment of an acute attack of gout( acute gouty arthritis)
The first attack of gouty arthritis is best treated in a hospital
. As often the first manifestation of gout, unfortunately, usually becomes a developed gouty attack, its treatment is usually performed in a hospital - in the rheumatology department of the hospital.
This is necessary not so much to cure this attack, but how to conduct a full-fledged examination and make the correct diagnosis. After acute arthritis of the joint can be with a variety of diseases - infectious or reactive arthritis, as well as with other ailments.
After the diagnosis of "gouty arthritis" is set, there is usually no need for repeated hospitalizations.
So, what medicines do doctors use to take a gout?
1. Non-steroidal anti-inflammatory drugs
NSAIDs, including all known diclofenac, ibuprofen, naproxen and other agents. These drugs are good at both pain relief and effective reduction of inflammation in the affected joint. They are prescribed in certain dosages according to the scheme, and anti-inflammatory drugs are an important component of the complex treatment of a gouty attack.
Note: Non-steroidal anti-inflammatory drugs do not treat gout really: they are needed in order to reduce the severity of its symptoms - pain and inflammation in the joints. Do not try to treat gouty arthritis yourself with NSAIDs, consult a doctor!
treatment of this disease should be prescribed only by the doctor
Colchicine is a medicine that can reduce inflammation in acute gouty attacks and restore the function of the sick joint.
This drug is prescribed by a special scheme and is taken every few hours for 1-1.5 days - until the severity of the attack does not go down or when it becomes clear that you need to use another medicine.
In those cases when colchicine did not have a therapeutic effect( as it sometimes happens), the doctor prescribes hormonal drugs that suppress inflammation - glucocorticoids. This group of drugs includes such drugs as methylprednisolone and betamethasone. They are usually administered topically as injections into the joint area.
Using this or that means, doctors manage to defeat a gouty attack already within one and a half to two days from the beginning. But, as you know, treating an acute attack of gout is only part of the therapy.
Another interesting and useful video about this disease is the fragment of the program "Live Healthily" with Elena Malysheva:
Treatment of the disease outside of seizures
As this form of arthritis is a metabolic disease and arises from the increase in the amount of urate in the body,will be aimed at reducing the content of these substances in the body.
For this, during the interictal period, the doctor prescribes medications to the patient that reduce the formation of uric acid salts( eg, allopurinol) in the body, as well as drugs that increase the excretion of these substances from the body.
Diet for gout
In fact, it is difficult to name any other disease, in the treatment of which nutrition is so important.
therapeutic diet is an important element of the recovery of
Even if you after the first attack of arthritis received this disappointing diagnosis, then, following the right diet and taking medications, after a while you will be able to give up medicines only due to the fact that you will comply with the rules of therapeutic nutrition. And it, unfortunately, is not so simple, considering what foods can not be eaten with this disease.
Thus, on the anti-gouty diet, it is necessary to exclude red meat and its products, meat by-products( kidneys, liver, heart), fatty fish, legumes, sharp and salty cheeses, and also alcoholic beverages( this concerns cognac,beer, champagne and sweet dessert wines).Learn more about what you can, and what you can not eat with this disease, you can read in the article Therapeutic diet for gout.
Despite the fact that gout is accompanied by a painful attack of arthritis, remember that this disease with timely access to a doctor is successfully treated, and not only medicamental, but also folk remedies.
Therefore, if you find symptoms of gout listed in this article, do not suffer pain, consult a doctor, and very soon mobility and health will return to your joints again!
The appearance of pain in the joints is an occasion to immediately consult a doctor who will exclude other arthritic conditions - systemic lupus erythematosus and rheumatoid arthritis, which have symptoms similar to gout.
Fig.: joint damage in systemic lupus erythematosus
A set of diagnostic methods for the detection of this disease include:
- blood test , which will show whether the urate level is elevated. Although there are cases in which the crystals of uric acid are contained in the blood at a normal level, but gout occurs.
- take a sample of tissue( under local anesthesia) or intraarticular fluid( the procedure is very painful, but necessary) for the presence of needle crystals of urates in them.
- X-ray studies of , showing gouty bone injuries and tofusi.
The diagnosis of "gouty arthritis" is based on anamnesis and clinical examination of the patient.
Video: how gout-affected joints of the extremities look like
What provokes gout? Since the disease is directly associated with hyperuricemia, the lack of treatment leads to the accumulation of excess uric acid salts in the body and subsequent changes in internal organs( primarily in the kidneys).
In a quarter of all cases, gout patients with kidney disease develop kidney disease and kidney failure.
Other possible complications of gout are:
- appearance of gouty kidney( tissue damage);
- complete renal failure;
- erosive-destructive polyarthritis;
- marked atherosclerosis.
Tired of chronic pain in joints? You can remove the symptoms with an ointment with anti-inflammatory effect. Learn more about this here.
Methods for treating gout ↑
An integrated approach is important in the treatment of gout. An indispensable condition is the normalization of the balance of the metabolic process, the restoration of kidney function and the administration of medications.
The general plan of treatment includes the removal of pain and constant intake of necessary medications in order to avoid repeated attacks and prevent subsequent deposition of urates.
For the treatment of acute attacks, colchicine is used, after which the pain subsides for 12 hours and disappears completely in 48 hours.
Non-steroidal anti-inflammatory drugs( ibuprofen, diclofenac, indomethacin, etc.) are used to relieve pain.
Photo: colchicine for the treatment of gout
Corticosteroids( for example, dispropan), which are potent anti-inflammatory drugs, are also widely prescribed for treatment.
In addition, prescribed drugs that excrete uric acid( usually it's allopurinol).
There is also a treatment of gout with ointments that have a local anesthetic and anti-inflammatory effect.
It should be remembered that medical therapy, conducted in a timely manner, can solve the problem of gout once and for all.
In addition, to stop the attacks of the disease apply compresses with 50% dimexide solution, which has a pronounced analgesic and anti-inflammatory effect.
To do this, mix 1 tablespoon.dimexide solution with 1 tbsp.water and ampoule of novocaine or analgin, compress on the affected joint for 30-40 minutes. Typically, the course of treatment with a solution of dimexide is 10-20 procedures.
This type of therapy helps to remove acute attacks of the disease.
The most commonly used:
- ultraviolet irradiation of the affected area, for example, the knee joint, which can help even before the appearance of swelling and redness, i.e.stop the approaching gout attack
- treatment with ultrasound : thus, the patient's joint is resorptive, analgesic and anti-inflammatory.
- laser therapy : the laser destroys the accumulation of salts in the joints( so-called tofusy).
- phonophoresis with hydrocortisone( sometimes combined with ultrasound therapy): helps to weaken the inflammatory process, strengthen the lymph and blood circulation and accelerate the excretion of salts from the affected tissues.
Photo: hardware treatment of gout
Particularly helps with the treatment of a combination of chronic gouty arthritis with osteoarthritis.
Homeopathic remedies China, Sabina, Colchicum, Berberis are used for the treatment of this disease.
They can correct minor deformities, remove swelling, and also correct related disorders.
The necessary drug is selected individually by a specialist homeopath.
In the remission period of the disease heat treatment is applied:
- applications with mud;
This treatment reduces the pain, the severity of the inflammatory process and improves the function of the joints.
Photo: treatment of gout with mud
Also often as a method of rehabilitation prescribed spa treatment, including balneotherapy( iodine-bromine, radon, sodium chloride and hydrogen sulphide baths).
- to improve microcirculation and circulation in tissues;
- enhanced kidney and liver function;
- normalization of lipid metabolism in the body.
In complex treatment can additionally apply the reception of alkaline mineral water and diet food.
Surgically, joint puncture is often performed with the simultaneous introduction of intra-articular corticosteroids.
Sometimes, urate deposits are removed quickly, large gouty nodes( especially in fistula and skin ulceration).
Photo: Gouty tofus
Shockwave therapy destroys kidney stones, which are then excreted in the urine.
In some cases, with significant destruction of cartilage after removal of tofus, resort to restorative joint surgery( arthroplasty).
Treatment by the method of Dr. Bubnovsky
The method of Dr. Bubnovsky uses therapeutic exercises and kinesitherapy.
A specially selected set of exercises makes the musculoskeletal system function normally, as a result of which it is possible to get rid of gout and pain accompanying it.
Video: joint exercises for Bubnovsky
New in the treatment of gout
To date, innovations in the treatment of the disease are:
- the creation of new drugs from the class of non-steroidal anti-inflammatory drugs: Celebrex, Arkoksia, Nimesulide fulflex, etc., which are much milder on the gastrointestinal tractthe intestinal tract than their predecessors.
- application of hardware purification of blood from uric acid( plasmaphoresogemosorption).This new method of treatment is considered sparing and is carried out on special medical equipment.
Photo: preparation Celebrex
Nutrition is an integral part of gout treatment, it includes compliance with a special regimen.
Menu for gout should be changed.
So, it is necessary to reduce to a minimum:
- meat products, including the liver( only lean beef is allowed)
- fish products, including seafood( only lean large fish are allowed)
- consumption of legumes, sorrel, eggplant, cauliflower, mushrooms, radish
- consumption of chocolate
- quantity of marinades, canned food, salted varieties of cheese
In addition, it is necessary to reduce the amount of milk, butter and eggs consumed.
Alcoholic beverages for gout should be completely ruled out.
The amount of carbohydrate food increases in the diet:
Gout( literally, the shackles on the legs) is a disease that occurs when the exchange of purines - the natural substances present in all cells of the human body - is disturbed. The main signs of the disease are crystalline formations of uric acid. Tofusy with gout - this is the granular accumulation, concentrated in the soft tissues of the legs.Tofus formation
Tofus formation occurs in the feet, shins and hips. Their presence leads to large problems with the normal function of the joints. Visually, tofus are like nodules, which indicate a prolonged nature of the disease.
Why crystals appear
The main reason is the local deposition of uric acid salts. And correctly diagnosed and treated gout is possible only after the discovery of urines in the gout. The causes of the appearance of tofus can be the following:
- In the body, too much purine is synthesized, which begin to exceed the daily norm.
- The disturbed metabolism is not able to process in time the purines coming in with food and those that the body produces.
- Tofus formation means that the disease progresses at least five years and there are already a lot of crystals.
- Granules can appear with bone marrow diseases of an oncological nature.
- To provoke the onset of tofusi are capable of serious kidney diseases.
- Crystalline formations may appear as a result of a chronic illness that hampers the removal of purines.
Most often, men suffer from gout after reaching the age of forty. At the initial stage of the disease, the patient may not be aware of its existence, since gout does not appear externally. However, after several years of progressive development, the tofus is formed over the joints of the legs, indicating a long duration of the disease.
How do gout granules look likeToxic signs do not appear immediately. They may be preceded by an acute attack of gout. After it, and begin to appear peculiar knot formations in different parts of the legs. Tofusy can occur in other places, but their greatest concentration always falls on the lower limbs of a person.
Basic visual signs:
- There is a roughness of the skin in the place of nodule formation.
- Crystal formation has clearly defined boundaries under the skin.
- The internal contents of the pellet have a fairly dense structure, this is felt to the touch.
- Clusters of crystals are visible under the skin, they resemble cartilaginous tissues.
- Usually, the contents of tofus have a whitish or yellowish color, and this can be seen through the skin.
- The main site of localization and concentration of granular deposits are the super-joint areas of the legs.
- In some cases, a fistula is formed in tofus, which ruptures the skin and releases the contents of the node.
Whatever the signs, they are always visible, which indicates a severe form of gout development.
Methods for removing crystalline deposits
There are several effective methods that allow you to remove tofus and cure the disease. Usually therapy is aimed at reducing the purine content in the body and restoring the function of their complete elimination. The doctor prescribes medication with special medications that can reduce the number of uric acid compounds in the body. To do this, use uricosuric drugs:
- Usual aspirin. Salicylates are good for crystalline formations, but the drug is taken in a large dose, which borders on intolerance.
- Butadione. Has good effect at high doses. It is prescribed strictly individually, since the drug can cause dangerous side effects.
- Anturan. Recognized as the most effective drug. After two to three weeks, the uric acid content comes to normal.
- BENEMID.Tofus after its use are reduced or completely disappear. Has a diuretic effect. But the drug should be taken, making small breaks.
These medications are used with good kidney function and at the age of the patient not exceeding sixty years. To treat chronic gout and remove formations use urikodepressivnye drugs. They contain milurite, which suppresses the synthesis of uric acid and reduces its level in the body.
Non-medicamentous treatment of
If tofusi have grown strongly and there are a large number of them, surgical intervention is prescribed. In this case, the tofus removal takes place with gout by the method of cutting out a tofus tumor with the formation of a significant area of the wound surface.
You need to dissect the affected area with a small growth of the node. For each patient, the operation is carried out according to an individual scheme. In this case, the surgeon chooses the number and shape of the incisions, depending on the size and location of the subcutaneous formation.
Folk remedies and diet
To effectively combat gout, a person has to radically change his lifestyle. It is necessary to abandon the bad habits that suppress the excretion of uric acid from the body. Food should contain a minimum amount of purines. A strict diet is prescribed and strict adherence to it.
With gout, fasting is excluded. The diet should be sufficient and varied. Adequate physical activities are welcome.
Folk ways of treating tophi and gout itself can include:
- Drinking fresh birch juice.
- The reception of herbal decoctions from nettles or flaxseeds.
- Water treatments with infusion of flowers of a medicinal camomile.
- Application of lotions infused on oat straw or Siberian larch.
- Treatment by the method of bee bites in the affected area.
- Use of "live" alkaline water.
Whatever method is used to treat, effectively eliminate the disease and tofusnye knots can only be a comprehensive therapeutic and operative approach. This means that to prevent the removal of the inflammatory process, you can choose a diet and advice of traditional medicine, to suppress uric acid, use medicines, and to remove complex nodes resort to surgical intervention.