Agonizing, intolerable, miserable, excruciating, stabbed with a knife, worse than childbirth.
As a urologist specializing in the treatment of patients with kidney stones I have learned a new lexicon exclusive to stone formers describing bouts of renal colic.
Pain, the hallmark symptom of stone disease, accounts for over one million emergency room visits by such patients in the United States each year.
Over the past several decades considerable progress has been made gaining insight into the physiology of renal colic and optimizing methods to treat it. However, despite improved scientific explanations we as clinicians still lack a perfect understanding of why it occurs.
PAIN FROM STONE PASSAGE
Patients have been suffering from renal colic secondary to stone disease for over two thousand years. As a matter of fact, it is remarkable how little has changed in its clinical presentation over this time period. In 400 B.C. Hippocrates referred to it as first disease of the kidneys. He was one of the initial observers to comprehend the association between urinary obstruction and pain, writing:
An acute pain is felt in the kidney, the loins, the flank and the testis of the affected side; the patient passes urine frequently; gradually the urine is suppressed. With the urine, sand is passed; as the sand passes along the urethra, it causes severe pain which is relieved when it is expelled; then the same sufferings begin again.
We have since come to appreciate the complex physiologic basis for this relationship at a much deeper level.
How Pain Begins
The first step in this process is acute obstruction, most commonly from a stone. But in stone formers masses of crystals can create obstruction, as can blood clots if bleeding is particularly brisk.
Urine from the kidney can no longer pass to the bladder and as a result builds up and stretches the proximal – closest to the kidney – ureter and renal collecting system. This stretch activates nociceptive nerve fibers – fibers which sense injury – within an entire neuronal network located submucosally in the renal pelvis, calyces, capsule and ureter.
Figure 1 (left) – Example of obstructing proximal ureteral stone with dilation and stretch of the collecting system above the level of obstruction.
These fibers then transmit afferent signals to the T11 – L1 spinal cord which the body interprets as pain at the corresponding level of neuronal activation. As the stone migrates from the kidney down the ureter and towards the bladder, pain usually shifts downward as well. It is commonly sensed as high as the upper flank when the stone is lodged in the proximal ureter and as low as the labia/testicle when down near the uretero-vesical junction at the entry to the bladder.
Patients passing stones may experience other symptoms in addition to pain. Many of the nerves involved in the process of obstruction are intimately linked to innervation of adjacent organs, for example the gastrointestinal tract. Cross activation of these associated nerve fibers has been proposed as an explanation for the nausea and vomiting which so often occurs in the setting of an acute episode of renal colic.
In rare instances patients may even have alternative symptoms without any pain at all. In some cases, particularly when the stone is at the uretero-vesical junction, urinary symptoms predominate and the only appreciable symptoms are urinary frequency, urgency and discomfort while voiding. These symptoms mimic urinary infection and often result in temporary mis-treatment with antibiotics until the correct diagnosis is made.
What Happens Later
Increasing renal pelvis pressure from persistent obstruction causes a release of prostaglandin E2. This chemical mediator of injury response produces a perfect storm.
It causes ureteral hyperperistalsis (increased intensity of the waves of coordinated ureteral contractions which normally drive urine down to the bladder) and eventually even ureteral spasm. It also leads to dilation of the afferent arterioles – those tiny resistance vessels which control the flow of blood into the capillaries of the kidneys.
The arteriolar dilation increases blood flow to the kidney and promotes a temporary diuresis just as ureteral smooth muscle hyperperistalsis and ultimately spasm tighten the ureter around the stone and worsen obstruction. Spasm leads to lactic acid build up, as occurs when any muscle is over-exercised, and sets off an inflammatory cascade that itself can worsen pain.
With time, blood flow to the affected kidney falls, even though the arterioles which let blood into the renal capillaries remain dilated. It falls because the efferent arterioles, which let blood out of the capillaries where filtration occurs, begin to constrict and raise filtration by the renal glomerulae. The increased filtration maintains and can even raise pressures.
Figure 2 – Diagram of blood flow to the nephron. Blood enters through the afferent arteriole and is then filtered within the glomerulus, producing urine in the process. Blood exits through the efferent arteriole. Both the afferent and efferent arteriole are able to dilate and constrict in order to regulate pressure and ultimately filtration via urine production.
In many ways, this complex system is analogous to the soaker hoses many people use to water their lawns. The afferent arterioles are the faucet the hose is connected to and the efferent arterioles are the opening at the end of the hose which can be closed or left open into a sprinkler.
Filtration is the many tiny flows of water all along the hose which keep the grass growing.
When working appropriately, the faucet and the end are both open and water (urine) is produced at a slow, constant rate (Figure 4 – left). With an obstructing stone the faucet – so to speak – is opened more and the end clamped more so more fluid – water – is filtered out along the length of the hose at high pressure (Figure 4 – right). In the kidney this filtration is into the nephrons and raises pressure. When the clamp is tightened, the total amount of flow through the hose can fall just as the amount of water filtered out along the hose rises.
Figure 4 – Soaker Hose Analogy to Renal Blood Flow and Filtration. On the left, there is little pressure in the system and water (urine) seeps out slowly from along its length. On the right, the inflow is much higher than the outflow and water (urine) shoots out from along the hose at exceedingly high pressure.
Three Phases of Pain in more Detail
The Physiology
No discussion regarding ureteral obstruction would be complete without the work of E. Darracott Vaughan, who characterized the physiology of urinary obstruction in the 1970’s.
Assuming two functional kidneys, the physiologic effects of acute unilat
eral ureteral obstruction can be marked by three distinct phases.
In phase one, the effects of the inflammatory cascade described above cause a progressive rise in renal blood flow and renal pelvis and ureteral pressure. This phase lasts for approximately one to one and a half hours. This is the portion where the afferent arteriole – the faucet – is maximally opened.
Phase two is marked by efferent arteriolar vasoconstriction which causes a decrease in overall renal blood flow but an increase in ureteral pressure for up to five hours. The faucet is opened and the end clamp is tightened.
Phase three is marked by a further decrease in renal blood flow to the affected kidney and ultimately decreased ureteral pressure. The end clamp is progressively tightened so blood flow to the kidney is reduced enough that filtration and urine production begin to fall, and pressure with it.
Measurements of ureteral pressure (red) and renal blood flow (blue) after onset of acute unilateral ureteral obstruction. (Courtesy Campbell-Walsh Urology, Tenth Edition, Elsevier Inc.)
The fall in blood flow is not injurious during an acute attack, but over time it can be. This means that relief of an obstructing stone is an important matter. Commonly stones pass of themselves. But stone attacks need medical attention because if the stone continues to obstruct it must be removed.
The Symptoms
It is easy to conjecture how these three distinct phases correlate clinically to the symptoms experienced during an acute episode of colic.
The onset of pain classically correlates to phase one and the inciting obstructive event. It is at this point that the patient commonly seeks care in the emergency room or physician’s office.
The pain classically persists at a severe level for several hours (phase two) but ultimately subsides, at least partially (phase three).
In many instances pain comes in waves, potentially a sign of intermittent obstruction activating the above pathway each time urinary flow is obstructed. This occurs through a combination of the stone moving and the tensions of the ureter with increases or decreases of muscle spasm.
THE CONUNDRUM – Pain Without Obstruction
Opinions of Urologists in General
Though the physiologic basis of pain in the setting of obstruction is clear, it does not provide an explanation for one of the most commonly encountered conundrums in stone disease – the symptomatic non-obstructing stone. These can be actual free stones that have not passed, stones attached to plaque, or actual plugs in the kidney tubules that are massed together enough to show up on a CT scan as ‘stones’ though actually tissue calcifications.
There is perhaps as much variation in clinical opinion in such instances as any other clinical scenario in the field.
If one were to ask a group of urologists whether they believed that small nonobstructing stones could cause renal colic, opinions would range from absolute certainty to complete dismissal of the concept altogether.
What Happens to Patients
As a result, there is no standard of care regarding how to optimally manage such patients. In all cases it is first imperative to rule out other potential sources of pain; however, such workups often end with the same result – a patient with bothersome flank pain and evidence of one or more nonobstructing stones on imaging.
Lacking a physiologic explanation to explain their symptoms, patients with pain and non obstructing stones are often sent for detailed workups, secondary and tertiary consultations and referral to pain specialists and even psychiatrists. However, in an age where flexible ureteroscopy can be performed quite safely and on an outpatient basis one must wonder whether such patients are being treated appropriately.
A Specific Example
As an example, I recently met a patient who had been referred from several hours away seeking a fourth opinion regarding her chronic flank pain. For months she had suffered from a severe ache in her left flank that had limited her ability to work and live her normal life.
She had attributed the pain to a 7 mm lower pole nonobstructing renal stone on that side which was discovered on a CT
scan during her initial presentation to an outside emergency room (Figure 3). However, none of the physicians she had seen agreed with her self diagnosis.
Figure 3 – CT image of left lower pole nonobstructing stone (red arrow). There is no evidence of obstruction or inflammation around the kidney.
In the ER she was given narcotic pain medication and sent home to follow-up with a urologist.
The first urologist she saw told her that while the stone was visible, its location within the kidney meant that it could not possibly be causing her pain. He refilled her prescription for pain medication and sent her to see a pain specialist.
The pain specialist tried physical therapy for what he thought may be a musculoskeletal source but ultimately this did not prove effective and she was given more pain medication.
She later sought care from a second urologist who also told her that the stone could not possibly be causing her pain in the absence of obstruction. This time however she was accused of having an agenda and seeking care specifically to get pain medication. Similar visits to a variety of emergency rooms elicited more CT scans as well as accusations of seeking pain medications. Each CT result was the same though, all demonstrating a 7 mm non obstructing left lower pole stone.
On one instance a treating practitioner even admonished her, saying that nonobstructing stones don’t cause pain and he should know since he too had been diagnosed with such stones incidentally on a CT scan.
Ultimately she made her way to the clinic for consultation at which point she was offered a ureteroscopy and stone removal. The procedure went well and she was discharged with a stent for one week. She was last seen back 5 weeks after the procedure and reported complete resolution of her pain. She was no longer taking any pain medication whatsoever and there was no evidence of any stone or hydronephrosis on follow-up imaging.
What is Known to Date
Such patients are frequently encountered. Despite a lack of physiologic explanation as to why these non-obstructing stones may cause pain, there is emerging evidence that they do and therefore that removal can cure it.
In 2006 Taub et al. described outcomes of twenty such patients who had chronic flank pain as well as radiographically evident calcifications within their papillae without obvious collecting system stones. Ureteroscopy with laser papillotomy to unroof and remove all evident stone was performed on twenty seven kidneys. Pain improvement was seen in 85% of cases with a durable improvement for greater than one year in nearly 60% of cases.
This study was then repeated on a multi-institutional level with 65 patients undergoing similar procedures over a ten year period. Overall there were 176 procedures performed in this cohort with patients reporting less pain after the procedure 85% of the time. The mean duration of response was 26 months with 60% of patients having sustainable improvements in their pain levels for over one year.
Finally, this clinical scenario is seen commonly enough that it garnered its own nickname at Massachusetts General Hospital where it has been described as “small stone syndrome”. In a retrospective review of patients treated there with ureteroscopic removal of small nonobstructing stones (<4mm) for reasons related to chronic pain, 11/13 patients reported being pain free after the procedure with the other two noting a partial response.
What I think
We still do not completely understand the physiologic explanation for pain in these patients. However, much like Hippocrates over two thousand years ago, clinical observation often precedes scientific understanding. In this regard it is unfair to dismiss the notion that small non obstructing stones can elicit legitimate renal colic.
Physiologic breakthroughs in the understanding of pain signaling and inflammation are currently happening at a rapid rate and it is likely that in time we may be able to better decipher which non-obstructing stones are truly responsible for symptoms. However, until then, such scenarios will continue to be a commonly encountered clinical complexity for urologists.
For the time being I would still advocate consideration of alternative causes of pain in such situations including urinary infection, obstruction and malignancy. A careful history is critical to rule out non-urologic sources such as pathology within the musculoskeletal, pulmonary, gynecologic and gastrointestinal systems. Another important element of the history is whether the patient has previously passed a stone and if the current symptoms are similar to that experience.
Once other explanations have been ruled out, offering stone removal is entirely reasonable. This not only has the potential to improve pain but may also decrease the risk of future stone growth or spontaneous passage at a later date. In such instances, I prefer flexible ureteroscopy with stone removal to shock wave lithotripsy. First, ureteroscopy maximizes the likelihood that all stones can be identified and removed which is especially important in the event that pain persists after the procedure. Second, with ureteroscopy one can inspect the inside of the kidney in high definition which has the potential to offer information not readily available on x-rays and CT scans such as embedded stones, tissue calcifications, and other pathology (Figure 4).
Figure 4 – High definition images obtained during renal endoscopy demonstrating tubular plugging (stones embedded in the kidney) (Courtesy: AE Evan, IMCD and BD plugs: Do they have a role in stone formation).
Finally, it is critical to establish realistic expectations before surgery in regards to pain control. Our understanding of this concept is in evolution and the published literature suggesting a treatment response is limited to relatively few patients. However, as science and history have shown us, just because we don’t fully understand the connection doesn’t mean it doesn’t exist.
More You Might Like
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Types of Kidney Stones
Do We Need to Analyse All Those Stones?
How Kidney Stones Form
When Crystals Plug The Kidneys
Medullary Sponge Kidneys
U.A.E. Hi! Dr. i just want to ask if dizziness is symptoms of kidney stone. I suffer from dizziness almost 1 week i cannot concentrate and feel lightheaded with little head pain. My doc check my blood for anemia and creatinine but the result is normal. Last Dec 28, 2015 i make CT scan and find 6mm stone on my right lower ureter and 3mm on my right kidney. After 1 month and half i make ultrasound and they cannot find any stone at all. I was still suffering from mild lower back pain and my urine become dark (yellow) and bubbly when i was not regularly drinking water ( every hour). I didn’t also feel any severe pain which is associated when passing a stone. Now i stop taking my medicine omnic ocas, rowatinex, and urocit-k because of my severe dizziness but still i feel the same dizzy. Im taking only cystone 2 tablets twice a day and drink 3-4 lt of water. What should i do?, is dizziness is also associated with the stone? What is the best thing to do?
Hi Deon; No, kidney stones are not a cause of dizziness. I think the dizziness should be evaluated and treated as a completely separate problem. As for the stones, being multiple, they can be prevented in a conventional manner. Regards, Fred Coe
I get dizzy from the unfocused pain. It’s like being punched in the gut, and I feel faint. I’ve known I’ve had unobstructed stones for years, but this Friday, one small one became lose and I was told there are much larger ones in the kidney. I get more pain from these than the one that got loose. Tomorrow I see a urologist for the first time; I have no idea what to expect. Figures I have a prepaid cruise coming up in less than 2 weeks.
Dear Jenny, I wish the problem of pain from non obstructing stones were better attended to. There are a lot of people like yourself. Fortunately a number of surgeons consider the matter very important and I am hopeful of progress. The stones that are free in the kidney and do or could obstruct should certainly be removed. Regards, Fred Coe
this article just mad me cry. I am on year 10 of multiple stones from passing a 17 mm to having a 2 mm stuck. I thought I found a great urologist but again im being pushed off. I would have what you call small stone syndrome, but a lot of them. Last proceed 72 to be exact. I have brushrite stones with fast recurring had 10 back 3 weeks after procedure. now been 4 months 12 er visits 7 uti 1 severe kidney infection. And once again the head doctor at ohio state said go upstairs and see the physiatrist. Now I am being pushed to see an infectious dieses doctor.
Dear Andrea, I am sorry you are having so much trouble. Brushite stones are indeed a problem – high recurrence is not rare, and they are hard and not so easy to fragment. Mineral deposits in kidney tissue are sparse but large. Prevention measures have not been formally tried but in fact most patients have idiopathic hypercalciuria which can be treated with low sodium diet, and thiazide diuretic agents – together – along with high fluids. I would advise this approach strongly because recurrence simply maintains the pain and urological difficulties. You should pursue 24 your urine and blood testing to establish the cause of stones, and if it is idiopathic hypercalciuria have it treated. If it is another cause, it can be treated as well. Perhaps you, like many people with chronic illness, might benefit from mental health professional counselling, but you will surely benefit from well organized stone prevention care as well. Regards, Fred Coe
I have had 24 and 48 hr urines done the all show high calcium and no uric acid. I follow low sodium and take diuretics. My blood calcium stays at 9 to 10.4. Parathyroid level at the last high part of normal. I drink a liter of fresh lemonade a day along with water with more water. My potassium stays low I feel awful. I am a active mom with 9 kids. I coach jr high softball and play womens league. I cant do it anymore and am lost. It has took over my daily living. guess just looking for something or someone that can help somewhere. I do agree counseling does help a lot, but when a doctor knows you go they push you off as crazy.
Thank you
Dear Andrea, You have hypercalciuria and the common treatments are not working, so they are not being used enough to lower your urine supersaturation. I suspect your urine sodium is too high – can you put up the number? That would lower your potassium. I also suspect your urine volume needs to be higher. These are just suggestions. But the main point is that your problem is technical: You just need to get the volume high enough the sodium low enough so the calcium is low enough, and the supersaturation will fall and the stones will stop forming. Given the borderline calcium and PTH have your doctor be sure about primary hyperparathyroidism. Regards, Fred Coe
i see the doctor Friday I will get my numbers. I haven’t heard anything about sodium levels in my urine. it is sally low in my blood work.
The urine sodium is the same as your salt intake, and lower intake will lower your urine calcium. Regards, Fred Coe
Really interesting, i have had pain around flank, groin and back for months, i have been off work 1 month and have stopped playing golf as too painful. I have been treated by hip surgeon as a slightly arthritic hip has shown up in MRI. Had cortisone injections for hip but pain much to the surgeons surprise did not clear up. All urine test continially show up with blood in. I had CT scan last week and 11mm stone found. Seeing urology chap tomorrow. So pain from kidney stone can occur whilst stone still in Kidney, maybe the end of pain is in sight as long as urologist agrees that pain can occur without having to pass.
Hi Steve, Yes, a stone that is not in the ureter and causing obstruction can cause pain. Firstly it can on and off obstruct the junction where the ureter joins the renal pelvis, which I guess is the case with you. Second, it would seem that large numbers of people with small stones up in the renal calyces have lots of pain, often. Regards, Fred Coe
Thanks for reply, having a laser into my ureter tomorrow to break up stone. It will be interesting if pain clears up.
Thanks,
Good Luck Steve; I hope the pain goes away promptly. Regards, Fred Coe
I have been passing kidney stones since I was 16 I am now 32 I have had several Dr.. tell me stones do not hurt while in the kidney. until reading this I was beginning to wonder if it was just in my head. on top of having a stone in my kidney that has been in the same place for over six months I also pass stones at least once a month. at least now I know that I’m not the only one that feels pain when the stones are in the kidney. plus knowing that it can be removed brings hope to being pain free.
Your discussion of pain associated with non-obstructing stones focuses on small stones; so I am wondering your thoughts on larger, non-obstructing stones? My husband was diagnosed with a 1 cm (10mm) nonobstructing stone in the midpole. He was treated with ESWL which failed to have any affect on the stone and he continues to experience pain that comes and goes (seems to intensify when he is more active). His treating urologists are discussing how to treat the stone after the ESWL didn’t work but seem to be skeptical that my husband is really experiencing any pain. My husband is young, active, and otherwise healthy. He had a ureterscopy 2 years ago for a ureteral stone (the pain experienced then was definitely more acute).
Hi Cait, A 1 cm stone is too large to pass – more or less so disrupting it will ultimately be essential. ESWL did not work and I am sure your husband’s urologist is planning flexible ureteroscopy, which is very likely to result in a stone free kidney. As the stone pain story unfolds I am having less and less trouble believing that stones do indeed cause pain when they are not actively obstructing. By the way, when stone free, be sure he sets out on a proper plan for prevention. Stones can come back, and often do. Regards, Fred Coe
I too have some non obstructing cystine stones that are causing pain and discomfit. We are trying to dissolve them with mist potcit for three months, but I wonder if it’s worth trying or just have the stones removed
To dissolve cystine stones you need to have a large volume of urine because you need to lower cystine supersaturation below about 0.5. Only one commercial vendor – Litholink Corp – produces a cystine supersaturation product. If your physician can get that test and your insurance will pay it can aid in the process. It is always better to avoid surgery if that is possible.
To be clear, my mention of Litholink could be viewed as a conflict of interest as I consult for them, and I want to make that potential conflict perfectly clear. If there is indeed another company that produces a cystine supersaturation test, I have no reason to favor Litholink over that company- I do not know of such another company or I would give the name here. Fred Coe
Dear Dr Coe,
I was diagnosed with 7 or more small kidney stones (3mm) in my left kidney in May 2015 after having an attack where i was on the floor profusely sweating, doubled over, began dry heaving and the worse pain ever….worse than child birth and I have four children. I was told the kidney stones did not cause this or the pain that has been non-stop in my left kidney since May of 2015. I also have a 1.4 cm simple cyst in my left kidney. Since May 2015 I have seen three urologists (all who say the stones are not causing my pain) had an upper GI, colonoscopy, DNC, saw an endometriosis specialist and all of the doctors cannot find anything. Everyone is saying the kidney stones could not be causing the pain. I have also been to the emergency room three times now with three more of the attacks that I described above. I have refused any pain meds as I have felt that some doctors think I am a drug seeker which I absolutely am not. All three emergency room visits came with the same result that i have several small non-obstructing stones that would not cause the pain. Do you have any suggestions for resources or doctors that actually believe small stones can cause pain. I am miserable! The pain is constant in my left flank area but does vary in degree of pain from day to day. I have noticed when i wake in the morning feeling dehydrated the flank pain is more severe. Any guidance or suggestions you can provide would be greatly appreciated. Thank you ~Deb
Hi Deb, I think from the intensity of the attacks you are passing crystals or very small stones. Stones in the kidneys do cause real pain but usually not so horrid as what you describe. Of course the correct approach is to reduce crystallization via a fall in supersaturation. Read through the link and its associated articles and get this for yourself. I believe these terrible attacks may mitigate. Regards, Fred Coe
Hi Dr. Coe, Thank you for your response. Just to clarify, the daily pain I experience is more like a heavy feeling in the kidney. It even hurts to lay on my left side to sleep at night. I have been told I have a lot of kidney stones in that kidney but none are obstructing. The renal colic horrible feeling has only happened four times with four trips to the ER but no evidence that I actually passed a stone. I am wondering is the constant flank pain likely from the many stones I have in the kidney? What is the best approach to attacking this? I have had this constant pain for 10 months now. Some days it is not as noticeable as others. I have had every other test run on me all to come out negative. Any suggestions on how to handle the daily pain would be greatly appreciated. I have to believe they are from the stones. Please advise and thank you. Oh, I was also recently told that I have Medullary nephrocalcinosis. I am not even sure what that is or if it causes pain and needs to be treated. Again, any help you can provide would be greatly appreciated. Deb
Hi Deb, Quite a number of patients with numerous stones in the kidneys experience chronic pain even though there is no acute obstruction. The only possible treatment so far is surgical removal of stones – usually flexible ureteroscopy, but that has not been tested rigorously. If the pain becomes a serious impediment to living, it could be considered as a treatment. Regards, Fred Coe
Dear Dr. Coe,
I experienced what I first thought was atrophic vaginitis for several days beginning Mar. 18th, but after a few days of increasing intensity I realized it was a bladder infection. Increasing pain and blood in my urine, so I got a UA on 3/22 which reported blood and some leukocytes. Flank pain was extremely intense, it feels like there is a swollen thing underneath my ribs. Sent for an ultrasound, which was negative. Given pyridium. Had to fly across the country for a trip I’d planned long ago. Upon arrival in Boston another doctor looked at my labs and prescribed Bactrim DS x 7 days. Lots of improvement for about 4 days, but then woke up with increased flank pain again, but had to fly back across the country again, went to my doctor on 3/29 with super-intense back pain. I am in recovery from addiction and have not asked for any pain medication at these visits, as that only clouds the issue, but I have to tell you this really hurts! 3/29 UA showed traces of blood but no bacteria, but was sent for culture. Was given 1 gm of Rocefin IM, and cefuroxime 500mg BID x 7days, which I started yesterday. Today the culture came back negative. CT is tomorrow.
Does this sound like a stone that began as an infection? The Bactrim really helped, and my urine smelled nasty until I’d taken several days of it.
Because I am a recovering addict, they do not seem to believe the blood in the urine was mine, or that it actually came from my ureters and not my vagina, even though I have not had a period for at least a year, as I am on hormones and do not do the monthly week off to have a period (I take the hormones continuously).
I have a history of kidney stones and multiple UTIs.
I’d just appreciate any input you have 🙂 and thanks.
– Katy TW
Hi Katy, The CT scan is crucial. It will show stones, obstruction and all related problems. If it is negative, the pain is arising from elsewhere than the kidneys. The urine odor suggests infection with a urea splitting organism, as they impart an ammonia like smell. Let me know. Best, Fred Coe
I am so confused. I have been in severe pain for about two weeks now. Went to Urologist back a few months ago and he told me i had stones inside the kidney and they were too big to pass so he scheduled a lipo and I had to cancel due to another emergency surgery. Now after 6 months the pain has come back and I have suffered for two weeks. Went to ER they said stones were not obstructing anything so I called and made apt with urologist. The first apt available was 6 months away they finally gave me apt in two days after constantly calling the office. no one can live with this pain. They act like they don.t believe me. I have had three kidney stone surgeries in the past but this time I could not get a urologist to meet me at the hospital or get me in to see the doctor any sooner I am taking pain meds which do not hep at all. I do not sleep or hardly eat the pain is so bad. I have two more days to go and then dont know what they will do. Any advise???
Dear Darlene, I am sure the physicians do not realize how much pain you are having. Possibly one of the stones is obstructing or you are infected. If you cannot get care with your current physicians consider asking for referral. If there is a university hospital near enough to use, consider going there. With so much pain, long wait times do not seem ideal. Of course, I am distant so my remarks are general and not specific to your case. Regards, Fred Coe
My 16 yo old daughter was diagnosed with multiple small nonobstucting kidney stones about a year ago after a UTI. Was told by two urologists they were not causing her the mostly right sided, back occasional groin pain she has had for the full year. She has seen gyn, gi and had endo and colonoscopy scans. Was scheduled for a lap with appendix removal till she passed he first stone (we believe, anyway) last week and has had blood in her urine which caused the surgeon to cancel/postpone the lap :((( Kid has had every test and work up and appt possible and we are soooo frustated. Her pain is pretty constant on the right, sometimes more of a discomfort than intense pain but has highly restricted her from doing what she loves – basketball and horse back riding. The pain intensifies with physical activity always but can be present at rest as well, usually just not as intense. No one has ever considered the small 2-3mm stones in both kidneys as possibly contibuting to her pain issues??? Any suggestions or thoughts to disprove that theory??? Am planning on rescheduling the lap but am not too hopeful it will reveal anything diagnostic or specific. Needless to say, we are at out wits end. Have had other urologists recommended to us but am told they will not see a patient under 18 yeas of age. OMG!!! Any input would be greatly appreciated….
Hi Wendy, As the article by MIke Borofsky makes clear the issue is still unresolved. But Many patients and physicians have encountered this kind of pain from what appear to be non obstructing small multiple stones. I would be suspicious that these are part of her problem. Her appendix as a cause seems a rather long reach, but of course I am at a great distance and cannot hazard an opinion about the pending surgery. That she has passed a stone is reasonable given they are in the kidneys. Of high importance is prevention of more stones and crystals; the latter may well cause pain, and that can be tested by lowering supersaturations in the urine so none will form. Sometimes pain improves. Prevention is crucial altogether as more stones could make everything worse. That her pain worsens with exercise has two implications. Possibly dehydration with exercise is causing crystals and pain. Possibly her pain is musculo-skeletal, and being worsened by exercise and being ascribed to her kidneys or other internal source. Physical medicine physicians can be helpful. Infection in some of her small stones is not unlikely but that will not be visible in the urine and antibiotics would be inappropriate. So, I have to very general ideas for you. The first is a very strong effort at changing urine chemistries to reduce crystallization – link above; the second is possibly another surgical consultation at a center that has interested itself in this matter. Mike references several in his article. I might put off the appendix surgery for a while to see if the pain can be moderated as I have mentioned and likewise what another surgical group might offer. Regards, Fred Coe
Dear Wendy,
I agree with Dr. Coe entirely. Whether or not the stones are causing the pain, the fact that she has stones at this relatively young age suggests that something should be done to try and determine why they are forming and what can be done to prevent them. As evidenced by the large response that this post has generated, there are many patients who do seem to have pain attributable to small non obstructing stones, though I caution that with stones being a common finding it does not mean that other medical issues can’t be contributing to pain as well. In situations such as the one you have described I highly recommend having a team based approach by members of several specialties who are willing to work together. For instance, a urologist to address the stones as well as a general surgeon and gynecologist to address other possible abdominal causes. Laparoscopy in particular deserves coordinated consideration with both general surgeon and gynecologist as this procedure can also be helpful in the workup, diagnosis and treatment of endometriosis, another disease that can be challenging to diagnose but frequently causes nonspecific pain. Abdominal surgery here should be a last resort, though it sounds like you have seen a number of specialists already. Additionally, if her pain seems to have gotten better since the stone has passed this may also point to the stones being the source. Wish her the best.
Mike Borofsky
I wrote on this site last year in regards to a small non-obstructive kidney stone that I thought was causing my pain. Finally I got a urologist to listen to me and has agreed to remove the 3mm kidney stone on my right kidney! Thanks to your article I managed to convince him. Anyway, when the doctor went in there to take out my stone he discovered a narrow kinky ureter so he has had to insert a stent for 2 weeks before they attempt to take it out again. He will then take the stone out in another two weeks and I will likely have another stent for a week or so. Whilst I’m glad things are finally moving forward, I was wondering how normal it is to have some pain and discomfort with the stent? Yesterday (2 days after surgery), I was in excruciating pain, today my body seems to have adjusted and I can move around and do things more but still have a constant ache in my side and am experiencing a lot of discomfort. Heat packs and pain medication have helped ease the pain. I was just wondering whether pain and discomfort from the stent is normal? Will this go on the entire 2-4 weeks i have the stent in me or will it get more tolerable? Will the pain and discomfort ease as soon as the stent is removed or will it take a few days after it’s removed to return back to ‘normal’? After everything I’ve been through I just want to go back to a normal pain-free life! Any help would be appreciated 🙂
Hi Anna, Stents are known for their discomfort and I am sorry you have to have one. I do hope that when your ureter is dilated and the stone removed it will all have been worthwhile. Please write again so we can find out. I for one send along all hopes and best wishes for you. Fred Coe
recently on April 24th after having 3 days of pain that got worse and continued with vomiting I went to the er as I have a history of kidney stones I had left flank pain along with pain shooting down towards pelvic area and was extremely nauseated I received an ultrasound where it showed I have 3 6mm non obstructive stones and my urinalysis came back with few bacteria 100 protein and 3-5 rbc. they gave me Zofran and iv pain meds in the hospital and sent me home with some pain meds. I have a bleeding disorder so I can not take any nsaid due to the affects it can have on my platelet’s. the er doctor told me one stone was in the lower pole of my kidney and that I might have passed one upon arrival. the last few days the pain has gotten worse leaving me to tears and same shooting pain from flank to groin I have an urge to urinate constantly but not much comes out and I have severe pain in the lower area when I do urinate bringing me to the point of not wanting to urinate due to the pain. I currently do not have medical coverage and the urologist that will see me is booked for over two months. why am I having this pain if it is in the lower pole? what can I do to help ease the pain? I do not want to go back to the er due to the fact I don’t want them thinking I just want drugs so I have been taking Tylenol and ibprofen(not suppose to but pain is horrible).is there anything I can do it is becoming hard to even play with my soon to be 2 year old as at times it hurts no matter if I sit stand lay down. do you have any suggestions on what I could/should do.
Hi Candace, I suspect you have a stone lodged at the junction of the ureter and bladder. Such a stone can cause your symptoms. Your urologist should want to see you promptly in as it could be removed. Alternatively the ER physicians can probably see it on a radiograph and prescribe proper pain medications. Of course I am far away and just hazarding an opinion, and they are there. Ask about it. Regards, Fred Coe
Hello Candace! I also suffer from kidney stones and have gotten them often. I had three lithotripsies last year and the most recent one broke up about a 9mm stone. I have been having chronic pain for almost a year now due to the stones reforming and once causing an obstuction. My most recent scan showed the 9mm stone had not moved, yet I am still so often in pain. And just as you, I cannot take NSAIDs or aspirin due to a platelet disorder, but sometimes I cannot help it. If you find any information out on how to manage the pain/ why a non moving stone is causing so much pain please share! I am often nauseas and so exhausted I find myself unable to do much and enjoy it.
I have recently diagnosed kidney stones in my both kidneys. CT scan pyelogram findings show that 3-4 small calculi largest in left kidney lower pole measures 0.9 cm. I have mild pain and it increases when I move my body and do physical work. Pain also increase on less intake of water. Please suggest me its treatment.
Hi Saman, ureteroscopy can remove these stones, and it is reasonable if the pain warrants it. Prevention is key; take a look. Regards, Fred Coe
Having two stones. One is about 5.6mm and other is about 4mm. 5.6mm calculus is coming to urinary tube and it’s not coming out so my kidney gets swollen what should I do?
Hi Param, with stones passing you must have medical attention to be sure the stones indeed pass and the kidney is not obstructed excessively. So at the moment an emergency room or at least physician’s office. When they are gone, pursue prevention so they do not keep coming. Regards, Fred Coe
I was diagnosed with 2 stones day before yesterday only. One in the right ureter of 5 mm and other in right kidney of 2.6 mm. It pained a lot. I’m drinking lot of water but there’s no pressure created in the ureter I suppose. I have to travel to Australia from India in 5 days. Please suggest me some measure so that if it pains just in case when I’m in the flight what should I do?
Thanks
Hi Saurav, You need a urologist. These stones could act up on the long flight and there is little that could be done for you. Possibly they can obstruct the kidneys. I would think your urologist needs to determine if you are fit to fly right now. Regards, Fred Coe
Hi,
It is for the first time that I have become a victim of kidney stones, last week I had a sudden attack of pain around my left kidney area and it was unbearable. After scan, I came to know that there is a 5.2mm stone in the left ureter causing pain, and two more stones of 4.7mm & 3.8mm in right kidney causing no pain till now.
My parents had the same problem years ago and the first drink every morning they used to have was bitter gourd juice. And amazingly it worked for them, stones got removed within the period of 7-10 days. I too, started taking this and have good relief from the pain, 4 days completed another few days and lets see what it results in the next scan.
I was diagnosed with kidney stones in 2008 after being admitted to the hospital with a kidney infection while pregnant with my first child. I dealt with them through 3 more pregnancies. They seemed to cause me the most pain then, or that I only had them when I was pregnant so not much could be done. I’ve been having pain almost exclusively in the left flank. The pain doesn’t move, and I haven’t passed any stones recently that I can tell. I had an appointment with my urologist a few months ago and had a CT scan. Both kidneys are full of small stones (too small for lithotripsy). I have yet to call and get a copy of the image/results. I have a follow-up with the urologist in a couple weeks to discuss options (remove them all, or do nothing). Just yesterday I had horrible pain in the same spot. After reading this, I am wondering if maybe I have pain from non-obstructive stones. Also, any time I have a urinalysis at a regular appointment, they put me on an antibiotic. Can stones cause a false uti test result?
Dear Angela, With a lot of stones pain is not surprising. Urinalysis is not an ideal basis for antibiotics – urine culture is needed, and stones can cause an abnormal urinalysis by themselves. If your pain is so substantial as to warrant something so invasive as possible surgery then that option should be considered. Flexible digital ureteroscopy would be ideal, in general. Perhaps you should discuss this with your personal physicians. If pain is coming in attacks, it may be that one of your stones is intermittently obstructing the kidney, and that certainly can be remedied. Regards, Fred Coe
Update: my followup appointments with my urologist, he was unavailable. The first followup. The PA totally dismissed the idea that nonobstructive stones cause pain and put me on chlorthalidone. I didn’t like the side effects so I discontinued that. The 2nd followup appt, urologist wasn’t available so I cancelled the appt and asked for a referral to a nephrologist. This may be unrelated, but on Monday this week, I started having pain in the front of my right shoulder. It would get worse as the day progressed. Everyone I took a breath, the pain would increase, and bending over or laying down with my kids before bed was almost unbearable. Pain was so much worse Tuesday night that I was in tears. Wednesday night I could feel the pain starting again, so I went to the ER. They did a CT of my chest, xray of shoulder, checked my heart, and ultrasound to check liver, gallbladder, ect. Everything was fine, except that the ultrasound tech was finding >7mm stones in my right kidney. The CT scan didn’t show my kidneys. ER Dr didn’t think anything of stones, gave me a sling for my arm (even though he knew there wasn’t anything actually wrong with my shoulder), and a prescription for hydrocodone. They suspected my gallbladder, but could kidney pain be referred to my shoulder?
I saw the nephrologist yesterday. He just looked over my records and ordered another 24 hr collection, bloodwork, change my diet, drink more water, and prescribed potassium citrate, allopurinol, and hydrochlorathiazide. He also said without missing a beat that nonobstructive stones do not cause pain and there is no way to dissolve the stones I have and that surgery would be intrusive. Here are my concerns: if I am put on all these treatments to prevent stones, how will they know any of them work if the older stones are still there? And I’m not to thrilled about having all of the stones sitting in my kidneys. Couldn’t they damage my kidneys? I don’t see any Dr when I have the flank pain, mostly because I feel like I should just deal with it, or that nobody will believe me and dismiss me as just trying to get pain pills. Maybe I should start going in every time so there is an actual record of it? Maybe someone would take it seriously?
Hi Angela, the pain in your shoulder does not have the characteristics of kidney stone pain, which may be bothersome or severe but is not influenced by position, movement, or any of the factors you describe. Pain from gall stones likewise. So I think – I am very far away – it was muscle or tendon pain. Stones in the kidneys so cause pain – I think we are as a community coming to that conclusion – but it is not as you describe: a sudden shoulder pain made worse by moving and bending. One knows if a treatment is effective because over time the numbers of stones in the kidneys does not increase, and stone passage is accompanied by loss of prior stones. Usually stones in a kidney to not cause damage unless they care causing obstruction – that is a urological decision. You mention flank pain, which would be different from the shoulder pain, and that may well be from the stones. The issue is whether such pain is bad enough to be worth having a surgery – that is a decision you have to make with your physicians. If the flank pain is from tiny stone passage there may be blood or crystals in the urine so it is worth having this checked as it will clarify the cause of pain. Prevention is important – it needs to be orderly. Here is a reasonable guide. Be sure all of the steps have been covered. Regards, Fred Coe
My mother, 83 years old was diagnosed with kidney stones yesterday. If at any point, the doctor tells us she has to undergo surgery to remove the stones, is that still acceptable co doddering her age? Thank you.
Hi Eleanor, Stones need to be removed when they cause pain, obstruction, infection, or serious bleeding. If this is the case, surgery is very important. Perhaps you should discuss the reasons with her physician, as I am sure one of these is the reason. It is indeed odd for stones to begin so late in life. Often they are uric acid or from infection. Regards, Fred Coe
Hello,
I have a right non-obstructing kidney stone approx 4mm in size.. I have had it for some time now. Over the past year I have seen many specialist as I have consistent right flank pain with episodes of severe pain in the same area that come and go. I have also had positive bacteria cultures every 4 weeks for the past year all with the enterococcus species . I have seen many specialist and ruled out may other anatomical issues and all finding have thankfully been negative. However, every specialist I see seems to denied any connection of my pain to this kidney stone or even the possibly kidney stone and bacteria connection. How could I go about finding the right urologist to explore this opinion. My case sound so similar to the case listed above. I am so desperate for my life back. Thank you kindly,
Hi Natalie, I believe I have answered your query, at least as best I could. But now that I see enterococcus, I am rather concerned that the stone is infected or could become so, and enlarge. Enterococcus is one of the bacteria that possess urease, an enzyme that degrades urea in urine to ammonia and produces struvite stones. Of course this may not have happened as yet in you: The enterococcus may be only in the lower urinary tract and the stone sterile, but I would ask your physicians if it is not time to be concerned about an infected stone and consider ureteroscopic removal – as an alternative. The handling of a potentially infected stone is complex, as they will surely know. That the enterococcus persists makes me concerned that the stone is indeed infected. Regards, Fred Coe
Hello,
I have a right kidney stone 3-4mm. I have been having UTI’s positive urine cultures every four weeks for the past year. I have seen multiple urologist with no resolution or solutions. I experience right flank pain daily which is the side the stone is located, urinary urgency and frequency. Can the stone be causing these symptoms and how could I convince a urologist to take me seriously… Thank you kindly, Nat
Dear Natalie, Te one stone should not be perpetuating so much infection, but could be even so. The bacteria found monthly is important. What are they? Is the stone growing, a suggestion that it is from infection or itself infected. If you have pain and infection, perhaps it is time to remove the stone. Shock wave lithotripsy is not unreasonable with one small stone, or perhaps ureteroscopy. Regards, Fred Coe
Dear Natalie,
I agree with Dr. Coe that it is worth trying to have the stone removed. There was recently a nice study from the Cleveland Clinic showing that treatment for such stones will resolve the recurrent infections about 50% of the time. Below is a link to the article you might find interesting.
http://www.renalandurologynews.com/urinary-tract-infections-uti/kidney-stone-removal-helps-recurrent-urinary-tract-infections/article/441173/
Best,
Mike Borofsky
I was in 6 months of pregnancy first time pain started in my left kidney side.now is total 9 months finished bt now my left kidney below the ribs it’s paining. Pain its comes n goes in day 3to 4 times. .plz advise me
Hi Luccy, Is your pain from stones? If so, are they obstructing your kidneys? You meed to have a urological surgeon taking care of things, and soon. Regards, Fred Coe
I have multiple small stones both kidneys 5 per ultrasound and ct this time no obstruction doctor after doctor 3 urologist so far and all say the pain isn’t from the stones I have stones several times a year almost monthly it seems this pain is so intense it’s to the point of unbearable I have lupus sle and diabetes among other issues now renal colic has been added but no one will help me any advise
Hi Stacy, would guess you are passing tiny stones that cause these attacks. Try and strain your urine when one begins so catch any crystals. Because you are diabetic you could form uric acid stones so look out for any red or orange crystals in your urine. During an attack have your physician take a look at your urine for blood and crystals. Regards, Fred Coe
Thank you for the info I have been straining no blood or colored stones granules are being caught still puzzled at the pain as i am being told they shouldn’t hurt at this size
The puzzle is that the pain is in attacks; this is much like crystal attacks. Prevention of crystals is the best course. Take a look. Regards, Fred Coe
I tried it for one month and passed out the stones naturally without any pain. VINIDIA, GC and ACIDIM are probably the best natural products that I have ever used for curing my kidney stones. My CT scan now shows that I don’t have any kidney stones.
Hi Sourav, I have a policy of putting up what patients say, but I do have to mention that the experience of one person is not a basis for the care of others and I know of no studies that support these materials as a valid stone treatment. Regards, Fred Coe
Reading this while in pain ? my pain started 2.5 weeks ago went to the ER like vomiting from pain after 2 injections of (i don’t know what) the pain came down a bit not completely, after x-ray and ultrasound they referred me to a urologist he told me that I might have had a stone and have passed it with no more stons to worry about, I was happy that I am done with that but 2 days before, came from work the pain started again in the same area right flank after 30 mins trying to cope with no result I went to the ER again and the whole thins starts again two injections go home next day the same my back was filled with injection marks, after speaking the the doctor he said I must have a CT and IVP scan, now just waiting for that,
Hi Alkoos, It sounds like you may be passing stones. The CT scans will show what is happening. Good luck, Regards, Fred Coe
Hi, I woke up early ( around 5:39am) with the need to urinate however I was feeling really sleepy so I decided to pee really hard mid way through my urination so that I could go back to sleep sooner but I was greeted with a stabbing pain in my penis shaft as if something moved forward because of the immense strain I was putting on my penis to urinate quicker. As soon as that happened the flow of my urine drastically slowed down and it feels like a glass shard is in my penis, there is also NO Blood in my urine.
This has been going on from the morning and it only hurts when I pee or move in a certain position. I also have a stabbing pain in my rectum after this whole incident occurred.
I have had Kidney stones before and although this feels very similar, the fact that I had no pain before all this seems strange. I had no back pain or anything.
Is it possible that I sprained something or damaged something down there by peeing too hard?
Pls advise. Thanks!
Hi Germ, Perhaps you passed a small stone which is lodged in the urethra. If so, that will become reasonably clear on its own. Otherwise, it is probably as you say. Regards, Fred Coe
Hi. I have been having increasing left flank pain, although it is intermittent. CT showed a 9 mm stone in the renal pelvis without obstruction (I’m 34). My PCP said that since there is no obstruction it cannot be causing the pain. I am unsure how to approach my Dr now but also fearful not to do anything because the pain is getting worse. I’ve had a thorough workup and there is no other source for the pain. I have nausea during the intense pain and microscopic hematuria. Is it possibly that the stone is intermittently causing obstruction acting like a plug? Or can the tissue of the renal pelvis be sensitive to a stone moving around? The pain is interfering now with work and home life. Thank you.
Dear Chelsea, It is very likely that is indeed happening, and I am sure your physician will agree when you describe the nature of your attacks. Intermittent obstruction is very common with pelvic stones. Regards, Fred Coe
For two weeks on and off I’ve had severe pain in my left side. I have noticed it’s a pattern of the days I work. I have early shifts working in s supermarket. Within ten minutes of starting work were I’m standing my pain starts and after several hours calms down. My doctor has already got me a scan and waiting on urology appointment. I just wondered if standing and lifting can set the pain off as when I’m not working I’m not having spasms
Dear Karen, although I have not seen you, I am suspicious that your pain is not from stones but simply from sore muscles due to work posture. Ask your physicians if that might not be the case. Regards, Fred Coe
I’ve been developing stones for the last two years. They do not pass. I’ve had two procedures. With the first procedure, the urologist couldn’t get to the kidney as my ureters were too narrow. I wore a stent for three months and the next procedure.was successful. Three months later, I developed a 5mm nonobstructing stone in the same place, the lower pole of my left kidney. That’s when the new symptom started which I described below.
After starting to urinate, sometimes right before, I get a lot of pressure in my left flank The pain will sometimes continue for about ten minutes afterwards. It’s worse with the first urine void in the morning. However when I I have a bowel movement, this does not happen. I’ve experimented to see if there is a difference and there is. I get the same type of pain throughout the day and it’s the pain I had is the same as before. The difference is that urinating can actually start the pain At this point in time, it has not been removed.
The pain is like a vise tightening in my side. I sometimes get the pain throughout the day. The intensity as well as the occurrence varies. It’s worse when I am lying in bed. Sometimes I get nauseous. All my blood/urine tests are normal so the urologist simply shrugs and repeats this.
I don’t have gas or bloating when this happens. Nothing has been seen in the CScans. I know I am not imagining this.
What might cause this?
Thanks.
Hi Steph, I gather that by negative there is no stone in the left kidney? The pain seems very related to voiding and there was a left stent so I wonder if there is reflux on the left because of the long standing stent. This would not be common, but perhaps a voiding study might be of value. Ask your urologist if that seems reasonable. Regards, Fred Coe
I have a 8*6 mm(+1248HU) stone located in the interpolar calyx. Do I need surgery?
Hi Sanjeet, In general stones are removed if they cause pain, serious bleeding, obstruction, or are a site of infection. Barring that, they can be left alone. Regards, Fred Coe
Since December 2104, 12 er visits, 7 laser lithotripsy procedures, two admission for pain control. Only change in lifestyle/diet was that I quit drinking coffee. The best treatment for pain in the ER for me has been an injection of toradol, works within ten minutes, pain level goes from to 10+ to zero.
Hi Richard, I am glad you found a proper remedy for pain. Be sure and get on track for prevention so these stones stop. Regards, Fred Coe
I have kidney stones but the other day I was on toilet and screamed on the toilet for about 25 mine the pain was giving birth i even was like wanting to push them after I got the runs do you think i passed my kidney stone
Hi Rita, If the stone did not pass so you could be sure of it, your physician will want to know and get a followup ultrasound or even a CT. Stones can obstruct a kidney so you want to be sure where it is or where it went. Regards, Fred Coe
How will I know if I passed my kidney stone can any harm come buy having kidney stone for 2years
Hi Rita, If there is any uncertainty your physician will want to look – usually a CT scan or perhaps ultrasound. It is very important to not leave a stone without knowing what happened because a kidney can be obstructed and thereby damaged. Be sure your physician is aware of the stone and that it may still be there. Regards, Fred Coe
I have has several stones in the last 3 years. I also don’t have any obstructing but am in excruciating pai.. 15-20 ER visits, same in PCP visits, 2 different urologists, No help or preventive car. My quality of life sucks, where do I turn to for help? Sick of living with right flank and lower abdominal pain!?
Hi Hope, A lot depends on the character of the pain. If it is constant I would suspect that kidney stones have led to pain from another cause like back muscle spasms – and you need physical therapy. One way to tell is that muscle/fascial pain is affected by posture, bending, turning, whereas kidney stone pain is unaffected. If pain is coming in spells, I would suspect small stones or even crystal attacks. Try to figure out which fits your situation. Regards, Fred Coe
Hi Dr. Coe, I want to apologize for the things I said to you. Otherwise , the remainder of what I said I feel strongly about. As I stated I’ve had urologic problems and procedures since I was 9 years old. I’m 56 and even though I’ve spent the majority of my life as a medical professional working with doctors, my life has often been a roller coaster ride especially with urologist. I’m jaded when it comes to this subject or doctors in general. However, I didn’t know you were part of this great article and after reading some of the comments followed by your very competent advice, I must truly apologize. Please remove my earlier replies. Thanks.
I think I passed a stone Tuesday. I’m still in pain but the pain is now coming and going on my left side where the pain was only on my right side and down the middle. The urologist thinks I’m passing more stones. If so would my pain move to the other side???
Hi Mona, You may well be passing another. Be sure your physician knows and the passage of the stone properly monitored. If the side has changed it is likely the stone is passing from the side with pain. Regards, Fred Coe
I had pain mild to moderate in my rt flank since 9 months .no obstruction in ureters .1 ct done .3ultrasounds .no decrease in pain .pain goes away immidiately on lying down.occasional pain in lower part of penis. Taken lot of physical therapy.got some relief but pain comes back again.evenings are usually better.occasional hematuria in urine from last 5 months.repeat CT appointment on 15 sep 2016 .earlier CT showed 6mm stone in rt an 5.5 mm stone on left kidney with multiple small calculi in right kidney.please helpe further. …..
Hi This seems like a duplicate of your other post. I have left it here in case I am wrong but I think I answered to your question. Fred Coe
I had pain mild to moderate in my rt flank since 9 months .no obstruction in ureters .1 ct done .3ultrasounds .no decrease in pain .pain goes away immidiately on lying down.occasional pain in lower part of penis. Taken lot of physical therapy.got some relief but pain comes back again.evenings are usually better.occasional hematuria in urine from last 5 months.repeat CT appointment on 15 sep 2016 .earlier CT showed 6mm stone in rt an 5.5 mm stone on left kidney with multiple small calculi in right kidney.please helpe further. …..
Hi Gurmukh, Although the ureters are not obstructed perhaps stones in the kidneys are causing obstruction in the kidneys themselves. The problem in your case is to be sure there is pain from the stones because surgery is always an issue. That it ceases on lying down makes me unsure if the back pain is from the kidneys – they produce pain that is very unrelated to posture, position or activity. Here is where your physicians really need to make a decision for you, because if the pain is not from the kidney stones a surgical procedure to remove them will not help and could cause problems. The penile pain, on the other hand, can be from small masses of crystals, which your physicians can look for. Regards, Fred Coe
Are you serious that there is NO PAIN with a lower pole stone?!?!?!?!!! I currently have one 6mm. Yes it does hurt.. Its a dull achy pain.. Two months worth and its getting worse. To whoever reads this, yes you can have pain and its real. It doesn’t have to be in the ureter to cause pain. Its only when its there that the pain is unbearable. SMH
Hi Stephanie, I do not think Mike Borofsky intended that lower pole stones do not cause pain; such pain as you describe is rather commonly encountered. What you describe, pain from non obstructing stones in the kidney is coming under considerable scrutiny by urological surgeons – disclaimer, I am not a surgeon – who increasingly believe such pain does occur and may benefit from surgery. The problem is that surgery is so large an intervention research is needed to test its benefits. The question is this: Will surgical removal really benefit the pain or just make matters worse. That decision is for each person to make with their physician, and hope the outcome is a good one. Regards, Fred Coe
Dear Stephanie,
Certainly I believe that you can experience pain from a lower pole stone. As discussed in the article much of our understanding regarding how stones cause pain is based upon a model of urinary obstruction when stones become dislodged in the ureter. The precise mechanism by which a stone can cause pain when still in the kidney (such as the lower pole stone you describe) is much less well understood. I have seen many patients like you who have non obstructing stones in the kidney that cause pain. Interestingly, many patients with non obstructing kidney stones have no symptoms at all. When symptoms do occur though (such as you describe) stone removal should be considered. I hope this is helpful, please feel free to ask further questions if you have any.
Sincerely,
Mike Borofsky
Dr. Borofsky,
I have a non obstructing 5mm lower pole calculus in my right kidney. I also have mild right lower pole cortical scarring. I had a CT w/ contrast and all other findings were normal. I have mod to severe lower back pain (depending on the day) and pain in my pelvis/abdomen, but more pain on left side than right. I donated my left kidney 16 years ago. What is the thought about removing the stone vs. letting it pass on it’s own for a patient with one kidney? Do the stones always pass or is it possible for them to remain non obstructing?
Sincerely,
CeCe
This article was a lifesaver for me. I had a burning pain on my right hand side, constant urination, fever and chills. The doctors told me I had a kidney infection but it took multiple courses of antibiotics to even touch the symptoms. Once the infection symptoms such as fever, shakes etc. finally went away the pain remained. I knew something was wrong so insisted on a scan. Turns out I had a 3mm non-obstructive kidney stone on my right hand side. I saw multiple urologists and all insisted the stone wasn’t the course of my pain OR my infection. Seemed mighty coincidental that my pain was in the exact spot the kidney stone was in and the infection was only on the right hand side. Anyway I continued to live an average quality of life until I finally saw a urologist who agreed to surgically remove the stupid thing. He still didn’t believe that it was causing me pain but I literally begged him until he just gave in. Best thing I ever did. The stent was the most physically painful thing I’ve ever experienced in my life and I had quite a lot of post-surgery pain due to a narrow ureter with a kink in it, but those symptoms eventually subsided. I’m now back to my old self and have my quality of life back. I no longer spend weekends lying in bed with a heatpack and taking painkillers!! To anyone reading this, there is hope! Find a doctor who will listen and even if they don’t really believe you just beg them to take it out. Eventually someone will give in. I even had to go to the same urologist twice!! To the writers of the article – thank you. This article was one of the reasons I finally felt understood and not like I was going crazy. If you’ve helped me I”m sure you’ve helped many others around the world feel understood. Open-minded doctors who think outside the box are a rarity and worth their weight in gold (particularly urologists). The world needs more people like you – thanks for changing my life 🙂
Thank you Anna, that is a very kind note and we are so happy you are doing well.
Mike Borofsky
I have a 4mm stone in the lower pole, i’m feeling pain when drinking water. What should i do about treatment?
Thanks!
Regards,
Aamir Ali
Hi Aamir, It all depends. The stone is probably causing the pain, but your physician can help decide if this probability is high or not. If the pain is bothersome enough to warrant surgery and your physician is reasonably sure the stone is causing the pain then the stone can be removed. But surgery is not trivial, so it pays to be as sure as possible it will be of help. Regards, Fred Coe
I have been diagnosed with kidney stone on my left side and the pain is too much now. The urologist fix a tube for me since February this year, I don’t know what to do
Hi Sainabou, I cannot be sure what is meant by ‘fix a tube’ but it sounds like something was wrong with a ureter and that led to a surgery. As you are having pain and perhaps have some urological problem it is very important that your surgeon help with the problem. From so far away I cannot do anything but urge you to see that doctor and get help. If that is impossible see another urologist. Pain could be from obstruction and that can injure the kidney. Regards, Fred Coe
I went to the doctor for flank pain was given cipro for possible infection. A week later still had the same symptoms and was referred to a urologist who ordered a CT scan. the findings were Nonobstructing calcifications are seen in each kidney. There is no hydronephrosis or hydroureter. No stones are seen along the course of either ureter. So my urologist said that since the stones were not obstructing it could not cause pain. My question is should I get a second opinion? Or continue to live with this pain?
Hi Kelly, So much is unclear here, it is hard to answer. Were you really infected – I mean a proven positive urine culture? What was the organism? I gather the pain was of recent onset and the stones are not obstructing, so it is not clear what changed. Stones without obstruction can cause pain, many patients attest to this, but why now? I would review the cultures – perhaps you are still infected. Was there a follow up culture after the antibiotic? Regards, Fred Coe
Dr Coe,
My PCP decided to give the antibiotics as a precaution. She sent the urine to be cultured and it never was infected. I only found this out after I went back for a follow up because I didn’t feel better after a week. The only things that changed recently for me is I lost 30 pounds since March 1 (on purpose through diet and exercise)and now am at a good BMI. Also, unfortunately I have been chronically dehydrated through most of the summer I live in Virginia and work in a hot environment. Could this be why I have pain now maybe? I read your articles on supersaturation and crystals and know better now. I have been urinating a lot more! Thanks for the great information. Kelly
Hi Kelly, I see. You were never infected and the pain may have come on because of crystals from dehydration and your diet. If so then hydration should gradually reverse the problem. Be sure and take all of the right steps for prevention, it is just not all fluids. Regards, Fred Coe
Hi Dr Coe,
I had an incident of hematuria in MARCH of this year. I had plenty of water and the problem seemed to pass away.
A month later in April, I’d a very strenuous day. Returned home and peed blood that day and the days after.
I went to the urologist this time. Did Xrays, usg, creatinine and other tests done. The urologist saw that the reports were all normal and asked me to observe for a month.
I did a lot of online research and dreaded this was bladder cancer. Took another urinalysis a week later. This said ‘RBC Numerous’. Came to the urologist. He wanted me to observe further. I did not feel much pain except for occassional throbbing pain near my penis.
Over the next few urinalysis tests, my RBC came down to nil. I was happy that the problems had passed.
Around June, I began feeling a pain near my left abdomen. It was like a muscle cramp. Also, I had white discharge every one to two days while taking a hard dump in the mornings.
I saw another GP around end of July. He told me this was nothing.
Then the pain vanished for a few days. Then came the burning sensation after peeing.
Finally two days back, while peeing a 1.5mm stone came out. I managed to collect it as it fell on the dry end of the commode. Am now at the urologist’s again.
My question is, I still occassionally feel a slight discomfot on the left side. Not the same intensity. And the location of pain seems to have travelled a bit upwards toward my left belly.
Does this mean there may be more stones or this is just a residual pain?
FYI I no longer have the burning sensation while peeing. However the white discharge happened during this morning again.
Your feedback will be appreciated.
Thanks in advance
Hi Tashrock, Be sure the stone is analysed. The way to find out about other stones is a CT which is advisable. The blood is most likely to have come from the stone, but most urologists advise checking for other causes which I am sure your physician will want to do. Prevention of more stones is reasonable. Here is an approach you might find useful. Best wishes, Fred Coe
My sister, who is 68, has been diagnosed with a kidney stone that is ’embedded’ in her kidney. She has had, almost constant, urinary infections for three or more years. She had been told that she must live with both the stone, the pain and the resulting infections and drink more cranberry juice. I have suggested that she seeks a second opinion. I would value your thoughts on this.
Regards
Hi Gill, I think she should indeed discuss with her physician the relationship between the stone and her infections. Stones do become infected, and can perpetuate infection episodes. A second opinion is also a normal practice and I am sure her physician would be pleased to help obtain one. If a university is nearby, sometimes in this kind of complex situation it is an excellent source. Regards, Fred Coe
Yesterday when I was in my office, there was a sudden onset of a horrible pain on the left side of my waist, a pain that I has never ever encountered. I even slightly fainted suddenly and lost control of my legs and felt down. Later I was given IV and 3 more injections and the pain subsided after 4 hours. I underwent an ultrasound and was diagnosed with a kidney stone of 3.7 mm wch had shifted down and now at any moment can enter the bladder. There was swelling in the kidneys which had caused that excruciating pain. It was hell. I have been given medicines and have been asked to drink lots of water so as to make it pass through urine. I want to know, how many days will it take to pass and when it will enter the bladder, is it going to hurt? Christ, I don’t want that pain again..
Hi Anumika, I am sorry about the pain and the stone. YOur personal physician will have to help with the details of passage as each person is unique. But there are a few things I can tell you that no one will consider wrong. When the stone passes, get it analysed – do not lose it. Then, get a full evaluation to find out why stones formed. After that prevention should be effective and very reasonable to do. Regards, Fred Coe
my doctor told me there is tiny kidney stone in my kidney and can remove by water easily .but is it remedy and what is other alternative quickly remove?
Hi belete, Water is wonderful for prevention of new stones but is unlikely to dissolve a stone. Nothing I know of will actually remove a stone. But if is not causing obstruction, pain, bleeding or infection there is no reason to do anything about it. Perhaps you might check with your physician to be sure it is not doing any of those four things, and if not perhaps simply leave it alone. But if you have formed a stone, high fluid intake will tend to prevent more, and I think that is what your physician was saying. Regards, Fred Coe
I have a ~2mm stone (for 2 months) in the ureter how can I know if its obstrucing or non-obstructing. If its non-obstructing is it really necessary to have it removed?
Regards
Hi Lance, Ultrasound testing is usually fine for that purpose. The question of what to do with a lodged stone after 2 months is very individual and something your surgeon will have to answer. Your only work is to be sure and stay on his/her radar. Regards, Fred Coe
UPDATE: Maybe this could be helpful for others, maybe not. Originally, after serious pain (ER) I was diagnosed with 1mm and 2mm stone in the ureter. After a month, they had not moved and the Dr wanted to use a scope to remove them. They were not causing any pain but the concern was that they could still cause kidney damage. I put the operation off and yesterday (Sep 5) 3 months following the 2nd consultation, there were no stones. I was super happy about that, especially since I didn’t have any pain. They either passed or just dissolved (no idea), but it took time. I opted for a more wait, drink lots of water, exercise, and pray to Jesus that the stones would go, however the Dr was more into more invasive procedures. In my case, either approach was probably correct. Point being that you have to do you best to find the way ahead for you. For larger stones I am reasonably sure a procedure would have been required, but that was not my case. Had they still been in the ureta, I am still not sure what I would have opted for but I didn’t need to make that decision. Hope that helps some one.
Thanks, Lance. Regards, Fred Coe
I have kidney stone problem that when I go to the CT scan and x-ray they cannot find any kidney stone even they do the urs cannot find any kidney stone but the kidney stone is visible in ultrasound from 0.7 eswl til 0.3 mm but after a lot of session of eswl the kidney stone still in that exact position on the top of kidney near ribs still 0.3 won’t broken down. I have flank pain in the left kidney and nause when pressed the kidney. It’s been 6 months. What’s the recommendation? Thx
Hi Rob, If one cannot find a stone on ureteroscopy or CT there is no stone. I do not know what the ultrasound is showing but it is not likely to be of importance stone wise. I would not have more SWL sessions for an ultrasound finding unconfirmed by CT and also by URS. The nausea from pressing on the kidney is not a sign of stones. I would stop. Regards Fred Coe
Is it normal for pain to be very intermittent? I was diagnosed about 48 hours ago now with a 2mm stone through a CT scan. Apparently it had already moved halfway down my ureter. I will be pain free for hours at a time, then have an hour or hours of very bad pain in my flank. The ER PA wasn’t clear on whether I should drink a lot of fluids to help it pass, but I feel like I should. Thoughts?
Hi Art, It is indeed very common to come and go. Hopefully the thing will move on and then pain will cease. Fluids are a good idea. The big thing is prevention of more. Here is a good path to follow. Regards, Fred Coe
I have non obstructing kidney stones in both of my kidneys for 2 weeks.(size-5,7mm). My doctor advise is to drink plenty of fluids with some prescribed medications. But how do I know whether i have passed those stones or not. Will there be burning sensation during urine (I feel burning sensations during urination). How long will it remain. Even after urination it also feels like burning for few minutes. Is it normal or some kind of infection?
Hi Shubh, I gather you just found out about the stones – they would have formed in a prior period of time. Passage or not is usually obvious – lots of pain, not subtle. Ultrasound monitoring is always a good way as well. The burning may be from crystals meaning you have excessive urine supersaturations. Here is a good way to go about prevention – stones and crystals, too. Regards, Fred Coe
I am 31 years old and I have suffered with kidney stones since I was 16. I almost cried when I read this article. I have been told I was crazy, just looking for pain meds, and everything you can think of. I have gotten so used to the pain I don’t even know when I have an infection anymore until I am running a high fever or my urine smells so bad. I have been told more times than I can remember that yes, there are several stones in the kidney but they don’t seem to be moving so, I shouldn’t be in pain.I have been to more urologist than I can remember. It has gotten to the point to where I don’t trust them. Why do doctors not think that a foreign body located in your kidney can cause you pain? A gallstone can cause you pain. I believe that I am printing this article out and going to find a new doctor.
Hi Ashley, It is very important to discuss your own personal situation with your physicians. Infections can involve stones and in some cases removal of stones can reduce infections. But you do need physicians to help you make this kind of important decision because surgery is a major undertaking. But, yes, stones can cause pain and infection, bleeding and obstruction, as you say. Regards, Fred Coe
Re: small stone syndrome
I think only flank pain was discussed. Is it possible for a stone in the kidney to cause chronic lower back pain? I have a 4mm stone in my left kidney that was seen on CT 2 yrs ago when a stone in my rt kidney had to be removed. I do have Lumbar spine issues that were diagnosed by MRI but you can never tell what if anything is actually causing the pain. My urologist wanted to do Litho at the time but I declined. If I knew that the stone is responsible for this misery I would do it, or rather, ask for Ureteroscopy.
Hi Connie, This is tricky. Stone pain can radiate but low back pain is more likely than not to be from the back itself. Your physicians can examine you and make a judgment. Likewise a physical medicine physician. Regards, Fred Coe
I had been diagonised with a 7.2mm stone 12yrs back and it was removed with endoscopy. Now I’m diagnosed with a 6mm stone in left ureter(mid), 2 months back. The doc believes that it should move out with medicines and fluid intake. I had a follow up a month ago and it has moved to bottom without any pain. But today, I have an excruciating pain and frequent urination and even constant bowel movements. What does it indicate? Can u help me to know it doc?
Hi Juby, You have made new stones, and I hope you take steps toward preventing more of them. This present one will certainly resolve with your physician’s help. Take a look at a very reasonable plan to get prevention. Regards, Fred Coe