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.
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I was just diagnosed by CT with 2 stones in left kidney, 7mm and 8mm one in tube and one still in kidney. Went to doc because pain was bad. That was 4 days ago. No pain. Is that normal? It started with dark urine. No problems with stream. Now urine is clear. What is going on? Do I really need the stones removed or have they dissolved? Thanks for your response.
Hi Gene, The one in the ureter needs to be managed by your physicians. The one in the kidney depends on where it is and if it is obstruction within the kidney, or causing pain, bleeding or infection. There are complex decisions but this is what your physicians need to determine. If the stone in the kidney is doing none of the aforesaid it can be led ft in place. Regards, Fred Coe
I have been suffering from kidney stones for over 30 years. Had lithotripsy through UofC in the 80’s when only NW had a device, that was with water. Had ultrasonic lithotripsy about 8 years ago for a stone the size of a small marble when I was in Philadelphia. I moved back to Chicago in 2010 and my regular doctor prescribes pain killers since I pass one every other month or so. I recently decided to see a Urologist because this current pain has been lasting for a couple of months now. KUB, CT-scan all confirm kidney stones, the largest being 5mm. But my current Urologist does not believe I have pain since there is no blockage so I fall into this conundrum. The pain I have is the same pain I have had for all these years and goes away when I ultimately pass the stone. But since there is no blockage, no pain killers from this Dr. which is the only thing that helps. Should I change Urologist’s? I’m not a fan of taking pain killers because of the gastro issues that I suffer but it is the only thing that helps. What do you suggest?
Hi Don, You are indeed in the midst of a controversy. Physicians are loathe to use chronic narcotic, for reasons medical and reasons arising from the unfortunate criminalization of narcotic drugs by the ‘War’. But in fact, it sounds like you have accumulated many stones and have pain, and the pain may indeed be arising from the stones. I would think you would want both serious prevention efforts to halt further buildup and perhaps ureteroscopic removal of the stones. Perhaps your personal physicians might be helpful in this regard. Regards, Fred Coe
Dr. Coe,
Thank you very much for your reply, I think I’ll print this and give it to my Urologist but I’m sure he still won’t agree. And yes, my personal physician of 30 years understands and provides the pain relief. Believe me, I am very aware of the dangers and misuse of opiates. Since I DO only use them when needed, it causes havoc on my system but I have not choice. My only other hope/wish at this time is that this condition gets put on the list for medical marijuana because that helps me with low grade pain more than anything and then I don’t have to use the opiates with their associated side affects. My Urologist at the University of Pennsylvania was great because he is a stone sufferer as well – I think that should be a prerequisite for those that treat kidney stones but I don’t wish this on anyone. I have used Potassium on and off for many years as it is supposed to prevent stones from forming but it hasn’t seemed to work for me. Thank you again, at least I know there are some out there that understand – wish I lived closer to U0fC!
And I just read your article on prevention. Great information – Thank You again. I do have my stones analyzed as my personal physician recommends and every time I am able to retrieve one (and i try even if it means grabbing them from a public toilet) they have all come back as calcium oxalate. Your information is fantastic and I appreciate the posts. Best regards, Don Ballje.
Hi Don, THis is in reply to both posts. Since all of the stones have been calcium oxalate, and there have been many, prevention is very critical. Please look through this article which provides an organized approach. The physicians at U Penn are very good and there are several who are very expert in stone disease. given this, I am sure you can get these to stop. Regards, Fred Coe
Hello,
what about a 4mm stone in the lower pole of a kidney with mild fullness in the other kidney and hematouria as well? Sometimes there is a burning sensation while urinating. The doc prescribed norfloxacin and nothing else. Pain is normally in the groin region. But ultrasound (KUB) showed no obstruction. Please suggest. Thanks
Hi Raj, This is complicated. The lower pole stone is not likely to cause urinary symptoms or groin pain. Perhaps you are infected, perhaps crystals are forming in the urine. Here is a place where the only good advice will come from your personal physician who has your CT scan, and can look at your urine under a microscope. Regards, Fred Coe
what about 7.8 mm stone .is there any quick pain reliever for kidney stone of size 7.8 mm .
Hi John, Given the size, it may or may not pass. Pain management is really complex and local – Your personal physicians need to direct it. The line between needing narcotics and how much and how often is totally clinical, and no one from far away, like me, can be of any use. Once the stone is gone, be sure and pursue prevention efforts, as they can come back. Regards, Fred Coe
Hx of oxalate stones in early-mid 20’s. Mixed benefit from lithotripsy. Passed 5mm stone. Had one remaining 3mm asymptomatic lingering stone. Didn’t think much of it. 12 years later (now) have had 3 month Hx of intermittent left and right testicle pain. Nrml labs and ultrasound. Recent CT rvealed stone is now 3x6mm in middle pole.
1. This the possible cause of pain?
2. Given the dimensions, this more likely to pass than 6mm round?
3. Can you comment on lithotripsy vs ureteroscopy for size, location, and composition?
Thank you for your time.
Hi CHarles, testicular pain is not rare from stones. A stone can always cause pain, often intermittent. From here it is hard – impossible – to make a serious recommendation about surgery, but in general modern ureteroscopy is proving superior to shock wave lithotripsy. You seem to have only one stone, of modest size, however, so the choice is difficult. Probably either modality will work. Whether surgery will cure the pain is impossible for me to assess as an outsider. Regards, Fred Coe
I have stone in kidney for last 3 years and I am using regular medicines sometimes not , because I hate medicines.But it is very painful, need to get ralief can I get relief from stone? Please give me some idea to get relief.i will be very thankful to you.
Hi Nafisur, For stones themselves in the kidneys the problems are surgical. For prevention, the approach is reasonably straightforward. Here is a reasonable guide. Regards, Fred Coe
I have had a long history over 7 years of occasional pain when I wake up on my left side. The pain is immediately relieved when I lie on back on my right side and doesn’t cause any other symptoms in the daytime.. I had a ultrasound done back then which was read as “possible vascular calcifications”. Then a couple years later I had an Xray for other reasons, and the radiologist said they were possible stones.. My ?’s are 1) should I get it further worked up/do they need to be treated? 2) is there anything besides increasing fluids and avoiding stone forming foods that I can naturally do to encourage the stones to dissolve? Is there any truth or logic to the olive oil/lemon/apple cider vinegar method?(I did see the other thread). Thank you!
Hi Lisa, I would suggest a CT scan – stone protocol – which has great sensitivity in detecting stones. If there are stones, it is best to follow an organized path to prevention. Here is one I like (because I wrote it). The world abounds in remedies that will prevent stones via magic, but they are unnecessary because fairly simple measures work and are in fact the diet portions of such measures are keys to good health in general. Let me know, Regards, Fred Coe
Hi Dr. Coe, Thanks for the response. Sorry for the delay here. I looked into this. Do you think the low radiation stone protocol is OK? Is that widely used now? I’m afraid of the radiation effects, then again, I do want an accurate diagnosis since the implications of renal artery calcifications do not sound good either. Thanks-I happen to be a physician (who probably doesn’t drink enough water 🙂
Hi Lisa, Low radiation machines are good, and the view can be kidney limited with shielding elsewhere, so I think it is a good bet. About the water, just be sure you do get a proper evaluation, physician or not! Regards, Fred
Hi again. What do you think of MR of the abdomen and pelvis for diagnostic and planning purposes in comparison, realizing that insurance coverage may be nonexistent
Hi Lisa, NMR is useless for stones because they do not show up. So if it is stone disease, CT works best. Regards, Fred Coe
Hi, I am 33 years and have been suffering with Kidney stones since I was about 20. I have seen a few urologists and have had blood work and 24 hours urine test done which all come back normal. I have also lithotripsy done ones. None of the urologists that I have seen can give me a reason for my stone. I just get told that my kidneys make very small stones. My last CT showed about 20 small stone in both of my kidneys. I have pain that comes and goes for the last 13 years, most of the time I just deal with pain until it goes away or I pass a small stone. I have found that when the pain gets bad heat and pressure on my Kidneys seems to help or chugging 2-3 bottles of water. I have had to stop using Ibuprofen because it seems to make the pain worse vs better. I have been dealing with this for so long and hope this not something that I will be dealing with for the rest of my life. I am hoping you can shed some light on this for me and maybe give me some suggestions or help.
Hi Cassandra, I am not very happy for you. If you have that many stones, your test results cannot be normal if obtained properly. Take a look here and be sure everything has been done properly. Here is a nifty guide to your own lab report. Here is a large article on treating what I think you are – an idiopathic calcium stone former. Reading is safe and easy, and perhaps may lead you to better prevention. Regards, Fred Coe
I just saw a urologist about a half hour ago about a stone that the CT scan September 27 showed to be about 3mm. I had kidney stones in the past. I have pain in my left flank, the dr told me that she is baffled because I shouldn’t be having any pain due to the stone being in the kidney. Which is still visible on the x-ray. This is frustrating I do not take pain medication I try to tough it out. It is affecting my daily life. I feel as though even though I showed her a picture of a stone i passed prior to the CT scan
she still didn’t believe me.
Hi Michelle, You are part of the emerging and exasperating problem of small stone pain. Most surgeons are beginning to think small stones can and so cause pain, but then there is the big decision: It surgery really appropriate being always some risk and a lot of trouble to patients, vs the problems and miseries of chronic pain. We need a trial that will take a while and be hard to do. In the meantime all we have is the ancient nostrum: IF the pain becomes severe enough you feel the problems and risks of surgery are the lesser evil – including the real risk that surgery may not help – your surgeon can help you decide. In passing I want to emphasize the best way of all is prevention. Be sure you have been properly evaluated and treated for that purpose. Regards, Fred Coe
If you are doing a study/research I would be willing to assist.
Thank you, Michelle. Regards, Fred Coe
I am a 58 y/o white male, recently admitted to hospital for kidney stone. After having blood in my urine I originally went to my PCP whom did not think it was a kidney stone. He checked sample and found that I had heightened white blood cells. PCP was to send sample to lab (Thur) and get back to me on Sat (Never heard from PCP) on Sunday night of course around 8:00 PM EST I just wasn’t able to get comfortable and pain began to increase. By 9:00 PM I was unable to get comfortable and took 2 oxycodone with no relief. Due to previous medical condition (Last March 2015 suffered from Aortic aneurism which then went to a dissection of the aorta) I went to the hospital that had treated me which was further away than local hospital. In ER B/P was 210/90 staff asked if I suffered from HBP? Only in pain. Dr prescribed Tramadol and Morphine which did nothing for pain. Ct Scan 2x first one without contrast and 2nd with. No evidence of Kidney stone, referenced previous ct scan and could not find stone. Evidence lead to stone Inflammation to Kidney and urethra. Blood cleared and 2 days later discharged. That was 2 months ago. Still have slight pain to right testicle area as though you sat wrong. And suffering from pain to the lower back nearly continuous. Had PSA level checked and found that PSA was at a 5 or 6.. Cardiologist did not want to take me off Blood thinner for biopsy.. DTE was done and did not feel any irregularity and felt biopsy could wait. My concern is lower right side back pain that wakes me up and the pain to the testicle. At hospital urologist offered to have a camera inserted and put through penis to look. This does not sound assuring.. Any suggestions?
Hi Bruce, Although I am far away and have no first hand knowledge of your situation pain radiating to the testicle and of the character you describe sounds lot like a possible stone. I agree with your physician that if you have continued trouble digital ureteroscopy is a reasonable idea. Of course, I assume that ultrasound has assured everyone that the kidney is not obstructed. To look or not is a complex surgical decision and of course your decision as well. Regards, Fred Coe
I went to the urologist for an 8mm kidney stone he was subpost to do surgery on the 2nd of November but my blood work was off anyway he had gave me 40 7.5 norcos for my pain at that time and now he is saying I shouldn’t be in pain because my stone isn’t obstructed and now that the surgery has been moved till the end of the month he won’t help what can I do it really does hurt and it makes me very angery that he doesn’t believe that
Dear Christy, You are in a large group of people with chronic pain from non obstructing stones, and physicians are unsure what to do. Even those who are very involved with the matter cannot in the absence of a trial know if surgery will in general improve matters when there is no obvious obstruction. It sounds like your surgeon plans to remove the stone. I hope it helps and I am sorry that the surgery is being delayed. In your case, given the size, is it possible that indeed the stone is obstructing the urinary track on and off? If so, it would be better to remove it sooner. Regards, Fred Coe
I have a 9mm stone, first identified as a 7mm in 2012. They tried EWSL back then but couldnt find it on ultrasound or xray on the day of the procedure. Today, Nov 7, I tried to have a utersocopy done to remove the stone as I have had multiple UTI’s with blood in the urine and bilateral hydronephrosis. The dr said he could not find the stone, that it must be in the “meaty” part of the kidney. He did say the hydronephrosis that was on two CT scans is better, but I have been in pain for months and really want the stone gone! Should I consider the surgery through the back? Or do you think that will fail too? Should I try another urologist? Should I just live with the stone and in pain?
Your website has been very informative and helpful! Thank you very much for your hard work!
Hi Anita, Quite possibly the calcification on CT is indeed a tissue calcium deposit that cannot be reached via ureteroscopy. That is not rare. Such a deposit would not cause hydronephrosis. It is not necessarily important to remove such a deposit, but I do not know what kind it is from your description. I would not simply suffer. I imagine your urologist, who has worked hard trying to be of help, would appreciate a second opinion, and would help you locate an appropriate person for that purpose. Regards, Fred Coe
Hi again, I did end up getting a second opinion. It turns out I had a calyceal diverticulum. And, the “big” 7-9mm stone turned out to be lots of little stones. So far, I have passed over 40 stones, ranging in size from 1-3mm. The dr was able to retrieve some larger ones, but not much larger than that. I asked him when he removed the stent why there were many small stones instead of a larger one and he said he had no idea. He is referring me to a nephrologist. He also did not have the analysis back yet for the stones. I was really hoping this last surgery would help the pain, but at 2 weeks post-op, it has not. I still feel the same “kidney stone” type pain (in my back, side, and groin) that I had before. I would appreciate any thoughts you might have. Thank you in advance!!
Hi Anita, Calyceal diverticulae trap urine which spontaneously crystallizes into innumerable tiny stones. Analysis usually reveals calcium oxalate with modest amounts of admixed calcium phosphate. The pain may reflect trauma from the surgery so I would let time go by and see. You should pursue a normal evaluation to look for stone risk factors and treat those found. Your nephrologist would certainly approve of this one. Regards, Fred Coe
I was diagnose 3 stones in my kidney , 1 at the right side and 2 at the left side. The doctor advice me to keep on drinking excess fluid like water cos it will help pass the stone through urine. I want to know what always Precipitate the pain. I drink a lot of alcohol, I have Sex almost everyday cos am living with my girl friend. The last time i nearly died of the pain, i was taking a bottle of beer, before they pain came. In-fact it was an emergency for me that day. I was rushed to the hospital. The doctor was confused, he was thinking that i have been poisoned , later he administered buscopan injection with some strong pain reliever before the pain subsided. My question is i need an advice, What causes the pain. ? is it alcohol, or sex? or any kind of strenuous activity? No 2, what other kind of medication can help to dissolve the stone? Help me doctor with dew respect, or anybody in this room. Thanks. stay blessed.
Hi Augustine, If the stones are causing pain, a likely idea, it is that they obstruct the kidney. Intercourse and alcohol are not able to affect whether stones obstruct or not and are not the reason for the pain. If the stones cannot pass your physician can remove them. As for dissolving stones, it is not necessarily possible. The real issue is to prevent more. Regards, Fred Coe
Thank you so much MD Fredric Coe, Am very very grateful for your candid medical advice. Stay blessed.
Hi Augustine, If the stones are causing pain, a likely idea, it is that they obstruct the kidney. Intercourse and alcohol are not able to affect whether stones obstruct or not and are not the reason for the pain. If the stones cannot pass your physician can remove them. As for dissolving stones, it is not necessarily possible. The real issue is to prevent more. Regards, Fred Coe
Hello Dr. Coe
I am a 64 year old female. I spoke with my OB/GYN about recurring pain in the right flank area for the past six months. She ordered an Abdominal Ultrasound, which revealed a kidney stone. What concerns me is that, at it’s worse, it is extremely painful, however I fall into the Pain Without Obstruction category. Upon urination, my urine is brown in color and somewhat cloudy. I’m scheduled to see a Urologist in the next few weeks and would like to know what I might say to him to help rid me of my pain without pain pills. Another question is that is it possible that my RA medication could be causing these stones? I take an IV infusion every six weeks of 800 mg of Remicade. After reading all the testimonials, I’m not very optimistic and not looking forward to my appointment. I thank you and I am anxious to hear your thoughts.
God bless, Yvonne
Hi Yvonne, I am sorry to hear about this stone. Ultrasound is not as sensitive to stones and the anatomical issues associated with them as are CT scans, and I suspect your urologist will want a CT scan prior to any surgical intervention. There is bleeding, pain, and perhaps infection – I would have the latter checked. I presume the stone is in the right kidney but it may be in the renal pelvis, and intermittently block outflow which can produce severe pain. Such stones are amenable to possibly shock wave lithotripsy and certainly to ureteroscopic fragmentation and removal. A PubMed search for remicade AND kidney stones gives no publications so it is very unlikely the drug is playing a role. Regards, Fred Coe
I have pain in kidney on right side. No obstruction with urine, at first I had heavy dizziness when standing up. Any advice, please, and thankyou.
Hi Herbert, pain on one side need not be from the kidney, and dizziness likewise. You need to have your physician figure out what is wrong. Regards, Fred Coe
Hello, I have a 1.2cm stone (yikes!) that is partially lodged at the beginning of my ureter but certainly not going any further. My surgery is not for a few weeks. I visited my urologist after a lot of on and off again blood in my urine. She was shocked that I had not been in pain. I, of course, was relieved. However, I have now started to have bouts of severe/ crippling pain. There is no infection (I had bloodworm to check) but a lot of pain and a lot of blood. Is there anything besides drugs and drinking lots of water that I can do to help relieve the pain. Does excessive water even help considering there is no way that this stone can pass naturally? Thank you!!!!
Hi Mo, A stone this big needs surgery. Given all your pain, I would think the surgery needs to be sooner. I see no reason why it is not apart from OR schedules but this much pain should be a major factor in getting the work done. Water and such are not reliable in that the pain is coming from obstruction by the stone. I would also be worried about the obstruction and perhaps a new ultrasound might be something your physician would want to do. regards, Fred Coe
I was diagnosed with a Kidney stone two week ago 11/15 in ER and had a CT one week ago 11/22 which indicated a backup of fluid in my kidney and a small stone about 1/3 down the ureter and I’m scheduled to have stone removed next Tues 12/6 (ureteroscopy). My concerns is that I have not been very good about using strainer during urination and for past three day I have had no pain at all and I feel 100% so I guess that it is possible that I passed the stone unknowingly, but my questions is would it be reasonable to have a stone in the ureter and have no pain at all for this long?
Hi Tom, It is possible to have a silent obstruction, also possible that the stone moved. Before any surgery your physician will confirm that the stone is there or not. Do not under any circumstances assume it is gone and fail to have physician followup as chronic obstruction neglected can destroy the kidney. Regards Fred Coe
Hi Dr. Coe, Thank you for the quick response. One other question – you indicated that before the surgery the doctor will confirm that the stone is still there – is that accomplished via a conventional Xray or Cat Scan? Much appreciated…
Tom, It all depends on the stone. Usually it is just a simple flat plate. But the decision is for the surgeon to make as the surgeon has to go in after the thing. Good luck, and afterwards be sure and get some prevention going. Regards, Fred Coe
I’m 27 years old . I have cystinuria. I produce cystine stones. I just had 2 ureterscopys and 1 lithotripsy back in april 2016 and may2016 3cm stone in my right kidney causing obstruction for at least 2 years. Kept getting misdiagnosed. Anyway finally found out I have cystine stones back in may. After the 3rd surgery one the one stone I was finally a lot better. Now 6 months later I have another cystine stone but in the left kidney 1cm in size but they said it’s in my lower pole kidney and it’s not obstructing . I’m nauseated a lot of days and I have pain in my side/back where my rib cage is but I was told I couldn’t be in any pain nor could I be nauseous from the non obstructing new stone. Urologist said I’m not going to go clean you out right away for your body just to do the same thing again. He also said I can guarantee you that the stone isn’t gonna go Anywhere but I had a 3cm stone move and make me really really sick in the past please help any advice appreciated
Hi Britney, Cystine stones can grow rapidly and get large. They can be prevented and dissolved but are a special part of stone disease. Prevention needs to be started now, and pursued life long. Ask your physician what his/her plans are for this and begin as soon as possible. Very high urine volumes, increase of urine pH with alkali, reduced diet sodium intake and reduced diet protein are first line; medications can be added but are complex and have side effects. See your physician about prevention right away so new stones do not grow back. The pain could be from infection, from the trauma of the procedure, or from the stones – they can cause pain sans obstruction. Regards, Fred Coe
Hi Fred,
I am three months postpartum, and have had two kidney infections within a month and a half of delivering my baby. The first time I had pain in the right kidney and was treated with oral antibiotics. The second time I was hospitalized and given antibiotics intravenously. After being released from the hospital I saw a urologist who ordered a CT scan and placed me on a low dose of antibiotics that I am to take every night. The nurse sent me a message saying that I have two stones and a cyst. I haven’t been able to speak with the doctor or the nurse and am not expected to see the doctor until the middle of January. At that time, the urologist wants to do a scope of my bladder (something the urologist decided to do prior to ordering the CT scan). I am wondering what the purpose of the bladder scope would be and if it is really necessary. My thinking would be that the kidney stones are causing the infections, so there would be no need to do a scope of the bladder (I am prone to UTIs, and am not comfortable having the scope done because I am concerned about it causing more trouble). What are your thoughts on the bladder scope?
I am also wondering if all types of kidney stones cause kidney infections or if only a certain type of stone would cause an infection.
Also, I drink a hot cup of lemon water each morning (8oz of water, juice of half a lemon, T of honey, and 1/2 tsp of turmeric powder) could the lemon juice have caused the stones? I am also drinking apple cider vinegar because I read that it could possibly help with kidney stones (about 2T or so twice a day). Would drinking apple cider vinegar be harmful or possibly cause more stones?
Since having my baby, I have been eating smoothies that contain almond milk and spinach….could this be the cause of the kidney stones in a matter of months? I am willing to change my diet any way I need to in order to prevent stones in the future, but I wasn’t sure if I should stop with the lemon water and the apple cider vinegar. I won’t be consuming spinach or almond milk from now on as per the list on this website.
I am experiencing some discomfort in my left kidney…it’s certainly not painful, but not comfortable either. Does this mean the stone is just staying in one place and not moving? Would this indicate that the stone is too large to pass? How long could it take to pass a stone? I drink approximately 104 oz of water everyday because I am nursing and have done so even before my baby was born. I am confused that I would develop any kind of kidney problem when I drink plenty of water.
Thank you for this website and all of the information…I’m completely in the dark on this matter because my doctor didn’t even call to talk to me about the results of the CT scan. I only got the brief online message from the nurse. Thank you so much for any advice you could offer.
Sincerely,
Ashley
Hi Ashley, I can understand your confusion because your physician has not spoken to you about his/her thinking and why the procedure is needed. I would suggest you schedule a visit with your urologist prior to any procedures for that purpose. Here is a nice plan for how to get the most out of physician visits. As for the odd foods, they are not ideal. Until you can be fully evaluated for why you make stones, the ideal diet is the US recommended healthy people diet. When you are ready get evaluated – here is a good plan. If your urologist is busy and it takes some time to get an appointment just postpone the procedure until you can get a visit appointment. Perhaps your primary care physician can help getting the schedule for you. Regards, Fred Coe
I have had one bout of severe colic 6 mo ago attributed to 5mm stone. recently after some chronic discomfort for a month identified a 1cm stone plus a bunch of other smaller ones right kidney only, I had flex laser lithoscopy, the doctor said he removed 6 stones by opening incision on lip of the chamber dividers and found no stones where he typically finds them in the chambers. Post op CT shows he missed 4 or more 5mm stones, he believes looking with radiologist that these are hidden in meat of kidney but were clearly a bit stumped and recommends only conservative wait and see. I don’t have a sense yet if my discomfort level is better than before but likely not worse. I could wait months like that but probably not lifetime. Any thoughts on how to proceed?
Hi, I gather that CT scan showed multiple stones but on URS your surgeon could not see them. After the URS there were calcifications. This is indeed calcifications in the kidney itself, and probably large tubule plugs. Usually this occurs in calcium phosphate stone formers. The other possibility is Medullary Sponge Kidney wherein the calcifications are in cysts and are hard to see by URS. Stones are often calcium oxalate. In any event it is important to pursue prevention – here is a good guide. If a movie was made during the URS or perhaps from memory your surgeon might consider if the papillae has the blunt sail shape of MSK and whether yellow plaque was seen – see plugging article. Regards, Fred Coe
I am a 37 year old female that has been diagnosed with kidney disease. I have had nine surgeries on my right kidney to include lithotripsy, cystostomy, and a stent put in for a month. The total of nine surgeries resolved my pain momentarily (2 years) but I have been experiencing the same type of pain that I had prior to my surgeries. I went to see my urologist and he confirmed that I have a kidney stone in the same kidney that I have experienced all the issues with, but it was not obstructed and therefore should not be causing pain, but I am in a terrible amount of pain. After the visit with the uroligist I went to see my primary care physician as recommended, who said I had blood in my urine sample. I also told the primary care physician that I am in a terrible amount of pain/pressure when I go to the bathroom urinate and bowel movement. Any advice?
Hi Natasha, I discarded the copy of your note leaving just one to post. You say you have kidney disease, but I think you mean stones with a lot of procedures but otherwise normal kidney function. With nine surgeries on the right kidney and present pain and a stone, I would be concerned the stone is causing pain perhaps by producing obstruction on and off. This is challenging to interpret from far away, as I am, but perhaps given so many procedures and new pain, and uncertainties about what to do you might want to ask for and obtain a second urological opinion. I am sure your physicians will be happy to help arrange for this. Regards, Fred Coe
Dr. Coe thank you for your help and support. The PCP prescribed me flomax in efforts to assist me with passing the stone as well as pain medication. I am a little hesitant to take the flomax because in the past when I have passed a stone it has be extremely painful and I got very ill, not to mention the PCP didn’t consult with the uroligist about this medication. I do know that I have numerous calcium deposits. Is that from not enough water consumption? I am definitely interested in prevention at this point. Thank you again for you time and dedication to these issues. God bless
Hi Natasha, Flomax is well established as an agent to facilitate stone passage, so your physician is acting in a good way. As for the cause of your stones, be sure and get a proper evaluation. Regards, Fred Coe
THE CONUNDRUM – Pain Without Obstruction
“Stuck Stones do not Hurt!” Not!
Short version- I have been going through this for quite a while, and that story is almost a mirror image of mine.
Over the last year I have been beyond miserable, I have complained of back pain and urinary tract pain. I was diagnosed with hyperparathyriodism in my early 30’s, but due to my sub-par insurance nothing has been done. I have had stones in the past and have insisted in my own kinda passive way that this pain is related to a stone. (a 10mm 5mm and 4mm) but they have been stuck and stuck stones don’t hurt. I have passed several small stones during the same time period. I have been given pain medicine for a ruptured disk in my back, but I have known they were 2 different animals. 2 weeks ago I ended up in the ER again in more pain than I have ever been in in my life (thinking I would just be sent home after feeling belittled) but the 10/5mm had passed and were both stuck in my left ureter. I had the laser lithotripsy done and a stent put in, and spent a couple of days in the hospital. I have been on Flomax and had the stent removed last Friday, it has been real up and down, but something is different. I am still dealing with a 4mm stone, but Sunday I felt really quite good. Almost no pain on minimal meds.
Is it possible? The only thing that has made me even slightly functional for quite a while has been pain meds. I am almost 6’3″ and got down to 140lbs because I could hardly eat for a while. Crushing depression with total lack of motivation. If I mowed the yard the pain in my left flank became out of control. I am 48 and am healthy, most people think I am in my 30’s, except for the fact that I have crashed and burned over what seems like half a lifetime. so drained and lost in what I have felt was most certainly the path to the end.
Could it be true? Just #$%$#% stones?
Wow…..
William in Texas…..
Hi William, lyes, stones cause pain, stuck or not, so there is no mystery about it. The worrisome thing for you is that you may indeed have primary hyperparathyroidism and if you do it must be cured because it is a systemic disease that can cause much harm apart from just stones. It is not an option to leave it, and no insurance company can deny surgery – it is immoral. That you can distinguish back pain from stone pain means you have an excellent sense, as they are indeed different. Prevention for you may well be parathyroid surgery – it is very safe, and almost always curative. Do not let anything stand in the way of that cure. Regards, Fred Coe
I can relate. Stuck stones in the kidney can hurt and allow you to go on with your life with transient pain. Since everyone feels pain differently these may need to be taken care of through surgery too. Stuck stones in the ureter hurt like hell and have to be taken care of ASAP. I could not stand a 3 millimeter stone in my ureter back in March. Had a blasted it out with a stent put in. Now I just got a call today that I have a 7 millimeter stone stuck in the lower part of my kidney. I am in a lot of pain from the left side of my kidney to the left side of my belly button. I am a post thyroidectomy with one parathyroid removed and 3 kept in the last part of October 2016. At the same time I was diagnosed with hyperparathyroidism I was diagnosed with thyroid cancer. Parathyroidism needs to be taken care of ASAP. Keep in mind that a hyperparathyroid is handled by an endocrinologist not a urologist. Ask to be referred to an endocrinologist if you have not done so already. Thyroid cancer can grow a bit slower, be asymptomatic but can spread. Revisit the parathyroidism because that is the cause of the kidney stones. Ask for an appeal if get denied on receiving treatment. Do it please! Let us know how you’re doing!
Here’s my story. I’m 34 years old.
Some months ago, I began to have on and off blood in my urine. i had no pain. After a CT scan, they found a 8mm kidney stone.
On December 13, I had an ureteroscopy and they use a laser to burst it and installed a double j stent. The first days I had on and off pain and blood in my urine. They told me to remove the stent on Saturday which I did. After that, I had MAJOR pain, so much that I went to ER on Sunday and they gave me morphine. During the night I peed huge blood cloths (several centimetres) and since then the pain is still there (on and off) but it can be control by tylenol so it’s ok.
After removing the stent, I began to saw small stones fragments in my urine (maybe 10 to this day). As if, with the stent installed, nothing passed except urine and now those huge blood cloths and small stones begin to pass after removing it. Notice that these huge blood cloths happened one time. Since I peed them, I had only very small “normal” cloths.
When I was at ER, they did a x-ray and ultrasound and told me that I had still a 4mm fragment in my kidney and some smaller ones in my ureter. Since I’m back home, I peed another one that was 3mm without any pain to my surprise.
1- Sometimes the pain is in the upper section of my belly and sometimes lower section. I suppose it’s because they are moving ? When they aren’t moving, there is no pain ? (if they don’t block ureter I mean).
2- Now I saw this pattern. When I have no pain for several hours, my urine has less blood. If I begin to have pain, the blood comes back. How much time does it take for these fragments to pass ? I drink a lot of water. They told me the 4mm still in my kidney could pass next day or in 6 months… The smaller ones in ureter should pass by themselves.
3- With all this blood I see in urine, is it dangerous ? I know that just a little of blood can impressive but nonetheless…
4- And even if they go down the ureter, they can stay in the bladder for a while before getting out ? Am I right ?
5- How can small stones (like grains of sand) can do so much pain ? They cannot block the ureter, they are too small… How can they stay in ureter for days ? I though the ureter was smooth. How can they stick to it ?
Right now I have pain in my lower belly, near my bladder. I suppose one will come out eventually.
thank you very much !
Hi Vincent, Yes, tiny crystal fragments can cause terrible pain. You need medication for it until they have all passed. The bleeding is usually not quantitatively important however alarming. Crystals can adhere to ureteral and bladder surfaces. Most important, collect as many of the fragments as possible and see that they are all analysed to find out the crystals they contain. That is a key step in stone prevention. Be sure you are fully evaluated so you can prevent more of this. Here is a good starting place. Regards, Fred Coe
Thank you for your answer !
I keep fragments with me but my urologist doesn’t want to analyse them. He said that one stone in 34 years is probably just “bad luck”… He said if I have more stones in the future, then we will analyse them…
Hi Vincent – Analyse them; ignorance is not bliss. Analyses are not expensive. I do not believe in luck where disease is concerned. The world is filled with surprises. Regards, Fred Coe
I’ll keep them with me and I’ll analyse them as you recommend.
Otherwise, it’s getting better everyday. I don’t have huge pain anymore. It’s more like discomfort from the kidney to the bladder. Probably because of the ureteroscopy, the stent and all the fragments from the last days/week. I suppose there is some irritation here. If I don’t think about it I don’t feel it so…
There is less blood in my urine. In fact, I would say that half of the time there is no blood at all (at least to the naked eye). When there is, it’s a light right or kind of brownish (very little).
I did not pee fragment for 2 or 3 days and the blood started decreasing at the same time. I don’t know if some are still there.
Is this little blood I have from time to time can be caused by some fragments still there or after all this I can still see little blood before my body heals completely ?
Thank you and merry Christmas !
oh and last question, I took flomax for 10 days. I had side effets like retrograde ejaculation. Now it’s been 4 days since I stopped taking it and the quantity of sperm getting out of my penis (instead of going to my bladder) increases but it’s still not perfect and I have some perineum pain when ejaculating.
How much time does flomax stays in body or how much time before being like before ?
Note that before I had absolutely no pain et ejaculation problem.
Thank you
Hi Vincent, Being an alpha blocker the drug can cause your symptom. The drug has an 18 hour half life although symptom persistence is noted for some weeks. It should go away. Regards, Fred Coe
thank you again.
My pharmacist told me that retrograde ejaculation is normal with Flomax but pain near the anus while ejaculating is not (seems to be the muscle that suppose to “expel” semen that hurts) …
This pain appeared after 6-7 days of flomax but not sure if it’s because of it or the ureteroscopy or the stent
Maybe I should consult again
Hi Vincent, Of course consulting with your physician is always worthwhile. Regards, Fred Coe
Hi Vincent, Surely the blood can come from all those fragments and outlast their passage by days or more. Regards, Fred Coe
Hi..i am aarushi. I was diagnosed with kidney stones last year and now i am feeling frequent pain due to stones. I have started to note the cause for it and one thing i found was whenever i consume alcohol the next day my stones start to pain. Please help me and suggest me what to do cause i think the pain is due to the stone movement(it passes out).
Hi Aarushi, Alcohol may worsen stone pain but is not a cause of stones. Here is a good overview of stones and what to do. Let me know if this helps. Regards, Fred Coe
I am in my mid forties and had my first bout with kidney stones in my early thirties. I have passed numerous stones in that time, with two being removed from ureter (on different occasions) after being struck for days. I can feel stones moving in kidneys sometimes. I have numerous 5 mm stones in left kidney currently. I was recently referred to my current urologist due to significant stabbing right kidney pain. Lithotripsy has been done twice breaking stones to 1mm and powder as of second round. The pain continues only on the right. It is daily and ramps up much most days throughout the day. It is debilitating kidney pain and is on the level of kidney stone pain within kidney when passing stones even though I am only passing kidney stone fragments. My Urologist says the same thing – no doubt I am in pain, but nothing is blocked. This is heading into fourth month and I am struggling to stay the course and stay out of ER. We’ve done blood work and urinalysis and CT and nothing sticks out except stones. Any recommendations for my discussion with my Urologist on “small stone disease”? The pain is real and I cannot tolerate much longer. Thank you so much for the article! It makes total sense to me.
Hi Jason, Of course I am not personally a urological surgeon and far away from the reality of your situation, but perhaps your surgeon might consider going up with a ureteroscope and removing all residual fragments. The procedure is more definitive than shock wave lithotripsy, and modern digital scopes provide a very clear view. By the way I did not see 24 hour testing in your list. It will not show normal results, and I do not see the stone analyses. Take a look here, you may benefit from more detailed testing and prevention. Regards, Fred Coe
Thank you for your reply Dr. Coe. No 24 hour testing has been done and stone fragments were analyzed and are calcium oxylate. I will discuss the removal procedure with my Urologist.
Hi I am 20 years and at 19 i discovered that i had kidney stones I had 9 in total in my left kidney which I had removed. the doctors have done most test, and a year down the line I have another 4. They are not sure why I keep getting them is there any way to prevent them. I have been drinking more and have changed my diet. The stones have varied in size the smallest 2mm to the biggest being 13mm
Hi Kielan, I hope you mean the 9 stones were removed and not the left kidney! Most important, what were the 9 stones made of?? Here is a good approach to stone prevention; it depends upon stone analysis. See if it fits your needs. Regards, Fred Coe
Thank you for all of the in depth and helpful information Dr. Coe and thank you confirming that my pain is from a non-obstructing kidney stone.
My urologist explained that since the stones were not near the left ureter that they are not causing the constant pain and discomfort of the last three weeks. And since I am also experiencing numbness and discomfort mid-front left thigh then the cause is lower back and sciatic nerve.
Can non-obstructing stones cause the symptoms in my left thigh as well?
Hi Joe, numbness is a sure sign of nerve origin of pain. WHereas non obstructing stones do appear to cause pain it is not in the thigh but usually in the flank region. Regards, Fred Coe
I am a 35 yo f and have been getting chronic stones ( I have had several hundred ) over the past 16yrs. I have been seen by numerous urologists and nephrologists over the course of this time and none thusfar have been able to determine a specific cause or offer any sort of long term treatment plan. Various doctors have put me on medication that is supposed to slow the stone formation, but none have succeeded. In April of 2011 I had a right whole nephrectomy due to severe chronic kidney and uti infections and the almost complete blockage of my right ureter from scar tissue buildup. Before the nephrectomy I had never had a stone in my left kidney, always the right. Two months after the surgery I developed the first stone in my remaining kidney. Since then I have had close to 80 stones, so far as I can recall, and my kidney has almost completely shut down on me twice. Living with this and the not knowing has been difficult to put it mildly, but the way that I have been treated by physicians over the years has been almost worse in a way. I have been portrayed as a drug seeker countless times, been laughed at, and in a few cases doctors have outright refused to continue to see me. Going through what I have, and still am, has been difficult enough. Combine that with the ill treatment I have received and it has made the situation almost unbearable. I am now afraid to seek care when I need it for fear of ridicule, and I put off being seen until it almost always requires hospitalization. I hope that in years to come doctors will gain a more complete understanding of non obstructive stone pain and find ways to better treat patients who suffer from it. This report is one of the only ones I’ve read that lends merit to people who live with this and I thank you for it.
Dear Erin, Your problem of accelerated stones is familiar to me as I have published several papers about such patients. But with all of the stones you did not say what they were made of. If they are simple calcium oxalate stones in the absence of systemic disease prevention is not difficult. If there is a more complex source, what is it. Prevention is crucial for you and must be pursued. Regards, Fred Coe
They are Struvite
Dear Erin, If they are all struvite they are arising from infection with bacteria that can hydrolyse urea to ammonia. This kind of disease requires special treatment that my site has not as yet discussed. Has your physician discussed specific treatment for these infection stones? If it is not possible for him/her to pursue prevention perhaps a referral can be made to someone convenient to you who can help. It is important that these be stopped. Regards, Fred Coe
at the onset they were not all struvite, they started out as calcium but the past 9 years or so all the stones that have been analyzed have been struvite. my current urologist has offered no options for treatment so far. i guess then that my next step would be to ask for a referral. its just discouraging, going from doctor to doctor, when none seem to have the slightest clue how to treat me.. and if their is a treatment for this, like you mentioned, why have none of my previous doctors thought to try it? is their a specialty, like a nephrologist, that i should be seeing? currently i am seeing just a urologist.
Dear Erin, if you once had calcium stones and now struvite, you have become secondarily infected. If the organisms producing struvite can be cultured – proteus, klebsiella, pseudomonas, enterococcus are usual – and are susceptible to antibiotics a course of properly chosen agents might clear things unless stones in the kidneys are infected. If cultures are negative you may be infected with a fastidious urea splitting organism and this needs to be searched out and treated. Acetohydroxamic acid is a nasty but effective aid that inhibits urea splitting and can be used while hunting and during definitive treatment efforts. Whatever, the stones are of bacterial origin and need to be treated as such. Regards, Fred Coe
I did a bit of reading up on the various things you last mentioned and from what I saw I would have to lean towards the fastidious urea splitting organism you mentioned. I have had many stents placed over the years and many would become very calcified within the month of placement. I have also had two nephrostomy tubes, one of which became so calcified on the interior of the site that, because I was pregnant at the time, they could not remove it without opening the site up. The calcification regarding that took only a week to build up. They ended up leaving part of the tube in and placed another next to it until I gave birth and they were able to operate safely.
While it may not turn out to be that, it’s the closest thing I have read as a possible link. Thank you very very much for shedding some light on this!
Hi Erin, I imagine they would have analysed the crusting on the stents and made cultures – check. If struvite is the culprit there is something living in you producing it. Obviously from your answer cultures are turning out unhelpful. Let me know, Regards, Fred Coe
I have been dealing with severe, non-stabbing pain in the upper right flank area for almost two weeks. Did the CT scan a few days ago and it showed several free-floating, non-obstructive stones the largest of which is 3mm. I have been told by doctor, as others have, that these stones should not be causing the pain I am having, but of course they are – and the pain is real and debilitating!! Have increased fluid intake, but generally drink a lot of fluids anyway. Pain has made it difficult to work. The pain moves from upper right flank to waist from time to time, but no pain below the waist. I am 60 and doctor says that he thinks this is shingles, although I have no rash. His suspicion is based on the fact that examination showed that I was flinching when he pressed on painful area. Of course I flinched – the whole flank area hurts!!! I know he is just trying to do what he thinks is best, but I have had shingles before and this is not the same kind of pain at all. I have no idea what type of stones these are, but from reading this site, I’m not sure what the next step should be? I can’t stay on these pain pills and they aren’t helping the pain much anyway. Should I be asking for a referral to a urologist? Thank you for this informative site!
Hi Kim, As you have read there is real controversy about the small stone pain issue but in all probability your pain is not herpes but related to the stones. One good question is whether the pain is related to motion – twisting, bending, lying, walking. Stone pain is indifferent to such, whereas muscle and skeletal pain is not. In the event it is likely to be from the stones the main choice is always your own: Is it enough to warrant the certain pain and effort of ureteroscopic removal? Regards, Fred Coe
Dr. Coe,
Thank you – and the pain is not affected at all by the muscular/skeletal movements, and I have no issues with range of motion or movement – which I showed my doctor during my latest visit yesterday. Yet, he is insisting on an MRI of my spine because he does not believe this pain is associated with these free-moving stones. To have to incur additional costs associated with a test that I believe to be unnecessary is very upsetting. Is it possible for the stone/stones to eventually pass on their own with increased fluid intake? Or if they become “lodged or attached” to something in the kidney, does that mean that the only choice is ureteroscopic removal? Besides the obvious pain I have, would some other procedure, such as the CT scan I had, be able to determine that stones are “lodged or attached” to something, warranting the ureterscopic removal?
Hi Kim, The stones may be causing pain. Whether to have them removed is a personal choice; surgery is itself intrusive and unpleasant so you have to weight out how much trouble the pain is vs. the undertaking of surgery. CT or other tests will not at this stage help in deciding if surgery will reduce pain. Regards, Fred Coe
I am 25 years of age, being on June 2016 i have diagnosed with 5mm stone in my left kidney, i have been taking medicines and proper intake of food etc., and later in the mid of October 2016, i had a pain in my left lower abdomen and again consulted doctor and got scanned, but the result was positive as no stones are in my kidney.But for the past one month , i am having a pain in my lower left abdomen and once in week i get trouble in digestive issues and looking for the solution.
Hi, Possibly the left sided stone is causing pain, or caused it; in June there was a stone, in October you say there was no stone so perhaps that stone passed. Do your physicians know where it went? Is it perhaps still in the ureter? I am afraid the information you offer is too vague for more right now. Regards, Fred Coe
My name is Vinay I have start kidney stones for 9 months I have really pain right & left side in scanning report the doctor say 3mm to 5 mm I am very sad my working is going to bad in my company please help me sir my number 9066300492
Hi Vinay, I am sorry you are having such problems. Of course your personal physicians are the ones who have to provide your care. I will try to call you, however. Regards, Fred Coe
Hi doc..its my uncle’s problem..he had severe flank pain about 9 months back n was diagnosed with ureteral stone 14 mm..he was given med n in a week it descended to lower ureter n after a few weeks of more meds n fluid..pain vanished and follow up xray had no visible stones..he was advised to follow up after 3months bt he completely forgot..after that he had been asymptomatic bt recently he developed mild pain over flank that reduced after fluid intake..is it possible the previous stone persisted and it might have done kidney damage??
Hi Niki, It is possible and he should not have forgotten what his physician asked for. He needs to be reevaluated and hope the kidney is still alright. Regards, Fred Coe
Is it possible to pass stones without pain? I sometimes have black flakes and specks in my urine. Recently my bladder was bothering me a little. I assumed uti but I found what looks like a tiny kidney stone when I took a bath right after I used the toilet one night. How it got there, I don’t know lol. I saved it in case I decide to call my doctor. I know that’s the only way to get answers. But the fact there was no agonizing pain and only mild bladder discomfort is odd and goes against everything the internet says happens with stones. It stops me from calling my doctor because I don’t want to be told I’m crazy.
Hi A, The best course is to have the material analysed. It may not be stone at all, in other words it may contain no crystals. If it is a stone, you should seek prevention, and not let matters progress. Regards, Fred Coe
“Is it possible to pass stones without pain?” Short answer, Yes. But I can usually retrieve them and pass em on to MD to ck. I’m a white 60 yr old male whose has passed a lot of stones over the last 20 yrs. Many passed. Several lithotripcies, 1 awful lithotomy, finally found an urologist familiar with Litholink, and got a med that almost completely stopped my previous 8 yrs of continual stone production. Due to low blood pressure the MD reduces the med and I started passing an occasional stone, with only a brief mild flash of pain as I passed it out b4 the clink of it hitting the ceramic toilet. I rinse em of and give them to the MD but they are the same old calcium stones I always pass. I was recenty taken off the hydrochlorothiazide completely due to complications (low blood pressure) taken with Carvedilol. In just 2 months the stones got bigger, from 1 to 2 mm up to 3 mm with no pain. But one, maybe bigger, is hurtin bad now.
Hi Mike, Thanks for the useful note. Of course they can be without pain and your comment is a valuable point. As for the drug, it is probably acting by lowering urine calcium. If you cannot use the drug you can substitute very low sodium diet which will accomplish the same thing and perhaps with less symptoms. Regards, Fred Coe
Thank you for this question. I searched and found this article after my husband passed one this morning without pain. Everything I had ever heard was about how excruciatingly painful they are to pass, so I thought passing one without pain might be abnormal. Glad to read that others have had it happen without pain, too.
Hey Doc, thanks for the article. i have had extreme pain in my left side two days ago it was unbearable i visted ER. they diagnosed me with ( Mild Hydronephrosis and upper hydroureter, by 5mm vesico ureteric stone). they told me to go home drink lots of water and do jump up and down. also prescribed me voltalin and flomax. the pain is still unbearable even with the voltalin. what i am worried about is if the stone passes the ureter and gets stuck in urethra. should i use the laser or ultrasound cure?
Best regards.
i am a 22 year old, 5.9 ft , 171 lb male
Hi Rebar, For the stone you now have, removal choices belong entirely to your surgeon – so many small local details matter. Given your age, prevention is a must. Be sure to get the stone analysed. Here is a plan for you. Regards, Fred Coe
Beautiful article! Finally, something extensive to take to my urologist to explain why my inch long (plus) chains of stones, in addition to plaques and free floating stones, may be causing my flank pain. I was formally diagnosed with MSK and nephrocalcinosis through lithotripsy and uteroscopy by the most wonderful Urologist…but once she moved, it has been difficult to explain the severity of my constant flank pain. Thank you!
Hi Heather, I am glad it is useful to you. Pain from small stones is a world wide observation. Treatment is not as yet very well established. Regards, Fred Coe
I’m so happy to have read this! I thought I was going crazy! I’m in so much pain for over a week now and I knew it was a stone from past experiences. The ER doctor was trying to convince me the stone wasn’t causing pain due to its location. He was giving me an attitude almost, like I was there trying to get pain meds. Needless to say, he sent me home without anything and told me to drink water and see my urologist. My urology appointment isn’t until the end of next week and then by the time they set up without trip see it’ll be at least another week. Meanwhile I’m supposed to live like this? I finally got my doctor to call me in something today, which I can’t wait until it gets to the pharmacy. This is worse pain than childbirth!
Hi Noel, If it feels like a stone it probably is something – either a small stone moving or perhaps one in the ureter missed, or even crystals. I would ask my physicians to help in looking for a source. Regards, Fred Coe
Same for me. Twice now. Doctors keep telling me that I don’t feel it it’s back pain it’s not my kidney I told him it’s my kidney they do a CT they see a kidney stone how did I know it was there if it doesn’t hurt it makes me very angry
Dr. Coe. My daughter has had pain and nausea and vomiting for over a year. She’s spent 2 months in the hospital after a couple of surgical procedures, first a partial gastrectomy with removal of an ulcer, then a roux n y procedure to try and stop the nausea and vomiting. She has had a total hyst, a cholecystectomy, appendectomy.
They say now that she has non obstructing stones on ct but don’t believe that is the cause of the pain which she describes as stabbing pain and like someone is burning her, along the upper abdomen just under the ribs. No pain in the lower abdomen at all. She does have difficulty urinating quite often and sometime is unable. I am waiting for a call from one of her surgeons to discuss this with him. Is there any advice that you can give me to get them to at least consider the stones as a possible source of the pain? When she had her gall bladder removed there were no stones, just a fine “sand” as the doc said but she still had tremendous pain. thanks.
Hi Donald, This is a very worrisome situation: partial gastrectomy then a diversion procedure and three more surgeries beside. Two months in a hospital itself worries one. I urge outside consultation. Her physicians have done what they can do and she is still in a hospital and ill. If she is not in a university hospital consider transfer to one. It is not that private hospitals are inferior to those of universities, it is that when things become so odd and serious as you describe one may need that extra element that university centers can provide. From here I could not even guess at the possible causes and treatments for her. Regards, Fred Coe
Thanks. She is in University Hospital in San Antonio and the Chief of Surgery is the one that has done her surgeries. The pain has remained unchanged despite the multiple surgeries and scopes. They did find an ulcer which I think we knew was present the last time they opened her up. It was on a Friday when they did the Roux n Y and then had to take her back on Sunday for emergency surgery because the pouch filled with blood and she aspirated some of it. Then they had to take her from the OR to Angio with her belly still open to try and locate the source of the bleeding, sealed off 2 places and left one that was leaking slightly. The kidney stones have been present on multiple CT’s with contrast and even though they are not obstructive I am concerned that with their presence and the unchanged nature of her pain that they might be related.
Hi, She is in a fine hospital, and having a lot of trouble. The stones are not likely to be a key issue at this point but as I am far away and she is very ill I can only recommend the physicians there who do a lot of kidney stone work might want to come by and help decide. She is an example of medical complexity far beyond the reach of an outsider. I hope for the best for her, and send my prayers. Fred
Dear Doc,
I was diagnosed just 1 day ago having a 9mm uretheral stone. I DON’T have pain at all. My only symptom is when I void I feel something is still left.
I was given a medicine (Harnal OCAS) to relieve the symptom and was ask to undergo shock-wave treatment.
I am afraid of the suggested treatment due to its probable long-term effect on other organs.
It is possible to pass this 9mm stone in the urether on its own? I am currently drinking lemon juice + olive oil + apple cider vinegar as per my friends’ advise since they too experience stones episodes in the past (but not this BIG).
Among the available operational treatment for stones, is it advisable to pick ‘laser’ treatment?
Thank YOU!
Hi Sergs, a 9 mm stone is not likely to pass. Perhaps given your concerns your urologist might want to do ureteroscopy but if it is only one single stone of that size in the renal pelvis or upper ureter SWL is indeed a reasonable treatment. Be sure to seek prevention against more of these. Regards, Fred Coe
Thank you Doc for a prompt response.
Just a follow up questions:
Why 9mm ureteral stone doesn’t cause me pain at all?
What is the possibility if I waited til Dec 2017 to have my stone remove since I prefer to have it done by a specialized doctor back home (I’m currently out-of-the country).
How safe is the shock-wave treatment as far as other organs near the stone is concerned (I’ve read some blogs saying it might cause diabetes in the future as it affects the nearby organs).
Thank you and more power!
Hi Sergs, Not all stones cause pain; it depends on how much obstruction and how sudden it was. As for waiting, only the physician caring for you can tell. If there is any kidney obstruction you can lose the function of that organ, so be certain your physician is willing to wait. As for diabetes etc, SWL does not cause it. Be careful!! Regards, Fred Coe
Third year medical student here. Thank you for the great article on this common condition. To help passage of stones is it recommended to drink lots of water, or will this cause hydronephrosis and worsen the pain and nausea due to blockage?
Hi Tim, Yes, fluids are recommended – not a lot of data. Whether hydronephrosis worsens, along with pain and all depends on how much the stone obstructs at the time. You can see that pressures rise then fall again. Regards, Fred Coe
Dr. Coe.
Thanks very much for the useful information. I read almost all of the posts on here. I too seem to fall in within the group with Calyceal non-obstructive kidney stones resulting in constant moderate flank pain. I had CT scan a week ago after insisting on it and the radiologist confirmed the presence of a 5mm stone in my right Kidney. Given the location, it was assumed that this perhaps the same 2.5mm stone that was recognized through a CT scan back in 2014 when I had minor neck injury. It must have grown gradually since then to a size that may have caused some pressure (who knows). My urologist insisted that this is not the cause of my pain, but I know my body and I recognize this pain from my previous, rather seldom, kidney stone dramas. I plan on scheduling an appointment with a surgeon to remove the stone, preferably with laser ureteroscopy if possible. Knowing the concepts of growing crystals (studied mineralogy/ontogeny of minerals for awhile) I would prefer not to have any tiny leftovers after the procedure, but I understand that is not always possible. Frankly, I don’t care if they think this is not the cause of my pain, but I will need the stone removed since it has the potential to grow even bigger. There should be more research on the is matter as it seems a lot of people have symptoms under similar circumstances. Do you think I’m doing the right thing? I appreciate your opinion and thanks for all your help provided to all of us poor-soul “stoners” :).
Hi Rado, Given the pain resembles stone pain surgery is not irrational. I hope it works. We do need a trial of surgery vs. no surgery and I hope for one. Be sure you prevent more stones – I know you have read through the site; remember this one. Regards, Fred Coe
I went through a URETEROSCOPIC STONE REMOVAL. Luckily there was not need to break up the stone with the laser.After the surgery I had some nasty pain associated with the stent in my ureter but once removed everything was back to normal i.o no moderate flank pain. The bottom line, at least from my experience, is that kidney stones hurt even if they are not in the ureter. Again, I had calyceal non-obstructive 5mm stone. Thanks and good luck to everyone reading this forum.
Hi Rado, Be sure and prevent more!
Thank you for this powerful and insightful article. I have a family history of kidney stones both maternal and paternal. I was first diagnosed in February of this year had a month of relief and then and passed a 5mm stone at the beginning of march. I started an acute episode today with pain around the bladder area and just slight flank pain. My questions are 1. Why is the pain always only on the left if we have two kidneys? 2. I drink water like it’s going out of style is it possible that despite the genetic factor could my water filtration system be contributing? 3. How besides drinking water can I prevent future episodes? I’m assuming don’t eat a lot of calcium enriched food but is there anything else?
Again thank you for this amazing and insightful article and thank you in advance for your response
Hi Amy, I would presume your pain is left sided because that is the side stones form on – presently. For stone prevention water is not enough. You need a full evaluation and focused measures. Low calcium diet has no place in such prevention. Regards, Fred Coe
I just passed another kidney stone a week and half ago. My first one was 11 years ago. I also drink a lot more water than I used to albeit more recently (within the last 2-3 years). From what I understand and what the doctor told me at the ER is citric acid has been proven to significantly lower your chances of forming more stones because it changes the PH of your urine and causes it to become more alkaline. The doctor mentioned that I should squeeze lemon juice in water regularly and that should help. So as a result, I have decided to do that and drink lemonade regularly. I’m hoping this works because I’d do anything to avoid another one even if it is every 11 years.
Hi Matthew, The idea is good but there is more. Some people need and benefit from potassium citrate, others have no need of it. Before doing something everyone needs to be sure about why stones are forming because you want treatment to focus on what is wrong. Here is a reasonable plan. If indeed your stones are calcium oxalate – not calcium phosphate or something else, and also if you have no systemic causes of stones, and if your urine citrate excretion is low enough to pose risk of stones – <400 mg/d, lemon juice could work, Crystal light, or potassium citrate pills. Citric acid will not help as it is metabolized without creating alkali; it is the citrate ion that is metabolized as citric acid, takes up a proton and produces alkali. THe higher urine pH is not what helps stones it is the higher urine citrate. Here are the trials. Regards, Fred Coe
Thank you for the article and the effort in answering all the questions. I’m 48 and without warning passed my first ever stone last week, 2 mm. CT scan reveals a 1 mm parked in the same kidney. No pain from the remaining one and I do NOT want to repeat the trip to the ER, so I’m drinking all the water I can. Will read your prevention article ASAP. Thanks again.
Hi DL, be sure and have the stone analysed! Regards, Fred Coe
Hi there., I wonder f you can help.
I was admitted to hospital last week with s.eduevere pain in left flank. I had a CT scan which revealed a partial obstruction by a 6mm kidney stone in my ureter. I am now at home but still have intermittent pain in left flank every day and I have been advised not to drive long distances . I am taking Diclofenac for pain and Tamsulosin (pilot medication, usually prescribed to men) What are the chances of a 6mm stone in ureter being passed naturally, without the need for surgery and is there anything i can do to minimise the risk of needing to have surgery. Thank you. Linda
Hi Linda, A stone this size may well pass, so let it be. Your urologist needs to be sure it does not obstruct your kidney too long – something you need to trust him/her about. The Tamsulosin helps relax the urinary tract smooth muscles by acting on the sympathetic autonomic nervous system. Your main purpose is prevention of more stones, and that requires a plan. Here is a reasonable one. Regards, Fred Coe
I have 7mm stone in right kidney at mid Pole but it is not so painful but my left kidney is paining… I did CT scan but thr is a stone in right side of kidney.. I m feeling confused why my left kidney is paining..
Plz advice me
Hi Tulshi, I cannot be sure from this distance. With a negative CT on the left, the left pain may be something other than a kidney stone. This is one your personal physicians have to figure out. Sorry. Regards, Fred Coe
Hi Tulshi, I cannot be sure from this distance. With a negative CT on the left, the left pain may be something other than a kidney stone. This is one your personal physicians have to figure out. Sorry. Regards, Fred Coe
3 weeks ago I woke in the middle of the night with severe pain in my right flank, unbearable and knowing here we go again! A little over three years ago woke up in pain finding out shortly after I had 8 stones scattered in both kidneys. Anyway, I saw my urologist and had a KUB, the pain stopped a few days later. The next day sever horrific pain on the left, went back, Ct scan done, ended up in ER, unimaginable pain. Left side is experiencing all the pain and right is not hurting which is where the stone is, 5mm, second Ct next day which shows it’s in the urerter on the right. I’ve never experienced pain in opposite side from the stone. It’s confusing to me. Urologist and others said it can happen, but what I don’t understand is why this one hurts like the death of me when I’ve passed bigger with less pain. It just sounds like no rhyme or reason to it. I still have one 9mm in one kidney and a 8mm in the other, both are stated to be stable but I have intermittent pain which is consistent with the pain and symptoms I feel with problem ones. The last scans show small cysts ( about 1/2″) one on each kidney, I’m told those are stable. Is the kidney stones causing cysts or is that unrelated?
Hi Bridge, The opposite side pain intrigues me but I do not know why. Just be sure the side with pain is for certain stone free. Of greater note, be sure that you are properly evaluated and treated so more stones do not form. Regards, Fred Coe
What causes a kidney stone to move out of the kidney?
Hi Kathy, Nothing you can so; when stones do it, they do it. It is random chance so far as I know. Regards, Fred Coe
Thanks a lot for such an inspiring page. i am 48 and i have been suffering from kidney stone pain for 8 years now. on my first CT laser test i found a 1.5 cm stone to which i applied lithotripsy in 2010. thinking that i had gotten rid of kidney stone pain once and for all, i had not diagnosed until 2014 when i discovered a stone as big as an egg -4 cm. they had to put a hole in my back to reach it, destroy it and extract its particles. since then i have been good until the last 4 months when i noticed a 9 ml stone again (very probably having remained from my last surgery). it is nonobtructing and it aches only whenever i do not drink enough water. hence my question: does drinking enough water have any influence on kidney stone pain? Thanks again!
Hi Malek, Water will not cure or treat kidney stone pain. But preventing stones and crystals will. What are these huge stones made of? Given the rate of new ones I suspect uric acid, but it matters a lot. Whatever they are you need effective prevention right away. Regards, Fred Coe
Malek. thanks Dr. Coe for your eye-opening directions. i really appreciate your noble dedication! I analyzed the composition of my kidneys and the results were a combination of calcium oxalate and calcium phosphates and uric acid. my doctor recommended mainly cutting dow on animal proteins and drinking plenty of water, especially ‘effervescent’-like water. After my last laser test i was sure i’m not a stone former. because the 9mm stone i found had been there since july 2014. the problem with it is that it aches every time i’m late to drink water. By the way, i haven’t drunk tap water since my last surgery. i always drink mineral water so as to minimize the chance of forming more stone as tap water in the place where i live (Meknes, Morocco) contains a lot of limestone/calcaire. i thought that the source of the pain was the hypothesis that with less water, the kidney shrinks or contracts, causing the stone -that must be sharp and edgy- to touch/scratch the interior of the kidney, and cause pain as a result. I wonder Dr. if my hypothesis is right. Thanks again for your concern!
Hi Malek, the combination of calcium oxalate, and calcium phosphate and uric acid in one person usually means extreme low urine volumes. I say this because the uric acid requires an acid urine the calcium phosphate an alkaline urine and urine cannot be both at once. Very low volumes, however, can get this to happen. Animal protein is a problem only for the uric acid stones, water is a very good idea. I do not think your pain is because the kidney shrinks, but it may be crystals form when urine volume falls. You really should be fully evaluated to figure out the cause of the stones. Here is a good plan. Regards, Fred Coe
Thank you very much Dr. Coe!
Hello Doctor,
Suffered from stones, once before I knew it, only three times. Just a question about blood flow. Does the blood flow equally? Or does it flow in series to the kidneys? I understand the flow is regulated by constriction of the vessels in and out, per your article. But does blood flow by first one kidney then another? Meaning is one more prone to stone formation. My left kidney has been assaulted thrice now and right only once. Luckily passed them all naturally. I really appreciate the article. I hate taking pills for pain. Too often it is just the easy way out with no solution offered.
Hi Bryan, Blood flows from the aorta into each kidney separately. Neither is more prone to stones. To avoid more stones, try this approach. Regards, Fred Coe
Friday morning right after work I went to the ER I know my pain levels and can usually guess the size of my stones and be right, this pain is the pain I have felt one other time about a year ago another 9mm but this time in the right kidney, last year I passed the 9mm by myself, the pain was so unbearable I felt like I was having an out of body experience, last time the 9mm took weeks to finally drop I pray this isn’t the case!
Hi Christina, I too hope things work out for you this time. Have you seen to prevention? If not, perhaps you might want to. Regards, Fred Coe
I have had non-obstructive stones for the last 15 years which do not move (except for one 1 mm that exited), and have even been told during an abdominal ultrasound that the kidney was hydronephrotic. A later scan showed no hydronephrosis or resolution. Consequently, after being referred to a urologist for evaluation, she noticed that I had hematuria on a regular basis, and any pathology was ruled out with a cytoscope.
A strange thing has happened. Last week I twisted my body as I rolled over in bed and experienced severe pain with immobility in left upper and lower quadrant. It was diagnosed as a psoas strain. That same week I have my semi-annual US for the non-obstructive kidney stones and get a call back that they are now 8 and 5mm, but in the same spot and no hydronephrosis. Interestingly, I had IBS attack while the US tech was scanning my bladder, as the mild pressure caused pain – actually any pressure normally causes pain, but not that easily.
So now I have constant mid abdominal pain wrapping around to my back with bloating, burping, pinching, pressure, difficulty taking a deep breath, and mild nausea. The urologist on call says it has absolutely nothing to do with the unobstructed stones. I am leaving for a 3 week European vacation in very soon (once in a lifetime trip). What do I do? My plan is to call primary care office or my regular urologist next week if things don’t subside. My family will be extremely angry if they lose out. Previously, the only pain I had was IBS intermittently, pain when pressing lower left rib in flank and pain with wire bras or snug waistbands. I think I should have one more US before I leave to ensure no movement or swelling. Is the on-call urologist correct (this has nothing to do with stones)? Am I wrong? If I fly and the 8mm causes hydronephrosis, how long do I have to get to ER before my kidney goes bad?
Thanks.
Hi Jenny, Because so much of the problem reflects only in the images I am afraid my opinion will be of little value. Your symptoms do not sound like stone passage. If you feel another ultrasound will reassure you, it is worth the time and money for just that purpose. Finally, Europe is first world medically and if needed care readily at hand. Good Luck, Fred Coe
Thanks so much for your quick reply. I appreciate your opinion. One thing is for sure, I am going to do the procedure she suggests so I won’t have to worry about my next vacation!
I apologize in advance if this question has already been asked and answered. I’ve been diagnosed with kidney stones in the past. Two days ago, I went to see my doctor about having flank pain on the right side. A urinalysis showed blood in the urine (+2 moderate), but not visible to the naked eye. An x-ray showed a small stone in my right kidney, but nothing in the ureters. Would/Could a stone that is still in the kidney cause microscopic blood to be in the urine? Or, is blood in the urine only possible when the stone(s) begins to move down the tube? I thank you for any feedback you can provide.
Hi Andrea, The blood and right sided pain go with a stone that is in the kidney and intermittently blocking the junction of the ureter and renal pelvis. ALternatively you may be passing crystals in large enough amounts to cause pain. Be sure you have been properly evaluated. And treated – to prevent more stones. Regards, Fred Coe
Last week I was diagnosed with a 4×2 cm staghorn calculi on the left kidney. I’ve been having left flank pain for 2-3 years. However, the reason for the imaging work-up was newly diagnosed UTI-like symptoms of burning on urination, Suprapubic pain, pelvic floor pain and even penile discomfort. Urine culture x2 negative and 3 courses of various antibiotics only partially relieved some of these symptoms. Currently I still have penile discomfort with intermittent throbbing pain (seconds duration), pelvic discomfort, and occasional left flank moderate pain. There was no bladder stone found on the CT scan. Currently I take Uribel and Azo without much relief. My Urologist thinks that the passage of small stones could have inflamed my urethra and bladder. These symptoms are constant unlike the flank pain that is only intermittent. Question: are these genital and pelvic symptoms attributed to the passage of sand urine or microscopic stones?
Hi Richard, A staghorn could be infected and the organisms can be fastidious. I am sure your urologists have suggested removal of the stone, culture of it, after it is gone, use of antibiotics to clear the urinary system. Right now, without knowledge of whether this is an infection stone – struvite – or even uric acid or calcium, I cannot say much more. Your symptoms could be crystals, if so they should be visible under the microscope. Possibly the stone obstructs the kidney intermittently, and that pain can radiate – though usually into the testicle on that side. From this distance, there is not a lot more I can tell you. Regards, Fred Coe
Thanks for your reply Dr. Coe. Knowing that a large number of staghorn calculi are struvite infected stones, and currently I mostly have urethritis symptoms (I.e. Itching, throbbing pain within penis/urethra) without penile discharge or burning on urination, should I get tested for ureaplasma urealyticum or mycoplasma genitalum PCR in urine? I am scheduled for percutaneous nephrolithotomy in late August. However, I would like to get some relief from these urethritis-like symptoms until then. For instance, specific antibiotics for these bacterias. So far, ciprofloxacin, Bactrim or augmentin were of limited benefit. And Uribel is not effective either. I truly appreciate your response. Richard.
You may indeed be infected and you should ask your physician if this can be done. REgards, Fred Coe
After feeling horrible pain and nausea, I was diagnosed with a 5mm kidney stone that was partially blocking the left proximal ureter on July 5th. I was told drink 3 liters of fluid daily, strain my urine, and take Flomax. I’ve yet to pass the stone but the pain has greatly subsided over the past 4 days. Does the cessation of pain mean that I have passed the stone? I am scheduled for a cystoscopy and uteroscopy in a couple of weeks and would hate to waste the doctor’s time if the stone is no longer there. Thanks for your advice!
Hi Danielle, No, not necessarily. Your physician must be sure that your kidney is not obstructed. If it is not, you can wait for surgery if you do not pass it. Your doctor will not do a procedure without assuring a stone is really there. Regards, Fred Coe
Thank you for your timely reply and advice. I appreciate it!