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 unilateral ureteral obstruction can be marked by three distinct phases.
In phase one, the effects of the inflammatory cascade described above cause a progressive rise in renal blood flow and renal pelvis and ureteral pressure. This phase lasts for approximately one to one and a half hours. This is the portion where the afferent arteriole – the faucet – is maximally opened.
Phase two is marked by efferent arteriolar vasoconstriction which causes a decrease in overall renal blood flow but an increase in ureteral pressure for up to five hours. The faucet is opened and the end clamp is tightened.
Phase three is marked by a further decrease in renal blood flow to the affected kidney and ultimately decreased ureteral pressure. The end clamp is progressively tightened so blood flow to the kidney is reduced enough that filtration and urine production begin to fall, and pressure with it.
Measurements of ureteral pressure (red) and renal blood flow (blue) after onset of acute unilateral ureteral obstruction. (Courtesy Campbell-Walsh Urology, Tenth Edition, Elsevier Inc.)
The fall in blood flow is not injurious during an acute attack, but over time it can be. This means that relief of an obstructing stone is an important matter. Commonly stones pass of themselves. But stone attacks need medical attention because if the stone continues to obstruct it must be removed.
The Symptoms
It is easy to conjecture how these three distinct phases correlate clinically to the symptoms experienced during an acute episode of colic.
The onset of pain classically correlates to phase one and the inciting obstructive event. It is at this point that the patient commonly seeks care in the emergency room or physician’s office.
The pain classically persists at a severe level for several hours (phase two) but ultimately subsides, at least partially (phase three).
In many instances pain comes in waves, potentially a sign of intermittent obstruction activating the above pathway each time urinary flow is obstructed. This occurs through a combination of the stone moving and the tensions of the ureter with increases or decreases of muscle spasm.
THE CONUNDRUM – Pain Without Obstruction
Opinions of Urologists in General
Though the physiologic basis of pain in the setting of obstruction is clear, it does not provide an explanation for one of the most commonly encountered conundrums in stone disease – the symptomatic non-obstructing stone. These can be actual free stones that have not passed, stones attached to plaque, or actual plugs in the kidney tubules that are massed together enough to show up on a CT scan as ‘stones’ though actually tissue calcifications.
There is perhaps as much variation in clinical opinion in such instances as any other clinical scenario in the field.
If one were to ask a group of urologists whether they believed that small nonobstructing stones could cause renal colic, opinions would range from absolute certainty to complete dismissal of the concept altogether.
What Happens to Patients
As a result, there is no standard of care regarding how to optimally manage such patients. In all cases it is first imperative to rule out other potential sources of pain; however, such workups often end with the same result – a patient with bothersome flank pain and evidence of one or more nonobstructing stones on imaging.
Lacking a physiologic explanation to explain their symptoms, patients with pain and non obstructing stones are often sent for detailed workups, secondary and tertiary consultations and referral to pain specialists and even psychiatrists. However, in an age where flexible ureteroscopy can be performed quite safely and on an outpatient basis one must wonder whether such patients are being treated appropriately.
A Specific Example
As an example, I recently met a patient who had been referred from several hours away seeking a fourth opinion regarding her chronic flank pain. For months she had suffered from a severe ache in her left flank that had limited her ability to work and live her normal life.
She had attributed the pain to a 7 mm lower pole nonobstructing renal stone on that side which was discovered on a CT scan during her initial presentation to an outside emergency room (Figure 3). However, none of the physicians she had seen agreed with her self diagnosis.
Figure 3 – CT image of left lower pole nonobstructing stone (red arrow). There is no evidence of obstruction or inflammation around the kidney.
In the ER she was given narcotic pain medication and sent home to follow-up with a urologist.
The first urologist she saw told her that while the stone was visible, its location within the kidney meant that it could not possibly be causing her pain. He refilled her prescription for pain medication and sent her to see a pain specialist.
The pain specialist tried physical therapy for what he thought may be a musculoskeletal source but ultimately this did not prove effective and she was given more pain medication.
She later sought care from a second urologist who also told her that the stone could not possibly be causing her pain in the absence of obstruction. This time however she was accused of having an agenda and seeking care specifically to get pain medication. Similar visits to a variety of emergency rooms elicited more CT scans as well as accusations of seeking pain medications. Each CT result was the same though, all demonstrating a 7 mm non obstructing left lower pole stone.
On one instance a treating practitioner even admonished her, saying that nonobstructing stones don’t cause pain and he should know since he too had been diagnosed with such stones incidentally on a CT scan.
Ultimately she made her way to the clinic for consultation at which point she was offered a ureteroscopy and stone removal. The procedure went well and she was discharged with a stent for one week. She was last seen back 5 weeks after the procedure and reported complete resolution of her pain. She was no longer taking any pain medication whatsoever and there was no evidence of any stone or hydronephrosis on follow-up imaging.
What is Known to Date
Such patients are frequently encountered. Despite a lack of physiologic explanation as to why these non-obstructing stones may cause pain, there is emerging evidence that they do and therefore that removal can cure it.
In 2006 Taub et al. described outcomes of twenty such patients who had chronic flank pain as well as radiographically evident calcifications within their papillae without obvious collecting system stones. Ureteroscopy with laser papillotomy to unroof and remove all evident stone was performed on twenty seven kidneys. Pain improvement was seen in 85% of cases with a durable improvement for greater than one year in nearly 60% of cases.
This study was then repeated on a multi-institutional level with 65 patients undergoing similar procedures over a ten year period. Overall there were 176 procedures performed in this cohort with patients reporting less pain after the procedure 85% of the time. The mean duration of response was 26 months with 60% of patients having sustainable improvements in their pain levels for over one year.
Finally, this clinical scenario is seen commonly enough that it garnered its own nickname at Massachusetts General Hospital where it has been described as “small stone syndrome”. In a retrospective review of patients treated there with ureteroscopic removal of small nonobstructing stones (<4mm) for reasons related to chronic pain, 11/13 patients reported being pain free after the procedure with the other two noting a partial response.
What I think
We still do not completely understand the physiologic explanation for pain in these patients. However, much like Hippocrates over two thousand years ago, clinical observation often precedes scientific understanding. In this regard it is unfair to dismiss the notion that small non obstructing stones can elicit legitimate renal colic.
Physiologic breakthroughs in the understanding of pain signaling and inflammation are currently happening at a rapid rate and it is likely that in time we may be able to better decipher which non-obstructing stones are truly responsible for symptoms. However, until then, such scenarios will continue to be a commonly encountered clinical complexity for urologists.
For the time being I would still advocate consideration of alternative causes of pain in such situations including urinary infection, obstruction and malignancy. A careful history is critical to rule out non-urologic sources such as pathology within the musculoskeletal, pulmonary, gynecologic and gastrointestinal systems. Another important element of the history is whether the patient has previously passed a stone and if the current symptoms are similar to that experience.
Once other explanations have been ruled out, offering stone removal is entirely reasonable. This not only has the potential to improve pain but may also decrease the risk of future stone growth or spontaneous passage at a later date. In such instances, I prefer flexible ureteroscopy with stone removal to shock wave lithotripsy. First, ureteroscopy maximizes the likelihood that all stones can be identified and removed which is especially important in the event that pain persists after the procedure. Second, with ureteroscopy one can inspect the inside of the kidney in high definition which has the potential to offer information not readily available on x-rays and CT scans such as embedded stones, tissue calcifications, and other pathology (Figure 4).
Figure 4 – High definition images obtained during renal endoscopy demonstrating tubular plugging (stones embedded in the kidney) (Courtesy: AE Evan, IMCD and BD plugs: Do they have a role in stone formation).
Finally, it is critical to establish realistic expectations before surgery in regards to pain control. Our understanding of this concept is in evolution and the published literature suggesting a treatment response is limited to relatively few patients. However, as science and history have shown us, just because we don’t fully understand the connection doesn’t mean it doesn’t exist.
More You Might Like
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Types of Kidney Stones
Do We Need to Analyse All Those Stones?
How Kidney Stones Form
When Crystals Plug The Kidneys
Medullary Sponge Kidneys
I have a kidney cyst and no one believes it is the source of my pain. I cannot sleep anymore on the side my kidney cyst is located. I have kidney pain/pressure and pain on my side. I would like to know if there is someone at a teaching hospital that can remove this at little or no cost as I do not have the means to pay for anything. God will someone help??
Hi Betty, A painful cyst is not a rare problem. As for surgery the best bet is a university hospital. I would suggest the one nearest to you. I am sure they will take care of this for you. Regards, Fred Coe
Hi Doc. I came to the ER last Dec 30 after experiencing extreme pain (left plank pain, radiated on my groin, testes and genitals) worst than the usual strangury I’m having previously. That consistent strangury already gave me hints that I have some kidney or urinary system problem (aside from the fact that my previous UA back in college showed traces of calcium oxalate crystals). And that kind of confirmed my self diagnosis when the ER doctor did a sonogram and said I have a ureter stone and left mild hydronephrosis. Had a CBC cleared and UA showed RBC +++. Gave me pain meds and Tamsulosin hcl which helped me pass urine frequently. He mentioned that the latter is actually a med for BPH but is also used for patients with kidney stones. I was given a referral to see a urologist and to have a CT scan. But the earliest schedule they gave me is after a month. This is the bad thing about working in a foreign country (China), I can’t really trust the doctors that I question their proficiency in terms of practice. Since I’m a nurse, it helped me a lot when I did research about it especially the Tamsulosin hcl that significantly improved my urinary output. However I’m not sure whether I already passed a stone because I was not able to strain my urine since then. This time I don’t experience the extreme pain I had except for dysuria. The pain is evident when I’m on the latter part of the stream or should I say near complete voiding. I’ve been experiencing this since my first kidney pain attack. I already saw a urologist earlier (outside the hospital) and gave me a referral for CT scan and schedule is early compared to the one given in the hospital. What I would like to know is what causes the pain (dysuria) I’m having that I have specifically described. To add, I did not have a fever for the last 6 months.
Thank you, your response will be very much appreciated.
Hi Allan, I gather that you had a ureteral stone, never passed a stone, had hydronephrosis, but no CT. So you may have a stone at the UV junction causing urinary symptoms, and it may be obstructing or not. You need the CT. An obstructed kidney can be destroyed. If you cannot get the CT get another US to be sure about obstruction. Regards, Fred Coe
How do you diagnose kidney endometriosis?
Hi Cindy Lou, Endometriosis arises from the uterus. Rarely, the ureters can be involved. The kidneys never. The diagnosis of endometriosis is made by your Gyne and any urinary tract involvement by your urologist or Gyne. Regards, Fred Coe
Thanks.
My cousin was told she may have endo inside her kidney, as she is having intense kidney pain and thought it was a kidney stone but no stone is there. She will be doing further tests to confirm.
Hi Cindy, I presume your cousin is having endoscopy of her kidney. That seems a reasonable idea given pain. Regards, Fred Coe
Hi – your website is quite informative. I have a question. Does kidney stone pain get worse before a womans menstrual cycle? I have received various opinions, some say no, but some say yes. I have a pesky stone now and it seems to intensify before period. Not sure why…..
Hi Mary, It could because of changes in pelvic blood flow. But kidney stone pain per se is usually from stone passage whereas you are referring, I think, to chronic pain not related to stone passage. If there is an actual stone causing pain because it is partly blocking the kidney, for example, that certainly might cause pain that varied with the menstrual cycle. But it also should be removed. Regards, Fred Coe
Hi, Mary, I am curious to know how long you have been experiencing the pain and if you plan to have the stone removed. I am scheduled for a CT scan on Thursday the 25th, and have been experiencing chronic flank pain for several years, never tested positive for a UTI, but my GYN thinks I passed a stone on the 10th based on my symptoms, unfortunately, I am still in pain. Previously, during other episodes of flank pain, the pain generally felt worse as my cycle approached, so I have experienced what you have stated. I have endometriosis.
Hi Doctor.
I have a question.
I have had stones in the past, some have passed and some I needed surgery for. My GFR goes up and down like a yo-yo and I am given no explanation for it. Can stones cause permanent damage to kidneys?
Hi Tony, stone passage can affect GFR, so it goes down then up. Stone obstruction and procedures can damage kidneys and cause permanent loss of function in some instances. Regards, Fred Coe
My experience with a stent being put in was terrible pain. It hurt for a year later. I preferred the lithotripsy. Actually, I would prefer a cure.
Hi Michael, Prevention of stones is rather well defined right now and works reasonably well. Take a look here. Regards, Fred Coe
I had two stones couple years ago. Passed both from right kidney.
I feel as if I keep making stones. Perhaps not big but I get the same sharp pain right kidney then moves to my lower right front abdomen and seems to get stuck there for month or more. I had ultra sound today came back nothing but not surprised never showed my other two. My first stone never showed on CT. Was given contrast. On second stone CT showed 4mm stone she said they should have not used contrast looking for stone. No blood in urine couple days ago. Can you have a stone with no blood in urine? I’m sure CT is going to be next. Most of my pain is front right side. I do get sharp kidney pains initially but pain stays mostly right front.
Hi Elissa, One can have crystal attacks or very small stones with pain and missed blood. You need evaluation as to cause and prevention to stop this. Take a look here as perhaps a good start. Regards, Fred Coe
Hi Doc,
I had really bad flank pain Jan 24th. I passed stones on the 27th. I ended up in the ER with flank pain and a sharp stabbing pain in my left abdomen. They did a CT and X-ray and advised me I had a “floating stone” that would not be the cause of my pain. After waiting a week and still bad pain I went to another ER they did an US and advised me I have no stones. Blood work showed perfect function of kidneys and no stones. Well I passed another stone and my left side stabbing pain went away. Now I am still continually having flank pain. Dr said it’s just from passing the stone. So my question is should I still be having the flank pain like this? It literally feels like someone is squeezing the life out of my kidney.
Hi Dusty, CT is very good at identifying stones, US is only fair. So you could have another. If the pain continues I am sure your physician will get a CT. You do not mention 24 hour urine testing, nor prevention efforts, but should get to that soon so as to prevent more stones. Regards, Fred Coe
I have a question. Can you see stones better on MRI or CT Scan or X-ray?
I have had far too many CT scans and am concerned about all the radiation… how do I monitor regularly if stones are there or gone without excess radiation?
Hi Eric, MRI does not show stones; ultrasound does. It is not as exacting but will do for routine followup. Regards, Fred Coe
Hello Dr.,
I have been looking up the the internet for days and failed to find answers for the following questions:
1- I read somewhere that the severe pain starts when the stone starts to move. How long will it take for the stone to pass after the first severe pain happens?
2- should the patient go to bathroom and try to urinate when the pain occurs?
3- is there any posture that reduces the pain while urinating?
Hi Alex, The pain can last for hours or days and not rarely comes and goes. Stone passage depends on stone size and your anatomy. It can take up to weeks but if the kidney is obstructed physicians need to intervene and remove it. Of highest importance, you need a urologist to supervise this kind of event to avoid any risk of kidney damage from obstruction. Urinating does nothing per se to alter stone passage. Posture notably likewise has no effect. The key is after it passes take action to prevent more. Here is a good place to start. Regards, Fred Coe
I have a question. I am suppose to have a stone in the upper area of both kidneys. My question is would these cause pain? I have had pain in my back since November. I found out they were there when they did a CT scan. A PA in a urologists office told me they would not hurt. I’m wondering if they do because I still have back pain. It moves all over my back. Sometimes it’s flank pain, sometimes it is really low and sometimes in the middle of my back. Would this be from my kidneys? I would be so grateful for some insite on this. Thank you so much!!
Hi Christi, immobile stones do seem to cause pain as judged by massive amounts of similar complaints to yours. The question is always the balance between the pain and the surgery. If the pain disturbs you enough to warrant surgery the stones can be removed, preferably by ureteroscopy so as to insure stone free kidneys. Regards, Fred Coe
So glad you posted this. I have been suffering with a 2mm kidney stone in my left kidney since Aug 2017. It has not moved, really. It causes me daily, chronic pain. I avoid taking medicines of any kind until I can’t avoid it no more. Just today, I was released from the ER because the Dr said that this same small stone is not causing me pain, even though the pain was so severe it almost caused me to pass out several times, kept my heart beat between 130-160bpm and my blood pressure 183/116. I had extreme sharp, stabbing pain that would start in my back on the left side, travel down to the front of my groin and up to the upper left side of my abdomen.
Now, I was admitted on Jan 26 2018 for pyelonephritis. Now, today it is March 1, 2018 and I am back in the ER due to this stone in my left kidney…that I have been dealing with since Aug 2017. Yes, it is the same stone because since Aug 2017, I have been to the ER 6 times, admitted 3 times and the CT scan shows the same stone in the same place!
My GP Dr in Houston TX said that she believes I have become tachycardia because I am in daily pain on my left side and my heart is pumping adrenaline to try to compensate for the pain. My now resting heart beat is 110 bpm. If I get up to walk to the bathroom, about 30 feet roundtrip, my heart beat will be around 120-135 bpm!
I am here to confirm that a kidney stone, no matter the size, DOES IN FACT CAUSE PAIN JUST BEING IN THE KIDNEY.
Thank you for this article and research.
I am still in need of getting this stone removed so I can be relieved of this daily, chronic pain.
Hi Debi, given the extreme pain and numbers of ER visits I imagine your surgeon will want to remove the stone. Given the pyelonephritis, perhaps the stone is infected. I would hope the stone removal might be via ureteroscopy as that would provide a look into the kidney. Of course the surgeon is in charge of how and when things are done, and I a distant voice. Regards, Fred Coe
A POSITIVE STORY ON URETEROSCOPY!!!! I am a 56 year old male and I had mild intermittent pain on left flank for 8 months. Finally went to a Urologist and scan showed a 10mm stone in lower pole of left kidney. He told me that usually if it was in the kidney it would not cause pain and it could be Musculoskeletal problem. But he did advise me to have a Ureteroscopy to rid the stone. After reading all the horror stories I almost canceled the procedure. I am VERY GLAD I went through with it. The doctor told me what to expect through the whole thing. At 11:00 AM the procedure was under general anesthesia and was painless. I woke up with a string hanging out of my penis. Before I left the doctors office I urinated with blood and it burned pretty bad. But they said that is normal, so it didn’t bother me that much knowing that was normal.
The rest of the day I drank water and urinated evey 15 minutes to flush it out. It burned every time and the stent caused
a cramping pain in my kidney and bladder for 10 minutes after going. It was not easy knowing that evey time I urinated it would burn bad but knowing that was normal made it easier to push through and continue on. I only took 2 Advil every 6 hours and by midnight I felt good and my urine had very little blood. The cramping continued for several days but it would only last for 5 minutes after urinating. I felt so good the next morning that I shoveled snow which later caused blood in urine. I learned that I better take it easy. But by Day 3, I had no blood and got used to the string and never really noticed the stent.
The doctor told me the stent needed to remain in for a week. By day 5, 6 and 7 I was feeling great and went to work.
I felt so good I didn’t want to think about pulling the stent out. Everything I read said that pulling it out was very painfull
and caused more bleeding. Well the morning of day 7 I laid in a hot bath an hour after taking 3 advil and was prepared for a painful experience. I decided to not hesitate and just do it. Well there was absolutely no pain at all and no blood at all!
I worried for no reason. So all in all I’m glad that I read the horror stories to be prepared, but found out it wasn’t that bad.
It’s been 10 days now since and the pain I had for 8 months seems to be gone.
Dear Team,
I have 6MM stone in my UV junction & i have undegone RIGHT URS on 17/01/2018 & DJ stenting on 05/02/2018. Almost 1 month passed, i have still some intermediate mild pain in my exterme Right side of abdomen(paining exactly in the same area where i have while stone exsists..). Does it is nomal?
Hi Sachin, The issue is whether the stone is gone. Only your surgeon is close enough to the details to be of any real help. He/she needs to be sure, usually by xray or even a brief second look with a scope. Regards, Fred Coe
Can a kidney cyst cause numbness and tingling in hands? I have a cyst in the left kidney and my left hand goes numb and seems to be getting worse. I have no diabetes either. This is quite odd and strange but since I have been IGNORED for so long I wonder if its now affecting my nerves.
Hi Terry, a renal cyst will not cause left hand tingling and numbness. Common causes are carpel tunnel syndrome – firsts two fingers, and ulnar nerve damage – little finger and outer side of ring finger. Regards, Fred Coe
I have a 5x6mm stone in the lower ureter, close to bladder. This caused sharp pain in my right lower back. According to abdomen USG, my kidney is swollen.
1. Is the pain caused by the stone moving down the ureter or by back pressure to the kidney created by the liquid on the way down to the bladder that is obstructed?
2. Many people try lemons or apel cider vinegar therapy and some other and they succeeded. What is the limit that I can still continue trying the herbal therapy route without damaging the kidney sooner?
Thank you very much.
Hi Irfan, the pain is no doubt – swollen kidney – caused by obstruction. As for remedies, that is a very inefficient way to proceed. Here is my best article on the topic. Regards, Fred Coe
I wish there was a clinic or center that specialized in helping patients with stones when other doctors refuse to help. It is beyond disgusting that all these people are suffering and doctors refuse to take out stones especially given some of the scary facts they are linked to heart attacks too!!
Hi Kirsten, There are centers, and as well many urologists are very effective in stone removal. I see the main issues in stone prevention. It is not routine for many physicians – thence this site, to try to help, and Jill Harris’s course, as well. Regards, Fred Coe
Hi Kirsten, There are centers, and as well many urologists are very effective in stone removal. I see the main issues in stone prevention. It is not routine for many physicians – thence this site, to try to help, and Jill Harris’s course, as well. Regards, Fred Coe
I have a very different problem. I have all the classic symptoms of passing a kidney stone, but no kidney stone can be found. I’m a somewhat slightly overweight 66 year old woman and every month for the last 8 months Ive been turning up at Emergency Dept with a pain in mid lower right back, as though Ive been kicked by a horse. Scale about 8-9 out of 10. very sudden onset, and can be accompanied by violent vomiting. Usual treatment by hospital, paracetemol, anti nausea, muscle relaxant, and morphine and saline drip. Visits can be up to 7 hours, sometimes admitted, CT scan taken while in pain, NO STONE FOUND. Feel fine the next day expect for sore stomach with vomiting.
All this started some 2 years ago when I sank to my knees with pain and various treatments tried ending up with admission. Cyst found on RHS Adrenal gland and another on LHS Kidney. Have had multiple xrays, ultrasounds, CT scans, MRI and contrast dye, all during this period.
I have also had full hormone tests and fasting urine tests galore, nothing has produced anything but ‘normal’ results
The Cyst on my LHS kidney has been classified as a Bosniak 3 type cyst, with a very thick wall, but no apparent activity and is approx. 36 mm long, partially in and out of the kidney. I have chosen to have the cyst removed, rather than a whole kidney.
However, I have been told that this may have nothing to do at all with my monthly ‘Phantom” kidney stones and my doctor has nothing further to suggest apart from maybe seeing and paying for a private specialist.
I have also been told I have calcium oxalate stones in my urine and in my gall bladder but NONE IN MY KIDNEY.
I am at my wits end…and also in New Zealand…and ANYTHING that you could suggest I ( and my doctor) can try, my surgery is not scheduled until June at this stage.
Hi Sue, I gather your physicians mean you have calcium oxalate crystals in your urine and gall stones – not calcium oxalate. Your attacks could be from crystals themselves – usually blood appears in the urine along with the pain. Surgery is always possible but the cyst should not cause intermittent pain without infection, and repeatedly. If it is crystal attacks, try maintaining very high urine flow for a while – months – and see if that ends the attacks. I mean over 3 liters of fluids a day and evenly throughout the day, no periods of dehydration. Maybe, given the problem, even more than that. It might work. Regards, Fred Coe
Hi Fredric, thanks for that answer. They have found a small amount of blood in my urine, but only twice out of 8 times they have tested, and they have not found crystals every time either, only once, and in a urine test 2 years ago.
I have been told my cyst has a 50% chance of being cancerous, and would rather it was removed.
3 litres a day seems an awful lot, but I can try…cannot see me getting much sleep though. Any changes to diet recommended as well?
Hi Sue, I think that fluids are a safe and reasonable bet. If your cyst is viewed with suspicion perhaps your physicians might want to arrange for its removal. Usually that is done by specialists in the cyst surgery field. Regards, Fred Coe
Hi Sue,
I have just a question, maybe I didn’t read it correctly. But have they mentioned not all Stones do not show up on X Ray’s, CT’s, And/Or MRI’s? I have three of the multiple types of stones. The acid stones do not show up . I found out the very hard way. I was at the end of my rope when I had changed Urologist because he said “I couldn’t be hurting like I said because the stone or stone’s I had were not obstructing” (issue) anyway I went to one I didn’t work with as I was a RN in the Operating Room. And Told the Urologist the get a Cysto / Retrograde done and get the stone out. It was killing me. He schedule, I think to satisfy me more than anything else. Thinking I didn’t have one as they are rare but I had a 6 mm stone in the lower left ureter oblong embled in the wall that did not show up on any of the test except urine for Red Blood Cells. I had all same symptoms of like you of my other stone’s. Colic, severe pain, sudden onset ie…Whole nine yards. He apologized for weeks. But let’s just say he has listen every since. And tested every stone I have had. I have bad genetics plus where I live ( in the Carolina’s) Stone Belt as they call it. But I do know persistent and finding the right Urologist is Key ! Stay away from ER’s if at all possible. I know if it is after hours you have no choice but they are just there to get you through until the next day. NO HELP. Good Luck in June.
I am having one done tomorrow. 7 mm in my pelvis of my kidney on it’s way down. Hit me like a ton of bricks. And I drinks more water than I can hold. I stay away from boiled tea and other things they say that could cause certain one’s. I guess it may have helped a little. This is my first in about 2 years. After 32 plus stones. Awful . Just know you are your own Health care advocate. And if you don’t take charge, the Doctor’s sure won’t. Bless !!
Hi Kelly, Thanks for posting such a useful answer to Sue. On CT calcium and uric acid stones both show up well; it is KUB xrays that do not show uric acid. MRI does not show stones at all reliably apart from special imaging not usually available. As for you, given 3 kinds of stones, I hope you are pursuing prevention for yourself. Here is my favorite article for the calcium stones, and this for the uric acid. Regards, Fred Coe
I’ve had pain in my lower left back and sometimes groin area since I was 16. I am now 24 and I have a kidney cyst and a stone located near the cyst that hasn’t moved in years. I also urinate frequently. Last time I went to the doctors they found traces of blood and said that it is nothing to be concerned about. They are also convinced that the pain isn’t coming from the kidney stones. I have gotten zero answers in 8 years. Any suggestions or similar experiences? I really just want to get rid of this stone and see how I feel from there
Hi AJ, You are a stone former – stone in your kidney, and your attacks could be from crystals – blood and pain on and off. Crystals can also irritate the urinary system and cause frequency. I would advise a proper evaluation for kidney stone causes and a prevention program. That is the most practical approach for you, and most likely to succeed. Regards, Fred Coe
I have a small stones in both kidney. Dr advice me for drinks a lot of water and some stone crusher medic. Sudden pain in my left kidney and it is unbearable. I don’t know whether a stone is out or not.
Hi Langs z wang, the sudden pain may well be a stones. Be sure your physician evaluates this pain and provides a treatment. Regards, Fred Coe
I have been having 1.5 +/- cm stones removed every 2 years since 2005. I get a colic pain when I walk, if I lay down, it goes away. I usually fight this for about 6 months. I take 2 Aleves if I have keep going and I can push through it. I have gone to 5 different urologist over the years. Each one blast it with laser and removes the pieces. I get a stent which is removed roughly 2 weeks later. I have severe spasms after every stent removal. I feel great for about a year, then the horrble cycle starts over again. My quality of life has been terribly impacted by this. No Dr.s have been anke to figure out the cause. Also, only in the right kidney. I am really bad again right now and I’m just depressed to have to live this way. Last Dr thinks maybe my ureter is too narrow. Whwre does one go to get answers, I’m at my wits end. Im trying Chanca Piedra right now, who knows?
Hi Linda, You need prevention and have none. Here is my best as a starting place. Follow it into the other articles and get a plan for yourself so stones stop. Regards, Fred Coe
I have a 5mm stone as we speak. Very very painful. Have asked Urologist to remove it. Just keeps brushing me under the carpet. Tells me if pain continues go to ER. Go to ER they tell me to go to Urologist. Just remove the d*** thing please…
Lori F
Hi LOri F, I gather the stone is not obstructing anything so pain seems unlikely to your – as to most physicians. Many have your exact complaint. If you have considerable pain and believe the stone causes it, I am sure your physicians will remove it; but it is possible the pain may not go away. We need a trial, here. Ultimately it is your choice, in principle, although you will be asking a surgeon to do what she/he does not want to do. Regards, Fred Coe
I have been reading all the posts here and must say, I am really DISGUSTED at the fact that so many people are suffering and their pain is being dismissed. I wonder just how fast the issue would be resolved if these doctors who dismissed them were doubled over in pain and had the same pain. I am very disappointed with the level of care people receive. Beyond disgusting. Sorry but it must be said.
Hi Sally B, I am not so much disgusted as frustrated and unhappy for everyone who has so much pain and misery. Prevention is my only present way to help, and it is a powerful help albeit a long term and not so easy road. Not all doctors are heartless, nor dismissive, but I regret those who are and wish for better. We need more trials concerning chronic pain in stone formers – It is not my scientific home to do such trials, so all I can do is – as I do – bring the matter to public attention. Thanks for your compassion. Regards, Fred
OMG I’M LITERALLY IN TEARS RIGHT NOW! I AM CURRENTLY GOING THROUGH THIS RIGHT NOW! I HAVE BEEN DEALING WITH THESE STONES SINCE A INCIDENT THAT SENT ME TO THE ER IN 2014…HAD MY GALLBLADDER REMOVED DUE TO STONES IN IT..NOW I HAVE 13 STONES IN MY RIGHT KIDNEY AND 10 STONES IN MY LEFT. AND I HAVE BEEN COMPLAINING TO MY DR..TELLING HIM I WAS STILL HAVING PAIN AFTER THE LITHO SURGERY I HAD LAST MONTH…IM PEEING EVERY HALF AN HOUR..SEVERE PAIN ON MY RIGHT SIDE BY MY RIBS..PRESSURE AND PAIN IN MY LOWER ABS AND PRESSURE IN MY BACKSIDE ALMOST AS IF I WAS PREGNANT AND IN LABOR HAVING TO PUSH! LIKE THE LADY MENTIONED IN THE ARTICLE I WAS EXPERIENCING THE SAMETHING..CANT WORK..CANT REALLY ENJOY ME LIFE!! IT IS SO FRUSTRATING AND MAKES YOU CRY AND WANT TO GIVE UP!! THESE DR THINK JUST BECAUSE IT’S NOT LOWER THAT IT DOES NOT CAUSE PAIN AND I’M A LIVING BREATHING PROOF IT DOES! I EVEN WENT TO MY OBYN TO RULE OUT ANYTHING ELES THAT CAN BE CAUSING THIS PAIN. I’M SO HAPPY I CAME ACROSS THIS ARTICLE IN MY SEARCH ! THANK YOU SO MUCH AND I WILL BE DEFINITELY BE SHOWING MY DR THIS ARTICLE.
Hi Tori, you have a lot of stones in your kidneys and possibly there may be fragments in the ureters. Your urologist can no doubt exclude this. We have no trials as yet concerning benefits of removing small non obstructing stones such as I presume you have; some surgeons offer to remove them but that is a complex decision and much debated. If your pain cannot be explained, and your physicians feel there is benefit, removal of the stones is possibly an alternative, but from this far away I am afraid I cannot venture an opinion. Regards, Fred Coe
I have been having pain for two years since my last CT scan, when I was told that I had a 5mm non obstructive stone. I felt pain and I’m still in pain. Drs. are telling me that this can’t be the cause of my pain, but I KNOW it is. I don’t ever remember having ANY pain in this area until I had kidney stones. I’m experiencing pain, terrible pain. I can’t sleep on my right side. I now feel confident to tell my doctor that I want this removed because I’m tired of suffering.
Hi LaChan, Small stone pain is a very common issue. If you have such pain as you describe and your physician is willing to remove the stone I hope it will improve matters for you. We lack trials, so right now there is little evidence to guide us. Regards, Fred Coe
With kidney infections, does a fever always have to accompany it? I had intense pain, pelvic and back also sides and some chills this morning and burning a bit when peeing… but no fever. I lost my appetite suddenly too..
Hi Cara, Fever can be absent even with blood stream infection. Be sure your physician checks for infection and treats you if you have it. Regards, Fred Coe
I have struggled for years with this issue. In 2011 doctor in the emergency room found what looks like a grape cluster of stones in my left kidney while I was passing a 4 millimeter stone that had dropped. After passing the stone I continue to suffer from pain on and off for 2 years and was continuously labeled as soliciting narcotics by emergency room doctors and also my urologist. It is extremely frustrating and has driven Me 2 periods of suicidal ideations during pain related with stones. There’s nothing more frustrating me and decorating as being called a liar while you are writhing in pain.
Hi Kevin, I gather you have many left sided stones, and pain on that side. One possibility is to have your physicians remove those stones in hopes of reducing pain. Couple this with active stone prevention so they will not grow back. Regards, Fred Coe
I have been to one e.r 14 times in last 3 weeks. With left flank pain, pubic pain, nausea, vomiting etc. Confirmed 2 weeks ago I have 2 LG stones ( 10mm 12mm) as well as smaller ones (6mm 8mm) as well as smaller ones. I go in excruciating pain , they give me pain meds, and tell me that non moving stones don’t cause pain. Go home and rest. I have been rushed to e.r via paramedics even cause I blacked out due to pain. The stones are entirely to large to pass so why not blast them and give me relief.
Hi Jessica, Given stones too large to pass and such pain, one usually removes the stones. If your present urologist is not comfortable with such removal, perhaps he/she might want to obtain a second opinion for you. In general large stones + pain mean removal. Regards, Fred Coe
Dr Coe,
1, Can any of these procedures be performed after a stone has migrated intothe bladder? 2, Have you knowledge or evidence of effectiveness of potassium citrate in crushing or diminishing the size of stones? – Many thanks.
Hi Mark, Of course one can always remove stones from the bladder using scopes. Potassium citrate has been tried after surgery – here are the trials. It seems beneficial. Of course stone prevention may involve much more. Thence this whole site. Regards, Fred Coe
What causes kidney stones to form ??
Hi Jeannie, What a wonderful question. Here is my favorite answer – long, though. This chapter links to other articles and even a video. Regards, Fred Coe
Hi Dr. Coe,
Thank you so much for all of your helpful information. I’ve passed 2 stones so far and have been dealing with on and off pain associated with other stones for over 2 years now, as well as recurrent UTIs. My question for you is, do you know why my feet and legs cramp/tingle when I’m passing stones? It’s almost like a precursor, so I can tell when my body is disrupted. But the tingling sensations continue throughout the entire passing of the stone. I recently had blood work and my kidney function is fine, so I’m wondering if this is associated more with nerve pain?
Thank you!
Marissa
Hi Marissa, the most likely reason is unconscious hyperventilating that raises your blood pH and lowers ionized calcium. It is harmless and avoidable. Be sure about prevention. Regards, Fred Coe
I knew it.
I have passed approximately twenty kidney stones since the age of fourteen, and I’m currently twenty-two. I have nephrolithiasis, and at any given time there are 1-4 kidney stones in one or both kidneys. I have had to visit the hospital once every four months for the past eight years, and there’s about a 50% chance that a stone will be passing. When one isn’t passing, I am dismissed as a drug-seeker, with some doctors outright laughing at me while I scream in pain. I stopped going to the hospital because I had gotten tired of the way they treat me. Thank you for confirming what I already supposed was true. It won’t stop the pain, but at least I know I’m right.
Hi Eric, Sorry about your unfortunate treatment. Do pursue prevention – it works. Here is a good introduction. Regards, Fred Coe
Just got back from er with my 15 yo son. They found 2 stones. He’s a soccer player. My question is whether his excessive intake of seltzer could be the cause. (Yes, we keep a constant supply of it at home and he tends to drink at least a few cans everyday).
Hi Mike, Perhaps, but I doubt that is the full reason. Have him evaluated properly; idiopathic hypercalciuria is genetic and present at birth and a main cause of stones. Here is a good place to start. Regards, Fred Coe
Hi Doctor,
I has 2mm renal calculus in my right kidney.I am feeling pain at right side back below ribs. Can you please explain to me how to eradicate that. I causes any big problem to me
Hi Lokesh, stones can cause pain, and if pain is significant the only treatment is surgical removal of the stone. But so small a stone may not be the cause of pain, so your physicians need to make the proper decision for you. Also, you should take steps to prevent more stones. Regards, Fred Coe
Why would kidneys hurt after exercise? I am in horrendous pain after exercise. I’ve had stones in the past but am afraid I have more again.
I also want to say (from the other posts I’ve read) I feel its really terrible to keep people in pain like this when the procedures to remove stones are fairly easy and safe to perform. Why would anyone not not want to rid patients of their constant pain???
Hi Hally, Your pain may be from kidney stones or not – given your past stones it would be good to look and see. But whether surgery or not remains vexed. No trials, so surgery might or might not be helpful in the absence of obstruction. That is the problem. I think surgeons would gladly remove stones when pain is present if they were more sure it would help. Regards, Fred Coe
Was wondering if moving around more will help to pass kidney stones and ease the pain or is it ideal to lay around? Which will ease the pain when taking no narcotics
Hi Ashley, Moving around is probably better than just lying down, but no data. What you want is prevention so new stones will not form. Be sure and get it. Then you won’t have pain anymore. Regards, Fred Coe
Hi Doctor,
Last July 5, I was rushed to ER due to severe pain in my abdomen that radiates to my back.
In ultrasound and CT scan, it was found that I have 5mm ureter stone. The doctor gave me meds and one of those is Rowatinex. Does Rowatinex helps dissolve the stone or alleviate the pain? Last week I had severe pain again that lasted for hours and I have a feeling that I have to go to the toilet but the stone did not pass. After that, I did not experience the pain for one week already. I went back to the doctor for follow up with an x-ray result. Based on the x-ray, the doctor said the stone is still there. But I don’t have pain anymore. He said I have to continue with the meds and if after one week if the stone will not pass he has to do a procedure. Please help.
Thanks,
Lemuel
Why does it hurt in my kidney after exercise? Do stones or cysts cause this? I am sick and tired of kidney pain and not being taken seriously. You “DOCS” need to get your $hit together!!
Hi Helen, stones and cysts can both cause pain, and exercise could aggravate that pain. Kidney pain has some special features: it is not much affected by position, by bending or turning, whereas muscle and spine pain are, so you might evaluate this on your own. I gather you indeed have stones, and perhaps a cyst, and so the distinction between kidneys as a source of pain matters a lot. Obviously, from this distance I cannot much help with the details, but perhaps your physicians might do so. I am sorry if you are not receiving attentive care; but not all physicians are uncaring so perhaps you need to consider new ones who might be better able to help you. Regards, Fred Coe
Hi Lemuel, Rowatinex is a combination of oils and I know of no evidence to support its use in dissolving stones. It might affect muscle tone in the urinary system and promote stone passage – there is an old trial from 1992 suggesting it does this. In your case it failed and your physician is right to follow up and take care of it with a procedure. Loss of pain makes no difference if the stones is obstructing the kidney. Regards, Fred Coe
Please provide names or clinic or those willing to remove cysts and stones at a reduced cost or can work pro-bono. My wife is in AGONY every day and I cant handle dealing with these incompetant doctors anymore. You have a website FILLED with tons of comments of people in horrendous pain who arent getting help. We are talking about a human life here! So please do more and provide all of us with names of people who can help. I dont want it emailed to me.. I want it written here so others can see it and get help. Enough is enough!!!
Hi Toby, I wish I could do what you ask but the US is a big place and I do not know the answer. However in general, the county hospital nearest you – if there is one – can help at a low cost. As well, medical school hospitals have obligations to help those without insurance as part of their payback for tax dollars that support their educational and research missions. Finally, the terrible problem you describe reflects on our need to provide health care affordably to everyone, something not as yet attainable. I apologize for my lack of a full answer. Fred Coe
I went to the ER with moderated pain a week ago where it was found through a CT scan that I have non obstructive kidney stones. I followed up with my primary care physician and local urologist who said that shouldn’t cause pain. What do I do now when doctors don’t take what you’ve told them seriously? I’m still in pain but don’t know who could help.
Hi Mary, Many people complain of pain from stones that clearly do not obstruct. Most of us are sure these stones cause pain. Surgery is then a complex decision. If the pain is disturbing enough one can remove the stones, but there is no guarantee this will cure the pain. So it is a matter of judgment – how bad is the pain in terms of the real bother and modest risk of a procedure. That is something I cannot tell from this far away. Regards, Fred Coe
My daughter had imaging done and it showed that she has a kidney cyst. She said she is having intense pain in her kidney but the doctor said kidney cysts usually dont cause pain. She also has Endometriosis. I am very concerned and wonder, how can they tell whether it is a cyst or could it be Endometriosis?
Hi Katherine, This question is a bit out of range for the site. Special radiologists and surgeons evaluate cysts and endometriosis in relation to kidney pain, and I cannot help except to say one expects sufficient expertise from those physicians for a definite answer. Regards, Fred Coe
Wow! Thank God I found this website!
I feel like I’m about to die from the horrendous kidney pain! I was told it is “back pain”……look patients aren’t idiots. I know the difference between back pain and an actual ORGAN inside me hurting! I am on strong opioids daily and really can’t function much anymore with all this pain. I live in New York and I want to find a good urologist who will take this pain seriously and do what they have to in order to rid me of this constant pain. I have a daughter who is being looked after by her grandmother because I can’t keep up with taking care of her due to this chronic kidney pain. I am beyond saddened by this and quite frankly utterly disgusted by the way I have been treated.
Hi Cassie, Dr David Goldfarb in NY is an excellent physician with high skills in kidney stone management. Please feel free to use my name as a reference. Regards, Fred Coe
Thank you very much for the quick reply and providing me with this info!! Lord, please let there be light soon!
Great website!
I have a question. What does mild prominance of the collecting system of the upper pole kidney mean?
Related to stones?
Hi Sandra, Thanks. It means nothing in itself. If you had a pain attack it could mean prior stone passage, but that sounds unlikely as you would have said so. Regards, Fred Coe
I have been reading some of the other posts and it seems like they are describing me! I finally feel like I am not losing my marbles as I clearly am not the only one dealing with all this pain! I One urologist told me that stones inside the kidney dont cause pain so isnt helping me. I recently lost my job because I cannot function with this constant pain. So now I jobless, have limited funds and stuck with chronic and severe kidney pain. I just dont know what to do.
Hi Henry, Stone pain ruins life for a lot of people. Small stones in kidneys do cause pain, and if you cannot work discuss with your surgeons the idea of removing them via ureteroscopy. If s/he feels this is not ideal, ask for another opinion. Ultimately, your physicians determine your care, and there may be reasons why stone removal will be ineffective. Pain can also come from crystal attacks, so 24 hour testing is essential, and if you have high stone risk reversing it may prevent pain. Regards, Fred Coe
In June I had a dull ache in the side that progressed into severe flank pain. After several hours it subsided and I wrote it off as something intestinal, maybe constipation. A few weeks later it happened again, but the pain lasted all day and I went to see my doctor. She examined me and we talked about it being either a kidney infection or kidney stone. She gave me a prescription for Naproxen and scheduled an ultrasound. After the ultrasound the doctors office called me back and said they had great news. The ultrasound was clear to which I asked “so what caused the pain?” So they scheduled a CT scan and arranged an appointment with a urologist. The CT scan showed a 6 mm stone, constipation, and lower back arthritis. The urologist checked my urine and said that my urine was free of blood and “did you know that you have arthritis in your lower back”. He thought I could wait 3 months and come back and check to see if anything has changed. He also said that I could have had this stone for 15 years and another 15 years without problem. Needless to say the problem did not go away. Another atttack and this time I said take it out. He was still hesitant, reminded me of my arthritis, but ultimately agreed. The next day I had a huge attack but because of the impending procedure requiring no blood thinners and it being the start of the weekend I suffered until Monday taking only Tylenol. I was sure however, that because the pain had started high in my flank and seemed to progress downward my groin that the stone had moved to my bladder. On Monday I saw the urologist and told him what had happpened. I expected that the X-ray would show that the stone had moved, but it had not. Once again the urologist was looking at me as if something does not make sense – pinched nerve issue maybe he thought. Because the stone had not moved and my urine was free of blood and I experience nausea and severe flank pain, he ruled out the pinched nerve, but decided that I should see someone about my gallbladder as it is the only other thing that can cause pain on that side of the flank. He wanted to postpone the lithotripsy procedure until another ultrasound and CT scan could be made on the gallbladder. After meeting with the surgeon about my gallbladder, the surgeon and I agreed that removing the stone should happen first and then if I am still in pain have further testing performed. I am a researcher and looking up things is fun for me. The urologist confused me by thinking that a gall issue was causing me pain and had me casting doubt on what I thought I knew, but this article was just the thing to set my mind at ease. Had I seen this article sooner, I may have asked for a recommended urologist in my area.
I have recently been diagnosed with hyperparathyroidism. My blood Ca levels have ranged from 10-11 for the past 8 years at least (as far back as I can document.) I have a consult with a surgeon next week. I have been experiencing a dull burning back pain for many years. It comes and goes, occurs almost daily and is sometimes so intense that I can barely function. It is either bilateral or unilateral and just below my rib cage along my spine. I have always considered it to be Musculoskeletal. I have been treated with chiropractic care and physical therapy to no avail. Pain medication is the only thing that makes it go away. I do not like taking it and am very careful as sixty tablets usually last me 6-9 months. Since this hyperparathyroid diagnosis and the occurrence of kidney stones with it, I am fairly certain this is renal colic. I would liken it to the discomfort in the back when one is dehydrated. I have never experienced acute pain or ever “passed a stone” and hope not to! Once the parathyroid is addressed I will request further diagnostic testing of my kidneys if my discomfort is not resolved. I have been searching for information that refers to chronic aching pain rather than sharp acute pain in the kidney area. Thanks for this article!! I may have to come see you!
Hi Cristi, I would think your physicians might want to obtain a kidney CT in advance of surgery as stones are not at all unlikely and one might want to know about them prior to a planned surgery. Good luck, and expect a cure of the parathyroid disease. Regards, Fred Coe
I have been scheduled for parathyroidectomy in September and I have my first appointment with an Endocrinologist this week. I will discuss your suggestion with her. Thanks Dr Coe!
Just as a follow-up… My parathyroidectomy went well. There has been NO burning achy back pain since surgery!
Dear Cristi, I am happy to hear this. Be sure your 24 hour urine chemistry is normal, as urine calcium can remain high despite cure of the PHPT. Regards, Fred Coe
Hello – (Appreciate your attentive answers and calm demeanor even with sometimes more pressing or angry posts.) I had a “one-time” kidney stone and went to the ER last October (2017) where the diagnosis by the docs there confirmed a stone
(they did Ultrasound and a CT scan, etc.). I believe the cause was due to high calcium from Hyperparathyroidism which was subsequently diagnosed and I have since had correcting PTH surgery (February 2018) and my calcium is now back to normal. However, during the original ER visit they discovered an additional stone than the one suspected of causing me the agony (which was assumed to have passed during the 3-4 hour ER visit). This second stone they described in the ER report as: “A nonobstructive 4 mm left lower pole stone is present” and the doc suggested it may pass at some subsequent time. In the past 3 weeks have had some renewed left flank pain and mild to moderate abdominal cramping, which often worsens just after eating. Does it seem that these symptoms I just described in the previous sentence could be due to the second stone they found and described in the ER report? (I.e., “small stone syndrome”?) i have an app’t with my urologist (he’s very good so far as my experience has been in the past) in a week, and hopefully he will help get to the bottom of this.
Hi Paul, Given a stone and pain, I always suspect the stone. By the way, urine calcium often remains high after cure of PHPT so your physicians should check for that and treat it if present – an ongoing cause of more stones. Regards, Fred Coe
Hello again Dr. Coe. Since the above reply I have had another urinalysis, a 24-hr. urine analysis (won’t know results until my next visit), and another ultrasound, where my urologist could subsequently see the 4mm “non-obstructing lower left pole stone” referred to in the first post. He is recommending lithotripsy. When I asked about removing it with the newer/smaller tools through the ureter up into the kidney his response was that their efficacy depends upon the location of the stone, and that mine was in a location where it was impractical or impossible to reach. He will be doing a cystoscopy next, but I’m wrestling with whether or not to have the lithotripsy. Any thoughts or suggestions that might help me make up my mind? (I’ve read about possible increased rates of diabetes and hypertension, although I don’t consider those probabilities to be enlarged enough to bother me a lot.)
Hi Paul, I am not a surgeon nor your physician so I cannot venture further into your exact treatment. I worry that shock wave treatment of a lower pole stone will simply leave fragments in the lower pole that may not clear. But being what I said, my opinion is worthless in any one particular case where I know no details. If you have any uncertainties just get a second surgical opinion. Your present urologist can easily arrange for it. Regards, Fred Coe
Dr. Coe, I now have the results of the 24-hr. urine collection and also a report on the recent ultrasound.
Regarding the Ultrasound, the Radiologist’s interpretation indicated a 6 mm stone in the proximal ureter/renal collection area, and another smaller non-obstructing one an upper renal area. This is quite a different situation from the Oct. 2017 original ultrasound in the ER which reported a “4mm non-obstructing lower left pole stone.” Perhaps that 4mm stone grew between then and the February 2018 hyper-parathyroid surgery and is now the “6mm” stone in the collection area, having moved form the lower left pole. The other new smaller stone reported by the radiologist might be a new stone (or possibly even the old 4mm stone – although that seems unlikely to me?). Anyway, my Urologist ordered an x-ray to see if these two stones reported by the radiologist from the recent ultrasound could be verified.
I am scheduled for lithotripsy to deal with both of these recently-reported stones (my Urologist thinks if the 6mm stone is actually that big it probably won’t pass). Hopefully they both will get pulverized and the remains pass.
My main concern is that once these are treated that I don’t form new stones. Since the stone of Oct. 2017 which passed at the ER was “out of the blue” and I was suffering from hyperparathyroidism, though not diagnosed and treated until 6 months later, I’m hoping that the two new stones reported from the recent ultrasound were formed (or that one of them grew larger) between the time of the ER visit and hyperparathyroidism surgery. I,e., I hope that HPTH was the culprit and now that has been resolved, I will be stone-free again.
I’m wondering if you see anything in the 24-urine results which would indicate future problems?:
24-Hr. Collection Results:
= = = = = = = = = = = = = = =
Creatinine Ur / 124
Creatinine per 24h / 1612
Sodium, Ur mmol / 95
Sodium per 24h / 124
Potassium, Ur mmol / 70
Potassium per 24h / 91
Chloride Ur mmol / 89
Chloride per 24h / 116
Calcium, Ur mg / 20.2
Calcium per 24h / 263
Magnesium, Ur mg / 6.0
Magnesium per 24h / 78
Phosporus Ur mg / 81
Phosporus per 24h / 1053
Uric Acid, Ur mg / 41.9
Uric Acid per 24h / 545
pH Ur / 5.78
Oxalate, Ur per volume / 15 mg
Oxalate, Ur per 24h / 20 mg
Citric Acid, Ur per volume / 1117 mg
Citric Acid per 24 hr / 1452
Hi Paul, I do indeed see a problem. Your urine sodium is 95 mmol/liter and 124 mmol/day; this gives a urine volume of 124/95 or 1.30 liter per day. That is woefully insufficient and could cause new stones to form given you already have some stones in the kidneys. The safe volume is above 2.25 liters, and I would vote for 2.5 liters/day. You have a lowish urine pH and high urine citrate that make we wonder if your BMI is on the high side, or you have other elements of the metabolic syndrome such as lipid or blood pressure disorders. If so, your physicians need to deal with them. from here, with little to go on, I cannot say much more. Regards, Fred Coe
Dr. Coe,
I done further reading through your info about 24-hour urine tests, and then drove to the medical center to obtain the one I had done last March (2018) to compare with the one I just posted above. Surprisingly (to me at least), the ENT who ordered it only requested Urine Calcium and the rest of the items were not included in the lab report. Those results for urine calcium were:
Calcium Ur mg / 39.6
Calcium 24hr / 376
Given that the later test I previously posted had urine calcium of 20.2 and 263, I am hopefully concluding that the change resulted from fixing the HPTH problem with the late March surgery that was done between the two tests.
By way of correction, I neglected to post the Volume parameter with all the 24-hr urine results listed above – it was: 1300.
So based on what I’ve read, it seems that:
1 – I’m a “low-flow” person who needs to intake more water/fluids.
2 – Urine calcium, at 263, though my urologist feels anything under 300 is OK, would by your recommendations be over the 200 or so range where stone risk becomes a consideration – i.e., still high (though not nearly as high as before the surgery) .
3 – My sodium is somewhat high and that’s something I could work on.
Are there other stone warning flags from the 24-hour urine that I am missing?
Hi Paul, I already calculated your volume in the prior comment, and it is indeed too low. No doubt the prior high calcium was from PHPT and that is not presumably cured. Yes, your sodium is high and I would reduce it. I commented on other ideas in my other note. Regards, Fred Coe
Dr. Borosky, I desperately seek help in my stone treatment. I currently have 6 stones . I had 8 but have passed two in the last 18 months. my right kidney is constantly in pain. I have seen urologist at mayo and UW health Madison being told that my stones are too small and non obstructing so my pain should be something else. i had 12 stones removed in 2015, but developed the 8 new ones by spring of 2017 and been suffering ever since. I will do anything to seek treatment to get rid of these things. I have been struggling with stones since 2009. I had severe pain for 4 years before passing a 9mm stone and it’s been hell since then. reading your you article hits the nail on the head. I’ve seen back dr.s, nephrologists, rehumetologist, gastrologist you name it I’ve seen them. nephrologist however at least the two I have seen explain that non obstructing stones can be painful but to find a urologist to as agree, my lord good luck. I will go anywhere to get these out so I can get off all the pain medicine that the dr.s have me on. thank you Brian
Hi Brian, I believe we corresponded and you are considering several surgical consultants. Regards, Fred Coe
I can attest that a 4mm nonobstructing stone in the kidney CAN cause chronic kidney pain. I’m currently experiencing it. I’ve passed many kidney stones over the years and definitely know the different between “back” pain and kidney pain. Its kidney pain
Hi Cindy, I missed the multiple versions of this comment. That you have passed stones and can recognize this pain as like a stone is valuable to know. I have always assumed these stones cause local internal obstruction or inflammation, but have no real data to support that assumption. Regards, Fred Coe
My mother aged 48 yrs had upper abdominal pain and radiating towards back for past 15 days(come and go). After Ultra sound-scan, it is found that she have 2.33 mm calculus in the middle calyx of right kidney. My first doubt is whether 2.3 mm stone will cause pain in upper abdomen? Nothing else also negative in scan except fatty liver Grade 1. She dont have any vomiting or pain during urine. Please clarify?
Hi Manikandan, upper abdominal pain radiating to the back is more like a gallstone or pancreatitis than a right sided kidney stone. I suspect the gall stone as most likely, but her physicians will need to sort this out. Regards, Fred Coe
My mother aged 48 yrs had upper abdominal pain and radiating towards back for past 15 days(come and go). After Ultra sound-scan, it is found that she have 2.33 mm calculus in the middle calyx of right kidney. My first doubt is whether 2.3 mm stone will cause pain in upper abdomen? Nothing else also negative in scan except fatty liver Grade 1. She don’t have any vomiting or pain during urine. Please clarify?
I can attest that a 4mm nonobstructing stone in the kidney CAN cause chronic kidney pain. I’m currently experiencing it
Hi CIndy, Few would disagree; the issue is whether surgery helps or not. Regards, Fred Coe
I can attest that a 4mm nonobstructing stone in the kidney CAN cause chronic kidney pain. I’m currently experiencing it. I’ve passed many kidney stones over the years and definitely know the different between “back” pain and kidney pain. Its kidney pain.
I’m looking for a good urologist near Chesterfield, MO.
Hi Cindy, The closest kidney stone experts would be at Indianapolis (IUPUI); Dr James Lingeman is an outstanding surgeon there. Regards, Fred Coe
I found this site after once again not feeling well. I woke up in the middle of the night with extreme mid back side pain. So I went to the er..they mention maybe kidney.. so I peed in cup.well they said urine was fine..so I told them I have ddd in my neck.so.maybe that was it. anyway I was sent home with no further information.. the next day pain was still intense so I went to see regular doc..my heart rate was up 160 so they did ekg..but it went down. While on monitor..he did blood work and sent me for cat scans..blood work was fine other than he said I have borderline high cholesterol..i don’t eat greasy food and I weigh 124 and was 37 at time..so that was weird..catscan showed 5mm low renal acid stone and calcium deposits in pelvis..i hurt at my spine a lot near what I call my kidneys ..ive had urine, kidney and bladder infection all at the same time..went to doc for that ..then my scalp got inflamed .and hair started coming out cause of it..ive now had this kidney stone.for 7 or more and inflammation running all through my body ..but they say kidney stone.woukdnt hurt and there’s nothing wrong with me even when they treated me for all..nor have I been given any pain meds during all of this ..theres times I cry at night saying whatever u r go ahead and take me I’m tired and body can’t handle the pain anymore. Moral of story..im still looking for a miracle ..and maybe y’alls insight can help
Hi, I gather you have kidney stone or stones, and pain. I also gather that the stone does not seem to be obstructing the kidney, but your pain is considerable. Possibly the pain is not from the stone, or perhaps there are other causes related to the stone such as crystals in the ureters. From the little information, I cannot do much to help. If the pain remains severe and nothing is found except the one stone, perhaps your surgeons can consider if removing it would help. Regards, Fred Coe
I am a 36 yr old women that has SLE Lupus. I have had kidney and bladder infections off & on for long time. I also have compact fractures in everyone of my vertebrates. So I know pain. But September,9 I started hurting extremely bad in my lower right side of my back & in the middle. I had CT done it showed 4 mm stone in my kidney. My regular family dr priscribed flomax. I’ve taken 3 so far. She just gave them to me a few days ago after I went to the er. I went back to er today. The dr did another CT and said it shouldn’t be causing my pain. And told me to go back to my back dr. O ya i also have a stimulator implant in my back. I don’t know if this help or not but also have to stake steroids for my lupus. Something isn’t right I know my regular back pain. This is like a knife in my back and its twisting. Would anyone have any suggestions one what my next move should be? Thank u very much. Andrea
Hi Andrea, I think perhaps a urologist might help in this decision. Some stones that do not obstruct the main drainage of the kidney – the ureter – can obstruct interior channels. Your description of the pain does sound like the pain stone patients describe but you also have significant back trouble from fractures. The decision is complex because if you believe the pain is from the stone, the surgery to remove it is itself a major undertaking. Regards, Fred Coe