Why Do Kidney Stones Cause Pain?

P6140312Agonizing, 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.


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

renal-stonesThe 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.

glomerulus copy

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.

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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 unilatScreen Shot 2015-05-21 at 11.04.09 PMeral 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 CTScreen Shot 2015-05-21 at 2.32.24 PM 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).

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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

What Kidney Stones Are

Types of Kidney Stones

Do We Need to Analyse All Those Stones?

How Kidney Stones Form

When Crystals Plug The Kidneys

Medullary Sponge Kidneys





783 Responses to “Why Do Kidney Stones Cause Pain?”

  1. Ivan

    When one experiences flank pain from a kidney stone, how long does the pain last. I have had some symptoms of a kidney stone such as a feeling of a need to pee. Then today, I experienced a gripping pain on my left side for 2-3 seconds then complete resolution. Does that sound like Kidney stone pain or something else? My thought was that true kidney stone pain would last for minutes to hours, not 2-3 seconds.

  2. Thomson Wither

    I am a 40 year old that has been diagnosed with kidney disease. I went to see my urologist and he confirmed that I have a kidney stone in the same kidney, 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, My doctor advised me to use OSPAREN product of Germany. I found it very effective , and I will continue to use it!”

    • Fredric L Coe

      Hi Thomson Wither, I looked in vain for a reliable article on osparen both on line – useless and in PubMed. Three articles arose from PubMed with the search OSPAREN AND Kidney stones, but I could not find this agent in any of the three. On the web I found myriads of ads, in German mostly. I think the material is an herb but that is a guess. If it helps you, I am happy, but lacking even one reliable article I am also unconvinced for the general public. Regards, Fred Coe

  3. LINTO

    Last 8 months i suffer pain for both testis and the legs. I take ultrasound of abdomen & pelvis & scrotum. 3 mm stone find the right kidneys lower pole. I took many medicines and check another ultra sound but it was there. i consulted many urologists,surgeons but no one find the actual reason for pain.They all says this stone don’t cause pain.please replay for me.

    • Fredric L Coe

      Hi Linto, possibly the stone moves out of the lower pole from time to time and obstructs the kidney – that pain can radiate into the testicle. Possibly you form crystals copious enough to cause transient obstruction and that causes testicular pain. If possible, you should have blood and 24 hour urine testing, and analysis for crystals in the urine – microscopy of a morning sample is a good start – to figure out what is happening. Regards, Fred Coe

  4. Tanya

    I have a stone in my lower right pole. It may have been there for over for months and growing. Over the past 4 months since I found out it was there. I keep getting urine samples that show blood, leukocytes and even had e Coli
    during this time. I have had 2 rounds of antibiotics but the blood and leukocytes just keeping getting higher once I am off the antibiotics. Can the stone being causing the results of urine test. I have urgency as well and slight discomfort when I urinate.

    • Fredric L Coe

      Hi Tanya, Yes, a stone can become infected and lead to recurrences such as you describe. But the decision whether to remove it is complex and your physicians have to make their own evaluation. That it is growing and possibly infected may prompt them to remove it. Lower pole stones may be best reated with ureteroscopy, but that also is for your surgeon to decide. Regards, Fred Coe

  5. Ann

    I just recently had to go to the emergency room due to unbearable pain that I have never felt in my life and I gave natural birth to a 8 lbs child 10 years ago. I was vomiting and was so restless and the pain… oh the pain. Turned out I had a stone stuck in my ureter and multiple stones in my kidneys. I followed up with my PCP last week and she told me that I passed the stone in my ureter (after doing a STAT CTSCAN and blood work). I never felt it pass and still have extreme left sides flank pain. She even had the nerve to tell me k have no more kidney stones and I got my ctscan back and I have 4 kidney stones that are 4mm in size it said they were in my lower pole. All I know is I can literally point to my back and tell you exactly where my kidney is. It hurts. Not as bad as the on being in my ureter, that was horrid pain!!! I fear it will happen again. I’m terrified of it happening again. My kidney function was very low when it happened and I had fluid stuck in my kidneys due to it. Well I found out what that fluid was apparently when the stone broke into sediment and i had urine flow again, I urinated all puss. This is a very scary thing. I wish all of you the best in this scary journey.

  6. Steve Beers

    Finally, what I have been looking for! It is so frustrating to have medical professionals and literature talking about kidney stones that ONLY cause pain once they drop into the ureter or block the passage of urine. Which I fully agree with. But even after having 6 stones pass (and collected), one by surgical ureteroscopy, in the last 2 years, my current 3.5 mm lower right pole kidney stone cannot possibly be giving me pain because according to 2 ER visits with two different ultrasounds and a recent prescribed CT scan, show nothing is being obstructed. Dx : Pain not caused by kidney stone. One ER told me it is referred pain from a left sided pneumonia. What!? I have no doubt this current stone exist (by CT) and no doubt it is causing pain just like the other 6. In fact the pain started the same day number 6 passed. I did not know I would have a 7th stone try to pass on the same day! This has been going on for 3 months. I hope it just passes because I am done with pain for the last 2 years. And I’m done with most medical professionals having closed minds, even after admitting they don’t quite understand the nerve pathways of the UT system. Sounds contradictory to me.

    • Fredric L Coe

      Hi Steve, Pain from non obstructing stones is certainly possible. The problem is lack of trials. Does surgery to remove such stones reduce pain, or not? That holds physicians back, because what can they do but surgery for them. However you should do all you can to prevent more, as stones often recur. Take a look here. Regards, Fred Coe

  7. Prasanna Chidambaram

    I had 2 stones one in ureter 7 mm which has been removed by ureteroscopy, and one more in right kidney 3 mm which is non obstructing but it is causing pain when I work. Urologist believe I will pass this stone, I too can’t go for another surgery. Wish me luck and relief from this grave pain.

  8. Melissa Gordon

    Hi there, my name is Melissa. I’m a 21 year old female with a previous history of cystine type kidney stones. At age 16 I had previous bilateral renal stones removed with laser surgery, with a stent in place for 2 weeks to help pass the fragments. I have passed small stones since then on my own, resulting in a bit of pain for about 6 hours or so but then subsiding. 4 small stones in the last 3 weeks. For roughly 9 days now (including two visits to hospital) I have been dealing with incredible pain in my upper and lower back, also under my ribs. It was confirmed at the hospital with CT, x-ray and ultrasound that I have multiple stones in my right kidney, one being 8mm.

    At the hospital they were very dismissive, and persisted that the pain was not related to the kidney stones in the kidney as there was no obstructions. They even tried to say it was due to constipation, from the fecal mass seen in my x-ray, probably due to the medication I have been taking to help tolerate the pain. My bloods and urine came back normal. I am now doing a 24 hr urine before seeing an out-patient urologist in just over a weeks time.

    I believe they are not taking me seriously. I can recognize this pain due to the pain i experienced when I was younger, then having the renal stones removed. the pain IS the same. and I cannot bare it any longer. I cannot go to work at the moment or to university. I am so worried for my studies because I feel like I cant get this sorted.

    I will be taking the information from this study to my appointment in a weeks time, to express my concerns as I absolutely believe pain can be caused from stones in the kidney, not just when they travel to the ureter. I recognize the pain, and it feels exactly the same. I am on multiple medications and muscle relaxants, as my doctor keeps giving me medication and tells me to suppress it.

    After reading this information it is so wonderful to know that there are people out there like me, and that I’m not alone. It is not all in my head like they tell me, and it is excruciatingly painful physically and mentally.

    • Fredric L Coe

      Hi Melissa, cystinuria is a very serious and complex form of stone disease and is best treated in a center that has considerable experience with it. Even if your care needs be local you should be evaluated at a center and your treatment guided in part by experts. I am quite sure your stones could cause a lot of pain, and even more sure that your prevention is inadequate as you are forming more stones. I urge you to seek expert help to aid your local physicians in your care as the disease is not like ordinary stone disease. Regards, Fred Coe

      • debbie Henson

        Dear Mr. Coe
        I am wondering if you can recommend center that have expertise in Cystenuria. I have a son who has been misdiagnosed for 6 years, and because my daughter at 23 has just been diagnosed with Cystenuria, he too did urine test with Litholink. We are having difficulty finding experts. We are in Indiana, and Charlotte NC. Any information would be greatly appreciated!! Sincerely, Debbie Henson

    • Marijane

      I understand how you feel completely. I have been dealing with kidney stones since 2010. And I 2016 I had my first obstructing 8mm stone that had to be removed. Since I have 3 more lithrotripsy to remove 7mm and up size stones. Currently I have 6mm in kidney and 3mm in other kidney and flank pain. Urology said no way pain is from stone while in kidney. It is so frustrating. Especially for people who have dealt with more than one stone, we know that pain. It is not like any other pain. She tried to say it could be muscular or gastrointestinal. It took her 10 minutes to see me and that was it. I am sure I will be back in the ER with unbearable pain in the near future. She offered to remove the 3mm because it was midpole but said she would leave the 6mm because its lower pole and isnt an issue but there are days I can literally feel the stone in my kidney. I feel like urologist doctors who havent experienced chronic stones dismiss us very quickly. Goodluck with your health and I hope things get resolved. But I feel your pain and I believe your pain.

      • Fredric L Coe

        Hi Marijane, pain with non obstructing stones is very common, and lacking trials no one knows what is the best course of action. No one has much question that the pain is real, and many of us believe it is indeed from the stones. I am hoping for some surgical trials to tell us if the risk and miseries of surgery are worth it. Regards, Fred Coe

    • Dawn Bare

      Hi Melissa,
      First , I am so sorry to hear you have Cystinuria. But I would like to know if you are aware of our foundation, The International Cystinuria Foundation? If not, check it out and if you are interested in support and advocating, we welcome you to join our Facebook Page for The International Cystinuria Foudation where we operate in a private setting of support with over 1400 members now. Our President serves as the moderator and you will definitely find a huge amount of support within the group. Hope you can join. I am a mother of 3 Cystinuria children and have known Cystinuria all my life as my mother suffers as well. Unfortunately renal failure was an end result for her but fortunately men sister was able to donate her kidney, As I sit with my eldest once again in a Childrens Hospital setting, I saw this page and felt I must respond to these comments and to invite any Cystinuria sufferers to our group. We all understand the hardship behind these constant burdensome stones that constantly pass with and without surgical intervention. My eldest has had over 30 surgeries , even auto transplanting her own kidneys to minimize pain and obstruction. The biggest issue I am finding throughout and within the medical system is the belief that YES YES! These nonpbstructing stones are painful. My children are definite proof of this and so are the hundreds within our group as well. Hopefully you will join us but if not, good luck and please take care of your self.

      • Tonya

        Can a stone in the pole cause infection ?
        I keep getting them and the only thing that I seem to know is it started it when we found a stone in the right lower pole and appears to be there 4 months later and bigger in size.

        • Fredric L Coe

          Hi Tonya, I believe I already answered this. Regards, Fred Coe


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