Urinary stone disease: early diagnosis allows simple treatment strategies

Ah! Screamed Ali, a 15-year old boy, who was brought to the emergency room. His worried parents said that he had been having mild flank pain off and on for the last two weeks, and would settle down with simple painkillers taken at home. His mother was attributing the pain to "gas".
March 8 is the 'World Kidney Day' However since the previous night, his pain had become quite severe and would not settle down with the pain medication taken at home. He was now vomiting everything he ate or drunk and had also passed reddish coloured urine early in the morning.
Ali was in great distress and was rolling about in pain. He was immediately given an intravenous painkiller after which his pain settled down to some extent. X-rays were done and this confirmed that he has a 6mm stone in the ureter halfway between his kidney and bladder.
A CT scan was arranged and this confirmed the presence of stone in his mid ureter resulting in significant obstruction to his kidneys. Ali had his exams coming up in a fortnight and was worried how he would prepare for the exams. His parents were counselled and Ali was taken to the operating room the same day.
His stone was removed with the help of ureteroscope, a thin instrument which is passed into the urinary tract under anaesthesia. No cuts were given. Ali was fine and was sent home the next day to prepare for his exams which he passed with flying colours.
Stone disease is one of the commonest problems affecting the kidneys in our part of the world. In fact after diabetes and hypertension it is the 3rd commonest cause of renal failure in patients in Pakistan. Pakistan lies in that part of the world which is known as the Stone Belt and this extends from Southern Europe across the Mediterranean, through parts of Asia like Jordan, Iraq, Iran and extends to Pakistan and India before reaching Far Eastern countries like Thailand and Vietnam.
It is called the Stone Belt because incidence of stone disease in this part of the world is very high. In Pakistan, stones can be found in the urinary tract of children as young as a few months old to the elderly. No age is excluded and also the disease extends to all social classes.
Particularly affected are the 20-40 years old young men who are in the prime of their age and economically one of the most important groups of our society. A very rough estimate of the cost of man hours lost by the disease is about Rs 100 crore, and if we include the cost of medical treatment, this figure becomes even more astronomical.
Why is stone disease so common in Pakistan? The answer to this question is that it is multi factorial. Not just environmental temperature, but also genetic predispositions, dietary habits, socio-economic conditions, inadequate fluid intake and quality of water contribute to the high incidence of urinary stones disease in Pakistan. Stones usually originate in either the kidney or in the bladder but can migrate to reach anywhere in the urinary tract.
Symptoms of urinary stone disease largely depend upon the location of the stone but can be quite variable. It is important to understand that there is no co-relationship between size of stone and intensity of pain. Sometimes large stone in the kidney can be without symptoms whereas tiny stones of only a few millimeter can sometimes cause extremely severe pain.
Along with pain, one can have nausea and vomiting as well particularly with kidney and ureteric stones. Pain is often in the flank area and sometime radiating down to the groin. Stones in the last part of ureter or in the bladder can cause groin pain or pain below the belly button, sometimes radiating toward the genital area. Along with pain, one can also have urinary symptoms such as burning micturation, increased urinary frequency and sometime even blood in the urine giving it a red colour.
Timely and proper diagnosis and treatment of stones is essential, because if left untreated, the stone not only grows in size but also causes a variety of complications. Complications can vary from infection and blood in the urine to renal damage which can progress ultimately to kidney failure. The diagnosis is usually not very difficult.
A urine analysis usually shows presence of red cells and white cells. Some form of imaging such as ultrasound or plain x-ray of abdomen would usually show the stone but sometimes special x-rays of kidney such as IVP or CT scan are required for confirmation and also to decide the best way of treating such a stone.
Treatment of urinary stones has drastically changed in the last couple of decades. Though small stones can pass out spontaneously by medical treatment alone, larger stones require some form of intervention. Previously open surgery was the only option available. But now a variety of less painful options are present.
Stones in the kidney are easily treated by ESWL. ESWL is usually a day care procedure. Special shock waves are focused through the abdominal wall onto the stone without any anaesthesia and within 30-40 minutes the stone is completely or partially fragmented depending upon initial size of stone. The fragments of the stones are usually small enough to pass out with the urine. Slightly larger stones may require more than one session to achieve complete fragmentation. Another technique used for even larger stones in the kidney is keyhole surgery called PCNL.
In this procedure, which is done under either general or spinal anaesthesia, a small hole is made in the back below the ribs through which a special telescopic tube like instrument is introduced in to the kidney. The stone is completely fragmented and removed usually within 30-60 minutes. After this the patient goes home the next day and can return to work in a few days.
For stone in the ureter, again the option is between ESWL and endoscopic removal as was done in our patient. Both forms of treatment are usually done as an out patient and allow the patient to return to work the next day. Open surgery is usually reserved for very large stones often with associated complications. Hence it is clear that early diagnosis allows simple treatment strategies which are associated with lesser complications.
A special word about stone prevention. It is important to remember that those patients who have formed a stone once, carry a higher chance of reforming stones. Hence it is important to understand the causative factors. A chemical analysis of the stones gives valuable information as to the composition and type of stone. Other tests in the blood and urine allow a more comprehensive picture upon the basis of which appropriate dietary measures and treatment strategies for preventive care can be planned.
8th March is the "World Kidney Day". Let us all make a resolution today that we would seek early treatment once the diagnosis of stone is made. One of the most effective ways of preventing stone is to drink enough water and the best way to ensure this is to keep a close eye on the colour of urine.
As long as it is colourless or just light yellow we can be sure we are drinking enough water. For an average person this means 21/2 - 3 liter of water per day. Additional amount may be required in summer or if there is additional outdoor actively to ensure that urine does not become yellow in colour.
Studies in Pakistan have shown that low amounts of citrate in the urine is one of the most common causes of stone formation. Citrate in the urine is an inhibitor of stone formation. Now there are medicines available which can improve urinary citrate levels and this would go a long way in preventing stone formation.