Looking at Kidney Stones

Today I thought I’d talk about something dear to my heart, because it's something that I see and treat on a regular basis. Kidney stones. Kidney stones are painful, really painful. Most patients may present with classic symptoms with colic and hematuria. The colicky pain is severe, often described as 10 out of 10 and radiating from the flank towards the groin. There is often associated nausea as well. But sometimes there could just be vague abdominal pain with no radiation and no other symptoms.

Kidney stones should always be in the differential when someone presents with back, flank, or abdominal pain. The presence of red blood cells in the urine can be very helpful in making the diagnosis. There are certain factors that can also help to make a diagnosis such as a personal history of nephrolithiasis in the past, a family history of nephrolithiasis, or changes in diet and dehydration. 

Once a stone is suspected, imaging is performed, the gold standard being a non-contrast CT scan. If your patient is pregnant then ultrasound would be your next choice. Many healthcare practitioners like to get a plain film first, but this will not detect any uric acid stones, and often misses calcium stones if the stones are overlying a bony structure.

Over 80% of stones are calcium stones, but there are other types as well such as uric acid stones, struvite stones and cystine stones. Some people get a stone once and never get another stone, but others have recurrent stones

Treatment consists of pain medication and hydration. If the stone is small, it's best to get the stone to pass on its own. Most stones smaller than 5mm will pass on their own. Pain control is traditionally managed with NSAIDs and opioids. If there is no contraindication, ketorolac IV is often a good first choice. Many studies have looked at both NSAIDs and opioids for pain management of stones and they are relatively equivocal. At least one trial has shown a benefit of combination therapy.

For the patient who has had more than one stone, it is best to send the patient to someone familiar with the management of nephrolithiasis, usually a nephrologist or a urologist, so that metabolic disorders can be evaluated and management options can be reviewed.