By Tedler D. Depaynos, MD
The patient is a well respected lawyer and has been complaining of slight right lumbar “discomfort” from time to time. He attributed this to his chronic position where most of the time he is sitting down busy with the thick papers of his various clients or in front of his busy computer. He had his back massaged from time to time by his wife and not contented, they even hired a blind masseur twice. Slight relief was obtained but the “discomfort” persisted. Since it was tolerable he never sought any consultation.
On one occasion, he noticed his urine to be darkly colored. Actually he experienced this from time to time but not so concentrated especially so that he had increased his daily water intake to at least 10 glasses per day. He has been attributing this to the dark imported bottled fluid he has been taking especially if he had a court hearing.
After the urging of one of his secretaries, he had his urine examined. He was surprised that his urine contained RBCs which was too numerous to count or TNMC in short. He must have been urinating blood from time to time! This forced him to consult a young MD who has been his client from time to time.
The MD requested routine abdominal x-rays and ultrasound (UTZ) of the kidneys, ureters and bladder (KUB) of the lawyer which revealed a “stone at the right ureter and that the proximal part appeared to be dilated” implying that the stone is causing an obstruction. The ureter is the duct pathway of the urine from the kidney to the urinary bladder.
The young MD was surprised that the lawyer patient never complained of severe pain because in cases he encountered, severe excruciating pain is always experienced when the stone from the kidney travels down the ureter. Because the moving stone may erode the walls of the ureter, bleeding may occur but because the blood is admixed with urine especially that coming from the other kidney it may not be noticed and may only be seen thru the microscope. When the stone stops moving, the severe pain will also subside.
In this patient there were no complaints of severe pain and the urinary bleeding was very obvious, making the case “unclassical” to the point of view of the young MD. He even joked that probably when the stone was moving down the ureter, the lawyer patient was super tipsy with his favorite black drink. The MD then referred the patient to a Urologist who is much more experienced in these cases.
The Urologist who trained in the National Kidney Center agreed that excruciating back pains usually occur when the “stone” moves but he admits that they had also encountered similar cases with tolerable pain. The bleeding in the urine may come from other sources but likewise they also encountered such bleeding that originated from the ureter. In short he advised that patients with similar manifestations should undergo similar work –ups just to rule out problems in the KUB.
After further study, the Urologist recommended that the stone should be removed especially so because it is causing urinary obstruction. Without obstruction and with no apparent tendency to obstruct, the stones may be observed meantime. The stones being foreign bodies may however make the patient more susceptible to or worsen urinary tract infections. If present in the urinary bladder, it may cause malignancy. Hence, it is best for the Urologist to make the decision.
Small stones measuring around .4 cm. in diameter may pass the whole length of the ureter into the urinary bladder and finally excreted thru the urethra. To see the small stones passed out, urination thru a gauze which would act as a screen is advised. The stone could be collected and sent to the laboratory for analysis.
The lawyer patient obviously has a large stone. If the stone would not be removed, the dilatation would worsen and may extend into the involved kidney which may eventually be destroyed. The Urologist then mentioned that the dilated ureters or kidneys may cause vague back aches or “discomfort” which may worsen with further dilatation.
The patient underwent “shock wave” theraphy by the use of a Lithotripter machine. With the use of ultrasound or x-rays to pinpoint exactly the location of the stones, adjoining tissues are left undamaged making the procedure highly safe. In general the size of the stone should be around 2 cm or less for a single session of shock wave therapy. Bigger stones may require several sessions or outright surgery depending on the expert assessment of the attending urologist. Fortunately for the patient, he underwent only a single therapy.
The patient was sedated or anesthetized during the procedure so that he was asleep during the procedure and felt nothing. It lasted for an hour and when he was awakened, he was immediately discharged and not confined. To celebrate the successful procedure he invited his MDs and friends to a nearby restaurant to taste the Black bottle he kept in the trunk of his old SUV.**
