Dr. Kardi Suteja, SpU

Flank pain is not a complaint that is rarely experienced in everyday life. What needs to be observed, is flank pain really a disease or just a “disease”? In newlyweds who are actively ‘working overtime’ often early in the morning when they wake up, their body aches and their waist hurts. People who rarely exercise then overtax themselves can also experience the same condition. However, it is whole other problem if the waist hurts after an accident, or falling from a motorcycle or other vehicle. Or there are times when for no apparent reason the waist aches or even experience severe pain which then spreads to surrounding parts. This is often accompanied by nausea, vomiting and cold sweat. This of course need immediate attention.

Broadly speaking there are several causes of back pain, namely trauma, inflammation, tumors, and the most common congenital abnormalities are obstruction of the urinary tract due to stones. The existence of urinary obstruction can be likened to PDAM water which has a blockage in the pipeline. Water will turn back to the center of the reservoir, even if the pressure is very high, causing a backflow to break down like a reservoir. Then what about the kidney that functions as a urine factory? Kidney as a urine plant will also be damaged if the blockage causes an extraordinary reverse flow. It can even fall in the condition of kidney failure.

Urinary tract stones are the most important cause of kidney failure. If you have kidney failure, there are only two options for survival: dialysis (hemodialysis) or kidney transplantation. The first choice is very expensive in terms of cost and it reduces the quality of life. The second choice, although it is a definitive measure, proves very difficult when finding the kidney donor for transplant and of course it is not cheap either.

Most widely

Urinary tract stones can be found in the kidneys, ureters (the upper urinary tract between the kidneys, and the bladder), bladder and urethra (lower urinary tract after the urinary content reaches the bladder hole). The more advanced the public’s knowledge of the health field, the lesser urinary tract diseases will be contracted, even if there is usually only a small stone in the kidney. The less advanced the public’s knowledge of public health, usually the larger the stones found in patients. In Indonesia, urinary tract disease is the most common urological disease. Stones occupy the kidney first before stones in the ureter and bladder follow. However the stone in the ureter is more often a secondary stone which was previously a small sized bladder stone.

Kidney Pain

Pain in the kidney is typically felt as a constant and blunt pain at the angle of the ribs with the spine (costovertebra), the side of the lower back muscles (sacrospinal) and under the ribs 12. This pain usually spreads forward along the bottom of the ribs to the navel area.

Lower back pain is a manifestation of kidney disease which causes a sudden stretch of the kidney capsule. It can be acute inflammation of the kidneys, and an obstruction in the acute ureter which results in sudden urinary back pressure. But in kidney cancer, chronic inflammation of the kidneys, large kidney stones, kidney tuberculosis, kidney cysts and dilation of the kidney system (pelviocalises) often do not show symptoms of lower back pain.

Ureter Pain

Pain in the ureter is typically stimulated by a sudden blockage, either due to stones or blood clots in the urine. In this situation there is a stretching of the kidney capsule combined with constant pain and spread (colic) that proliferate from the corner of the spine with ribs (costovertebra) towards the lower abdomen.

In men it can be felt in the bladder, scrotum or testicles. In women it can spread to the genitals. The severity of persistent and pervasive (colic) pain is caused by peristalsis (automatic movements) and extraordinary spasm (spasms) of the urethral smooth muscle.

Urologists can determine the position of urethral stones based on the history of pain and the location of its spread. If the stones are trapped and block the upper ureter, the pain will spread to the testes because the innervation of the kidneys and ureters is the same. In the middle ureter obstruction will spread to the lower front abdomen. Obstruction in the right side can be like symptoms of appendicitis. The left side will resemble inflammation of the large intestine. In the stone blockage that approaches the bladder causes inflammation in the urethral estuary causing symptoms of frequent urination.

Not seen in X-rays

Suspicion of stones in the urinary tract can be taken from interviews with patients (anamnesis), physical examination, laboratory tests of urine and certainly more evident by radiological examination.

Symptoms that the patient complained of were not just back pain. But usually accompanied by reddish urine, sometimes cloudy and gritty. Or there was a history of urinating out a stone. On physical examination there is usually tenderness or knocking pain at the angle of the ribs. If the stone blockage in the urinary tract is total and has been going on for a long time then the kidneys can be palpably enlarged.

The most important laboratory test for abnormalities in the urinary tract is urine testing. In the chemical contents of urine, its urine specific gravity, acidity of urine and urine sediments can be known. Urine specific gravity and urine volume has become one of the benchmarks for kidney failure.

Urine acidity can be a benchmark for the types of stones that form in the urinary tract. If it is more acidic than normal, the most common is uric acid stones. If it is more alkaline than normal most often the stone is due to infection. In the urine sediment the presence or absence of blood in the urine can be seen microscopically, as well as the presence or absence of crystals in the urine.

Do not be upset if blood samples are taken for laboratory tests because there are still other tests to see the kidney’s function as a urine factory by looking at chemical elements in the blood. For example creatinine urea and blood uric acid.

Radiological examination can be used to establish the diagnosis of the presence or absence of stones in the urinary tract. Stones found in the urinary tract are visible on X-rays (radiopaque) and some are not (radiolucent). When patients’ X-rays that do not reveal the stones are injected with contrast, it will show a picture of kidney function and its channel with the effects caused by the stone on the X-ray. For example, widening of the renal pelviocalises system or widening of the ureter.

Ultrasound examination (USG) can be used on stones that cannot be visualized by X-rays. An ultrasound examination is also done if an X-ray contrast cannot be done because the kidney function has deteriorated.

More Non-Invasive

History of handling urinary tract stones has been around since hundreds of years BC. In the 6th century BC, a Hindu surgeon, Susruta, had told of the expenditure of bladder stones through the perineum. The development of urology is so rapid. Management of urinary tract stones leads to non-invasive actions. Currently only large stones (> 2cm) have open surgery. Or open surgery is a last resort if endoscopy is not possible (urinary binoculars with a special urology tool).

After discovering the technique of rhythmic puncture from the skin in 1976 then a technique was developed for breaking stones with ultrasonic, pneumatic, electro-hydraulic or laser waves through channels made from the skin into the kidney bed. This technique, called percutaneous nephrolithotripsy (PCNL), was developed since 1981.

Stones in the middle and lower ureters can be broken by ultrasonic waves or other rock breaking energy sources through a URS (ureterorenoscopy) device. In stones in the bladder that are less than 2.5 cm in size, mechanical breakdown with an endoscope can be done.

For stones in the kidney and upper and lower ureters that meet the requirements can be broken down from outside the body with shock waves (ESWL = extra corporeal shock wave lithotripsy). This technology has developed since the 1980s in Europe. With this technology, patients with urinary tract stones can be treated without major surgery so that morbidity is greatly reduced and this method is often done without patients having to be hospitalized. The minimally invasive procedure will certainly make the patient more comfortable.

Whatever action is chosen in dealing with kidney stones and urinary tract is suffered by the patient. The most important thing to remember is that it is better to remove the stone from the body than to delay the action until the condition reaches kidney failure. In cases of kidney failure, along with the stones the kidneys are also removed.

Dr. Kardi Suteja, SpU.  is a specialist in urological surgery at Karsuneka Clinic Denpasar and several private hospitals in Bali.