Case 105: Loin pain
A 45 year old man is referred with right loin pain. It occurs occasionally and usually lasts only a few hours at a time. His GP noted microscopic haematuria on urine dipstick.
1. What does the xray show?
There is a large radio-opaque calculus located at the right renal pelvis. There are also several calcifications in the pelvis. These are not in the expected line of the ureters and are likel to be phleboliths, or calcification within pelvic veins.
2. How would you manage this condition?
A large stone such as this is unlikely to pass spontaneously. In view of its location in the renal pelvis the options are Extracorporeal shock wave lithotripsy (ESWL) or percutaneous nephrolithotripsy (PCNL).
ESWL is less invasive and is usually the first line therapy.
3. Having undergone treatment he has now developed severe unremitting pain in the abdomen and groin. What has happened?
Lithotripsy has been performed with fragmentation of the calculus. The fragments have passed into the ureter but unfortunately have lodged at the vesico-ureteric junction. The cast of fragments can be seen to demonstrate the lower end of the ureter. This is known as "steinstrasse" or stone-street.
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