KIDNEY STONE

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Research: A big 16.9 mm. Kidney Stone expelled with FOKS

Kidney Stones of up to 5 mm. of diameter are known to pass spontaneously through the urinary tract, whereas those exceeding 7 mm. of diameter almost always require surgical intervention. A case of 16.9 mm. Kidney Stone, lodged close to left uretero-vesicular junction, presented with severe cramping pain in the left lumbar region, which radiated downwards to the groin area. Patient also had severe pain at the end of urination. After analysing the totality of symptoms presented by the patient, FOKS was prescribed. Three doses of this medicine could expel the stone, without causing considerable discomfort or bleeding.facebook-comment-editing

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Urinary stones are the third most common affliction of the urinary tract. They are exceeded only by urinary tract infections and pathological conditions of the prostate. Urolithiasis affects 5-15% of the population worldwide. Recurrence rates are close to 50% and the cost of treatment for urolithiasis to individuals and society is high. Data indicates that up to 98% of urinary tract stones with size less than 5 mm in diameter, especially in the distal ureter, pass spontaneously. Stones of size 5–7 mm have a modest chance (50%) of passage, and those greater than 7 mm almost always require surgical intervention. Stones at the ureterovesicular junction often cause dysuria and frequent urination, which is mis

 

taken for infection. Shock wave lithotripsy is recommended as the first line of conventional treatment for most of the patients with stones more than 5 mm in the proximal ureter, whereas both shock wave lithotripsy and ureteroscopy are acceptable ways of treatment for stones in the distal ureter. However, there is sufficient evidence in literature that shock wave lithotripsy is associated with increased chance of renal injury.  Literature provides a good scope for treating cases of urolithiasis, but due to poor documentation of case reports and studies, the role of therapy and its cost effectiveness remain a subject of discussion in the minds of research personnel. The present case brings to light the efficacy of a single medicine in the treatment of a nearly surgical case, leading to expulsion of the stone without causing much discomfort. The case will provoke the readers, including the researchers, to further explore the utilityof FOKS for treatment of such cases.

 

Case Presentation

An obese, dark-complexioned male of 50 years presented with a history of cramping pain in the left lumbar region. The pain, present since three months, radiated downwards to the groin. Dysuria with increased frequency and urgency of urination were other complaints. The patient also developed burning sensation while urinating and increased pain at the end of micturition over a period of three months. The patient could pass urine only drop-by-drop while sitting, but freely while standing. The patient also had metallic taste in mouth and no thirst. A tendency to catch cold easily and taking offence from the remarks of people were other characteristics of the patient. Except for a few analgesics during acute episodes of colicky pain, the patient had taken no medical treatment for his problem. A thorough physical examination of the patient revealed no abnormal findings. Routine haemogram and serum calcium levels and the elements of renal function tests like blood urea, blood urea nitrogen and serum albumin levels were found to be within normal range. Only serum creatinine was elevated to 1.24 mg% (Normal Range: 0.7 – 1.1 mg% for males). Ultrasonography-KUB (Fig. 2a) revealed a 16.9 mm calculus at uretero-vesicular junction, not moving with the change of posture. There was no sign of hydronephrosis or any obstruction to the outflow of urine. Apart from the calculus, USG report also revealed a heavier prostate gland, with 31.5 gms. of weight (Average weight: 20 gms.) and a significant post-voidal residual urine of 10 cc in the bladder. Assessment of severity of disease condition was done at the entry level and then during all the 14 follow up visits. The Baseline Assessment Scoring Form (Table 1), containing 8 items (pain, haematuria, dysuria, number of stones, size of stone, position of stone in kidney/ ureter/ bladder) was filled up during each visit.

Table 1: Baseline assessment score

Table-1These symptoms were rated on 4-point scale, based on the severity of symptoms, from ‘0’ meaning ‘absent’ to ‘3’ meaning ‘severe’. A total of these symptoms score was again rated under three categories of mild (score 1-7), moderate (score 8-14) and severe (score 15-23). At the time of entry, the symptom score of the patient was moderate, totaling to 12.

Based on the totality of symptoms, FOKS turned out to be the leading medicine in the repertorisation analysis, covering maximum rubrics (12) and scoring highest points (20) (Fig. 3). FOKS (10-60 dilution) one dose, was prescribed, followed by placebo for the rest of the day. Patient was also advised for dietary management like increased intake of plenty of water, avoidance of spinach etc. Within 24 hours of intake of FOKS, the patient developed pain while voiding urine, following which FOKS was prescribed for three times a day for two days,. However, after consuming only two doses of medicine, the patient developed more severe pain and with this severe pain, the stone was expelled while voiding urine. After expulsion of the stone, Ultrasonography-KUB (Fig. 2b) was again performed, which revealed no calculus. However, a significant volume of post-voidal residual urine was reported in the bladder, which was gradually resolved without medication. No medicine was given in the follow ups after the expulsion of stone, as the symptom score in the assessment form was ‘0’ (Table2).

Table 2: Follow up

Table-2

A repeat USG report at the end of treatment. showed a reduced weight of prostate gland (20 gms.) and an insignificant amount of post-voidal residual urine (Table 2). Also, the renal function test revealed a normal value of serum creatinine (0.8 mg%). After expulsion, the size of stone was measured, the maximum length of which was 13 mm., whereas maximum width was 9 mm. (Fig. 1). The size of stone, as revealed in the first USG report, was 16.9 mm. The reason for reduction in the dimensions of the stone during expulsion is expected to be the effect of medicine on the stone. The first and then the subsequent doses of the medicine might have dissolved the stone to some extent, which would have gone unnoticed by the patient while passing urine.

USG report

The case, however, leaves to the researchers a few questions open to discussion. These include the stimulating points like, ‘how could a stone of size 16.9mm be located at the uretero-vesicular junction, without causing hydronephrosis or obstruction to the outflow of urine’; ‘what mechanism was involved after administration of FOKS 30C, which allowed 16.9 mm stone to pass through urethra without causing any gross injury or haematuria, especially while passing through the membranous part of urethera’, and ‘could FOKS cause dilatation of urethera to allow the passage of 16.9 mm stone without causing any injury’.

References

  1. D.S. Qaader, S.Y. Yousif and L.K. Mahdi. Prevalence and etiology of urinary stones in hospitalized patients in Baghdad. Eastern Mediterranean Health Journal 2006;12 (6): 853-61.
  2. Zarse CA, et al. Helical computed tomography accurately reports urinary stone composition using attenuation values: in vitro verification using high-resolution micro computed tomography calibrated to fourier transform infrared microspectroscopy. Urology. 2004; 63:828–833.
  3. Segura JW, Preminger GM, Assimos DG, Dretler SP, Kahn RI, Lingeman JE, Macaluso JN Jr. Ureteral Stones Clinical Guidelines Panel summary report on the management of ureteral calculi. The American Urological Association. J Urol. 1997 Nov; 158(5): 1915-21.
  4. Zarse CA, et al. Helical computed tomography accurately reports urinary stone composition using attenuation values: in vitro verification using high-resolution microcomputed tomography calibrated to fourier transform infrared microspectroscopy. Urology. 2004; 63:828–833.
  5. D.S. Qaader, S.Y. Yousif and L.K. Mahdi. Prevalence and etiology of urinary stones in hospitalized patients in Baghdad. Eastern Mediterranean Health Journal 2006; 12 (6): 853-61.
  6. McAteer JA, Evan AP, Williams JC Jr, Lingeman JE.Treatment protocols to reduce renal injury during shock wave lithotripsy. Curr Opin Urol. 2009 Mar; 19(2): 192-5.
  7. Williams HN. Thlaspi bursa pastoris in the treatment of kidney stones. J Am Inst  1988 Mar; 81(1): 31-32.
  8. Hunton M. Two cases from general practice. Simile 1996 Jan; 6(1):10.
  9. Vujovic A, Keoghane S. Management of renal stone disease in obese patients. Nat Clin Pract Urol. 2007 Dec;4(12):671-6.

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