Now that you have finished the reading passages up to this chapter, it is important for us to review many of the factors surrounding your stone formation and stone prevention. You may be stone free at this time and it is important to review some of the facts as to how you enhance your likelihood of remaining stone free. It is important to manage your expectations on stone prevention and steps required to achieve this goal. This chapter discusses tips allowing patients to manage their expectations and inspiring individuals to minimize their risk of future stones.

First, you may recall the pain that you had during your last stone attack. You may have had flank pain associated with nausea, vomiting, fever and/or chills. The pain may have radiated to the groin associated with discomfort in the testis in men or in the labia or vaginal area in women. On the other hand, you may have blood in the urine as the only presenting sign of your stone.

If you have these symptoms again, it may be a new stone or a persistent recurrence of a stone. It is important not to lose sight that these symptoms may be an indication that another disease process is present and unrelated to your stone. It maybe a sign related to the urinary tract, or one completely unrelated to the urinary tract.

In the case of the flank pain, it may be a stone blocking the flow of urine, resulting in renal swelling, known as hydronephrosis. On the other hand, this pain may be something within the gastrointestinal (GI) tract or muscle skeletal system. Think about your symptoms of your GI tract. Do you have a history of constipation? When was your last bowel movement? Did you have previous abdominal surgery? With previous abdominal surgery, this may be small bowel obstruction secondary to adhesions.

On the other hand, if you are having right lower quadrant pain, it is important to entertain appendicitis or rule out a ruptured ovarian cyst in the differential diagnosis. If the pain is in the left lower quadrant, the differential diagnosis should include diverticulitis.

If the pain is in the scrotum, the differential diagnosis may be an infection of the epididymis, known as epididymitis. More importantly, it may be a twisting of the testis, often referred to as a testicular torsion. Testicular torsion represents a urological emergency that requires surgical intervention.

Finally, blood in the urine may be a stone irritating the lining of urinary tract within the kidney, ureter or bladder. On the other hand, it may be something as simple as a urinary tract infection. Alternatively, it may be something more serious, such as a renal tumor, ureteral tumor or bladder tumor. It is important to make your Urologist aware of these symptoms so that s/he can completely evaluate your urinary tract and make certain that no stones are left unturned!

Remember, when it looks like a duck, quacks like a duck, moves like a duck, it is usually is a duck! However, do not lose sight that these symptoms may be a “red herring” and may be the unexpected elephant in the room! It is critical that when you have any of these symptoms previously described, that you don’t simply attribute them as being associated with a stone. It is paramount that you consult your urologist, primary care physician and/or Gynecologist to initiate the work up and make a definitive diagnosis.

In my experience over the years, I have found that over time, patients have become quite sophisticated about understanding their bodies and appreciating their symptoms associated with stones. Once a patient has had a stone, or what I have described as a “stone veteran”, they have become quite in tune with their body and know exactly what their symptoms are like for a stone recurrence.

Not all tremors result in earthquakes. If you have a small “twinge” or pressure feeling in your flank, don’t automatically assume that it is a stone. Remember, stone pain can be relentless and sometimes persistent. The presence of flank pain for a few seconds may not be stone related. However, if that pain is persistent, consider that this may in fact be a stone.

My experience with stone patients has taught me that individuals have a heightened degree of suspicion once they had a stone attack. Every patient recalls that first time they experienced flank pain associated with a stone. While it may have taken several days for it to crescendo into “full blown” flank pain, patients often recall several days or even a week of suspected “gas pain” or even “muscle ache” that the individual self-diagnosed and nursed on their own before they ended up in the ER.

Moving forward, after that first bout of pain, patients have a heightened degree of suspicion about what stone pain is all about. Their threshold for suspected stone pain is much less for making that “self” diagnosis and calling the urologist. While this is ideal for not allowing the pain to linger into a full-blown flank pain, the room for misdiagnosis and “the boy who cried wolf” potentially greater. Remember, not all flank pain is stone related. Not all stones present with pain. Be aware and be vigilant!