J Phys Ther. 2010;1:72-79. Ureteral Cal culi and Low Back Pain

Case report

Ureteral Calculi as a Source of Low Back Pain- a Case Report Sathishkumar Anandan MPT,a Deepak Sebastian BPT, PGDR, MHS, MTC, DPT, ND, PhD, OCS, FAAOMPT,b*

INTRODUCTION

ABSTRACT

Low back pain is one of the most common impairments encountered in physical therapy practice. The larger majority of low back pain is considered to be of an unknown origin. This presentation is termed as non 1,2 specific back pain. While this presentation still restricts thinking within the realm of muscular, skeletal and ligamentous structures, a wider degree of suspicion of structures outside of the musculoskeletal system is warranted. A treatment based classification system was proposed to increase awareness of potential non musculoskeletal sources of back pain. The system described three levels. The first level of classification or stage one is to determine whether the patient with low back pain is appropriate for physical therapy intervention or requires referral to an appropriate health care practitioner. In other words the symptom at hand is still back pain but the need being an appropriate determination of the source of origin, either fit for physical therapy 3 intervention or cross referral. The following case description of a 49 year old male with left sided back pain

This case report describes a 49 year old male with complaints of back pain that was diagnosed as degenerative low back pain and referred to the physical therapist. The mode of onset was insidious and the pain was intermittent with no relief from specific intervention as in rest, heat or analgesics. There was no report of changes in urinary frequency or color, and any vomiting sensation. This patient was appropriately screened by a physical therapist who suspected a pain origin that could potentially be of a viscerogenic origin. He was referred back to the primary care physician who ordered an ultrasound and a CT-KUB (Computerized Tomography-Kidney, Ureter, Bladder) which revealed a 10.5 mm calculi in the left upper ureter. The patient was then referred to a urologist who confirmed the findings and performed a ureterorenoscopy (URS) lithoclast fragmentation and J-J stenting under spinal anaesthesia. The result was an excellent symptomatic and functional outcome. The need for lateral thinking in the evaluation of non specific low back pain is enumerated. The treatment based classification system is a referenced model. The emerging role of the physical therapist in screening of back pain as a first contact practitioner and the responsibility therein, is described. Key words: Non-specific low back pain, physical examination, screening, viscerogenic low back pain Authors’ information: *- Corresponding author. [email protected]

a- Post graduate student and C-OMPT candidate, Tamil Nadu Dr MGR Medical University, Chennai, India. b- Clinical instructor and program director, Institute of Therapeutic Sciences, Northville, MI, USA. appropriately suggests the need for this mode of thinking. CASE DESCRIPTION History and clinical findings

The patient described

here was a 49 year old male who experienced pain in the left lumbar area radiating into the flank and buttock area of a three month duration. He denied pain radiating into the lower extremities.

Key points and pre-publication history of this article is available at the end of the paper.

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Case report The mode of onset was insidious and the pain was on and off with no relief from specific intervention as in rest, heat or analgesics. The pain increased with long standing and side lying and was relieved temporarily lying prone. The pain was not easily changed with position. He denied any difficulty or changes in urinary frequency or color and any vomiting sensation. He reported of relative relief of passing urine and stools. He is a type 2 diabetic and hypertensive, on treatment. He suggests a history moderate alcohol consumption and betel nut chewing for the past twenty five years. He consulted a family practitioner who performed a clinical examination and offered a diagnosis of degenerative arthritis of the low back. He then prescribed him analgesics which were of no effect on the pain. The patient continued to live with the pain which was sporadic for almost two months, as he has a busy entrepreneur who owned and managed a peanut oil factory. At the end of this period the pain was severe one night, however, not colicky. He availed the services of a house visit physician who administered a pain injection and analgesics and referred the patient to the physical therapist. On observation the physical therapist noted mild redness and puffiness on the left lumbar and flank areas. Movement tests revealed no restriction patterns except for side bending to the right that caused minimal discomfort. Myotomes and dermatomes of

the lower extremity were normal. Patella and ankle reflexes were 2+ with a normal plantar response on stroking the sole of the foot. He exhibited minimal tightness in his hip flexors and hamstrings. He had difficulty executing movement when the transverses abdominis was tested. Gluteus medius strength was 3+ bilaterally. Slump testing and straight leg rising was negative bilaterally. Palpation revealed excessive warmth in the left lumbar and flank areas. Murphy's sign was positive and elicited extreme 4 discomfort. The test involves placing the palm of one hand over the lower lumbar area at or below the thoraco-lumbar junction and applying a pounding force with the other hand over the dorsum of the hand placed on the back. Prior to the injection, during the acute episode, the patient described his pain to be 10/10 on the numeric pain rating scale. EVALUATION, DIAGNOSIS & PROGNOSIS

The negative findings on movement and neurological examination, and the positive finding on percussion with a relevant history and back / flank pain prompted the physical therapist to refer the patient back to the primary care physician. The primary care physician ordered an ultrasound examination which revealed 10.5 mm calculi in the upper part of the left ureter. He then ordered a CTKUB (Computerized Tomography-Kidney, Ureter, Bladder- figure 1a and 1b) which revealed a 10.5 mm

calculi in the left upper ureter. The patient was then referred to a urologist who confirmed the findings and suggested a ureterorenos copy (URS) lithoclast fragmentation and JJ stenting under spinal anaesthesia. An URS permits visual inspection of the interior of the ureter and kidney by means of a fiberoptic endoscope as for biopsy or removal or crushing of stones. A JJ stent is a specially designed hollow tube, made of a flexible plastic material that is placed in the ureter. It allows urine to flow from the kidney to the bladder even when the ureter is blocked with calculi. This avoids the kidney from being obstructed and avoids the severe pain that can occur when proper drainage does not occur. The possibility of an infection is 5 also reduced significantly. INTERVENTION/ OUTCOMES

An ureterorenoscopy (URS) lithoclast fragmentation and JJ stenting under spinal anaesthesia was performed. Following surgery the patient was placed under bed rest with a cathetral tube and the excess urine was passed with a mild amount of haematuria. Subjectively, the patient complained of a burning sensation with the cathetral tube, but he reported of a distinct decrease in pain intensity in the back and flank area. Two days later the urinary catheter was removed and the patient was discharged. The patient continued to experience some

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Case report

(1a)

(1b)

Figure 1a- Frontal view of CT-KUB (Computerized Tomography-Kidney, Ureter, Bladder) showing a calculi in the left upper ureter Figure 1b- Sagittal view of CT-KUB (Computerized Tomography-Kidney, Ureter, Bladder) showing a calculi in the left upper ureter

burning in the genital area and also reported mild haematuria on and off for three days. He reviewed with his surgeon two weeks later who advised resuming regular activity. At this time the patient was completely pain free except for minimal discomfort while lying on the left side.

indentation in the kidney that gives it its bean shape. As it enters the cortex, the artery branches to envelope the nephrons. The glomerulus, which contains a network of

tiny blood vessels known as capillaries is the filter found in the nephron. The fluid filtered from the blood by the glomerulus then travels down a tiny tube-like structure called

DISCUSSION

The kidney is a bean shaped organs located at the level of the thoracolumbar junction, one on each side of the vertebral column. Each adult kidney is about the size of a fist consisting of an outer layer called the cortex, which contains a million filtering units, the nephrons. It then has an inner part, the medulla which has 10 to 15 fan-shaped structures called pyramids. These drain urine into the adjacent tubes called calyces. Blood travels to each kidney through the renal artery which is an extension of the descending aorta. It enters the kidney at the hilus, the

Figure 2- Anatomical proximity of the kidney, ureter and bladder and to the low back region (1. Kidney; 2. Ureter; 3. Renal artery; 4. Renal vein; 5. Bladder)

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Case report a tubule, which adjusts the level of salts, water, and wastes that are excreted in the urine. Filtered blood leaves the kidney through the renal vein and flows back to the heart. While the blood is in the kidneys, water and some of the other blood components (such as acids, glucose, and other nutrients) are reabsorbed back into the bloodstream. The remainder of the fluid is urine which is a concentrated solution of waste material containing water, urea, salts, amino acids, byproducts of bile from the liver, ammonia, and other substances that cannot be reabsorbed into the blood. The renal pelvis, located near the hilus, collects the urine flowing from the calyxes. From the renal pelvis, urine is transported out of the kidneys through the ureters, which are tubes that carry the urine out of each kidney to the urinary bladder. When the bladder is full, nerve endings in its wall send impulses to the brain, which helps the bladder walls to contract. At this time the sphincter, a ring-like muscle that helps to close the exit from the bladder to the urethra, relaxes. The urine is then ejected from the bladder and out of the body through 6 the urethra. Most calculi arise in the kidney when urine becomes supersaturated with a salt that is capable of forming solid crystals. Symptoms arise as these calculi become impacted within the ureter as they pass toward the urinary bladder Kidney stones typically leave the body by passage in the

urine stream, and many stones are formed and passed without causing symptoms. If stones grow to sufficient size before passage on the order of at least 2-3 millimeters they can cause obstruction of the ureter. The resulting obstruction causes dilation or stretching of the upper ureter and renal pelvis (the part of the kidney where the urine collects before entering the ureter) as well as muscle spasm of the ureter, trying to move the stone. Obstruction of flow of urine can cause distension of the kidney. This leads to pain, most commonly felt in the flank, lower abdomen and groin (a condition called renal colic). Renal colic can be associated with nausea and vomiting. There can be blood in the urine, visible with the naked eye or under the microscope (macroscopic or microscopic hematuria) due to damage to 7 the lining of the urinary tract. There are several types of kidney stones based on the type of crystals of which they consist. The majority are calcium oxalate stones, followed by calcium phosphate stones. More rarely, struvite stones are produced by ureasplitting bacteria in people with urinary tract infections, and people with certain metabolic abnormalities may produce uric acid stones or cystine 7,8 stones. Mechanism of pain generation

Obstruction of urine flow results in distension of the kidney causing pain. Renal disease, ovarian cyst rupture, pain fibers are primarily

preganglionic sympathetic nerves that reach spinal cord levels T-11 to L-2 through the dorsal nerve roots. Spinal transmission of renal pain signals occurs primarily through the ascending spinothalamic tracts. In the lower ureter, pain signals are also distributed through the genitofemoral and ilioinguinal nerves. The nervi erigentes, which innervates the intramural ureter and bladder, is responsible for some of the bladder symptoms that often accompany an intramural ureteral calculus. Pain from upper ureteral stones tends to radiate to the flank and lumbar areas. On the right side, this can be confused with cholecystitis or cholelithiasis; on the left, the differential diagnoses include acute pancreatitis, peptic ulcer disease, and gastritis. Midureteral calculi cause pain that radiates anteriorly and caudally. This midureteral pain in particular can easily mimic appendicitis on the right or acute diverticulitis on the left. Distal ureteral stones cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female because the pain is referred from the ilioinguinal or genitofemoral nerves. If a stone is lodged in the intramural ureter, symptoms may appear similar to cystitis or urethritis. These symptoms include suprapubic pain, urinary frequency, urgency, dysuria, stranguria, pain at the tip of the penis, and sometimes various bowel symptoms, such as diarrhea and tenesmus. These symptoms can be confused with pelvic inflammatory

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Case report or torsion and menstrual pain in women. Distention seems to be more important in the development of the pain of acute renal colic than spasm, local irritation, or ureteral hyperperistalsis. In the ureter, an increase in proximal peristalsis through activation of intrinsic ureteral pacemakers may contribute to the perception of pain. Muscle spasm, increased proximal peristalsis, local inflammation, irritation, and edema at the site of obstruction may contribute to the development of pain through chemoreceptor activation and stretching of submucosal free nerve 9-12 endings. Nausea and vomiting are often associated with acute renal colic and occur in at least 50% of patients. which is often compounded by the effects of narcotic analgesics, and nonsteroidal antiinflammatory drugs (NSAIDs) prescribed for the pain. Screening by the physical therapist

The history and physical findings in this patient were correlative to a suspicion of non mechanical low back pain being generated from renal calculi. The following are pertinent factors in the subjective and objective examination of back pain that may alert the physical therapist to the possible 13,14 presence of a renal calculi. The probability may further increase in the absence of relevant musculoskeletal signs and symptoms.

Figure 4- Diagrammatic representation of pain mediation to the lumbo-pelvic region from the kidney (1.ventral ramus; 2. dorsal ramus; 3. spinal cord; 4. dorsal root ganglion; 5.spinal nerve; 6. sympathetic trunk; 7. renal blood vessels; 8. renal nerves)

History Previous history of kidney stones Sudden onset of pain with no specific physical exertion Male gender more so caucasian High protein diet Obesity Hypercalcemia Living in a warm climatic environment Poor fluid intake or alcoholism History of diabetes, hypertension, hyperparathyroidism, renal tubular acidosis, irritable bowel syndrome, gout, and cystic fibrosis.

Medications such as antacids, steroids, colchicines, diuretics, dilantin, cefrinaxone, ciproflaxcin and indinavir. Physical examination Flank, groin, genital or back pain Pain does not easily change with position Blood in the urine Nausea or vomiting Urgency or feeling of relief on urinating Increased temperature general or local Enlarges lymph nodes in the groin Percussion or compression produces pain (Murphy’s sign )

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Case report Description of Murphy’s sign

As distension is described as the cause for pain, a firm blow over the distended area may reproduce or aggravate symptoms. This may be used by the physical therapist as an effective screening test when a kidney stone is suspected. The patient is seated in an upright position and is then instructed to bend forward. The examiner from behind, places the left hand flat upon the back of the patient over the kidney of the one side or the other, care being taken to have the hand pressed firmly upon the back. The clenched right hand of the examiner is then brought down with a firm force upon the dorsum of the fixed hand. If an acute congestion, infarction, or urethral obstruction exists in that kidney, the patient experiences pain with the blow. A control test by first using the blow on the ‘sound organ’ side and then on the suspected side, is recommended. Pain is reproduced on striking an over distended or inflamed viscus that contains extremely sensitive nerve endings.

Clinical relevance to the physical therapist

Low back syndrome is defined as a clinical entity that is characterized by the occurrence or presence of one or more of the following signs or symptoms: (a) pain in the area of the lumbosacral spine, buttock, or referred to the thigh area to the knee but thought to be of spinal origin; (b) pain,

Figure 5a and 5b- Steps in eliciting Murphy’s sign. (for detailed description, see text).

paresthesia, or other changes in cutaneous sensation located in the leg or foot area but believed to be of spinal origin (radicular symptoms); or (c) alterations in reflexes or loss of motor function in the lower extremities, again from spinal origin (radicular signs). Despite the limitations of

the traditional "pathology based model," which implies symptoms should be proportional to organ pathology, it continues to be a prevailing method of diagnosis of low back pain. To further complicate the situation, the physical

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Case report therapist may insist in her / his clinical reasoning that the organ of source is the musculoskeletal system ( facet, disc, nerve root and muscle). While this may be appropriate in a medical referral based practice system, it may prove erroneous in first contact practice where the patient seeks the service of a physical therapist without prior consultation with the medical practitioner. The reason being, organs other than the musculoskeletal system may refer pain in the low back region by passing the clinical judgment of the musculoskeletal trained physical therapist. With the advent of a first contact practice pattern, the physical therapist's collegial alliance with the medical model to rule out an emergent musculoskeletal, or a systemic source of pain is absent. The patient presenting with symptoms of pain may in actuality have pain of a systemic origin with varying degrees of vulnerability. The varying degrees of vulnerability necessitates the physical therapist to identify clinical situations at an appropriate time, as some of the conditions may be time sensitive from a management perspective termed red flags (appendix 1). Appropriate identification of a red flag or a systemic source of pain may necessitate an appropriate referral and constitute the abilities of a direct access practitioner. While this is considered the first stage in the treatment based classification model, one must clearly understand that this strategy poses no threat of infringement on the medical

model as to arrive at an accurate medical diagnosis. The intention is to only determine appropriateness of the patient for physical therapy intervention or cross referral. No pain has more relevance to the physical therapist than muscle and joint pain. When consumer awareness with regards to direct access to physical therapy improves, musculoskeletal pain may be a common symptom that leads the patient to physical therapy services. Traditional training may lead the physical therapist to think musculoskeletal but clearly an unaffordable practice pattern as a first contact practitioner. The mind may have to change, maybe permanently, better yet in the infancy of clinical practice. The following table depicts traditional thought process of evaluation in musculoskeletal physical therapy practice. However, literature suggests other additional sources to present as pain regionally i.e. back 15 pain suggesting a more elaborate mode of thinking in the evaluation process. REFERENCES 1. Taguchi T. Low back pain in young and middle-aged people. Japan Medical Association Journal. 2003;46:417–423.

4. Aldea PA, Meehan JP, Sternbach G. The acute abdomen and Murphy's signs. J Emerg Med. 1986;4:57-63. 5. Hofmann R. Ureteroscopy (URS) for ureteric calculi. Urologe A. 2006;45(5):37-46. 6. Michos O. Kidney development: from ureteric bud formation to branching morphogenesis. Curr Opin Genet Dev. 2009;19:484-90. 7. Hall PM. Nephrolithiasis: treatment, causes, and prevention. Cleve Clin J Med. 2009;76:583-91. 8. Kawakami N, Yamaguti S, Okuyama M, Katoh Y, Takashita N. Two cases of silicate urolithiasis (article in Japanese). Hinyokika Kiyo. 2006;52:49-53. 9. Ammons WS. Bowditch Lecture. Renal afferent inputs to ascending spinal pathways.Am J Physiol. 1992;262:165-176. 10. Ammons WS. Primate spinothalamic cell responses to ureteral occlusion. Brain Research. 1989 ;496:124-130. 11. Ammons WS. Responses of primate spinothalamic tract neurons to renal pelvic distension. J Neurophysiol. 1989;62:778-788. 12. Ammons WS. Electrophysiological characteristics of primate spinothalamic neurons with renal and somatic inputs. J Neurophysiol. 1989;61:1121-1130. 13. Trinchieri A, Mandressi A, Luongo P, Longo G, Pisani E. The influence of diet on urinary risk factors for stones in healthy subjects and idiopathic renal calcium stone formers. British J Urology. 1991;67:230-6. 14. Moe OW. Kidney stones : pathophysiology and medical management. Lancet. 2006;367:333344. 15. Collins RD. Differential diagnosis in primary care. Philadelphia; Williams and Wilkins; 2004.

2. Loney PL, Stratford PW. The prevalence of low back pain in adults: a methodological review of the literature. 16. Elton TJ, Roth CS, Berquist TH, Silverstein MD.A clinical prediction rule Phys Ther. 1999;79:384–396. for the diagnosis of ureteral calculi in 3. Delitto A, Erhard RE, Bowling RW. A emergency departments. J Gen Intern Med. 1993;8:57-62. treatment based classification approach to low back syndrome: identifying and staging patients for conservative treatment. Phys Ther. 1995;75:470- 489.

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Case report ACKNOWLEGMENTS

The patient for providing full consent to use his clinical findings, photographs and investigation films for this paper.

Key points: Past- Differential diagnosis and clinical reasoning were used in physical therapy practice to identify somatic and non-somatic sources of patient symptoms.

CONFLICTS OF INTEREST

None identified. Article pre-publication history: nd

Date of submission- 2 April 2010. Ref no- JPT-2010-ERN-111. Reviewer- P. Senthil Kumar Sent for revision and resubmission22nd April 2010. Date of resubmission- 28th April 2010. Reviewer- Arun Balasubbramaniam Date of acceptance- 2nd June 2010. Date of publication- 4th July 2010. WFIN: JPT-2010-ERN-111-1(2)-72-79

Present- The current case report is of a patient who presented with a non-mechanical low back pain, who was tested positive for Murphy’s sign, suggestive of ureteral calculi. Future- Screening for red flags and ruling out serious pathologies in patients attending physical therapy, is important for further medical referral so as to strengthen professional autonomy and independent first-contact practice.

Appendix 1 Comparison of hypothetico-deductive clinical reasoning for source of low back pain symptoms based on traditional thought process and the authors’ recommended thought process. Traditional thought process

Trauma Immobility Degenerative

Recommended thought process

Vascular Infection/ inflammation Malignancy Congenital Drug/ chemical Endocrine Auto-immune

Biochemical deficiency

Tendinitis, bursitis, neuritis, fractures, sprains and strains Post-operative state, disuse, post-traumatic state Osteoarthritis, disc degeneration, neuritis Abdominal aneurysm, renal infarct Epidural abscess, kidney stones (renal calculi) Multiple myeloma, prostate cancer Sacralization, spina bifida, retroflexed uterus Lipid lowering status Hyperparathyroidism, acromegaly Rheumatoid arthritis, systemic lupus erythematosis, uterine fibroid Vitamin B12, magnesium, vitamin-D deficiency

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