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April 11, 2020

Does Size Matter…When It Comes to Kidney Stones? Dr. Mistry and Donna Lee Answer a Listener’s Question on Kidney Stone Treatment

Speaker 1: 

Welcome back to the Armor Men’s Health Hour with Dr. Mistry and Donna Lee.

Dr. Mistry: 

Hello and welcome back to the Armor Men’s Health Hour. I’m Dr. Mistry, your host, board certified urologist, and consummate professional, here with my cohost, Donna Lee.

Donna Lee: 

That’s right. I’m always professional as well, on Monday and Tuesdays.

Dr. Mistry: 

You know, despite what’s going on in the community related to the Covid-19 crisis, some things haven’t taken a back seat.

Donna Lee: 

Speaking of seat…well no, there’s no segway.

Dr. Mistry: 

No, there’s no segway for that. In this case, kidney stones. Kidney stones still are occurring and they’re still driving people to the emergency room. It’s the main reason that we are having to go to the emergency room to treat patients.

Donna Lee: 

I know it’s terrible. It’s about to be kidney stone season, isn’t it?

Dr. Mistry: 

It is.

Donna Lee: 

When it gets hot.

Dr. Mistry: 

It is. Under better circumstances, we would be celebrating a urology Christmas…

Donna Lee: 

Right?

Dr. Mistry: 

…which is when the dehydration and heat that accompanies summertime leads to an increased formation of stones, and thus leads to tremendous ER visits, lots of ER calls, and then of course lots of patients seen in the clinic for kidney stones.

Donna Lee: 

You know, I have a funny story about kidney stones in our family. My husband has a pretty unique Italian last name–not McBride. His brother was seen at the Lakeway hospital, same last name, for kidney stones.

Dr. Mistry: 

Yes.

Donna Lee: 

And then the ER doctor, like we were making fun of him, telling him what a pussy was for having kidney stones, just giving him crap about being so weak that he had kidney stones. And then a week later, my husband had kidney stones. Ended up at the same year at the same doctor, and the guy was like, “I’m going to break every HIPAA law, but I’m imagining y’all are related.” So now I think it’s genetics.

Dr. Mistry: 

That’s very funny. I like that.

Donna Lee: 

And then we drink the same water because we’re in the same neighborhood, is that it?

Dr. Mistry: 

It’s not even the funniest story of that stone. Of course, he got married right afterwards and I had to take care of his kidney stone.

Donna Lee: 

In Las Vegas.

Dr. Mistry: 

In Las Vegas. You know, that raises an interesting question on whether or not there’s a genetic basis for kidney stone formation. When you acutely have a stone and have pain, you may or may not need surgery for it depending on the size, the location, and the degree of obstruction, the amount of pain, or whether or not it’s associated with a fever. But that’s the immediate aftermath. So there’s sometimes surgery required, whether it be invasive or noninvasive, using ultrasound and shockwave. Sometimes stents and other kinds of prosthetic type drainage devices are necessary. And then once you recover from that, where is your urologist pointing you towards? Are they doing additional tests to determine what changes in your life or lifestyle you might need to make that are going to help you from getting stones? I hear every day from patients coming up with old wives tales kind of ideas of why their stones formed, or what they should do about it.

Donna Lee: 

What are they?

Dr. Mistry: 

You know, sometimes they’ll talk about putting a little bit of lemon in your water, or that I drink too many Diet Cokes, or that it’s the hard water that I’m drinking. And these are, they may have a like glimmer of truth, but not necessarily the truth about what’s going on with you. A little bit of lemon in your water is not going to give you the citrate you need to dramatically reduce your stone formation. Whether or not Diet Cokes or any type of sodas are the main cause of your of your stone formation, we can find out using testing, and there’s no real difference that Diet Coke versus regular Coke would have any other difference on stone formation.

Donna Lee: 

I know somebody drinks too many diet Cokes.

Dr. Mistry: 

Well, you know…

Donna Lee: 

He’s in this room, 6 feet away.

Dr. Mistry: 

Well, you know, 6 feet safe distance. I can still throw a stapler at you. And then the issue of hard water, so even if you have lots of calcium deposits in your, in the water that’s being, circulating through your house, the likelihood that that calcium that you’re consuming by liquid is then contributing to calcium stone formation is very low. In fact, our bodies have an amazing mechanism of modifying how much calcium our gut absorbs. So that’s less likely. Instead of kind of haphazardly throwing darts at the board wondering what is the cause of stone formation, really it would be in your best interest, especially if you’re a recurrent stone former, to go through a formal 24 hour urine and blood collection type analysis in which we can very, very accurately pinpoint what is it about your metabolism that’s leading to stone formation. Even if you don’t have a stone that we can analyze for its composition, it’s okay. That 24 hour urine testing is something covered by insurance and can give us a wealth of information, including the amount of hydration that you need to be considered at low risk for stone formation, whether or not you have enough of the stone busting chemicals that we like to see in the urine–citrate and magnesium–whether or not you are at risk for calcium oxalate formation, calcium phosphate formation, uric acid formation–hese are all different types of stones–a wealth of information. And it’s not just that you’re going to be put on some kind of highly restrictive diet. Most of the time, just a small reduction in the intake of sodium or the intake of certain types of chemicals called oxalates or certain types of animal proteins, just small amounts, 10%, 20%, 30% reductions can make a dramatic difference on your stone formation risk. And then we have Robert Mendiola, our registered dietician right here in the office, that’s armed and ready to give you advice on exactly what you need to change.

Donna Lee: 

We also have something called KSP tabs.

Dr. Mistry: 

That’s right. KSB tabs were then bended by urologists. They have very high amounts of citrate and magnesium and we give them to all of our patients that are recurrent stone formers. It’s one of the things that you can do that gets a very dramatic difference in the amount of stone busting agents that are in the urine and it works from the very first tablet.

Donna Lee: 

It’s amazing. I’d hear women always talking into, our patients, always talking about how the kidney stone pain was more than childbirth, natural childbirth.

Dr. Mistry: 

Well, I’m never going to get to experience that.

Donna Lee: 

So I know it must be bad for you guys because y’all can’t handle pain like the women can, that’s for sure.

Dr. Mistry: 

Another interesting thing that I hear a lot from patients is that they’re surprised that small stones cause pain that’s different than what big stones caused. I hear it all the time. “Well, I can’t believe that that stone caused me so much pain. It’s only two or three millimeters.” When in fact the size of the stone and the amount of pain have no relationship to one another. Size does not matter.

Donna Lee: 

Oh, it doesn’t matter here?

Dr. Mistry: 

Apparently not here.

Donna Lee: 

That’s NOT what she said.

Dr. Mistry: 

That’s right. Sometimes really, really, really large stones can cause a silent obstruction and you not have any pain at all. And those are in many times the scariest kinds of stones. Recently this week, we had a patient who had a six millimeter stone that I’m convinced has been there since November because he had pain in November, it went away, and then all of a sudden he had pain and bleeding again here 5 months later. And he was surprised that it could be the same stone. But you know, if you have had a stone that caused pain, was identified on X-Ray and you didn’t see it passed and you’ve been having atypical symptoms like urinary urgency or frequency or intermittent bleeding in the urine, then it’s very likely that stone is still there and you will need to get evaluated again.

Donna Lee: 

Speaking of stone there, we had a perfect question, perfect timing. This gentleman sent in, “I’ve had a kidney stone with no symptoms for the last 4 years. Would you recommend if it’s not bothering me to just hope that it never moves? They’ve tried to blast it with sound but were unsuccessful. I’m wondering what my chances are that it will ever dislodge.”

Dr. Mistry: 

That’s a great question. So sometimes calcifications that we see in the kidney that don’t respond to shock wave lithotripsy are really not kidney stones at all. They’re just little bitty concretions of stone fragments on some of the internal anatomy of the kidney. In such a case, taking care of it has no value. But if it’s pretty clear that it’s a free flowing kidney stone, then there is a chance probably somewhere in the, you know, 20% to 30% chance that it could move at some point and start traversing the tube causing pain and…

Donna Lee: 

Is it typical, though, to sit there that long? 4 years?

Dr. Mistry: 

It sure can. It sure can. So, when we have that, if you, if you’ve already had it attempted to be treated once, I don’t usually recommend going again for another shockwave. But what I do try to do is do the testing and the changes to keep that stone from getting any bigger. Because that stone is a crystal. It’s going to be a certain size. And if the urine chemistry remains abnormal, it’s going to get bigger and bigger and bigger. And then the bigger it gets, the more problem it’s going to be to take care of it ultimately when it does decide to move. But another interesting thing that I do and had been doing for about 13 years, is something called positional therapy. So if the stone didn’t come out because it’s lying at the bottom of the kidney, the kidney is like a tub of water, and if it’s at the bottom of the kidney, it may not come out unless you kind of invert yourself. And so a lot of times, what we will do is have patients do a type of inversion therapy after shockwave to try and get these little fragments out of them. But if you have a stone that’s asymptomatic, that’s less than 4 millimeters, then doing nothing about it I think is a pretty reasonable approach except for the nutritional changes to keep it from getting bigger. But if it’s bigger than that, if it’s a 7, 8, 10 millimeter stone, then really what you’re at major risk for is the stone causing blockage potentially in a silent way. If you’ve had more than one shockwave, I certainly wouldn’t consider doing another one. But if you have a large 10 millimeter stone or 8 millimeter stone in the kidney, then I would consider being seen and potentially having what’s called a ureteroscopy where we put the tube all the way up your tube into the kidney and use a little laser beam with direct visualization to treat it, especially if you’re at any higher risk–if you have diabetes, if you have anything that immunocompromise you, a predilection for urinary tract infections, if you have a solitary kidney, any history of any type of cancer, all of these things make suffering from a kidney stone even more dangerous for you, any preexisting kidney damage. And so for all those reasons, sometimes prophylactically taking care of these stones is in your best interest. What a great question, Donna Lee.

Donna Lee: 

That was a good question.

Dr. Mistry: 

I love our listeners.

Donna Lee: 

I know. I’m going to respond back to him to make sure that we get on the same page with him. And my favorite Friends episode is about kidney stones, so Google that. Google, “Friends kidney stone scene.”

Dr. Mistry: 

Funny. Well thanks a lot for a great show, Donna Lee.

Donna Lee: 

Yeah, thank you. That was fun. You can reach us during the week at (512) 238-0762. Email us these amazing questions so we can get them answered. And you can have a free consultation with Dr. Mistry every weekend. Armormenshealth@gmail.com. Our website’s armormenshealth.com. Have a great rest of your day!

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The Armor Men’s Health Hour is brought to you by Urology Specialists of Austin. For questions or to schedule an appointment, please call (512) 238-0762 or online at armormenshealth.com.

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