Intended for healthcare professionals

Endgames Case Report

A man with bilateral loin pain

BMJ 2013; 346 doi: (Published 09 May 2013) Cite this as: BMJ 2013;346:f2850
  1. Mohammed Hayat Ashrafi, core trainee year 2, general surgery1,
  2. Usman Bhatty, foundation year 2 doctor, urology1,
  3. Katie Hall, clinical fellow, urology1,
  4. Moeketsi Mokete, consultant urologist1
  1. 1Department of Urology, Lancashire Teaching Hospitals NHS Foundation Trust, Preston PR2 9HT, UK
  1. Correspondence to: M H Ashrafi mohammedashrafi{at}

A 65 year old man presented with a 12 month history of bilateral flank pain but no fever or lower urinary tract symptoms. Over the preceding 10 years he had had multiple interventions, including extracorporeal shock wave lithotripsy and ureteroscopic laser stone fragmentation, for cystine renal stones. He had type 2 diabetes and hypertension, and he was also obese.

A plain radiograph showed a large renal pelvic calculus measuring 3.4 cm in the right kidney and a 4.4 cm partial staghorn calculus projected over the left kidney. A dimercaptosuccinic acid scan showed a relative function of 47.5% for the right kidney and 52.5% for the left kidney.

A staged percutaneous nephrolithotomy was performed successfully on the simpler right stone, but postoperatively he developed pain in the right loin. A nephrostogram showed debris partially occluding the right ureter, which resulted in a filling defect; this was thought to be a clot and it later passed. Stone analysis confirmed cystine stones. Three months later a percutaneous nephrolithotomy was undertaken on the left side. Postoperative recovery was uneventful and radiography showed no residual stones.


  • 1 What is the most common clinical presentation of renal tract stones?

  • 2 What are the causative factors for renal tract stones?

  • 3 What are the causes of loin pain and what investigations are used to differentiate them?

  • 4 What is the best management approach for staghorn calculi?


1 What is the most common clinical presentation of renal tract stones?

Short answer

Loin pain.

Long answer

The presentation of renal tract stones can vary. The classic presentation is sudden onset excruciating loin to groin pain, which causes restlessness and severe distress.

The narrow …

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