Introduction

Urolithiasis is now one of the most common diseases ailing humanity with ever increasing worldwide incidence and prevalence (1). Literature reports that 12 % of men and 6% of women will have Ureteric colic once in their lifetime. Majority of patients with ureteric colic do not require intervention. But the recurrence rate is as high as 50% (2,3,4,5). Ureteric Colic is one of most common emergencies in medical practice. It is typically described as severe lateralizing flank pain radiating to groin with or without microscopic hematuria (6,7)

Colic Equivalent denotes atypical clinical presentation of Ureteric stone with referred testicular and/or penile tip and/or groin pain with or without lower urinary tract symptoms (LUTS) without classic severe flank pain (3,5,8). Colic Equivalent is a new terminology and author intends to emphasize on uncommon presentation of a common pathology- Ureteric Stone. The emphasis is well justified as significant counts present with such atypical symptoms to Emergency and Out-patients Department but are disposed unidentified for needful Urology referral. In fact, they frequently receive treatment for Epididymo-orchitis and Prostatitis with Testicular/groin pain and LUTS. And there is delay in diagnosis of ureteric stone with resultant complications like persistent pain misery and renal dysfunction (9). Similar equivalence is seen for atypical presentation of Angina Pectoris for Coronary event and the term is both established and recognized as Angina Equivalent (10,11). This includes presentations other than chest pain like neck pain, arm pain, sweating etc. Angina equivalent is a well-known terminology, generating adequate response for prompt identification and management. It is this pre-existing terminology of ‘Angina Equivalent’ that led the author emphasizing for ‘Colic Equivalent’. In clinical practice, we often find atypical presentations for various illnesses but few of us recognize the importance of sharing their experience. Such experience sharing has major impact on improving patients’ care. It is with similar intentions, case details of a patient will be shared in following paragraphs. Author practicing in stone belt region has experienced various atypical presentations for symptomatic ureteric stones and those symptoms are acknowledged widely in literature. These include groin, Testicular & nonspecific abdominal pains, LUTS with predominantly Storage type (Frequency & Urgency) with or without dysuria and Strangury. All those with testicular pain had normal physical examination with normal Scrotal Ultrasonography. Some of the patients had all routine investigations (CBC, Creatinine and Urine Analysis and even Ultrasound and Xray KUB) reported as normal. In such patients, with high index of suspicion and persistent symptoms CT Abdomen Pelvis without contrast was performed to yield a Ureteric stone. One such patient is described in this Case Report.

Discussion

Traditionally described ‘Renal Colic’ emerges as lateralizing flank pain due to smooth muscle contraction waves from pelvicalyceal system down to UVJ in response to partial or complete obstruction in the Urinary tract. Lately the term is appropriately changed to ‘Ureteric Colic’ as pain is secondary to ureteric obstruction. The obstruction here is most commonly related to stones followed by blood clot and papillary necrosis slough. It is interesting to note that the severity of pain has no correlation to size of the stone and a 3 mm stone may cause more intense pain than a 10 mm or larger stones.

It is well observed by clinicians that patients with ureteric stones do present with atypical symptoms as referred pain in Scrotum (Labia Majora in females), Testis, penile tip or groin region. They do present with nonspecific abdominal pain with or without Lower Urinary Tract Symptoms (LUTS) (7,8). Referred pain and other symptoms have anatomic and embryologic bases. Topographically it has been identified that few of the Longitudinal muscle fibres from ureter extends down to the urethra in the region of Veru Monatum (12). This explains the LUTS, pricking sensation at meatus and penile tip pain with ureteric stones. LUTS are also attributed to the widespread alpha receptors all along ureter (13). LUTS include predominantly frequency, urgency and strangury. Strangury is a strong desire to void with or without dysuria. This urge is mostly disproportionate to the volume voided, occasionally hardly few drops. Embryologically, kidneys have pelvic location which ascends to its abdominal position well before birth. This ascent explains the sharing of various dermatomes and nerves with different organs, thus causing the referred pain. The nerve supply of Kidneys, Ureter and Testis comes from following nerve roots (12,14):

Kidneys           T 8-12 and L1

Ureters             T10 to L2

Testis               T10, L1 and L2

This background clearly explains the symptom complex with ureteric stones and naming it as ‘Colic Equivalent’. The symptom complex is certainly not a classic presentation for Ureteric stone but patients not very infrequently do present with such symptoms as Testicular pain with normal physical examination, Penile tip or groin pain with or without dysuria, LUTS including Strangury and non-specific abdominal pain. Occasionally a young patient may present with Acute Urinary Retention and Radiologic investigation showing no Bladder or Urethral pathology but a ureteric stone. The Symptoms may some times mimic ‘epididymoorchitis’, ‘prostatitis,’ Urethritis and Urinary Tract Infections. Physicians may consider other differentials than ureteric stone, thus delaying actual diagnosis.

Hence history taking eliciting short onset, past history and Family history of stone formation, absence of extramarital contact and examination revealing normal scrotum/testis and meatus without palpable bladder along with application of basic knowledge help reaching diagnosis. Ignoring atypical symptoms with ureteric stones, may lead to longer sufferings, running through physicians with pain, loss of work and renal dysfunction. Here renal dysfunction may be ‘reflex nephropathy’ for unilateral and obstructive nephropathy with Bilateral ureteric stones ( 15). So it is essential to identify Colic Equivalents and prompt referral to Urologists. It is equally important for International Urologic Societies to recognize the symptoms complex-Colic Equivalents in guidelines and convey insurance companies similar message to regularize for needful in treatment process in terms of diagnosis, medication and surgical intervention.

Conclusions

Colic equivalents that include testicular and/or penile tip pain with or without dysuria and LUTS, are frequently observed as atypical presentation in patients with ureteric stones.

Early recognition of Colic Equivalents is crucial to reduce patients’ misery with pain and associated complications.

The term ‘Colic Equivalent’ should be duly recognized by Urological Societies in guidelines.

Reference

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