A 76-year-old male with past medical history of hypertension, lumbar spinal stenosis, morbid obesity, and erectile dysfunction presented to an emergency department with acute right-sided worsening of his chronic back pain. He was subsequently found to have a 7-mm obstructing right distal ureteral stone accompanied by hydroureteronephrosis on abdominal computed tomography (CT) imaging. He then underwent cystoscopy and right ureteral stent placement.
Following this episode of care at an outside institution, he presented to the emergency department at our hospital 1 week later with intractable right flank pain. He had no history of nephrolithiasis or urinary tract pathologies.
The patient was an obese and elderly gentleman, who appeared consistent with stated age and in mild distress. He was afebrile with normal vital signs. He did not have a leukocytosis, and his urinalysis revealed mild hematuria. Imaging from his recent encounter was unavailable. Outside records from his recent encounter were unavailable. Therefore, a stone-protocol abdominopelvic CT was obtained and revealed a well-placed stent, stable lower pole cyst, no hydroureteronephrosis, and a distal right ureteral stone that measured 8 mm by 9 mm and appeared to be crowning into the bladder (figure 1). His symptoms responded well to medical therapy and he was discharged with plans for outpatient follow-up, including surgical planning.
Four days later, however, he returned to the office complaining of severe right flank pain without nausea, emesis, fevers, lower urinary tract symptoms, or hematuria. Concern for failed trial of passage and possible re-obstruction of the right upper tract were discussed. This prompted consent and planning for endoscopic management. Further imaging prior to this was not considered in light of the patient presentation and recent imaging obtained.