How to Deal With (and Avoid) Kidney Stones with Dr. Manoj Monga

Podcast Transcript

Nada Youssef:   Hi, thank you for joining us. I'm your host, Nada Youssef, and you're listening to Health Essentials Podcast by Cleveland Clinic. Today we're broadcasting from Cleveland Clinic main campus here in Cleveland, Ohio, and we're here with Dr. Manoj Monga. Dr. Monga is the Director of the Center for Endourology and Stone Disease in the Department of Urology here at Cleveland Clinic. Today we're talking about kidney stones. Thank you so much for being here today.

Manoj Monga:  Nada, thank you, it's a pleasure to be here.

Nada Youssef:   Thank you, and please remember this is for informational purposes only. It's not intended to replace your own physician's advice. So, before we jump into topic, I'm just going to ask you some random questions, just personal, to get to know you better if that's okay. First of all, what is the best meal that you've ever had?

Manoj Monga:  The best meal would have to be my mom's curry.

Nada Youssef:   Okay, yes.

Manoj Monga:  But really, more important than what the meal is, is who you're eating with. It's a real pleasure to have had a chance to meet many people around the world and share in their cuisine.

Nada Youssef:   That's amazing, I love curry. And then if you could live anywhere, anywhere, and do the same thing you're doing, where would that be?

Manoj Monga:  Apart from Cleveland, really there's been many places I've had a fun opportunity to live in, Chicago, New Orleans, San Diego, and every city has its own character and its own culture. I feel I could live anywhere, because everywhere has something special.

Nada Youssef:   Good answer. And then if you weren't a physician today, what would you be doing?

Manoj Monga:  I'd be a musician. I'd love to be a musician and travel around and play and, again, get a chance to interact with people from different cultures.

Nada Youssef:   And what do you play?

Manoj Monga:  Saxophone.

Nada Youssef:   Oh, that's amazing, that's great. Well, today we're talking about kidney stones, and kidney stones send half a million people to the emergency room every year. In many cases, stones pass through the body naturally, but some stones may not pass and may require surgical treatments. So I wanted to talk about that, but before our discussion, can I have a moment for you to introduce yourself to our viewers and tell us what kind of patients you see?

Manoj Monga:  Certainly. I'm an urologist, an urologist is a surgeon who looks after illnesses of the kidneys, the bladder, the ureter, and other reproductive organs. My area focuses in kidney stones, we work both in regards to surgical therapy for stones as well as medical prevention and dietary prevention to try to avoid the surgeries that we're performing on a daily basis.

Nada Youssef:   Okay, so any urologist is also a surgeon?

Manoj Monga:  Yes, any urologist is also a surgeon.

Nada Youssef:   Okay. So first let's go ahead and talk about kidney stones. What are they made out of, what is the estimated size as well?

Manoj Monga:  Kidney stones typically are either calcium oxalate, calcium phosphate, or uric acid. A rarer type of stone is cystine. And stones range in size from a millimeter to three or four centimeters. They can come in all shapes and sizes and colors.

Nada Youssef:   So if someone thinks that they have a kidney stone, what kind of tests are performed to diagnose the patient?

Manoj Monga:  We always start off with eliciting a history, finding out why do they feel they have a stone, what type of symptoms do they have, an examination to see whether the discomforts they're having are in the region of the kidney. Then we would typically check a urine test to look for any signs of infection or blood, and from there would proceed to imaging.

Nada Youssef:   Okay. With imaging, are you able to determine the location, then, of the stone?

Manoj Monga:  Yes, there's a variety of types of imaging, ultrasound and CT scans. Some of them are better in terms of less radiation and cost, and some of them are better in terms of the accuracy with which they can give us information to help guide a patient.

Nada Youssef:   Okay. So let's talk about how they pass. Do they pass on their own? Obviously we know that there could be surgery as well. So can we talk about what things to expect, when is it time to see a physician?

Manoj Monga:  The most common presentation, the most common way that a stone will pass, is that a patient will report having an excruciating pain out of the blue, often waking them up or bringing them to their knees, and that pain is probably what characterizes kidney stone disease the greatest. The pain is typically underneath the ribcage, and can radiate towards the front. There can be some nausea and vomiting associated with this. Those would be the things that would most commonly lead to the patient visiting the emergency room and having the evaluation to see if the kidney stone is the issue.

Nada Youssef:   Okay, and then what are the options if the stone doesn't pass?

Manoj Monga:  The options if the stone doesn't pass depend on the size and location of the stone, as well as certain things related to the patient. Are they on blood thinners, are they slender or obese, those could tailor which therapy we recommend. In general, there would be four options: observing the stone to see if it would pass by itself; shockwave to break it up into little pieces; or one of two types of endoscopic procedures.

Nada Youssef:   Okay, great. Are kids also able to get kidney stones as well? Do you deal with pediatrics as well?

Manoj Monga:  Yes, kids also form kidney stones, though the most common age to present with a stone is around the age of 40-50. Unfortunately, the risk of kidney stones is increasing in children, so we do have to not only modify our surgical approaches to the smaller size of a child, but also work a little more closely on prevention.

Nada Youssef:   And you said the risks have been increasing?

Manoj Monga:  They have, yes.

Nada Youssef:   Is there a reason for that?

Manoj Monga:  The thought is that it's most likely related either to exercise or diet, or both. In the diet, the most common things that are associated with a higher risk or increasing likelihood of people forming stones is too much salt in the diet, and too much fructose.

Nada Youssef:   Okay, so too much sugar and too much salt is what kids are eating, and that's causing more kidney stones?

Manoj Monga:  Yes.

Nada Youssef:   So are there long-term consequences of having a kidney stone? And what is the risk of getting another one once you have one?

Manoj Monga:  The risk of forming a second stone after the first one is about 50/50 over the course of five years. The long-term effects, beyond repeated bouts of pain from passing the stone, are relatively few. The chance of having kidney damage of other long-term issues from a kidney stone are unlikely, as long as, if there is a stone that gets stuck, it gets treated in an expeditious manner.

Nada Youssef:   Okay. Now, I know we talked about treatment with some of these procedures, but how do you determine which procedure is right for each patient?

Manoj Monga:  We review the imaging, and when we discuss the types of imaging, the one that gives us the most information is a CAT scan. With a CAT scan, we can measure the size, the hardness of the stone, how deep the stone is in the body, and the location. Those four things would guide us as to whether the shockwave might be an alternative, or whether they would be better suited for an endoscopic approach.

Nada Youssef:   Okay, and then I've also read that open stone surgery, which is a major surgical procedure, is rarely performed, is that correct? What you're mentioning there are all minimally invasive procedures, correct? These are not open surgeries.

Manoj Monga:  Yes, that's right. The evolution of stone therapy really started in the 1980s, and since then there was a rapid change away from large incisions to minimally invasive approaches.

Nada Youssef:   So there are some chances that there may be a need for an open surgery for these kidneys, if it's too big?

Manoj Monga:  Typically not for a kidney stone. Sometimes people will have large stones in the bladder, in which case it might be better to remove it with an open surgery than to do something more endoscopic.

Nada Youssef:   Is there any way the stone passes without me knowing, or is it very, very painful for every single person?

Manoj Monga:  Some people are fortunate that they don't have much discomfort with their stone passage, but the majority of people would know.

Nada Youssef:   They would know, okay. And how long does it usually take once you have it? Or does it, again, depend on the size and location?

Manoj Monga:  It does depend on the size, yes. On average, it might take a few days if it's a one or two millimeter stone. But it might take up to three or four weeks if it's a six or seven millimeter stone.

Nada Youssef:   Wow, okay. And can these be fatal at all?

Manoj Monga:  On a rare occasion they can, most commonly if there is an associated infection. If one has a stone and an infection, if the urine isn't draining well, it can lead to serious issues.

Nada Youssef:   Okay, and then earlier you mentioned that some of the symptoms included sharp pain from the ribcage area you said?

Manoj Monga:  Yes.

Nada Youssef:   And then also nausea. Are there any other symptoms that, if we have it, could be a kidney stone?

Manoj Monga:  Yes, I might rephrase it that it's more of a dull ache that comes and goes in waves underneath the ribcage and radiating sometimes to the front.

Nada Youssef:   Okay, so it goes and comes back, it's not-

Manoj Monga:  Exactly right.

Nada Youssef:   Okay, it's not permanent. And then how about silent stones? I've heard silent stones have no symptoms at all. Why is that, and how would we know if we do have it?

Manoj Monga:  We believe that the pain occurs when the kidney gets blocked, so silent stones might be a stone that may even reach a large size, but somehow the urine finds a way around the stone. And without the blockage, there's no pain.

Nada Youssef:   Sure. And let's talk a little bit about the causes and the risks of developing those kidney stones. We talked about diet, you said fructose, sugar, and salt, as well as exercise. When you say exercise, lack of exercise could cause a kidney stone?

Manoj Monga:  Yes, and first maybe I'll backtrack to say that it's a combination, as with most things in medicine, it's genetic predisposition as well as how you live your life. Depending on the type of stone, up to 80% of your risk of forming a stone is related to your genetics. That doesn't necessarily mean that you can't modify that risk by being healthy, eating well, exercising, avoiding being obese. Certainly obesity and lack of exercise can increase your risk of stones.

Nada Youssef:   Okay. Now, lack of drinking water, does that cause kidney stones? I've heard that before, is that true?

Manoj Monga:  Yes, keeping the urine as diluted as possible will decrease the chance that crystals come together to form a stone. Whether it be water or any other type of fluid that one enjoys drinking, drinking a lot is important.

Nada Youssef:   Okay, so what do you recommend as a healthy diet for someone to prevent having kidney stones?

Manoj Monga:  The target is to drink about 2 to 2 1/2 liters of fluids a day, any type of liquids except for black tea and dark colas, those two things may increase your risk of stones. But anything else is good to drink. Limiting the sodium to less than 1500-2000 milligrams a day. Watching your salt, that means eating fresh, eating at home, eating healthy.

The third thing is taking an adequate amount of calcium. Often there is a misconception that one should limit your calcium if you have a calcium stone, but it's important to take an adequate amount of calcium a day, which means two to three servings per day of a calcium-rich food. And then the fourth thing is eating lots of fruits and vegetables, especially those that are rich in citrates, lemons, limes, oranges, and melons, because citrate is an important inhibitor of stones forming.

Nada Youssef:   Okay, great. So you mentioned black tea. I'm a big fan of black tea, can you tell me why, what is it about black tea that could cause kidney stones?

Manoj Monga:  Yeah, there's a substance called oxalate, which can be a component of some types of stones. And there's a high amount of oxalate in black tea compared to green tea. If one adds milk to the tea, then that'll help offset the oxalates because the calcium in the milk will bind the oxalates and prevent it from being a problem.

Nada Youssef:   Okay. So if someone's listening to us right now and they're having any of the symptoms that you just mentioned, when is it absolutely the time to call your physician?

Manoj Monga:  Anytime that you have a concern about your health, it's important to see your physician. The time is right now. If you are having things that you're concerned of, talk to your physician, they'll, as I mentioned, examine you, and elicit more details about what you're feeling, and decide whether imaging would be appropriate.

Nada Youssef:   Okay, and then once I see a doctor, let's say it's a kidney stone that is passing, do I still see a urologist who's also a surgeon, or do you see a different physician if no surgery is needed?

Manoj Monga:  The decision to see an urologist will be to a certain degree guided by either your primary doctor or the emergency room doctor who sees you initially. It's always helpful to see an urologist even if you pass your stone, there may be other stones that are silent in the kidney that need to be discussed. And then we can also work with you on the preventive aspects of stone disease.

Nada Youssef:   Sure. Now, when you mentioned that there are different types of stones, what predicts what kind of stone you end up developing?

Manoj Monga:  Once again, we come back to genetics. Part of what type of stone you form is likely related to your genetics. It may be related to your microbiome, which is the type of bacteria that are in your body. We try to predict what type of stone it may be by evaluating the urine with a test where you collect the urine for 24 hours, and that can often guide us not only as to what type of stone you're prone to, but also what are the best approaches to preventing those stones.

Nada Youssef:   Sure, sure. Okay, well this was short and sweet. But if there's anything else you would like to add for our viewers and our audience, to help them prevent any kind of development of kidney stones, what would you say?

Manoj Monga:  The general things I would tell people who don't necessarily have stones is to do the same things that your doctor tells you to be healthy for your heart, for your brain, which is eating well, exercising, getting good rest, and trying to avoid stress.

Nada Youssef:   Okay, avoid stress, that's a hard one now, isn't it? All right, thank you so much, it's been a pleasure.

Manoj Monga:  My pleasure.

Nada Youssef:   And to schedule an appointment with Dr. Monga, or another kidney stone specialist, please call 216-444-5600, and for more information please download our treatment guide at clevelandclinic.org/kidneystones. Thanks again to our listeners for listening today, and if you would like to listen to more of our Health Essentials Podcast from Cleveland Clinic experts, make sure you go to clevelandclinic.org/hepodcast, or you can subscribe on iTunes. And for more health tips, news, and information, make sure you're following us on Facebook, Twitter, Snapchat, and Instagram @clevelandclinic, just one word. Thank you, we'll see you again next time.