Renal Colic

Introduction

Renal Colic (nephrolithiasis) is a common presenting problem to the emergency department. It occurs in 2-5% of the population at some point of their life, most often occurs between 20-50 years of age and is more common in men. 75% of stones are calcium based.

The immediate priority is pain relief. 90% of stones pass spontaneously

Larger stones (>5mm) are less likely to pass spontaneously.

Risk Factors

There are a number of pre-disposing factors including;

  • Dehydration

  • Hypertension

  • Prolonged immobilisation

  • Family history

  • Peptic Ulcer Disease

  • Hyperparathyroidism

  • Inflammatory Bowel Disease

  • Gout

  • Malignancy

  • Renal Tubular Acidosis

  • Drugs

    • Diuretics

    • Calcium supplements

Clinical Features

 

Symptoms

  • Pain

    • Typically abrupt onset, severe and colicky in nature

    • “Loin to groin” or LIF/RIF, Testes/labia

  • Nausea and vomiting are common

  • Haematuria

  • Urgency and frequency may occur

Signs

  • Uncomfortable, distressed patient, continually moving

  • Elevated HR and BP due to pain

  • If signs of sepsis present should be concerned for infected obstructed kidney

  • Usually benign abdominal exam

Complications

  • Infection/Pyelonephritis

  • Severe hydronephrosis and renal impairment

  • Pelvic calyceal rupture

Differential Diagnosis

Genitourinary

  • Pyelonephritis

  • Testicular pathology

  • External compression of ureter (ie: from tumour)

Gynaecology

  • Ruptured cyst

  • Ovarian torsion

  • Ectopic pregnancy

Gastro-intestinal

  • Diverticulitis

  • Appendicitis

  • Bowel obstruction

Vascular

  • Ruptured AAA

  • Retroperitoneal haematoma

Clinical Investigations

Dipstick%2BUrine%2Bjpg.jpg

Bedside

  • Urinary BHCG is mandatory in all women of child bearing age

  • Urinalysis

    • microscopic haematuria is common

    • 10-30% pts with nephrolithiasis do NOT have haematuria

    • look for evidence of infection

  • VBG – abnormal VBG concerning for sinister pathology not renal colic.

  • POCUS

    • out rule AAA

 
blood bottles.jpg

Laboratory

  • FBC – WCC often mildly elevated. Marked leucocystosis ? infection

  • U&E - ? evidence of renal impairment

  • CRP – if elevated concerning for infection or other DDx

  • LFT + Amylase – looking for other diagnoses

ureteric stone.png

Radiology

  • Non Contrast CT KUB = investigation of choice

    • Highly sensitive and specific

    • Shows presence of complications

  • Xray KUB – ONLY if CT positive for stone

    • Approx 60% sensitive.

    • If stone visible can be used to monitor position when followed up by urology

Treatment and Disposition

 

Initial Resuscitation

If patient requires resuscitation you should be concerned about more sinister pathology

 
 
 
 

Specific Treatment

  • Likelihood of spontaneous passage depends on size of stone and location within the ureter

    • < 4mm 90% will pass within 1 month

    • 5-7mm 50% will pass within 1 month

    • >7mm 5% will pass within 1 month

    • Proximal stones have a 25% likelihood of passing spontaneously vs 75% in distal ureteric stones

  • PO Alpha Blocker (Tamsulosin)

    • may increases likelihood of spontaneous stone clearance however more recent evidence suggests this might not be the case

    • alpha blockers do increase the risk of falls in elderly patients

  • Fever/Sepsis – Broad spectrum IV abx as per local guidelines. May require urgent discussion with interventional radiology re nephrostomy tube if infected obstructed kidney

  • Large obstructing stones may require operative intervention with urology e.g. lithotripsy

Symptomatic Treatment

  • Due to severity of pain analgesia is generally the immediate priority

    • IV Opioid titrated to effect for severe pain

    • PR diclofenac 100mg – NSAIDs are known to be as effective as opioids but have a longer onset of action time.

  • IV Anti-emetic as indicated

  • IV fluids if vomiting

 

Disposition

  • Stones < 5mm can generally be managed as an outpatient with simple PO analgesia including an NSAID +/- PO Tamsulosin with urology OPD follow up

  • Urology admission is necessary if;

    • Stone > 5mm

    • Stone in proximal ureter

    • Associated fever/sepsis

    • Intractable pain

    • Severe hydronephrosis

    • Single functioning kidney

    • Transplanted kidney.

 

References

1.    Ardense S. Renal Colic, in Cameron et al, “Textbook of Adult Emergency Medicine” 4th Ed. 2015

2.    Case courtesy of Dr Roberto Schubert, Radiopaedia.org, rID: 16407

3.    3. Cordell WH et al. Indomethacin suppositories versus IV titrated morphine for treatment of ureteric colic. Ann Emerg Med. 23:262-9 1994

This blog was written by Dr. Deirdre Glynn and was last updated in October 2020

Before you go have another look at the clinical case and see have any of your answers changed