Renal Colic Diagnosis and Treatment

Intravenous Pyelography

Ultrasound

Non-Contrast Helical CT

Treatment

Urine Straining

Hydration

Antibiotics

Pain Control

Medical Expulsive Therapy

Indications for Referral

References

About this Document

Generally, completion of spontaneous passage or facilitated passage of ureteral stones is reduced by increasing size of the stone and enhanced by distal location in the urinary tract. It is now possible to medically facilitate the passage of stones up to 10 mm. in diameter.

Diagnosis

Those with limited facilities and with limited skills in imaging interpretation will prefer abdominal plain films followed, if negative, by IVP, particularly if early diagnosis is needed. Other imaging options offer advantages.

Urinalysis

· Blood usually present, but absence does not exclude the diagnosis.

· If WBC’s present or a leukocytosis, consider UTI or sepsis and use antibiotic coverage.

· Urine culture should always be done.

Abdominal Plain Films

· Will miss radiolucent urate stones

· Will miss small stones overlying bone.

· Less sensitive for obstruction.

· Interpretation often difficult.

Intravenous Pyelography

· Best study in absence of a skilled Radiologist. Previous gold standard

· Good for diagnosis of obstruction.

· Risk of contrast reactions and increased radiation exposure.

Ultrasound

· Study of choice in pregnancy.

· Sensitive for obstruction.

· Can miss small stones in ureter.

· Requires skilled interpretation.

Non-contrast Helical CT Scan

· Requires skilled interpretation

· Present gold standard when available.

· Sensitive in diagnosis of obstruction.

· Often reveals alternative or accompanying diagnosis.

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Treatment

Major advances have been made in pain control and in medical expulsive therapy as an alternative to ultrasound and surgical modalities.

1. Strain urine and save any stones for analysis.

2. Maintain adequate hydration. There is no evidence for usefulness of forced hydration [1].

3. Antibiotics only if suspected UTI or sepsis. Vigilance is required in presence of complete obstruction and if there is prolonged time to stone expulsion. Urinalysis, culture and CBC should always be obtained.

4. Pain Control (Preferred therapy in bold)

· NSAIDS are often superior to narcotics, but higher and prolonged doses should be avoided in kidney disease and in the elderly.

· Rectal indomethacin 100 mg. produces equivalent relief to parenteral morphine after 30 minutes. Morphine produces relief more quickly [2].

· Ketorolac IV 30-60 mg. has been shown to be superior to meperidine [3, 4, 5, 6, 7]. It produces significantly less vomiting [8], and patients are fit earlier for discharge because of much reduced sedation and other adverse effects [5].

· Narcotic can be given in addition to NSAIDS or given as an alternative. The combination can be more effective than either alone [9].

· Metoclopramide 10 mg. every 4-6 hours can be effective for both pain and nausea [10]. It is necessary if narcotics are used, but often not needed with Ketorolac because of reduced incidence of nausea [11].

5. Medical Expulsive Therapy (Preferred therapy in bold)

· Nifedipine XL 30 mg. daily can increase stone expulsion rate from 35% to 79% when combined with a steroid [12, 13]. Number needed to treat (NNT) 3.9.

· Tamsulosin (Flomax) .4 mg. daily produces alpha receptor blockade and greatly increases chance of spontaneous stone expulsion [14]. NNT 3.3.

· Adverse effects for tamsulosin (hypotension, asthenia, dizziness, malaise and diarrhea) occur in 4% of patients. Nifedipine produces hypotension, palpitations, GI effects, headache, edema and asthenia in 15.4% [15].

· Prednisone 10 mg. bid in a 5 day burst without taper can be added to calcium channel or alpha blockade. This may be useful in reducing expulsion time for larger stones by reducing the intense inflammatory reaction [16].

· There is no convincing superiority for expulsion in comparing Nifedipine and Tamsulosin, however the latter has a much reduced incidence of side effects [15].

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Indications for Referral [17]

· Stone over 10 mm.

· High grade obstruction

· Urosepsis

· Acute renal failure

· Diminished renal reserve

· Anuria

· Unremitting pain, nausea or vomiting

· Non-passage of stone within 4-6 weeks.

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References

1. Springhart WP, Marguet CG, Sur RL, Norris RD, Delvecchio FC, Young MD, Sprague P, Gerardo CA, Albala DM, Preminger GM. Forced versus minimal intravenous hydration in the management of acute renal colic: a randomized trial. J Endourol. 2006 Oct;20(10):713-6.

2. Cordell WH, Larson TA, Lingeman JE, et al. Indomethacin suppositories versus intravenously titrated morphine for the treatment of ureteral colic. Ann Emerg Med 1994 23(2):262-269.

3. Cordell WH, Wright SW, Wolfson AB, et al. Comparison of intravenous ketorolac, meperidine, and both (balanced analgesia) for renal colic. Ann Emerg Med 1996; 28(2):151-158.

7. Wood VM, Christenson JM, Innes GD, Lesperance M, McKnight D. The NARC (Nonsteroidal Anti-inflammatory in Renal Colic) Trial. Single-dose intravenous ketorolac versus titrated intravenous meperidine in acute renal colic: a randomized clinical trial. CJEM. 2000; 2(2): 83-89.

8. Holdgate A, Pollock T. Nonsteroidal anti-inflammatory drugs (NSAIDS) versus opioids for acute renal colic. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD004137. DOI: 10.1002/14651858.CD004137.pub3.

9. Safdar B, Degutis LC, Landry K, Vedere SR, Moscovitz HC, D'Onofrio G. Intravenous morphine plus ketorolac is superior to either drug alone for treatment of acute renal colic. Ann Emerg Med. 2006; 48(2): 173-181, 181.e1.

10. Hedenbro JL, Olsson AM. Metoclopramide and ureteric colic. Acta Chir Scand. 1988; 154(7-8): 439-440.

11. Munro HM, Riegger LQ, Reynolds PI, Wilton NC, Lewis IH. Comparison of the analgesic and emetic properties of ketorolac and morphine for paediatric outpatient strabismus surgery. Br J Anaesth. 1994; 72(6): 624-628.

12. Porpiglia F, Ghignone G, Fiori C, et al. Nifedipine versus tamsulosin for the management of lower ureteral stones. J Urol 2004;172:568-71.

13. Saita A, Bonaccorsi A, Marchese F, et al. Our experience with nifedipine and prednisolone as expulsive therapy for ureteral stones. Urol Int 2004;72(Suppl 1):43-5.

14. Dellabella M, Milanese G, Muzzonigro G. Medical-expulsive therapy for distal ureterolithiasis: randomized prospective study on role of corticosteroids used in combination with tamsulosin-simplified treatment regimen and health-related quality of life. J Urol 2005;66:712-5.

15. Singh A, Alter HJ, Littlepage A. A systematic review of medical therapy to facilitate passage of ureteral calculi. Ann Emerg Med. 2007 Nov;50(5):552-63. Epub 2007 Aug 3.

16. Liu M, Henderson SO. Myth: Nephrolithiasis and medical expulsive therapy. CJEM 2007; 9(6): 463-465.

17. Curhan GC, et al. Diagnosis and management of suspected nephrolithiasis in adults. In: UpToDate, Rose BD (Ed), UpToDate, Waltham, MA, 2008.