14 Urology seminar

Modern management of renal colic

ALISTAIR STEWART AND ADRIAN JOYCE

Renal stones are often asymptomatic, having been detected incidentally on imaging for other disorders. Renal stones
can, however, cause severe pain when they move or obstruct the drainage of urine. Topics considered in this review of
modern management of acute renal colic include clinical, laboratory and radiological diagnosis, analgesia, emergency
scenarios and definitive stone management, including ureteroscopy and extracorporeal shockwave lithotripsy.

Mr A.B. Stewart, BM, MRCS, Specialist Registrar in Urology; Clinical features

Mr A.D. Joyce, MS, FRCS, Consultant Urological Surgeon, St Small intra-renal stones are often asymptomatic, detected
Jamess University Hospital, Leeds.
incidentally on imaging for other disorders. Stones
rinary stone disease has a long history in the archives become symptomatic when they either move or have
U of medicine, with the earliest recorded examples being
detected in Egyptian mummies dated to 4800 BC.
reached sufficient size to cause loin pain or haematuria.
Pain secondary to a stone (colic), either renal or ureteric,
Urolithiasis continues to be a common disorder with an occurs when the stone obstructs the drainage of urine
increasing incidence. The average lifetime risk of stone with high pressure and is commonly described as one of
formation is 510 per cent.1 The historic predominance the most severe forms of pain experienced by a person.
of stone formation in men (3:1 ratio of men to women)2 Small stones (<4mm) usually pass spontaneously and
is changing, with equality of incidence being achieved may require no intervention. Larger stones are less likely
between the sexes this millennium. Most patients will pro- to pass, may become impacted and cause obstruction to
duce their first stone during their 30s and 40s. The typical urinary flow. Impaction in the ureter classically occurs at
stone types seen in the UK are: three anatomical sites:
calcium oxalate/phosphate, 70 per cent; the pelvi-ureteric junction;
infective (struvite), 25 per cent; at the level of the pelvic brim as the ureter crosses the
metabolic (cystine and urate), 5 per cent. iliac vessels;
Infective stones tend to present in children or later life, as the ureter enters the bladder, within the bladder wall
and metabolic stones earlier. (vesico-ureteric junction).
Renal colic typically presents with flank pain that radi-
ates to the groin as the stone passes down the ureter.
Box 1. Alternative causes of loin pain. Patients often find it impossible to be still, and writhe in
agony. As the stone passes on towards the vesico-ureteric
Vascular Gynaecological junction, patients can develop a strong urge to pass urine
Abdominal aortic aneurysm Ectopic pregnancy secondary to trigonal irritation. The pain of renal colic is
Endometriosis thought to be a result of ureteric smooth muscle spasm,
Renal Ovarian cyst rupture or torsion
oedema and inflammation at the level of the stone in asso-
Pyelonephritis Pelvic inflammatory disease
ciation with increased ureteric pressure and peristalsis
Renal abscess
proximally.
Renal tumours Testicular
Clot colic Testicular pain Renal colic is usually but not always accompanied by
Papillary necrosis Epididymo-orchitis nausea, vomiting and microscopic haematuria.
Pelvi-ureteric junction obstruction Testicular torsion Microscopic haematuria may be absent in up to 15 per
Renal infarction cent of cases.3 Abdominal signs are usually absent on
Ureteric stricture Medical
examination in renal colic.
Retroperitoneal fibrosis Herpes zoster
The presence of sepsis with loin pain and rigors sug-
Musculoskeletal pain
gests superadded infection, and the association of infec-
Gastrointestinal Pleuritis
Diverticulitis Pneumonia tion in an obstructed kidney is a life-threatening surgical
Appendicitis Radiculitis emergency requiring urgent hospital admission. After
Crohns disease Myocardial infarction blood and urine cultures, appropriate antibiotics must be
given immediately. The presence of hydronephrosis, con-

Trends in Urology Gynaecology & Sexual Health May/June 2008 www.tugsh.com


Box 2. Metabolic investigations for renal colic.
Urine
Volume, pH, calcium, urate, magnesium, citrate, phosphate,
oxalate, creatinine
Blood
Creatinine, potassium, calcium, urate, parathyroid hormone
firmed by ultrasound or computed tomography (CT), dic-
tates that urgent decompression with a percutaneous
nephrostomy is required.
The symptoms of renal colic may be confused with
other pathologies (Box 1).
Laboratory investigations
Urinalysis with a combination of dipstick and microscopy
is mandatory in all patients with renal colic. Microscopic
or macroscopic haematuria will be present in at least 85
per cent of cases. Attention should be paid to the presence
or absence of nitrites, leucocytes and bacteria indicative of
infection.
Urinary calculi are pH dependent. At alkaline pH,
infective struvite stones are more likely. The urea-splitting
organisms Pseudomonas or Klebsiella sp. are commonly asso-
ciated with these complex, often stag-horn-shaped, calculi.
An acidic pH predisposes to uric acid or cystine stone for-
mation in susceptible individuals. Calcium oxalate stones
are more common in neutral to acidic urine, pH <6.5.
Retrieved calculi are no longer routinely analysed
chemically. Two 24-hour urine samples and post-fasting
serum are now routinely taken to detect specific metabol-
ic abnormalities (Box 2).
Radiological investigations
A clinical diagnosis of renal colic should be supported by
appropriate radiological investigations. Traditionally, the
standard investigation was a plain kidney-ureter-bladder
(KUB) radiograph followed by an intravenous urogram
(IVU; Figure 1). This has now been replaced by non-con-
trast helical CT (Figure 2), with a sensitivity of up to 100 per
cent and a specificity of up to 98 per cent in the diagnosis
of acute flank pain.4,5 IVU has lower sensitivity and specifici-
ty (64 and 92 per cent, respectively) for investigating renal
colic and provides limited information about other condi-
tions that can be detected by non-contrast CT.4,5
Kidney-ureter-bladder radiograph
The plain KUB is simple, accessible and inexpensive.
However, not all stones are visible on plain films; they may
www.tugsh.com
Urology seminar 15
be radiolucent, too small or obscured by overlying gas,
stool or bone. Other calcifications such as phleboliths and
calcified lymph nodes can be mistaken for ureteric stones
on the plain KUB. KUB-detected calculi may be followed
on repeat films to track the progress of the stone.
Intravenous urogram
In units without access to emergency non-contrast CT,
IVU (Figure 1) may continue to be used in the diagnosis
of acute renal colic. It can provide useful information
regarding renal function, pelvi-calyceal and ureteric
anatomy and stone size. IVU should not be carried out in
patients with:
documented allergy to contrast media;
elevated serum creatinine >200mmol/l;
diabetes who are on metformin;
myelomatosis.
Renal ultrasound
Ultrasound is fast, easy, safe and relatively inexpensive to
perform. It is effective in diagnosing hydronephrosis and
renal stones. It may detect ureteric dilation, but its role in
the visualisation of ureteric stones is much less reliable.
Non-contrast helical CT
Non-contrast CT (Figure 2) is the most sensitive and spe-
cific diagnostic investigation in renal colic. It facilitates
rapid definitive diagnosis, provides information on non-
urological pathology and is now the investigation of
choice. Information regarding renal obstruction has a
major influence in the treatment algorithm of renal colic.
However, non-contrast CT provides no direct measure of
renal function, and obstruction can be inferred only by
the presence of perinephric stranding, uretero-
hydronephrosis and urinoma. Non-contrast CT can over-
estimate the craniocaudal stone length;6 the technique is
expensive, is not always accessible, and delivers a slightly
higher radiation dose than multifilm IVU. If helical CT is
not available, plain film KUB plus ultrasound is an alterna-
tive option.
Pain management
Non-steroidal anti-inflammatory drugs and opioids
Non-steroidal anti-inflammatory drugs (NSAIDs) and opi-
oid analgesics remain the mainstay of analgesia for acute
renal colic. Their effectiveness is similar.7 In practice, rec-
tal administration of an NSAID is often the first-line anal-
gesia, followed by intravenous opiate for refractory pain.
NSAIDs act by inhibiting prostaglandin synthesis; in renal
colic this reduces ureteric oedema, inflammation and
spasm. Inhibition of prostaglandin synthesis in the kidney
Trends in Urology Gynaecology & Sexual Health May/June 2008
16 Urology seminar
Figure 1. Intravenous urogram showing an obstructing left ureteric calculus.
prevents afferent arteriolar vasodilatation and increased
vascular permeability, which would otherwise promote
diuresis and a rise in renal pelvic pressure. As this mecha-
nism may involve a decrease in renal blood flow, care must
be taken in patients with pre-existing renal failure, which
can potentially be exacerbated. Intravenous opioids can
be titrated to give rapid effective pain relief in renal colic
refractory to NSAIDs, in spite of the evidence that they
might increase ureteric tone.8 An anti-emetic is usually
prescribed with the opioid.
Alternative drug therapy
Antimuscarinic drugs such as buscopan decrease ureteric
activity and can be used in renal colic, although their use is
often limited by quite significant side-effects. Calcium chan-
nel antagonists have been trialled in renal colic; however,
the results have been conflicting,9 and, as such, they are not
currently in routine use. A recent meta-analysis including
11 randomised control trials of alpha-receptor antagonist
therapy for the treatment of ureteric stones has shown that
their use significantly improves the rate of spontaneous
stone expulsion from the distal ureter.10 Many centres now
routinely use alpha-receptor antagonist therapy in selected
cases of ureteric colic. The proposed mechanism of action
is via alpha-1 adrenoceptor-mediated ureteric smooth mus-
cle relaxation.
Management of ureteric stones
Emergency scenarios
All cases of suspected renal colic presenting in primary
care require referral. Patients whose symptoms are man-
ageable with oral NSAID analgesia and an anti-emetic may
be referred for an urgent outpatient opinion. If present,
the degree of ureteric obstruction does not always corre-
Trends in Urology Gynaecology & Sexual Health May/June 2008
Figure 2. Non-contrast computed tomography scan of a distal right ureteric
stone (arrow). The opacity seen on the left is outside the ureter and
represents a phlebolith.
late with the severity of pain. Obstructing ureteric stones
must be treated promptly to prevent irreversible loss of
renal function.
Emergency scenarios requiring urgent urological
admission include: renal colic refractory to oral analgesia;
the infected, obstructed kidney requiring urgent decom-
pression with a percutaneous nephrostomy; anuria; or
acute renal failure secondary to suspected bilateral ureteric
obstruction or suspected obstruction in a solitary kidney.
Definitive stone management
Once obstruction has been excluded and following ade-
quate analgesia, a structured management plan can be
formulated, influenced by the size and site of the stone
with regards to the efficacy of treatment.
Stones less than 4mm in size will pass in 80 per cent of
cases;11 thus stones less than 5mm are generally given an
opportunity to pass spontaneously. Stones greater than 7mm
have a low chance of spontaneous passage, but the overall
passage rate also depends on the stone location. Distal stones
are more likely to pass spontaneously than more proximally
located stones; therefore small distal ureteric stones can be
treated conservatively with analgesia and an alpha-blocker
and reviewed two to three weeks later with a KUB in clinic, or
ultrasound if the stone is radiolucent.
The indications for surgical intervention include:
stones larger than 6mm;
failure of conservative management;
persistent pain or concern over obstruction or renal
failure;
patient choice, eg airline pilots are grounded until they
are stone-free.
www.tugsh.com

Figure 3. Ureteroscopic view of a ureteric calculus.
The treatment options for ureteric calculi include:
ureteroscopy and fragmentation of the stone, with either
a laser or ballistic device;
extracorporeal shockwave lithotripsy (ESWL).
Shockwave lithotripsy is a non-invasive method of frag-
menting stones by the generation of shockwaves outside the
body, which are focused on the stone using X-ray or ultra-
sound guidance. ESWL can be used for favourably situated
ureteric stones in the emergency situation. Stone fragments
must pass spontaneously, hence the risk of future fragments
becoming impacted, causing ureteric obstruction, and
resulting in the need for further intervention.
The advent of ureteroscopy (Figure 3) means that the
whole of the urinary tract is now accessible to endoscopic
examination and manipulation, the safest and most com-
monly used technology being laser. Endoscopic surgical
intervention is associated with greater and faster stone-
free rates than either spontaneous passage or ESWL.
However, there is an associated operative morbidity, and
this has to be taken into consideration. Open surgical
intervention for ureteric calculi is now virtually a historic
procedure in established stone units.
Prevention and recurrence of renal stones
Recurrence rates vary from between 50 and 70 per cent
over 10 years. Most urologists advocate a basic metabolic
screen for patients who present for the first time and for
those who appear to be forming stones more frequently
than expected (Box 2). If detected, specific metabolic
abnormalities can be corrected. The aim is to prevent or
reduce the formation of new stones. In our series, more
than 80 per cent of patients had a detectable abnormality
of uric acid metabolism (36 per cent), calcium/oxalate
metabolism (27 per cent) or low fluid intake (17 per
www.tugsh.com
Urology seminar 17
cent), which are amenable to some form of improve-
ment.12 The problem is that, to be effective, the treatment
has to be continuous and possibly lifelong, resulting in
poor patient compliance. The easiest advice in the
absence of any definable metabolic disorder is to main-
tain a high fluid intake with a 24-hour urinary volume
in excess of 2 litres, keep to a reduced animal protein
and low sodium diet and avoid excess weight gain.
References
1. Tiselius HG, Ackerman D, Alken P, et al. Guidelines on urolithiasis. Eur
Urol 2001; 40(4): 362-71.
2. Fetter TL, Zimskind PD. Statistical analysis of patients with urinary
calculi. JAMA 1961; 186: 21.
3. Press SM, Smith AD. Incidence of negative haematuria in patients with
acute urinary lithiasis presenting to the emergency room with flank
pain. Urology 1995; 45: 753-7.
4. Yimaz S, Sindel T, Arslan G. Renal colic; comparison of spiral CT, US
and IVU in the detection of ureteral calculi. Eur Radiol 1998; 8: 212-17.
5. Niall O, Russell J, MacGregor R, et al. A comparison of non contrast
computerized tomography with excretory urography in the assessment
of acute flank pain. J Urol 1999; 161: 534-7.
6. Van Appledorn S, Ball AJ, Patel VR, et al. Limitations of non contrast CT
for measuring ureteral stones. J Endourol 2003; 17: 851-4.
7. Cordell WH, Larson TA, Lingeman JE, et al. Indomethacin suppositories
versus intravenous titrated morphine for the treatment of ureteral colic.
Ann Emerg Med 1994; 23: 262-9.
8. Lennon GM, Bourke J, Ryan PC, et al. Pharmacological options for the
treatment of acute ureteric colic. Br J Urol 1993; 71: 401-7.
9. Davenport K, Timoney AG, Keeley FX. Conventional and alternative
methods for providing analgesia in renal colic. BJU Int 2005; 95: 297-300.
10. Parsons JK, Hergan LA, Sakamoto K, et al. Efficacy of alpha-blockers for
the treatment of ureteral stones. J Urol 2007; 177: 983-7.
11. Miller OF, Kane CJ. Time to stone passage for observed ureteral calculi:
a guide for patient education. J Urol 1999; 162: 688-90.
12. Olsburgh J, Chow W, Lloyd SN, et al. No stone left unturned. Br J Urol
1998: 81(4): 47.
KEY POINTS
A careful history is required in a patient with suspected renal
stones, to exclude other diagnoses.
A metabolic screen is recommended to detect specific metabolic
abnormalities in patients with renal colic.
An infected, obstructed kidney requires emergency treatment.
Non-contrast helical computed tomography has replaced the
intravenous urogram.
If stones are <4mm in size, treat conservatively with careful
follow-up.
Stones that are >6mm often need treatment using endoscopic
fragmentation techniques or extracorporeal shockwave
lithotripsy.
Advise patients to maintain a high fluid intake.
Trends in Urology Gynaecology & Sexual Health May/June 2008