Review
European Eur Urol 2001;39:241–249
Urology
Renal Colic: Pathophysiology, Diagnosis
and Treatment
Ahmed A. Shokeir
Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
Key Words
Kidney · Ureter · Colic · Stone · Obstruction
Introduction
Acute renal colic is one of the most anguishing forms of
pain in humans that needs quick diagnosis and treatment.
The magnitude of the problem is large worldwide; the life-
time risk of developing an acute attack of renal colic is esti-
mated at 1–10% [1]. It is caused by acute partial or com-
plete ureteric obstruction due to a calculus in the vast
majority of cases. In approximately 5% of the patients, re-
nal colic may be caused by abnormalities of the urinary tract
unrelated to a stone disease such as pyelonephritis and
pelviureteric junction (PUJ) obstruction [2]. A proportion of
up to 10% of patients with renal colic may have extrinsic
ureteral obstruction by a variety of other conditions includ-
ing intestinal, gynecological, retroperitoneal and vascular
lesions [2]. The aim of the present review is to provide new
insights into renal colic caused by a stone disease with spe-
cial emphasis on the most recent advances in this field. The
review is divided into sections discussing pathophysiology,
diagnosis and treatment.
Pathophysiology
The traditional explanation for renal colic has been that
the ureteric obstruction causes a direct increase in intralu-
minal pressure of the collecting system, physically stretch-
ing it, and stimulating nerve endings in the lamina propria.
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In response to this distension, the smooth muscle in the wall
of the ureter contracts as it tries to move the stone. If the
stone becomes lodged and unable to move, these muscles
develop spasm. A prolonged isotonic contraction leads to
increased production of lactic acid which irritates both
slow-type A and fast-type C fibers. Afferent impulses are
generated that travel to the spinal cord, adjoining it at the
T11 to L1 levels with subsequent projections to higher lev-
els of the central nervous system. This pain can also be per-
ceived in any organ sharing the urinary tract innervation
such as the gastrointestinal organs and other components of
the genitourinary system [3].
Moody et al. [4] showed that there is a triphasic change
in renal blood flow (RBF) and ureteral pressure (UP) fol-
lowing total unilateral ureteral obstruction (UUO): (i)
0–1.5 h, RBF and UP rise; (ii) 1.5–5 h, RBF falls while UP
continues to rise, and (iii) c5 h, RBF and UP fall together
[4]. The initial increase in RBF is due to preglomerular va-
sodilatation. Most of the evidence indicates that local pro-
duction of eicosanoids, mainly prostaglandin (PG) E2
(PGE2) and prostacyclin (PGI2), may account for the in-
creased RBF observed after the onset of obstruction [5].
The role of nitric oxide in reducing preglomerular vascular
resistance has recently been suggested [6]. The subsequent
decrease in RBF is due to an increase in intrarenal resis-
tance caused by preglomerular vasoconstriction. Consensus
does not exist on the mediators of vasoconstriction; among
these are: angiotensin II, thromboxane A2 and antidiuretic
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A.A. Shokeir, MD, PhD
University of Pittsburgh
Urology and Nephrology Center
Mansoura University
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Mansoura (Egypt)
Fax +20 966 2 66 95 541
hormone [5]. Reys and Klahr [7] recently provided evi- Table 1. Sensitivity and specificity of the diagnostic modalities of
dence that endothelin also has a role in preglomerular vaso- acute renal colic
constiction.
Study Number of Sensitivity Specificity
Within 1 h of acute UUO, there is an increase in UP fol- patients % %
lowed 4–5 h later by a decrease. This decrease is considered
as a defence mechanism against parenchymal atrophy and Clinical diagnosis
may explain, in part, the clinical observation of spontaneous Mutagi et al. [9] 85 73 46
Eskelinen et al. [10] 1,333 84 99
improvement in the severity of renal colic a few hours after
KUB
its onset in most of the patients. The decline in UP is due to Haddad et al. [8] 101 45 90
a decrease in glomerular filtration rate (GFR) and an in- Mutagi et al. [9] 85 58 69
crease in the venous and lymphatic reabsorption of urine Levine et al. [11] 151 59 71
(pyelovenous and pyelolymphatic backflow). The reduction Conventional US
Haddad et al. [8] 101 91 90
in GFR is due to a decrease in the net hydraulic pressure
Hill et al. [15] 61 66 100
gradient across the glomerular capillaries due to an increase Sinclair et al. [16] 85 85 100
in the tubular pressure caused by the increase in UP. KUB + Conventional US
Haddad et al. [8] 101 94 90
Palma et al. [17] 180 95 67
DUS
Diagnosis
Shokeir et al. [23] 117 88 98
de Toledo et al. [24] 191 70 93
Besides routine clinical examination, acute renal colic Tublin et al. [21] 32 44 82
has long been diagnosed by the traditional plain abdominal IVP
X-ray (KUB), conventional gray-scale ultrasonography Hill et al. [15] 61 85 100
Sinclair et al. [16] 85 90 94
(US) and excretory urography (IVP). In the past few years, Miller et al. [30] 106 87 94
the introduction of Doppler US (DUS) and noncontrast Yilmaz et al. [32] 112 52 94
computerized tomography (NCCT) has changed the strate- NCCT
gy of diagnosis of renal colic. Other less commonly used Dalrymple et al. [2] 417 95 98
methods include MRI and radionuclide renal study. Table 1 Miller et al. [30] 106 87 94
Fielding et al. [31] 100 98 100
summarizes the sensitivity and specificity of the most com- Yilmaz et al. [32] 112 94 97
mon diagnostic modalities of acute renal colic. Vieweg et al. [33] 105 98 98

Clinical Examination
Typical renal colic is felt as a colicky and constant ache
in the costovertebral angle just lateral to the sacrospinalis
and just below the last rib. This pain often spreads along the
subcostal area toward the umbilicus or lower abdominal
quadrant along the course of the ureter. In men, it may also
be felt in the bladder, scrotum, or testicle. In women, it may
radiate into the vulva. The physician may be able to judge
the position of a ureteric stone by the site of referral. If the
stone is lodged in the upper ureter, the pain radiates to the
testicle, since the nerve supply of this organ is similar to that
of the kidney and upper ureter (T11–12). With stones in the
mid ureter on the right side, the pain is referred to McBur-
ney’s point and may therefore simulate appendicitis; on the
left side, it may resemble diverticulitis or other diseases of
the descending or sigmoid colon. As the stone approaches
the bladder, inflammation and edema of the ureteral orifice
ensue, and symptoms of vesical irritability may occur.
Pain caused by a urinary concrement usually results in
microscopic hematuria and may be associated with gastro-
intestinal symptoms because of reflex stimulation of the
celiac ganglion and because of the proximity of adjacent in-
traperitoneal organs. Thus, renal pain may be confused with
pain of intraperitoneal origin. However, intraperitoneal pain
is seldom colicky, frequently radiates into the shoulder due
to irritation of the phrenic nerve and diaphragm, and the pa-
tients prefer to lie motionless to minimize the pain, whereas
patients with renal colic usually are more comfortable mov-
ing around and holding the flank.
Renal pain may be confused with pain resulting from
irritation of the costal nerves, most commonly T10–T12.
Such pain has a similar distribution from the costovertebral
angle across the flank toward the umbilicus. The pain, how-
ever, is not colicky in nature. Furthermore, the intensity of
radicular pain may be altered by changing position; this is
not the case with renal pain.
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242 Eur Urol 2001;39:241–249 Shokeir

University of Pittsburgh
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 Renal colic almost always occurs on the same side as the
underlying pathology, but rarely it may occur on the side
contralateral to the stimulus, a phenomenon termed ‘mirror
pain’ that has recently been described by Clark and Norman
[3]. Atypical presentation of renal colic may also occur in
patients with horseshoe kidneys or renal ectopia.
In a study by Haddad et al. [8], the clinical diagnosis was
accurate in only 70 of 101 patients in whom the kidney
problem was the cause of pain. Mutagi et al. [9] reported
that the sensitivity and specificity of a clinical scoring sys-
tem based on signs and symptoms was 73 and 46%, respec-
tively, in 85 patients with suspected renal colic. To sum up
the contribution of the most significant clinical diagnostic
factors, a clinical diagnostic score was recently built by Es-
kelinen et al. [10] and showed that acute abdominal pain
with short duration (b12 h), loin or renal tenderness and
hematuria (erythrocytes c10) are the most significant pre-
dictors of acute renal colic.
KUB and US
The simplest imaging examination for patients with re-
nal colic remains the KUB. The sensitivity of KUB in de-
tecting ureteral calculi ranges from 45 to 59%, thus provid-
ing limited value in the diagnosis of ureteral stones [8, 9,
11]. Superimposed bowel and bone obscure some calculi,
and vascular calcifications, especially pelvic phleboliths,
may be confused with stones. Moreover, faintly opaque and
nonopaque calculi could not be identified by KUB. Evi-
dence of an abdominal calculus on KUB is not a sure sign
that the calcification is in the urinary tract. Therefore, the
diagnosis of acute stone disease could not be confidently
made on the basis of KUB alone.
US has many attributes which make it ideal as a method
for initial evaluation and further follow-up of patients with
renal colic. It is noninvasive, quick, portable, repeatable and
relatively inexpensive. Moreover, the avoidance of ionizing
radiation and contrast material makes it an attractive screen-
ing modality in pregnancy and renal impairment. Conven-
tional gray-scale US helps in the diagnosis of acute renal
colic directly through visualization of calculi and/or indi-
rectly through demonstration of pyelocaliectasis. Moreover,
the recent introduction of DUS enhanced the value of US in
the diagnosis of acute renal obstruction through study of re-
nal resistive index (RI) and assessment of ureteric jets.
Gray-scale US allows direct demonstration of urinary
stones located at the PUJ, vesicoureteric junction (VUJ) and
in the renal pelvis or calyces. Transrectal or transvaginal US
may aid in the identification of distal ureteric stones [12,
13]. However, stones located between PUJ and VUJ are ex-
tremely difficult to visualize with US. Pyelocaliectasis or
Renal Colic: Pathophysiology, Diagnosis
and Treatment
separation by c5 mm of the renal sinus echoes is consid-
ered as an indirect sign of renal obstruction. Nevertheless,
dilatation of the collecting system depends on the size and
location of the stone, the duration and the degree of ob-
struction. It takes many hours for frank pyelocaliectasis to
develop after sudden, even complete obstruction. Conse-
quently, it is not surprising that US misses 20–30% of acute
obstructions caused by a ureteric stone [14–16]. Moreover,
a false-positive diagnosis of obstruction could occur in pa-
tients with pyelonephritis, vesicoureteric reflux, residual
dilatation after relief of obstruction or overdistension of
the bladder. The combination of KUB and gray-scale US
through demonstration of calculi and/or pyelocaliectasis is
very helpful [8, 17]. In a study by Haddad et al. [8], this
combination yielded a sensitivity of 94% and specificity of
90% in the diagnosis of acute renal colic.
DUS
DUS has recently been introduced in the diagnosis of ob-
structive uropathy through measurement of renal RI [18].
The RI is defined as: (peak systolic velocity – lowest dias-
tolic velocity)/peak systolic velocity. It has been observed
that obstructive hydronephrosis produces changes in
Doppler waveforms whereby an increase in downstream re-
sistance results in a more marked reduction in diastolic
blood flow than in the systolic component. This difference
causes an increase in RI. In chronic obstruction, an RI of
0.70 is accepted by most investigators as the discriminatory
value to differentiate obstructive from unobstructive dilata-
tion. This threshold value achieved a good diagnostic accu-
racy in diagnosing the presence or absence of chronic ob-
struction in the adult [18] as well as in children [19, 20].
Nevertheless, several studies confirmed that an RI of a0.70
is of limited value in the diagnosis of acute obstruction be-
cause the time is too short to allow RI to reach this thresh-
old value [21, 22]. More recent studies used the difference
between RI of obstructed and nonobstructed kidneys (∆RI)
and obtained satisfactory results [23–26]. With a ∆RI of
a 0.04 we have recently obtained a sensitivity of 95%, a
specificity of 100% and an overall accuracy of 99% in the
diagnosis of acute unilateral ureteric obstruction [26].
The advantage is that DUS involves no contrast medium
or radiation, but there are some disadvantages. The test is
operator-dependent, needs special experience and provides
very limited information about the level of obstruction. In
the presence of obstruction of a solitary kidney or bilateral
obstruction, albeit uncommon clinically, ∆RI is of no value.
Moreover, there is no universal agreement on the discrimi-
natory thresholds for obstruction for either RI or ∆RI. Dif-
ferences in the results could be attributed to differences in
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Eur Urol 2001;39:241–249 243
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the degree and duration of obstruction and the use of non-
steroidal anti-inflammatory drugs (NSAIDs). To achieve
the highest diagnostic accuracy, we advise performing DUS
before giving NSAIDs [27].
Another use of DUS in the evaluation of possible ob-
struction is the assessment of ureteric jets. When a ureter is
patent, a jet of urine can be detected within the urinary blad-
der near the vesicoureteric junction. With complete obstuc-
tion, no ureteric jet is detectable; partial obstruction of one
ureter can result in a continuous low-level jet pattern that is
asymmetric to the other ureter [28].
NCCT
Smith et al. [29] were the first to advocate the use of
NCCT in the diagnosis of acute renal colic. Several recent
studies confirmed that NCCT is an accurate radiographic
modality for the evaluation of renal colic giving a sensitivi-
ty of up to 98% and a specificity of up to 100% [2, 30–33].
When compared with IVP, advantages include safety be-
cause no contrast medium is required, therefore, NCCT is
attractive particularly in patients with contrast allergies and
those with pre-existing renal failure. In addition, NCCT
provides visualization of small radiolucent stones that may
not be seen on IVP while decreasing the time for comple-
tion of the diagnostic study. The procedure takes only 5 min
and in some health systems it has been estimated to cost no
more than IVP. When stone disease is absent, NCCT accu-
rately identifies other urinary and nonurinary abnormalities
to direct further imaging and management.
Regardless of composition, all stones are visible on
NCCT. In addition, several secondary NCCT signs of
ureteric obstruction are often present and they are useful
when a stone is not readily identified. These secondary
signs include ureteric and renal dilatation, stranding of the
perinephric fat, the soft tissue ring sign and perinephric
fluid.
There are a number of potential pitfalls in the interpreta-
tion of NCCT. Phleboliths within the pelvis can often be
seen along the normal anatomical course of the ureter and
they can mimic ureteric stones. The ring sign denotes visu-
alization of a rim of soft tissue surrounding a stone. This
sign likely represents the edematous wall of the ureter and it
is helpful in distinguishing stones from phleboliths. In addi-
tion, a gonadal vein can sometimes be confused with a di-
lated ureter and can be distinguished by following the supe-
rior course of the structure in question.
The main disadvantage of NCCT in comparison to IVP
is the absence of evaluation of renal function. Moreover, the
radiation exposure of NCCT is generally higher limiting its
use in pregnancy. In addition, CT services are not univer-
244 Eur Urol 2001;39:241–249
sally available, particularly throughout a 24-hour period,
and a radiologist is required for the accurate interpretation
of the films.
IVP
IVP has long been considered the diagnostic method of
choice for evaluating patients with renal colic. It is readily
available in every emergency department, reliable and rela-
tively safe and economic. Classical findings of an acutely
obstructed kidney include delay in the appearance of
nephrogram which becomes increasingly dense in subse-
quent films, delay in the appearance of contrast medium in
the pelvicalyceal system and a ureteric dilatation proximal
to the site of obstruction. However, IVP is associated with a
few limitations and complications, which are mostly due to
contrast-induced or allergic reactions particularly with ion-
ic contrast media which may occasionally result in fatal
anaphylactoid reactions. Since the advent of low-osmolari-
ty contrast media, the risk of fatal anaphylactoid allergy has
been markedly reduced to less than 1 in 100,000. Retro-
grade or antegrade pyelography may be carried out in some
patients in whom IVP is contraindicated.
Many centers still consider IVP as the reference standard
for the diagnosis of acute renal colic. Nevertheless, the in-
troduction of the recent DUS and the NCCT has reduced the
use of IVP in some other centers.
Other Methods of Diagnosis
MRI
MRI can provide anatomical information about a possi-
bly obstructed kidney without nephrotoxic contrast media
or ionizing radiation. Nevertheless, unlike CT, MRI cannot
provide direct image of the stone. In a recent study, MR
urography was prospectively compared with IVP in the as-
sessment of ureteric obstruction [34]. Among 41 obstructed
kidneys, MR urography correctly diagnosed obstruction in
100% and showed the site of obstruction in 80% [34]. MRI
has the potential to become a significant imaging modality
in obstructive uropathy, but there are too few studies to pro-
vide solid conclusions and more work is needed in this area.
Radionuclide Renal Study
Radionuclide renal study has been proposed by some au-
thors as an initial investigation in the evaluation of patients
with suspected renal colic. It has the advantages of provid-
ing functional and urodynamic assessment of each kidney
separately and giving prognostic information in cases of im-
paired function resulting from prolonged obstruction. How-
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Fig. 1. An algorithm for the diagnosis of re-
nal colic. KUB = Plain abdominal X-ray; US
= ultrasonography; DUS = Doppler ultra-
sonography; positive DUS = RI difference of
a0.04; negative DUS = RI difference of
d0.04; NCCT = noncontrast computerized
tomography.
ever, radionuclide study has several limitations that prevent
its wide acceptance as an initial procedure in the evaluation
of patients with suspected renal colic. It uses radioisotopes
and ionizing radiation and its results depend upon different
variables including renal function, state of hydration of the
patient and the type of the radiopharmaceutical. It is also af-
fected by the shape and distensibility of renal pelvis, gravi-
ty, presence of VUR and bladder filling. It is only by careful
consideration of all of the contributory factors, with stan-
dardization of as many as possible, that the results can be in-
terpreted with confidence. In a study by Gutman et al. [35].,
5 of 57 patients with severe or partial obstruction on the ra-
dionuclide study had a subsequent normal IVP and 5 of 23
patients with a normal radionuclide study showed partial
obstruction on IVP.
Guidelines for Diagnosis
The diagnostic approach of acute flank pain is contro-
versial and can vary from center to center, from city to city
or from country to country depending on what is considered
Renal Colic: Pathophysiology, Diagnosis
and Treatment
acceptable. Important factors include the local prevalence
of stone disease, the medical resources available, relative
costs within a particular system, and the merits and limita-
tions of each diagnostic modality. However, there is an in-
creasing trend towards noninvasive or minimally invasive
procedures. Our approach to diagnosis of acute renal colic
is given in figure 1. Many cases could be diagnosed through
initial screening by clinical examination, KUB and conven-
tional US. The noninvasive DUS, with a ∆RI of 0.04 as the
dividing line between obstruction and no obstruction, is
helpful in equivocal cases. NCCT is a very sensitive and
specific test, however, in view of some limitations it seems
more realistic to be reserved for cases in whom KUB and
US with Doppler assistance could not reach the diagnosis.
IVP is used for diagnosis in a few cases in whom other non-
invasive procedures are indeterminate. Nevertheless, IVP is
indispensable if interventional treatment is planned.
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Eur Urol 2001;39:241–249 245
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 Treatment
The goals of treatment of renal colic are to relieve the
pain and maximally preserve renal function by release of
ureteric obstruction. Although morphine and pethidine have
been the traditional agents for relieving the pain of acute
ureteric obstruction, more recently the NSAIDs have gained
increasing use. Sometimes, opiate analgesics are still re-
quired as rescue analgesia. Other less commonly used
methods of pain relief include intranasal desmopressin and
acupuncture.
NSAIDs
Many studies have documented the effectiveness of
NSAIDs in the treatment of renal colic [36–42]. NSAIDs do
not have the addictive potential of narcotics, yet provide the
same degree of pain relief in some clinical settings. In addi-
tion, NSAIDs do not produce significant respiratory depres-
sion, constipation, or mental status changes caused by nar-
cotics [36].
NSAIDs exert their multitude of clinical effect by in-
hibiting the cyclooxygenase (COX) pathway of arachidonic
acid metabolism and therefore decreasing PGs and throm-
boxane A2 production. PGs have been known to increase in-
trapelvic pressure through an initial increase in RBF and di-
uresis after acute UUO. PGs also sensitize pain receptors to
stimuli such as bradykinin and histamine and have effects
on central pain mechanisms [36]. Therefore, inhibiting PG
synthesis can reduce renal colic through a decrease in in-
trapelvic pressure and interference with both local and cen-
tral pain mechanisms. A study in dogs with acute UUO
showed 30–50% reductions in renal pelvic pressure after
administration of 4 types of NSAIDs [37]. Lennon et al.
[38] demonstrated that both pethidine and NSAIDs inhibit-
ed spontaneous contractile activity in ureteral segments.
These effects on the ureter may relieve colic and also facil-
itate stone passage. In an experimental study, Perlmutter et
al. [36] demonstrated that NSAIDs decreased RBF by 35%
in acute UUO. Further clinical studies are invited to inves-
tigate the effect of NSAIDs on RBF and GFR among pa-
tients with renal colic.
NSAIDs are used in the treatment of renal colic in a va-
riety of routes including the intramuscular, intravenous,
oral, rectal and sublingual. Laerum et al. [39] compared the
pain-relieving effect and safety of diclofenac administered
intramuscularly to indomethacin given intravenously and
found that the former had better analgesic treatment of renal
colic. The same authors conducted a double-blind random-
ized placebo-controlled trial with oral diclofenac to study
the prophylactic effect on renal colic recurrence and sponta-
246 Eur Urol 2001;39:241–249
neous stone expulsion rate. They demonstrated that oral
treatment with diclofenac was effective as short-term pro-
phylaxis of new colic episodes, especially during the first 4
days, and reduced the number of hospital readmissions sig-
nificantly. Nevertheless, the stone passage rate was not af-
fected [40]. A randomized clinical trial evaluated the effica-
cy of indomethacin, 100 mg rectally, versus 50 mg of the
same drug given intravenously and showed that the rectal
route was less effective than the intravenous route [41]. In a
recent study, Supervia et al. [42] compared the therapeutic
effect of 40 mg sublingual piroxicam with intramuscular
75 mg diclofenac, as a reference drug, on acute renal colic
in a randomized double-blind controlled clinical trial. They
concluded that sublingual piroxicam is as effective as par-
enteral diclofenac in emergency renal colic treatment. Fur-
thermore, its ease of self-administration increases patient
compliance and potential use in general practice [42].
As mentioned above, NSAIDs interfere with the COX
pathway of arachidonic acid. Currently, there are 2 types of
COX: COX-1 is present in all cells and constitutively ex-
pressed, and COX-2 is present in certain cells and responsi-
ble for inflammation. Evidence is now accumulating that
COX-2 inhibition provides the therapeutic effects of
NSAIDs, whereas inhibition of the constitutive COX-1 is
responsible for gastric and renal side effects. Most known
NSAIDs are inhibitors of both COX-1 and COX-2. Cur-
rently, there are some drugs that can selectively inhibit
COX-2 and leave COX-1 undisturbed, thereby providing
the therapeutic effects of NSIADs without their known side
effects. Examples of readly available COX-2 inhibitors are
meloxicam and celcoxib.
Other Methods of Pain Relief
In a recent study, El-Sherif et al. [43] used desmopressin
intranasal spray for treatment of patients with acute renal
colic due to stone disease and demonstrated a significant de-
crease in the pain intensity. This study is significantly ham-
pered by the lack of adequate controls and the small sample
size but, nonetheless, the high rate of favorable response
compels further investigation. The mechanism of analgesic
action of desmopressin in renal colic is uncertain. At the pe-
ripheral level, desmopressin may alleviate the acute renal
colic through its potent antidiuretic effect or by relaxing the
renal pelvic and ureteral smooth muscles. The central anal-
gesic effect of desmopressin by stimulating the release of
the hypothalamic β-endorphin is also proposed [43].
Acupuncture is another method for the treatment of renal
colic that is common in China. Lee et al. [44] performed a
prospective randomized study to compare the effect of
acupuncture and a conventional analgesic agent in the treat-
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ment of renal colic and showed that acupuncture is a safe
and effective alternative. The mechanism of acupuncture
analgesia may be related to its ability to increase cere-
brospinal fluid levels of endogenous opiates such as β-en-
dorphin and metenkephalin, which may modify sensory af-
ferent impulses at a spinal level.
Treatment of Ureteric Stones
If a stone is determined to be the cause of obstruction
and no complicating factors are present, then many patients
can be treated conservatively. Stones of d5 mm were re-
ported to pass spontaneously in 29–98% of patients if locat-
ed in the proximal ureter and in 71–98% if located distally.
Stones of 5–10 mm pass spontaneously from the proximal
ureter in 10–53% and from the distal ureter in 25–
53% of patients [45]. The rate of spontaneous passage di-
minishes as stone size increases. Onward progression of the
stone requires ureteric peristalsis, therefore, the use of anti-
spasmodics is likely to be unhelpful. Diuresis must be dis-
couraged in the presence of obstruction as it will increase
intraluminal pressure that will reduce effective peristalsis
[46].
Intervention is indicated if conservative treatment fails
or if complications occur such as infection, intractable pain
for c72 h or evidence of renal functional impairment. In
situ ESWL is the least invasive method of treatment and
it is successful in 88–91% of cases [47]. There is a general
consensus that the insertion of a ureteric stent does not im-
prove the results of ESWL. In an experimental study, Ryan
et al. [48] showed that in situ ureteric stents impair ureteric
motility, thereby delaying the transit time of ureteric calculi.
The use of a JJ stent may be required in patients in whom
the stone is causing a severe degree of obstruction and
mandatory in patients with a solitary obstructed kidney
[46].
Ureteroscopy is a safe and effective alternative to
ESWL. In a recent study, Tawfiek and Bagley [49] reported
success in all but 1 of 82 patients with proximal, middle and
distal ureteric stones. All their patients were treated in a
day-care setting, the authors reported no long-term compli-
cations.
When ESWL or endoscopic access is impossible or im-
practical because of ureteric anatomy or the size of the
stone, a laparoscopic approach may be a worthwhile alter-
native to open surgery [50].
If a ureteric stone is associated with infection and fever,
appropriate antibiotics must be given preferably through the
intravenous route. It may be necessary to perform tempo-
rary relief of obstruction through percutaneous nephrosto-
my (PCN), ordinary ureteric catheter or JJ stent. After re-
Renal Colic: Pathophysiology, Diagnosis
and Treatment
solution of the acute condition, the stone must be treated
appropriately.
Special Situations
Stones in Children
Urolithiasis in children are unusual in the United States
and Europe but are not infrequently seen in developing
countries. The incidence in the United States ranges be-
tween 1 in 1,000 and 1 in 7,600 hospital admissions annual-
ly [51]. Pediatric urolithiasis occurs in 3 epidemological
patterns: (i) endemic stones seen in the Middle and Far
East; (ii) infection-related stones occurring most commonly
in Great Britain, and (iii) metabolic stones encountered
most frequently in the United States and Scandinavian
countries.
ESWL is effective in children who can pass big stone
fragments more easily than adults. With continuing im-
provements to and advances in endourologic technology,
the endoscopic management of children with upper urinary
tract stone disease has become an increasingly viable alter-
native to open surgery [46]. Ureteroscopes as small as 4
french are available and are well suited for use in children.
The choice between ESWL and ureteroscopy must be tai-
lored according to the clinical situation.
Renal Colic in Pregnancy
Urolithiasis is an infrequent but significant problem dur-
ing pregnancy with a reported incidence of 1 in 1,500 preg-
nancies [51]. Ureteric stones in pregnancy cause flank pain
in 84–100% of cases. However, abdominal pain during
pregnancy is sufficiently common to lead to errors in the di-
agnosis. An incorrect diagnosis of appendicitis, diverticuli-
tis or placental abruption was made in 28% of patients with
a confirmed stone [52]. However, the almost universal find-
ing of hematuria in either the gross or microscopic forms
helps in the diagnosis.
The use of fluoroscopy for the diagnosis of stones during
pregnancy remains controversial. Several investigators
have highlighted the problems related to the exposure of
pregnant patients to X-rays and the incidence of tumors in
children who were irradiated during fetal life. It has been re-
ported that the first trimester is the only significant risk pe-
riod for limited ionizing radiation exposure during pregnan-
cy, after that time birth defects and spontaneous abortion
are unlikely. Therefore, some authors still recommend lim-
ited or three-shot IVP in the diagnosis of renal colic in preg-
nant women. US is the safest method of diagnosis; pyelo-
caliectasis is the main finding suggestive of renal
198.143.32.65 - 8/15/2015 1:25:13 PM
Eur Urol 2001;39:241–249 247
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obstruction. Nevertheless, the frequent finding of pregnan-
cy-induced upper tract dilatation makes gray-scale US a
nonspecific detector of obstruction. DUS strengthens the
role of US in this regard. We have recently shown that ∆RI
value of a0.04 is highly sensitive and specific in the diag-
nosis of acute unilateral renal colic in pregnant women [26].
Treatment of renal colic in pregnancy represents a sig-
nificant problem because renal colic may precipitate prema-
ture labor, and invasive therapeutic procedures may be
potentially harmful to the fetus. Therefore, conservative
temporizing treatments are commonly recommended when
urolithiasis is suspected during pregnancy. The safest anal-
gesics to use are opiate-based drugs, NSAIDs should be
avoided [46]. In 50–80% of cases, the stone is passed spon-
taneously. However, in some patients, the onset of fever, in-
fection and persistent pain may require treatment of the pa-
tient before spontaneous elimination of the stone. ESWL is
contraindicated and the available options are ureteroscopy,
an indwelling ureteric stent or PCN. Both ureteric stent and
PCN carry the risk of urinary tract infection, demand regu-
lar changing to avoid encrustation, and cause discomfort to
the patient, particularly if placed early in pregnancy. There-
fore, ureteroscopy seems the most suitable procedure and
has been shown to be safe and effective [53]. Nevertheless,
ureteroscopy must be carried out by an experienced urolo-
gist because if complications arise the fetus may be at risk.
Indinivan Stones
Indinivan sulfate is used for the treatment of HIV pa-
tients. It is poorly soluble and 20% is excreted unchanged in
the urine causing indinivan stones in up to 36% of the pa-
tients [46]. Pure indinivan stones cannot be visualized by
KUB or CT. A high degree of clinical suspicion is necessary
for diagnosis. Microscopic hematuria is always present and
characteristic rectangular crystals may be seen by urine mi-
croscopy with cross-polarized filters. Ultrasonography, IVP
and CT are much less often diagnostic than stones of other
constituents and ureteroscopy may be both diagnosic and
therapeutic [46]. Treatment is conservative in most of the
cases. Indinivan may be stopped temporarily and adequate
hydration must be insured [46].

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