Canadian Association of Radiologists Journal xx (2019) 1e8

www.carjonline.org

Trauma and Emergency Room Imaging / L’imagerie des urgences et des traumatismes

Renal Colic Imaging: Myths, Recent Trends, and Controversies

Abdullah Alabousi, MDa, Michael N. Patlas, MD, FRCPC, FSARb,*, Vincent M. Mellnick, MDc,
Victoria Chernyak, MD, MS, FSARd, Nataly Farshait, MSe,
Douglas S. Katz, MD, FACR, FASERf
a
Department of Radiology, McMaster University, St Joseph’s Healthcare, Hamilton, Ontario, Canada
b
Department of Radiology, McMaster University, Hamilton General Hospital, Hamilton, Ontario, Canada
c
Mallinckrodt Institute of Radiology, St Louis, Missouri, USA
d
Montefiore Medical Center, Bronx, New York, USA
e
Humber River Hospital, Toronto, Ontario, Canada
f
NYU Winthrop-University Hospital, Mineola, New York, USA

Abstract
There has been a substantial increase in the utilization of imaging, particularly of multi-detector computed tomography (MDCT), for the
evaluation of patients with suspected urolithiasis over the past 2 decades. While the diagnostic accuracy of computed tomography (CT) for
urolithiasis is excellent, it has also resulted in substantial medical expenditures and increased ionizing radiation exposure. This is especially
concerning in patients with known nephrolithiasis and in younger patients. This pictorial review will focus on recent trends and controversies
in imaging of patients with suspected urolithiasis, including the current roles of ultrasound (US), MDCT, and magnetic resonance imaging,
the estimated radiation dose from MDCT and dose reduction strategies, as well as imaging of suspected renal colic in pregnant patients. The
current epidemiological, clinical, and practice management literature will be appraised.

R
esum
e
Au cours des deux dernieres d
ecennies, le recours a l’imagerie a connu une hausse consid
erable, notamment la tomodensitom
etrie haute
r
esolution (TDM-HR), pour
evaluer les patients pr
esentant des soupçons de lithiase urinaire. Bien que pour la lithiase urinaire, l’exactitude
diagnostique de la tomodensitom
etrie (TDM) soit excellente, cette technique a
egalement entra^ın
e une hausse substantielle des d
epenses dans
le secteur m
edical et de l’exposition aux rayonnements ionisants. Ce ph
enomene est particulierement pr
eoccupant chez les patients pr
esentant
un diagnostic de lithiase r
enale et chez les jeunes. Cette synthese dresse le tableau des dernieres tendances et controverses touchant le
domaine de l’imagerie des patients pr
esentant des soupçons de lithiase urinaire, y compris le poids actuel de l’
echographie, de la TDM-HR et
de l’imagerie par r
esonance magn
etique (IRM), la dose de rayonnement estim
ee appliqu
ee par la TDM-HR et les strat
egies de r
eduction de
cette dose, ainsi que l’imagerie des soupçons de colique n
ephr
etique chez les patientes enceintes. Cette synthese bibliographique porte sur les
aspects
epid
emiologiques, cliniques et pratiques de la prise en charge de la lithiase urinaire.
Ó 2018 Canadian Association of Radiologists. All rights reserved.

Key Words: Renal colic; Urolithiasis; Ultrasound; Multi-detector computed tomography; Magnetic resonance imaging

Suspected renal colic accounts for nearly 2% of all adult
visits to the emergency department (ED) in the United States
[1]. The number of ED visits for urolithiasis in the USA has
increased from 178 to 340 per 100,000 patients from 1992e
2009 [2]. The greatest increase has occurred amongst in
* Address for correspondence Michael N. Patlas, MD, FRCPC, FSAR,
Department of Radiology, McMaster University, Hamilton General Hospital,
Hamilton, Ontario L8L 2X2, Canada.
E-mail address: patlas@hhsc.ca (M. N. Patlas).
women and in individuals ages 24e44 [2]. Some proposed
explanations for these trends this include increased obesity
rates, increased incidence of diabetes, decreasing water
intake, and increased use of calcium supplements [2]. Those
at increased risk for urolithiasis include individuals with
intestinal malabsorption, as well as those with metabolic
disturbances such as gout, renal tubular acidosis, and
hypercalciuria.
Imaging plays a key role in diagnosing urolithiasis and
guiding management, as well as diagnosing or excluding

0846-5371/$ - see front matter Ó 2018 Canadian Association of Radiologists. All rights reserved.
https://doi.org/10.1016/j.carj.2018.09.008
2 A. Alabousi et al. / Canadian Association of Radiologists Journal xx (2019) 1e8
alternative causes of symptoms. Ultrasound (US), multi-
detector computed tomography (MDCT), and magnetic
resonance imaging/urography (MRI/MRU) are the imaging
modalities of choice for assessing patients with suspected
urolithiasis. On the other hand, radiography is primarily
reserved for selectively following patients with known
urolithiasis.
This pictorial essay reviews the current relevant literature
pertaining to the epidemiology, clinical factors, and man-
agement options in patients with known or suspected uro-
lithiasis. We discuss the role of cross-sectional imaging for
the evaluation of patients with suspected renal colic, evaluate
the estimated radiation dose from MDCT for suspected renal
colic, suggest radiation dose reduction strategies, and review
the recent trends and controversies in imaging patients with
suspected renal colic.
Imaging Overview
Imaging has been increasingly utilized for the evaluation
of patients with suspected renal colic. The proportion of ED
visits for suspected urolithiasis where patients underwent
imaging in the USA has increased from 56% of visits in
1995e1997 to 79% of visits in 2007e2009 [2]. More spe-
cifically, the utilization of non-enhanced (computed tomog-
raphy) CT for these patients has increased from 21% of visits
in 1998e2000, to 71% of visits in 2007e2009 [2]. The use
of CT in younger patients (those ages 25e44) has increased
from 19% of visits in 1998e2000 to 73% of visits in 2007e
2009 [2]. This increase in the utilization of imaging,
particularly MDCT, has resulted in relatively substantial
medical expenditures and increased radiation exposure. This
is especially of concern for patients with known neph-
rolithiasis needing repeated exams and in younger patients
and in those with known nephrolithiasis needing repeated
exams.
A study by Hyams et al assessed imaging trends for pa-
tients presenting to the ED with suspected urolithiasis and
found that from 2000e2008 there was a statistically signif-
icant increase in the utilization of MDCT from 19e45% of
patients [3]. At the same time, the utilization of US remained
stable at 5e7% of patients [3]. Of note, during that period,
the proportion of patients with suspected urolithiasis who
had this diagnosis confirmed on imaging remained stable at
approximately 20% (Table 1) [3].
While CT has the largest current role in imaging patients
with suspected urolithiasis, some radiologists and clinicians
Table 1
Summary of findings from Hyams et al [3]
Utilization of MDCT
Utilization of US
Proportion of patients with suspected urolithiasis
who had this diagnosis confirmed on imaging
CI ¼ confidence interval; MDCT ¼ multi-detector computed tomography; US ¼ ultrasound.
advocate using US as a first-line modality instead, in both
adults and pediatric patients [4,5]. MRI is reserved as a
second- or even a third-line modality for problem solving
[6,7].
Role of Ultrasound
The current European Association of Urology guidelines
state that in patients with suspected urolithiasis, US should
be the primary diagnostic imaging examination [4]. This
should especially be the case in younger patients and in fe-
male patients, particularly those who are pregnant, and those
presenting with classic signs and symptoms. The European
Association of Urology guidelines also state that non-
contrast CT should be reserved for patients with non-
resolving symptoms or suspicion of an alternate diagnosis
[4].
A study by Smith-Bindman et al showed that patients who
had been assessed by US at initial presentation had no sta-
tistically significant differences in high-risk diagnoses,
complications, serious adverse events, self-reported pain
scores, return ED visits, or hospitalizations in comparison
with MDCT [5]. Moreover, a normal renal US has been
shown to predict a low-likelihood for urologic intervention
within 90 days for adult ED patients with suspected uro-
lithiasis [8].
However, US can be challenging in obese patients and
generally offers limited or poor visualization of the mid
ureter. In addition, US has a limited ability to depict renal or
ureteral calculi which are smaller than 5 mm. However,
detection of calculi smaller than 5 mm is of questionable
clinical significance, as such patients are unlikely to require
urological intervention [5]. 68% of such calculi are believed
to pass spontaneously [6]. However, detecting sub-5 mm
calculi has potential implications for future patient man-
agement and prevention of recurrence.
The utilization of gray-scale US along with color
Doppler to look for the ‘‘twinkling artifact’’ has been
demonstrated to be helpful in detecting renal and ureteral
calculi [9]. On the other hand, assessing for the presence or
absence of ureteral jets has been shown to be less reliable,
as many such calculi may only cause partial obstruction
(Figure 1) [7].
In addition to assessing for hydronephrosis and hydro-
ureter, as well as renal and ureteral calculi, US allows for the
detection of additional findings and alternate diagnoses.
These include, but are not limited to, renal neoplasms and
2000 2008
19.6% [95% CI, 14.5e26.0] 45.5% [95% CI, 40.4e50.7]
5.6% [95% CI, 3.4e9.0] 6.9% [95% CI, 3.6e10.1]
21.9% [95% CI, 16.8e27.9] 22.8% [95% CI, 18.7e27.5]
 Renal colic imaging / Canadian Association of Radiologists Journal xx (2019) 1e8 3

Figure 1. A 32-year-old pregnant woman with ultrasound showing mild right hydronephrosis (A, arrow), and debris in the bladder (B, arrow). Doppler shows a
‘‘twinkle’’ artifact at the right ureterovesical junction, which represents a small obstructive calculus (C, arrow).

abscesses, as well as pathology affecting other organ systems
with presenting symptoms mimicking urolithiasis.
Also, patients who receive US as the initial imaging ex-
amination for suspected urolithiasis are more likely to
require additional imaging in the acute setting [5]. In one
study, 40% of patients who underwent point-of-care US and
27% of patients who underwent standard renal US underwent
additional evaluation with CT [5]. Only 5% of patients who
were initially imaged with CT had additional imaging with
US [5]. However, despite the additional imaging, the mean
total cost for the ED visit were still slightly lower for patients
who had US first [5].
US is the first-line imaging examination of choice for
pregnant patients [7]. It is a safe, fast, and relatively inex-
pensive examination. However, as is the case with many
patients, the mid ureter, and even the bladder may be
obscured by the gravid uterus. Transvaginal US may help
visualize the distal ureter and ureterovesical junction (UVJ)
if not well visualized on transabdominal US (Figure 2).
Overall, the utilization of US as the first-line modality in
assessing patients with renal colic has several advantages
including availability, lower cost compared to MDCT and
MRI, as well as reduced radiation exposure. However, the
accuracy and reliability of US is lower compared with
MDCT and MRI. This is related to limitations related to
patient’s body habitus, condition, as well as the operator’s
skill and experience.
Role of Multi-Detector Computer Tomography
The American College of Radiology Appropriateness
Criteria states that a low-dose non-enhanced CT of the
abdomen and pelvis is the imaging examination of choice for
evaluating patients with suspected urolithiasis (sensitivity
97% and specificity 95%) [6]. Some have suggested that for
the diagnosis of suspected urolithiasis, CT is the truth
(Figure 3).
Non-enhanced multi-detector (CT) MDCT of the
abdomen and pelvis in patients with suspected urolithiasis
allows for the comprehensive evaluation of the kidneys,
ureters, and bladder. It further allows for the determination of
the location and size of almost all calculi, and any resultant
hydronephrosis and/or hydroureter, and any other secondary
signs including renal swelling, perinephric stranding, and/or

Figure 2. A 23-year-old pregnant woman with ultrasound showing moderate right hydronephrosis (A, arrow) and hydroureter (B, arrow). Evaluation of the
ureterovesical junction is precluded by the gravid uterus (C). Computed tomography or magnetic resonance imaging could be performed in this patient if an
obstructing calculus is strongly suspected.
4 A. Alabousi et al. / Canadian Association of Radiologists Journal xx (2019) 1e8

Figure 3. A 26-year-old pregnant woman with an intravenous and oral contrast-enhanced computed tomography showing moderate right-sided hydronephrosis
(A, arrow) caused by an obstructive right ureterovesical junction calculus (B, arrow). A partially-imaged fetus is also noted (star).

periureteric stranding/edema. MDCT will also demonstrate
any associated findings or complications including calyceal
rupture, signs of infections, and any fluid/urine collections in
the abdomen or pelvis. Intravenous contrast may be neces-
sary in selective patients to better assess for signs of infection
and/or organized collections. Image reconstruction and post-
processing, most notably multiplanar reformatting, should be
utilized to their maximum potential to aid in making the
correct diagnosis (Figure 4).
Currently, the radiation dose for an abdominopelvic
MDCT varies relatively widely among practices [10].
Depending on the specific protocol, the effective dose can

Figure 4. A 62-year-old woman with computed tomography and magnetic resonance imaging performed for the workup of colon cancer. Incidental right renal
central collecting system calculus on coronal computed tomography and coronal post-contrast magnetic resonance imaging (A and B, arrows), with abnormal
urothelial thickening and hyperenhancement consistent with associated inflammation/infection (C, axial T2-weighted image, arrow).
 Renal colic imaging / Canadian Association of Radiologists Journal xx (2019) 1e8 5

Figure 5. Standard (A) and low-dose (B) axial computed tomography (CT) images showing that despite increased noise, the low-dose CT shows an unchanged
calculus (arrows) in an 18-year-old man with known nephrolithiasis. The dose-length product was 350 on the low-dose scandless than a quarter of the dose of
the previous standard CT (1641). The left kidney is also noted to be atrophic.

range from 8e16 mSv [10]. Therefore, the increased utili-
zation of MDCT not only raises cost concerns relative to US,
but also has potential associated radiation risks, leading
many centres and practices to adopt low-dose and ultra-low
dose CT techniques for detecting urolithiasis, particularly
for patients with known calculi [11]. A low-dose MDCT
(<3 mSv) can be used for diagnosing urolithiasis, with
excellent inter-observer and intra-observer agreement (kappa
values 0.87e0.98). Dose reduction techniques include the
use of iterative reconstruction, as well as tube current mod-
ulation, although the latter can be problematic in obese pa-
tients. Regardless, radiation dose should be kept as low as
reasonably achievable while maintaining diagnostic CT
quality (Figure 5).
MDCT allows for the detection of nearly all types of
urinary tract calculi, including uric acid, xanthine, and
cystine stones, which are otherwise radiolucent on conven-
tional radiographs. The only exceptions are pure matrix
stones and calculi in patients on indinavir, which can be
difficult or impossible to visualize on MDCT, as they are
usually of soft-tissue attenuation (15e30 HU).
In addition to the detection of urolithiasis and associated
findings, including hydroureteronephrosis, calyceal rupture,
and organized urine/fluid collections, MDCT is far superior for
assessing overall stone burden, which can help guide man-
agement. This includes the number of stones, stone size, and
volume. Moreover, with the relatively increased availability of
dual-energy CT (DECT), there is a growing interest in the
characterization of stone composition [12]. With DECT, this is
achieved based on the principle of attenuation differences of
calculi based on their composition at different X-ray energies.
The focus has been mainly on differentiating uric acid calculi
from the other calcium-dominant subtypes [12].
While US is the first-line imaging modality for pregnant
patients with suspected urolithiasis, it has been suggested
that CT can be safely used selectively as a second-line im-
aging examination [6]. The typical dose from a low-dose or
even standard MDCT assessing for urolithiasis is well below
the 50 mGy threshold above which radiation-induced fetal
anomalies can potentially occur. However, as will be dis-
cussed below, if MRI is available, it should be considered
following US in evaluating pregnant patients. CT should be
reserved for problematic patients where a diagnosis cannot
be made on US or MRI.
All things considered, MDCT is an excellent modality for
imaging most patients with suspected urolithiasis, and, in

Figure 6. A 47-year-old woman with hematuria received a magnetic resonance (MR) urography, as well as a follow-up computed tomography 4 weeks later.
There is right-sided hydronephrosis on an axial post-contrast MR (A, arrow) with a large obstructive distal ureteral calculus on coronal T2-weighted MR image,
and on subsequent coronal CT images (B and C, arrows).
6 A. Alabousi et al. / Canadian Association of Radiologists Journal xx (2019) 1e8

Figure 7. A 75-year-old man underwent magnetic resonance imaging for routine follow-up of a pancreatic intraductal papillary mucinous neoplasm. Axial post-
contrast magnetic resonance imaging demonstrate new right urothelial thickening and hyperenhancement of the proximal right ureter, concerning for a
urothelial neoplasm (A and B, arrows). Follow-up computed tomography urogram showed a calculus in the right ureter with associated reactive urothelial
thickening (C, arrow). A bowel anastomosis is noted in the anterior abdomen.

terms of imaging, it is still definitely the reference standard.
Emerging technologies, particularly DECT, will likely
further reinforce the current dominance of CT as the mo-
dality of choice for renal calculus imaging in most non-
pregnant adult patients, and particularly on initial
presentation.
Role of Magnetic Resonance Imaging/Urography
MRI/MRU is overall a good modality for the diagnosis of
urolithiasis, where calculi appear as a focus of decreased
signal on T1- and T2-weighted sequences. It is an excellent
modality for detecting the secondary effects of urolithiasis,

Figure 8. A 29-year-old pregnant woman with right flank pain. Coronal T2-weighted magnetic resonance imaging show right-sided hydronephrosis (A, arrow)
and an obstructing right distal ureteral calculus (B, arrow). A partially-imaged fetus is also noted (star).
 Renal colic imaging / Canadian Association of Radiologists Journal xx (2019) 1e8
Figure 9. A 22-year-old pregnant woman with coronal T2-weighted magnetic resonance imaging showing right-sided hydronephrosis with perinephric fluid (A,
arrows). Right hydroureter was noted (arrow), without a ureteral calculus seen on axial T2-weighted magnetic resonance imaging; a partially-imaged fetus is
also noted (star) (B). Ultrasound confirmed the presence of a 4 mm obstructing calculus at the right ureterovesical junction (C, calipers).
including obstruction and infection [13]. However, it has a
limited role for selected patients, as it is relatively expensive
and may not be widely available, especially after hours.
However, MRI can be utilized in complex situations where
US and MDCT fail to explain the patient’s symptoms. In
addition, non-contrast MRI/MRU should be considered as a
second-line examination after an equivocal or non-
diagnostic US in pregnant patients with suspected urolith-
iasis [14,15]. MRI can be used safely in this patient
population instead of MDCT. MRI can also be useful as a
second-line examination following US in the pediatric
population, where MDCT is generally avoided unless
absolutely necessary [15].
An MRI/MRU study is can be performed on a 1.5T or
3T scanner as a static-fluid examination (also known as
static MR urography, MR hydrography, or T2-weighted
MR urography), or can be performed as excretory MR
urography (also known as T1-weighted MR urography)
(Figure 6) [15]. The static MR urography examination is
achieved with heavily T2-weighted sequences and is per-
formed without intravenous gadolinium contrast, which is
almost always avoided in pregnancy. Static MRU can also
be obtained with single-shot fast spin-echo techniques.
Cine images have the potential to demonstrate ureteral
peristalsis and can be used to exclude a fixed area of nar-
rowing/stenosis in the urinary tract [15]. Also, to ensure
adequate distention of the collecting systems, it has been
suggested that intravenous hydration could be utilized [15]
(Figures 7e9).
On the other hand, excretory MR urography is essentially
analogous to CT urography and requires intravenous gado-
linium contrast [15]. The collecting systems are then imaged
during the excretory phase [15]. This is of limited utility in
patients with severely compromised renal function, as gad-
olinium contrast cannot be administered.
Conclusion
This pictorial essay focused on current trends and con-
troversies in imaging patients with suspected urolithiasis,
7
including evaluating the current roles of US, MDCT, and
MRI/MRU in different clinical settings. We have explored
the increased utilization of imaging in patients with sus-
pected urolithiasis. This is especially concerning as there
has been increased utilization of MDCT, even in young
patients. However, even with the increased utilization of
imaging, there has been no significant increase in the
proportion of patients with confirmed urolithiasis on im-
aging. Our hope is that the clinicians and radiologists in
North America and elsewhere will consider the European
trend of relying more on US as the first-line imaging mo-
dality for younger patients with initial and particularly for
repeated episodes of suspected renal colic. MRI can play a
useful adjunct role in pregnant and in pediatric patients
with equivocal or non-diagnostic initial US findings.
MDCT should be reserved in these patients when US is
non-diagnostic or when an alternative diagnosis is
suspected.
References
[1] Westphalen AC, Hsia RY, Maselli JH, Wang R, Gonzales R. Radio-
logical imaging of patients with suspected urinary tract stones: Na-
tional trends, diagnoses, and predictors. Acad Emerg Med 2011;18:
699e707.
[2] Fwu C-W, Eggers PW, Kimmel PL, Kusek JW, Kirkali Z. Emergency
department visits, use of imaging, and drugs for urolithiasis have
increased in the United States. Kidney Int 2013;83:479e86.
[3] Hyams ES, Korley FK, Pham JC, Matlaga BR. Trends in imaging use
during the emergency department evaluation of flank pain. J Urol 2011;
186:2270e4.
[4] T€urk C, Petr
ık A, Sarica K, et al. EAU guidelines on diagnosis and
conservative management of urolithiasis. Eur Urol 2016;69:468e74.
[5] Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus
computed tomography for suspected nephrolithiasis. N Engl J Med
2014;371:1100e10.
[6] Coursey CA, Casalino DD, Remer EM, et al. ACR Appropriateness
CriteriaÒ acute onset flank painesuspicion of stone disease. Ultra-
sound Q 2012;28:227e33.
[7] Blanco LT, Socarras MR, Montero RF, et al. Renal colic during preg-
nancy: Diagnostic and therapeutic aspects. Literature review. Cent Eur
J Urol 2017;70:93e100.
8 A. Alabousi et al. / Canadian Association of Radiologists Journal xx (2019) 1e8
[8] Edmonds ML, Yan JW, Sedran RJ, McLeod SL, Theakston KD. The
utility of renal ultrasonography in the diagnosis of renal colic in
emergency department patients. CJEM 2010;12:201e6.
[9] Ripoll
es T, Mart
ınez-P
erez MJ, Vizuete J, Miralles S, Delgado F, Pastor-
Navarro T. Sonographic diagnosis of symptomatic ureteral calculi: use-
fulness of the twinkling artifact. Abdom Imaging 2013;38:863e9.
[10] Niemann T, Kollmann T, Bongartz G. Diagnostic performance of low-
dose CT for the detection of urolithiasis: a meta-analysis. Am J
Roentgenol 2008;191:396e401.
[11] Jin DH, Lamberton GR, Broome DR, et al. Effect of reduced radiation CT
protocols on the detection of renal calculi. Radiology 2010;255:100e7.
[12] Jepperson MA, Cernigliaro JG, Sella D, et al. Dual-energy CT for the
evaluation of urinary calculi: Image interpretation, pitfalls and stone
mimics. Clin Radiol 2013;68:e707e14.
[13] Regan F, Bohlman ME, Khazan R, Rodriguez R, Schultze-Haakh H.
MR urography using HASTE imaging in the assessment of ureteric
obstruction. Am J Roentgenol 1996;167:1115e20.
[14] Roy C, Saussine C, LeBras Y, et al. Assessment of painful ureter-
ohydronephrosis during pregnancy by MR urography. Eur Radiol 1996;
6:334e8.
[15] Leyendecker JR, Barnes CE, Zagoria RJ. MR urography: techniques
and clinical applications. RadioGraphics 2008;28:23e46.