Renal Colic and Urinary

Retention

dr. Gampo Alam Irdam, SpU(K)

PIT IDI Karawang – Karawang Emergency Updates -2
6 November 2022
Outline

Renal Colic Urinary Retention

• Epidemiology

• Etiology

• Evaluation

• Management
 Renal Colic

PIT IDI Karawang – Karawang Emergency Updates -2

 Acute Abdominal Pain in Emergency Room
Leading Causes of Acute Abdominal Pain in ER (n= 5,430 cases)
35.00%

30.00%

25.00%
59.8% of those (renal
colic) readmitted to
20.00%
the ED within 30
days was due to renal
15.00% colic pain

10.00%

5.00%

0.00%
Non-specific Renal colic Billiary colic / Appendicitis Divericulitis UTI and other Gastritis Others Iatrogenic pain Gynecologic
abdominal cholecystitis urologic pain pain
pain

Cervellin G, et al. Epidemiology and outcomes of acute abdominal pain in a large urban Emergency Department: retrospective analysis of 5,340 cases. Ann Transl Med. 2016 Oct;4(19):362.
 Urolithiasis
• Global prevalence ranging from 7 to 13%
• Its formation is Influenced by genetic, pre-existing disease, lifestyle and
environmental risk factors

Initially may not cause any symptoms (asymptomatic)

100%
Pain is the most common symptom
80%
Chief complain  flank pain (61,6%),
60%
abdominal pain (24,8%), back pain (5,3%),
40%
other (5,6%)
20%
0%

Krambeck AE, Lieske JC, Li X, Bergstralh EJ, et al. Effect of age on the clinical presentation of incident symptomatic urolithiasis in the general population. J Urol. 2013 Jan;189(1):158-64.
 Renoureteral Pain
COLIC PAIN

• Intense and intermittent pain due to sudden obstruction on hollow organ

• Often accompanied by nausea, vomiting, restlessness, and excessive sweating
• Nociceptor location renal pelvis and ureter

PARENCHYMAL PAIN

• Dull and constant pain

• Due to distension, inflammation, or infection within the parenchyma of the GU organ
• Nociceptor location  submucosa and the lamina propria of the peripelvic renal
capsule

Tanagho, and Jack W. McAninch. Smith's General Urology. 19 th ed. 2020

 Factors associated with Pain Severity
Individual pain threshold

Change in hydrostatic pressure

• Slow progression without sudden capsular distention  painless
renal stone

Duration
• Prolonged obstruction induce activation of autoregulatory
mechanisms  lower the pressure  limits the pain

Travaglini F, Bartoletti R, Gacci M, Rizzo M. Pathophysiology of reno-ureteral colic. Urol Int. 2004;72 Suppl 1:20-3.
 Pathophysiology of Renal Colic

Edema and
Increased wall tension Stimulates Pain Nerve
Inflammation
Acute ureteral
Increased endoluminal
obstruction due to
pressure
lodged stone
Inflammatory cascade Prostaglandin
Muscle Spasm
activation accumulation

Vasodilatation and
Diuresis

Rakowska M, Królikowska K, Jobs K, Placzyńska M, Kalicki B. Pathophysiology and symptoms of renal colic in children - a case report. Dev Period Med. 2018;22(3):265-269.
 Phases of Renal Colic Pain
Renal colic usually peaks within 90 to 120 minutes and last for a few
hours

ONSET (30 PLATEAU (3- ABATEMENT

min – 3 hours) 12 hours) (1,5-2 hours)

Continuous Constant Pain

pain rising to pain in a diminished
its peak, variable gradually or
sometimes duration for up spontaneously
with acute to 12 h
paroxysms

Travaglini F, Bartoletti R, Gacci M, Rizzo M. Pathophysiology of reno-ureteral colic. Urol Int. 2004;72 Suppl 1:20-3.
 Neuroanatomy of Renal Colic Pain
In cerebral cortex, pain are
specified by location, character
and intensity

After being modulated by

descending stimulations, impulses
join the spinothalamic tracts
Descending
modulation
Ascending
Dorsal Horn
input
Dorsal root ganglion
Nociceptive impulses travel along
with Aδ and C fiber to dorsal horn
at spinal cord (T11-L2)
Spinothalamic
tract

Visceral afferent
with Aδ and C fiber
Acute increase renal pressure
Peripheral activate nociceptors at renal
nociceptors
capsule, renal pelvis, and ureter .

Travaglini F, Bartoletti R, Gacci M, Rizzo M. Pathophysiology of reno-ureteral colic. Urol Int. 2004;72 Suppl 1:20-3.
 Associated Symptoms
Nausea, vomiting, tachycardia

Pain receptors are transmitted by

sympathetic fibers through the renal,
celiac, and superior mesenteric
ganglion that reach the spinal cord at
the same level

Travaglini F, Bartoletti R, Gacci M, Rizzo M. Pathophysiology of reno-ureteral colic. Urol Int. 2004;72 Suppl 1:20-3.
 Evaluation of Renal Colic Pain
History Taking
Physical Examination
Characteristics of Pain
(OPQRST)
Signs and symptoms related Vital Sign
to urolithiasis, sepsis, or
other differential diagnoses
Risk factors for urolithiasis
Previous personal and
family history of urolithiasis
EAU Guidelines of Urolithiasis 2022
Laboratory Test
Urological status
Imaging
Full physical examination Complete Blood Count
Kidney Function
Urinalysis During colic renal pain
• USG
Other lab test such as
pregnancy test to exclude • NCCT
differential diagnosis
Other imaging for
urolithiasis
• Plain Abdominal
Radiography
• IVU
• Contrast CT-Scan
 Differential Diagnosis of Flank Pain
Pancreatic and
Urological Gastrointestinal Gynecological Vascular Musculoskeletal
hepatobilitary

Pyelonephritis Appendicitis Ovarian cyst Cholelithiasis Ruptured aortic Fracture

Renal Cysts Diverticulitis Ovarian torsion Cholecystitis aneurysm Osseous metastasis
RCC Aortic dissection Tubo-ovarian Choledocholithiasi Intraperitoneal Neuromuscular
TCC Meckel abscess s hemorrhage pain
Renal hemorrhage diverticulitis Ovarian neoplasm Pancreatitis Retroperitoneal Varicella Zooster
Urolithiasis Hernia Degenerating Hepatitis hemorrhage
Small bowel fibroid
obstruction Ectopic pregnancy
Inflammatory
bowel disease
Peptic Ulcers

Rucker CM, Menias CO, Bhalla S. Mimics of renal colic: alternative diagnoses at unenhanced helical CT. Radiographics. 2005;24:S11–S3
 How to Differentiate Symptoms
Gastrointestinal Problems Urolithiasis

• Peritoneal irritation leads to tenderness • CVA tenderness

in any abdominal motion (more on posterior)
• Tenderness more pronounced anterior • Colic pain induce restlessness, patient
such in Murphy sign (cholelithiasis) looks in agony
• May cause ipsilateral shoulder pain • Often have urinary symptoms or
due to diaphragmatic irritation via abnormal urinalysis (hematuria)
phrenic nerve • Pain can be radiating to the lower
• Pain mostly localized abdominal quadrant and/or testis

Tanagho, and Jack W. McAninch. Smith's General Urology. 19 th ed. 2020

Paajanen H, Tainio H, Laato M. A chance of misdiagnosis between acute appendicitis and renal colic. Scand J Urol Nephrol. 1996 Oct;30(5):363-6
 Renal Colic vs Lumbar Pain
Likelihood of having renal VAS Score (p <0.0001)
colic increases 5.42-fold per 7

1-point increase of VAS score 6

6 (1-10)

5
4 (2-5)
4

2
A VAS score of ≥5 should
warn the necessity of routine 1

urinary stone examinations 0

Renal Colic Pain (n=36) Lumbar Pain (n=29)

VAS Score

Should be more aware of renal colic in Patients with complaints of flank pain in urology clinic
higher VAS score

Caniklioğlu M, Özkaya M. The Use of Visual Analogue Scale Score as a Predicting Tool in Differentiating Renal Colic From Lumbar Back Pain. Cureus. 2021 Jul 13;13(7):e16377
 Recommended Imaging in Renal Colic
CT-Scan
• Reduced-radiation dose CT is preferrable
• CT can be avoided in
• Younger patients (<35 years old) with a presentation typical for kidney stones, and adequate
pain relief
• In middle-aged patients (<55 years old), CT may be avoided if there is a prior history of kidney
stones
• Older patients (>75 years old), CT should generally be obtained.

USG
• Point of Care USG  1st line modality in patients with less typical signs and symptoms
• hydronephrosis to predict urolithiasis  sensitivity 70,2% and specificity 75,4%
• Modality of choice for pregnant and pediatric patients

Moore CL, et al. Imaging in Suspected Renal Colic: Systematic Review of the Literature and Multispecialty Consensus. J Urol. 2019 Sep;202(3):475-483.
Wong C, et al. The Accuracy and Prognostic Value of Point-of-care Ultrasound for Nephrolithiasis in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med. 2018 Jun;25(6):684-698.
 Treatment of Renal Colic Pain

NSAIDS/
Opioids
Paracetamol

EAU Guidelines of Urolithiasis 2022

 What type and what route of NSAIDS should be chosen for
Acute Renal Colic?
65 RCTs with 8633 participants
Diclofenac IM, Ibuprofen IV, Ketorolac IV
and were superior for the management of
acute renal colic

Limitation: RCT on ibuprofen IV and

ketorolac IV being small thus still need
further RCT to confirm

Combination therapy is an alternative choice for

uncontrolled pain after the use of NSAIDs

No recommendation regarding specific 1st stage: comparing NSAIDS to other treatment

type of NSAID or route is given on EAU 2 stage : the effect of routes of administration on treatment of colic pain
nd

Guidelines

Gu HY, Luo J, Wu JY, Yao QS, Niu YM, Zhang C. Increasing Nonsteroidal Anti-inflammatory Drugs and Reducing Opioids or Paracetamol in the Management of Acute Renal Colic: Based on Three-Stage Study Design of Network Meta-
Analysis of Randomized Controlled Trials. Front Pharmacol. 2019 Feb 22;10:96.
 Other Adjunctive Treatment
Alpha-blocker Combination NSAIDS and alpha-blocker reduce recurrent renal colic

Alpha blocker as MET more beneficial for distal ureteric stone 5-10 mm
and given for 4 weeks
Antibiotics Start antibiotics immediately in patient with sepsis  use based on
antibiogram findings
Delay definitive treatment of the stone until sepsis in resolved

Antiemetics Symptomatic treatment

Several drugs can be used  ondansentron, metoclopramid

EAU Guidelines of Urolithiasis 2022

Urinary Retention

PIT IDI Karawang – Karawang Emergency Updates -2

 Urinary Retention : Epidemiology

• The overall incidence is much higher in men than women and

increases dramatically as men age.

• Estimates for men range from 4.5 to 6.8 per 1,000 person-years,
increasing up to 300 per 1,000 person-years for men in their 80s,
whereas the incidence in women is only 7 per 100,000 per year.

Meigs JB, Barry MJ, Giovannucci E, Rimm EB, Stampfer MJ, Kawachi I. Incidence rates and risk factors for acute urinary retention: the health professionals followup study. J Urol. 1999;162(2):376-382
Jacobsen SJ, Jacobson DJ, Girman CJ, et al. Natural history of pros- tatism: risk factors for acute urinary retention. J Urol. 1997;158(2): 481-487.
 Urinary Retention inability to voluntarily pass an adequate amount
of urine

the painful inability to void with relief of the pain following drainage
Acute of a large volume of urine from the bladder

inability to completely empty the bladder whilst maintaining the

Chronic ability to urinate, with residual volumes of >300ml

High Pressure associated with a tense bladder and renal impairment due to
hydronephrosis
Chronic

Serlin DC, Heidelbaugh JJ, Stoffel JT. Urinary Retention in Adults: Evaluation and Initial Management. Am Fam Physician. 2018 Oct 15;98(8):496-503. PMID: 30277739.
 Complications of Urinary Retention

Bladder Diverticular Hydroureteroneph

Trabeculations
Hypertrophy Formation rosis

Renal Failure Recurrent UTI Urolithiasis

Serlin DC, Heidelbaugh JJ, Stoffel JT. Urinary Retention in Adults: Evaluation and Initial Management. Am Fam Physician. 2018 Oct 15;98(8):496-503. PMID: 30277739.
 Etiologies

Supravesica • Motor and sensory nerve innervation disorders

• Local conditions (bladder tumor/stone)

Vesica • Antimuscarinic/anticholinergic drugs (low
bladder pressure)

• Bladder outlet obstruction (anatomic)

Infravesica • Increased urethral resistance
• Sympathomimetic drugs (physiological)

Serlin DC, Heidelbaugh JJ, Stoffel JT. Urinary Retention in Adults: Evaluation and Initial Management. Am Fam Physician. 2018 Oct 15;98(8):496-503. PMID: 30277739.
 Evaluation of Urinary Retention

Detailed Physical
History Taking Examination

Post Void
Residual (PVR)

Serlin DC, Heidelbaugh JJ, Stoffel JT. Urinary Retention in Adults: Evaluation and Initial Management. Am Fam Physician. 2018 Oct 15;98(8):496-503. PMID: 30277739.
 Additional Modalities
Laboratory Indication Imaging Indication
Prostate-specific antigen Prostate cancer, BPH, prostatitis, and acute MRI of spine Lumbosacral disk herniation, spinal cord
(PSA) retention compression/tumor
Serum blood glucose Underdiagnosed or uncontrolled DM in CT/MRI of brain Intracranial lesion (tumor, stroke,
neurogenic bladder multiple sclerosis)
BUN, creatinine, & Renal failure from lower urinary tract Pelvic USG, CT abdomen Suspected pelvic, abdominal, or
electrolyte obstruction & pelvis retroperitoneal mass
Urinalysis Infection, hematuria, proteinuria, and Renal and bladder USG Infection, hematuria, proteinuria, and
glucosuria glucosuria

Other Indication

Urethro-cystoscopy, Suspected bladder tumor,

retrograde bladder/urethral stones or strictures
cystourethrography
Urodynamic studies Bladder function in neurogenic bladder

Serlin DC, Heidelbaugh JJ, Stoffel JT. Urinary Retention in Adults: Evaluation and Initial Management. Am Fam Physician. 2018 Oct 15;98(8):496-503. PMID: 30277739.
 Management of Acute Urinary
Retention
Urology consultation for
Access not possible
urinary drainage

Acute urinary retention Assess urethral access Unsuccessful

Confirmation form physical History of stricture, lower

examination & imaging urinary tract surgery/trauma
Attempt 16 Fr urethral Continuous drainage for 3 Consider starting
Access possible alpha blocker
catheter placement, if not days
contraindicated

Suspected
stricture: 10-12
Fr Voiding trial

Suspected
enlarged
prostate: 20-22
Fr

Serlin DC, Heidelbaugh JJ, Stoffel JT. Urinary Retention in Adults: Evaluation and Initial Management. Am Fam Physician. 2018 Oct 15;98(8):496-503. PMID: 30277739.
Dougherty JM, Aeddula NR. Male Urinary Retention. [Updated 2020 Dec 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.  Available from: https://www.ncbi.nlm.nih.gov/books/NBK538499/
 Urethral Catheter Insertion

Placement of a urinary catheter is

Diagnostic
a simple and routine way for
• Obtain sterile urine specimen
external urinary drainage
• Assess PVR
• Assess abdominal/pelvic pain and other GU conditions
Therapeutic
• Relieve bladder outlet obstruction
• Drain a hypotonic bladder
• Facilitate urinary elimination (example: gross hematuria)
While most patients tolerate UC with • Instill irrigation fluids/medications
minimal discomfort or complications, • • Allow surgical repair of lower urinary tract
Discomfort/pain
some patients experience difficult urinary • Risk injury Monitoring
catheterization (DUC) • Measure urinary output in critically ill patients
organs/structures

Bianchi A, Chesnut GT. Difficult Foley Catheterization. [Updated 2021 Feb 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.  
 Difficult Urethral Catheterization
Inability by nurses, other physicians and
Common Causes of Difficult Urinary Catheterization
urologists to pass any Foley (coude, regular,
silicone) catheter into the bladder before using
more invasive techniques (filiforms/followers,
flexible cystoscopy, glide wires etc.)

What to Do?

• Understand patient-reported symptoms and proper

physical exam
• Identify possible anatomic challenges &
contraindication (urethral injury)
Other important causes of DUC not yet mentioned are related to difficulty gaining access to the
• Prepare tools and instruments to assist the procedure urethral meatus because of phimosis, meatal stenosis, morbid obesity, or advanced penile
cancer

Bianchi A, Chesnut GT. Difficult Foley Catheterization. [Updated 2021 Feb 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-
Villanueva C, Hemstreet GP 3rd. Difficult male urethral catheterization: a review of different approaches. Int Braz J Urol. 2008 Jul-Aug;34(4):401-11.
 Difficult Urethral Catheterization Technique
ALGORITHM Techniques to ensure proper urinary catheter placement must account for
anatomic variations and gender (male vs female)

Careful history and physical examination to identify potential cause of DUC

is essential to facilitate selection of appropriate instrumentation
History: past urologic surgeries, previous catheterization difficulties, voiding
symptoms, and additional information from previous attempts (distance of
obstruction felt, balloon inflation, and number of attempts)
PE: identification of obvious causes (penoscrotal edema, phimosis, meatal
stenosis, prostate cancer, etc.)

Patient’s preparation  prep the area with an antiseptic and drape the patient
down
Equipment preparation  lubrication, catheters, and others

Villanueva C, Hemstreet GP. Difficult catheterization: tricks of the trade. AUA Updates. 2011; 30:5.
 Suprapubic Catheterization
Rationale of SPC Open Technique
• It is the urologist’s or surgeon’s preference the bladder is identified visually, by pushing aside
• There is difficulty inserting initial urethral catheter peritoneum and loose fatty tissue
because of obstruction
• Urethral re-catheterization is identified as difficult patients. Closed/Percutaneous Technique
• Completely obliterated urethra
• Urethral catheters are expelled because of a weak pelvic the bladder is identified without dissecting surrounding
floor. tissue (percutaneous placement)
• Procedure follows complex urethral surgery
(urethroplasty).
• Urethral trauma has been experienced.
• Urinary retention has been experienced.
• Procedure is better suited to patient’s need, for example, if
he or she uses a wheelchair.
• To avoid catheter contamination in patients who have fecal
incontinence.
• Patient is sexually active

Robinson J. Insertion, care and management of suprapubic catheters. Nurs Stand. 2008 Oct 29-Nov 4;23(8):49-56; quiz 58.
Take Home Messages
Renal Colic and Urinary Retention are the two most common urological
emergencies in daily practice.

Thorough history taking, physical examination is important is diagnosing

Renal Colic and Urinary Retention

Don’t perform repeated attempts of urinary catheterization without prior

planning and preparation in difficult cases.

Physicians should know how to initially manage emergency situations and

refer to urologist for further management.
 Thank You!

PIT IDI Karawang – Karawang Emergency Updates -2