Scott G. Hubosky, MD
BASICS
DESCRIPTION
• Renal colic is a constellation of symptoms that usually accompanies upper urinary tract obstruction (1)[C]
– Pain
Involves the flank and/or groin, with radiation to the ipsilateral scrotum or labia majora
Pain character is colicky with patients demonstrating a restless nature, unable to stay still
Pain is abrupt in onset and not associated with physical activity or positions
– Nausea/vomiting
Simultaneously presents with flank pain but not in all cases
– Irritative or obstructive voiding complaints which are not present at baseline
Urinary frequency, feeling of incomplete emptying, hesitancy
– Hematuria
Gross or microscopic
Presence of hematuria strongly suggests underlying urologic etiology over gastrointestinal origin
EPIDEMIOLOGY
Incidence
Renal colic accounts for about 1% of all emergency department visits (2,3)[C] representing over 1 million cases per year
Prevalence
• Renal colic caused by nephrolithiasis has an estimated prevalence of 6.3% in men and 4.1% in women over a study period of 1988–1994 (4)[C]
– Prevalence seems to be increasing compared to past estimates
RISK FACTORS
• History of nephrolithiasis
• Recent urologic surgery
• History of ureteral stricture
– Pelvic radiation history
Genetics
N/A
PATHOPHYSIOLOGY
• Presence of obstruction anywhere along the course of the ureter results in stretching of involuntary smooth muscle lining the ureter and renal pelvis
• This stretching of the ureteral smooth muscle is exacerbated by baseline ureteral peristalsis
• Stretching of hollow viscera, such as the ureter/renal pelvis, is a well-known stimulus for pain as transmitted by the autonomic nervous system (1)[C]
• The kidneys, proximal ureters, and stomach are all served by the celiac ganglion thus explaining why nausea and vomiting frequently accompany renal colic
ASSOCIATED CONDITIONS
• Any process causing obstruction of the upper urinary tract
– Ureteral stone
– Ureteral stricture
– Upper tract urothelial neoplasm
– Extrinsic ureteral obstruction
– Iatrogenic ureteral injury
Ureteral ligation during hysterectomy or colectomy
• Upper urinary tract infection
– Pyelonephritis
– Renal abscess
• Recent urologic surgery
– Obstructing blood clots from upper tract
– Ureteral stent in poor position
– Presence of poorly draining percutaneous nephrostomy tube
– Residual ureteral stone fragments after lithotripsy
• Miscellaneous
– Renal artery embolus/infarction
– Renal vein thrombosis
GENERAL PREVENTION
• Empiric advice for nephrolithiasis prevention
– Adequate hydration
Enough fluid consumption to generate 2.5 L of urine output per day
– Low-sodium diet
Daily sodium intake should be <2,500 mg
Diets high in sodium result in hypercalciuria
About 82% of renal stones produced have calcium as a constituent
– Normal calcium diet
Daily calcium intake should range between 800 and 1,200 mg
Vitamins, supplements, and antacids should be considered
DIAGNOSIS
HISTORY
• Sudden onset of colicky flank pain
– May be associated with simultaneous nausea or vomiting
– May have associated gross or microhematuria
– May have radiation to ipsilateral groin or scrotum/labia majora
– Pain is colicky and intermittent
• The location and characteristics of renal colic pain relating to urolithiasis (5):
– Stones obstructing UPJ: Mild to severe deep flank pain without radiation to the groin; irritative voiding symptoms (eg, frequency, dysuria); suprapubic pain, urinary frequency/urgency, dysuria, stranguria, bowel symptoms
– Stones within ureter: Abrupt, severe, colicky pain in the flank and ipsilateral lower abdomen; radiation to testicles or vulvar area; intense nausea with or without vomiting
– Upper ureteral stones: Radiate to flank or lumbar areas
– Midureteral calculi: Radiate anteriorly and caudally
– Distal ureteral stones: Radiate into groin or testicle (men) or labia majora (women)
– An objective clinical prediction rule for uncomplicated ureteral stones that uses 5 patient factors—sex, timing, origin (ie, race), nausea, and erythrocytes(STONE)—to create a score between 0 and 13 (the STONE score). With a high STONE score, patients are likely to have a kidney stone.
PHYSICAL EXAM
• General appearance is that of a restless patient unable to be still
• Usually unilateral flank pain with radiation to ipsilateral lower quadrant
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Serum creatinine/BUN and electrolytes
• Complete blood count
• Urinalysis
– Look for signs of blood or infection
• Urine culture
Imaging
• CT scan of abdomen and pelvis without any contrast
– Most sensitive way to detect urinary tract calculi (99% sensitivity to detect ureteral stones)
– Relatively expensive and subjects patients to radiation exposure
Low-dose radiation stone protocol still gives 95% sensitivity for ureteral stone detection with 60% less radiation exposure
• CT urogram
– CT scan of abdomen/pelvis with IV contrast which is useful to expand diagnostic capability when no ureteral stones are found
Can diagnose causes of colic not caused by stones such as UPJ obstructions or intraluminal filling defects such as neoplasms, fungus balls, or blood clots
• Renal/bladder ultrasound
– No radiation exposure/safe in pregnancy and in pediatric patients
– Ask for Doppler assessment of ureteral jets
Presence of ureteral jets rules out complete ureteral obstruction (although partial obstruction may exist)
Absence of ureteral jet may indicate obstruction or dehydration
– Relies on indirect evidence to diagnosis obstruction
Hydronephrosis
Presence or absence of ureteral jets
– Not very sensitive for detecting small ureteral stones
• KUB x-ray
– May detect calcification along the expected course of the ureter
– Not very sensitive or specific
– Benefits are low-radiation dose and is inexpensive
Diagnostic Procedures/Surgery
• Relief of obstruction may be necessary
– Ureteral stent placement
– Percutaneous nephrostomy
• Culture-specific antibiotics
– If infection is present
• Definitive surgical procedure as dictated by underlying condition
Pathologic Findings
N/A
DIFFERENTIAL DIAGNOSIS
• Ureteral calculus
• Ureteral stricture
• UPJ obstruction
• Upper tract urothelial neoplasm
– Upper tract urothelial carcinoma
– Fibroepithelial polyps
• Iatrogenic ureteral obstruction
– Ureteral ligation after hysterectomy or colon resection
– Obstructing residual stone fragments after lithotripsy
– Obstructing blood clots following upper tract urologic procedure
• Upper urinary tract infection
– Pyelonephritis
– Pyonephrosis
– Renal abscess
– Obstructing fungus ball
• Renal vascular etiology
– Renal artery embolus/renal infarction
– Renal vein thrombosis
TREATMENT
GENERAL MEASURES
• Rule out sepsis
• Treat infection
• Control pain
• Alleviate obstruction, if present
MEDICATION
First Line
• Analgesia based on degree of discomfort
– Narcotic analgesics for more severe pain
Given PO or IV
Morphine sulfate, oxycodone/APAP, hydrocodone/APAP, meperidine, nalbuphine
– Ketorolac
– IV acetaminophen
Less dizziness and hypotension than morphine in one study
• Antiemetics (metoclopramide, ondansetron)
Second Line
• α-blockers: Tamsulosin, alfuzosin, silodosin
– Given to relieve ureteral smooth muscle spasm patients with ureteral stones
– Off-label use in cases of urolithiasis
Alfuzosin (10 mg/d)
Silodosin (8 mg/d)
Tamsulosin (start 0.4 mg to max 0.8 mg); most reported data
SURGERY/OTHER PROCEDURES
• Initial stent placement for significant obstruction
• Lithotripsy for nephrolithiasis
– Ureteroscopy with laser lithotripsy
– ESWL (extracorporeal shock wave lithotripsy)
– PCNL (Percutaneous nephrolithotomy)
• Ureteral stricture treatment
– Balloon dilation, laser incision
– Open or laparoscopic reconstruction
• UPJ obstruction
– Pyeloplasty (open, laparoscopic, robotic)
– Endopyelotomy (retrograde, antegrade)
• Upper tract neoplasm
– Ureteroscopic ablation
– Nephroureterectomy (open or laparoscopic)
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Obtain adequate drainage if necessary, especially if the patient appears septic
– Ureteral stenting is usually a good 1st choice
Chronically obstructed patients often have significant ureteral tortuosity making retrograde access challenging
– Percutaneous drainage
Can be performed with conscious sedation
Optimal in cases of significant extrinsic ureteral compression
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
Depends on underlying etiology but usually good once obstruction is relieved and infection treated, if present
COMPLICATIONS
• Persistent obstruction if left untreated
– Renal cortical loss
Could lead to nonfunctioning kidney
– Serious infection
FOLLOW-UP
Patient Monitoring
Renal/bladder ultrasound after treatment to ensure no evidence of silent hydronephrosis or recurrent obstruction
Patient Resources
Urology Care Foundation http://www.urologyhealth.org/urology/index.cfm?article=148
REFERENCES
1. Silen W. The colics. In: Cope’s Early Diagnosis of the Acute Abdomen. 22nd ed. New York, NY: Oxford University Press; 2010.
2. Brown J. Diagnostic and treatment patterns for renal colic in US emergency departments. Int Uro Nephrol. 2006;38:87–92.
3. Chauhan V, Eskin B, Allegra JR, et al. Effect of season, age and gender on renal colic incidence. Am J Emerg Med. 2004;22:560–563.
4. Stamatelou KK, Francis ME, Jones CA, et al. Time trends in reported prevalence of kidney stones in the United States: 1976–1994. Kidney Int. 2003;63:1817–1823.
5. Wolf JS. Medscape practice essentials: Nephrolithiasis. Available online at http://emedicine.medscape.com/article/437096-overview. Accessed January 5, 2014.
ADDITIONAL READING
• Malo C, Audette-Côté JS, Emond M, et al. Tamsulosin for treatment of unilateral distal ureterolithiasis: A systematic review and meta-analysis. CJEM. 2013;15(0):1–14.
• Moore CL, Bomann S, Daniels B, et al. Derivation and validation of a clinical prediction rule for uncomplicated ureteral stone–the STONE score: retrospective and prospective observational cohort studies. BMJ. 2014;348:g2191.
See Also (Topic, Algorithm, Media)
• Flank Pain, General
• Pyonephrosis
• Pyelonephritis, Acute, Adult
• Renal Colic Image 
• Urolithiasis, Renal
• Urolithiasis, Ureteral
CODES
ICD9
• 599.69 Urinary obstruction, not elsewhere classified
• 787.01 Nausea with vomiting
• 788.0 Renal colic
ICD10
• N13.8 Other obstructive and reflux uropathy
• N23 Unspecified renal colic
• R11.2 Nausea with vomiting, unspecified
CLINICAL/SURGICAL PEARLS
• Vast majority of patients with renal colic will have calculi.
• Young patients with hydronephrosis and no evidence of calculus likely have congenital UPJ obstruction or other upper tract narrowing.
• Support patient with medicines to alleviate the acute pain of renal colic.
• Treat infection if present.