Renal colic - Clinical Review

5 July 2013Be the First to Comment

How to manage renal stones and prevent recurrence. By Dr Matt Varrier,

Ms Susan Willis and Marlies Ostermann.

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Renal ultrasound showing

hydronephrosis (patient had mid-ureteric stone)

Section 1: Epidemiology and aetiology

Renal colic, resulting from the passage of stones, is a common cause of morbidity. Treatment aimed
at prevention of recurrence can be effective and should be an opportunity to address lifestyle factors.
Renal stones are common, with a lifetime prevalence of about 10% in industrialised nations. They are
about twice as common in men, although they may be increasing in women. Those of European or
Middle Eastern descent appear to have an increased risk.
Stones form in the renal tubules and collecting system when a supersaturation threshold is reached
for the constituent concerned. This depends on a number of factors, including its urinary

concentration, the urinary pH and citrate concentration. Most stones are calcium based and the rate
of recurrence is as high as 50% at 10 years (see table 1).
TABLE 1: TYPES AND FREQUENCY OF RENAL STONE
Type of renal stone

Frequency

Calcium oxalate/mixed calcium

80%

Uric acid

5-10%

Magnesium ammonium phosphate (struvite), uric acid

5-10%

Calcium phosphate

5%

Cystine

1-2%

There is an increased incidence of stones in people with metabolic syndrome. In this population,
stones are more likely than average to be uric acid in nature, although calcium stones are still the
most common.
Renal stone colic is pain caused by the attempted passage of stones along the urinary tract. The
classic waxing and waning character is a result of the peristaltic contraction of the ureter. Although
variable, it can be extremely painful. The most common sites for stones lodging are the pelvicoureteric junction (PUJ) and vesico-ureteric junction (VUJ).
Classification
Eighty per cent of patients with renal stones form calcium stones, most of which are composed
primarily of calcium oxalate or, less often, calcium phosphate. The other main types include uric
acid, struvite (magnesium ammonium phosphate) and cystine stones. The same patient may have
more than one type of stone concurrently.

Section 2: Making the diagnosis

Renal stones are often asymptomatic. Incidental stones are identified in about 5% of patients by
abdominal ultrasonography or CT imaging.
Renal colic classically presents as sudden onset, severe flank pain, which may be intermittent. It
often radiates to the groin, such that pain in the testicle, penile tip, labia or clitoris may be described.
The severity may cause tachycardia, sweating, nausea and vomiting or even collapse. A patient with
renal colic will be rolling around or pacing the floor, in contrast to a patient with peritonitis, who will
lie completely still.

Other presentations of renal stones include the painless passage of grit, stones or visible blood,
dysuria, urgency or less typical flank or abdominal pains.
Investigations
Dipstick haematuria is common and supports the diagnosis, but is not a universal finding.
To secure a diagnosis of renal colic, imaging is required, because the differential diagnoses include a
range of vascular, urological, intestinal, upper GI and gynaecological causes of severe abdominal
pain.
The current gold standard first-line imaging for acute flank pain is a non-contrast CT scan (NCCT).
This has near 100% sensitivity, even for small stones, and will usually demonstrate urinary
obstruction if present. In the absence of stones, it may demonstrate an alternative significant
diagnosis.
IV urogram (IVU) has fallen out of favour because numerous trials have shown inferior sensitivity
and specificity to NCCT, with the potential toxicity of a contrast load. It does, however, give better
demonstration of obstruction if present.
A plain kidneys, ureters, bladder (KUB) X-ray may be helpful in known radio-opaque stone formers
with a classic presentation.
Ultrasound scanning (USS) is safe, inexpensive and good at demonstrating stones >5mm in the renal
calyces, PUJ and VUJ. It is limited by its ability to detect ureteric stones.
USS may be useful in pregnant patients, or ruling out specific differentials such as gallstones,
abdominal aortic aneurysm and ovarian cyst pathology. It is good for detecting hydronephrosis.
The following basic investigations are useful in cases of renal colic:

FBC - a raised WCC may signify infection, although WCC up to 16x109/L is often seen in
acute renal colic
U&Es

Bone profile (to include calcium and phosphate)

Serum urate

Urine microscopy, culture and sensitivity

The patient should also be advised to sieve their urine and collect any stone/sediment for analysis.

Section 3: Managing the condition

In suspected renal colic, initial management can be carried out at home if these criteria are met:

No signs of infection (negative dipstick for leucocytes/nitrites, afebrile, systemically well).

Low risk of renal failure (no chronic kidney disease, single functioning kidney or renal
transplant; unilateral symptoms; passing good volumes of urine).
Good initial response to symptomatic measures.

Symptom control with oral medication (analgesia, antiemetics).

Ability to maintain sufficient fluid intake.

Ideally less than 60 years of age (ensure telephone contact and adequate social support in

place).
Pregnancy excluded in women of childbearing age.
No diagnostic uncertainty regarding serious alternative diagnoses (for example, leaking
abdominal aortic aneurysm).

If these criteria are met, fast-track referral to hospital for diagnostic imaging (NCCT for a first
presentation) should be within seven days. If not, the patient should be referred to hospital for
emergency urological evaluation.
Analgesia
For most patients, the best initial analgesia is rectal diclofenac (50-100mg). Alternatively, for initial
control, the parenteral route may be used (diclofenac 75mg IM).
If there are contraindications to NSAIDs (renal impairment, upper GI disease, volume depletion,
ACE inhibitors), opiates may be used, although they are usually not as effective and may worsen the

nausea. Consider diamorphine 1.25-2.5mg IV or 2.5mg subcutaneously. Pethidine is generally

avoided.
Maintenance can often be achieved with a combination of:

Diclofenac 25-50mg three times a day oral/rectal

Paracetamol 1g four times a day oral/rectal

Codeine 30-60mg every six hours

Antiemetics
Nausea and vomiting are common; initial parenteral options include IM or oral cyclizine,
prochlorperazine or metoclopramide.
Additional therapies
The successful passage of ureteric stones depends on their size and position. Most stones <5mm will
eventually pass, although this may take several weeks. About 50% of 5-10mm stones will pass
spontaneously. Stones >10mm are unlikely to pass without intervention.
Conservative management with observation and reassessment is reasonable in the absence of
infection, hydronephrosis and unmanageable symptoms if the stone is <10mm.
Medical expulsive therapy uses pharmacological smooth muscle relaxation to aid stone passage.
For 5-10mm stones, this may increase the passage rate by 30%. With smaller stones, it may reduce
transit time and symptoms. The best evidence is for alpha-blockers (tamsulosin 400 microgram once
a day).
Infection in an obstructed system is an emergency, as it can destroy nephrons and progress to septic
shock. Management involves broad-spectrum IV antibiotics and decompression with nephrostomy
or stent.
Ureteric stone removal is indicated for stones >15mm, smaller stones that are failing to progress,
persistent obstruction or unmanagable symptoms. The most common techniques are extracorporeal
shock wave lithotripsy and ureteroscopy with laser lithotripsy.
General measures
Measures applicable to all stone formers include:

Maintain fluid intake to excrete >2.5L per day and drink before going to bed, to induce

nocturia
Restrict sodium intake to reduce urinary calcium and increase bicarbonate
Cut animal protein intake
Maintain a healthy weight

Section 4: Prognosis
Most stone formers have no genetic, anatomical or tubular defect predisposing them to stones. They
have calcium-containing stones, often in the context of modifiable metabolic and lifestyle factors.
Recurrent stones are common and can cause significant morbidity, including progressive renal
failure.
A large registry analysis including >3m adults from North America showed that even a single kidney
stone episode was associated with a significant increase in the likelihood of chronic kidney disease,
including end-stage renal failure.1 Therefore, in patients with renal stones, control of cardiovascular
risk factors and modification of lifestyle are essential.
Recurrent stone formers (especially those adhering to the measures above) should be assessed in a
specialist clinic.
Prevention of renal stones
A recent systematic review including 28 RCTs showed that increased fluid intake substantially
reduced the risk for recurrent calcium stones.2
In men with high soft-drink consumption, decreasing intake also reduced recurrent stone risk.
Results were mixed for the potential benefit of other dietary interventions.
In those with multiple past calcium stones, adjunctive treatment with thiazides, citrate and/or
allopurinol further reduced the risk for stone recurrence. Baseline biochemistry did not predict
efficacy of any treatment, apart from uric acid levels.

Section 5: Case study

A 46-year-old male calls his out-of-hours GP with a six-hour history of sudden onset, severe left loin
pain.
When the doctor arrives, the patient is on his knees, grasping his loin. He has vomited and reports
urinary urgency and frequency.
He has recently been diagnosed with type 2 diabetes and takes metformin, simvastatin and
bisoprolol. His says his father had kidney stones, although there is no personal history. His job
involves a lot of time driving and working in air-conditioned offices. He drinks two cups of tea and
one or two cans of soft drink a day.

He is overweight (BMI 31). His pulse is 94bpm, BP 150/95mmHg and temperature 36.4 degsC.
Abdominal examination is unremarkable. Urine dipstick shows blood 2+ and leucocytes 1+, and is
sent for microscopy, culture and sensitivity.
A working diagnosis of renal colic is made, and 10mg morphine IM plus 75mg rectal diclofenac
administered, with immediate relief. He is prescribed co-codamol and diclofenac and advised to
sieve his urine.
Next day, the pain has subsided. The patient is sent for a plain KUB X-ray, which shows a 7mm
radio-opaque density in the left VUJ. He is given a prescription for tamsulosin 400 microgram once
a day.
Five days later the patient attends for follow-up. His pain has gone and he presents a small, irregular
brown stone, which is sent for analysis. His MSU showed no growth. Bloods are requested for FBC,
U&Es, calcium, phosphate and urate.
During the consultation he is asked about dietary habits and admits to eating a lot of meat products
and fast food. He is advised that he has a 50% chance of forming another stone within 10 years, and
that preventive measures should include cutting down on meat and salt, but most importantly,
maintaining a high urine output.

Section 6: Evidence base

Clinical trials

Alexander RT, Hemmelgarn BR, Wiebe N et al. Kidney stones and kidney function loss: a

cohort study. BMJ 2012; 345: e5287.

Fink HA, Wilt TJ, Eidman KE et al. Medical management to prevent recurrent
nephrolithiasis in adults: a systematic review for an American College of Physicians Clinical

Guideline. Ann Intern Med 2013; 158: 535-43.

Online

The British Association of Urological Surgeons. Stone guidelines.

2012.www.baus.org.uk/AboutBAUS/publications/stones-guidelines
Clinical Knowledge Summaries. Renal colic - acute. 2009.www.cks.nhs.uk/renal_colic_acute
Turk C, Knoll T, Petrik A et al. European Association of Urology. Guidelines on urolithiasis.

2013.www.uroweb.org/gls/pdf/21_Urolithiasis_LR.pdf
By Dr Matt Varrier, specialist registrar in renal medicine, Ms Susan Willis, specialist registrar
in urology, and Dr Marlies Ostermann, consultant in renal medicine and critical care, Guy's & St
Thomas' NHS Foundation Trust, London.
CPD IMPACT: EARN MORE CREDITS

These further action points may allow you to earn more credits by
increasing the time spent and the impact achieved.

Talk to colleagues and a radiologist about a protocol for CT

scanning, KUB X-ray or ultrasound for renal colic.

Audit patients with a history of renal colic in the past two years and
ensure they have had FBC, U&Es, bone profile, serum urate and MSU.

Create a dietary advice sheet, with the help of the dietitians, to

reduce the risk of renal colic.
Save this article and add notes with your free online CPD organiser
at gponline.com/cpd
Take clinical tests and claim certificates for CPD atmyCME.com/gp
References
1. Alexander RT, Hemmelgarn BR, Wiebe N et al. Kidney stones and kidney function loss: a cohort
study. BMJ 2012; 345: e5287.
2. Fink HA, Wilt TJ, Eidman KE et al. Medical management to prevent recurrent nephrolithiasis in
adults: a systematic review for an American College of Physicians Clinical Guideline. Ann Intern Med
2013; 158: 535-43.