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Stuck between a Rock and a Hard Place: Navigating Renal Colic Treatment

Renal colic is a common presenting symptom in the ED, with an estimated prevalence as high as 10-15% in the US. It accounts for approximately 1% of all ED visits per year. Most patients will pass these calculi spontaneously and do not require surgical intervention, therefore focus on pain relief is of utmost importance in the emergency department. NSAIDs have shown to be as effective, if not more effective than opioids, making them a reliable first line agent. Opioids still provide a viable option in those with kidney disease or gastric ulcer disease, however they may be best utilized as combination agents to decrease the need for rescue analgesia. There is weak evidence to support the use…

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 Management of kidney stones

Unenhanced helical computed tomography is the best radiographic technique for diagnosing urolithiasis. Shock wave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy have replaced open surgery for treating urolithiasis. Most simple renal calculi (80-85%) can be treated with shock wave lithotripsy. Percutaneous nephrolithotomy is the treatment of choice for complex renal calculi. Staghorn calculi should be treated, and percutaneous nephrolithotomy is the preferred treatment in most patients. Ureteroscopy is the preferred treatment in pregnant, morbidly obese, or patients with coagulopathy. Most ureteral calculi <5 mm in diameter will pass spontaneously within four weeks of the onset of symptoms.

 Urolithiasis: ED Presentations, Evaluation, Management, and Disposition

Stone size and location on CT are critical components to the likelihood of spontaneous passage. Stones <5mm and distal are the most likely to pass spontaneously, while those proximal and >10 are the most likely to require intervention. There are two hard indications for urgent urological intervention: infection and obstruction with known or impending kidney injury. Once either is suspected, start broad-spectrum antibiotics, and obtain CT imaging emergently to guide operative planning.

Articles of Interest

Adjunctive Pain Management of Renal Colic and Migraines

“In this study, we concluded that administration of intravenous 50mg/kg magnesium sulfate could be as effective as morphine in reducing renal colic without any further complications.” Clinical Take Home Point: In this small, single center RCT magnesium sulfate reduced pain in renal colic at 20 minutes similar to morphine. However, morphine was quicker acting with more pain relief at 10 minutes. This study makes the argument that adding magnesium sulfate to the treatment of renal colic, may help spare opioids as 1st line agents.

Alpha Blockers in Renal Colic: A Systematic Review

This systematic review and meta-analysis is an excellent example of the “crap in = crap out” theory. Recent high quality RCTs have demonstrated that in a general population of patients presenting with renal colic, alpha blockers add no additional benefit to symptomatic management. The very same studies suggest that there may be a small benefit in the subset of patients presenting with large stones. The addition of multiple low quality studies at significant risk for bias, add nothing but statistical noise to these high quality randomized control trials. Given the totality of the data, the universal use of alpha blockers to all patients with renal colic is not supported by the available evidence.

Can Tamsulosin Get That STONE to Drop?

Tamsulosin should not routinely be prescribed to patients with ureteral colic and, at this point, it is unclear if there is any subgroup that may benefit. There will be continued conjecture that larger stones may benefit due to inconsistency in the literature and the absence of a RDCT primarily looking at passage of larger stones.

Clinical Conundrums: Do We Need to Order a CT for Every Patient with Renal Colic?

In older patients with flank pain whom you have a concern for alternative diagnoses, obtain a contrast-enhanced CT. In a young patient who has a clear clinical diagnosis, there is no required imaging. POCUS can help guide imaging decisions. The practice of getting a CT scan in every renal colic patient at every visit should be ended.

Diagnosis and Management of Acute Renal Colic: An Evidence Based Update

Renal colic is an diagnostic entity emergency providers see almost every shift, often cited as the “worst pain imaginable”... Renal colic has been touted as being one of the most painful events one may experience. Thus, providing appropriate analgesia in the Emergency Department is of paramount importance. A Cochrane review in 2005 demonstrated that both NSAIDs and Opioids are effective for the treatment of acute renal colic pain. In 2015, another Cochrane review demonstrated benefit for NSAIDs over antispasmodics.

Imaging in Suspected Renal Colic: Systematic Review of the Literature and Multispecialty Consensus

Evidence and multispecialty consensus support ultrasonography or no further imaging in specific clinical scenarios, with reduced-radiation-dose CT to be used when CT is needed for patients with suspected renal colic.

Intravenous lidocaine for renal colic

Yes, we need more evidence about IV lidocaine for acute renal colic, because most of the evidence available regarding IV lidocaine surrounds peri-operative use. However, by extrapolating that data along with the limited ED literature, IV lidocaine may be considered a safe and effective analgesic for renal colic. Administer 1.5 mg/kg lidocaine IV over 10 minutes via a smart pump along with ketorolac 15 mg IV for a synergistic multimodal approach.

IV Lidocaine for Renal Colic?

The addition of lidocaine to ketorolac for the treatment of suspected renal colic has no clinical benefit, but may result in increased adverse events. Lidocaine should not be recommended for routine widespread use for treatment of renal colic in the ED.

Managing patients with renal colic in primary care: Know when to hold them

The pain of renal colic develops suddenly and is often described by patients as “the worst pain they have ever felt”. Despite this severe presentation, the majority of urinary stones pass spontaneously. Therefore many patients with renal colic can be managed in primary care with a watchful waiting approach if there are no red flags present, their pain can be controlled and a prompt referral for imaging is arranged.

Medical Expulsion Therapy in Ureteral Colic: An Update

These studies may have finally identified a population who will benefit. However, in order to identify this group, a CT scan will be required. In the past couple of years, we have recognized the issues of CT overuse, particularly in patients with ureteric colic. A return to scanning all of these patients would have an overall deleterious effect without a significant benefit. Scanning everyone looking for the small subgroup of patients that may benefit is nonsensical.

Medical Student Curriculum: Kidney Stone

Number of days to pass stone (mean} and % Likelihood of eventual need for intervention...2mm or less - 8days - 3%... 3mm - 12days - 14%... 4-6mm - 22days - 50%... > 6mm -- 99%...Two-thirds of ureteral stones that pass spontaneously pass within 4 weeks of the onset of symptoms.

Nephrolithiasis: Diagnosis and Management in the ED

Medical expulsive therapy (MET): Alpha-1 antagonists are frequently used to relax ureteral smooth muscle cells and improve stone passage. A recent systematic review concluded that Tamsulosin (Flomax) improved stone passage when compared to placebo.9 While a few trials suggested that tamsulosin is an effective way to clear ureteral stones,9,11 other studies suggest that there is no benefit.10 So, the bottom line is that it is unclear if this is actually beneficial for the passage of renal stones, and therefore is not employed as primary management of renal colic in the Emergency Department.

New treatment could ease the passage of kidney stones

Muscle relaxants delivered to the ureter can reduce contractions that cause pain when passing a stone.

Pain management of Renal Colic

Patients with the presumed diagnosis of renal colic had better pain scores when morphine and ketorolac were given in combination versus either alone.

Renal Calculi: Emergency Department Diagnosis And Treatment

Renal colic is one of the most severe pain syndromes commonly diagnosed and managed in the ED. While the morbidity and mortality of urolithiasis is relatively low in comparison to other conditions, these patients need to be assessed quickly for potential life-threatening mimics. In addition, they need to receive appropriate control of nausea and vomiting as well as appropriate and judicious use of analgesics.

Renal Colic Imaging, Analgesia, Fluids & Medical Expulsive Therapy

While IM diclofenax and IV acetaminophen may provide superior relief to inadequate doses of IV morphine, this does not translate to appropriate or adequate pain relief for the patient. Although 68% and 66% percent of patients in the diclofenax and acetaminophen groups experienced a 50% reduction in pain at 30 minutes, 32% and 34% did not. 12% and 20% required rescue analgesia. These reductions in pain were achieved at 30-minutes following medication administration. With the appropriately titrated dose of morphine, adequate pain relief can be achieved far earlier. And while this data certainly demonstrates that NSAIDs are reasonable options over the course of a patient’s Emergency Department stay, it should not dissuade us from the early and appropriate use of IV opiate analgesics when clinically necessary.

Renal Colic Pain

Rapid and effective analgesia is one of the most critical aspect of managing patients with renal colic in the ED. Based on available evidence, NSAIDs are the first-line agents in alleviating the pain of renal colic, with opioids being used as a second-line agent (either as an adjunct to NSAIDs or as a rescue).

Renal Colic – Diagnosis

Common presenting symptoms include flank pain, nausea/vomiting, dysuria, urinary urgency and/or frequency, and hematuria. Absence of hematuria does not rule out nephrolithiasis. Up to 35% of patients will NOT have hematuria by day 3 of symptoms.

Therapeutic Approaches for Renal Colic in the Emergency Department: A Review Article

Nowadays, opiates and NSAIDs are used in most countries for the control of renal colic pain. Knowing that these drugs have side effects, the administration of alternative therapies would appear to be inevitable. In the present review we presented almost all possible treatments for renal colic. However, more studies are needed to be conducted on the use of alternative therapies in renal colic. Some medications such as lidocaine and papaverine have worked well in patients resistant to conventional therapies; however, as inadequate evidence is available in this regard, further studies are needed.

Ureteral Colic

Ureteral colic is a clinical diagnosis. The goal of diagnostic tests is not to confirm the presence or absence of a ureteral stone but rather to exclude other more serious causes of the patient’s symptoms.

Resources

Resident360

Most kidney stones contain calcium combined with either oxalate, phosphate, or uric acid, and all calcium-containing stones are radio-opaque. Conditions causing hypercalciuria can contribute to the formation of calcium stones. These include diseases such as primary hyperparathyroidism, certain malignancies, granulomatous diseases, sarcoidosis, and thyrotoxicosis.

StatPearls

Many ureteral stones will pass spontaneously, but some will need elective surgical intervention. Such procedures include extracorporeal shockwave lithotripsy (ESWL), cystoscopy with double J stenting, and ureteroscopy. Some clinical situations may require urgent surgical intervention, such as sepsis from obstructive pyelonephritis (pyonephrosis), where the infected renal pelvis needs to be drained emergently.