InnovAiT, 0(0), 1–7 DOI: 10.

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Renal colic

R
enal colic is defined as ‘acute and severe loin pain caused by a urinary
stone’. Renal colic is a common urological presentation with approximately
1 in 11 people receiving a diagnosis of renal colic in their lifetime. More
than half of patients with renal colic will have recurrent symptoms within 5 to 10
years. This article will consider the diagnosis and management of adult renal colic
in primary and secondary care, including indications for appropriate referral to
secondary care and longer-term management of patients with renal colic.

The GP curriculum and renal colic

Clinical module 3.03: Care of acutely ill people requires GPs to:
. Know the symptoms, signs and presentation of common severe illness
. Determine whether urgent action is necessary for patients who are acutely ill to ensure correct and timely
treatment and to ensure that patients with similar symptoms for whom urgent treatment is not needed are
protected from the potential harm of unnecessary investigations and/or therapeutic interventions
. Know when it is safe and appropriate to manage a patient in the community and when the patient needs to be
referred to hospital for assessment or admission

Clinical module 3.07: Men’s health requires GPs to:

. Manage primary contact with patients who have male genito-urinary problems

pain and progress to spasmodic pain lasting for a few

Pathophysiology
...........................................................................................................

........................................................... minutes to several hours. Patients often report difficulty

finding a comfortable position, and may writhe around or
Ureteric colic is a more accurate term than renal colic, as
pace up and down. This feature can help to differentiate
the pain is caused by obstruction of the ureter (Bultitude &
renal colic from peritonitis, where the patient lies flat and
Rees, 2012). Stones can have various chemical compos-
remains still. The pain of renal colic will often radiate to
itions; however, 80% of them contain calcium. They are
the groin and testicle in men or labia in women, depend-
formed from normally soluble urinary chemicals, which
ing on the location of the stone. Women have described
when present in higher concentrations and under certain
the pain as more severe than that experienced when in
conditions undergo precipitation and form stones. Calcium
labour. Patients may report urinary urgency, increased
oxalate stones are the most commonly seen stones, fol-
urinary frequency and the passage of small volumes of
lowed by calcium phosphate, uric acid, struvite and cyst-
urine if the stone has reached the vesico-ureteric junction
ine. Table 1 describes the different stone compositions
(VUJ) where it causes irritation of the detrusor muscle.
and conditions in which they may be formed.
There may also be a history of nausea and vomiting or
Risk factors
...........................................................
visible haematuria. A concomitant urinary infection may
cause fevers, rigors or sweats (Bultitude & Rees, 2012;
There are a number of risk factors for renal calculus for- National Institute for Health and Clinical Excellence
mation, ranging from underlying diseases, genetic pre- (NICE), 2015; Portis & Sundaram 2001).
disposition, drugs and anatomical abnormalities. Table 2
lists some these predisposing factors. The differential diagnosis for patients with an acute abdo-
men includes renal colic. It is therefore important to con-
sider other differential diagnoses during the work-up of
History
...........................................................
any patient with renal colic. The work-up includes a
detailed history of the site and nature of the pain,
The classic definition of renal colic is the sudden onset of any associated symptoms, the duration of symptoms
unilateral flank pain. The pain may start as vague flank and, in female patients, a brief gynaecological history.

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Table 1. Pathophysiology of stones.

Stone composition Notes

Calcium stones (including Associated with low urine volumes and raised urine pH
oxalate and phosphate)
Uric acid stones Associated with low urine pH and raised uric acid including in gout

Struvite stones These are composed of magnesium, ammonium and phosphate. They
are associated with bacterial infections, for example, Proteus species,
Klebsiella, Pseudomanas and Ureaplasma urealyticum. This results in
rapidly forming large stones known as Staghorn calculi

Cystine stones Associated with a homozygous recessive condition resulting in

cystinuria

Source: Badalato, Leslie, and Teichman (2016) and NICE (2015).

Examination

...................................................................................................................................................................
Table 2. Risk factors for renal calculi.
...........................................................
General Diseases A thorough examination should follow a detailed history,
. Warmer climates . Hyperparathyroidism and include testicular examination in male patients. The
. Dehydration . Renal tubular acidosis kidneys and the testes share a nerve supply from the
. Increasing age . Nephrocalcinosis same nerve root, and therefore, the site of pain may or
. Male . Myeloproliferative may not coincide with the origin of the pain.
. Obesity disorders
. Diet including . Gastrointestinal Vital observations must be documented as part of the
high levels of conditions including assessment to identify those patients requiring urgent hos-
animal protein Crohn’s disease, pital admission. A urine dipstick will identify haematuria,
. Family history jejuno-ileal bypass, and this supports a diagnosis of renal colic. The presence
. Urinary tract malabsorptive of leucocytes with nitrites suggests infection. In female
infection conditions patients, a urine pregnancy test is recommended.
. Cystic fibrosis
. Gout
. Sarcoidosis
. Hypertension When should a patient
Drugs Anatomical
be admitted to
. Vitamin D
and calcium
abnormalities
. Horseshoe kidney
secondary care?
...........................................................
supplements . Ureteral stricture Before discussing management within primary care, it is
. Diuretics . Ureteropelvic junction important to consider which patients require urgent hos-
. Protease inhibitors obstruction pital admission. Reasons for urgent admission are con-
. Chemotherapy . Vesico-uretero-renal sidered in Box 1 and require assessment of any previous
. Topiramate reflux renal history, adequacy of pain control and signs of
. Ureterocele sepsis. Urgent hospital admission may also be warranted
when there is difficulty investigating the patient in pri-
Source: Bultitude and Rees (2012), NICE (2015) and Turk et al.
mary care.
(2015).

Patients suffering from drug dependence may present

Management within
with symptoms of renal colic as an attempt to gain primary care
...........................................................
access to opiates. Figure 1 provides a list of possible
differential diagnoses to consider; although not exhaust- Analgesia
ive this provides a good starting point for the assessment Management within primary care requires adequate anal-
of patients. gesia. Non-steroidal anti-inflammatory drugs (NSAIDs)

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Box 1 Reasons for admission to hospital. Blood tests
The BAUS recommends investigation with a full
. Signs of sepsis blood count, and urea and electrolyte tests in all patients
. Increased risk of acute kidney injury – especially with renal colic. These should be performed within pri-
in patients with a solitary or transplanted kidney mary care in patients who are stable and not being
and background of chronic kidney disease
admitted to secondary care, or in the Emergency
. Suspected bilateral stones
Department if they are pyrexial or have underlying
. If the patient is pregnant
renal disease or abnormalities at the time of admission.
. Risk of dehydration
Additional tests include calcium and uric acid to deter-
. Diagnostic uncertainty, especially if worried
mine potential metabolic causes of renal calculi (BAUS,
about a leaking abdominal aneurysm
2012; Turk et al., 2015).
. Inadequate pain control
Source: Bultitude and Rees (2012) and NICE (2015).

Imaging
and paracetamol are first line analgesics with opiates There are different imaging modalities that can aid
being second line. NSAIDs can be given orally, rectally diagnosis of renal calculi; access to these can vary
or parenterally, and provide a significant reduction in pain locally. Table 3 shows the sensitivities and specificities
scores, they also reduce the requirement for further anal- of different imaging modalities in the diagnosis of renal
gesia compared with opiates (British Association of calculi.
Urological Surgeons (BAUS), 2012; Bultitude & Rees,
2012). Diclofenac is suggested as the NSAID of choice, Historically, universal quick access has encouraged the
with NICE recommending 75–150 mg daily in two or use of X-rays of the kidney, ureter and bladder in the
three divided doses (NICE, 2015). acute setting. However, now there is increased use of
non-contrast computed tomography (NCCT). X-rays are
If NSAIDs are contraindicated, paracetamol and weak particularly helpful in differentiating between radiopaque
opioids are recommended. Opiates are associated with and radiolucent stones, and for comparing imaging in
vomiting, and patients often require additional analgesia. follow-up outpatient appointments (Bultitude & Rees,
If opiates are prescribed, it is advisable to avoid pethid- 2012; Turk et al., 2015).
ine, due to the increased risk of vomiting (BAUS, 2012;
Turk et al., 2015). Co-prescribing of antiemetic medica- The ultrasound (US) scanning of the kidney, ureter and
tion, such as metoclopramide, cyclizine or prochlorpera- bladder of stable patients with renal colic is the most
zine is recommended to manage any associated nausea frequently requested imaging modality by primary care.
and vomiting. Advantages include the lack of radiation exposure and

Figure 1. Renal colic differential diagnosis.

Source: NICE (2015).

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the relatively low cost when compared with NCCT. US Referral
scanning can identify stones, especially if more than 5 Stable patients are those with a clear diagnosis, without
mm in diameter, throughout the pelvicalyceal system and renal abnormalities or co-morbidities and with well-
VUJ, and can also identify dilation of the renal tract sec- controlled pain (Bultitude & Rees, 2012). NICE recom-
ondary to a stone. US scans are less able to identify mends that stable patients have an urgent urology out-
stones between the pelvi-ureteric junction and VUJ patient referral for further investigation to confirm the
(Bultitude & Rees, 2012; Turk et al., 2015). diagnosis and plan further management. Ideally, this
should be within 7 days of patient presentation, but
NCCT is now the gold standard for diagnosis of local guidelines should be followed (NICE, 2015).
renal calculi. However, access to NCCT from primary
care is not universally available. NCCT can also identify Patients awaiting outpatient review should be advised to
uric acid and xanthine stones, which tend to be radio- remain well-hydrated and given effective analgesia.
lucent on plain X-ray scans. NCCT can also aid Patients should also be advised that stones might pass
further management, as information on stone density, spontaneously. They should sieve urine through a tea
stone structure, skin-to-stone distance and other strainer or stockings, thereby allowing the stone to be
pathology can be identified. There is also no risk of filtered out and sent for analysis. It is also important to
nephrotoxicity or allergic reactions to intravenous con-
offer clear safety netting advice to patients. They should
trast (Turk et al., 2015).
seek urgent review if there is worsening pain, fevers or
rigors (NICE, 2015).

Table 3. Sensitivities and specificities of

imaging modalities. Management within
Imaging Sensitivity
(%)
Specificity
(%)
secondary care
...........................................................
Emergency intervention is necessary for an obstructed
X-ray of the kidney, 44–77 80–87 infected kidney, bilateral kidney obstruction, obstruction
ureter and bladder of a solitary kidney and when pain is not controlled.
Ultrasound: Ureteric 45 94
stones Emergency treatment may include fluid resuscitation and
antibiotics. Additional procedures including nephros-
Ultrasound: Renal 45 88 tomies or retrograde stent insertion may be required in
stones patients with obstruction (Bultitude & Rees, 2012; Gill,
Britnell, & Kumar, 2015). Further management options
Non-contrast computed 94–100 92–100
are discussed below, with Figure 2 offering a summary
tomography
of the management of calculi as determined by size and
Source: Bultitude and Rees (2012) and Turk et al. (2015). location.

Figure 2. Summary of treatment options depending upon stone location.

Source: Turk et al. (2015).

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Conservative management Extracorporeal shock wave lithotripsy
A ‘watch and wait’ approach may be adopted in patients Extracorporeal shock wave lithotripsy (ESWL) involves
with ureteric stones of less than 10 mm in diameter in the production of shock waves that are focused onto the
absence of pain, sepsis and hydronephrosis. Ureteral stone in order to break it into small fragments that are
stones measuring 3 mm in diameter have an 86% easy for the patient to pass (Badalato et al., 2016).
chance of passing spontaneously, whereas stones mea- Patients with ureteric stones are often treated in specialist
suring 4 to 6 mm in diameter have a 50% chance of lithotripsy centres. ESWL can be performed as an out-
passing spontaneously (Badalato, Leslie, & Teichman, patient procedure and is often well-tolerated by patients.
2016). Conservative management is offered to patients The success rate of the procedure is affected by the
with stable renal function and who are pain-free. stone size, location and composition. Patients may
However, if the stone has not passed within 4 to 6 require multiple treatments.
weeks, additional treatment may be needed. Further
treatment depends upon stone size, site and shape. Anticoagulants, pregnancy, recurrent urinary tract infec-
tions and severe skeletal malformations are all contraindi-
The patient’s occupation needs to be considered and this cations to ESWL (Gill et al., 2015; Turk et al., 2015). The
may affect the management plan. For example, the Civil most common complications following the procedure
Aviation Authority has strict guidance and imposes include haematuria, flank pain (as stone fragments are
restrictions on pilots with renal stones. passed), urinary tract infections and bruising of the skin
(BAUS, 2016).
Medical management
Medical expulsive therapy (MET) continues to be
researched; however, currently its use remains contro-
Ureteroscopy
versial. Use of this treatment, in the form of cal- Ureteroscopy is performed under general anaesthetic
cium channel blockers and a blockers, is largely and involves the insertion of the ureteroscope into the
restricted to secondary care, due to the contraindications calculus, the calculus is then either removed completely
that apply.
or in fragments after being broken into pieces by the use
of a laser. Studies have shown more than 97% of patients
Nifedipine is the only calcium channel blocker to be
are stone-free following treatment with ureteroscopy
investigated; it acts by relaxing ureteric smooth muscles
(Walton, 2011). It is performed as a day-case procedure.
to facilitate stone passage (Bultitude & Rees, 2012;
The most common complications following ureteroscopy
Walton, 2011).
include dysuria and infection. If a stent is inserted,
patients can experience increased urinary frequency,
Tamsulosin is the most commonly used a blocker; how-
pain and haematuria (BAUS, 2016).
ever, other a blockers have been shown to be equally
effective. These drugs act at the distal ureter, causing
smooth muscle relaxation (Bultitude & Rees, 2012;
Walton, 2011). Percutaneous nephrolithotomy
Percutaneous nephrolithotomy (PCNL) is the treatment
However, tamsulosin has been shown to be more of choice for large renal stones (see Fig. 2). The proced-
effective than nifedipine in accelerating stone passage ure is performed under general anaesthetic with the
(Turk et al., 2015). One meta-analysis demonstrated placement of a nephrostomy into the renal collecting
a 65% greater chance of stone passage with a system. A nephroscope is passed following this, which
blockers than in the control studies. However, a single allows introduction of different instruments including
randomised controlled trial showed tamsulosin to be lasers or graspers to fragment or remove stones.
inferior to placebo in accelerating stone passage,
although it reduced the need for further analgesia PCNL is more invasive, has a longer recovery time,
(Hermanns et al., 2009; Walton, 2011). Recent additional increased analgesia requirement and risk of bleeding.
meta-analyses and studies on the benefits of MET in Relative contraindications include anticoagulants.
facilitating stone passage have reported contradictory Anticoagulants must be stopped prior to the procedure
findings (Hollingsworth et al., 2016; Pickard et al., and patients monitored. Absolute contraindications
2015). It is therefore currently not routinely recom- include patients with suspected malignancies or preg-
mended to patients. nancy (Badalato et al., 2016; Turk et al., 2015; Walton,
2011).
There are several contraindications to MET including,
stones greater than 7 mm in diameter, uncontrolled
pain, underlying infection, obstruction in a solitary
kidney or bilateral obstruction (Walton, 2011). Patients Open surgery and laparoscopic surgery
need to be advised about the side effects of the The use of open and laparoscopic surgical procedures for
medications and of the off-label usage of medication renal calculi has reduced with improving success rates
in MET. with ESWL, PCNL and ureteroscopy. It is reserved largely

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for complex stones, failure of PCNL, transplanted kid- . On admission, urgent imaging, ideally a NCCT
neys and a non-functioning kidney. Obesity can affect scan of the renal tract, is used to confirm the diag-
the success rates of ESWL and PCNL, thus, patients nosis and locate renal tract stones
may require surgery to remove stones (Turk et al., . Urgent (within 1 week) urology outpatient referral
2015; Walton, 2011). As with most open procedures, is appropriate for stable, apyexial patients with no
patients are at risk of infection, bleeding and scarring. renal abnormalities or complicating co-morbities
Open and laparoscopic surgeries also present a risk of and adequate analegsia
injury to nearby structures and damage to abdominal . Secondary care management may require inter-
wall muscles. Patients may require stent insertion vention (ESWL, ureteroscopy, PCNL and surgery)
during a procedure that will require subsequent or a conservative approach
removal (BAUS, 2016).
References and further information
. Badalato, G., Leslie, S. W., and Teichman, J.
Prognosis (2016). Kidney stones. Retrieved from www.
There is a 30–40% risk of stone recurrence within 5 years auanet.org/education/kidney-stones.cfm
(Bultitude & Rees, 2012). Therefore, it is important to . BAUS. (2012). Guidelines of acute management of
consider preventive measures. These are divided into first presentation of renal/ureteric lithiasis.
general and stone-specific measures. Retrieved from www.baus.org.uk/_userfiles/
pages/files/Publications/RevisedAcuteStoneMgt
Patients are advised to drink 2.5–3 L of fluids a day with Guidelines.pdf
the consequent increase in urine output. These fluids . BAUS. (2016). Stone procedures – patient infor-
should be of a neutral pH and patients are advised to mation leaflets. Retrieved from www.baus.org.uk/
avoid sugary soft drinks. A balanced diet, rich in fruit and patients/information_leaflets/category/10/stone_
vegetables, is recommended. Patients are advised to procedures
reduce salt intake to less than 3 g a day, to reduce . Bultitude, M., & Rees, J. (2012). Management of
animal protein, maintain a healthy weight and undertake renal colic. BMJ, 345, e5499. doi: 10.1136/
regular physical exercise (NICE, 2015; Turk et al., 2015). bmj.e5499
. Civil Aviation Authority. Renal stone guidance.
For patients with calcium stones, a diet low in oxalate-rich Retrieved from www.caa.co.uk/WorkArea/Down
food is recommended, including rhubarb, spinach, cocoa loadAsset.aspx?id¼4294973863
and strawberries. Calcium supplements should be . Gill, N., Britnell, W., and Kumar, S. (2015). Referral
avoided, and a diet with reduced animal protein and and management of renal colic. Retrieved from
salt intake is also recommended www.gponline.com/referral-management-renal-
colic/miscellaneous/article/1338831
For patients with urate stones, avoidance of urate-rich
. Hermanns, T., Sauermann, P., Rufibach, K.,
food, such as liver, kidney, sardines or anchovies is rec-
Frauenfelder, T., Sulser, T., & Strebel, R. T.
ommended (NICE, 2015). Low levels of citrate contribute
(2009). Is there a role for Tamsulosin in the treat-
to both calcium and uric acid stones, and patients are
ment of distal ureteral stones of 7 mm or less?
given citrate supplements and advice on improving diet-
Results of a randomised, double-blind, placebo-
ary intake with, for example, the use of lemonade.
controlled trial. European Urology, 56, 407–412.
doi: 10.1016/j.eururo.2009.03.076
Cystine stones can be reduced by a high fluid intake to
. Hollingsworth, J. M., Canales, B. K., Rogers, M.
achieve a urine output of 3 L or more a day. Some
A., Sukumar, S., Yan, P., Kuntz, G. M., & Dahm, P.
patients may require Tiopronin, which forms a soluble
(2016). Alpha blockers for treatment of ureteric
complex with cystine (Badalato et al., 2016; Turk et al.,
stones: Systematic review and meta-analysis.
2015).
BMJ, 355, i6112. doi: 10.1136/bmj.i6112
. Morgan, M. S. C., & Pearle, M. S. (2016). Medical
management of renal stones. BMJ, 352, i52. doi:
10.1136/bmj.i52
Key points . NICE. (2015). Clinical knowledge summary: Renal
or ureteric colic – acute. Retrieved from https://
. Renal colic is a common acute urological cks.nice.org.uk/renal-or-ureteric-colic-acute#!
presentation topicsummary
. A thorough history and examination are important . Pickard, R., Starr, K., MacLennan, G., Lam, T.,
in primary care assessment and diagnosis Thomas, R., Burr, J., . . . McClinton, S. (2015).
. Emergency hospital admission is necessary for Medical expulsive therapy in adults with ureteric
patients with renal colic and sepsis, pregnancy, colic: A multicenter, randomised, placebo-con-
bilateral stones, poor pain control, risk of acute trolled trial. Lancet, 386(9991), 341–349. doi:
kidney injury or diagnostic uncertainty 10.1016/S0140-6736(15)60933-3

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. Portis, A. J., & Sundaram, C. P. (2001). Diagnosis urolithiasis. The Netherlands: Arnhem, European
and initial management of kidney stones. American Association of Urology
Family Physician, 63(7), 1329–1339 . Walton, T. (2011). Management of renal and ure-
. RCGP. Clinical module 3.03: Care of acutely ill teric stones. Retrieved from www.baus.org.uk/_
people. Retrieved from www.rcgp.org.uk/train- userfiles/pages/files/professionals/surg/TJW-Mx-
ing-exams/gp-curriculum-overview/online-curricu- Renal-and-Ureteric-Stones.pdf
lum/applying-clinical-knowledge-section-1/3-03-
acutely-ill-people.aspx
. RCGP. Clinical module 3.07: Men’s health.
Retrieved from www.rcgp.org.uk/training-exams/
Acknowledgement
We would like to thank Dr Jennifer Hopwood for her
gp-curriculum-overview/online-curriculum/caring-
help with the writing of this article under the InnovAiT
for-the-whole-person/3-07-mens-health.aspx
‘buddy’ scheme.
. Turk, C., Knoll, T., Petrik, A., Sarica, K., Skolarikos,
A., Straub, M., and Seitz, C. (2015). Guidelines on

Dr Preetha Biyani
St Martin’s Practice, Leeds
Email: preethabiyani@nhs.net

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