Renal / ureteric colic

• Suspicion of ureteric colic should be raised when a patient presents with a typical history of sudden onset colicky renal angle pain radiating to the groin
• There may be a past history of proven or suspect ureteric colic
• Give analgesia early: diclofenac is the first-line analgesic choice in renal colic (unless contra-indicated)- it should be best given per rectum, but can be given orally or IM if needed
• Get IV access, and check U&Es
• Prescribe IV fluids to aid renal stone passage, and to encourage production of a urine sample
• 95% of patients with radiologically proven renal colic have positive dipstick (microscopic) haematuria
  • If there is no haematuria there may be an alternative diagnosis, however renal colic can exist without objective microscopic haematuria
• In any patient over the age of 60 years, pain similar to that of renal colic can be mimicked by an expanding / ruptured abdominal aortic aneurysm or iliac aneurysm. This is a well known medico-legal pitfall as missing this diagnosis could clearly have catastrophic consequences. Always examine the abdomen. In patients over 60 years old have this differential diagnosis in the back of your mind when assessing patients with possible renal colic. AAA patients may have dipstick haematuria too.

For patients who are suspected of having acute renal colic, diclofenac is the drug of choice.

On discharge they can be advised to take paracetamol for analgesia PLUS ibuprofen 200-400mg.

Patients presenting with a good clinical picture of renal colic & usually dipstick or frank haematuria should have a CTKUB performed as it is the investigation of choice in renal colic. If a stone is shown they will also have a plain XR (KUB) to check that the stone is radio-opaque as lithotripsy requires this for localisation.

In hours a CT KUB can be requested on TRAK and can be performed. Out of hours the patient can be ambulated if suitable, however in the relevant patient group a differential of AAA should be ruled out.

CT KUBs are not performed out of hours at SJH unless there is a pressing clinical need, in which case discussion with the on-call radiologist is required.

Younger females should be considered for USS before, or instead of, CT KUB. It may also be more appropriate to consider other imaging in patients who have had multiple or recent CT KUB.

Where a CT scan cannot be arranged for the same day, patients can be ambulated as per the CTKUB ambulatory protocol, if:

1. AAA can be clinically or radiologically excluded
2. None of the above admission criteria are met
3. The patient can reliably return as per the CTKUB ambulatory protocol

Where a CT scan cannot be arranged for the same day, and the ambulatory criteria above cannot be met, the patient should be clinically assessed for their suitability to admit for observation to DOSA. A CTKUB should be organised for the next day, and adequate analgesia prescribed.

Patients with proven colic should be discussed with urology for admission if any of the following pertain:

1. Inadequate pain relief
   • i.e. pain recurs after initial one or two doses of diclofenac
2. Evidence of acute renal impairment – discuss with urology and admit for IV fluids
3. Evidence of infection
   • e.g. with fever, constitutional symptoms, positive urine nitrites / WBCs on dipstick testing,
     raised WCC. Should be admitted for IV antibiotics.
4. CTKUB showing large stone > 5 mm
5. CTKUB showing abnormal or absent contralateral kidney
6. CTKUB showing completely obstructed kidney

Patients with proven colic can be allowed home if they are clinically well and none of the above criteria are met. As well as TTO analgesia, urology frequently recommend prescribing a short course (e.g. 20 days) of tamsulosin. Encourage oral fluid intake to aid stone passage.

Follow-up for patients with confirmed stones can be arranged by completing the WGH Scottish Lithotripsy Centre referral form, and scanning this to the appropriate email address.