Acute Renal Colic from Ureteral Calculus

Abstract

The new england journal of medicine n engl j med 350;7 www.nejm.org february 12, 2004 684 This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations.A 39-year-old man reports an eight-hour history of colicky pain in the right lower quadrant radiating to the tip of his penis. He had previously had a kidney stone, which passed spontaneously. Physical examination shows that he is in distress, is afebrile, and has tenderness of the right costovertebral angle and lower quadrant. Urinalysis shows microhematuria. Helical computed tomography (CT) of the abdomen and pelvis shows a 6-mm calculus of the right distal ureter and mild hydroureteronephrosis. How should this patient be treated?Up to 12 percent of the population will have a urinary stone during their lifetime, and recurrence rates approach 50 percent. 1 In the United States, white men have the highest incidence of stones, followed in order by white women, black women, and black men. 2,3 Fifty-five percent of those with recurrent stones have a family history of urolithiasis, 4 and having such a history increases the risk of stones by a factor of three. 5The classic presentation of a renal stone is acute, colicky flank pain radiating to the groin. As the stone descends in the ureter, the pain may localize in the abdominal area overlying the stone and radiate to the gonad. Peritoneal signs are absent. As the stone approaches the ureterovesical junction (Fig. 1), lower-quadrant pain radiating to the tip of the urethra, urinary urgency and frequency, and dysuria are characteristic, mimicking the symptoms of bacterial cystitis. Physical examination typically shows a patient who is often writhing in distress, trying to find a comfortable position. Tenderness of the costovertebral angle or lower quadrant may be present. Gross or microscopic hematuria occurs in approximately 90 percent of patients; however, the absence of hematuria does not preclude the presence of stones. 6 Owing to the shared splanchnic innervation of the renal capsule and intestines, hydronephrosis and distention of the renal capsule may produce nausea and vomiting. Thus, acute renal colic may mimic acute abdominal or pelvic conditions. diagnosisThe best imaging study to confirm the diagnosis of a urinary stone in a patient with acute flank pain is unenhanced, helical CT of the abdomen and pelvis (Fig. 1). 7 In a prospective trial of 106 adults with acute flank pain, all patients underwent both unenhanced helical CT and intravenous urography (the previous gold standard), 8 and the results of each were interpreted separately and in a blinded fashion by a radiologist. Seventy-five patients received a diagnosis of ureteral stones. The sensitivity of CT was 96 percent, as compared with 87 percent for urography, and the respective specificities were 100 percent and 94 percent (P<0.001 for both compar...

Emergency Ureteroscopic Management of Ureteral Stones: Why Not?

“…© 2007 Elsevier Inc. R enal colic is often caused by ureteral stones, with most of them located in the distal ureter. 1 When conservative drug therapy does not resolve the symptoms, the placement of a ureteral catheter or nephrostomy tube represents the classic procedure performed for renal colic due to acute ureteral obstruction. These maneuvers can offer a prompt relief from pain for the patient, and they are usually followed by ureteroscopy (URS) or extracorporeal shockwave lithotripsy (ESWL), which currently represents the mainstay of treatment for ureteral stones.…”

The utility of renal ultrasonography in the diagnosis of renal colic in emergency department patients

“…Ultrasonography (US) is an imaging modality that may be used to investigate renal colic that does not expose the patient to radiation or contrast material. 19 Although reported estimates of the sensitivity of US to visualize ureteral calculi vary widely and are lower than that of CT (12%-93%), 20,21 US is highly accurate in detecting hydronephrosis, perinephric fluid and abnormal urinary jets, which often indicate the presence of calculi with sensitivity nearing 100%. 22,23 The specificity of US for direct or indirect findings compatible with ureterolithiasis is greater than 90% in some studies.…”

Urolithiasis Location and Size and the Association with Microhematuria and Stone-Related Symptoms

“…4,5 Other risk factors include a positive family history and a variety of endocrine or metabolic abnormalities. 6 Unfortunately, the occurrence of urinary lithiasis is not always a benign entity. Most commonly, these stone episodes can cause renal colic resulting in flank or abdominal pain, urinary urgency or frequency, fevers or chills, nausea or vomiting, and gross or microscopic hematuria.…”