• blockage in ureter causes inc. tension in urinary tract wall

    • stimulating synthesis of prostaglandin

      • vasodilation

        • diuresis

        • inc. pressure within kidney

      • smooth muscle spasm of ureter

        • waves of pain

    • stones

    • blood clots

      • sickle cell

      • dm

      • long term use of anagleisa

      • lymphadenopahty

  • 80% of stones contain calcium

    • calcium oxalate

  • Calcium phosphate and urate also found

  • bateria can also cause formation of calculi - infection stones

    • magnisum ammonium phosphate -> large and branched

    • = “staghorn cacluli”

  • pain develops suddenly

    • “worse pain they have ever felt”

  • majority of stones pass spont.

Risk factors

  • chornic dehydration (\<1L urine/day)

  • family history: 2.5x

  • abdnormal urainry tract

  • obesity

  • hyperparathyroidsim

  • gout

  • idiopathic hypercalcuiea

  • exposure to hot environment

30-40% experience recurrent renal colic wihtin five years of first episode

Diagnosis

  • sudden sevre loin pain

  • waves

  • accompanied by N&V

  • symptom free bbetweenepisodes (some)

  • site of pain not useful for predicting location of stone

  • vesico-ureteric juntion: straining when urinarting with painful anf grequent passage of small volumes of urine

    • stone irritating detrusor muscle

  • examination

    • restless

    • classic;

      • located costovertbral angle; lateral to sacrospinus muscle beneath 12 rib

      • radiate to flank, groin, tesetes, labia majora

  • AKI = concern

  • be aware of previous nephrectomy

  • assess sx and symton of infection

    • pyelonephrosis

      • infection of renal system above an obstructing stone

Ddx

  • biliary colic and cholecystits

  • aortic and iliac aneurysms

  • appendicitis, diverticulitis, peritonitis

    • generally prefer to lie still

  • Gynaecological

    • endometriosis

    • ovarian torsion

    • ectopic

  • Testicular torsion

Investigaitons

  • Urine dipstick

    • 90% return positive test for haematurai on urine dipstick

  • midstream urine culture

    • microscopy

      • dysmorphic red blood cells and casts

        • dexclude glomerular injury

  • FBC

  • Cr

  • electrolytes

  • urate

  • calcium

  • phosphate

red flags

  • fever or other features consistent with systemic infection

  • suspected bilateral obstructing stones

  • known clinically signiifant renal impairment

  • one kidney

  • pregnancy

CTU

  • = gold standard

  • USS and xr approach CTU

    • full bladder - identify stones at VUJ

  • 2-4mm = pass 13d

  • 6-8mm = pass 22d

  • if VUJ = 79% pass

  • prox ureter = 48% pass

Management

  1. Acute pain:

    1. NSAID

      1. first line

      2. greater reductions in pain scores

      3. longer duration of action

      4. inhibit prostaglandin

      5. Diclofenac

        1. strongest eveidnece of efectiveness in managmeent of renal colic

        2. immediate/modified release oral, injectable and supp

          1. MPSO

        3. 75mg IM in deep intragluteal injection in upper outer quadrant

        4. combined with oral diclofenac to max 150mg od for max 2 days

        5. contraindicated if MI in previous 12 mo

    2. morphine

      1. pethidine no more effective than morphine

      2. increase rate of adverse effects

      3. 5-10mg IM

      4. (+ anti-emetic)

  2. Labs

  3. Prompt referral (same day)

    1. CTU

  4. analgesia for ongoign pain management

  5. alpha blocker (or caclium antagonist)

    1. relax smooth muslce without altering peristalsis

      1. accelerate passage of stone

    2. reduce pain episodes

    3. doxazosin 1-4mg at night for four weeks or until stone passes

  6. see patient following day

Referral

  • if \<4mm on CTU

    • manage in community

    • follow-up radiology not required as likely stone will pass wihtout need for surgery

    • monitor for signs of infection

    • pass urine through sieve - pantyhose fabric

  • if >4mm then discuss with urologist (or stone in kidney or multiple urinary stones)

    • require follow-up imaging

  • if >6mm

    • discuss urgently

    • low likelihood of spontaneous passage

preventing stone recurrnece

  • increase water intake - dilute urine output

  • reduce salt intake

  • maintain healthy diet

  • avoid fructose containing soft drinks

    • increase urate levels

  • avoid rich oxalate foods

    • tea

    • chocolate

    • spinach

    • beetroot

    • rhubarb

    • peanuts

    • cola

    • supplementary vit C

  • potassium citrate under SA

    • recurrent calcium oxalate stones

    • >2 episodes in previous 2 years

  • urate stones

    • red meat/offal

    • seafood

    • urinary pH 6.0-6.5 increase solubility of urate

  • Allopurinol both urate and oxalate

    • if reoccur despite lifestyle modifications

    • 1090mg od and increase by 100mg until target urate \<0.36

    • lower doses if \<60