EM · Renal colic and nephrolithiasis
Renal colic and nephrolithiasis
Also known as Renal colic · Ureteric colic · Nephrolithiasis · Kidney stone · Urolithiasis · Pyonephrosis
Renal colic — the acute ureteric obstruction by a stone producing severe colicky flank pain radiating to the groin, with nausea, vomiting and haematuria; investigated by urinalysis, urine culture, U&E and creatinine, and CT KUB (the gold standard), with ultrasound reserved for pregnancy, children and recurrent known stone-formers; managed with diclofenac 75 mg IM (NSAID first-line) and morphine 5 mg IV for refractory pain, an antiemetic, medical expulsive therapy (tamsulosin 0.4 mg nocte for distal stones 5 to 10 mm), a stone filter and outpatient urology follow-up — with the infected obstructed system (pyonephrosis) distinguished as the urological emergency needing urgent decompression by ureteric stent or percutaneous nephrostomy and intravenous antibiotics. ACEM-primary, globally tagged.
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- Acute abdominal pain — the emergency department approach
- Testicular torsion
- Ectopic pregnancy
- Acute appendicitis
- Abdominal aortic aneurysm (ruptured and intact)
- Biliary disease — biliary colic, acute cholecystitis and ascending cholangitis
- Point-of-care ultrasound: biliary and renal (and the incidental AAA)
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Red flags
- Fever with an obstructed kidney is pyonephrosis — a urological emergency requiring urgent decompression by ureteric stent or percutaneous nephrostomy within hours, not antibiotics alone
- Anuria in a patient with a solitary or transplanted kidney, or bilateral obstructing stones, is an emergency — urgent decompression to salvage renal function
- An older patient with apparent renal colic has a ruptured abdominal aortic aneurysm until proven otherwise — palpate the aorta and image before attributing the pain to a stone
- Every male with apparent renal colic must have the genitalia examined — testicular torsion presents identically and is a surgical emergency
- Absence of haematuria does not exclude a ureteric stone — up to 15 per cent of confirmed stones have no blood on urinalysis
Meet the patient
A 38-year-old man rolls through the doors at 3am, gripping the rail of the trolley, unable to sit, unable to lie, rolling side to side with sudden severe left flank pain that has crept into his groin over the last hour. He is pale, sweaty, nauseated, and has thrown up twice. Dipstick urine is bright with blood. He is afebrile, his observations are normal, and he is the uncomplicated stone.[1]
Now hold a second patient beside him: a 68-year-old diabetic woman, febrile to 39.2 degrees, two rigors in the last hour, confused, blood pressure 88 over 52, lactate 4.2, with the same flank pain and a stone on the CT. She is not colic. She is an infected obstructed kidney — pyonephrosis — and she will die of urosepsis if you treat her the way you treat him. The Fellowship fork lives between these two beds.[1]
References7ShowHide
- [1]Holdgate A, Pollock T. Systematic review of the relative efficacy of non-steroidal anti-inflammatory drugs and opioids in the treatment of acute renal colic BMJ, 2004.PMID 15178585
- [2]Gottlieb M, Nakitende D Comparison of Tamsulosin, Nifedipine, and Placebo for Ureteric Colic CJEM, 2017.PMID 26584627
- [3]Ali A, Akram F, Hussain S, et al. Non-Contrast Enhanced Multi-Slice Ct-Kub In Renal Colic: Spectrum Of Abnormalities Detected On Ct Kub And Assessment Of Referral Patterns J Ayub Med Coll Abbottabad, 2019.PMID 31535518
- [4]Yaowalaorng J, Kunthasook W, Lokeskrawee T, et al. Superior efficacy of intramuscular diclofenac compared to intravenous tramadol for acute renal colic in northern Thai patients: A randomised double-blind, sham-controlled trial Emerg Med Australas, 2025.PMID 39763427
- [5]Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus computed tomography for suspected nephrolithiasis N Engl J Med, 2014.PMID 25229916
- [6]Pickard R, Starr K, MacLennan G, et al. Use of drug therapy in the management of symptomatic ureteric stones in hospitalised adults: a multicentre, placebo-controlled, randomised controlled trial and cost-effectiveness analysis of a calcium channel blocker (nifedipine) and an alpha-blocker (tamsulosin) (the SUSPEND trial) Health Technol Assess, 2015.PMID 26244520
- [7]Meltzer AC, Burrows PK, Wolfson AB, et al. Effect of Tamsulosin on Passage of Symptomatic Ureteral Stones: A Randomized Clinical Trial JAMA Intern Med, 2018.PMID 29913020