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Dr Anna
LawrenceUrologist
Auckland Surgical Centre
Auckland
16:30 - 17:25 WS #86: Urology in General Practice: All Things Wet and Painful
17:35 - 18:30 WS #98: Urology in General Practice: All Things Wet and Painful
(Repeated)
Dr Morgan
PokornyUrologist
Robotic and Laparoscopic Surgeon
Auckland
Management of renal colic in primary care
DR MORGAN POKORNY M B C H B P H D F R A C S ( U R O L )R O B OT I C A N D L A PA R O S C O P I C U R O LO G I C S U R G E O N
Financial Disclosure
• My wife and kids spend everything I earn
• Nothing real to disclose
Background
• Renal colic – stone obstructing ureter
• Severe pain
• 12% men, peak 40-60yo
• 6% women, peak late 20’s
• Severe, sudden pain
• 80% stones contain calcium
• Other : urate, CaP, Infection stones – MgNH4PO4
Pathophysiology
• Stone obstructs ureter
• Causes increased tension in ureter wall
• Prostaglandins released = vasodilation
• More urine produced = diuresis
• Kidney- swollen with urine, capsule distended = more pain
• Prostaglandins cause smooth muscle spasm of ureter –waves of pain
At risk groups
• Chronic dehydration (<1L per day)
• Family history – 2.5 x risk
• Abnormality of urinary tract
• Hyperparathyroidism
• Obesity
• Gout
• Idiopathic hypercalciuria
• Hot environment
• 30-40 % will experience another episode of renal colic in 5 years
Diagnosis
CLINICAL:
• Sudden severe pain in waves
• Restless, switching position
• N+V
• sometimes fever
• Urinary urge and frequency – VUJ stones
• Loin to groin pain
• Visible haematuria - rare
Diagnosis
CLINICAL MIMICS:
• Clot colic
• Sloughed papilla - diabetics
• Biliary Colic/Cholecystitis
• Aortic and iliac aneurysm
• Appendicitis, diverticulitis, peritonitis
• Gynaecologic – Endometriosis, ovarian torsion, ectopic pregnancy
• Testicular torsion
Diagnosis
INVESTIGATIONS:
• Urine dipstick – 90% have haematuria
• MSU + culture
• FBC, U+E, Creat
• Serum calcium, urate, phosphate
IMAGING:
• CT KUB – Gold Standard
• USS + XR KUB
RED FLAGS
Management
1. Acute pain control – NSAID or morphine
2. Lab tests
3. Same day imaging - CT KUB
4. Prescription for ongoing analgesia
5. Alpha blocker
6. See next day to review +/- referral
Pain Management
• NSAIDS 1st line RX vs opiods
• Greater reductions in pain score
• Longer duration of action
• Reduced analgesia requirement in short term
• Bypasses drug-seeking behaviour concerns
• Opioids :
• In addition or alone –
• Pts with risk of NSAID S/E – renal impairment, dehydrated, peptic ulcers
• Pethidine – out of favour- vomiting, toxic metabolite
Pain Management
Pain Management
• Diclofenac contra-indicated in pts with signifcardiovascular risk – instead use:
• Naproxen
• Ibuprofen
Pain Management
• Alternative to NSAIDs
• Acute pain : Morphine 5-10mg IM (preferred in pregnant women)
• Then oral morphine 5-10mg in community for ongoing analgesia
• Paracetamol
• Weak opioids - tramadol
Fluid intake
• Drink enough to prevent AKI – esp if on NSAIDS
• Excessive drinking can increase diuresis and thereby increase pain
• Aim for light coloured urine
• IV fluids if available, and if transferring to ED urgently
Alpha blockers
• Doxazosin, terazosin, tamsulosin
• Can accelerate stone passage
• Relax smooth muscle, preserve peristalsis
• Reduce pain episodes and analgesia requirements
• Prescribe nocturnal dose for 2-4 weeks
• Conflicting evidence in recent Systematic Reviews-better for larger distal stones : > 5mm
• Most studies had duration of 1 month
Predicting stone passage
• See patient for F/U ASAP with CT KUB and bloods
• Smaller distal stones pass quicker
• 2-4mm diameter – average time to pass = 13d
• 6-8mm stone = 22d
• VUJ stones - 79% pass spontaneously
• Proximal ureter – 48% pass spontaneously
Managing in Community
Transverse diameter NB for stone passage
Managing in Community
Managing in Community
Managing in the Community
• Single stone <4mm on CT KUB
• If Pt can cope at home, has support
• Patient should sieve all urine
• Refer if stone not passed in 2-3 weeks
• Review for analgesia requirements, recheck renal function at 2 weeks if stone not passed
• Stone >4mm, with renal or other ureteric stones-discuss with urologist
• >6mm stone – unlikely to pass - discuss same day with Urologist
Immediate Referral to Urology
• Febrile
• Single Kidney
• Bilateral ureteric stones on imaging
• Very large stones (>7mm diameter)
• Significant renal impairment (Creat >150)
• Pregnancy
• Solo parent, work commitments, imminent travel
Renal colic in Pregnancy
• Higher risk of renal stones in pregnancy
• CaPO4 stones more common
• Most pass
• Hydronephrosis common in pregnancy
• Complications of untreated renal colic:
• PROM, Pre-term labour, mild pre-eclampsia, infection
• Investigate – Renal and bladder USS
• Most stones will still pass – manage pain
• Avoid NSAIDS in 1/3 and 3/3
Renal colic in Pregnancy
• Can use morphine
• Doxazosin – not teratogenic
• If ongoing severe pain or fevers – urgent referral
• Hospital management –
• Nephrostomy
• Stenting under GA
Preventing further stones
• Increased water intake – 2L urine per day
• Reduce salt intake
• Healthy diet
• Do not reduce calcium in diet
• Avoid fructose containing drinks – uric acid
• K-Citrate for recurrent Ca-Oxalate stones
• Allopurinol for uric acid stones refractory to diet changes
