Renal Colic

Question 1

Describe the pain associated

Answer 1

very sudden onset
colicky in nature
Radiates to the groin as the stone passes into the lower ureter.
May change in location, from the flank to the groin, (the location of the pain does not always provide a good indication of the position of the stone)
The patient cannot get comfortable, and may roll around in agony.
Associated with nausea / Vomiting
Visible or non-visible hematuria (85%)

Question 2

How do symptoms of renal colic come about?

Answer 2

As the stone descends the ureter, pain may localise to the part of the abdomen overlying the stone.

As the stone approaches the VUJ, lower quadrant pain, urinary urgency, frequency, strangury and dysuria are common and may mimic cystitis.

Symptoms of acute renal colic may mimic other acute abdominal conditions.

Question 3

Describe the presentation of renal colic

Answer 3

Struvite stones: Rec UTIs, Malaise, weakness, and loss of appetite.

Complicated Stone presentation: pyuria, fever, leucocytosis, or bacteriuria suggestive of a urinary infection and the potential for an infected obstructed renal unit or pyonephrosis. (Life threatening)

Question 4

Give differential diagnosis for renal colic

Answer 4

UT:PUJ obstruction (sloughed papilla), pyelonephritis, bacterial cystitis 
Chest: Lobar pneumonia Rib fractures 
Acute abdomen: bowel, biliary, pancreas or abdominal aortic aneurysm sources 
Gynecologic (ectopic pregnancy, ovarian cyst, torsion or rupture)
Referred pain (orchitis)
Radicular pain (L1 herpes zoster, sciatica)

Question 5

Renal colic bedside investigations

Answer 5

**Urinalysis (Hematuria, Pyuria .. Alkaline or Acidic?)

**Serum chemistry (renal functions… Ca, Uric acid, Mg, Phosphate).

**In women: Pregnancy test

Question 6

Renal colic radiological investigations

Answer 6

1- Non-contrast CT KUB (MOST SENSITIVE):
Great specificity (95%) and sensitivity (97%) for diagnosing ureteric stones
Can identify other, non-stone causes of flank pain.
No need for contrast administration.
Fast, taking just a few minutes

2- Plain X- ray (radiopacity , Follow up in expectant management)
3- USS (Pregnant women)

Question 7

What implies the presence of stones?

Answer 7

Radio-opacity: implies the presence of substantial amounts of calcium within the stone
Radiopaque: Ca phosphate, Ca oxalate
Relatively radiolucent: Cystine, struvite stones
Radiolucent: Uric acid, xanthine, triamine, silicate stones & Indinavir stones (Both PUT & CT KUB).

Question 8

How to treat renal stones?

Answer 8

• Treatment of the Stone:
• Pain relief:
  NSAIDs
  Intramuscular or intravenous injection, Oral, or rectal
  +/- Opiate analgesics (pethidine or morphine).
  α – blockers (in lower ureteric stones)
  watchful waiting’ with analgesic supplements
  95% of stones measuring 5mm or less pass spontaneously
  Specific treatment
• Temporary relief of the obstruction
  Insertion of a JJ stent or percutaneous nephrostomy tube.
• Definitive treatment of a urinary stone

Question 9

Indications for intervention

Answer 9

Persistent pain despite adequate medication
Persistent obstruction with risk of impaired renal function
Stone with urinary tract infection
Risk of pyonephrosis or urosepsis
Bilateral obstruction.
Obstructing calculus in a solitary functioning kidney

Question 10

What is ESWL?

Answer 10

surgical intervention when:
1- Stone <2 cm
2- Favorable anatomy

Contraindications:
1- Prenancy
2- Distal obstruction
3- Uncorrected coaguloapthy
4- Pacemaker?? (Consult a Cardiologist)

Question 11

What is PCNL?

Answer 11

The preferred technique for treating large stones (over 2cm in diameter) within the kidney

Indications:
Staghorn calculi
Stone >2cm
Multiple stones >1cm
Proximal ureteral stone >1cm

Contrandications:

Active infection
Coagulopathy
Pregnancy
Unsafe access.

Question 12

Describe Uretoscopy

Answer 12

Removal of stones in the ureter (or kidney!!) through the ureterosope.

Advantages:
Could be used in patients with stones who are:
1- Pregnant
2- With coagulopathies
3- With stones that can’t be visualized on Fluroscopy.

• Small stone are removed via basket device.

* Larger stones are disintegrated using one of the following power sources:
1- Laser
2- ultrasonic
3- Electrohydraulic
4- Pneumatic

Question 13

Describe Cystoscopy

Answer 13

• For bladder stones
  Either lithotripsy or litholapaxy ( using lithotrite)
  Lithotrite is not used in children.