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Renal calculi.
Colic due to the presence of a stone in the ureter is a pain emergency. The non-steroidal anti-inflammatories are as effect as opiates in this situation,1,2 and cause less vomiting, so consider their use in a patient with the characteristic features of acute flank pain and haematuria without fever or pyuria and with normal renal function. Hyoscine is not particularly effective 3: if NSAIDs are contra-indicated, consider morphine (plus metoclopramide for the nausea), or, for less severe pain, paracetamol. Patients are often quite nauseous already, so tramadol is not a particularly sensible alternative.
Time to passage of large stones may be shortened by up to 4 days (relative to control) by use of alpha-blockers4
Single episodes of renal colic in the absence of other disease probably do not warrant further investigation other than confirmation that urea and creatinine are normal. If there is a recurrence, an attempt should be made to retrieve the stone, when it is passed, for chemical analysis. If pain does not settle or if fever develops, an ultrasound and/or IVP and urological referral is warranted. Patients with recurrent stones should be referred to a urologist for further investigation.
Increased water intake is touted as effective for secondary prevention, but the evidence for this is very limited – a single trial of 200 patients found an ARR of 15% (27% control, 12% in the group increasing fluid intake in order to produce at least two litres of urine daily) for stone recurrence.5
Holdgate A, Pollock T. Nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for acute renal colic (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. John Wiley & Sons, Ltd ↩
Pathan SA, Mitra B, Cameron PA. A Systematic Review and Meta-analysis Comparing the Efficacy of Nonsteroidal Anti-inflammatory Drugs, Opioids, and Paracetamol in the Treatment of Acute Renal Colic. Eur Urol. 2018 Apr;73(4):583-595. doi: 10.1016/j.eururo.2017.11.001. Epub 2017 Nov 22. PMID: 29174580. ↩
Papadopoulos G, Bourdoumis A, Kachrilas S. Hyoscine N-Butylbromide in the Treatment of Acute Ureteral Colic: What Is the Evidence? Urol Int 2014;92:253-257 ↩
Hollingsworth JM, Canales BK, Rogers MA, Sukumar S, Yan P, Kuntz GM, Dahm P. Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ. 2016 Dec 1;355:i6112. doi: 10.1136/bmj.i6112. PMID: 27908918; PMCID: PMC5131734. ↩
Borghi L, Meschi T, Amato F, Briganti A, Novarini A, Giannini A. Urinary volume, water and recurrences in idiopathic calcium nephrolithiasis: a 5‐year randomized prospective study. Journal of Urology 1996;155(3):839‐43. [MEDLINE: 8583588] ↩