Definition

Acute ureteric colic is a pain syndrome caused by partial or complete obstruction of the ureter, most commonly due to a migrating urinary stone. It represents the most frequent acute presentation of stone disease and is the principal cause of stone-related pain.

Clinical Presentation

Typical features include:

• Sudden onset severe flank pain
• Radiation to the groin or external genitalia (some present with only testicular pain)
• Restlessness and inability to find a comfortable position
• Nausea and vomiting
• Lower urinary tract symptoms (LUTS) with distal ureteric stones
• Visible or non-visible haematuria
  • Haematuria is common but absent in ~10% of CT-confirmed cases and should not exclude the diagnosis if clinical suspicion is high
• Do not miss sepsis! If you suspect an infected obstructed kidney – it is a urological emergency!

Pathophysiology

Ureteric obstruction leads to:

• Rapid rise in intraluminal pressure
• Prostaglandin-mediated vasodilation and increased renal blood flow
• Increased diuresis
• Ureteric smooth muscle spasm
• Activation of visceral afferent pain pathways

Differential diagnoses of “Flank pain”

Beware of the leaking aortic aneurysm, as it can mimic ureteric colic!

Red flags need to have FAST scan in A&E:

• Male > 65yrs
• Sudden severe pain in back and/or abdomen
• Can have non-visible haematuria
• Hypotension
• Feeling cold, clammy, sweaty, faint and breathless
• Loss of consciousness
• Abdominal pulsatile mass

Investigation

• ✓
  Urinalysis

  • May help with the diagnosis of a concurrent UTI alongside a urinary tract stone
    • Send a urine culture if infection suspected
  • The absence of haematuria does not exclude ureteric obstruction
• ✓
  Blood tests

  • Not diagnostic for stone disease, useful to assess for contributing factors and complications
  • U&Es – assess renal function and obstruction
  • Adjusted calcium – screen for hypercalcaemia/metabolic disease
  • Urate – high levels may suggest uric acid stones
  • FBC, CRP and VBG – required to assess infection markers and lactate and is necessary for pre-operative planning
  • INR – patient may require intervention (e.g., nephrostomy)
• ✓
  Imaging

  • Imaging should generally be performed within 24 hours unless urgent intervention is required
  • Low-dose non-contrast CT KUB – first-line in most adults (gold standard)
    • Sensitivity and specificity = 95–97%
    • Defines stone location, size, location, burden, obstruction and alternative diagnoses, detect complications
  • Plain X-ray KUB – not suitable for diagnosing, but may be useful for follow-up
    • The scout film performed before CT imaging can be used as a guide to see if the patient's stone can be seen on X-ray KUB
  • US KUB – can be useful in patients who aren't appropriate for CT as a screening tool (e.g., pregnant, women of fertile age)
    • Good for visualising renal stones and seeing hydronephrosis but can miss ureteric calculi
  • MRI / MRI urography – may be considered for patients who cannot have a CT and USS is insufficient to make a clinical decision (e.g. pregnant women)

Treatment

Principles of Management

Management Options

• 1
  Analgesia

  • First-line treatment for all patients without immediate surgical indication
    • NSAIDs are first line – reduce ureteric smooth muscle spasm and prostaglandin-mediated pain
      • Best outcomes are via the PR route (e.g. Diclofenac 100mg STAT OR 50mg TDS, max 150mg/24hrs, 8hrly)
      • Avoid NSAIDs or use cautiously in significant AKI
    • Paracetamol
    • Opioids (e.g. morphine) if pain persists despite NSAIDs
    • Antiemetics (e.g. ondansetron, cyclizine) if required
• 2
  Medical Expulsive Therapy (MET)

  • Alpha-blockers (e.g. tamsulosin 400 mcg) until stone passed or failure of conservative management
    • Practical tip – When discharging patient give prescription for 28 days
  • The evidence for MET is mixed, the strongest evidence supports their use in distal ureteric stones 5–10 mm.
• 3
  Observation

  • Appropriate for: Clinically stable patients, No infection or renal impairment, Stones with reasonable likelihood of SSP
  • Duration: Typically up to 4 weeks, provided symptoms are controlled
  • Must-have follow-up: This usually involves repeat imaging, review of symptoms and renal function
  • If stone is still present after 4–6 weeks, then it is very unlikely to pass and will require intervention
• 4
  Surgical Management

  Indicated if: Failure of conservative management, Ongoing pain, obstruction, or deterioration in renal function, Low likelihood of spontaneous passage

  • Ureteric stent: Emergency decompression (e.g. sepsis, AKI), doesn’t treat the stone. Will need to be booked for definitive stone treatment.
  • Nephrostomy insertion: Done by IR, but trusts may have very limited access to IR. Advantages – can be done under LA, shows urine output from the corresponding kidney, can be used as surgical access for future stone surgery.
  • Ureteroscopy (URS) + laser lithotripsy: Definitive treatment. Can be done at time of acute presentation or if failed MET.
  • Extracorporeal Shock Wave Lithotripsy (ESWL): Suitable for selected stones (size, density, stone-to-skin distance dependent)

Follow-up:

All patients need to have follow-up — see your local pathway for specifics, as this can vary!

• 1
  Prescribe adequate analgesia - regular Paracetamol, PRN Dihydrocodeine + Diclofenac
• 2
  MET – variable practice and depends on local policy – check with Urology SpR
• 3
  Book imaging in 3-4 weeks

  • Modalities – CT KUB (limited pelvis if distal ureter /VUJ), XR KUB, USS KUB.
  • Choice depends on local practice
• 4
  Follow-up with results. This can be done via:

  • Stone clinic
  • General Urology clinic
  • “Write with results”