A diagnosis of renal / ureteric colic can usually be made clinically, and examination is not necessarily required. Typical symptoms are sudden onset of severe loin pain (often described as the worst pain ever experienced), sometimes radiating to the flank, groin and testes / labia majora. Nausea is common, and patients will be restless, unable to get comfortable, in contrast with peritonitic conditions where the patient wants to remain still. Visible haematuria is not uncommon. Pain is a colic, with severe pain lasting minutes before easing – patients are often pain free between episodes.
It is vital not to miss an infected obstructed urinary system – a temperature reading is essential, even if consulting remotely. Likewise, a leaking aneurysm can mimic left sided renal colic, so have a low threshold for admitting patients in the higher risk demographic for vascular disease.
Acute colic can be managed in the community with NSAIDs (usually naproxen 500mg bd, or diclofenac 100mg suppositories) provided pain can be controlled and in the absence of red flags:
- Suspected infection (presence of fever >37.5 in association with symptoms of ureteric colic)
- Diagnostic uncertainty particularly if leaking aortic aneurysm a possibility, (consider admission in those >60 unless known stone former with typical symptoms)
- Solitary kidney or
- A significant deterioration in renal function (difficult to quantify – discuss with urology if unclear)
Failure to achieve adequate pain relief will require admission via the urology on call team. The timescale for this will depend on pain severity – for those in severe pain, this may be just a few hours.
If symptoms settle without hospital involvement, the key is to arrange imaging of the renal tract (as per local pathways – usually a renal CT scan)- if pain has settled and renal function is acceptable, this can be deferred until routine scanning is again available, as the purpose of the scan is primarily to assess ongoing stone burden in case further stones require intervention. If symptoms recur quickly, then a scan is essential.
Dr Jon Rees is a GPSI in urology in Somerset and chair of the Primary Care Urology Society