From the Guidelines
Intramuscular diclofenac 75 mg is recommended as the first line of treatment for renal colic from kidney stones when the diagnosis is clear and there are no signs of complications. This approach is based on the most recent and highest quality study available, which emphasizes the importance of a pre-established integrated pathway of care across the primary-secondary care interface 1.
Key Considerations
- The management of renal colic should prioritize pain control and facilitating stone passage while preventing complications.
- If severe pain does not remit within an hour, the patient should be admitted to hospital for further evaluation and treatment.
- All patients, whether managed at home or in hospital, should be offered fast-track urological investigation with follow-up to ensure proper diagnosis and treatment.
- Imaging studies such as opaque radiography, ultrasound, and spiral computed tomography may be used to aid in diagnosis and treatment planning, depending on the specific situation and availability 1.
Additional Recommendations
- Patients should be encouraged to stay hydrated, but there is no benefit to forced hydration.
- Medical expulsive therapy with alpha-blockers may be considered to help facilitate stone passage, although this is not explicitly mentioned in the provided study.
- Patients should be advised to strain their urine to collect passed stones for analysis and to seek immediate medical attention if they experience fever, worsening pain, or inability to urinate, as these may indicate complications requiring intervention.
From the Research
Management of Renal Colic from Kidney Stone
- Renal colic is an acute syndrome involving unilateral flank pain, linked to an obstruction in the upper urinary tract, and the first step in management is to control the pain 2.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) and strong opioid analgesics have comparable efficacy in relieving pain, with diclofenac and morphine being the most widely studied 2.
- NSAIDs are associated with fewer adverse effects than opioids, but expose patients to a risk of functional renal impairment, especially in certain patient groups 2.
- The combination of NSAIDs and morphine may provide greater analgesic effect than either agent used alone, in about 10% of patients 2.
Treatment Options
- NSAIDs, such as diclofenac, are effective in reducing pain and are recommended as the first-line treatment for renal colic 3, 4.
- Opioids, such as morphine, are also effective, but may have more adverse effects, such as vomiting, and are often used when NSAIDs are contraindicated or ineffective 2, 4.
- Paracetamol has not been evaluated in comparative trials of renal colic, and its effectiveness is unclear 2, 4.
- Antispasmodics, such as scopolamine, have not been shown to provide additional efficacy when added to morphine 2.
- Alpha-adrenoceptor antagonists, such as tamsulosin, may be effective in increasing the rate of spontaneous stone passage and decreasing the severity of renal colic 5.
Trends in Acute Pain Management
- There is a trend towards decreased use of opioids and increased use of non-opioids, such as NSAIDs, in the management of renal colic in the emergency department 6.
- This trend may be due to increasing physician awareness of opioid addiction and stricter legislation prohibiting opioid prescribing 6.