From the Guidelines
Renal colic management should begin with prompt pain control using NSAIDs as first-line therapy, specifically intramuscular diclofenac 75 mg, as recommended by the BMJ study 1. The management of renal colic involves a combination of pain control, fluid therapy, and medical expulsive therapy.
- Pain control: NSAIDs, such as diclofenac, are preferred over opioids as they target prostaglandin-mediated ureteral spasm and inflammation while avoiding opioid side effects 1.
- Fluid therapy: patients should be encouraged to drink fluids as tolerated, with a goal of achieving at least 2 L of urine per day to help prevent recurrent nephrolithiasis 1.
- Medical expulsive therapy: tamsulosin 0.4mg daily may help pass stones <10mm in the distal ureter. Some key points to consider in renal colic management include:
- Urological consultation is indicated for stones >10mm, complete obstruction, infection, refractory pain, or renal insufficiency.
- Patients should strain their urine to collect passed stones for analysis.
- Follow-up imaging with CT or ultrasound is recommended within 2-4 weeks. It is essential to note that the American College of Physicians recommends management with increased fluid intake and pharmacologic monotherapy with a thiazide diuretic, citrate, or allopurinol to prevent recurrent nephrolithiasis in patients with active disease 1. However, the most recent and highest quality study on renal colic management, which is the 2002 BMJ study 1, recommends intramuscular diclofenac 75 mg as the first line of treatment, and this should be prioritized in clinical practice.
From the Research
Renal Colic Management
- Renal colic is an acute syndrome involving unilateral flank pain, linked to an obstruction in the upper urinary tract, often requiring immediate pain relief 2.
- The first step in managing renal colic is to control the pain, considering other diagnoses and checking for signs of complication 2.
Pain Management
- Nonsteroidal anti-inflammatory drugs (NSAIDs) and strong opioid analgesics have comparable efficacy in relieving renal colic pain 2.
- NSAIDs, such as diclofenac, are associated with fewer adverse effects than opioids, which can cause vomiting in about 20% of patients 2.
- Morphine is an effective alternative to NSAIDs, especially when NSAIDs are contraindicated or ineffective 2, 3.
- Intravenous ibuprofen is more effective than intravenous paracetamol in ceasing renal colic at 30 minutes 4.
- NSAIDs may reduce renal colic pain in 30 minutes compared to placebo, although the evidence is of low certainty 5.
Hydration
- Maintenance intravenous fluids are as efficacious as forced hydration with regard to patient pain perception and narcotic use in uncomplicated renal colic 6.
- The state of hydration has little impact on stone passage in patients with renal colic 6.
Other Treatments
- Local active warming, taking care to avoid burns, was effective against pain in one trial, reducing pain by at least 50% using a device delivering 42 degrees C to the abdomen or lower back 2.
- Antispasmodics, such as scopolamine, do not seem to provide additional efficacy when added to morphine 2.
- Medical expulsive therapy and surgical intervention may be required in some cases of renal colic 3.