What is the initial management for colic pain?

Initial Management for Colic Pain

The initial management for renal colic pain should include rapid administration of intramuscular diclofenac 75 mg as the first-line analgesic, with assessment of pain relief within one hour to determine if hospital admission is necessary. 1

Diagnosis and Assessment

When a patient presents with suspected renal colic:

• Patients with acute symptoms should receive medical assessment within 30 minutes 1
• Diagnosis is primarily based on history of abrupt onset of severe unilateral flank pain radiating into the groin or genitals 1
• Key differential diagnoses to consider:
  • In patients over 60 years: leaking abdominal aortic aneurysm
  • In women with delayed menses: ectopic pregnancy 1

Physical Examination

• Examine the abdomen to establish site of maximal tenderness
• Assess vital signs (pulse, blood pressure, temperature) to exclude shock and systemic infection
• Immediate hospital admission is required for patients with:
  • Shock
  • Fever
  • Signs of peritonitis 1

Diagnostic Testing

• Urinalysis for hematuria supports the diagnosis (>80% of renal colic patients test positive) 1
• If practicable, collect urine for testing, though this may not always be possible during the acute episode 1

Treatment Algorithm

First-Line Analgesia

1. Administer analgesia quickly to provide pain relief within 30 minutes 1
2. Preferred medication: Diclofenac 75 mg via intramuscular injection 1
   • Intramuscular route is preferred as oral and rectal administration are less reliable
   • Intravenous administration is often impractical in primary care settings

Alternative Analgesia

• If NSAIDs are contraindicated, use an opiate combined with an antiemetic:
  • Morphine sulfate with cyclizine 1
• For oral administration when appropriate, ibuprofen can be used at a dose of 400 mg every 4-6 hours as necessary for pain relief 2

Follow-up Assessment

1. Follow up by telephone one hour after initial assessment and administration of analgesia 1
2. If pain is not alleviated within 60 minutes, arrange immediate hospital admission by telephone 1
3. If severe pain recurs abruptly, immediate hospital admission is also warranted 1

Home Management Instructions

For patients who respond to initial analgesia and can be managed at home:

1. Drink plenty of fluids 1
2. Void urine into a container or through a tea strainer/gauze to catch any identifiable calculus 1
3. Contact the doctor if:
   • Pain worsens
   • Unexpected or more distressing symptoms develop 1

Further Management

All patients with suspected renal colic should receive follow-up investigations to:

• Identify if a calculus is present, including its size and location
• Determine if intervention is needed for an existing calculus
• Consider alternative diagnoses if no calculus is found
• Assess risk of developing further episodes 1

Pitfalls and Caveats

• Failure to consider serious alternative diagnoses (aortic aneurysm, ectopic pregnancy) can lead to significant morbidity and mortality
• Inadequate analgesia prolongs suffering unnecessarily - don't hesitate to provide adequate pain control
• Delay in arranging hospital admission for patients who fail to respond to initial analgesia within one hour can lead to complications
• The pathophysiology of renal colic pain involves increased hydrostatic pressure in the urinary system above the obstruction 3, which explains why prompt and effective analgesia is crucial

Remember that the primary goal of initial management is effective pain control, with subsequent investigation to determine the underlying cause and appropriate definitive treatment.