What are the guidelines for managing renal colic?

Guidelines for Managing Renal Colic

NSAIDs are strongly recommended as the first-line treatment for renal colic pain, with diclofenac 75mg intramuscularly being the preferred initial option for severe pain. 1

Diagnosis and Assessment

• Key Diagnostic Features:

  • Abrupt onset of severe unilateral flank pain radiating into groin or genitals
  • Examination to establish site of maximal tenderness
  • Assessment of vital signs to exclude shock and systemic infection 1

• Initial Workup:

  • Urinalysis (hematuria present in >80% of cases supports diagnosis)
  • Consider alternative diagnoses if urinalysis is negative 1

• Red Flags Requiring Immediate Hospital Referral:

  • Shock
  • Fever
  • Oligoanuria
  • Age over 60 years
  • Delayed menses in women 1

Treatment Algorithm

First-Line Pain Management

• NSAIDs (high-quality evidence shows they are more effective than opioids) 1, 2
  • Diclofenac 75mg intramuscularly for severe pain
  • Oral diclofenac 50mg initially, followed by 50mg every 8 hours for moderate pain or as follow-up therapy
  • Alternative NSAIDs if diclofenac is contraindicated:
    • Ibuprofen
    • Ketoprofen
    • Ketorolac (may be less effective than ibuprofen in some formulations) 1

Second-Line Pain Management

• Opioids with an antiemetic when NSAIDs are contraindicated 1, 3

  • Avoid pethidine due to higher rates of vomiting
  • Preferred alternatives for patients with kidney disease:
    • Oxycodone
    • Hydromorphone
    • Fentanyl 1
  • Note: Morphine can be given intravenously or subcutaneously 3

• Drotaverine 80mg intramuscularly as an alternative when NSAIDs are contraindicated 1

NSAID Contraindications and Cautions

• Severe renal impairment
• Heart failure
• Pregnancy (especially after 30 weeks gestation)
• History of peptic ulcer disease
• Cardiovascular disease
• Concurrent use of ACE inhibitors, ARBs, or diuretics 1

Patient Instructions

• Maintain high fluid intake
• Strain urine to catch any passed calculi
• Contact healthcare provider if pain worsens or new symptoms develop
• Reduce salt and animal protein in diet to help reduce risk of recurrence 1

Follow-up and Referral

• Follow-up assessment 1 hour after initial administration
• Fast-track investigation within 7 days of symptom onset
• Urgent urology outpatient appointment within 7-14 days if renal imaging shows a problem requiring intervention 1

Medical Expulsive Therapy

While not explicitly mentioned in the primary guidelines, research suggests alpha-adrenoceptor antagonists like tamsulosin may be beneficial:

• Increases spontaneous stone passage rate by approximately 50% for small distal stones
• Decreases severity of renal colic 4
• Well-tolerated in elderly patients 4

Long-term Management for Recurrent Stones

• Increased fluid intake
• Preventive strategies:
  • Thiazides
  • Citrates
  • Allopurinol
• Potassium citrate for uric acid and cystine stones to raise urinary pH 1
• 24-hour urine collection within six months of treatment initiation to assess response to therapy 1

Special Considerations for Elderly Patients

• Screen for contraindications to NSAID therapy
• Use downward-adjusted doses of opioids with careful monitoring to prevent confusion and respiratory depression 4
• Alpha-adrenoceptor antagonists like tamsulosin are generally well-tolerated 4

The evidence strongly supports NSAIDs as first-line therapy for renal colic, with opioids reserved for cases where NSAIDs are contraindicated or insufficient. Proper follow-up and preventive strategies are essential to reduce recurrence risk.