What are the indications for admitting a patient with kidney stones to the hospital?

Indications for Hospital Admission in Kidney Stone Patients

Patients with kidney stones should be admitted to the hospital if they have shock, fever, failure to respond to analgesia within one hour, or abrupt recurrence of severe pain. 1

Immediate Admission Criteria

• Shock or signs of systemic infection - Patients presenting with abnormal vital signs indicating shock or systemic infection require immediate hospital admission 1
• Fever - The presence of fever suggests possible infection with obstruction, which can rapidly progress to sepsis and requires urgent intervention 1
• Failure to respond to analgesia within one hour - Patients whose pain is not controlled within 60 minutes of appropriate analgesia administration should be admitted immediately 1
• Abrupt recurrence of severe pain after initial relief suggests possible complications or stone movement requiring hospital management 1

Additional Indications for Admission

• Suspected dangerous alternative diagnoses - Particularly leaking abdominal aortic aneurysm in patients over 60 years or ruptured ectopic pregnancy in women with delayed menses 1
• Sepsis with obstructed kidney - Requires urgent decompression of the system via percutaneous nephrostomy or ureteral stenting 2
• Anuria with obstruction - Complete urinary obstruction is a urologic emergency requiring immediate intervention 2, 3
• Inability to maintain oral hydration due to severe nausea/vomiting, which can worsen stone formation and dehydration 4, 5
• Renal impairment - Acute kidney injury secondary to obstruction requires prompt intervention 1, 6

Management Algorithm for Suspected Kidney Stone Patients

1. Initial Assessment:

   • Evaluate for shock, fever, or signs of systemic infection 1
   • Assess pain severity and location 1
   • Check vital signs including temperature, blood pressure, and pulse 1
   • Perform urinalysis if possible (hematuria supports diagnosis) 1

2. First-line Treatment:

   • Administer analgesia promptly (within 30 minutes) 1, 2
   • Preferably intramuscular diclofenac 75 mg (if not contraindicated) 1, 2
   • If NSAIDs contraindicated, use opioid with antiemetic 2

3. Reassessment at 60 Minutes:

   • If pain not controlled → admit to hospital 1
   • If pain controlled → consider outpatient management with follow-up 1

4. Ongoing Monitoring:

   • Follow up by telephone one hour after initial assessment 1
   • Instruct patient to report worsening pain or new symptoms 1
   • Arrange imaging within 7 days 1

Special Considerations

• Infected stones require complete stone removal and are a urologic emergency as they can result in sepsis 3
• Obstructive pyelonephritis is a urologic emergency requiring immediate decompression 3
• Stones >10 mm may require procedural intervention and closer monitoring 5, 6

Common Pitfalls to Avoid

• Delaying analgesia while waiting for diagnostic tests can lead to unnecessary suffering 7
• Failing to recognize signs of infection with obstruction, which can rapidly progress to sepsis 1, 3
• Discharging patients too early before ensuring adequate pain control and ability to maintain hydration 1
• Missing alternative diagnoses that may mimic renal colic but require different urgent management 1
• Using standard opioid dosing in patients with renal failure; always start with lower doses and titrate carefully 2