What is the management for acute ureteric colic?

Management of Acute Ureteric Colic

Administer intramuscular diclofenac 75 mg immediately as first-line analgesia for acute ureteric colic when the diagnosis is clear and there are no contraindications. 1

Initial Assessment and Diagnosis

Timing is critical: Patients with acute symptoms require medical assessment within 30 minutes of presentation 1.

Diagnostic criteria:

• Diagnosis centers on abrupt onset of severe unilateral flank pain radiating into the groin or genitals 1, 2
• Examination must include abdominal assessment to exclude peritonitis and measurement of vital signs (pulse, blood pressure, temperature) to identify shock or systemic infection 1

Critical red flags requiring immediate hospital admission:

• Patients over 60 years: consider leaking abdominal aortic aneurysm 1, 3, 2
• Women with delayed menses: consider ectopic pregnancy 1, 3, 2
• Shock or fever indicating possible sepsis 3

Analgesic Management

First-line treatment:

• Intramuscular diclofenac 75 mg is the preferred route and agent 1, 4
• The intramuscular route is superior because oral and rectal administration are unreliable, and intravenous administration may be impractical in primary care settings 1
• NSAIDs are significantly more effective than placebo (RR 2.28 for 50% pain reduction within one hour) and superior to antispasmodics 5

Alternative when NSAIDs are contraindicated:

• Administer an opiate combined with an antiemetic, such as morphine sulfate and cyclizine 1
• Note that opioids cause more nonspecific adverse events and vomiting compared to NSAIDs 4

Important contraindications to NSAIDs:

• Patients with impaired renal function, dehydration, hypovolemia, heart failure, or liver dysfunction 6
• Those taking diuretics, ACE inhibitors, or ARBs 6
• History of serious skin reactions to NSAIDs 6
• Aspirin-sensitive asthma 6

Reassessment and Hospital Admission Criteria

One-hour reassessment is mandatory:

• Follow up with a telephone call one hour after initial assessment and analgesia administration 1
• If pain is not alleviated within 60 minutes, arrange immediate hospital admission by telephone 1, 3
• Abrupt recurrence of severe pain also warrants immediate admission 1, 3

Additional admission criteria:

• Shock or signs of systemic infection 3
• Fever suggesting infection with obstruction (risk of rapid progression to sepsis) 3
• Anuria with obstruction (urologic emergency) 3
• Renal impairment or acute kidney injury secondary to obstruction 3

Home Management Instructions

For patients managed at home:

• Instruct patients to drink large volumes of fluids 1
• Have patients void urine into a container or through a tea strainer/gauze to catch any identifiable calculus 1
• Contact the doctor immediately if pain worsens or unexpected symptoms develop 1

Note on fluid therapy: Despite theoretical benefits, there is no reliable evidence supporting high-volume IV or oral fluid therapy for expediting stone passage, though adequate hydration remains reasonable 7

Follow-Up Investigations

All patients whose symptoms resolve require investigation to determine:

• Was a calculus identified? If so, what was its size and location? 1
• If a calculus is still present, is intervention likely needed? 1
• If no calculus is present, should alternative diagnoses be considered? 1
• Is the patient at risk of developing further episodes? 1

Imaging timeline:

• Arrange radiology appointment within seven days of symptom onset 1
• Urgent urology outpatient appointment within one week if imaging shows a problem requiring intervention 1

Common Pitfalls to Avoid

• Never delay analgesia while waiting for diagnostic tests - this causes unnecessary suffering 3
• Do not issue limited quantities of oral or rectal analgesics for recurrent pain due to potential for drug misuse 1
• Failing to recognize infection with obstruction can lead to rapid progression to sepsis 3
• Missing alternative diagnoses (AAA in elderly, ectopic pregnancy in women of childbearing age) that mimic renal colic 3, 2
• Discharging patients before ensuring adequate pain control and ability to maintain hydration 3

Additional Considerations

Combination therapy: Adding antispasmodics to NSAIDs does not improve pain control and is unnecessary 5, 8. However, combination therapy may be considered for uncontrolled pain after NSAIDs alone 4.

Medical expulsive therapy: Recent evidence from the SUSPEND trial showed no difference between tamsulosin, nifedipine, and placebo for spontaneous passage of ureteric stones 9.