Role of Dicyclomine in Ureteric Colic
Dicyclomine has no established role in the treatment of ureteric colic and should not be used. NSAIDs, specifically diclofenac 75 mg intramuscularly, are the evidence-based first-line treatment for renal colic pain control.
Evidence-Based Pain Management for Ureteric Colic
First-Line Treatment: NSAIDs (Not Antispasmodics)
NSAIDs are the gold standard for renal colic pain management, with diclofenac being the most strongly recommended agent 1, 2.
- Intramuscular diclofenac 75 mg is the specific first-line treatment when the diagnosis is clear and there are no contraindications 1, 2.
- NSAIDs work by reducing inflammation and lowering pressure inside the urinary collecting system, directly addressing the pathophysiology of renal colic 3, 4.
- NSAIDs reduce the need for additional analgesia compared to opioids and have fewer side effects 1, 2.
- Pain relief should be achieved within 30 minutes of administration 1.
Why Not Antispasmodics Like Dicyclomine?
The evidence base for ureteric colic management makes no mention of antispasmodic agents such as dicyclomine. The comprehensive European Association of Urology guidelines (2025) and multiple other authoritative sources consistently recommend NSAIDs as first-line therapy, with opioids as second-line 1, 2. There is no role for smooth muscle antispasmodics in current evidence-based practice for ureteric colic.
Second-Line Treatment: Opioids
- When NSAIDs are contraindicated or insufficient, opioids should be used as second-line therapy 1, 2.
- Recommended opioid agents include hydromorphone, pentazocine, or tramadol—avoid pethidine due to high rates of vomiting and need for additional analgesia 1, 2.
- For patients with renal impairment, fentanyl is preferred as it does not accumulate active metabolites 2.
- Opioids should be combined with an antiemetic such as cyclizine 1.
Treatment Algorithm
Initial Assessment and Treatment
- Administer intramuscular diclofenac 75 mg immediately after confirming the diagnosis 1, 2.
- The intramuscular route is preferred over oral or rectal routes, which are unreliable 1.
- Complete pain control should be maintained for at least six hours 1, 2.
Response Assessment at One Hour
- If pain is not relieved within 60 minutes, arrange immediate hospital admission 1, 2.
- Follow up by telephone one hour after initial assessment to check analgesic response 1, 2.
- Abrupt recurrence of severe pain also warrants immediate admission 1.
Contraindications to NSAIDs
- When NSAIDs are definitively contraindicated, use morphine sulfate combined with cyclizine 1.
- NSAIDs may impact renal function in patients with low glomerular filtration rate 1.
- NSAIDs increase cardiovascular and gastrointestinal risks, so use the lowest effective dose 1.
Important Clinical Caveats
Immediate Hospital Admission Required For:
- Patients with shock or fever (possible infected obstructed system) 1, 3.
- Signs of peritonitis or systemic infection 3.
- Sepsis and/or anuria in an obstructed kidney—requires urgent decompression via percutaneous nephrostomy or ureteral stenting 1, 2.
- Failure to respond to analgesia within one hour 1, 2.
Common Pitfalls to Avoid
- Do not use dicyclomine or other antispasmodics—they have no evidence base for ureteric colic.
- Do not use pethidine as the opioid of choice due to high vomiting rates 1, 2.
- Avoid standard opioid dosing in renal failure; start with lower doses and titrate carefully 2.
- Never use morphine, codeine, or tramadol as first-line agents in patients with renal failure 2.
- Do not combine NSAIDs with diuretics and ACE inhibitors/ARBs (the "triple whammy") as this dramatically increases acute kidney injury risk 5.