What is the preferred medication, Buscopan (hyoscine butylbromide) or Diclofenac (nonsteroidal anti-inflammatory drug), for managing renal stone pain?

Diclofenac for Renal Stone Pain

Diclofenac should be given as first-line treatment for renal stone pain, not Buscopan (hyoscine butylbromide). NSAIDs, specifically diclofenac 75 mg intramuscularly, are the evidence-based standard of care for acute renal colic, while Buscopan has been shown to be no more effective than placebo. 1, 2, 3

Why Diclofenac is Superior

NSAIDs are the first-line treatment for renal colic according to the most recent European Association of Urology guidelines (2025). 1 The mechanism is dual: NSAIDs block prostaglandin synthesis in the kidney, which reduces both ureteral smooth muscle spasm and diuresis, directly addressing the pathophysiology of renal colic. 4

Evidence Supporting Diclofenac

• Diclofenac 75 mg IM is specifically recommended as the initial treatment of choice for renal colic. 2

• NSAIDs reduce the need for additional analgesia compared to opioids and have fewer side effects, particularly less vomiting and nausea. 1

• A comprehensive network meta-analysis of 65 RCTs with 8,633 participants found that diclofenac via IM route ranked among the top three most effective treatments for acute renal colic pain control. 5

• The CDC guidelines (2022) confirm that NSAIDs are at least as effective as opioids for kidney stone pain and are preferred when not contraindicated. 1

Why Buscopan Should Not Be Used

Buscopan (hyoscine butylbromide) is not superior to placebo for renal colic pain management. 3 While it is an antispasmodic, the pain of renal colic is primarily driven by prostaglandin-mediated inflammation and ureteral distension, not simple smooth muscle spasm that responds to anticholinergics.

Practical Administration Protocol

First-Line Treatment

• Administer diclofenac 75 mg intramuscularly as the initial analgesic. 2, 5

• Alternative NSAIDs include ketorolac IV or ibuprofen IV if diclofenac is unavailable, though there is more clinical evidence supporting diclofenac IM. 5

Second-Line Treatment

• If pain is not controlled within one hour, the patient should be admitted to hospital. 2

• Opioids are second-line therapy when NSAIDs are contraindicated or insufficient. 1

• If opioids are required, use hydromorphone, pentazocine, or tramadol rather than pethidine, which has higher rates of vomiting. 1

Critical Contraindications and Precautions

When to Avoid NSAIDs

Do not use diclofenac in patients with:

• Advanced renal disease or significant renal impairment - NSAIDs can precipitate acute renal decompensation in patients where renal prostaglandins maintain compensatory perfusion. 6

• History of peptic ulcer disease or GI bleeding - These patients have a greater than 10-fold increased risk of GI bleeding with NSAIDs. 6

• Cardiovascular disease or risk factors - NSAIDs carry cardiovascular risks that must be weighed against benefits. 1, 6

• Concurrent use of anticoagulants, corticosteroids, or the "triple whammy" combination (NSAIDs + diuretics + ACE inhibitors/ARBs), which dramatically increases AKI risk. 7, 6

Monitoring Requirements

• Use the lowest effective dose for the shortest duration to minimize GI and cardiovascular risks. 1, 6

• For patients with considerable dehydration, use caution when initiating diclofenac treatment. 6

• Monitor liver transaminases within 4-8 weeks if long-term NSAID therapy is anticipated, though this is rarely relevant for acute renal colic. 6

Special Clinical Scenarios

If NSAIDs Are Contraindicated

• Use opioids as primary analgesia (hydromorphone, pentazocine, or tramadol). 1

• For patients with renal impairment requiring opioids, fentanyl is preferred as it does not accumulate active metabolites. 2

Combination Therapy

• Combination therapy (NSAIDs plus opioids) is more effective than NSAIDs alone but causes more adverse events. 5

• Reserve combination therapy for uncontrolled pain after initial NSAID administration rather than as first-line treatment. 5

Medical Expulsive Therapy

• Consider adding alpha-blockers (tamsulosin) for stones >5 mm in the distal ureter to facilitate spontaneous passage, though this addresses stone passage rather than acute pain. 1

Common Pitfalls to Avoid

• Do not use Buscopan as primary analgesia - it lacks evidence of efficacy beyond placebo. 3

• Do not overhydrate patients - this has no advantage and carries risk of pelvic rupture with urine extravasation and infection. 3

• Do not use standard opioid dosing in renal failure - always start with lower doses and titrate carefully. 2

• Never use morphine, codeine, or tramadol as first-line in renal failure - these accumulate toxic metabolites. 2

When to Escalate Care

Urgent decompression with percutaneous nephrostomy or ureteral stenting is required for: 1

• Sepsis with obstructed kidney
• Anuria with obstruction
• Failure to respond to analgesia within one hour 2

1, 2, 6, 3, 5, 4