What is the treatment for renal colic (kidney stone pain)?

From the Guidelines

Renal colic treatment should begin with pain management using NSAIDs as first-line therapy, specifically diclofenac 75mg IM, as recommended by the consensus group 1.

Key Considerations

• The treatment of renal colic should focus on providing rapid pain relief, with analgesia given within half an hour of assessment 1.
• Diclofenac given by intramuscular injection is the preferred initial treatment for renal colic, according to the consensus group 1.
• If severe pain does not remit within an hour, the patient should be admitted to hospital 1.
• All patients, whether managed at home or in hospital, should be offered fast track urological investigation with follow up 1.
• Patients should be advised to maintain higher fluid intake and attempt to sieve urine to collect passed stones for analysis 1.

Additional Recommendations

• Opioids like morphine or hydromorphone can be added for severe pain not controlled by NSAIDs.
• Fluid therapy should be moderate rather than aggressive, as excessive hydration may worsen pain by increasing ureteral pressure.
• Medical expulsive therapy with tamsulosin may be considered for patients with distal ureteral stones 5-10mm in size.
• Urgent urological consultation is necessary for patients with fever, signs of infection, acute kidney injury, intractable pain, or complete obstruction.
• Follow-up imaging with CT scan or ultrasound is recommended to confirm stone passage.
• Prevention of recurrence includes maintaining daily fluid intake of 2-3 liters, limiting sodium and animal protein intake, and possibly taking thiazide diuretics, potassium citrate, or allopurinol based on stone composition and metabolic evaluation.

From the Research

Treatment Options for Renal Colic

• Nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids are effective for pain relief in renal colic, with NSAIDs having a more favorable risk-benefit balance 2.
• The most widely studied NSAID is diclofenac, given intramuscularly at a dose of 50 mg or 75 mg, while morphine is given intravenously 2.
• A meta-analysis of 20 trials found that NSAIDs and strong opioid analgesics have comparable efficacy in relieving pain in renal colic 2.
• NSAIDs are associated with fewer adverse effects than opioids, which cause vomiting in about 20% of patients 2, 3, 4.
• The combination of NSAIDs and antispasmodics is not superior to NSAIDs alone in terms of pain control 5.
• Indomethacin is less effective than other NSAIDs in reducing pain in renal colic 5.
• Local active warming, taking care to avoid burns, is effective against pain in renal colic, with pain reduced by at least 50% using a device delivering 42 degrees C to the abdomen or lower back 2.

Comparison of NSAIDs and Opioids

• Both NSAIDs and opioids lead to clinically significant falls in patient-reported pain scores, but NSAIDs are associated with a lower incidence of adverse events, particularly vomiting 3, 4.
• Patients treated with NSAIDs are significantly less likely to require rescue medication than those treated with opioids 3, 4.
• Opioids, particularly pethidine, are associated with a higher rate of vomiting compared to NSAIDs 3, 4.

Special Considerations

• In pregnant women, morphine carries a lower risk of adverse effects than NSAIDs 2.
• In elderly patients, the use of NSAIDs and opioids requires careful consideration due to the potential for adverse effects, such as renal impairment and respiratory depression 6.
• Alpha-adrenoceptor antagonists, such as tamsulosin, may be effective in increasing the rate of spontaneous stone passage and decreasing the severity of renal colic in elderly patients 6.