What should be done for a patient experiencing dull to sharp stabbing pain in the left kidney area?

Management of Acute Left Flank Pain Suspicious for Renal Colic

This patient requires immediate medical assessment within 30 minutes, followed by rapid analgesia with intramuscular diclofenac 75 mg to achieve pain relief within 30 minutes of evaluation. 1, 2

Immediate Assessment Protocol

Timing and Triage

• Medical evaluation must occur within 30 minutes of presentation to prevent progression and ensure adequate pain control 1
• If assessment cannot be provided within this timeframe, arrange emergency transport to the nearest emergency department 1

Clinical Evaluation Components

History Focus:

• The diagnosis centers on abrupt onset of severe unilateral flank pain radiating to the groin or genitals 1
• Document pain character (dull vs. sharp/stabbing), radiation pattern, and associated symptoms (nausea, vomiting, hematuria) 1

Critical Red Flags Requiring Immediate Hospital Admission:

• Fever or signs of systemic infection (suggests infected obstructed kidney requiring urgent decompression) 1, 3
• Shock or hemodynamic instability 1
• Age over 60 years: consider leaking abdominal aortic aneurysm as alternative diagnosis 1
• Women with delayed menses: rule out ectopic pregnancy 1

Physical Examination:

• Examine abdomen to establish maximal tenderness location and exclude peritonitis 1
• Assess vital signs to exclude shock and systemic infection 1

Urinalysis:

• Perform if practical, as over 80% of renal colic patients have hematuria 1
• However, absence of hematuria does not exclude the diagnosis 1

First-Line Analgesic Treatment

Preferred Regimen:

• Intramuscular diclofenac 75 mg is the first-line agent with strongest evidence 1, 2, 3
• NSAIDs provide superior pain control compared to opioids and reduce need for additional analgesia 2
• The intramuscular route is preferred because oral and rectal routes are unreliable in acute settings 1, 3
• Pain relief should be achieved within 30 minutes of administration 1, 3
• Maintain pain control for at least 6 hours 1

Alternative NSAIDs:

• Ibuprofen or metamizole can be used, though diclofenac has the strongest evidence base 2

Second-Line Treatment When NSAIDs Contraindicated

Use opioids only when NSAIDs cannot be given due to:

• Renal impairment 2
• Cardiovascular disease 2
• History of gastrointestinal bleeding 2
• Pregnancy 2

Recommended Opioid Regimen:

• Morphine sulfate plus cyclizine (antiemetic) is the preferred combination 1, 3
• In renal impairment specifically: use fentanyl as it does not accumulate active metabolites 2, 3
• Avoid morphine, codeine, or tramadol in renal failure 2, 3
• Avoid pethidine due to highest rate of vomiting and need for additional analgesia 2

Critical Monitoring and Failure Criteria

One-Hour Assessment:

• If pain is not controlled within 60 minutes of appropriate analgesia, immediate hospital admission is mandatory 1, 2, 3
• Follow-up can be conducted via telephone; a second visit is not required 1
• Abrupt recurrence of severe pain also warrants immediate admission 1, 3

Home Management Instructions (If Pain Controlled)

• Increase fluid intake significantly 1
• Void urine through a strainer or gauze to catch any stone for analysis 1
• Contact physician immediately if pain worsens or new symptoms develop 1

Follow-Up Imaging and Specialist Referral

• Arrange renal imaging within 7 days of symptom onset for patients managed at home 1
• Urgent urology appointment within one week if imaging shows a problem requiring intervention 1
• For stones >5 mm in distal ureter, consider medical expulsive therapy with alpha-blockers (tamsulosin) 2

Common Pitfalls to Avoid

• Never delay analgesia while waiting for diagnostic tests 3
• Do not discharge before ensuring adequate pain control for at least 6 hours 3
• NSAIDs may worsen renal function in patients with low GFR—use lowest effective dose and monitor carefully 2
• NSAIDs increase cardiovascular and gastrointestinal risks in elderly patients with comorbidities 2
• Missing signs of infection with obstruction requires urgent decompression via percutaneous nephrostomy or ureteral stenting 2, 3