A patient treated yesterday for renal colic with tamsulosin (0.4 mg daily) and analgesics now has persistent vomiting and only one void in the past 24 hours—what is the appropriate management?

Immediate Hospital Admission Required

This patient needs immediate hospital admission for evaluation of possible urinary obstruction with anuria and management of intractable vomiting. The combination of persistent vomiting and only one void in 24 hours represents failure of outpatient management and raises concern for complete or near-complete obstruction with potential for acute kidney injury and sepsis 1, 2.

Critical Red Flags Present

This patient has two urgent indications for hospital admission:

• Anuria or severe oliguria (only one void in 24 hours) in the setting of an obstructed kidney requires urgent decompression via percutaneous nephrostomy or ureteral stenting 1, 3
• Persistent vomiting indicates either inadequate pain control, complications from opioid analgesics, or progression to complete obstruction 1, 2
• Failure of initial analgesic therapy beyond 60 minutes mandates immediate hospital admission without further attempts at outpatient management 1, 2

Immediate Actions

Before Transport

• Check vital signs immediately to exclude fever (suggesting sepsis) or shock, both of which require emergency admission 1
• If fever is present with obstruction, this represents a urological emergency requiring urgent decompression and immediate antibiotics 1

Hospital Evaluation Required

The patient needs:

• Urgent imaging (CT urography or ultrasound) to assess degree of obstruction and hydronephrosis 1, 2
• Laboratory testing including creatinine, electrolytes, CBC, and CRP to evaluate renal function and exclude infection 1
• Urine culture before any intervention if infection is suspected 1
• Assessment for urgent decompression if anuria is confirmed or if sepsis is present 1, 3

Why Outpatient Management Has Failed

Inadequate Pain Control

• The patient likely received opioids as analgesics, which have a high rate of vomiting (particularly pethidine) and are inferior to NSAIDs for renal colic 1
• Opioids require additional analgesia more frequently than NSAIDs and cause more nausea 3, 4

Possible Complications

• Complete obstruction: Only one void in 24 hours suggests either bilateral obstruction, obstruction of a solitary kidney, or severe dehydration from vomiting 1
• Developing sepsis: Vomiting with obstruction can indicate pyelonephritis, which requires urgent decompression 1, 3
• Medication side effects: Opioid-induced nausea and vomiting may be compounding the clinical picture 1, 3

Critical Pitfalls to Avoid

• Do not attempt further outpatient management with different oral medications or antiemetics—this patient has already failed conservative therapy 1, 2
• Do not delay admission for additional phone follow-up or observation—the 60-minute window for analgesic response has long passed 1, 2
• Do not assume tamsulosin alone will resolve the obstruction—while medical expulsive therapy is appropriate for stones >5mm in the distal ureter, it does not address acute anuria or vomiting 1, 3
• Do not miss sepsis—fever with obstruction requires immediate decompression and antibiotics before definitive stone treatment 1

What Should Have Been Done Initially

For context on optimal initial management (though this patient is now beyond this point):

• First-line analgesia should have been NSAIDs (diclofenac 75mg intramuscularly), not opioids, as NSAIDs provide superior pain control with less vomiting 1, 3
• Telephone follow-up at 1 hour should have been arranged to assess analgesic response 1, 2
• Clear admission criteria should have been communicated: failure of pain control within 60 minutes, persistent vomiting, inability to void, or fever 1, 2

Bottom Line

Call emergency services or transport this patient to the hospital immediately. Do not attempt additional outpatient interventions. The patient requires urgent evaluation for urinary obstruction, possible decompression, intravenous fluids for dehydration from vomiting, and reassessment of the stone management strategy 1, 2.