This document discusses the presentation, evaluation, and management of ureteric colic or kidney stone pain. Key points include: - Ureteric colic presents with continuous flank or abdominal pain that may radiate to the groin. Evaluation includes urine analysis, ultrasound, and non-contrast CT. - Medical expulsive therapy with alpha-blockers can help distal ureteric stones <10mm pass spontaneously. Larger stones may require stenting or percutaneous nephrostomy. - During pregnancy, ureteric colic evaluation prioritizes ultrasound and limited IVU to avoid radiation. Most stones will pass spontaneously with pain control and hydration. Surgical intervention is reserved for

1. Ureteric colic
Sukhdev, CMC Vellore

2. • Most common urological case in emergency department
• Mandates urgent investigation
• Colic is a misnomer – pain is usually continuous

3. Phases of ureteric colic
Acute or onset phase Constant phase Abatement or relief
phase
Usually continuous
Sometimes in
paroxysms
Most patients arrive in
ED in this phase
Relieves
spontaneously or by
medications
Lasts 1-2 hours Lasts 1-4 hours

4. The pain
• Upper ureteral calculi – flanks
• Mid ureteral calculi – anteriorly and caudally
• Distal ureteral calculi – symptoms may mimic cystitis or detrusor
overactivity
• Hematuria(micro/macro) is seen in 85% of patients with colic

5. Mechanism of ureteric colic
• Dilatation of UUT proximal to calculus causing stretching of renal
capsule – increased PgE2 promotes afferent arteriolar vasodilatation and diuresis further increasing
proximal tract pressure
• Spasm of ureteral smooth muscle surrounding the calculus

6. Renal function recovery post obstruction
• 100% after 1 week
• 30% after 4 weeks

7. Differential diagnoses
• Acute appendicitis
• Acute cholecystitis
• Acute pyelonephritis
• Torsion testis
• Torsion ovary
• Ovarian cyst rupture
• Diverticulitis
• Aneurysm rupture

8. Lab investigations
• Hematuria has a negative predictive value of 65%
• Can have leucocytosis and raised creatinine
• Urine crystals may predict the type of stone

9. Radiological investigations
• Plain abdominal radiograph
• USG
• IVU
• NCCT KUB

10. X RAY KUB
• 90% of urinary calculi are radio opaque
Phlebolith vs distal ureteric calculi:
• Phlebolith are calcified veins and so will have a radiolucent centre

11. Renal ultrasound
• Can detect hydronephrosis
• X ray KUB + USG = alternative to NCCT KUB

12. IVU
• Not done in emergency setting
• However, provides a road map for subsequent endoscopic surgeries

13. NCCT KUB
• Adopted as investigation of choice for ureteric colic
• Sensitivity and specificity of 94-100%
• Ureteric calculi have peripheral ‘rim sign’ due to mucosal edema which can be used to differentiate them
from phlebolith
Merits
• Can detect radiolucent stones(exception of indinavir stones)
• Gives idea about HUN and calyceal anatomy
• Can diagnose other pathologies
Demerits:
• If CT collimation is small, can miss small stones
• Ideally 5 mm cuts are preferred
• Lacks the orientation which the surgeons prefer. However, 3D reconstruction eliminates this

14. Rim sign

15. Do you need an X ray KUB when the patient
has an NCCT KUB
• To tell whether the stone is radiolucent or radio opaque
• To tell the approximate size of stone comparing it to known bony
landmarks like vertebrae
• Gives the surgical orientation of most endourological procedures

16. Management
• Ureteric colic patients can have vomiting and the ensuing hydration
should be addressed
• Forced diuresis is contraindicated as it doesn’t facilitate stone
passage(it worsens obstruction)
• Replacement of vomitus + maintenance fluids is more than enough

17. Analgesia
• Diclofenac 37.5 mg or ketorolac 30 mg IV or IM
• IV paracetamol 1 g
• Morphine 0.1 mg/kg
• IV lidocaine 120 mg/100 ml normal saline over 10 minutes

18. Spontaneous passage
• ≤4 mm will pass spontaneously 94% of the time
• >6 mm stones(larger than ureteral diameter) wont usually pass
spontaneously

19. MET
• Medical expulsive therapy
• Facilitates stone passage
• Recommended for distal ureteric stones >5 mm but <10 mm(EAU)
• Alpha blockers better than calcium channel blockers
• Alpha receptors are more in distal ureter
• Duration of MET: ≤6 weeks(AUA)

20. Hospitalisation
• Most ureteric colic patients can be treated as OPD
Patients who require admission are:
• Pain refractory to routine analgesia
• Refractory vomiting
• Infection
• AKI
• Solitary kidney
• Bilateral obstructing calculi

21. Cont’d
These patients will require emergency JJ stenting or Percutaneous
nephrostomy

22. Urolithiasis in pregnancy

23. • Most common non obstetric cause of acute abdomen
• 1/1500 pregnancies
• Incidence not more than similar age group childbearing non pregnant
population
• More common in multiparous women
• More common in 2nd and 3rd trimester

24. Why worrisome?
• Risk of premature labour
• Other complications like pre eclampsia, pregnancy loss are unaffected

25. Physiological changes in pregnancy
1. Physiological HUN:
• starts at 6 months(24 weeks) and increases till 32 weeks(8 months)
and stays stable thereafter
• 90% of RK and 67% of LK will have HUN
• Due to dextrorotation of gravid uterus and protection of left ureter by
gas filled sigmoid colon
• Progesterone induced smooth muscle dilatation

26. Cont’d
2.Increased GFR and renal plasma flow
3.Creatinine clearance increases by 50%, with an average creatinine of
0.4-0.8 mg/dl

27. Lithogenicity in pregnancy
• Gestational hypercalciuria – due to ↑ GFR and thus, ↑ filtered load of calcium. Also due to
placental 1α hydroxylase which ↑vitamin D production
• Gestational hyperuricosuria
• Physiological HUN
But still, the incidence of lithiasis in pregnant women is the same as in non pregnant women
because of:
• Increase in anti lithogenic factors in urine like citrate, glycosaminoglycans
• Relative alkalinity of urine due to physiological respiratory alkalosis
• So, the most common stone in pregnancy is calcium phosphate

28. Investigations
• USG
• MRI
• Limited IVU

29. USG
• Less predictive value due to physiological HUN
• RI >0.7 can indirectly indicate obstruction
• Asymmetric Urine jet can indicate unilateral obstruction(sensitivity
100% and specificity 91%)
Overall sensitivity is 76% and specificity is 67% in pregnancy
Transvaginal USG for distal ureters if TAUS is inconclusive

30. MR urography
• Relatively insensitive for stones but signs of obstruction can be
apparent

31. IVU
• Limited or 3 shot IVU
• Scout, 30 seconds and 20 minute films
• Demerits:
• Iodinated contrast media can cross placenta
• Fetal skeleton can obscure the calculi

32. CT
• Low dose and ultra low dose CT protocols have been devised
• But still better to avoid

34. Medications
NSAIDS contraindicated
• Can cause premature closure of ductus arteriosus when used near
term and can cause pulmonary hypertension
• Paracetamol safe to use(Category B)
Morphine can be used but in a limited dose and over limited time
Tamsulosin can be used(category B)

35. Surgery
70-80% of stones will pass spontaneously
JJ stenting alone
• will need frequent stent changes(Q4-6 weeks to avoid encrustation)
• Stents can shift to bladder because of physiological HUN
PCN
• if pregnancy ≤22 weeks