Renal colic

1. Renal ColicRenal Colic
Amina Al-QaysiAmina Al-Qaysi

2. IntroductionIntroduction
•T10-12, L1 roots innervate the renal
capsule and ureter.
•Pain from these structures is felt in these
dermatomes.
•Urinary tract & GIT share the same
autonomic innervation, that’s why renal
colic is usually associated with GI
symptoms.

4. •Site:Site: Loin (space below 12
th
rib & iliac crest),
Renal angle (between 12
th
rib & edge of erector
spinae muscle).
•Radiation:Radiation: Towards the umbilicus.
•Onset:Onset: Sudden.
•Duration:Duration: variable.
•Nature:Nature: Dull, aching pain .
•Intensity:Intensity: Severe.
Renal ColicRenal Colic

5. •Course:Course: constant.
•ProgressionProgression: progressive.
•Relieving & Exacerbating factors: Relieving & Exacerbating factors: patient
tries changing his position in bed, or walking,
but usually fails to relieve the pain. Relieved
by analgesics.
•Associated Associated Hematuria, urinary frequency,
dysuria, fever, sweating, nausea & vomiting.

6. Renal ColicRenal Colic

7. •Patient usually describesdescribes the pain by
spreading his hand around his waist with
his fingers covering the renal angle & his
thumb above the anterior superior iliac
spine.
•Acute Pyelonephritis and acute
ureteral obstruction both cause
this typical pain.

8. Ureteral ColicUreteral Colic
•Site: Site: Originates at the costo-vertebral
angle.
•Radiation: Radiation: Lower quadrant of abdomen,
upper thigh and ipsilateral testicle or
labium.
•Onset:Onset: Sudden.
•Duration:Duration: variable.
•Nature: Nature: colicky, gripping.
•Intensity:Intensity: Severe.

9. •Course:Course: attacks, pain is less severe in
between, but never disappears
completely.
•ProgressionProgression: progressive.
•Relieving & Exacerbating factors: Relieving & Exacerbating factors:
patient tries changing his position in bed,
or walking, but usually fails to relieve the
pain. Relieved by analgesics.
•Associated Associated Hematuria, urinary frequency,
dysuria, fever, sweating, nausea &
vomiting.

11. Ureteral ColicUreteral Colic
•Typical of sudden ureteric distension &
associated distension of the renal pelvis.
•Most commonly due to calculi.
•Less commonly due to tumor, or blood
clot.

12. •Ureteral colic caused by stone in the
upper ureter may be associated with
severe pain in the ipsilateral testicle; due
to the common innervation of these
structures (T11–12).
•Stone in the lower ureter may cause pain
referred to the scrotal wall.

13. •Stones in mid-ureter on the right side,
causes pain referred to McBurney’s point
and may therefore simulate appendicitis.
•On left side it may resemble diverticulitis
or other diseases of the descending or
sigmoid colon (T12, L1).

14. On ExaminationOn Examination
•General examination: Agitated, in pain,
pallor, fever, tachycardia.
•Abdomen tense & rigid.
•Loin tenderness.
•Kidney enlargement.

15. InvestigationsInvestigations
LaboratoryLaboratory::
•CBC, ESR.
•Serum electrolytes.
•Blood urea.
•Renal Function Test.
•Urinalysis, Urine culture & sensitivity.
•24 hours urine: calcium, phosphorus, uric
acid, oxalate, cystine, citrate.
•Biochemical assessment of stone.

16. RadiologyRadiology::
•KUB: 90% of renal stones are radio-
opaque.
•Intravenous Urography (IVU): Filing defect,
delayed excretion of contrast, dilated
ureter.
•Ultrasound: stone visualization, acoustic
shadow, dilated ureter.
•Non-enhanced spiral CT scan: most
accurate assessment, identify non-opaque
stones.

17. Left Ureteric CalculusLeft Ureteric Calculus

18. IVU Vs. CT scanIVU Vs. CT scan
IVUIVU::
• More readily available.
• Less irradiation.
• Easy to interpret.
• More economical.
• Kidney function.

19. CT scanCT scan::
•Quick.
• No risk of contrast allergy.
• High specificity.
•Detailed anatomy.
• Shows other pathology.

20. ManagementManagement
•Bed rest.
•Hydration.
•Analgesia: Morphine I.M. (10-20 mg),
Pethidine I.M. (100 mg).
•Anti-emetic.
•Further management according to the
cause.

21. Renal Stones ManagementRenal Stones Management
•On this conservative regime 60% of all
stones pass spontaneously.
•However 30% of stones do require
surgical removal whilst the remaining 10%
may be followed expectantly.

22. •>90% of kidney stones are treated by
Extracorporeal Shock Wave Lithotripsy.
•For Staghorn calculi: Percutaneous
Nephrolithotomy or conventional open
surgery (Pyelolithotomy) are still indicated
on occasion.

23. Extracorporeal Shock Wave Extracorporeal Shock Wave
LithotripsyLithotripsy

24. Surgery indicated ifSurgery indicated if::
1.Large stone.
2.Infection with severe obstruction.
3.Failure of conservative measures.
4.To correct anatomical abnormalities.

25. Ureteric Stones ManagementUreteric Stones Management
•60% of all ureteric calculi will pass within a
week to a month of onset of symptoms.
•Only 30% will require surgical removal.
•Most ureteric calculi are treated by ESWL.
•Push-bang treatment.

26. •Rigid or flexible Ureteroscopes can be
used if ESWL fail.
•Stone fragmentation using laser, EHL and
Ultrasound probes.

27. Surgery indicated ifSurgery indicated if::
1.Stone is too large to pass spontaneously
(>7 mm).
2.Causing obstruction & impairing renal
function.
3.Proximal infection combined with
obstruction.

28. ReferencesReferences::
1.Smith’s General Urology, 17
th
edition, Chapter 3,
Page 30-34.
2.Davidsons’s principles & practice of medicine.
3.Oxford handbook of urology.
4.Bates’ guide to physical examination and history
taking, 10
th
edition, Chapter 11, Page 428-429.
5.Textbook of medicine, Das.
5. Browse’s introduction to the symptoms & signs of
surgical disease, Chapter 16, Page 435-436.
6. Hutchinson’s clinical methods, 22
nd
edition, Chapter
14, Page 293.