Ureteric colic

 is defined as a medical condition characterized
by the presence of a urinary stone, leading to a
severe urinary system pain. An excruciating pain
that can strike without a warning, ureteric colic or
renal colic is caused by dilation, stretching and
spasm of the ureter.

ureteric colic is an important and frequent
emergency in medical practice.
 It is most commonly caused by the
obstruction of the urinary tract by calculi.
 Between 5–12% of the population will
have a urinary tract stone during their
lifetime, and recurrence rates approach
50%(Sierakowski R,et al 1998;15:438–41).

 The classic presentation of a ureteric colic is
acute, colicky flank pain radiating to the
groin.
 Ureteric colic occurs as a result of obstruction
of the urinary tract by calculi at the narrowest
anatomical areas of the ureter: the
pelviureteric junction (PUJ), near the pelvic
brim at the crossing of the iliac vessels and
the narrowest area, the vesicoureteric
junction (VUJ).(Reichard SR, et al. 2008;52:982-7)

 As the stone approaches the
vesicoureteric junction, symptoms of
bladder irritability may occur.
 Calcium stones (calcium oxalate,
calcium phosphate and mixed calcium
oxalate and phosphate) are the most
common type of stone, while up to
20% of cases present with uric acid,
cystine and struvite stones. (Mutgi A,et
al1991; 151:1589-92

The pain of ureteric colic is due to
obstruction of urinary flow, with a
subsequent increase in wall tension.
 Rising pressure in the renal pelvis
stimulates the local synthesis and release
of prostaglandins, and subsequent
vasodilatation induces a diuresis which
further increases intrarenal
pressure.(Holdgate.A,etal.2014;(1):CD004137)

 Pain is the hallmark of ureteral colic
 Originates in the flank and radiates
around the abdomen to the testicle (men)
or labia majora (women)
 Dysuria is common
 Nausea and vomiting are common
 Gross hematuria is present in about 1/3
of patients. (Mutgi A,et al1991; 151:1589-92.

Prostaglandins also act directly on the
ureter to induce spasm of the smooth
muscle.
Owing to the shared splanchnic
innervation of the renal capsule and
intestines, hydronephrosis and
distension of the renal capsule may
produce nausea and vomiting.

A. Calcium oxalate (75%)
Typically result from hypercalciuria from
hyperexcretion
Causes: hyperparathyroidism,
exogenous calcium intake (i.e. antacids)
B. Magnesium-ammonium-phosphate
(struvite) stones (15%)
Result from urinary tract infection with
urea-splitting organisms (Klebsiella,
Pseudomonas, Providencia and Proteus
species)

C. Uric acid stones (5-10%)
Caused by hyperexcretion of uric acid
Tend to be radiolucent
D. Cystine stones (1-2%)
Pain is caused by the passage of the
stone through the ureter, bladder and
urethra. Calculi within the kidney do not
cause pain
 Stones that obstruct the collecting
system cause hydronephrosis

 Ureteric stones usually form within the
kidney.
 Urinary stasis, infection and changes
in the solute concentration of the
urine predispose to stone formation.
 The commonly encountered stone
varieties are oxalate and tri-
phosphate stones.
 Uric acid stones, Xanthine stones and
cystine stones are rare.
 Urinary tract infection with proteus
spp result in acidic urine and increase
the risk of tri-phosphate stones.

 Gout and cystinuria predispose to uric
acid stones and cystine stones
respectively.[TEICHMAN JOEL ,et al 26 August 2014]
 Patients with gross haematuria are at
risk of clot colic.
 Renal papillary necrosis is associated
with diabetes mellitus, analgesic
abuse, pyelonephritis, sickle cell
disease and obstruction of the urinary
tract.[JUNG D,cet al 26 August 2014]

 Besides routine history and clinical
examination,
investigations of patients with
suspected ureteric colic include plain
abdominal radiography,
ultrasound,
intravenous urography and computed
tomography.

Urinalysis
Hematuria (gross or microscopic) is seen
in the majority (70-90%) of but not all
patients (its absence does not rule out
urolithiasis)
 Pyuria (presence of WBCs)
Concomitant UTI should be considered
when WBCs are present AND if the patient
has other concerning KUB with Stone
 KUB with Stone
symptoms (fever, chills, dysuria)
Can result from inflammation without
infection

 Imaging
Imaging to confirm the presence of a
ureteral calculus is frequently unnecessary
in the ED (even for first-time stones).
 KUB (Kidney, Ureter and Bladder) X-ray
90% of stones are radiopaque
Other structures can confuse findings on
X-ray (phleboliths and calcified lymph
nodes have a similar appearance)

 Often used by urologists to track the
progress of stones through the ureter
Limited utility in isolation in the ED,
though may be combined with US
Ultrasound (US)
An US-first approach appears
reasonable
(Smith-Bindman 2014)

 CT Scan
CT need not be performed in all
patients with ureteral colic symptoms
as it exposes patients to ionizing
radiation and increases health care
costs (Firestone 2014)
Superior diagnostic characteristics (Smith
1996, Pfister 2003)
Sensitivity: 97%. Specificity: 96 – 100
Added benefit of ability to identify
other pathology: malignancy, AAA,
renal abscess

 Indications for CT: Concern for
infected stone (with or without
obstruction), concern for alternate
serious diagnosis (especially in elderly
patients), solitary kidney
 Typically performed without IV
contrast as almost all stones are
visible
 IV contrast may be helpful in
differentiating distal ureteral stones
from pelvic phleboliths, and may also
aid in the evaluation of infection as
well as alternate diagnoses

 Urinary tract infection (UTI)
 Abdominal aortic aneurysm (or
dissection)
 Renal artery thrombosis (renal
infarction) or dissection
 Acute appendicitis
 Testicular torsion
 Ectopic pregnancy
 Ruptured ovarian cyst
 Herpes Zoster

 Given that most ureteric stones will pass
spontaneously, conservative treatment in
the form of observation with analgesia is
the preferred approach.
 Ureteric stones require radiological or
surgical intervention only when the
conservative treatment fails.
 The probability of spontaneous passage
is based on a number of factors
including stone size, stone position,
degree of impaction and degree of
obstruction. (Miller OF, et al. 2017;162:688-90).

 NSAIDs: block prostaglandin-induced
effects. They also reduce local edema
and inflammation, and inhibit the
stimulation of ureteric smooth muscle,
which is responsible for increased
peristalsis and subsequently increased
ureteric pressure.(Gronseth JE, etal.2015;28:10811)

 Although NSAIDs reduce pain
associated with ureteric colic, they
may potentially interfere with the
kidney's autoregulatory response to
obstruction by reducing renal blood
flow, and renal failure may be induced
with pre-existing renal disease.(Gronseth
JE, etal. 2015;28:108-11)

 Calcium antagonists: Ureteric smooth
muscle uses an active calcium channel
pump in order to contract. Calcium
antagonists suppress the fast
component of ureteric con-traction,
leaving peristaltic rhythm unchanged.
 Therefore calcium channel blockers,
have been used to relax ureteric
smooth muscle and enhance stone
passage.(Salman S,et al 2018;13:150-2)

 a-Blockers: al-Adrenergic antagonists
are currently commonly used as first-line
treatment in men with lower urinary tract
symptoms.
 a1-Adrenergic antagonists inhibit the
basal tone, peristaltic wave frequency
and the ureteric contraction in the
intramural parts.
 As a result the intraureteric pressure
below the stone decreases and
elimination of the stone can be
achieved.(Milanese G, et al. 2015;24:142-8.)

 Patients treated with calcium antagonists
or a-blockers had a 65% greater
likelihood of spontaneous stone passage
than patients not given these drugs.
Calcium-channel blockers and a-blockers
seemed well tolerated.
 The addition of corticosteroids might
have a small advantage but the benefit of
drug therapy is not lost in those patients
for whom corticosteroids might be
contraindicated.

 Patients have a significantly reduced time
to stone passage, significantly fewer pain
episodes, lower analogue pain scores,
and need significantly lower doses of
analgesics.
 When conservative therapy fails, the
choice of treatment lies between shock
wave lithotripsy and ureteroscopy.
 Surgical management is beyond the
scope of this article and it is not
discussed here.(Fiori C, etal. . Urology 2010;56:579-
83

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of a 2 adrenoceptor subtypes in the human ureter. Neurourol Urodyn
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 22 Porpiglia F, Destefanis P, Fiori C, etal. Effectiveness of nifedipine
and defluzacort in

Ureteric colic

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