Ureteric Colic - Clinicals, Diagnosis, and Management

Urology

Clinicals - History

Fact Explanation
Loin and abdominal pain Ureterolithiasis is a common cause of emergency admission to surgical wards. It is mostly seen in middle aged patients. Obstruction of the ureter leads to intermittent spasms of ureteric wall proximal to the obstruction. This results in severe intermittent pain which starts in the loin region and radiates to the groin. Ureteric colic is most often due to ureteric stones and rarely may be due to blood clots, tumor fragments or renal papillae. Loin and abdominal pain
Ureterolithiasis is a common cause of emergency admission to surgical wards. It is mostly seen in middle aged patients. Obstruction of the ureter leads to intermittent spasms of ureteric wall proximal to the obstruction. This results in severe intermittent pain which starts in the loin region and radiates to the groin. Ureteric colic is most often due to ureteric stones and rarely may be due to blood clots, tumor fragments or renal papillae.
Radiation of pain from the loin to groin The pain of ureteric colic is distributed along the nervous innervation of the ureter. The pain appears to originate in the loin and radiates around the flank to the groin, external genitalia and the anterior surface of the thigh. The radiation is more prominent as the stone descends along the ureter. Radiation of pain from the loin to groin
The pain of ureteric colic is distributed along the nervous innervation of the ureter. The pain appears to originate in the loin and radiates around the flank to the groin, external genitalia and the anterior surface of the thigh. The radiation is more prominent as the stone descends along the ureter.
Haematuria Microscopic haematuria may be present due to traumatization of the ureteric wall by the stone. Suspect clot colic if gross haematuria is present. Haematuria
Microscopic haematuria may be present due to traumatization of the ureteric wall by the stone. Suspect clot colic if gross haematuria is present.
Patient appears agitated and restless The pain is severe and the patients are restless, moves about during bouts of pain. Patient appears agitated and restless
The pain is severe and the patients are restless, moves about during bouts of pain.
Pain during micturition/ Strangury These symptoms are prominent when the stone is migrating through the intramural part of the ureter. Pain during micturition/ Strangury
These symptoms are prominent when the stone is migrating through the intramural part of the ureter.
Presentation with complications Ureteric obstruction may lead to hydronephrosis which present with abdominal discomfort. Stasis if urine predisposes to infection, pyelonephritis presents with high fever, rigors, loin pain & tenderness. Perforation of the ureter is a rare complication. Extravasation of urine into the peritoneum may present with acute onset severe abdominal pain, features of peritonitis and inability to pass urine. Presentation with complications
Ureteric obstruction may lead to hydronephrosis which present with abdominal discomfort. Stasis if urine predisposes to infection, pyelonephritis presents with high fever, rigors, loin pain & tenderness. Perforation of the ureter is a rare complication. Extravasation of urine into the peritoneum may present with acute onset severe abdominal pain, features of peritonitis and inability to pass urine.
Risk factors/ Associations 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. 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. Risk factors/ Associations
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. 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.

Clinicals - Examination

Fact Explanation
General examination : Anxious and distressed patient Due to severe pain. General examination : Anxious and distressed patient
Due to severe pain.
General examination : Features of dehydration Due to reduced intake of fluids. General examination : Features of dehydration
Due to reduced intake of fluids.
Abdominal examination : Abdominal tenderness The loin and flank region may be tender. Rest of the abdominal examination is usually normal. Abdominal examination : Abdominal tenderness
The loin and flank region may be tender. Rest of the abdominal examination is usually normal.

Investigations - Diagnosis

Fact Explanation
Abdominal X-ray Majority of ureteric stones are radio-opaque. Pure uric acid stones and xanthine stones are radio-lucent. Trace the pathway of the ureter in the X-ray from the renal hilum along the tips of the transverse processes of the lumbar vertebra. Gallstones, calcified lymph nodes, faecoliths, phleboliths and intestinal foreign bodies may be mistaken for ureteric stones. Abdominal X-ray
Majority of ureteric stones are radio-opaque. Pure uric acid stones and xanthine stones are radio-lucent. Trace the pathway of the ureter in the X-ray from the renal hilum along the tips of the transverse processes of the lumbar vertebra. Gallstones, calcified lymph nodes, faecoliths, phleboliths and intestinal foreign bodies may be mistaken for ureteric stones.
CT scan CT scan is being increasingly used to diagnose patients presenting with ureteric colic. Spiral CT is considered a diagnostic investigation with high sensitivity and specificity. The presence of a stone and the morphology of the kidney and ureter can be assessed by CT scan. CT scan
CT scan is being increasingly used to diagnose patients presenting with ureteric colic. Spiral CT is considered a diagnostic investigation with high sensitivity and specificity. The presence of a stone and the morphology of the kidney and ureter can be assessed by CT scan.
Intravenous urogram (IVU) Radiolucent stones can be diagnosed by IVU as a filling defect in the contrast-filled urinary tract. Extravasation of contrast may suggest ureteric perforation. Combination of IVU with ultrasound scan can increase the diagnostic accuracy. Intravenous urogram (IVU)
Radiolucent stones can be diagnosed by IVU as a filling defect in the contrast-filled urinary tract. Extravasation of contrast may suggest ureteric perforation. Combination of IVU with ultrasound scan can increase the diagnostic accuracy.
Ultrasound scan The presence of hydronephrosis and hydroureter can be excluded by USS. Presence of an obstructed urinary system requires prompt intervention. Ultrasound scan
The presence of hydronephrosis and hydroureter can be excluded by USS. Presence of an obstructed urinary system requires prompt intervention.
Urinalysis Red blood cells can be found in urine. Urinalysis
Red blood cells can be found in urine.

Investigations - Management

Fact Explanation
Renal function tests : Serum electrolytes, blood urea and serum creatinine To assess renal function. If open surgery is considered prior to surgery renal function tests should be carried out. Renal function tests : Serum electrolytes, blood urea and serum creatinine
To assess renal function. If open surgery is considered prior to surgery renal function tests should be carried out.
Full blood count If open surgery is considered. Full blood count
If open surgery is considered.

Management - Supportive

Fact Explanation
Reassurance and patient education Provide information about the diagnosis. The aetiology, complications, investigations and treatment options should be discussed with the patient. The patient may be distressed and worried due to the severe pain. Reassurance should be provided. Reassurance and patient education
Provide information about the diagnosis. The aetiology, complications, investigations and treatment options should be discussed with the patient. The patient may be distressed and worried due to the severe pain. Reassurance should be provided.
Pain relief Pain relief can be achieved with non-steroidal anti-inflammatory agents such as diclofenac sodium. Tramadol or opioids such as pethidine and morphine may be occasionally required in severe pain. Pain relief
Pain relief can be achieved with non-steroidal anti-inflammatory agents such as diclofenac sodium. Tramadol or opioids such as pethidine and morphine may be occasionally required in severe pain.
Use of smooth muscle relaxants Smooth muscle relaxants such as propantheline have being tried in certain centers. Further evaluation is required to recommend routine use. Use of smooth muscle relaxants
Smooth muscle relaxants such as propantheline have being tried in certain centers. Further evaluation is required to recommend routine use.

Management - Specific

Fact Explanation
Expectant management - Spontaneous Expulsion Ureteric stones smaller than 0.5cm can be observed with regular X-ray as 80% of such stones pass spontaneously with urine. Expectant management - Spontaneous Expulsion
Ureteric stones smaller than 0.5cm can be observed with regular X-ray as 80% of such stones pass spontaneously with urine.
Medical Expulsion Therapy Despite the possibility of spontaneous expulsion, patient factors such as poor pain tolerance and development of infection necessitate active expulsion of the stone which are less than 10mm in diameter in means of reducing contraction and basal tone of the ureteric musculature and reducing the peristalsis. Alpha blockers such as Tamsulosin and Nifedipine are used in this purpose and corticosteroids are also reported to facilitate the expulsion as well.
However, studies have demonstrated the effect of MET to be most useful in combination with shockwave lithotripsy
Medical Expulsion Therapy
Despite the possibility of spontaneous expulsion, patient factors such as poor pain tolerance and development of infection necessitate active expulsion of the stone which are less than 10mm in diameter in means of reducing contraction and basal tone of the ureteric musculature and reducing the peristalsis. Alpha blockers such as Tamsulosin and Nifedipine are used in this purpose and corticosteroids are also reported to facilitate the expulsion as well.
However, studies have demonstrated the effect of MET to be most useful in combination with shockwave lithotripsy
Indications for surgical intervention Consider surgical removal of the stone when the stone is large, is not moving down the ureter, complicated with urinary infection, repeated attacks of severe colics occur and when there is complete obstruction of the kidney. Removal can be by endoscopic techniques or by open surgery. Obstruction of the urinary tract causing hydronephrosis and hydroureter requires surgical intervention to prevent infection and kidney damage. Stone removal should be expedited in pre-existing renal dysfunction and in single functioning kidney. Indications for surgical intervention
Consider surgical removal of the stone when the stone is large, is not moving down the ureter, complicated with urinary infection, repeated attacks of severe colics occur and when there is complete obstruction of the kidney. Removal can be by endoscopic techniques or by open surgery. Obstruction of the urinary tract causing hydronephrosis and hydroureter requires surgical intervention to prevent infection and kidney damage. Stone removal should be expedited in pre-existing renal dysfunction and in single functioning kidney.
Endoscopic removal Endoscope/ ureteroscope can be used as a minimally invasive procedure. The ureter is entered into via the bladder and the stone is directly visualized. It may be removed by Dormia basket or by grasping forceps. The stone that can’t be removed as a whole fragmented by laser, percussive force or electrohydraulic force. Endoscopic ureteric meatotomy can be used if the stone is lodged within the intramural part of the ureter. An incision is made at the meatus to widen the ureteric meatus. Endoscopic removal
Endoscope/ ureteroscope can be used as a minimally invasive procedure. The ureter is entered into via the bladder and the stone is directly visualized. It may be removed by Dormia basket or by grasping forceps. The stone that can’t be removed as a whole fragmented by laser, percussive force or electrohydraulic force. Endoscopic ureteric meatotomy can be used if the stone is lodged within the intramural part of the ureter. An incision is made at the meatus to widen the ureteric meatus.
Lithotripsy in situ Ureteric stones can be fragmented within the ureter by a lithotripter. Avoid this technique when large stones are encountered and if the stone is deeply embedded within the wall of the ureter. Lithotripsy in situ
Ureteric stones can be fragmented within the ureter by a lithotripter. Avoid this technique when large stones are encountered and if the stone is deeply embedded within the wall of the ureter.
Open surgery : Ureterolithotomy Open surgery is rarely used for longstanding large ureteric stones. The abdominal X-ray is used identify the position of the stone within the ureter. An appropriately cited surgical incision is made to the expose the ureter. Slings are applied proximally and distally to the stone to prevent movement of the stone during surgery. Ureterotomy is performed directly over the stone. The stone is freed by blunt dissection and removed. The ureter is closed with absorbable sutures and a drain is left in situ. Laparoscopic approach has being introduced sussessfully in the recent past with good results. Open surgery : Ureterolithotomy
Open surgery is rarely used for longstanding large ureteric stones. The abdominal X-ray is used identify the position of the stone within the ureter. An appropriately cited surgical incision is made to the expose the ureter. Slings are applied proximally and distally to the stone to prevent movement of the stone during surgery. Ureterotomy is performed directly over the stone. The stone is freed by blunt dissection and removed. The ureter is closed with absorbable sutures and a drain is left in situ. Laparoscopic approach has being introduced sussessfully in the recent past with good results.

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