Ureteric Colic

Ureteric colic is acute pain from a calculus lodged in the ureter, producing obstruction and spasm.

• Sites of impaction: pelviureteric junction, pelvic brim (iliac vessels), and vesicoureteric junction, the narrowest point.
• Spontaneous passage rates: 80 to 90 percent for stones below 5 mm, 50 percent for 5 to 7 mm, and 10 to 25 percent above 7 mm (rare above 10 mm); distal stones pass more readily.
• Stones are calcium oxalate (most), calcium phosphate, uric acid, struvite and cystine.

Severe, abrupt, colicky pain in the loin radiating to the lower abdomen, groin, scrotum or labium (lower ureter), with nausea, vomiting, haematuria, sweating and restlessness.

• Lower ureteric stones cause frequency, urgency and strangury (bladder irritability); testicular pain without testicular tenderness.
• Differential diagnosis: appendicitis, diverticulitis, ectopic pregnancy, ovarian cyst accident or torsion, testicular torsion, pelvic inflammatory disease, aortic aneurysm, biliary colic, acute pyelonephritis, small bowel obstruction, hernia, lumbar disc disease.
• Complications: hydronephrosis, infected obstructed kidney (urosepsis), acute kidney injury, ureteric stricture, ureteric perforation, loss of renal function after prolonged obstruction (more than 4 to 6 weeks), and recurrent stone disease.

Urinalysis, urine culture, serum creatinine, electrolytes, calcium, urate, full blood count, C-reactive protein, pregnancy test.

• Non-contrast low dose CT of kidneys, ureters and bladder to confirm the stone's size, position and density (density above 1000 Hounsfield units predicts resistance to shock wave lithotripsy) and secondary signs (hydroureter, perinephric stranding).
• Ultrasound with plain radiograph for follow-up or in pregnancy; magnetic resonance urography without gadolinium in pregnancy.
• Renal function assessment (isotope renography) after prolonged obstruction.

Supportive: oral hydration, antiemetics, heat; watchful waiting for stones below 10 mm without infection or uncontrolled pain, for up to 4 to 6 weeks with imaging.

Pharmacological

• Analgesia: diclofenac 75 mg IM or 50 mg orally every 8 hours (maximum 150 mg daily) with paracetamol 1 g every 6 hours; morphine 2.5 to 5 mg IV for breakthrough pain.
• Medical expulsive therapy for distal stones 5 to 10 mm: tamsulosin 0.4 mg daily or silodosin 8 mg daily for up to 4 weeks; nifedipine 30 mg daily.
• Antibiotics for infection: ceftriaxone 1 to 2 g IV daily, or piperacillin-tazobactam 4.5 g IV every 6 hours, adjusted to culture.

Procedures

• Urgent decompression with a ureteric stent or percutaneous nephrostomy for infection, solitary kidney, bilateral obstruction or acute kidney injury; definitive stone treatment follows once infection is cleared (2 to 4 weeks).
• Indications for intervention: stone above 10 mm, persistent pain, no progress at 4 to 6 weeks, infection, renal impairment.
• Proximal ureteric stone below 10 mm: extracorporeal shock wave lithotripsy or ureteroscopy; above 10 mm: ureteroscopy with laser lithotripsy (or antegrade ureteroscopy for large impacted proximal stones).
• Mid and distal ureteric stones: ureteroscopy with holmium laser lithotripsy (stone free in above 90 percent).
• Stent for 1 to 2 weeks after ureteroscopy; remove with alpha blockers and anticholinergics for stent symptoms (tamsulosin 0.4 mg, solifenacin 5 mg).

Special groups: pregnancy (conservative care; stent or nephrostomy for infection), children (ibuprofen 5 to 10 mg/kg, ureteroscopy), solitary kidney (early intervention).

Red flags: fever, hypotension, anuria, rising creatinine, intractable pain, solitary kidney, stone above 10 mm.

Follow-up: imaging at 2 to 4 weeks; stone analysis; metabolic evaluation after recurrent stones; prevention with fluids and diet.