Renal Colic

You are the urology CT1 asked to see a 45-year-old design engineer who has presented with 12-hour history of colicky left-sided loin to groin pain, which has now progressed to left flank pain. He is known to form renal stones and has had percutaneous nephrolithotomy in the past. How would you proceed?

Example answer introduction

I suspect that this gentleman may have renal colic, but I would be looking to ensure they did not have a ruptured AAA which could present as a renal colic. I would take a focused history, perform a focused examination and request the relevant investigations depending on my clinical suspicions. I would then initiate treatment and escalate to my registrar for senior review. 

Initial Assessment and Simultaneous Resuscitation

 

On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.

  • Airway 

  • Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns  give high flow oxygen 

  • Circulation

    • Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic

    • IV access - large bore and bloods including CRP

    • Give fluid challenge of 250ml crystalloid solution if evidence of shock 

    • If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol

  • Disability - GCS, pupillary response, blood sugar, temperature

  • Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!

 

During this acute phase state remember to provide constant reassessment

During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, Amylase, blood glucose, clotting studies, Group and Save and blood and urine cultures if spiking a temperature. 

Focused history​

  • Allergies

  • Medications 

  • Past medical history – Previous renal tract infections or calculi, sexual history, previous urological procedures

  • Last meal

  • Events leading up to this point – duration of symptoms, nausea and vomiting, dysuria, frequency, hesitancy, urgency, haematuria, nocturia, poor stream, when last passed urine and amount

Abdominal examination and initial investigations

Abdominal and external genitalia examination

 

  • Inspect – distention, surgical/traumatic scars

  • Palpate – general abdomen, AAA, renal angle tenderness

  • Digital rectal examination – Prostate enlargement, prostatitis, 

 

 

 

 

I would then request further investigations – 

 

  • Urine dip – looking for blood, leukocytes, nitrites, glucose, ketones

  • Send urine for microscopy and culture

  • Bladder scan – I would site urethral catheter if in acute retention. 

  • Depending on my findings he may require a CT kidneys, ureters and bladder (KUB) but I would discuss this with the registrar first. 

Example questions to progress the station

Q1 He is septic and has not passed urine in the last 12 hours and cannot do so when you ask him. His blood tests show a stage 3 acute kidney injury. 

The CT KUB shows a large left renal pelvis stone and significant hydronephrosis. How would you proceed?

Q1 Answer

He has an infected and obstructed urinary tract. I would implement the sepsis-6 protocol and treat him with antibiotics according to local protocol. I would discuss with the urology registrar as he may need to go to theatre for placement of a nephrostomy tube. 

 

Initial management

  • Analgesia according to the WHO pain ladder

  • Keep nil-by-mouth

  • Prep for theatre 

  • Keep patient and any relatives informed

  • Document, document, document!!!

Escalation
I would inform the Registrar to review the patient in a timely manner, to ensure my diagnosis and management plan were correct.
It may be expected of you to put the patient on the emergency list so close communication with theatre staff and anaesthetics may be necessary. 
It is unlikely you would be expected to call interventional radiology however knowledge that they often place nephrostomies is important. 
Useful Resources

Update on interventional uroradiology. Urologic Clinics of North America

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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