The clinical presentation is highly variable. Most patients with renal stone disease are asymptomatic, whereas others present with pain, hematuria, urinary tract infection (UTI) or urinary tract obstruction. A common presentation is acute loin pain radiating to the anterior abdominal wall, together with hematuria, termed as renal colic. This is most commonly caused by ureteric obstruction by a calculus but the same symptom can occur in association with sloughed renal papilla, tumor or blood clot. The patient is suddenly aware of pain in the loin which radiates round the flank to the groin and often into the testes or labium in the sensory distribution of the first lumbar nerve. The pain steadily increases in intensity to reach the peak in a few minutes. The patient is restless and tries unsuccessfully to obtain relief by changing position or pacing the room. There is pallor, sweating and often vomiting. Frequency, dysuria and hematuria may occur. The intense pain usually subsides within 2 hours but may continue unabated for hours or days. It is usually constant during attacks, although slight fluctuation in severity may be seen. Intermittent dull pain in the loin or back may persist for several hours following the attack of renal colic. Other symptoms that may be present include fever with rigors and chills, urinary retention, abdominal bloating, loss of appetite and abnormally colored urine.

• Severe Pain

  In renal colic there is generally severe pain leading from the kidneys down through the abdomen and groin. [britannica.com]

  The obstruction of the urinary tract by calculi at the narrowest anatomical areas leads to impaired drainage and severe pain (renal colic). [storzmedical.com]

  Overview Consider AAA as diagnosis in elderly with 'renal colic' (the presence of pain and haematuria does not necessarily rule out AAA) Give early pain relief for severe pain (do not presume opiate-seeking behaviour) Renal obstruction PLUS infection [emedsa.org.au]

  Patients arrive in severe pain because of renal colic from kidney stones. [mdedge.com]

  The pain caused is extremely violent and is one of the worst known in medicine. Symptoms An extremely severe pain is felt suddenly, originating at the lumbar and moving towards the genitals. [health.ccm.net]

• High Fever

  High Fever People with this disorder also suffer from increased body temperatures. High fever is usually accompanied with chills in the hand and feet. Gas In patients of Renal Colic gas formation can also cause much discomfort. [primehealthchannel.com]

  Along with abdominal pain, which could manifest in the back or the groin as well, you can also have Blood in the urine or hematuria Fever, especially with chills Nausea and vomiting Severe vomiting, very high fever or continuous pain might mean that you [home-remedies-for-you.com]

• Chronic Infection

  Renal failure Ureteral stricture Urine extravasation Perinephric abscess Xanthogranulomatous pyelonephritis Xanthogranulomatous pyelonephritis is an unusual suppurative granulomatous reaction to chronic infection, often in the presence of chronic obstruction [rcemlearning.co.uk]

  Staghorn renal calculi, which are frequently the result of, and a persistent focus for, chronic infection are clearly associated with renal damage. 30 These large stones should be treated when they are detected. [aafp.org]

• Recurrent Infection

  This extra step is probably unnecessary for most patients with recurrent infections, but for the more resistant or severe cases, it may be very helpful. [web.archive.org]

• Vomiting

  Opioids are associated with a higher incidence of adverse events, particularly vomiting. [ncbi.nlm.nih.gov]

  Background Kidney stones Investigations Differential Dx Management Colic policy MUH Pregnancy Links Background The average lifetime risk of stone formation is 5-10% Acute colic usually characteristic loin (to groin) pain ± vomiting ±fever If fever >38.0 [emed.ie]

  It is usually accompanied by general symptoms, sweating, nausea and/or vomiting and, frequently, fever. [urologiaserrateribal.com]

  While narcotics themselves can cause nausea, and parenteral ketorolac does not, the nausea and vomiting usually abate when the pain is controlled. [journals.lww.com]

• Nausea

  CONCLUSIONS: Using lidocaine may be recommended as an effective, safe, and inexpensive adjuvant to morphine in improving nausea and reducing the time needed to achieve pain and nausea relief in patients visiting the ED with acute RC. [ncbi.nlm.nih.gov]

  Administer I.V. 0.9% sodium chloride solution, an opiate for pain control, and ondansetron for nausea, as prescribed. [journals.lww.com]

  It is usually accompanied by general symptoms, sweating, nausea and/or vomiting and, frequently, fever. [urologiaserrateribal.com]

• Abdominal Pain

  METHODS: A total of 215 patients who presented with abdominal pain and who were histopathologically diagnosed as AA, and 200 patients who presented with abdominal pain and who were diagnosed as renal colic were included into the study. [ncbi.nlm.nih.gov]

  A statement on the website continued: “Leo Messi will not be playing after waking up on Thursday morning with renal colic, a type of abdominal pain commonly caused by kidney stones. [theguardian.com]

• Right Flank Pain

  A 31 year old man with prosthetic aortic valve replacement presented with sudden onset of colic right flank pain. Analysis of the urine revealed haematuria, and the international normalised ratio was suboptimal. [ncbi.nlm.nih.gov]

  Cases Journal volume 2, Article number: 8225 (2009) Cite this article Abstract A 26-year-old female presented with a two-week history of right flank pain. [casesjournal.biomedcentral.com]

  Obstructing stone at the right ureterovesical junction in a 26-year-old woman with right flank pain. [pubs.rsna.org]

• Acute Abdomen

  abdomen) 중증 복통(Severe abdominal pain) (국소적, localized) (전반적, generalized) (복경직 동반, with abdominal rigidity) R10.1 상복부에 국한된 동통(Pain localized to upper abdomen) 상복부 통(Epigastric pain) R10.2 골반 및 회음부 동통(Pelvic and perineal pain) R10.3 기타 하복부에 국한된 동통(Pain [dic.impact.pe.kr]

  Table 1: Differential Diagnosis of Acute Renal Colic in Adults Renal or ureteral stone Hydronephrosis (ureteropelvic junction obstruction, sloughed papilla) Bacterial cystitis or pyleonephritis Lobar Pnemonia Rib fractures Acute abdomen (bowel, biliary [auanet.org]

  It is now believed to be a relatively common clinical entity that is frequently misdiagnosed initially as acute renal colic, pyelonephritis, or acute abdomen. Acute renal infarction affects both kidneys and both sexes equally. [web.archive.org]

  Unstable trauma patients should receive a FAST and surgical exploration of the abdomen. [emdocs.net]

• Flushing

  They are usually flushed out of the kidney but can stay in there for years and may grow bigger. The pain is caused when your body tries to get rid of the stone(s) through the ureter. [imagingpathways.health.wa.gov.au]

  You may be instructed to increase your water intake to help flush out small stones. Pain is controlled with medications. Certain types of stones can be dissolved with medication. [kidneystoneclinic.com.au]

  Drink liquids as directed to help decrease pain and flush blockages from your urinary tract. Ask how much liquid to drink each day and which liquids are best for you. You may need to drink about 3 liters (12 glasses) of liquids each day. [drugs.com]

  Drinking more fluid may not always improve renal colic or help flush stones out of the urinary tract, but it will, at least, prevent dehydration. [medicalnewstoday.com]

• Back Pain

  pain. patient history, physical exam can provide valuable clues to the cause of back pain. [newyorkurologyspecialists.com]

  […] type - code to pain by site, such as: abdomen pain ( R10.- ) back pain ( M54.9 ) breast pain ( N64.4 ) chest pain ( R07.1- R07.9 ) ear pain ( H92.0- ) eye pain ( H57.1 ) headache ( R51 ) joint pain ( M25.5- ) limb pain ( M79.6- ) lumbar region pain [icd10data.com]

  Indications -Amavata (Rheumatism), Prishta shoola (Back pain), Sandhi shoola (Joint pain) Dosage -10 ml in 50 ml of water twice daily, empty stomach / as directed by the physician. [indiamart.com]

  However, evidence from other studies shows that subcutaneous infiltration of water relieved renal colic, myofascial pain, and back pain during labor. 8,9 Subcutaneous field block for treatment of renal colic, as used in this patient, was described in [anesthesiology.pubs.asahq.org]

• Low Back Pain

  Renal colic is pain in right or left lower abdomen or low back pain due to disease in the kidney, ureter or bladder. Causes of Renal Colic. Renal stones are main reason for renal colic.. [specialityclinic.com]

  Acta Anaesthesiol Scand 1991; 35: 52–3Byrn, C Borenstein, P Linder, LE Labrecque M, Nouwen A, Bergeron M, Rancourt JF: A randomized controlled trial of nonpharmacologic approaches for relief of low back pain during labor. [anesthesiology.pubs.asahq.org]

  Efficacy and tolerability of paracetamol/tramadol (325 mg/37.5 mg) combination treatment compared with tramadol (50 mg) monotherapy in patients with subacute low back pain: a multicenter, randomized, double-blind, parallel-group, 10-day treatment study [numonthly.com]

• Flank Pain

  We sought to examine the validity of this score in younger, noninfected flank pain patients. [ncbi.nlm.nih.gov]

  Closed-loop bowel obstruction in a 70-year-old man with left flank pain. [pubs.rsna.org]

  Only a controlled trial to eliminate the stone and look for pain relief would confirm the association between small renal stones and flank pain. [ajronline.org]

• Dysuria

  […] relieved) Known solitary kidney Co-existent UTI Transplant kidney Discharge instructions Outpatient CT in one week and GP review of CT Prophylactic indomethacin or panadeine forte for 5 days Strain urine and save stone for analysis Return if fever or dysuria [emedsa.org.au]

  • AssociatedAssociated Hematuria, urinary frequency, dysuria, fever, sweating, nausea & vomiting. 5. [slideshare.net]

  […] the urinary bladder, “shooting” pains may be felt in the scrotum (men) or labia (women) and associated with the following additional symptoms: Frequency of urination Urgency (perceived need to urinate, although the urinary bladder is relatively empty) Dysuria [sharecare.com]

  Mutrakrichra, Vrikka roga (Diseases of kidney), problems related to kidney, nephritis, Mootrashmari (Urinary calculi), Dysuria, Urethritis, Uraemia, UTI Dosage -10 ml in 100 ml of water twice daily, empty stomach / as directed by the physician. [indiamart.com]

• Flank Pain Radiating to the Groin

  Clinical Scenario A 24 year old male presents to the emergency department with sudden onset of right flank pain radiating to the groin. A clinical diagnosis of renal colic is made. However, the patient is allergic to opioids. [bestbets.org]

  Clinical Presentation The classic presentation of a renal stone is acute, colicky flank pain radiating to the groin or scrotum, often associated with nausea and vomiting. [auanet.org]

  Upper ureter and renal pelvis: Pain from upper ureteral stones tends to radiate to the flank and lumbar areas. [web.archive.org]

• Stroke

  The age of PRBCs in transfusion The usefulness of lidocaine in renal colic The utility of oxygen therapy in Stroke ...Read More January 16, 2017 Alpha Blockers in Renal Colic: A Systematic Review Written by Anand Swaminathan REBEL EM Background: Ureteric [rebelem.com]

  […] are mostly asymptomatic.1 However sickle cell crisis can occur if the patient is exposed to hypoxic conditions, high altitude and intense physical exercise.1 Acute events include vaso-occlusive crises such as papillary necrosis of the kidney, ischemic stroke [revistanefrologia.com]

  Significant or unstable cardiovascular disease defined as: myocardial infarction or stroke less than 3 months prior to the study randomization planned revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass surgery [CABG] [clinicaltrials.gov]

  Researchers at the National Institute of Neurological Disorders and Stroke (NINDS) are working to better understand the process by which the immune system destroys or attacks the nerve insulating substance called myelin in autoimmune diseases or disorders [ninds.nih.gov]

• Agitation

  The patient will become pale, anxious and agitated and no position manages to relieve the pain. Urine usually remains normal in appearance, but can sometimes contain blood. [health.ccm.net]

  On ExaminationOn Examination • General examination: Agitated, in pain, pallor, fever, tachycardia. • Abdomen tense & rigid. • Loin tenderness. • Kidney enlargement. 13. [slideshare.net]

  I'm genuinely not sure if the commentator has ever seen Barca play. 10:44 13 min 'Big Phil' Scolari looking very agitated on the touchline. [telegraph.co.uk]

Patients with symptoms of renal colic should be investigated to determine the presence of the stone(s), to identify its location and to assess whether it is causing obstruction.

• Complete blood count: White blood count may be elevated in the presence of infection.
• 24-hour urine profile: The most common findings on 24-hour urine studies include hypercalciuria, hyperoxaluria, hyperuricosuria, hypocitraturia and low urinary volume.
• X-ray KUB: It is a very good initial investigation. The KUB film shows kidney, ureter and bladder. Over 90% of stones are radio-opaque so they are visible on plain X-ray. Calcium oxalate, struvite and phosphate stones are radio-opaque whereas uric acid stones are radiolucent.
• Ultrasonography: Majority of the stones can be diagnosed on ultrasonography.
• Intravenous urography: Renal function tests should be normal before performing intravenous urography. It provides the anatomical detail and functional status of the entire renal tract. If the renal function is disturbed, then intravenous urography should not be performed as contrast agent can further enhance renal injury. In such patients, renal function is assessed by measuring glomerular filtration rate via a 99Tc-DTPA renal scan.
• Non contrast enhanced helical CT KUB: This is currently the imaging modality of choice for renal tract stones. It accurately picks up almost all types of radiolucent and radio-opaque stones anywhere in the renal tract [10] [11].
• Retrograde pyelography: It can be performed safely in patients allergic to intravenous contrast media. It shows both radiolucent and radio-opaque stones, ureteral kinks and structures that may not be visualized easily on other studies.

Since most stones pass spontaneously through the urinary tract, the urine should be sieved for a few days after an episode of colic in order to collect the calculus for analysis.

The immediate treatment of renal colic is represented by the use of analgesia and antiemetics. Renal colic is often unbearably painful and demands powerful analgesia. Diclofenac 100mg given orally is often very effective. It can be followed by an intramuscular injection of 10-20mg morphine. There are various options for the treatment depending upon size, site and composition of the stones.

• Observation: 90% of stones which are less than 5mm usually pass spontaneously. Analgesia, antibiotics and plenty of fluid (3litres/day) is all that are needed.
• Medical expulsive therapy: 70% of stones which are 6-8mm in diameter can pass with medication. Tamsulosin 0.4mg given once at night, in addition to analgesics, is prescribed to ease the passage of the stone.
• Extracorporeal shock wave lithotripsy: This is a non-surgical modality for the treatment of stones. In extracorporeal shock wave lithotripsy, the stone is focused and bombarded with shock waves of sufficient energy to disintegrate the stone into fragments. These small fragments are then passed down the ureter into bladder and then to exterior through urethra.
• Percutaneous nephrolithotomy: The indications for this procedure include staghorn calculi, stones greater than 2.5cm in size, and failed extracorporeal shock wave lithotripsy. The stone is visualized and fragmented using ultrasonic, pneumatic or laser lithoclasts. 
• Retrograde intrarenal surgery: This is an endoscopic modality of renal stone removal. 
• Open surgery: The indications for open surgery include very large and complex stones occupying many calyces, morbidly obese patients and failure of previous procedures. Pyelithotomy is performed by placing the patient in lateral position via Morrison’s incision.

Most renal stones are small (less than 5 mm in diameter) and pass spontaneously in up to 80% of the people. A stone that has not passed within 1 to 2 months usually require intervention. The recurrence rate for urinary calculi is 50% within 5 years and 70% or higher within 10 years. The factors that predispose to recurrent stone formation include first attack before 25 years of age, single functioning kidney and abnormalities of the renal tract. Early recognition and immediate surgical drainage improves the prognosis.

Renal colic is caused by a blockage in the urinary tract which is mainly due to stones in the kidney. When these stones interfere with the flow of urine, they cause the kidneys to swell, producing waves of colicky pain. Kidney stones that can lead to renal colic can be made up of a variety of chemicals. Calcium oxalate stones occur due to hypercalciuria and hypercalcemia which mostly occurs in primary hyperparathyroidism [1] [2] [3]. Uric acid stones occur due to gout and myeloproliferative disorders. Struvite stones are formed by infection caused by urease producing bacteria e.g. Proteus and Staphylococci [4] [5]. Various enzyme disorders can lead to the formation of cysteine and xanthine stones [6] [7].

A number of factors increase the risk of developing renal stones. These include dehydration, hot climate, low fluid intake, high protein and salt intake, diet high in vitamin A, diuretic overuse, intestinal obstruction, family history of kidney stones, use of calcium based antacids, pregnancy, recent surgery and urinary tract infection. The congenital and inherited causes of kidney stones include familial hypercalciuria, hyperoxaluria, medullary sponge kidney, cystinuria and renal tubular acidosis type 1.

Renal stone disease is common, affecting individuals of all countries and ethnic groups. In the United States, the prevalence is about 1.2%, with a lifetime risk of developing a renal stone at age 60-70 of about 7% in men. In some regions, the risk is higher, most notably in countries like Saudi Arabia, where the lifetime risk of developing a renal stone in men aged 60 to 70 is over 20%. The risk of recurrence of stone formation within 1 year is 10% and within 10 years might be as high as 50%. Black people have a lower incidence of stone development compared to white people. The male to female ratio is 3:1; however, females have a higher incidence of infected hydronephrosis. Nephrolithiasis is rare in children. Approximately 5 to 10 children aged 10 months to 16 years develop kidney stones each year.

Urinary calculi consist of aggregates of crystals, usually containing calcium or phosphate in combination with small amounts of proteins and glycoproteins. Renal stones vary greatly in size. There might be sand-like particles anywhere in the urinary tract, or large round stones in the bladder. These stones are formed by the phenomenon of supersaturation of the urine by stone-forming constituents, including calcium, oxalate and uric acid [8] [9]. The resulting calculi may lead to muscle spasm, increased proximal peristalsis, local inflammation, irritation and edema at the site of obstruction. They can contribute to the development of pain through chemoreceptor activation and stretching of submucosal free nerve endings. The severity of pain depends on the degree and site of the obstruction, not on the size of stone. Staghorn calculi fill the whole renal pelvis and branch into the calyces. They are usually associated with infection and composed largely of struvite. Deposits of calcium may be present throughout the renal parenchyma, giving rise to fine calcification within it, especially in patients with renal tubular acidosis, hyperparathyroidism, vitamin D intoxication and healed renal tuberculosis. Cortical nephrocalcinosis may occur in areas of cortical necrosis, typically after acute renal injury in pregnancy or other severe acute kidney injury. Another factor that leads to stone development is the formation of Randall’s plaques. Calcium oxalate precipitates on the basement membrane of the thin loops of Henle, resulting in Randall’s plaque and eventually a calculus.

Renal colic can be prevented by making a few lifestyle modifications. These include:

• Excess fluid intake: The patient is encouraged to drink plenty of fluids to help decrease pain and flush blockages from the urinary tract. An intake of more than 2.5 liters of liquids per day is usually advised. 
• Dietary modifications: Eating foods like okra, oysters and raw broccoli that contain rich doses of magnesium can help strengthen the immune system and reduce the incidence of urinary tract infections that lead to stone formation. Foods rich in oxalate, vitamin C, cereal fiber, high salts and fats should be avoided. Sulfur containing protein (egg, meat, fish) should be restricted in cystinuria.
• Medications: Drugs (such as thiazide diuretics, allopurinol and calcium citrate) are given to reduce the risk of stone formation according to the type of the stone. Idiopathic hypercalciuria is treated with bendroflumethiazide.
• Frequent urination: This keeps the level of toxins down and prevents the formation of kidney stones.

Renal colic is a severe type of abdominal pain caused by kidney stones. It typically begins in the abdomen and radiates to the hypochondrium or the groin. The pain is often constant and colicky in character due to ureteral peristalsis. It may be associated with fever, rigors, chills, nausea, vomiting and blood in urine. The pain is usually located on one side, but might be on both sides of lower back. Nephrolithiasis is more common at 20 to 50 years of age. These stones consist of crystals, usually containing calcium or phosphate in combination with small amounts of proteins. Successful management includes removal of the stone and prevention of recurrence.

Renal colic is a type of pain caused by kidney stones. The pain begins in abdomen and radiates to the groin. It is most common in men between 20 to 30 years of age. The patients usually present with severe pain, fever, nausea, vomiting and blood in the urine. With proper treatment and preventive measures, the disease has a very good prognosis.

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