Renal Colic in the ED - Disposition

Many patients can be managed as short stay patients in ED (or SSW) for analgesia and imaging as necessary. The following patients will require admission and should be discussed with the urology team on-call as soon as analgesia and initial investigations are complete:

• Evidence of associated UTI (infected obstruction)
• Recurrent or unremitting pain
• Obstruction of single kidney
• Acute renal impairment

In addition, calculi >7mm are less likely to pass and should be discussed with urology regarding management.

Patients can be discharged from the ED if pain is controlled, diagnosis is reasonably secure, and they do not fit any of the categories above.

All patients discharged prior to CTKUB should have one arranged within 48 hours either via referral from ED or via their GP.

Patients with confirmed stone should be considered for urologist referral. Instructions should be given to sieve the urine and retain any calculi for biochemical analysis.

Patients should be discharged with 48 hours of regular NSAIDs and paracetamol. Pain not responding to oral analgesics, or a change in symptoms (eg fever) should prompt a return to ED.

Medical Expulsion Therapy (MET) for calculi may have some benefit. Calcium channel blockers and alpha blockers have been used for this purpose. Tamsulosin is a selective alpha-1 adrenoceptor blocker may be of benefit in selected patient groups( see links to recent papers and discussion on this topic on What's New section). Patients with large(>10mm) stones generally will require lithotripsy or surgical extraction and those with smaller stones (<4mm) do not benefit from MET.

Indications for tamsulosin for MET:

• Lower ureteric calculi
• No evidence of UTI
• Stone 4-10mm

Adverse effects:

• Postural hypotension
• Priapism

Contraindications:

• Severe liver/renal disease
• Orthostatic hypotension
• Other alpha blocking medication.

Patients should be given first tablet in ED then discharged to take 1 tablet daily for a further 6 days.

Further References and Resources

• Tamsulosin Facilitates Passage of Ureteral Stones 4–10 mm in Size - Daniel J Pallin MD MPH reviewing Wang RC et al. Ann Emerg Med, 8 September 2016.