Renal colic or kidney pain is one of the common complaints (symptom) in Urology patients. Renal colic can be confused with some diseases. To begin treatment, first of all, it is necessary to reveal the cause of the pain. Renal colic may be considered primarily in patients with a previous history of kidney stone reduction. However, the diagnosis still needs to be confirmed. Diagnosis of kidney pain is not very difficult. It is possible to make the diagnosis by questioning the patient, examination and radiological examinations. In this article, I will talk about the causes, diagnosis and treatment of renal colic.

What is renal colic?

Acute renal colic, or kidney pain, is a sudden onset of severe pain typically occurring in the lateral kidney region, radiating to the anterior abdominal wall and groin and testis. It usually occurs as a result of obstruction of the urinary tract with stones and obstruction of urine flow, and is often accompanied by nausea and vomiting.

Kidney pains are severe pains that occur mostly as a result of obstruction of the urinary canal (ureter) that carries urine from the kidney to the bladder. Unlike blunt pain, colic-style pain comes periodically, is usually accompanied by nausea and vomiting, and does not go away or relieve with rest. These periods of pain can last up to 20-60 minutes.

Renal colic pain is seen at a rate of 5-15% in the society. About 12% of men and 6% of women drop one or more stones in their lifetime and experience colic pain.

Renal colic often occurs due to stones in the three regions of the ureter, because the ureteral canal is narrow in these parts and the stones are easily obstructed and difficult to pass. These shadows;

• UPJ region
• The area where the ureter crosses with the iliac vessels at its mid-levels
• The part where the ureter enters the bladder (ureterovesical junction)

What is the mechanism of renal colic?

Renal colic occurs as a result of enlargement of the ureter and pelvis above the obstruction as a result of a stone in the ureteral canal blocking the canal. Colic pain is the result of contraction of the ureteral muscle, increased peristalsis of the ureter in the upper part of the obstruction as a result of the activation of ureteral signal transmission pathways, local inflammation due to stone, swelling in the kidney as a result of the expansion of the calyceal system in the inner part of the kidney, edema, irritation and stretching of the renal capsule. As a result of these events, tension receptors in the ureter, renal pelvis and renal capsule are stimulated and pain occurs.

There is not always a direct relationship between the severity of pain and the size of the stone. The pain is shorter in stones that completely close the ureteral canal, because in these cases, urinary drainage occurs with different compensation mechanisms. However, the pain is longer in patients with partial obstruction.

What are the causes and risk factors for renal colic?

The incidence of renal colic is not the same in everyone. Some risk factors increase the incidence of renal colic. These risk factors are:

• Dehydration:
• High dose vitamin D intake
• Overdose of diuretic use
• Having stones in the family
• Reducing kidney stones before
• Pregnancy
• Recent surgery
• Having a urinary tract infection
• Use of stomach medications containing calcium
• Excessive calcium excretion in the urine
• Diet rich in protein
• Some drugs
• Chrohn’s and Ulcerative colitis disease:
• Hyperparathyroidism

What diseases can be confused with renal colic?

Even without stone removal, people may experience kidney pain, or pain due to certain diseases may be confused with kidney pain. Any event that obstructs the ureteral canal, such as a blood clot or disease of neighboring organs, and the consequent obstruction of the ureteral canal can cause colic pain.

Many diseases can cause kidney pain and be confused with renal colic, but these are not acute renal colic as they are chronic events. These diseases are:

• Abdominal aortic aneurysm
• Angiomyolipoma
• Gallbladder and bile duct stones
• Iliac artery aneurysm
• Ovarian torsion in women
• Peritonitis
• Pyelonephritis
• Kidney cancer
• costochonritis
• Herpes Zoster
• Immediately after insertion or withdrawal of a double J catheter into the ureter
• Endometriosis in women
• Causes of external ureteral pressure
• Pains of neurological origin
• Pain arising from the musculoskeletal system
• Renal papillary necrosis
• Pains of pleural origin
• Pyelonephritis
• Reflected pain of other organs
• Kidney abscess, infarction
• Renal vein thrombosis
• Retroperitoneal fibrosis
• Kidney bleeding
• Ureteral strictures
• UPJ stenosis
• After ureteroscopic examinations
• Upper urinary tract infections
• Ectopic pregnancy
• Ovarian torsion
• Masses in the tubes in women
• Testicular torsion
• Testicular cancer
• Testicular infections (orchitis)
• acute aortic syndrome
• Kidney infarction
• Spleen infarction
• Bowel obstruction
• Diverticulitis
• appendicitis
• Acute bowel ischemia
• pneumonia
• Pulmonary embolism
• Retroperitoneal bleeding
• Iliopsoas abscess

What are the symptoms of renal colic?

There may be other clinical accompanying complaints in colic patients. These can sometimes be confused with diseases of the gastrointestinal tract. Common symptoms (symptoms) in patients with renal colic are:

• Flank pain: Patients with colic may have severe pain on the ipsilateral side, kidney area, ribs and lower chest. Sometimes these pains can spread to the abdomen and groin.
• Nausea and vomiting: Nausea and vomiting are often accompanied by colic pain. This is because there is a connection between the urinary system and the digestive system (gastrointestinal tract) nerves.
• Dysuria: Often, patients with colic experience burning during urination, this is related to the cause of the disease.
• Hematuria: There may be microscopic or macroscopic bleeding from the urine. In other words, bleeding that can be seen or seen in microscopic examination can be found together with colic.
• Cloudy urine: If there is an infection in the urinary tract, then the urine may be cloudy in patients with colic pains.
• Crystalluria: There may be crystals in the urine. Visible on microscopic examination. They are mostly calcium oxalate crystals.
• Urinary habits may change: Urinary complaints such as sudden urination and the need to urinate frequently may be seen depending on the underlying disease.
• Fever, chills and chills: In these cases, infection of the kidney parenchyma should be considered. These patients require urgent hospitalization and antibiotic treatment.
• Pollakuria, polyuria: There may be frequent urination and excessive urination.
• Globe vesica: It is the inability to urinate in patients. In older men, an enlarged prostate (BPH) may be a stone blocking the urethra.

What are the complications of renal colic?

If renal colic is not diagnosed early and on time and appropriate treatment is not done, it may cause some complications. These complications are;

• Treatment-related complications
• Inability to urinate
• Kidney damage
• Loss of kidney function
• Repetition of stones
• Urinary tract infections

When should the doctor be called?

It is not right for patients suffering from severe kidney pain to use painkillers at home without a doctor’s advice and prescription, and not to go to the hospital. In the following situations, patients suffering from kidney pain should definitely apply to the nearest hospital, Urology clinic.

• If there is ongoing and non-stop nausea and vomiting
• If bleeding continues in the urine
• No or very little urination
• If there is pain that does not improve with medications
• If there is a persistent high fever
• If you urinate more often than usual

Is it possible to prevent renal colic?

As with any disease, it is possible to be protected from kidney pain. Generally, patients with previous colic and stone removal were informed about prevention. In order to prevent renal colic or to prevent it from reoccurring later, we recommend our patients to follow our recommendations;

• Increasing daily water intake: It is important for those living in hot regions to increase their fluid intake. Patients who pass stones should consume at least 2.5-3 liters of fluid per day.
• Salt restriction: It is important for patients with kidney stones to limit their daily salt intake and eat a diet low in salt.
• Restricting animal protein intake: Stone formation is common in people who are fed a diet rich in animal protein. Feeding patients with stone loss with a diet low in animal protein reduces stone formation.
• Calcium restriction is not correct: Calcium restriction is not correct in patients who pass kidney stones, but if these patients are taking excessive calcium, they should decrease to normal levels.
• Avoiding the use of drugs containing calcium: Medicines containing excessive calcium are not suitable for stone patients. These drugs increase the formation of crystals in the urine and ultimately the formation of stones and colic.
• Avoiding oxalate-containing diets: It is important that patients who have oxalate stones do not consume too much oxalate in their diet.

How is renal colic treated?

Renal colic causes severe pain. In this regard, it is an emergency situation and the patient’s pain should be relieved as soon as possible. Before starting painkillers for a patient who comes to the emergency room with pain, the cause of the pain must be revealed. Because pain is not a disease, but a symptom of many diseases. In a patient who comes to us with pain, we start the treatment after definitively demonstrating that the cause of the pain is renal colic. Drugs that can be given for early pain relief in renal colic patients;

• NSAIDs
• Opiate group pain relievers
• Lidocaine (iv)
• Painkillers
• Drugs used in the treatment of colic

Apart from these pain relievers, drugs that can help the stone pass or prevent the formation of stones can be given in stone patients. These treatments are started after the emergency situation of the patients is relieved and they are used after discharge.

• Allopurinol
• Alpha blockers
• Antibiotics
• Treatment against cystine stones
• Diuretics
• Potassium citrate or sodium bicarbonate regulates the pH of the urine and prevents stone formation.

Note: A very important point to be considered when using painkillers in the treatment of renal colic; Aspirin is not used as a pain reliever. Because in these patients, if urgent surgical intervention is required, surgery cannot be performed because aspirin will increase bleeding.

Stone treatment can be done under normal conditions after the patients’ pain is relieved immediately. Today, stone surgery is mostly performed with closed methods (8 endoscopic). Open surgery is almost nonexistent. Endoscopic or minimally invasive stone treatment methods that we frequently use are as follows;

• ESWL: Breaking of stones with external shock waves
• Ureterorenoscope (URS): Breaking the stone by entering the urinary canal with the closed method
• Percutaneous nephrolithotomy (PCNL, PNL): Breaking the stone by making a 1 cm incision from the body with the closed method.
• Ureteral stent (ureteral catheter): stent placement in the ureter after stone fracture (double J stent). Sometimes these stents are placed temporarily in women who are pregnant and therefore cannot be operated on, and appropriate surgical/endoscopic procedure is performed after delivery.

Early surgical or endoscopic intervention is required in patients with ureteral colic in the following situations;

• Having a stone larger than 9 mm
• Large stone density (greater than 700 Hounsfield units)
• Having a stone of 0.2 cc and above
• Ureteral wall thickness of 2 mm or more
• Having an extrarenal pelvis
• Anteroposterior diameter of the renal pelvis 18 mm or more

In summary; Renal colic is a serious pain that usually occurs as a result of stone obstruction of the ureteral canal, accompanied by nausea and vomiting, and requires urgent treatment. After the diagnosis is made, the patient’s pain is relieved and then, under normal conditions, definitive treatment is given for stones or other causes.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY