Investigations for a patient coming woth loin to groin pain and management
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I have comprehensive content from Rosen's Emergency Medicine covering investigations and management of ureteric colic. I also have the surgical management from Campbell-Walsh Urology. Now I have enough to give a complete, well-referenced answer.
Loin to Groin Pain — Investigations & Management
Loin to groin pain is the hallmark presentation of ureteric colic (urolithiasis/renal calculi). The pain follows the path of the ureter from the renal angle to the groin (and often radiates to the ipsilateral testis/labia).
Differential Diagnosis to Consider
Before assuming ureteric colic, always consider:
- Ureteric/renal calculus (most common)
- Leaking/ruptured abdominal aortic aneurysm (AAA) — life-threatening mimic
- Pyelonephritis / perinephric abscess
- Renal infarction
- Appendicitis / ovarian pathology (right side)
- Psoas abscess
- Retroperitoneal pathology
Investigations
Bedside / Urine
| Test | Rationale |
|---|---|
| Urine dipstick | Haematuria (microscopic or macroscopic) supports calculus; absence does not exclude it. Nitrites/leucocytes suggest concurrent UTI |
| Urine microscopy & culture | Identify infection, crystalluria (oxalate, uric acid crystals); culture if dipstick positive |
| Urine pH | Alkaline urine → struvite/phosphate stones; acidic urine → uric acid stones |
| Pregnancy test (women) | Mandatory before imaging; ectopic pregnancy is a key mimic |
Blood Tests
| Test | Rationale |
|---|---|
| FBC (CBC) | Leukocytosis suggests infection/pyelonephritis; guides admission decision |
| U&E / Creatinine | Assess renal function; obstructive uropathy may raise creatinine |
| Serum calcium, phosphate, urate | Screen for metabolic causes (hyperparathyroidism, gout) |
| PTH | If hypercalcaemia detected |
| Coagulation screen | If intervention anticipated |
| Blood cultures | If sepsis suspected with obstructing stone — a urological emergency |
Imaging
1. Non-contrast CT KUB (CT urogram)
- Investigation of choice — sensitivity ~97%, specificity ~96%
- Identifies stone size, number, and location
- Detects complications: hydronephrosis, perinephric stranding, ureteric obstruction
- Identifies alternative diagnoses (AAA, appendicitis)
- Preferred over IVU in most centres
2. Ultrasound (renal tract)
- First-line in pregnancy and children (no radiation)
- Detects hydronephrosis and larger stones; misses small ureteric stones
- Useful for follow-up of known calculi
3. Plain X-ray (KUB)
- Detects radio-opaque stones (calcium oxalate, calcium phosphate, struvite) — ~60% of stones visible
- Uric acid stones are radiolucent — not visible on KUB
- Useful for monitoring stone passage
4. Intravenous Urography (IVU/IVP)
- Now largely superseded by CT KUB
- Shows site of obstruction ("standing column" of contrast)
— Rosen's Emergency Medicine, p. 1396–1400 | Campbell-Walsh Urology
Management
Immediate (Emergency Department)
Pain relief — PRIORITY:
- NSAIDs (e.g. diclofenac 75 mg IM/IV or PR) — first-line; reduce ureteric peristalsis and inflammation
- Opioids (e.g. morphine, pethidine IV/IM) — for severe pain or NSAID contraindication
- Combination analgesia if needed
- Antiemetics (metoclopramide, ondansetron) — nausea/vomiting are common
IV fluids:
- Correct dehydration; however, forced high-volume IV fluids do NOT accelerate stone passage
Alpha-1 blockers (Medical Expulsive Therapy — MET):
- Tamsulosin 0.4 mg OD — relaxes ureteric smooth muscle, facilitates passage of stones ≤10 mm, especially distal ureteric stones
- Evidence strongest for stones 5–10 mm
Indications for Urgent Admission / Urology Referral
Absolute indications for admission:
- Obstructing stone + signs of infection/sepsis → urological emergency (requires urgent drainage)
- Solitary kidney with obstruction
- Bilateral obstruction
- Intractable pain/vomiting not controlled in ED
- Urinary extravasation
- Hypercalcaemic crisis
Relative indications:
- High-grade obstruction
- Significant comorbidity
- Leukocytosis
- Intrinsic renal disease
— Rosen's Emergency Medicine, p. 1399
Definitive Management Based on Stone Size
| Stone Size | Likely Passage | Management |
|---|---|---|
| ≤4 mm | ~80% pass spontaneously | Conservative: hydration, analgesia, MET (tamsulosin), strain urine, follow-up |
| 5–10 mm | ~20–50% | MET (tamsulosin), close urological follow-up; consider intervention if not passed in 4–6 weeks |
| >10 mm | Unlikely to pass | Urological intervention required |
Surgical/Urological Interventions
1. Extracorporeal Shock Wave Lithotripsy (ESWL/SWL)
- Non-invasive; good for renal and proximal ureteric stones ≤20 mm
- Excellent safety profile; acceptable stone-free rates
2. Ureteroscopy + Laser Lithotripsy (URS)
- Endoscopic; preferred for ureteric stones
- Increasingly used for renal stones
- High stone-free rates with low morbidity
3. Percutaneous Nephrolithotomy (PCNL)
- Gold standard for large/complex/staghorn calculi (>20 mm, staghorn calculi)
- Higher stone-free rates for complex disease
4. Ureteric Stenting / Nephrostomy
- Temporising measure to relieve obstruction (especially with infection)
- Definitive treatment follows when patient stabilised
5. Laparoscopic/Robotic surgery
- Selected complex cases; open surgery now <1% of cases
— Campbell-Walsh Urology, p. 219–222
Prevention / Secondary Prophylaxis
After stone analysis and metabolic workup:
| Stone Type | Preventive Measure |
|---|---|
| Calcium oxalate (75%) | Increased fluid intake (>2.5 L/day), dietary oxalate restriction, thiazide diuretics, potassium citrate |
| Uric acid (10%) | Allopurinol, urinary alkalinisation (potassium citrate), reduce purine intake |
| Struvite (15%) | Treat underlying UTI; acetohydroxamic acid in selected cases |
| Calcium phosphate | Thiazides, avoid excess calcium supplementation |
Summary Algorithm
Loin-to-groin pain
↓
Exclude AAA (if >50 yr, pulsatile mass) → CT angiogram
↓
Urine dipstick + pregnancy test (females)
Blood: FBC, U&E, Ca²⁺, urate, CRP ± blood cultures
↓
CT KUB (non-contrast) — imaging of choice
↓
Stone confirmed?
├─ YES: Analgesia (NSAIDs ± opioids), antiemetics
│ ├─ ≤10 mm + no sepsis → MET (tamsulosin) + outpatient follow-up
│ └─ Sepsis / obstruction / solitary kidney → Urgent urology
└─ NO: Consider alternative diagnosis
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