Ureteric colic

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Ureteric Colic

Definition and Pathophysiology

Ureteric colic is the acute pain syndrome that results when a calculus passes from the renal pelvis into the ureter, causing partial or complete ureteric obstruction. Despite the name "colic," the pain does not fully remit - it waxes and wanes rather than disappearing between episodes. The most common stones responsible are small 3-5 mm calculi, and they most frequently lodge at the three points of natural ureteric narrowing:

Pelviureteric junction (PUJ)
Pelvic brim (where the ureter crosses the iliac vessels)
Vesicoureteric junction (VUJ) - the most common site

National Kidney Foundation Primer on Kidney Diseases, 8e, p.470
Bailey and Love's Short Practice of Surgery, 28th Ed.

Clinical Features

Pain pattern (varies by stone location):

Upper ureter / PUJ - severe loin pain radiating to the ipsilateral iliac fossa, testis (men), or labium majus (women); nausea and reflex vomiting are common
Lower ureter crossing pelvic brim - can mimic appendicitis (right) or diverticulitis (left)
VUJ - urinary frequency, urgency, and dysuria mimicking acute cystitis
General: the patient is typically in obvious pain and cannot find a comfortable position (unlike peritonitis, where patients lie still)

Examination: Ipsilateral costovertebral angle (renal angle) tenderness; bowel sounds may be absent due to reflex paralytic ileus. Importantly, peritonism is absent in uncomplicated cases.

Investigations

Urine

Microscopic haematuria - present in the majority (but may be absent if obstruction is complete, as no urine flows through that ureter)
Pyuria - may be sterile or due to infection
Leukocytosis - suggests concurrent infection
Urine culture if infection or definitive surgery is planned
Pregnancy test in women of childbearing age (mandatory)

Blood

Usually normal; FBC, U&E, calcium, phosphate, uric acid
Leukocytosis may reflect stress or infection

Imaging

Modality	Role
Non-contrast CT (NCCT)	Gold standard - detects stones ≥1 mm, including radiolucent uric acid stones; shows secondary signs (hydronephrosis, hydroureter, perinephric fat stranding); reveals alternative diagnoses
Ultrasound	Good first-line test; shows hydronephrosis and calculi at kidney/proximal or distal ureter with echogenic foci + posterior acoustic shadowing; limited for mid-ureter (obscured by bowel gas) and small stones <5 mm
KUB plain film	Limited - misses radiolucent stones and stones overlying bone (e.g. sacrum); not adequate alone
IVU	Largely superseded; requires contrast, delayed films up to 8 hours; cannot give alternative diagnoses
MRI	Useful in pregnancy if ultrasound inconclusive; no radiation but expensive and slow

Non-contrast CT has a dose of approximately 2-3 mSv with low-dose technique (comparable to a limited IVU series). It is the investigation of choice.

Ultrasound image showing kidney stone (arrow) with posterior echo shadow:

Differential Diagnosis

Urinary tract causes:

Clot colic (anticoagulation, haemophilia, vascular tumours)
Papillary necrosis (diabetes, NSAIDs, sickle cell disease)

Other organs:

Acute appendicitis
Ectopic pregnancy
Ovarian torsion
Abdominal aortic aneurysm (AAA) - must be excluded, especially if pulsatile abdominal mass
Acute intestinal obstruction
Acute cholecystitis (right PUJ stone)
Herpes zoster
Duodenal ulcer
Musculoskeletal pain

Critical: AAA can mimic ureteric colic and is life-threatening. Always examine the abdomen for a pulsatile mass.

Management

Analgesia (first priority)

NSAIDs are preferred - diclofenac sodium, indomethacin (can be given per rectum), or parenteral ketorolac. They are effective and have fewer side effects than opioids
Paracetamol is also effective as adjunct analgesia
Opioids (pethidine, morphine) for refractory pain
Antispasmodics are not necessary

Hydration

Adequate (not excessive) hydration is encouraged

Medical Expulsive Therapy (MET)

Tamsulosin 0.4 mg once daily (alpha-1 adrenergic blocker) - causes smooth muscle relaxation of the distal ureter, facilitating stone passage
Indicated for distal ureteric stones 5-10 mm in diameter
Meta-analysis evidence supports its use for facilitating passage of this stone size

Conservative (Watchful Waiting)

Up to 95% of stones ≤5 mm pass spontaneously
Up to 90% of 4-mm stones and 50% of 6-10 mm stones pass spontaneously
Acceptable for asymptomatic small (<5 mm), non-obstructive lower pole calculi with preserved renal function

Indications for Emergency Urinary Decompression

These are urgent - drain first, treat stone later:

Obstruction with infection ("pus under pressure") - pyrexia, continuous loin pain, sepsis above an impacted stone - a true emergency; blood and urine cultures + broad-spectrum IV antibiotics + urgent decompression
Complete obstruction of a solitary functioning kidney
Bilateral complete ureteric obstruction
Perforation of the ureter (rare)

Decompression options:

Ureteric stenting (retrograde JJ stent)
Percutaneous nephrostomy (PCN)

If clinically unstable, admit to critical care for initial stabilisation before urological intervention.

Surgical Indications (Non-Emergency)

Timing	Indication
Early (prompt)	Stone >1 cm; persistent unremitting bouts of colic despite analgesia
Elective	Failure to pass after ~6 weeks of conservative management

Surgical Options

Ureteroscopy (URS) with laser lithotripsy - preferred for ureteric stones; also possible in select symptomatic patients as primary treatment even without infection
Extracorporeal Shockwave Lithotripsy (ESWL/SWL) - non-invasive; localises stone with fluoroscopy or US; acoustic shockwaves fragment the stone. Steinstrasse ("street of stones") is a complication where stone fragments line up in the ureter
Percutaneous nephrolithotomy (PCNL) - for large renal/upper ureteric stones

Metabolic Evaluation (After Acute Episode)

For stone recurrence prevention:

Urine pH and crystal analysis
Serum calcium, phosphate, uric acid - to exclude hypercalcaemia, hyperuricaemia
Urine culture if surgery planned
Detailed 24-hour urine metabolic workup for high-risk/recurrent stone formers

Stone composition (first-time formers):

~90% contain calcium (most commonly calcium oxalate)
Others: uric acid, cystine, struvite (magnesium ammonium phosphate)

Key Points Summary

Feature	Key Fact
Most common stone site	Vesicoureteric junction (VUJ)
Best imaging	Non-contrast CT KUB
First-line analgesia	NSAIDs (e.g. diclofenac)
MET drug	Tamsulosin 0.4 mg OD
Pass spontaneously	~95% of ≤5 mm stones
Emergency indication	Obstruction + infection ("pus under pressure")
Emergency decompression	Ureteric stenting or PCN

Sources: Bailey and Love's Short Practice of Surgery 28th Ed. | National Kidney Foundation Primer on Kidney Diseases 8e | Pye's Surgical Handicraft 22nd Ed.

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