Renal Colic
Blood in the urine or hernaturia is either microscopic or gross. It can originate from either the upper urinary tract or the lower tract. A cafreful history shoulkd be recorded. Examination should include a careful exam of the external genitalia, abdomen and flanks. Males also require a rectal exam. Urinalysis as well as culture and sensitivity should be obtained on all patients with hematuria. If there is significant protein in addition to blood in the urine, medical renal parenchymal disease is likely and a referral to a nephrologist may be more appropriate.
Microscopic hernaturia can originate from either the upper or lower tracts. These patients should undergo further investigation with either an IVP or ultrasound. They should have a urology consult. Cystoscopy will likely be done to further delineate the source of bleeding. Gross hernaturia requires a semi-urgent urology consult. The majority of patients with asymptornatic microscopic hernaturia will have no identifiable abnormality but the work-up is necessary in order to pick up the 5% with serious disease.
Kidney Stone Disease
There are 4 major types of stones:
Calcium oxalate/phosphate
- approx 85% of al
Uric acid
- Radiolucent
Struvite
- alkaline urine
- secondary to infection
Cysteine
- Rare
- Only 1% of stone
Renal Colic
- With acute colic, the patient usually sweating, tachycardic, tachypneic, and slightly hypertensive from the pain.
- If temperature above 38.0, superimposed infection is likely.
- The patient's urine should be dipped and examined under the microscope. A high urinary pH points to struvite stones.
- All patients will have microscopic haematuria as the stone scrapes its way down the ureter.
- A few WBC on microscopy is common and does not necessarily represent infection.
- Traet the pain with parenteral or rectal NSAIDs and / or opiates
- Blood work should be obtained to rule out infection and compromised renal function.
- Raised urea / creatinine are make presence of a stone much more significant
- Poor renal function also precludes the possibility of doing an IVP as the contrast dye may be nephrotoxic.
- It is also important to ensure that all diabetic patients are adequately hydrated prior to the IVP.
- The best investigations include an IVP or non-contrast CT. The contrast dye part of the IVP is important because it will uncover radiolucent stones (filling defects). The functional status of the kidneys and the degree of obstruction can also be seen.
Not all patients with stones need to be admitted to hospital. 80% of stones will pass spontaneously with conservative therapy.
If surgery is needed may take form of Open, ESWL or Endoscopy.
If the stone can be retrieved it should be sent for analysis. If the patient has a second stone, the urologist will usually do metabolic work up. Although each type of stone can be treated differently the easiest and often most effective treatment is to increase fluid intake significantly (8 -10 glasses a day).
Protocol for suspected renal colic in the emergency department MUH.
Diagnosis:
History, Physical examination, Dipstick urinalysis, vital signs, FBC, U+E, Creatinine, Urine microscopy (only if dipstick equivocal), KUB, CT-KUB
Indications for Urology review +/- admission – after the above, with a CT-confirmed stone (if CT KUB has been performed):
- Pain not controlled by oral analgesiaw
- Pyrexia or sepsis
- Abnormal U+E (Electrolyte Levels)
- Obstruction
- Solitary kidney
Decision regarding admission can then be made by Urology on-call. - For patients presenting out of hours (i.e. when CT-KUB not available) with a suspected stone, who are well enough to be discharged, ED staff should arrange CT KUB. This can be done on PACS.
- The Radiology Department will accept referrals from ED staff who should include the patient’s contact telephone number on the referral form.
- The patient will be issued with an appointment for a CT KUB within 48 hours unless at weekends when the it will by done on the following Monday or Tuesday
- The patient should proceed directly to the Radiology Department for the investigation and return to the ED immediately afterwards.
- If the scan is negative, they will be reviewed by the EM team.
- If the scan is positive, and there are no complications (as listed under ‘Indications for Urology Review’ above), the patient can be referred to Urology OPD. If being discharged from the ED without Urology review, patients’ notes should be forwarded to the Urology secretaries for OPD follow-up to be arranged
- If the scan is positive and there are complications, they must be referred to Urology who should review the patient promptly.
- Patients without diagnosis of renal stones will not be referred to the Urology OPD
Where a patient presents out of hours and a strong clinical suspicion of a stone exists but that patient is not fit for discharge, they should be admitted under the care of the Urology service, with a view to Urology arranging a CT-KUB at the next available opportunity.
Return attendances at the ED are for diagnostic reasons only, after the CT KUB has been performed. Once a stone is confirmed, their follow-up is exclusively with the Urology service, either as an inpatient or in the OPD. Patients with confirmed stones will then be formally “discharged” from the Urology service following either inpatient Urology admission or Urology OPD review.
* If patients with confirmed stones are being discharged from the ED, they should always be advised to return if they develop further pain, nausea and vomiting, fevers, rigors or diaphoresis (intense sweating).
