A 29-year-old man presents with severe unilateral abdominal pain originating in the left loin and radiating to the groin. The patient is restless and cannot lie still, and he is also complaining of marked nausea. His urine dipstick is positive for blood only.

1. What is the most likely diagnosis?
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This patient has renal colic. The term renal colic is generally used to describe an acute and severe loin pain caused by a urinary tract stone obstructing the flow of urine. However, a more clinically accurate term is ureteric colic as the pain usually arises from obstruction of the ureter.

Renal or ureteric colic typically presents with an abrupt onset of severe unilateral abdominal pain originating in the loin or flank and radiating to the labia in women or to the groin or testicle in men.

The pain typically:

  • Lasts minutes to hours and occurs in spasms, with intervals of no pain or a dull ache
  • Is often accompanied by nausea, vomiting, and haematuria.
  • Is usually described as the most severe pain experienced by the person (many women describe the pain as more intense than that of childbirth).

 

The person:

  • Is restless and cannot lie still (which helps to differentiate renal colic from peritonitis)
  • May have a history of previous episodes
  • May present with fever and sweats if a concomitant urinary infection is present
  • May complain of dysuria, urinary frequency, and straining, when the stone reaches the vesicoureteric junction (due to the stone irritating the detrusor muscle).

2. Which simple bedside test should be arranged to assist with your diagnosis?

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Where possible, perform urine dipstick testing to support the diagnosis of ureteric colic and to look for evidence of a urinary tract infection (UTI).

  • Check for haematuria – the presence of haematuria can support the diagnosis of renal or ureteric colic. However, specificity and positive predictive values are poor, and the absence of haematuria does not exclude a diagnosis but should prompt consideration for other causes of pain.
  • Check for nitrite and leucocyte esterase – the presence of nitrite (with or without leucocyte esterase) in the urine suggests infection.

3. What is the investigation of choice to confirm the diagnosis?

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The clinical diagnosis of acute renal or ureteric colic should be supported by appropriate imaging:

  • Non-contrast helical computed tomography has now replaced intravenous urography as the imaging method of choice, and experts recommend it as the definitive investigation
  • Other imaging procedures include plain abdominal X-ray of the kidney, ureters, and bladder; renal tract ultrasonography; magnetic resonance urography; and retrograde ureterography/ureteroscopy.

 

 Further reading:

NICE guidelines on the assessment and management of renal and ureteric stones

 

Header image used on licence from Shutterstock

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