Kidney and Ureteral Stones

K i d n e y an d U re t e r a l S t o n e s
Jill Corbo, MD, RDMS*, Jessica Wang, MD, RDMS
KEYWORDS
Renal colic Kidney stone Urolithiasis Nephrolithiasis
KEY POINTS
There are other conditions that present similar to renal colic with hematuria, that is,
abdominal aortic aneurysms.
Check the urine for infection as well as hematuria. An infection with complete obstruction
is a urologic emergency.
Patients being discharged with an obstructing stone should have close urology follow-up.
An obstruction delayed past 2 weeks will progressively worsen the renal outcome.
BACKGROUND
Urinary stone disease (USD) is a generic term that refers to the presence of stones
within the urinary tract, commonly known as kidney stones, urolithiasis, or nephroli-
thiasis. USD is a common disease with annual incidence of approximately 7 to 12
cases/10,000 per year in the United States.1 Its prevalence has steadily increased
in the recent decades with greater than 8% of US population presently being
affected.2 Based on the acute nature of presentation, kidney stones generate a large
volume of emergency department (ED) visits and hospital admission. The Healthcare
Cost and Utilization Project reported that in 2009 there were 1.3 million ED visits for
kidney stones with greater than 3600 ED visits for stones every day.1 Given the
frequent presentation of USD in the ED, it is essential for the emergency practitioner
to have the expertise in diagnosis and the management of this disease.
EPIDEMIOLOGY
The prevalence of USD is estimated to be 10% to 15% of the US population, with life-
time risk of stone formation exceeding 12% to 14% in men and 6% in women.2 There
is a high probability of recurrence with up to 50% experiencing a recurrence within
5 years.3 Its prevalence has doubled over the past 15 years, although it is growing
even more rapidly in historically lower-risk groups such as women, children, and Black
The authors do not have any commercial or financial conflicts of interest and funding sources.
Department of Emergency Medicine, Jacobi Medical Center, Building 6, Room 1B25, 1400
Pelham Parkway South, Bronx, NY 10461, USA
* Corresponding author.
E-mail address: Jill.Corbo@nbhn.net
Emerg Med Clin N Am 37 (2019) 637–648

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638 Corbo & Wang
patients.2 In women it has increased by 75% since 1994, and in Black patients it has
increased by greater than 120%.2 The frequency of USD in children, who are histori-
cally low risk, has increased by approximately 4% to 6% yearly, particularly among
adolescents,4 due to multifactorial reasons, which include increase in obesity and
changes in diet such as decrease in calcium and increase in fructose intake among
adolescents.
This upward trend is significant, resulting in ED visits of greater than 1.3
million annually, repeat ED visits of 11% after initial evaluation, and 20% of
the ED visits that result in hospitalization.5 This increase is associated with signifi-
cant economic burden. According to the Urologic Disease in America Project
funded by the National Institute of Diabetes and Digestive and Kidney Diseases,
the annual direct medical cost of USD in the United States is $10 billion, making
USD the most expensive urologic condition.6 The peak incidence occurs between
age 20 and 50 years, with male to female ratio of 3:1 and a recurrence rate of
approximately 30% in the first 5 years and approximately 50% recurrence rate in
10 years.2
Geographic variation has been found to be a risk factor for USD, which is thought
to be related to higher ambient temperature.7 A landmark study characterizing stone
formation in the United States using data from the Cancer Prevention Study II7 iden-
tified an increasing prevalence of USD in the United States moving from north to
south and west to east8 establishing the concept of a “stone belt.” This is thought
to be related to the higher temperature. In fact, studies have demonstrated a corre-
lation of higher ambient month temperatures and the incidence of renal colic and
USD worldwide.9 Many have interpreted the stone belt maps to support the conclu-
sion that higher temperature is associated with an increase risk of stone disease
likely from insensible water loss (ie, from perspiration leading to dehydration, urine
concentration, and urine supersaturation).10 Others have postulated that in addition
to higher mean temperature, higher precipitation also contributes to the increased
risk of USD.11
RISK FACTORS
The risk factors for USD are influenced by urine composition, which can be affected by
many factors including dietary, systemic illness, and environment. Some are modifi-
able whereas others are not. Risk factors can be categorized into nondietary, dietary,
and urinary. See Box 1 for summary of risk factors.
Nondietary
Incidence of USD is 3 times more likely in men than in women and predominantly in
whites than in Black patients. The risk of USD is 2.5 times more likely if there is a family
history likely due to a genetic predisposition and similar environmental and dietary ex-
posures. Prior history of USD and systemic medical conditions such as diabetes,
obesity, gout, hypertension, chronic kidney disease, Crohn disease, hyperthyroidism,
primary hyperparathyroidism, sarcoidosis, and renal tubular acidosis have all been
implicated in increasing the risk of USD. Environmental exposures such as living in
warmer climates and certain occupations in which the individual works in higher tem-
perature have been proposed as risk factors for development of USD. This is thought
to be related to a combination of factors including insensible water loss from heat and
increased vitamin D exposure from living in warmer climates and low fluid intake due
to certain occupation’s lack of access to bathroom leading to lower urine volume and
a higher risk of stone formation.
Kidney and Ureteral Stones 639
Box 1
Risk factors of urinary stone disease
Nondietary
Male sex (3:1 to women)
White > Asian > Blacks
Prior history of USD
Family history
Systemic conditions: diabetes, obesity, gout, hypertension, chronic kidney disease, Crohn
disease, hyperthyroidism, primary hyperparathyroidism, sarcoidosis, renal tubular acidosis,
multiple myeloma
Environmental condition: warmer climate
Dietary
Low calcium diet
Low fluid intake
High sodium diet
High animal protein diet
High oxalate diet
Stone forming medications:
Medication stones: indinavir, triamterene, acyclovir
Promotes formation of calcium stones: loop diuretic, acetazolamide, theophylline,
glucocorticoids
Promotes uric acid stones: thiazide, salicylates, probenecid, allopurinol
Conditions that enhance enteric oxalate absorption often in the setting of malabsorption
such as patients with history of gastric bypass, bariatric surgery, and short bowel syndrome.
Urinary
Low urine volume
Urine concentration
Urine composition
Low urine pH
Hypercalciuria
Hyperoxaluria
Hypocitraturia
Dietary
The composition of urine is influenced by dietary intake and environment, and several
dietary factors have been implicated in the development of USD. Nutrients that have
been implicated include calcium, animal protein, oxalate, sodium, sucrose, magne-
sium, and potassium. Certain factors such as low fluid intake, low calcium diet, high
animal protein diet, and high sodium diet are known to contribute to the risk of
USD. In addition, the use of certain stone-forming medications also increases the
risk of stone formation.
Conditions that enhance enteric oxalate absorption often in the setting of malab-
sorption such as patients with history of gastric bypass, bariatric surgery, and short
bowel syndrome are discussed in the next section.
640 Corbo & Wang
Urinary
Urinary stone formation is intricately related to urine composition, low urine volume,
urine concentration, and urine pH. Conditions such as hypercalciuria, hyperoxaluria,
and hypocitraturia all increase urinary concentration of these ions and can cause stone
formation when the urine becomes supersaturated. The persistent low pH promotes
the precipitation of uric acid and is associated with the formation of uric acid stones.
CAUSE
There are 4 main types of urinary stones, with the majority (75%–90%) composed of
calcium oxalate, followed by uric acid (5%–20%), calcium phosphate (6%–13%), stru-
vite (2%–15%), and cystine (0.5–1).12 See Table 1 for stone types and composition.
The exact pathogenesis of stone formation is complex and involves both metabolic
and environmental factors. This pathogenesis is not entirely understood, but it is clear
that it is affected by urine composition.12 Stone formation usually starts in the kidney
and is due to urinary supersaturation with free ions (eg, calcium and oxalate in calcium
oxalate stones), and this leads to the formation of crystals.13 It is thought that the process
starts with the formation of a nucleus, which is a heterogeneous mixture of substances
such as uric acid, and this forms a nidus for nucleation, around which the stone grows.
Increased urinary ion excretion and decreased urine volume will favor stone formation.13
High urine flow rate will reduce supersaturation. However, despite similar degree of urine
saturation, stones form in some people whereas not in others, and this may be due to the
presence of promoters and inhibitors of crystallization in the urine.14
CLINICAL PRESENTATION
The classic presentation of kidney stone is an acute onset, severe unilateral flank pain
radiating to the ipsilateral groin; classically it starts at night. The pain is usually
Table 1
Stone composition and causes
Stone Composition Frequency (%) Causes

Calcium oxalate and 90 Hypercalciuria (high dietary sodium and protein,
calcium phosphate hypercalcemia)
Hyperuricosuria (high purine, high protein diet)
Hyperoxaluria (low dietary calcium, high oxalate
diet or oxalate absorption, genetic hyperoxaluria)
Hypocitraturia (chronic metabolic acidosis,
inflammatory bowel disease)
Struvite (magnesium- 2–15 Urine infection from urea-splitting bacteria (ie,
ammonium- Proteus, Klebsiella, Corynebacterium)
phosphate) Staghorn formation
High urine pH
Uric acid 5–20 Hyperuricosuria (gout)
Low urine pH
Radiolucent
Cystine w1 Cystinuria—autosomal recessive disorder of cystine,
ornithine, arginine, and lysine
Staghorn formation
Others <1% Medications (raltegravir, indinavir, triamterene)
Brener ZZ, Winchester JF, Salman H, et al. Nephrolithiasis: evaluation and management. Southern
Medical Journal. 2011;104(2):133-9.
episodic, lasting 20 to 60 minutes, and does not completely resolve before the next
wave of pain. The typical patient is usually writhing in distress and unable to find a
comfortable position. In contrast to the patient with acute abdomen, they do not lie
still. As the stone descend into the ureter, the pain may descend to the abdomen cor-
responding to the location of the stone with associated dysuria, urgency, and fre-
quency. Approximately 30% of patients will report hematuria.3 Patients will
experience nausea and vomiting due to the shared splanchnic innervations of the renal
capsule and intestine. Fever is not typically present, unless associated with infection.
There are several conditions that may mimic renal colic. Box 2 lists the most common.
EMERGENCY DEPARTMENT EVALUATION
The diagnosis of the USD includes a history and physical examination, evaluation of
patient’s risk factors and comorbid conditions, and the likelihood of an important alter-
nate diagnosis. Typically, laboratory evaluations are done, which include a complete
blood count, a metabolic panel to assess renal function, and urinalysis to assess for
the presence of hematuria and infection. Confirmatory imaging is not always neces-
sary. For example, in a patient with known history of kidney stones, with a typical pre-
sentation and low likelihood of an important alternate diagnosis or complications,
conservative management may be appropriate.
However, in patients with no prior history of USD and with high risk for complication
and alternate diagnosis, diagnostic imaging should be considered.
The development of a clinical prediction rule, the STONE score, aims to evaluate the
likelihood of uncomplicated ureteral stones and clinically important alternative diag-
nosis.15 This rule uses 5 objective criteria (gender, duration of pain, race, nausea/vom-
iting, and erythrocytes on urine dipstick) to categorize patients into low, moderate, and
high probability of having a ureteral stone. The total score is 0-13 and is divided into 3
groups: low-risk: 0-5, moderate-risk: 6-9, and high-risk: 10-13. This scoring system
attempts to predict the likelihood of uncomplicated ureteral stones and is inversely
associated with likelihood of an acutely important alternate diagnosis. This clinical
prediction rule has the potential to guide decision-making regarding diagnostic
Box 2
Differential diagnosis of renal colic
Abdominal aortic aneurysm

Acute myocardial Infarction
Pyelonephritis
Renal artery thrombosis and other renal diseases
Appendicitis
Diverticulitis
Intestinal obstruction
Pelvic and ovarian pathology such as cyst, torsion, ectopic pregnancy
Biliary colic
Herpes zoster
Testicular torsion
Incarcerated hernia
642 Corbo & Wang
imaging and treatment options. When this prediction rule15 was attempted to be exter-
nally validated, research found that the STONE score can aggregate patients into low-,
medium-, and high-risk groups but lacks the sensitivity (53%) to allow clinicians to
avoid obtaining a computed tomographic (CT) scan.16 Further investigation is war-
ranted regarding the utility of this prediction rule.
IMAGING MODALITIES
When a patient presents to the ED with suspected renal colic, there is no

consensus on which imaging modality should be obtained or even if imaging is
necessary in the ED. The pros to imaging a patient with suspected renal colic
include the following: confirm the diagnosis, obtain information about the stone
size and location, diagnose complications related to USD, and rule out any potential
disorders that mimic renal colic (see Box 2). Some physicians image every patient
who presents with suspected renal colic, others image only patients with first-time
stones. There is a consensus that imaging should be performed in any patient
whose abdominal aortic aneurysm is high in the differential. Some clinicians will
reserve CT for patients who do not improve with conservative therapy or if another
diagnosis is suspected.
CT of the abdomen and pelvis without contrast can be performed using low-
radiating dose scanning protocols or standard dose scanning protocols. CT of the
abdomen and pelvis without contrast using low-dose radiation scanning is the
preferred examination for most adults. It has the highest diagnostic accuracy for renal
and ureteral stones. It provides information on the stone size, location, and site of
obstruction. CT scan is also useful in determining alternate diagnosis. CT of the
abdomen and pelvis without contrast cannot evaluate kidney function. If low-dose ra-
diation CT scan is not available or if the patient has a weight of greater than 130 kg in
men and greater than 115 kg in women, then standard dose CT should be performed.
Low and standard CT scans have similar diagnostic accuracy with a sensitivity and
specificity of greater than 94% and greater than 97%, respectively.17 The role of intra-
venous contrast CT of the abdomen and pelvis does decrease the sensitivity of detect-
ing stones less than 3 mm. Of note, stones less than 3 mm have a greater than 85%
spontaneous passage rate making the absolute diagnosis of these stones debat-
able.18 The elderly population is the subgroup in whom the addition of intravenous
contrast may aid in the diagnosis when searching for alternative diagnosis.
Ultrasound of the kidney and bladder can help diagnose renal colic indirectly by
detecting hydronephrosis and the symmetry of the ureteral jets. Ultrasound can deter-
mine if a patient has unilateral or bilateral hydronephrosis and rarely can visualize pres-
ence of ureteral stones. This imaging modality is quick, noninvasive, and does not
expose the patient to radiation; therefore, it is the preferred imaging modality in the
pregnant patient. In addition, given the recurrent nature of USD, ultrasound should
be considered when considering cumulative lifetime exposure of radiation in these pa-
tients. The ultrasound has a low sensitivity (54%) and inability to size a stone accu-
rately.19 Thus, some clinicians will obtain a CT scan after performing an ultrasound,
either when an ultrasound is positive to confirm stone size and location in order to
formulate a treatment plan or when an ultrasound is negative to confirm the negative
test and to determine an alternate diagnosis. A recent multicenter trial with 2759 ED
patients presenting with suspected renal colic was randomized to CT scan of
abdomen and pelvis without contrast, ultrasound performed by the radiologist, or ul-
trasound performed in the ED by ED physician at the bedside.20 After the initial imag-
ing examination, the clinicians can order subsequent examinations at their own
discretion. The sensitivity of CT scan was 86%, ultrasound preformed by the radiolo-
gist was 57%, and ultrasound preformed by the ED physician was 54%. Physicians
ordered a CT scan 41% of the time after the initial test if the initial test was an ultra-
sound, whereas an ultrasound was ordered only 5% of the time after the initial test be-
ing a CT scan. There were no significant differences in high-risk diagnoses with
complications, adverse events, and hospitalizations between the 3 arms of the
study.20 Performing an ultrasound as the initial imaging test might decrease the
need to order an abdominal and pelvic CT scan and thus decrease the radiation expo-
sure to the patient.
The abdominal radiography at times has been used as an adjunct in the diagnosis of
managing patients with nephrolithiasis. The abdominal radiography cannot detect
hydronephrosis and has a sensitivity of 57% for stone detection and localization.21
The abdominal radiography is best when used in conjunction with ultrasound to eval-
uate progression of conservative therapy and interval stone growth.
An intravenous pyelography (IVP) involves radiographic imaging of the kidney, ure-
ters, and the bladder before and after intravenous contrast dye is administered. It can
diagnose hydronephrosis, evaluate renal function, and potentially show the position of
the stone. IVP has similar sensitivity to that of ultrasound. This examination generally is
not used as a first-line diagnostic imaging examination.
MRI of the abdomen and pelvis is seldom used for nephrolithiasis. MRI poorly de-
tects stones. Currently, MRI is used in nephrolithiasis in pregnant patients with hydro-
nephrosis on ultrasound. In these patients it can help determine the location of the
obstruction, while not subjecting these patients to radiation.
MANAGEMENT AND TREATMENT

Analgesia
Management of stone disease should be individualized as well as the decision to
consult a urologic specialist. When a patient presents with an acute stone episode,
one of the main goal is relief from pain. The pain that renal colic patients experience
is from an increase in collecting system pressure and urethral spasm, which is
modulated via prostaglandins. Because of this theory, nonsteroidal antiinflamma-
tory drugs (NSAIDs) have been the preferred drug for treatment of renal colic.
NSAIDs can decrease smooth muscle tone as well as inhibit prostaglandins.
NSAIDs should be avoided in patients with a history of a gastrointestinal bleed or
impaired renal function.22 Narcotics have also been found to be helpful in the treat-
ment of renal colic pain. Narcotics do not help with inhibiting prostaglandins, and in
fact some studies found that they increase ureteric muscle tone.23 Although the Eu-
ropean Association of Urology guidelines on urolithiasis recommend NSAIDs as the
first choice, many physicians use intravenous opioids as the first-line agents.24
There have been prospective trials that have shown that the combination of
morphine and ketorolac offer pain relief superior to either drug alone and decrease
the use of rescue analgesia.25 Cochrane reviewed the literature of these 2 treat-
ments for renal colic and found that there was equivalent level of analgesia with
a slightly higher side effect of vomiting and the need for rescue medication in the
opioid group.24 Lidocaine is an amide local anesthetic that blocks fast-voltage
gated sodium channels and thus prevents transmission of afferent pain signals.26
There was one clinical trial from Iran26 that found that lidocaine reduced pain inten-
sity better and more quickly when compared with morphine in renal colic patients.
Further studies need to be performed with the use of lidocaine for treatment of renal
colic.
644 Corbo & Wang
Hydration and Diuretics

Patients who are dehydrated from either vomiting or decrease in oral intake should
receive intravenous hydration. In theory, increase in fluid flow through the affected kid-
ney might expedite stone passage and thus improve the patient’s symptoms. Studies
have been preformed to prove this hypothesis by high-volume fluid hydration with or
without the addition of diuretics to increase urine output. The literature in fact does not
support the use of diuretics and high-volume fluid therapy in acute renal colic.27,28
Medical Expulsion Therapy

There have been several medical expulsion therapies (METs) that have increased the
passage rate of ureteral stones, which include alpha blockers, calcium channel
blockers, and antispasmodic agents.29 Treatments that increase stone passage
would benefit the patient by decreasing the need for interventional procedures. The
top 2 METs that have been studied for the treatment of renal colic are tamsulosin
(an alpha-adrenoceptor antagonist, a smooth muscle relaxant drug) and nifedipine
(a calcium channel blocker).30 A recent multicentre randomized placebo-controlled
study compared tamsulosin, nifedipine, or placebo and its effect on intervention for
stone clearance.27 Pickard’s study29 found similar rates of spontaneous stone
passage at 4 weeks and even 12 weeks with all 3 arms of the study. In 2018, a
meta-analysis of 67 trials showed a small benefit of alpha-blocker therapy with
stone passage than with a placebo control (relative risk 1.16, 95% confidence interval
1.07–1.25).31 A few studies showed a subgroup analysis in patients with larger stones
(5–10 mm); there was a higher rate of stone passage with tamsulosin compared with
placebo.32,33 Even though nifedipine has similar rate of passage to tamsulosin, the
rate of passage is slower in the nifedipine (28 days vs 14 days) and has more side ef-
fects (15% vs 4%).34 Thus, the use of MET in improving the passage of ureteral stones
needs further research. At this time, there is little downside in using tamsulosin in MET,
the cost of treatment is low, and there are few side effects.
Prognosis
Most patients who have a ureteral stone can be managed conservatively and dis-
charged home safely with pain management and observation because most of the
patients will pass the ureteral stone spontaneously. Factors that affect the sponta-
neous passage include stone size, stone location, and the degree of obstruction.
There is a progressive decrease in stone passage rate because the size of the stone
increases. Most stones less than 6 mm in diameter will pass spontaneously, whereas
stones greater than 9 mm are unlikely to pass spontaneously.23 Location of the stone
is also a factor in passage rate; approximately 50% of stones pass spontaneously
from the proximal ureter compared with 80% of stones at the ureterovesical
junction.23
Conservative management is appropriate if (1) there is no evidence of sepsis, (2)
there is normal renal function, (3) the ureteric stone is unilateral, (4) the contralateral
renal unit is normal, (5) it is able to tolerate PO, and (6) there is adequate pain control
with oral analgesia.24 If any of these criteria is not met, a urologic consultation should
be requested in the ED.
Patients should be discharged home with pain management and possibility of MET.
They should be instructed to strain his/her urine for a several days after discharge from
the ED so that the stone can be collected for analysis. This would help the physician
determine the stone composition and direct further preventive measures. Even though
stone composition is unknown when the patient is discharged from the ED, they
should be instructed to increase oral hydration, decrease animal protein consumption,

and decrease salt intake.
Patients should be instructed to return to the ED if he/she develops fever, intractable
pain, or vomiting or if the pain lasts longer than 2 weeks. Patients should be educated
that there is a high (50%) recurrent rate for renal stones.
Outpatient referral to an urologist should be individualized on a case by case basis.
In general, patients who have an increase in creatinine level or have a nonobstructing
stone with a concurrent urinary tract infection require close follow-up within the next
2 days. Those who have stones greater than 10 mm in size, recurrent renal stones,
or failed conservative outpatient management for passage of stones should be
referred to a urologist within 1 week.
Urology Consultation
Patients who are not able to be treated conservatively, due to having any one or
several criteria in Box 3, should consult an urologist in the ED for admission and
possible urgent intervention. Patients with an obstructing stone and urinary infection
should be admitted for intravenous antibiotics and decompression of the obstruction.
Patients with intractable vomiting should be admitted for intravenous hydration and
supportive care. As alike, patients with intractable pain who cannot be controlled on
oral agents should be admitted for supportive care. Patients with one functioning kid-
ney should also be admitted to the hospital.
COMPLICATIONS
Obstruction
Patients who have a ureteral stone obstruction should have relief of obstruction within
2 weeks. Studies have shown that time to relief of obstruction and the presence of
infection were the only significant predictors of outcome of long-term renal damage.35
If the obstruction was delayed past 2 weeks, renal outcome worsens progressively.
Thus, urologists can closely monitor patients with an obstruction that does not have
a concurrent infection, if they have a functioning contralateral kidney.
Infection
An infection in the presence of an obstructive stone is a urologic emergency. Antibi-
otics cannot be excreted unless there is relief of the obstruction. When there is a uri-
nary tract infection with a nonobstructing stone, patients can be treated with oral
antibiotics with close follow-up within 24 hours.
Box 3
Admission criteria
1. Urosepsis
2. Intractable vomiting
3. Infection with stone obstruction
4. Stone size greater than 15 mm
5. Bilateral obstruction.
6. Single kidney or transplanted kidney with an obstruction
7. Intractable pain
8. Significantly elevated creatinine level
646 Corbo & Wang
Stents
Patients with ureteral stents should be evaluated for obstruction, infection, and migra-
tion of the stents. This can be done by using abdominal and pelvic CT scan or a KUB
ultrasound. Such patients should consult a urologist for their management and
disposition.
SPECIAL CONCERNS
Pediatric
Stone disease in the pediatric population is uncommon, although its incidence is
increasing especially in teens. The presentation of children with stone disease differs
from that of an adult. Children usually present with a vague abdominal pain, not a
unilateral colicky flank pain. Gross hematuria is present in 14% to 33% of patients
and urinary tract infection affects 8% to 46% of stone pediatric patients.36 Ultra-
sound is the study of choice in the pediatric population due to concern over radiation
exposure. Indications for admission are the same as for the adults. All children
should be referred to a urologist and a work-up for metabolic stone disease should
be performed.
Pregnancy
There are anatomic and pathophysiologic changes in pregnancy that increase the
risk of renal colic. There is urinary stasis secondary to compression and increase
in progesterone levels. There is also hypercalciuria secondary to calcium supplemen-
tation and increase in glomerular rate. The renal ultrasound is the study of choice in
pregnant patients secondary to the radiation exposure of CT scan. Narcotics are
generally required for pain management because NSAIDs are contraindicated in
pregnancy. METs can be safely used in pregnancy. Indications for admission are
the same as for nonpregnant adults. Close follow-up with obstetrics as well as urol-
ogist is needed.
Geriatrics
The first important thing is to make the correct diagnosis. The differential diagnosis for
this patient population includes acute myocardial infarction and abdominal aortic
aneurysm. The average age of the first presentation for renal colic is 42 years, and it
is uncommon for this first presentation to occur in patients older than 60 years.37
Thus, if a patient older than 60 years presents with no history of USD with symptoms
that suggest renal colic, one must have high index of suspicion for an alternate diag-
nosis.37 The CT scan is the preferred imaging modality because it can evaluate both
the renal collecting system and the aorta as well as other possible alternate diagnoses.
The elderly population tend to have comorbid conditions and are on medications that
may preclude them from the standard pain management of USD. For example, in pa-
tients who have renal failure or peptic ulcer disease, the use of NSAIDs is
contraindicated.
REFERENCES
1. Foster G, Stocks C, Borofsky MS. Emergency Department Visits and Hospital Ad-
missions for Kidney Stone Disease, 2009: Statistical Brief #139. Healthcare Cost
and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency
for Healthcare Research and Quality (US); 2006–2012.
2. Scales CD, Smith AC, Hanley JM, et al. Urologic Diseases in America Project:
Prevalence of kidney stones in the United States. Eur Urol 2012;62:160–5.
3. Moe OW. Kidney stones: pathophysiology and medical management. Review.

Lancet 2006;367:333–44.
4. Tasian GE, Ross ME, Song L, et al. Annual incidence of nephrolithiasis among
children and adults in South Carolina from 1997 to 2012. Clin J Am Soc Nephrol
2017;11(3):488–96.
5. Pearle MS, Calhoun EA, Curhan GC. Urologic disease in American project: uro-
lithiasis. J Urol 2005;173:848–57.
6. Litwin MS, Saigal CS. Table 14-47: economic impact of urologic disease. NIH
Publication 12-7865. In: Litwin MS, Saigal CS, editors. Urologic diseases in Amer-
ica. Washington, DC: National Institute of Diabetes and Digestive and Kidney Dis-
ease, National Institute of Heatlth, Public Health Service, US Department of
Health and Human Services; 2012. p. 486.
7. Soucie JM, Thun MJ, CoatesRJ, et al. Demographic and geographic variability of
kidney stones in the United States. Kidney Int 1994;46:893–9.
8. Mandel NS, Mandel GS. Urinary tract stone disease in the United States veteran
population. I. Geographical frequency of occurrences. J Urol 1989;142:1513–5.
9. Geraghty RM, Proietti S, Traxer O, et al. Worldwide Impact of warmer seasons on
the incidence of renal colic and kidney stone disease: evidence from a system-
atic review of literature. J Endourol 2017;31:729–35.
10. Brinkowski TH, Lotan Y, Pearle MS. Limate-related increase in prevalence of uro-
lithiasis in the United States. Proc Natl Acad Sci U S A 2008;105:9841–6.
11. Dallas KB, Conti S, Liao JC, et al. Redefining the stone belt: Precipitation is asso-
ciated with increased risk of urinary stone disease. J Endourol 2017;31:1203–10.
12. Yu L, Yuntian C, Banghua L, et al. Epidemiology of urolithiasis in Asia. Asian J
Urol 2018;5(4):205–14.
13. Evan AP, Worcester EM, Coe FL, et al. Mechanisms of human kidney stone forma-
tion. Urolithiasis 2015;43(Suppl 1):19.
14. Fleisch H. Inhibitors and promoters of stone formation. Kidney Int 1978;13:
361–71.
15. Moore CL, Bomann S, Daniels B, et al. Derivation and validation of a clinical pre-
diction rule for uncomplicated ureteral stone- the STONE score: retrospective and
prospective observational cohort studies. BMJ 2014;348:g2191.
16. Wang R, Rodriguez R, Moghadassi M, et al. External validation of the STONE
score, a clinical prediction rule for ureteral stone: an observational multi-
institutional study. Ann Emerg Med 2016;67(4):423–32.
17. Poletti PA, Platon A, Rutschmann OT, et al. Low-dose versus standard-dose CT
protocol in patients with clinically suspected renal colic. AJR Am J Roentgenol
2007;188(4):927–33.
18. Coll DM, Varanelli MJ, Smith RC. Relationship of spontaneous passage of ureteral
calculi to stone size and location as revealed by unenhanced helical CT. AJR Am
J Roentgenol 2002;178:101.
19. Ganesan V, De S, Greene D, et al. Accuracy of ultrasonography for renal stone
detection and size determination: is it good enough for management decisions?
BJU Int 2017;119:464–9.
20. Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus computed to-
mography for suspected nephrolithiasis. N Engl J Med 2014;371:1100.
21. Fulgham PF, Assimos DG, Pearle MS, et al. Clinical effectiveness protocols for im-
aging in the management of ureteral calculous disease: AUA technology assess-
ment. J Urol 2003;189(4):1203–13.
648 Corbo & Wang
22. Safdar B, Degutis LC, Landry K, et al. Intravenous morphine plus ketorolac is su-
perior to either drug alone from treatment of acute renal colic. Ann Emerg Med
2006;48(2):173–81.
23. Cole RS, Fry CH, Shuttleworth KU. The action of the prostaglandins on isolated
human ureteric smooth muscle. Br J Urol 1988;61(1):19.
24. Turk C, Petrik A, Sarica K, et al. EAU guidelines on diagnosis and conservative
management of urolithiasis. Eur Urol 2016;69:468–74.
25. Holdgate A, Pollock T. Systematic review of the relative efficacy of nonsteroidal
anti-inflammatory drugs (NSAIDS) and opioids in the treatment of acute renal
colic. BMJ 2004;329(7473):1019.
26. Soleimanpour H, Hassanzadeh K, Vaezi H, et al. Effectiveness of intravenous
lidocaine versus intravenous morphine fro patients with renal colic in the emer-
gency department. BMC Urol 2012;12:13.
27. Worster AS, Bhanich Supapol W. Fluids and diuretics for acute ureteric colic. Co-
chrane Database Syst Rev 2012;(2):CD004926.
28. Kirschner J, Wilbur L. Do fluids facilitate stone passage in acute ureteral colic?
Ann Emerg Med 2013;62:36.
29. Pickard R, Starr K, MacLennan G, et al. Medical expulsive therapy in adults with
ureteric colic: a multicentre, randomized, placebo-controlled trial. Lancet 2015;
386:341.
30. Hollingsworth JM, Rogers MA, Kaufman SR, et al. Medical therapy to facilitate uri-
nary stone passage: a meta-analysis. Lancet 2006;368:1171–9.
31. Campschroer T, Zhu X, Vernooij RW, et al. Alpha-blockers as medical expulsive
therapy for ureteral stones. Cochrane Database Syst Rev 2018;(4):CD008509.
32. Ye Z, Zeng G, Yang H, et al. Efficacy and safety of Tamsulosin in medical expul-
sive therapy for distal ureteral stones with renal colic: a multicenter, randomized,
double-blind, placebo-controlled trial. Eur Urol 2017;73:385–91.
33. Wang RC, Smith-Bindman R, Whitaker E, et al. Effect of tamsulosin on stone pas-
sage for ureteral stones: a systematic review and meta-analysis. Ann Emerg Med
2017;69:353.
34. Cao D, Yang L, Liu L, et al. A comparison of nifedipine and tamsulosin as medical
expulsive therapy for the management of lower ureteral stones without. Sci Rep
2014;4:5254.
35. Lucarelli G, Ditonno P, Bettocchi C, et al. Delayed relief off ureteral obstruction is
implicated in the long-term development of renal damage and arterial hyperten-
sion in patients with unilateral ureteral injury. J Urol 2013;189:960–5.
36. Kokorowski PJ, Hubert K, Nelson CP. Evaluation of pediatric nephrolithiasis. In-
dian J Urol 2010;26(4):531–5.
37. Chauhan V, Eskin B, Allegra JR, et al. Effect of season, age, and gender on renal
colic incidence. Am J Emerg Med 2004;22:560–3.

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K i d n e y an d U re t e r a l S t o n e s

Jill Corbo, MD, RDMS*, Jessica Wang, MD, RDMS

Emerg Med Clin N Am 37 (2019) 637–648

Stone Composition Frequency (%) Causes

EMERGENCY DEPARTMENT EVALUATION

Abdominal aortic aneurysm

When a patient presents to the ED with suspected renal colic, there is no

MANAGEMENT AND TREATMENT

Hydration and Diuretics

Medical Expulsion Therapy

should be instructed to increase oral hydration, decrease animal protein consumption,

3. Moe OW. Kidney stones: pathophysiology and medical management. Review.

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