Current European Recommendations for the Treatment of Renal Colic Due to Urolithiasis
At the annual congress in Milan in 2023, new recommendations from the European Association of Urology (EAU) for the acute treatment of patients with renal colic were presented. We summarize the key points concerning primarily analgesic treatment.
Renal Colic Due to Urolithiasis
Renal colic is a manifestation of urolithiasis, caused by the blockage of urine flow through the hollow system by a stone. It presents as spasmodic, recurrent abdominal pain that develops suddenly, often accompanied by vomiting or intestinal atony. Urolithiasis occurs in approximately 4% of the domestic population, twice as often in men. Effective pain management and prevention of its recurrence are crucial in the case of renal colic.
Acute Pain Management
The primary therapeutic step for patients with acute urolithiasis is to alleviate the pain. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as metamizole, paracetamol, or, depending on cardiovascular risk factors, diclofenac, indomethacin, or ibuprofen, are effective for pain management. NSAIDs have shown to be more effective than opioids and are therefore recommended as the first-choice drugs. Their administration reduces the likelihood of needing additional analgesia in the short term. Adding antispasmodics to NSAIDs does not provide additional benefit. Ibuprofen has a faster onset of action compared to ketorolac, with a similar safety profile. Greater pain relief has been described with i.m. diclofenac compared to i.v. ibuprofen and ketorolac. Long-term oral diclofenac increases the risk of cardiovascular events and gastrointestinal bleeding. Its administration in high cardiovascular risk patients should be carefully considered, and it should generally be given in the lowest effective dose for the shortest duration.
Opioids, especially pethidine, are associated with a higher risk of vomiting and the need for additional early analgesia compared to NSAIDs. They are recommended as second-choice drugs (e.g., hydromorphone, pentazocine, or tramadol). The analgesic effect of opioids for renal colic is increased by the addition of an NSAID.
In cases of renal colic, pain management should proceed in parallel with the diagnostic process. Medication-assisted expulsion therapy (MET) using alpha1-blockers may be effective in alleviating pain. However, the evidence is inconsistent.
If analgesia cannot be achieved medically, drainage, stenting, percutaneous nephrostomy, or ureteroscopic stone removal is indicated.
In cases of sepsis, immediate decompression with a ureteral stent or percutaneous drainage is recommended, followed by antibiotic treatment and postponed definitive stone treatment.
Prevention of Recurrence
Patients expected to pass stones spontaneously and without complications (e.g., those with newly diagnosed small stones < 5 mm) should have regular check-ups. NSAIDs in tablets or suppositories (e.g., diclofenac 100–150 mg/day for 3–10 days) are appropriate for reducing inflammation and recurrence of pain. NSAIDs may worsen renal function in individuals with pre-existing reduced glomerular filtration. However, they do not have this effect in patients with normal renal function.
For patients not indicated for active stone removal, medication-assisted expulsion therapy using alpha1-blockers may be considered, especially for distal stones larger than 5 mm. However, MET should be discontinued if complications such as infection, refractory pain, or worsening renal function develop.
Oral chemolysis is possible in patients with uric acid stones through urine alkalization (using alkaline citrate or sodium bicarbonate) combined with the alpha1-blocker tamsulosin.
Indications for ureteral stone removal include low likelihood of spontaneous passage, pain persisting despite adequate analgesic treatment, persistent obstruction, and renal insufficiency (renal failure, bilateral obstruction, solitary kidney). For distal and proximal stones > 10 mm, ureteroscopy (URS, antegrade or retrograde) is recommended, with extracorporeal shock wave lithotripsy (SWL) as the second option. URS is associated with a higher probability of stone removal in one procedure but also with a higher risk of complications. It should be the first choice for patients with severe obesity. For stones ≤ 10 mm, a choice between SWL and URS can be made. SWL is contraindicated in pregnancy, uncorrected bleeding disorders, uncontrolled urinary tract infections, skeletal deformities, severe obesity, and arterial aneurysm near the stone. For large renal stones, percutaneous nephrolithotomy is the standard treatment. Endourological treatment should always be accompanied by perioperative antibiotic prophylaxis.
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Source: Skolarikos A., Jung H., Neisius A. et al. EAU guidelines on urolithiasis. EAU's 38th Annual Congress, Milan, 2023 Mar 10–13. Available at: https://uroweb.org/guidelines/urolithiasis/chapter/guidelines
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