Renal colic. Where to run? What to grab onto?

Renal colic. Where to run? What to grab onto?

Quiet winter evening (spring, summer or autumn – as convenient), you came home from work, had dinner, drank a glass of your favorite beer and sat comfortably on the couch, focusing on watching TV. Suddenly, you feel discomfort in the lumbar region, which gradually turns into aching, and then into a sharp pain. You are trying to find the position of the body in which the pain will be less pronounced – the effect is zero. The pain does not subside, you begin to roll on the floor or bed. You are shaking, weakness, nausea, vomiting – there is no relief. The abdomen is swollen like a drum, the gases do not go away. There are repeated painful urges to urinate. What it is?! Bad beer?! Fermented cabbage?! No, friends, this is renal colic! What’s this? Like this? For what? What to do? Let’s figure it out.

Renal colic (RC) is a collective term, it includes several symptoms that indicate a violation of the outflow of urine. The pain that occurs in this case belongs to the category of the most intense and furious. It is almost impossible to endure, the patient may even fall into a state of shock. It must be understood that the appearance of an attack of pain is only a symptom, and a dangerous condition for the health and life of the patient. As a rule, the occurrence of RC indicates urolithiasis and is currently associated with the migration of stones from the calyx or pelvis of the kidney to the ureter.

Renal colic. Where to run? What to grab onto?

Mechanism of the occurrence of RC: as a result of a violation of the outflow of urine, intrarenal (intrapelvic, to be more precise) pressure increases – figuratively speaking, the kidney inflates like a balloon with water. The pressure of urine on the parenchyma of the kidney leads to a violation of the microcirculation in it, the development of edema. All this together affects the receptors of the sensory nerves of the gate and the fibrous capsule of the kidney, which have a small potential for extensibility, resulting in the occurrence of a characteristic pain attack.

Renal colic. Where to run? What to grab onto?

The incidence of RC in the population is 1-12%, with more than half of the cases occurring in the male half of the population. It should be noted that 13% of cases of the total number of patients with renal colic are due to other diseases of the kidneys and ureter (tumors, tuberculosis, hydronephrosis, urovasal conflict, retroperitoneal fibrosis) and are associated with the discharge of blood clots, pus, mucus that close the lumen of the urinary tract.

Renal colic is one of the most severe types of pain that requires urgent diagnosis and treatment. RC, as a rule, occurs suddenly after driving, shaking, drinking plenty of fluids, alcohol. The pains are so severe that patients rush about the room, constantly changing location and posture, which usually does not bring them relief. This characteristic behavior of the patient often makes it possible to establish a diagnosis “at a distance”.

Pain can radiate to the groin, genitals (scrotum, penis, vagina and labia), increase with urination. Depending on the location of the obstruction, false urges to defecate and urinate may occur. The body temperature may rise to subfebrile numbers (37.1 – 37.5 ° C), the heart rate decreases and blood pressure slightly increases. Urine acquires a pink or red color when a stone damages the wall of the ureter or the cavity of the kidney. Pain sometimes lasts for several hours and even days, periodically subsiding.

WHAT TO DO? WHEN YOU HAVE A RC, YOU SHOULD IMMEDIATELY CALL EMERGENCY!

But it usually takes a long time before the team arrives at the scene. This is not the fault of doctors: traffic congestion, weather conditions, schedule congestion and many other things can prevent you from quickly arriving on call. Therefore, the patient himself and his relatives need to be able to recognize the danger and know what can be taken at the peak of pain, and what can be harmful.

  • First aid for renal colic – ensuring complete rest for the patient, providing free space. Patients usually rush about in a fit of pain, cannot find a place for themselves, so it is important to create comfortable conditions for them
  • If the pain can be tolerated until the arrival of doctors, then it is better to do without painkillers so that it is easier to make a preliminary diagnosis
  • If the patient is a stone excretor, suffering from urolithiasis for a long time, and this is not the first attack of renal colic in his life, if there is no increase in body temperature, then you can try placing him in hot water. And pay attention to the fact that the water should be very hot, which only a person is able to withstand.

A hot bath is contraindicated for those patients (especially the elderly) who have serious cardiovascular diseases and who have suffered a stroke or heart attack. For such people, to provide first aid for renal colic, you need to use a hot heating pad placed on the lower back, or mustard plasters placed on the kidney area.

The patient can take 2-3 tablets of No-shpy (Drotaverine), a Ketanov tablet or something from antispasmodics (papaverine – 1 tablet). If possible, it is better to administer drugs intramuscularly (Ketorol, Baralgin), and not in the form of tablets – the effectiveness increases several times, the effect of the drug comes faster. In the absence of these drugs, you can use nitroglycerin (half a tablet under the tongue), which also relaxes the smooth muscle muscles and can relieve spasm of the ureter.

Non-steroidal anti-inflammatory drugs, in particular Diclofenac, effectively relieve pain – I consider intramuscular injection of 75 mg or rectal administration of a suppository at a dosage of 100 mg to be optimal. Before the arrival of the doctor, it is necessary to write down the medications taken, and control the urine for the passage of calculi (it is best to collect urine in a vessel). If the attack subsides, it is impossible to cancel the call of the medical team, since there is a risk of the attack returning (the stone, if the cause is in it, can move forward and then the spasm disappears).

It may not always be necessary and useful to use painkillers for RC. Manifestations of urolithiasis (UCD) may resemble symptoms of other diseases of the abdominal cavity and retroperitoneal space. It should be noted that the presence of urolithiasis does not exclude the possibility of developing another acute pathology (for example, appendicitis). Therefore, if the attack is atypical, it is better not to do anything until the doctor arrives.

Heat and antispasmodics can exacerbate infectious and inflammatory processes in the case of acute appendicitis or another disease from the group of pathologies with an “acute abdomen” clinic. That is why it is better to wait for an ambulance doctor, who will first of all need to exclude such manifestations of an acute abdomen as acute appendicitis, ectopic pregnancy, cholelithiasis, peptic ulcer, etc., which sometimes needs to be done together with doctors of other specialties.

If you have an ovarian cyst, you must immediately tell the ambulance team about it. Particular attention should be paid to a patient with renal colic, if it is a pregnant woman. Treatment of women with renal colic, and even in the “position”, should be carried out only in a hospital. Renal colic in pregnant women is very similar to contractions in the clinic, so it is important not to hesitate and immediately call specialists. Do not forget to immediately say that the patient is pregnant and how long she is, then the team will arrive faster because of the possible threat to the life of the mother and baby.

So, you were examined by an ambulance doctor, diagnosed with renal colic. What to do next?

If the drugs administered by the ambulance doctor did not bring relief, actively insist on your hospitalization in the emergency urology! It is not a fact that you have renal colic, everyone can be wrong, especially in The first aid kit of an ambulance doctor does not include a portable ultrasound machine and a biochemical laboratory. As a rule, urological hospitals are structural divisions of large medical institutions, where there is a surgical department, a gynecological department, etc. In this medical institution, you can be examined more qualitatively with the involvement of related specialists, as well as provide specialized assistance.

If you managed to relieve the pain syndrome, then don’t relax, the problem has not been solved yet! We are waiting for the morning. We woke up (if we managed to doze off), washed ourselves, shaved and go to the urologist!

I recommend contacting medical Centers, which, among other things, deal with the problems of treatment of urolithiasis.

What, first of all, you should pay attention to in the resume of the urologist you applied for an appointment with (you can get such information on the clinic website):

  • Does he own modern diagnostic methods (ultrasound, X-ray) of ICD
  • Clinical experience with minimally invasive and endoscopic treatment of KSD
  • The equipment of the clinic is the availability of equipment that meets modern European standards for the quality of care for patients with KSD (remote lithotripter, contact lithotripter, laparoscopic stand)

Renal colic. Where to run? What to grab onto?

In such a medical center, a urologist will determine the cause of the colic in a short time, assess the degree of risk, and develop an algorithm for your further examination and treatment. You need to understand that renal colic is only a symptom and more often it is a sign of “blockage” of the urinary tract.

Renal colic. Where to run? What to grab onto?

Obstruction of the upper urinary tract  is an extremely dangerous phenomenon in which it is important to eliminate its cause as soon as possible with the help of competent treatment. Otherwise, the patient’s condition will progressively worsen due to the addition of a secondary infection, an increase in the level of intoxication of the body, not to mention a constant and unbearable pain syndrome. In some cases, it is with the release of the upper urinary tract that treatment begins. Why do I focus on the timing of the start of treatment? In the first hours after the onset of an attack of renal colic, an infectious inflammatory process does not yet have time to develop in the kidney – the situation is “uncomplicated”.

As a polyclinic urologist usually does: using additional research methods, he determines the size of the calculus, the level of its localization, the degree of obstruction of the upper urinary tract, evaluates changes in urine and blood parameters and prescribes stone expelling therapy … Is this correct?

It is generally accepted in the urological environment that stones up to 7 mm in size are able to move away on their own (Glybochko P.V., 2012). Therefore, a standard scheme of stone expelling therapy is prescribed and everyone begins to wait for the patient to “give birth” to this vile stone. They wait a day, two, a week, a month, etc. And at this time, repeated attacks of renal colic may occur, which are accompanied by the above symptoms. Which urologist can specifically tell the patient when the stone will come out?

Renal colic. Where to run? What to grab onto?

After all, the diameter of the ureter in the narrowest part (intramural section) is 2-3 mm, and we kind of want a 5-7 mm stone to come out. Yes, in most cases, such stones come out on their own. But, the question is – how can a patient know that he will fall into the number of this happy “majority”, how long he should wait and suffer at the same time ?! According to foreign authors (Preminger GM., 2007, Miller OF., 1999), the probability of independent discharge of ureteral calculi with dimensions <5 mm is 68%, >5 mm – 47%. The terms of independent discharge of calculi with dimensions <2 mm average 31 days, 2-4 mm – 40 days, > 4-6 mm – 39 days, respectively. Think about these numbers!

Modern minimally invasive and less traumatic methods of treating urolithiasis have radically changed the mentality of a whole generation of urologists, a distinctive feature of the current essence of which is that, regardless of the size and location of the stone, as well as its “behavior”, the patient must and can be from him spared! And this is correct, since even small, asymptomatic stones in the cups must be eliminated, since there is always a risk of their growth and the development of chronic pyelonephritis.

One of the most effective and less traumatic methods of treating KSD is remote lithotripsy (extracorporeal shock wave lithotripsy – ESWL). The remote lithotripter crushes stones in the kidneys and ureter using focused, high-intensity acoustic pulses.

Stone crushing occurs under the action of a shock wave consisting of ultra-high and ultra-low pressure pulses. This effect can be compared to the circles that form on the water after a stone falls into it. When the stone touches the water, it forms a high pressure, while pushing the water in all directions, after the stone has sunk, a zone of negative pressure is formed behind it. It is the divergent waves that can be compared with the propagation of a shock wave, under the influence of which the stone is destroyed.

Renal colic. Where to run? What to grab onto?

The destruction of the stone occurs in several stages: first, the dense frame of the stone is destroyed, then cracks are formed, penetrating deeper and deeper with each impulse, leading to the destruction of the stone into small fragments. Ultimately, their size does not exceed 3 mm, which allows them to independently and freely exit the urinary system, while relieving the patient of a urinary tract stone.

Renal colic. Where to run? What to grab onto?

Location and focusing uses an X-ray image, enhanced on many models of lithotripters with ultrasound guidance. External shock wave lithotripsy is so minimally invasive that it is used on an outpatient basis (Lopatkin N.A. et al., 1990, Beshliev D.A., Dzeranov N.K., 1992, Trapeznikova M.F. et al., 1992.). At present, many authors have proven the advantages of the method not only over open surgery, but also over percutaneous puncture nephrolithotripsy (Ramadan Salaheddin, 1992, Stepanov V.L. et al., 1993).

Renal colic. Where to run? What to grab onto?

The size of the stone is of paramount importance when performing remote crushing of stones in the kidneys and ureter. This largely determines the number of sessions that must be carried out for the complete fragmentation of the stone. An increase in the size of the stone leads to a decrease in the effectiveness of the primary session of remote stone crushing.

For example, with stone sizes up to 9 mm, only one session is needed in 80%, and with a size of up to 14 mm, the effectiveness of the primary session is reduced to 64%. The most effective is remote crushing of kidney stones with their size up to 15 mm, and remote crushing of stones in the ureter – with a size of up to 10 mm. With remote crushing of stones in the kidneys and ureter, it is also necessary to take into account the density of the calculus. The denser the stone, the harder it will be to crush it the first time.

Ureteral stones up to 10 mm in size should be crushed remotely (non-contact), the sooner, the better and more efficiently!!! It will be much easier and painless for the patient to “give birth” to fragments of calculus and sand after crushing

Renal colic. Where to run? What to grab onto?

I have observed a situation more than once when a patient crawls into the office with a wild attack of pain. Within 15 minutes of visual, palpation and ultrasound examination, I make a diagnosis of ureteral calculus. Another 45 minutes I spend a session of remote crushing. And after 1 hour, the patient leaves the ward of the day hospital absolutely healthy, rested, without pain and without a stone. Total: 2 hours!!!

When can we talk about stone expulsion therapy (this is my subjective opinion based on 17 years of clinical experience in the treatment of urolithiasis):

  • There is a clear tendency to discharge of the calculus – already in the first hours of an attack of renal colic, the stone descends into the lower third of the ureter (the ideal variant is the mouth of the ureter), with sonography we see urine emissions from the mouth of the corresponding ureter (even if weakened) and the size of the calculus is no more 7mm. A day later, sonographic control, control of the general analysis of blood, urine. With repeated attacks of colic, an increase in the degree of obstruction, a deterioration in laboratory parameters – remote crushing (ESL). If the patient feels satisfactory, wait up to 7 days. If the stone did not come out – remote or contact crushing.
  • Ureteral stone up to 7 mm in size, which is not technically possible to crush remotely (lack of sonographic and X-ray visualization of the calculus). At the same time, according to excretory urography, the calculus should be streamlined. Once every 3 days sonographic control, control of the general analysis of blood, urine. If the patient feels satisfactory, we wait a maximum of 2 weeks. In the event of a complication of the situation, or if the calculus has not come out, an endoscopic intervention is performed aimed at removing the calculus or draining the upper urinary tract.

Renal colic. Where to run? What to grab onto?

At the moment, extracorporeal shock wave lithotripsy (ESWL or ESWL) is the “gold standard” treatment for small urinary tract stones. Urolithiasis, undoubtedly, requires treatment, since there is a possibility of developing complications of various severity, leading to a decrease and loss of kidney function and its death. With the availability of high-tech non-invasive treatment methods, such as external lithotripsy, trauma and postoperative complications are minimized, and the number of patients who have successfully undergone treatment for urolithiasis tends to 100% every year.

Renal colic. Where to run? What to grab onto?

In our clinic, remote crushing of stones in the kidneys and ureter is actively and successfully performed using a modern, highly efficient Modulith SLK unit from Storz Medical (Switzerland). Remote crushing of stones is carried out by a specialist with 17 years of experience in minimally invasive treatment of KSD. External lithotripsy is performed under intravenous anesthesia with the involvement of anesthesiologists. Thanks to the well-coordinated work of the urologist-anaesthesiologist team, crushing is carried out on an outpatient basis – hospitalization is not required. The duration of stay in the clinic is 2-3 hours.

Rodion Fedoryshyn
UROLOGIST, Ph.D.
NEW LIFE INTERNATIONAL MEDICAL CLINIC. KYIV.
Doctors
New Life
Doctor David Noga David Noga
Head of the clinic, surgeon
Work experience: 34 years
Doctor Igor Grynda Igor Grynda
Obstetrician-gynecologist
Work experience: 19 years
Doctor Liliya Kovalerenko Liliya Kovalerenko
Radiologist
Work experience: 14 years
Doctor Rodion Fedorishin Rodion Fedorishin
Urologist, Ph.D.
Work experience: 25 years