Ureteric Colic - Symptoms, Diagnosis, and Treatment

Introduction

As the prevalence of urolithiasis is increasing worldwide, more ureteric colic cases are being reported. Urolithiasis, also known as kidney stones, refers to the formation of solid calcium salt deposits in the kidney or other structures within the urinary system. The urinary system comprises the kidneys, ureters, bladder, and urethra. Urine is formed in the kidneys. It is then transported to the bladder through the ureter. It is then stored in the bladder for some time before being excreted from the body through the urethra.

What Is Ureteric Colic?

This medical condition occurs due to calcium and other minerals within the ureter. There can be severe pain due to the obstruction in the ureter. The most common location of the block is at the junction with the kidney and the bladder. This is because it is the narrowest area. The obstruction causes an increase in tension in the ureter, causing much pain. The dilatation, stretching, and spasm of the ureter cause the pain. People between the age of 35 to 45 and individuals with a familial predisposition to kidney stones face a heightened risk of developing this condition.

Who Are the Risk Factors of Ureteric Colic?

The risk factors of ureteric colic can include the following;

• A high calcium level in urine.

• An increased amount of oxalate in the urine.

• Increased excretion of uric acid in urine.

• Deficiency of citrate in urine.

• Cystinuria (a rare condition in which stones are made from cysteine forms in the kidney, ureter, and bladder).

What Are the Differential Diagnosis of Ureteric Colic?

The differential diagnosis of ureteric colic can include the following;

• Urinary Tract Infection.

• Abdominal aortic aneurysm.

• Renal artery thrombosis.

• Acute appendicitis.

• Testicular torsion.

• Ectopic pregnancy.

• Ruptured ovarian cyst.

• Herpes zoster.

What Are the Symptoms of Ureteric Colic?

The symptoms seen in ureteric colic can include;

• Pain: The pain in ureteric colic is severe. It usually starts at the back, spreads to the lower abdomen groin, and radiates to the inner thighs. It is of sudden onset and increases in intensity. The pain can come on and off or be intermittent.

• Hematuria: Blood in the urine.

• Dysuria: Pain while passing urine.

• Nausea.

• Vomiting.

• Chills.

• Fever.

• Urine color may be different from usual.

• Urinary tract infection.

• Foul-smelling urine.

How Is Ureteric Colic Diagnosed?

The diagnostic approach to ureteric colic has improved immensely with the advancement of imaging technology. Recent advances in radiological imaging, like non-contrast computed tomography (CT) and intravenous urography, have made diagnosing these conditions more effortless and accurate. Intravenous urography is currently considered the gold standard for diagnosing ureteric colic.

1. Physical Examination: Physical examination can show a patient writhing in pain and trying to find a comfortable position. They are very uncomfortable and often cannot remain still due to pain. Abdominal palpation may not show any abnormal tenderness. If abnormal tenderness is felt, the differential diagnosis must be considered. Any pulsatile abdominal mass can be indicative of an abdominal aortic aneurysm. High temperatures can be indicative of an infection like a urinary tract infection.

2. Urine Analysis: The urine analysis of the patient might reveal hematuria (the presence of blood in urine). Hematuria is present in seventy to ninety percent of the patients. It might be absent in some patients, but its absence cannot rule out the condition. Pyuria, or the presence of white blood cells in urine, can be seen. These can be indicative of urinary tract infections. WBCs can be present in the urine as a sign of inflammation also.

3. Plain X-ray of the Kidney, Ureter, and Bladder (KUB): A plain X-ray of the kidney, ureter, and bladder has a forty-five to sixty percent sensitivity. Stool or gas that lies over the stone or phlebolith(calcifications found in the veins) can complicate diagnosing the condition. Ninety percent of the rocks are radio-opaque. The stone's size, shape, and location in the system can be assessed.

4. Ultrasonography: It provides better visibility of the stones in the pelvic ureteric junction, vesico ureteric junction (where the ureter connects with the bladder), and renal pelvis.

5. Intravenous Urography: Since its introduction in 1923, intravenous urography has been the golden standard for ureteric colic. It provides information about the site, size, and degree of obstruction. It is ninety percent sensitive. The disadvantage of the procedure can include radiation exposure, risk of nephrotoxicity (decrease in the function of the kidney due to the action of some chemicals or medications), contrast reaction (rashes or allergic reactions to the contrast used), and the time taken for the procedure.

6. Non-contrast Enhanced Computed Tomography: Non-contrast enhanced computed tomography is an alternative method of diagnosis for ureteric colic. It is more specific and sensitive than intravenous urography. It has a shorter duration for the procedure and permits alternative diagnoses as well. CT can help to visualize radio-opaque and radio-lucent stones. Another benefit of CT is that an intravenous contrast medium can be avoided. While CT help to diagnose the stone present, a plain X-ray will be required to determine if the stone is radio-opaque or radio-lucent. This is necessary to determine whether the stone should be moved or passed. CT can also help to reveal alternative urinary pathology during the primary investigation.

How Is Ureteric Colic Managed?

The most commonly accepted approach for managing ureteric colic is conservative treatment in observation after giving painkillers to control the pain, as the stone usually passes spontaneously. Other modes of treatment, like surgical or radiologic approaches, are considered only when the conservative method is a failure. Many factors, like the stone's size, position, degree of obstruction, etc., determine whether it would pass independently. The probability of the stone passing spontaneously decreases as the size of the stone increases.

Conclusion

The traditionally accepted mode of treatment mentioned above has been recently improved with the advancement of active medically expulsive therapy (MET). This was developed based on the possible causes for the failure of the stone to pass spontaneously. This includes muscle spasms, local edema, inflammation, and infection. Regimens including a corticosteroid (to reduce inflammation), antibiotics(to prevent infections), calcium antagonists, and alpha-blockers( to cause ureteral spasms to facilitate the movement of the stone) have been used currently. Combination therapy is preferred for short-term use.