Urolithiasis (renal colic)MANAGEMENT

GENITOURINARY AND REPRODUCTIVE PRESENTATIONS · 12 SECTIONS

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523 items

☷ Legend

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Cardiovascular Presentations66▾

Respiratory Presentations47▾

Neurological Presentations77▾

Gastrointestinal Presentations63▾

Genitourinary and Reproductive Presentations44▾

Acute Kidney Injury (ATN)Acute Kidney Injury (Post-renal)Acute Kidney Injury (Pre-renal)Amniotic Fluid Embolism Balanitis Bladder Rupture Breast Abscess Cystitis Ectopic pregnancy Epididymitis Glomerulonephritis Hematuria (gross)Hydrocele Interstitial Cystitis Mastitis Mittelschmerz Nephrolithiasis Nephrotic Syndrome Flare Nutcracker Syndrome Orchitis Ovarian Cyst Rupture Ovarian torsion Paraphimosis Pelvic Congestion Syndrome Pelvic Inflammatory Disease (PID)Phimosis Priapism Prostatitis Pyelonephritis Renal laceration Ruptured ovarian cyst Testicular torsion Torsion of Appendix Testis Tubo-ovarian abscess Ureteral Rupture Urethritis Urinary Retention Urinary tract infection (uncomplicated)Urolithiasis (renal colic)Vaginal bleeding (non-pregnant)Vaginitis (Bacterial)Vaginitis (Candidal)Varicocele Vulvovaginal Hematoma

Infectious Disease Presentations146▾

Trauma Presentations88▾

Toxicologic Presentations67▾

Psychiatric Presentations25▾

Musculoskeletal and Rheumatologic Presentations89▾

Dermatology Presentations21▾

Environmental and Exposure Presentations26▾

Hematologic and Oncologic Presentations30▾

Pediatric-Specific Presentations13▾

Endocrine and Metabolic Presentations42▾

ENT and Maxillofacial Presentations21▾

Ophthalmologic Presentations15▾

Obstetric Presentations17▾

Systemic and Miscellaneous Presentations15▾

01Approach to the Critical Patient/attcp37

Immediate threats

›Unstable renal colic presentation

›Shock physiology

›SBP < 90 mmHg

›Lactate >= 2.0 mmol/L

›Obstructed infected system

›Fever >= 38.0 C

›Rigors

›Altered mental status

›Severe uncontrolled pain

›Refractory to parenteral analgesia

›Intractable vomiting

›Solitary kidney risk

›Known single functioning kidney

›Kidney transplant

›Immediate actions

›If shock or sepsis, sepsis pathway

›If suspected infected obstruction, immediate urology and decompression planning

Monitoring and targets

›Monitoring set

›Vital sign frequency

›Every 15 minutes if uncontrolled pain or emesis

›Continuous pulse oximetry if parenteral opioids

›Analgesia targets

›Pain score reduction by 2 points within 30 minutes

›Functional goal tolerating oral fluids

›Renal function risk

›Urine output trend

›Creatinine delta from baseline

Key decisions early

›Early decision points

›Infection with obstruction pathway

›Broad spectrum antibiotics immediately

›Urgent decompression ureteral stent or percutaneous nephrostomy

›Consensus based Class I recommendation for urgent decompression in obstructed infected system

›Imaging pathway

›CT KUB vs ultrasound first strategy based on risk and radiation considerations

›Pregnancy ultrasound first

›Disposition pathway

›Admit if sepsis risk, AKI, refractory symptoms, solitary kidney, or large stone burden

02History/hx48

Symptom pattern and timeline

›Renal colic history core

›Pain characteristics

›Sudden onset flank pain

›Radiation to groin or testicle or labia

›Waxing and waning severity

›Associated symptoms

›Nausea

›Vomiting

›Dysuria

›Urinary frequency or urgency

›Time course

›Onset time

›Peak pain time

›Current pain level and response to meds

Infection and high risk features

›Red flags history

›Systemic infection features

›Fever or chills

›Rigors

›Malaise

›High risk anatomy

›Solitary kidney

›Kidney transplant

›Known strictures

›Immunocompromise

›Diabetes

›Chronic steroids

›Chemotherapy

›Pregnancy status

›Last menstrual period timing

›Positive pregnancy test history

Stone risk and prior care

›Stone context

›Prior stones

›Prior CT proven stones

›Prior interventions

›Prior infections

›Recurrent UTI history

›Prior pyelonephritis

›Hydration and exposures

›Low fluid intake

›Heavy sweating or heat exposure

›Medications

›Diuretics

›Topiramate

›Protease inhibitors

›Comorbid risks

›Gout

›Inflammatory bowel disease

›Bariatric surgery

03Physical Exam/exam32

General and vitals

›General exam focus

›Distress pattern

›Restless writhing behavior

›Unable to find position of comfort

›Vital signs

›Fever >= 38.0 C

›Tachycardia

›Hypotension

›Volume status

›Dry mucous membranes

›Orthostasis

Abdominal and flank exam

›Abdominal flank findings

›Costovertebral angle tenderness

›Unilateral CVA tenderness

›Bilateral CVA tenderness

›Abdominal tenderness

›Minimal abdominal tenderness typical

›Peritoneal signs atypical

›GU exam when indicated

›Testicular exam for torsion mimic

›Pelvic exam if gynecologic concern

PITFALLS

›Pitfalls

›Normal exam does not exclude obstructing stone

›Early obstruction with minimal tenderness

›Analgesia masking findings

›Fever absence does not exclude infection

›Elderly blunted febrile response

›Immunocompromise

›Abdominal guarding suggests alternate diagnosis

›Appendicitis

›AAA

›Ovarian torsion

04Differential Diagnosis/ddx52

Life threatening mimics

›Must not miss causes of flank or abdominal pain

›Abdominal aortic aneurysm rupture or leak

›Hypotension

›Pulsatile mass

›Aortic dissection

›Chest or back pain

›Pulse deficit

›Ectopic pregnancy

›Positive pregnancy test

›Pelvic pain

›Ovarian torsion

›Sudden unilateral pelvic pain

›Adnexal tenderness

›Testicular torsion

›Acute scrotal pain

›High riding testis

Renal and urinary conditions

›Renal urinary differentials

›Pyelonephritis

›Fever

›CVA tenderness with systemic symptoms

›Renal infarction

›Sudden flank pain with hematuria

›Atrial fibrillation history

›Papillary necrosis

›Sickle cell

›NSAID overuse

›Urinary retention

›Suprapubic fullness

›Low output

›Complicated UTI

›Structural abnormality history

›Immunocompromise

GI and musculoskeletal mimics

›Other mimics

›Appendicitis

›RLQ pain migration

›Anorexia

›Diverticulitis

›LLQ pain

›Fever

›Biliary colic

›RUQ pain after meals

›Murphy sign

›Musculoskeletal back pain

›Pain with movement

›Paraspinal tenderness

Coding alignment

›Coding terms

›Renal colic ICD-10 N23

›SNOMED CT concept renal colic

›Calculus of kidney ICD-10 N20.0

›SNOMED CT concept kidney stone

›Calculus of ureter ICD-10 N20.1

›SNOMED CT concept ureteral stone

05Laboratory Tests/lt39

Core labs

›Baseline labs set

›Urinalysis

›Hematuria

›Microscopic hematuria supportive

›Absent hematuria does not exclude stone

›Nitrites

›Positive supports bacteriuria

›False negatives possible

›Leukocyte esterase

›Positive supports pyuria

›Pyuria can occur with stone irritation

›Pregnancy test

›All patients with pregnancy potential

›Positive triggers pregnancy imaging pathway

›Serum creatinine and electrolytes

›AKI detection

›Rising creatinine suggests obstruction or dehydration

›Baseline unknown increases admission threshold

Infection and severity labs

›Infection assessment labs

›CBC

›Leukocytosis

›Stress leukocytosis possible

›Marked elevation increases infection concern

›Blood cultures

›If fever or sepsis physiology

›Before antibiotics when feasible

›Lactate

›If suspected sepsis

›Lactate >= 2.0 mmol/L supports hypoperfusion

›CRP or procalcitonin

›Optional adjunct

›Do not delay imaging or antibiotics

Culture strategy

›Microbiology

›Urine culture

›If pyuria or nitrites

›If antibiotics planned

›Pitfalls

›High grade obstruction can yield falsely negative urine culture

›Bacteremia possible despite bland urine in obstruction

06Diagnostic Tests/dt49

Scoring Systems

›Risk and decision support

›High risk criteria for admission

›Fever or rigors

›Tachycardia with systemic symptoms

›Creatinine elevation

›Solitary kidney or transplant

›Intractable pain or vomiting

›Sepsis screening integration

›qSOFA >= 2 supports high risk

›Persistent hypotension supports septic shock

›Imaging stewardship concepts

›Prior CT confirmed stones with similar symptoms lowers immediate CT need

›ACEP Level C recommendation for selective imaging based on risk and prior history

MRI

›MRI considerations

›Pregnancy second line imaging

›MR urography without gadolinium

›Hydronephrosis assessment

›Diagnostic limitations

›Reduced sensitivity for small stones vs CT

›Availability and time constraints

›Contraindications

›Non compatible implants

›Severe claustrophobia limiting tolerance

›CT strategy

›Noncontrast CT KUB

›Highest sensitivity for ureteral stones

›Secondary signs hydronephrosis and periureteral stranding

›Low dose CT option

›BMI appropriate protocols

›Stone detection preserved for most clinically relevant stones

›Contrast CT indications

›Alternate diagnosis concern

›Complication concern

›Evidence and guidance

›ACEP Level B recommendation for CT to define stone size and location when it changes management

›ACEP Level C recommendation for low dose CT when feasible

Ultrasound

›Ultrasound applications

›Renal ultrasound

›Hydronephrosis grading

›Renal pelvis dilation

›POCUS

›Rapid hydronephrosis assessment

›Bladder volume estimation if retention concern

›Pregnancy first line imaging

›Ultrasound first approach

›Adjunct Doppler ureteral jets

›Limitations

›Limited ureteral stone visualization

›False negatives in early obstruction or small stones

07Disposition/dispo31

Admission and consult criteria

›Admit indications

›Suspected infected obstruction

›Fever and hydronephrosis

›Sepsis physiology

›Renal function risk

›AKI

›Solitary kidney or transplant with obstruction

›Symptom control failure

›Intractable pain despite parenteral meds

›Intractable vomiting with dehydration

›Stone factors

›Large stone burden

›Proximal ureteral stone with significant hydronephrosis

›Urology consultation triggers

›Suspected infected obstruction

›AKI with obstruction

›Anuria

›Single kidney obstruction

Discharge criteria and follow up

›Discharge requirements

›Stable vitals

›Afebrile

›No hypotension

›Symptom control

›Pain controlled with oral regimen

›Tolerating oral fluids

›Low infection concern

›No systemic symptoms

›UA without convincing infection pattern

›Follow up plan

›Urology referral based on size and location

›Primary care follow up for stone prevention

08Treatment/t99

Analgesia

›Pain control pathway

›NSAIDs first line

›Ketorolac IV

›10 mg to 30 mg single dose based on local protocol and renal risk

›Avoid if significant AKI or high GI bleed risk

›Ibuprofen PO

›400 mg to 600 mg every 6 to 8 hours as needed

›Max daily dose per local policy

›Evidence

›NSAIDs reduce ureteral smooth muscle spasm and renal pelvic pressure

›ACEP Level B recommendation for NSAIDs as first line analgesia when no contraindication

›Opioid rescue

›Morphine IV

›Initiate 0.05 mg/kg

›Titrate 2 mg every 5 to 10 minutes to analgesic goal

›Monitor respiratory rate and oxygen saturation

›Hydromorphone IV

›Initiate 0.5 mg

›Titrate 0.2 mg to 0.5 mg every 10 minutes to analgesic goal

›Higher risk oversedation in opioid naive

›Discharge opioid strategy

›Lowest effective dose and quantity

›Avoid co prescription with sedatives

›Adjuncts

›Acetaminophen PO or IV

›1000 mg single dose

›Max daily dose per local policy

›Antispasmodics

›Limited evidence for routine use

›Avoid delaying definitive analgesia

Antiemetics and hydration

›Nausea and fluids

›Antiemetics

›Ondansetron IV

›4 mg single dose

›Repeat 4 mg after 15 to 30 minutes if persistent

›Metoclopramide IV

›10 mg single dose

›Avoid in prior dystonic reaction risk

›Fluids

›Isotonic crystalloid bolus

›10 mL/kg if dehydration

›Avoid forced diuresis for stone passage

›Oral hydration

›Encourage once nausea controlled

Medical expulsive therapy

›MET strategy

›Alpha blocker option

›Tamsulosin PO

›0.4 mg daily

›Best evidence for distal ureteral stones

›Counsel orthostasis risk

›Selection

›Distal ureteral stones most responsive

›Larger stones more likely to benefit than very small stones

›Evidence framing

›Mixed trial results

›Use when benefits outweigh risks and follow up is reliable

Infection and obstructed infected system

›Antibiotics and source control

›Suspected pyelonephritis without obstruction

›Antibiotic selection guided by local resistance

›Urine culture guided adjustment

›Suspected infected obstruction

›Initiate antibiotics immediately

›Ceftriaxone IV

›1 g to 2 g daily

›Dose selection per severity and local protocol

›Piperacillin tazobactam IV

›4.5 g every 6 to 8 hours

›Use in severe sepsis or resistant risk

›Allergy alternative

›Consult local stewardship

›Avoid delays to decompression planning

›Decompression

›Ureteral stent option

›Preferred when anatomy allows

›Rapid relief of obstruction

›Percutaneous nephrostomy option

›Alternative when stent not feasible

›Useful in severe infection

›Evidence and recommendations

›Consensus based Class I recommendation for urgent decompression plus antibiotics

›Do not discharge suspected infected obstruction

Definitive stone management triggers

›Procedure planning

›Likely spontaneous passage

›Small distal ureteral stones higher passage probability

›Pain controlled and no infection supports outpatient trial

›Low passage probability

›Large stone size

›Proximal location

›Persistent obstruction

›Urology interventions

›Ureteroscopy

›Definitive removal

›Stent placement common

›Shock wave lithotripsy

›Selected stones and anatomy

›Not for pregnancy

›Percutaneous nephrolithotomy

›Large renal stones

›Higher complication profile

09Special Populations/sp57

Pregnancy

›Pregnancy renal colic pathway

›Imaging priorities

›Ultrasound first

›Hydronephrosis assessment

›Ureteral jets adjunct

›MRI second line

›MR urography without gadolinium

›Use when ultrasound nondiagnostic and symptoms severe

›CT last resort

›Use only when maternal risk outweighs fetal radiation concern

›Lowest reasonable dose protocol

›Medication considerations

›NSAIDs avoidance in later pregnancy

›Ductus arteriosus risk in third trimester

›Oligohydramnios risk

›Opioids short course

›Use lowest effective dose

›Avoid prolonged exposure

›Antiemetics

›Ondansetron risk benefit discussion

›Obstetric collaboration

›Obstetrics involvement for viable gestations

›Fetal monitoring when clinically indicated

Geriatric

›Older adult considerations

›Atypical presentation risk

›Less classic colicky pattern

›Higher alternate diagnosis probability

›Medication sensitivity

›Opioid oversedation risk

›NSAID renal and GI risk

›Infection risk

›Higher bacteremia risk

›Lower fever response

›Imaging threshold

›Lower threshold for CT if first episode or unclear diagnosis

Pediatrics

›Pediatric pathway

›Imaging strategy

›Ultrasound first

›Reduce radiation exposure

›Hydronephrosis assessment

›CT selective

›Persistent diagnostic uncertainty

›Complication concern

›Analgesia dosing

›Ibuprofen PO

›10 mg/kg every 6 to 8 hours

›Max single dose per local policy

›Ketorolac IV

›0.5 mg/kg single dose

›Max 30 mg

›Morphine IV

›0.05 mg/kg to 0.1 mg/kg

›Titrate to effect with monitoring

›Etiology considerations

›Metabolic disorders

›Anatomic abnormalities

›Need for prevention workup after first stone

10Background/b46

Epidemiology

›Epidemiology overview

›Typical presentation

›Acute flank pain episodes common ED presentation

›Recurrence risk over lifetime significant

›Risk factors

›Dehydration

›High sodium diet

›Low citrate states

›Stone composition patterns

›Calcium oxalate most common category

›Uric acid radiolucent on plain radiograph

›Complication frequencies

›Obstruction can cause AKI in solitary kidney

›Infection plus obstruction increases sepsis risk

Pathophysiology

›Mechanisms

›Ureteral obstruction

›Increased renal pelvic pressure

›Smooth muscle spasm contributes to pain

›Inflammation

›Ureteral edema

›Hematuria from mucosal irritation

›Hydronephrosis

›Dilation proximal to obstruction

›Severity does not perfectly correlate with pain intensity

›Infected obstruction

›Trapped infected urine

›Rapid progression to bacteremia possible

Therapeutic Considerations

›Treatment rationale

›NSAIDs

›Reduce prostaglandin mediated renal vasodilation

›Reduce renal pelvic pressure and inflammation

›Opioids

›Central analgesia for rescue

›Does not treat pathophysiology of obstruction

›MET

›Alpha blockade reduces ureteral tone

›Benefit highest for distal stones

›Decompression

›Definitive source control for infected obstruction

›Delay increases sepsis mortality risk

›Imaging choice tradeoffs

›CT highest diagnostic accuracy

›Ultrasound reduces radiation and can identify hydronephrosis

›Evidence labeling

›ACEP Level B support for NSAIDs first line analgesia in renal colic

›ACEP Level C support for ultrasound first strategies in selected low risk patients

11Patient Discharge Instructions/pdi22

copy discharge instructions

›Discharge instructions renal colic

›Medications

›NSAID as directed if safe for kidneys and stomach

›Acetaminophen as directed

›Opioid only if prescribed and only as needed

›Hydration

›Regular fluids to keep urine pale yellow

›Avoid forced overhydration if it worsens nausea

›Stone capture

›Urine strainer use until stone passes

›Save stone for analysis if recovered

›Follow up

›Urology follow up if large stone or ongoing symptoms

›Primary care follow up for prevention counseling

›Return to ED immediately

›Fever or chills

›Vomiting unable to keep fluids down

›Worsening pain not controlled by medications

›Fainting or severe weakness

›New trouble urinating or very low urine output

›Blood in urine with clots or inability to urinate

›Pregnancy with worsening pain or bleeding

12References/r11

Clinical guidelines and evidence

›Reference set

›ACEP clinical policy topics for imaging and analgesia in suspected renal colic

›ACEP evidence levels Level A Level B Level C framework

›Selective imaging strategies for recurrent uncomplicated renal colic

›American Urological Association guidance on ureteral stones and medical expulsive therapy

›Indications for urgent decompression with infection and obstruction

›Follow up and prevention evaluation after stone event

›European Association of Urology guidance on urolithiasis

›Imaging recommendations by population and setting

›Antibiotics plus decompression for infected obstruction

›Source file used

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.