Emergency management of urolithiasis

General principles

Most episodes of renal colic do not require immediate surgery, but a stone becomes an emergency in the presence of:

• infected obstruction;
• anuria;
• progressive kidney injury;
• intractable pain or vomiting.

Initial assessment

• Pain severity, temperature, urine output.
• A solitary kidney, pregnancy, previous surgery.
• Assessment of kidney function and signs of systemic infection.

Analgesia

• NSAIDs are the preferred first option in the absence of contraindications.
• If the response is inadequate, use an opioid as rescue therapy.
• Treat vomiting and dehydration.
• Do not administer large volumes of fluid solely to “push” the stone through.

Diagnosis

• Ultrasonography is often used first.
• Low-dose noncontrast CT most accurately determines stone size, density, and level.
• Laboratory tests: CBC, creatinine, urinalysis, and culture if infection is suspected.

When to intervene

Absolute or urgent indications:

• infected obstruction;
• anuria;
• deteriorating kidney function;
• obstruction of a solitary kidney;
• bilateral obstruction;
• intractable pain;
• complications.

In infection, perform drainage first, not definitive stone removal.

Algorithm