Ureteral colicN23

Ureteral colic is an acute, intermittent, severe pain event due to a ureteral outflow obstruction (Kasper 2015).

s. Nephrolithiasis

Ureteral colic is a typical cavity pain, comparable to labor pain, which can be triggered by:

• Nephrolithiasis (by far the most frequent cause)
• Blood coagulation
• tumour thrombosis
• rejected papillae

(Vahlensieck 1979)

Ureteral colic occurs when a calculus, blood clot, etc. causes obstruction of the ureter.

The pain is caused by the increase in wall tension and the increase in pressure proximal to the obstruction and not, as previously assumed, by hyperperistalsis of the smooth muscles of the ureter (Ellinger 2011).

s. Nephrolithiasis

A ureteral colic starts suddenly as the strongest up and down swelling pain in the area of the flank with radiation - depending on the location of the obstruction - into:

• the upper abdomen or back (so-called costovertebral angle) in case of obstruction in the proximal part of the ureter
• the middle and lower abdomen in case of an obstruction at the pelvic junction of the ureter
• the groin, the ipsilateral testis or the ipsilateral labia in case of obstruction in the lower part of the ureter (Kasper 2015 / Herold 2020)

Ureteral colic may present as an acute abdomen and be accompanied by the following symptoms:

• sudden colicky pain (see "localization")
• Hematuria: in 90 % there is at least microhematuria, in 1 / 3 of the cases macrohematuria.
• Dysuria
• bladder amenorrhea
• motor restlessness (typical symptom)
• nausea
• vomiting
• reflexive subileus with retention of stool and wind
• Oliguria
• fever (Herold 2020 / Kasper 2015)

The Stone score can be used to calculate the probability of ureteral colic:

• Sex: male (2 points)
• Timing: short duration of pain (> 24 h: 0 points, 6 - 24 h: 1 point, < 6 h: 3 points).
• Origin: no colored (colored: 0 points, no colored: 3 points)
• Nausea: there isnauseaor vomiting (only nausea: 1, only vomiting: 2)
• Erythrocyturia: (microhematuria: 3 points)

Evaluation:

• low probability at 0 - 5 points
• moderate probability at 6 - 9 points
• high probability at 10 - 13 points (Moore 2014).

For detailed diagnostic workup see Nephrolithiasis.

Since ureteral colic may present under the picture of an acute abdomen, the differential diagnosis is extensive. It should be excluded:

• Tumors of the urinary tract and kidneys (initial diagnosis: sonography).
• Renal infarction (occurs most frequently in patients with atrial fibrillation; there is hematuria, proteinuria, very high LDL with at most slight changes in GOT and AP; diagnosis by color Doppler sonography)
• papillary necrosis due to e.g. analgesic nephropathy (papillary defect can be visualized in the urogram)
• renal vein thrombosis (proteinuria, in case of left-sided thrombosis venous congestion of the left-sided testis in men; diagnosis by color Doppler sonography)
• renal abscess (diagnosis by CT [Ellinger 2011])
• Pyelonephritis (high fever, diagnosis by ultrasound, CT / MRI [Ellinger 2011 / Schmelz 2006])
• cholecystolithiasis (pain in the right upper abdomen with (typically) radiation to the right shoulder, sonography etc.)
• acute cholecystitis (pain in the right upper abdomen with radiation to the right shoulder, sonography, laboratory evidence of inflammatory signs, etc.)
• incarcerated hernia (physical examination, guarding, sonography, CT [Bischoff 2018])
• acute appendicitis (usually insidious onset, tenderness McBurney point, temperature difference between rectal and axillary, sonography)
• Acute pancreatitis (physical examination [abdomen soft], laboratory changes, sonography, etc. [Beger 2013])
• Diverticulitis (history, abdominal palpation, laboratory changes, sonography, etc. [Leifeld 2018])
• Perforated ulcer (pain in the upper abdomen, guarding)
• Rupture of an abdominal aortic aneurysm (ultrasound, CT angio [Debus 2018]).
• Ileus (in mechanical: auscultatory no bowel sounds, exclude possible hernial orifices, abdominal sonography or abdominal X-ray).
• chronic inflammatory bowel disease (detailed history, sonography, etc.)
• Mesenteric infarction [Kuhlmann 2015] (patient age, serum lactate elevated, blood on fingerling rectal examination, diagnosis by biphasic contrast CT).
• Myocardial (posterior wall) infarction (ECG, typical laboratory chemical changes).
• pedunculated ovarian cyst (gynaecological examination, sonography)
• Extrauterine pregnancy (increased beta-HCG in urine, gynaecological examination, sonography)
• Adnexitis (gynaecological examination, sonography)
• Testicular torsion (physical examination, duplex sonography; diagnosis within 6 h, otherwise there is a risk of testicular loss) (Herold 2020 / Siegenthaler 2005)

• Urinary tract infection up to
• Urosepsis
  • Early symptoms of urosepsis are:
    • Tachypnea (> 20 breaths / min)
    • Tachycardia (> 90 beats / min)
    • Hyperthermia (> 38 ° C)
    • Hypothermia (< 36 ° C, alternating with episodes of fever) (Herold 2020)
• Fornix rupture due to pressure increase in the renal pelvic caliceal system (Hofmann 2018).

Unless treated early, the following damage is possible:

• permanent loss of renal parenchyma (so-called renal atrophy)
• Acute or chronic renal failure (Kasper 2015).

The therapeutic measures differ according to the etiology of ureteral colic.

Nephrolithiasis: If the ureteral colic is nephrolithiasis, the following applies:

If the stone size is < 5 mm (Herold 2020), spontaneous discharge can be awaited - with regular monitoring of body temperature and urine. In up to 90% of cases, stones of this size pass spontaneously (Herold 2020).

However, the likelihood of spontaneous clearance depends on the location of the calculi:

• proximal ureter: 25 %
• middle ureter: 45 %
• distal ureter: > 70 % (Schmelz 2006)

Drug expulsive therapy (MET) with alpha blockers and calcium channel blockers can increase the excretion rate and accelerate the rate of stone passage. (Seitz 2018)

Dosage recommendation: e.g. tamsulosin 1 x 0.4 mg / d (Truß 2005) or nifedipine 40 mg - 60 mg / d (Kuhlmann 2015).

Supportive effects are also:

• drink plenty of fluids
• local application of heat
• exercise (Herold 2020)

If fever and / or anuria occur, the patient should be immediately transferred to inpatient treatment (Herold 2020).

Detailed treatment of nephrolithiasis, see d.

Pain management:

In acute ureteral colic, analgesic treatment is the primary treatment.

Suitable analgesics are:

• Metamizol: 1 g - 2 g i.v. is the drug of first choice, as it also has a spasmolytic and antinociceptive effect on the ureter.
• Paracetamol: 1 g i. v.
• Diclofenac: 75 mg / kg bw i. v.
• Morphine: 0.1 mg / kg bw i. v. (Seitz 2018).

If the cause of colic is nephrolithiasis, ASA is contraindicated before a planned extracorporeal shock wave lithotripsy (ESWL) because of the risk of renal hematoma (Herold 2020).

In a randomized study, the combination of paracetamol and diclofenac was shown to be superior to the administration of morphine for pain relief (Seitz 2018).

Urinary diversion:

Patients presenting with urinary retention and signs of infection represent a medical emergency in which immediate relief by ureteral splinting or percutaneous nephrostomy plus antibiotic treatment (according to the antibiogram) should be given (Kuhlmann 2015).

The indication for urinary diversion is given in:

• high-grade obstruction with consecutive urinary retention kidney
• increasing retention values (indication of postrenal renal failure)
• colic that cannot be controlled with medication (Herold 2020).

In ureteral splinting, a distinction is made between the following catheters:

• Drainage from the ureter out of the body as in:
  • Mono J- catheter
  • Ureteral catheter (UK)
• by ureteral rails that can be retracted into the body, such as in the:
  • Double J catheter
  • Tumor stents

Ureteral stents can be drained transurethrally, transcutaneously, transvesically or via a urostomy (TUUC, ileum conduit)(Hofmann 2018).

Performance of transurethral ureteral stenosis: Before the procedure, a so-called "single-shot" periinterventional antibiotic prophylaxis is administered e.g. Levofloxacin 500 mg p. o. or Sultamicillin 750 mg p. o.. In addition, the stenosis is imaged retrogradely and documented radiologically, since it is no longer possible to determine the etiology of the stenosis after the splint has been inserted.

The procedure itself is usually performed under local anesthesia in the lithotomy position. Insertion of the cytoscope under visualization and visualization of the affected ostium. The ureteral catheter is inserted with the guide wire (the so-called "inner core") until the tip just appears in front of the optic. Careful advancement of the catheter into the ureter up to approx. 1 cm. The inner core is then removed. The catheter is continuously rinsed with 3 - 5 ml NaCl 0.9 % to prevent the formation of bubbles (if the catheter is applied intermittently, there is a risk of recurrent colic). After insertion of a usually 0.035 inch polytetrafluoroethylene coated wire or a soft double J-wire, the catheter is advanced further beyond the obstruction (a contrast agent may be required for this). Once the wire has reached the renal pelvis, the flexible end should be positioned in a calyx group to avoid any dislocation. The ureteral catheter is then completely removed leaving the wire in place. Replacement of the catheter, if at all necessary, is required after 3 to 6 months at the latest, as the catheter may otherwise become incrusted (Hofmann 2018).

Any discomfort from the ureteral stent such as:

• Urinary urgency
• Pollakisuria
• flank or lower abdominal pain
• slight macrohaematuria

Can be treated with an alpha blocker (Seitz 2018). Dosage recommendation: e.g. tamsulosin 1 x 0.4 mg / d (Hofmann 2018 / Truß 2005).

If the ureteral colic was triggered by nephrolithiasis, the prognosis is good. Up to 90 % of the calculi resolve spontaneously anyway (Herold 2020). The risk of recurrence in nephrolithiasis can be reduced to < 15 % by appropriate metaphylaxis (see Nephrolithiasis ) (Kuhlmann 2015).

For all other causes of ureteral colic, the prognosis depends on the underlying disease.

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