A GP's Guide to NICE Guidance on Renal and Ureteric Stones

Prof Fahad Rizvi

Disclosures

June 22, 2020

This article originally appeared on Univadis, part of the Medscape Professional Network. This transcript has been edited for clarity.

Today we will talk about renal and ureteric stones in National Institute for Health and Care Excellence (NICE) guidelines. It is a very complex problem in primary care, and we will try and tackle it in the next few minutes.

I am Professor Fahad Rizvi. I am a GP in Leicester. My background was urology training, all over the country, and currently, I am involved in teaching in a couple of universities, and also I do a lot of urological procedures in primary care.

This short film will aim to provide the latest NICE guidelines for the management of renal and ureteric stones. It will be useful for the GPs and trainees to understand these new guidelines.

Renal Stones

Renal stones are formed in the kidneys and they travel down this thin tube, the ureter, coming down into the bladder from where they are expelled out of the urethra.

They are mainly formed of calcium, oxalate and phosphate, which accounts for 80% of them. The rest, 20%, are mainly uric acid, struvite, and cystine.

The most painful part of the stones comes as they traverse through the ureter. This causes intense pain, and bleeding caused by injury to the ureters.

NICE has provided guidelines to standardise care and quality across the country.

Prevalence

Renal and ureteric stones are quite common with a prevalence of around 10%. Males are affected more commonly than females, and the age group is between 30 and 50 during the first presentation.

The cause of renal stones is often unknown but they are quite common in people who have high calcium levels in their blood, which can be because of hyperparathyroidism, or people who have recurrent infections, they may get struvite stones.

It is also linked with family history, and people who are housebound, or bed bound. If people don't drink enough liquids, this may cause stagnation of urine and lead to kidney stones.

Stones are important because they are very, very painful. Some people mention that they are worse than childbirth.

We also have complications linked with kidney stones. This could be sepsis, which could be life-threatening, or you may get a ureteric stricture, or irreversible kidney damage.

Presentation

As a clinician, you see loads of patients with abdominal pain, and one of the reasons could be a renal or ureteric stone.

These patients present with a loin-to-groin pain, which may radiate to the perineum.

The pain is often of sudden onset and may last from minutes to hours.

It can come in spasms or may be constant.

Patients will often have nausea and vomiting along with this pain, which is caused by the pain itself.

Diagnosis

The diagnosis of renal and ureteric stones is mainly done on the basis of a good history, examination, for example dipstick urine for haematuria, and the use of imaging, such as CT scans, and ultrasound scans for pregnant women.

There are lots of differential diagnoses for people coming in with loin-to-groin pain. There could be a problem in the kidney itself, which could be pyelonephritis, or a blocked kidney with some other reason. It could be because of a gynaecological cause, like a ruptured ovarian cyst. It could also be things like diverticulitis, or appendicitis, or a ruptured aneurysm.

It is quite distressing to see patients with renal or ureteric colic in primary care.

Management

The initial management is to provide them with NSAIDs, such as intramuscular diclofenac or per rectal diclofenac. And they may also need an intramuscular antiemetic, like metoclopramide.

If the pain is controlled, then I would send them home with some baseline investigations, which includes kidney function tests, serum calcium, and organise an urgent CT scan.

If the patients are not stable and they are still in pain, they may need more analgesic, like morphine, or intravenous paracetamol, as per the NICE guidelines, so they would require hospital admission.

I would organise urgent hospital admission if the patient is at risk, or the kidney is at risk.

For example, someone who is pregnant and has a renal stone, they should be offered admission to hospital.

Patients who are in septic shock, or with a high fever and tachycardia and high respiratory rate, should be offered admission. Similarly, people with transplanted kidneys, or having a single kidney, are high risk.

Imaging

The recommended imaging for kidney and ureteric stones is CT KUB. This CT scan is a low dose, non-contrast CT scan, which can be done in minutes and can provide good quality images and can locate the size and shape of the kidney stone.

Patients who can't have a CT KUB can have an ultrasound scan, such as pregnant females.

Pathway

We can look further into NICE guidelines, which provide a detailed chart of management and prevention of stones. It is a very useful tool to look at. I am sure clinicians and patients will find it useful.

So my advice to my colleagues and patients is to drink plenty of water. NICE advises adults to drink 2.5 to 3 litres of water per day, and children and young people (depending on their age) 1 to 2 litres. They may wish to add some lemon for taste, and also to decrease the formation of stones.

NICE guidelines also advise us to consider adding potassium citrate for patients who are recurrent stone formers. And also to consider adding a thiazide diuretic to their medications.

NICE provides very clear and easy guidance for management and prevention of kidney stones. I hope you found this video useful. Thank you for watching.

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