Executive summary
- Classic presentation: sudden severe flank pain (often radiating to groin), restlessness, nausea/vomiting; microscopic haematuria is common but absence does not exclude stones.
- Analgesia first: NSAIDs are typically first-line (check contraindications); add antiemetic and opiate rescue if needed.
- Do not miss emergencies: fever/rigors, sepsis features, AKI/anuria, solitary kidney, pregnancy, uncontrolled pain, or significant comorbidity = urgent assessment/admission pathway.
- Imaging is definitive: suspected stones generally need timely imaging (pathway dependent; CT is common in secondary care).
- Medical expulsive therapy (alpha-blocker such as tamsulosin) may be considered for selected ureteric stones via pathway (often initiated/endorsed by urology/ED protocols).
- Recurrence prevention is high yield: hydration, diet counselling, and metabolic work-up for recurrent/high-risk patients.
Primary care assessment (and immediate tests)
- History: pain onset/severity, radiation, lower urinary symptoms, nausea/vomiting, prior stones, family history, dehydration, diet, gout/hyperparathyroidism, bowel disease/bariatric surgery.
- Red flags: fever/rigors, hypotension, immunosuppression, single kidney, pregnancy, inability to keep fluids down, persistent severe pain, reduced urine output.
- Exam: vitals (sepsis screen), flank tenderness; consider abdominal exam if atypical.
- Urine dip: blood +/-; leucocytes/nitrites raise concern for infection (infected obstruction is a urological emergency).
- Bloods (if available/indicated): U&E/creatinine, CRP, FBC; pregnancy test where relevant.
Initial management (what to do while arranging pathway care)
- Analgesia: NSAID first-line if safe (e.g., ibuprofen/naproxen/diclofenac per local formulary). Add paracetamol and an opiate rescue plan if needed.
- Antiemetic: consider if vomiting limits oral analgesia/hydration (local options vary).
- Hydration: encourage oral fluids as tolerated (avoid forced overhydration; aim for steady intake).
- Strain urine: capture passed stone for analysis (helps tailored prevention).
- Safety net: urgent review if fever/rigors, worsening pain, vomiting/inability to hydrate, fainting, reduced urine, or new systemic symptoms.
When to refer urgently (practical threshold list)
- Suspected infected obstruction: renal colic + fever/rigors, sepsis features, or significant pyuria — treat as emergency.
- Renal compromise: anuria, rising creatinine/AKI, solitary kidney, bilateral obstruction concern.
- Pregnancy: urgent same-day pathway (imaging and management are specialised).
- Uncontrolled symptoms: severe pain not responding to oral therapy, persistent vomiting, dehydration.
- High-risk context: immunosuppression, significant comorbidity, or diagnostic uncertainty (AAA/appendicitis/pyelonephritis differentials).
Frequently asked questions
Can I rule out a stone if there is no haematuria on dip?
No. Haematuria is common but not universal. Use the clinical picture and route for imaging via your local renal colic pathway.
Are antibiotics needed routinely?
No — only if infection is suspected. Infection with obstruction is an emergency: urgent hospital/urology pathway.
Is tamsulosin always appropriate?
Not always. It is used as medical expulsive therapy in selected ureteric stones in some pathways. Use local guidance / urology-endorsed protocols (and consider contraindications).
What prevention advice is highest yield?
Consistent hydration (aim for pale urine), avoid dehydration triggers, and targeted dietary advice based on stone type if recurrent (often via urology/metabolic work-up).
What differentials should I keep in mind?
Pyelonephritis, AAA (especially older/vascular risk), appendicitis, ovarian pathology, biliary disease, and musculoskeletal pain — consider atypical features and vitals.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.