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costo-vertebral angle. This pain may radiate anteriorly towards the abdomen, umbilicus or ipsilateral
testis or labium. It may be described as paroxysmal or colicky, owing to ureteral peristalsis against an
obstruction, or steady, more commonly caused by an inflammatory process. Renal colic may present with
gastrointestinal symptoms such as nausea and emesis secondary to reflex stimulation of the coeliac
ganglion or proximity of adjacent organs. Renal pain typically has no association with peritoneal signs or
diaphragmatic irritation.
Obstruction of the ureter may result in acute hyper-peristalsis, spasm of ureteral smooth muscles, and
marked distension. This triad will result in acute ureteral symptoms, which can commonly be determined
by the locus of the referred pain. Mid-ureteral pain may mimic appendicitis on the right (McBurney’s
point1) or diverticulitis on the left. Lower ureteral obstruction may induce ipsilateral scrotal or labial
symptoms as in renal pain above. However, it may also cause vesical symptoms, which include
irritability, frequency, urgency, and urethral pain. Patients with calculus obstruction usually have
1 McBurney’s point: a point about 5 cm superomedial to the anterior superior spine of the ilium, on a line joining
that process and the umbilicus, where pressure elicits tenderness in acute appendicitis. After Charles McBurney,
American surgeon (1845-1913).
ICAO Preliminary Unedited Version — November 2009 III-6-3
difficulty finding comfortable positions. These patients commonly sit, stand, or pace up and down the
room without pain relief.
In general, fever is an uncommon sign in ureteral obstruction but blood pressure and pulse are often
elevated. Emergency urinary diversion may be necessary in the setting of an obstructive calculus with
fever. Immediate intervention and rapid relief of obstruction are mandatory to prevent urosepsis and
urological demise. Relief can be accomplished with ureteral stenting or placement of a percutaneous
nephrostomy tube.
Diagnosis
Early assurance of normal blood pressure, pulse and body temperature is paramount when renal calculus
disease is diagnosed. An evaluation of the renal function based on creatinine studies and urinalysis is also
necessary. The urinalysis may commonly reveal moderate to severe micro-haematuria. Marked pyuria or
bacteriuria and the presence of nitrite or leukocyte esterase should raise suspicion of an infected and
possibly obstructed stone.
After initial evaluation and stabilization, the expeditious anatomical diagnosis and complete resolution of
all renal or ureteral stones is mandatory in a licence holder. Diagnostic procedures such as stone analysis,
urine pH, 24-hour urine collection, and serum studies are necessary to understand the source of the stone
disease. Urine culture should be performed even in the absence of other signs of acute infection in order
to rule out an occult infectious process. Radiographic studies are also important for further functional and
anatomical evaluation of a possible obstructing calculus.
Of all the available radiographic studies, plain film radiographs of the kidneys, ureters and bladder are the
initial choice. Calcium-containing calculi may have various degrees of opacity, with calcium apatite
having the highest radiodensity. Radiolucent stones, which are difficult to see in plain films, may be
identified by non-contrast enhanced computed tomography (CT). Pure indinavir stones are not visible on
CT radiographs but are of little aeromedical concern as only patients treated for human immunodeficiency
virus (HIV) infection are taking protease inhibitors such as indinavir.
The intravenous urogram (IVU) is the urological “gold standard” radiographic study for patients with
renal colic. This study can provide both functional and anatomical information to guide the treatment of a
licence holder with a urinary calculus. Delayed contrast uptake into the renal parenchyma may reveal an
acute obstructive picture commonly known as the “obstructive” nephrogram. Further radiographic signs
of acute obstruction may include dilation of the collecting system, ipsilateral renal enlargement, and even
forniceal rupture with urinary extravasation. Chronic obstruction may present with a dilated, tortuous
ureter, renal parenchymal thinning, crescentic calyces, and a “soap bubble” nephrogram.
Although IVU provides a wealth of information in this disease process, computed tomography has in
recent years become the standard means for emergent evaluation of patients with renal colic. Its current
ubiquity, low risk of morbidity from contrast reactions, and speed make it an excellent choice for early
diagnosis. Helical or spiral CT scanning does not require contrast agents, is cost-effective, and will reveal
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Manual of Civil Aviation Medicine 1(149)
