Management of Nephrolithiasis in the Urgent Care Setting

Table of Contents

 

About This Issue

Nephrolithiasis, or kidney stone disease, is a common medical condition that is increasing in incidence. Urgent care clinicians need to be able to identify the variable presentation of this condition. In this issue, you will learn:

Common presenting symptoms that should prompt work-up for nephrolithiasis

The current recommendations for pain management for patients who present with kidney stones in the urgent care setting

Which patient groups are at high risk for complications from nephrolithiasis and how treatment and referral are different for these populations

The controversies in medical expulsive therapy recommendations, as well as cutting edge treatments

CHARTING & CODING: A presentation of unstable vital signs or comorbid conditions with possible nephrolithiasis will increase the complexity of documentation. Learn more in our monthly coding column.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Etiology and Pathophysiology
6. Differential Diagnosis
7. Urgent Care Evaluation
   1. History
   2. Physical Examination
8. Diagnostic Studies
   1. Laboratory Studies
      1. Imaging Studies
9. Treatment
   1. Pain Management
   2. Medical Expulsive Therapy
   3. Procedural Intervention
10. Special Populations
    1. Pediatric Patients
    2. Pregnant Patients
    3. Patients With Kidney Disease
11. Controversies and Cutting Edge
    1. Medical Expulsive Therapy
    2. Limiting Exposure to Radiation
    3. Ketamine
    4. Lidocaine
    5. Intradermal Sterile Water
12. Disposition
13. Summary
14. Risk Management Pitfalls to Avoid in the Urgent Care Management of Nephrolithiasis
15. Time- and Cost-Effective Strategies
16. Critical Appraisal of Literature
17. 5 Things That Will Change Your Practice
18. Case Conclusions
19. Coding & Charting: What You Need to Know
    1. Determining the Level of Service
       1. Problems Addressed
       2. Complexity of Data
       3. Risk of Complications
    2. Documentation
20. Coding Challenge: Nephrolithiasis in Urgent Care
21. Clinical Pathway for the Diagnosis and Management of Suspected Nephrolithiasis in the Urgent Care Setting
22. References

Abstract

The incidence of nephrolithiasis has been increasing in recent years, making it a common presenting condition in the urgent care. The clinical presentation of nephrolithiasis is variable and overlaps with other serious medical conditions, so urgent care clinicians must be able to identify the condition and be familiar with evidence-based recommendations for evaluation and treatment. This article reviews the pathogenesis, symptomatology, initial diagnostic workup, and current medical management of this condition in the urgent care setting. It also reviews clinical scenarios in which patients with nephrolithiasis should be emergently referred for specialty care.

Case Presentations

A 27-year-old man presents to the urgent care with complaints of right upper quadrant abdominal pain for 1 week...

• He reports some nausea but has not had any other gastrointestinal complaints.
• He has not noticed any urinary difficulties but reports his urine has been slightly darker than usual. He attributes this to not eating well due to nausea and feeling “dehydrated.”
• You wonder if a urine culture may be needed in addition to urinalysis...

An obese 35-year-old man walks into the urgent care with complaints of vomiting and pain over his left flank...

• Over the past 24 hours he has developed worsening pain over his left flank, and he started vomiting this morning.
• Other than having difficulty losing weight, he reports no other known medical problems.
• He has a family history of nephrolithiasis in his mother, and gout in an uncle.
• He is urinating more frequently and is sweaty on examination.
• You wonder if this could be a kidney stone or a kidney infection...

A 40-year-old woman presents at the urgent care clinic with 2 days of left-sided lower back pain that radiates down her left groin…

• Over the past 2 days, her pain has been moderate but is now starting to interrupt her sleep.
• She has a history of dysmenorrhea and polycystic ovary syndrome.
• She initially thought her pain was due to upcoming menses, but when she awakened this morning, she experienced dysuria.
• The patient asks you if you think she has a urinary tract infection...

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

16. * Wong C, Teitge B, Ross M, et al. The accuracy and prognostic value of point-of-care ultrasound for nephrolithiasis in the emergency department: a systematic review and meta-analysis. Acad Emerg Med. 2018;25(6):684-698. (Systematic review and meta-analysis; 5 studies, 1773 patients) DOI: 10.1111/acem.13388

17. * Rodger F, Roditi G, Aboumarzouk OM. Diagnostic accuracy of low and ultra-low dose CT for identification of urinary tract stones: a systematic review. Urol Int. 2018;100(4):375-385. (Systematic review; 12 studies, 1529 patients) DOI: 10.1159/000488062

19. * Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus computed tomography for suspected nephrolithiasis. N Engl J Med. 2014;371(12):1100-1110. (Comparative effectiveness; 2759 patients) DOI: 10.1056/NEJMoa1404446

25. * Garcia-Perdomo HA, Echeverria-Garcia F, Lopez H, et al. Pharmacologic interventions to treat renal colic pain in acute stone episodes: Systematic review and meta-analysis. Prog Urol. 2017;27(12):654-665. (Systematic review and meta-analysis; 9 studies, 3852 patients) DOI: 10.1016/j.purol.2017.05.011

29. * Pathan SA, Mitra B, Cameron PA. A systematic review and meta-analysis comparing the efficacy of nonsteroidal anti-inflammatory drugs, opioids, and paracetamol in the treatment of acute renal colic. Eur Urol. 2018;73(4):583-595. (Systematic review; 36 studies, 4887 patients) DOI: 10.1016/j.eururo.2017.11.001

31. * Raison N, Ahmed K, Brunckhorst O, et al. Alpha blockers in the management of ureteric lithiasis: a meta-analysis. Int J Clin Pract. 2017;71(1). (Systematic review and meta-analysis; 67 studies, 6654 patients) DOI: 10.1111/ijcp.12917

33. * Wang H, Man LB, Huang GL, et al. Comparative efficacy of tamsulosin versus nifedipine for distal ureteral calculi: a meta-analysis. Drug Des Devel Ther. 2016;10:1257-1265. (Meta-analysis; 12 studies, 4961 patients) DOI: 10.2147/DDDT.S99330

35. * Pickard R, Starr K, MacLennan G, et al. Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. Lancet. 2015;386(9991):341-349. (Randomized control trial; 1167 patients) DOI: 10.1016/S0140-6736(15)60933-3

41. * Pickard R, Starr K, MacLennan G, et al. Use of drug therapy in the management of symptomatic ureteric stones in hospitalised adults: a multicentre, placebo-controlled, randomised controlled trial and cost-effectiveness analysis of a calcium channel blocker (nifedipine) and an alpha-blocker (tamsulosin) (the SUSPEND trial). Health Technol Assess. 2015;19(63):vii-viii, 1-171. (Randomized control trial; 1167 patients) DOI: 10.3310/hta19630

42. * Meltzer AC, Burrows PK, Wolfson AB, et al. Effect of tamsulosin on passage of symptomatic ureteral stones: a randomized clinical trial. JAMA Intern Med. 2018;178(8):1051-1057. (Randomized control trial; 512 patients) DOI: 10.1001/jamainternmed.2018.2259

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Keywords: kidney stones, nephrolithiasis, kidney stone disease, renal colic, renal calculi, medical expulsive therapy, nonsteroidal anti-inflammatory drugs, flank pain, urinalysis, hematuria, urology, kidney stone imaging