Retrospective study on pain management pathway for patients with suspected renal/ ureteric colic in a U.K. accidents and emergency department: A quality improvement project

Introduction

Renal/ureteric colic refers to acute and severe loin pain caused by calculi in the upper urinary tract (Iravani et al., 2014; Weltings et al., 2021). As of 2019, the worldwide incidence was 115.55 million – a 48.57% rise over 29 years when compared to its global incidence of 77.78 million in 1990 (Qian et al., 2022). In the United Kingdom, it is estimated that the incidence of renal/ureteric colic was 88,632 in 2019/20, which is a 2.2% increase from the 2014/15 prevalence of 86,742 (Jour et al., 2022; Geraghty et al., 2020). This surge is likely due to lack of physical activity, dietary changes, low oral fluid intake, obesity, and global warming (Dawson & Tomson, 2012). It is also a huge financial burden, as existing data state that in 2014/15, renal/ureteric colic gulped between £190 million and £324 million in the United Kingdom (Geraghty et al., 2020). It is therefore reasonable to expect that, taking into consideration the effects of inflation, population increase, and rising number of persons with the disease, it is likely to cost up to £622 million by 2030 (Tyson et al., 2019; Geraghty et al., 2020).

Although the primary function of pain stemming from renal/ureteric colic is to indicate that something is wrong, therefore, acting as a defensive and protective mechanism, the sensation is unpleasant and excruciating. When urine becomes supersaturated, it creates a favourable niche for calcium, urate, and other salts present to crystallize and form pebbles, which in turn obstructs the free flow of urine, thus causing pain (Alelign & Petros, 2018; Papadopoulos et al., 2014). This often alters and lowers the quality of life (Patti & Leslie, 2024). While associated pain causes anxiety (Geraghty et al., 2020), depression (Liu & Kelliher, 2022), sleep disorders, and immunosuppression (Jin et al., 2023), it also results in hormonal imbalance, the most pertinent of which is initial hypercortisolemia followed by terminal hypocortisolemia (Tennant, 2013). Increased cortisol levels can cause tachycardia, hypertension, osteoporosis, hyperlipidemia, hyperglycemia, and mental degeneration. Hypocortisolemia leads to weight loss, muscle breakdown, hypotension (Jin et al., 2023), and sudden death (Tennant, 2013).

As renal/ureteric colic accounts for approximately 80,000 emergency department visits annually in the United Kingdom (Dawson & Tomson, 2012), with up to 12,000 admitted for care across the country per year (Dawson & Dawson, 2013) and a recurrence rate of 50% at 5 – 10 years (Alelign & Petros, 2018), and 80% at 20 years (Patti & Leslie, 2024), it is crucial for clinicians to pay adequate attention to effective pain management as it forms an integral part of overall care given to affected patients. The aim of this study was to explore the compliance rate of the pain management pathway for patients with suspected renal/ureteric colic in a U.K. emergency department to the National Institute for Health and Care Excellence (NICE) guidelines.

Methods

Results

Of the 78 patients (n = number of patients) suspected to have renal/ureteric colic in the first cycle, the male (n=43) to female (n=35) ratio was 1.2:1. NC-CTKUB confirmed that 87% (n=68) had stones and 3% (n=2) had no stones. 9% (n=7) did not have NC-CTKUB because they were young, and urinalysis showed no microscopic hematuria. 1% (n=1) self-discharged (S/D) before NC-CTKUB (Figure 1). Overall, compliance with the NICE pain management guidelines for suspected renal/ureteric colic was full in 23% (n=18) of cases but unsatisfactory in 77% (n=60) of cases (Figure 3). Having performed interventions, allowed a time interval of four months for clinicians to conform their practice to NICE guidelines, we performed a second cycle study - amongst the 57 patients suspected to have renal/ureteric colic, the NICE guideline was fully adhered to in 56% (n=32) but unsatisfactory in 44% (n=25) (Figure 3). The male (n=34) to female ratio (n=23) was 1.5:1.

Figure 1. Percentage of patients suspected to have renal/ureteric colic in the first cycle study who had non-contrast computerised tomography of kidney ureter and bladder done. S/D is abbreviation for “self-discharged”.

Figure 2. Bar chart demonstrating the number of patients given (and not given) hyoscine butyl bromide (HB) in the first and second cycle studies. HB is an antispasmodic.

Figure 3. Bar chart showing compliance rate in first and second cycle studies.

Discussion

Renal/ureteric colic has continued to remain a topical issue of discussion as its recurrence rate is high and poses a huge burden to patients as well as health care systems around the globe (Alelign & Petros, 2018; Tyson et al., 2019). In the United Kingdom, the existing literature indicates that it is more common in males than in females (Alelign & Petros, 2018); however, the gender gap appears to be closing (Gillams et al., 2021). NC-CTKUB is the gold standard test (Tyson et al., 2019), and pain management favors the administration of NSAIDs over intravenous paracetamol, opioids, and antispasmodics (Weltings et al., 2021; NICE, 2019), as they are the most effective of the four (Masoumi et al., 2014). Our study is consistent with its sex predisposition and diagnostic methods; however, there appears to be a disparity in the pain management pathway. We propose a need to consider the inclusion of certain variables to the existing standard guidelines.

While renal/ureteric colic has been found to be more common in males than females, the reasons remain unclear to date (Ferraro et al., 2023). In the United Kingdom, it is stipulated that between 1990 and 2007, M:F = 2.5:1 (Geraghty et al., 2020), which increased to 3:1 between 2016 and 2018 (NICE, 2020) and currently, and as more females are becoming affected, the gender gap seems to be closing (Alelign & Petros, 2018; Dawson & Tomson, 2012; Ferraro et al., 2023; NICE, 2020; Gillams et al., 2021; Feheley, 2021; Juliebo-Jones et al., 2023). For instance, a Northern Irish paper expressed it to be 1.93:1 (Tyson et al., 2019). In our study, of the 78 patients who were suspected to have renal/ureteric colic in the first cycle, 55.1% were males and 44.9% were females corresponding to 1.2:1. In our second-cycle study involving 57 patients, 34 were males and 23 were females; therefore, corresponding to 1.5:1.

NICE (2019) advocates that all patients suspected to have renal/ureteric colic should be considered for NSAIDs, and if needed, intravenous paracetamol and opioids should be administered, and antispasmodics should not be given. Although our second-cycle results showed a compliance rate of 56%, an improvement of more than twice the initial result (23%), work still needs to be done to attain full compliance. Four reasons were found to be the cause of the deviation. First, several patients were prescribed hyoscine butylbromide: 16.7% and 13% (Figure 2) in the first- and second-cycle studies respectively, as many clinicians, like in the Netherlands had for many years (Weltings et al., 2021), believed that the antispasmodic effect of hyoscine butylbromide was of analgesic benefit to patients. Furthermore, many clinicians simply preferred intravenous paracetamol and oral opioids over NSAIDs, as they judged them to be safer. Most feared that the latter may cause gastrointestinal, renal, respiratory, cerebrovascular, and cardiovascular problems regardless of how medically fit the patient was. Moreso, clinicians believed that, considering the level of pain experienced by patients with suspected renal/ureteric colic, intravenous paracetamol may not be very effective; thus, it was preferable to administer it as an adjunct to oral opioids. Finally, a few clinicians simply administered analgesics, provided that it was safe and effective regardless of the standard renal/ureteric colic pain management pathway.

Arguments against and for hyoscine butylbromide have been presented. For example, although its smooth muscle relaxing effect on the ureters is yet to be demonstrated (Weltings et al., 2021; Papadopoulos et al., 2014), continued intravenous administration is difficult (Weltings et al., 2021) and has a rare side effect of hemodynamic instability (Chen & Hsu, 2013), it has also been shown to have good effect on stones in the renal pelvis, less cardiac and renal side effects when compared to NSAIDs, and synergistic analgesic effects when combined with NSAIDs (Papadopoulos et al., 2014). In support of the use of hyoscine butylbromide in the United Kingdom to manage pain associated with renal/ureteric colic, a commentary published by three nephrologists, a urologist, and a patient representative in response to NICE guidelines advises that hyoscine butylbromide should not be entirely left out of the pain management pathway but should be considered for suitable patients (Sayer et al., 2021).

While it is true that NSAIDs are associated with Peptic Ulcer Disease (PUD), Liver and Respiratory problems, Renal failure, Myocardial and Cerebral ischemia (Fening, 2020), they can be safely administered to select patients at the lowest effective dose and, on a short-term basis (Bindu et al., 2020), taking into account the following factors: PUD - consider (a) per rectal diclofenac (Patti & Leslie, 2024), (b) intramuscular ketorolac (Patti & Leslie, 2024) (c) oral ibuprofen/aceclofenac (Drini, 2017) administered with Proton Pump Inhibitors/H2 Receptor Antagonists/Antacids (d) celecoxib, as it has the best gastric profile (Drini, 2017). Interestingly, concerns about the cardio- and cerebrovascular side effects of celecoxib have been described by the PRECISION study as not being different from non-selective NSAIDs (Nissen et al., 2016). Liver Toxicity – Oral Ibuprofen and Celecoxib have been shown to have the best safety profiles (Bindu et al., 2020). Asthma, Nasal Polyposis-Associated Chronic Rhinitis, Acute Respiratory Tract Reaction – celecoxib is not implicated; thus, it is safe (Bindu et al., 2020). Renal failure, myocardial ischemia, and cerebral ischemia - avoid NSAID’s. Although current NSAIDs have concerning side effects, newer versions are currently in the pipeline and show promising results (Bindu et al., 2020). These are likely to be of immense benefit to patients with suspected renal/ureteric colic.

Although the World Health Organization’s (WHO) analgesic ladder recommends paracetamol as a first-line painkiller, existing studies have proven that intravenous paracetamol is as potent (Montazer et al., 2017) and even more effective (Masoumi et al., 2014) than intravenous morphine in managing renal/ureteric colic. Because the side effects of opioids are worrisome, it is logical to conclude that intravenous paracetamol should be considered before opioids in affected patients.

As upper urinary tract stones can persist for prolonged periods, with affected persons experiencing agonizing pain without surgery or postoperatively (Intermountain Healthcare, 2023), it is crucial to mention the interplay between pain and the Hypothalamic-Pituitary-Adrenal-Thyroid-Gonadal (HPATG) axis. The initial phase of severe pain causes a surge in Triiodothyronine, Thyroxine, Cortisol, Pregnenolone, DHEA, and testosterone levels, and if pain persists for a long time, serum levels fall to critical levels (Tennant, 2013). From this, we can extrapolate the following. First, serum hormone levels can serve as biomarkers for severe and uncontrolled renal/ureteric colic. Second, it is vital to perform baseline hormonal assessments before embarking on pain management therapy, especially with opioids, as they also suppress the HPATG axis. Third, if any of the hormones is low, it is reasonable to infer that pain from renal/ureteric colic is likely severe and persisting for too long, disrupting the HPATG axis, causing associated hyperalgesia and allodynia (Tennant, 2013). Regardless of how much analgesics is being administered, severe pain will continue until the dysregulated hormones have been attended to, thus preventing excessive and unwarranted use of analgesics. Fourth, replacement of low hormones would be lifesaving – for instance ensuring hormonal homeostasis in an individual with pain associated serum cortisol level of less than 0.1 microgram per deciliter (Tennant, 2013) which otherwise would have been life threatening.

Of note is the clinicians’ ability to correctly diagnose renal/ureteric colic, as well as consideration for radiation risk-to-benefit. Clinicians attending to the 78 patients suspected of having renal/ureteric colic requested NC-CTKUB, and their suspicion was confirmed in 87% of cases, while 3% had no stones. NC-CTKUB was not performed in 9% of the patients because they were young, and urinalysis showed no microscopic hematuria. Its role in aiding the diagnosis of renal/ureteric colic cannot be overemphasized.

Conclusions

Although the literature indicates that renal/ureteric colic is significantly more common in males than in females, recent data suggest that the gap is closing, which is consistent with our study. While NICE advocates that NSAIDs should be considered before intravenous paracetamol and opioids and not to administer hyoscine butylbromide, we opine that there may be a need to accommodate hyoscine butylbromide for suitable patients and consider hormonal homeostasis in pain management workup. However, it is vital to strictly follow NICE guidelines until these suggestions are appraised. The use of NC-CTKUB in the diagnosis of renal/ureteric colic remains the gold standard, and our study demonstrated its efficiency in aiding its detection.