Renal stones

The formation or lodging of stones anywhere in the renal tract, such as the kidneys, ureters or bladder is known as urolithiasis (National Institute for Health and Care Excellence (NICE), 2020a). The severe, acute pain which can accompany the movement of these stones within the renal tract is called renal colic. Renal stones (also called renal calculi or nephrolithiasis) are composed of crystalloid and organic matter which are lodged in the renal tract (Antonelli and Maalouf, 2021).

Around 1-13% of the adult population have renal stones, although most people are asymptomatic (Lang et al, 2022). Identifying and managing urolithiasis is important as it has been linked to the development of chronic and end-stage kidney disease (Zhe and Hang, 2017).

The signs and symptoms of renal stones include the sudden onset of severe, unilateral abdominal pain. The pain often radiates from the loin to the genital area, affecting the labia and testes (NICE, 2020a). The pain associated with renal stones can last a few minutes to a few hours and is spasmodic, interspersed with periods of either a dull ache or no pain.

As well as pain, other signs and symptoms which accompany renal stones include:

• nausea and vomiting
• haematuria
• dysuria
• urinary frequency
• urinary straining

People experiencing the pain of renal stones are often restless. They may also present with pyrexia and sweating, either because of the pain or infection.

Renal stones are mostly formed in the kidneys; they may stay there or migrate to the ureters and bladder. Stones can be classified into those caused by infections, non-infectious causes, genetic defects or adverse drug effects (European Association of Urology, 2023).

Stones are often formed from a mixture of materials such as cholesterol and proteins and minerals including:

• calcium
• phosphate
• uric acid
• oxalate
• sodium
• magnesium (European Association of Urology, 2023)

Nurses should suspect renal stones in people presenting with sudden onset of unilateral pain which is severe and radiating to the groin. Risk factors for renal stones include:

• previous renal stones (European Association of Urology, 2023)
• chronic dehydration
• family history of renal stones
• polycystic kidney disease
• single kidney
• horseshoe kidney
• sarcoidosis
• cystic fibrosis
•  some gastrointestinal diseases, eg Crohn’s disease
• certain medications, eg protease inhibitors
• being an adult man
• being white
• eating a high salt diet (Antonelli and Maalouf, 2021)

The assessment requires taking a full history from the patient to identify any risk factors and the presence of any signs and symptoms. Urinalysis is helpful in establishing issues such as possible infection and dehydration (Antonelli and Maalouf, 2021).

Definitive diagnosis occurs via imaging, which is low-dose non-contrast- enhanced computed tomography for most adults or ultrasound for children, young people and those who are pregnant (European Association of Urology, 2023).

The management of acute presentations of renal stones includes the management of pain. The medication of choice is any non-steroidal anti-inflammatory drug (NSAID) given by whatever route is available (NICE, 2019). Where NSAIDs cannot be used, eg in people with chronic kidney disease, intravenous paracetamol may be prescribed and failing that, opioids – although the latter are generally less effective than NSAIDs or paracetamol (Pathan, 2018). Management approaches need to consider rehydration, if the patient is dehydrated

Where infection is present, management of the infection is a priority especially in preventing infective hydronephrosis. Management of the infection may involve decompression of the kidney with a ureteral stent or percutaneous nephrostomy tube is needed as a matter of urgency especially since removal of the stone should be delayed until any infection is cleared (Wang et al, 2016).

Depending on the severity of the presentation, the location of the stones within the

Nursing and Midwifery Council: standards of proficiency for registered nurses

Part 1: Procedures for assessing people’s needs for person-centred care

1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages

Part 2: Procedures for the planning, provision and management of person-centred nursing care

3.5 take appropriate action to reduce or minimise pain or discomfort

11. Procedural competencies required for best practice, evidence-based medicines administration and optimisation

Antonelli J, Maalouf N. BMJ best practice: nephrolithiasis. 2021. https://bestpractice.bmj.com/topics/en-gb/3000101 (accessed 5 February 2024)

Chaussy CG, Tiselius HG. How can and should we optimize extracorporeal shockwave lithotripsy? Urolithiasis. 2018;46:3–17. https://doi.org/10.1007/s00240-017-1020-z

European Association of Urology. Urolithiasis. 2023. https://uroweb.org/topics/urolithiasis (accessed 5 February 2024)

Ganpule P, Vijayakumar M, Malpani A, Desai MR. Percutaneous nephrolithotomy (PCNL) a critical review. Int J Surgery. 2016;36(D): 660-664. https://doi.org/10.1016/j.ijsu.2016.11.028

Lang J, Narendrula A, El-Zawahry A, Sindhwani P, Ekwenna O.
Global trends in incidence and burden of urolithiasis from 1990 to 2019: an analysis of global burden of disease study data. 2022:35;37-46. https://doi.org/10.1016/j.euros.2021.10.008 

National Institute for Health and Care Excellence (NICE). Renal and ureteric stones: assessment and management. 2019. https://www.nice.org.uk/guidance/NG118 (accessed 5 February 2024)

National Institute for Health and Care Excellence (NICE). Renal or ureteric colic - acute. 2020a. https://cks.nice.org.uk/topics/renal-or-ureteric-colic-acute/ (accessed 5 February 2024)

National Institute for Health and Care Excellence (NICE). Renal and ureteric stones. 2020b. https://www.nice.org.uk/guidance/qs195 (accessed 5