British Association of Urologic Surgeons. 2015. http// (accessed 30 January 2015)

Bechis SK, Eisner BH The STONE score can help diagnose urolithiasis and decrease the use of CT scans. Evid Based Med. 2014; 19:(6)

Managing patients with renal colic in primary care: know when to hold them. Best Practice Journal. 2014; 60:1-10

Bultitude M, Rees J Management of renal colic. BMJ. 2012; 345

Carter M, Green B Renal calculi: emergency department diagnosis and treatment. Emerg Med Pract. 2011; 13:(7)1-17

Clinical Appraisal Skills Programme. 2013. http// (accessed 30 January 2016)

Cullen IM, Cafferty F, Oon SF Evaluation of suspected renal colic with noncontrast CT in the emergency department: a single institution study. J Endourol. 2008; 22:(11)2441-5

Daniels B, Gross C, Singh D, Molinaro A, Moore C ED provider pretest probability predicts nephrolithiasis in CTS for suspected renal colic. Acad Emerg Med. 2013; 20

Daniels B, Gross C, Singh D, Moore C Identification of patients less likely to have significant alternate diagnoses on CT for renal colic. Acad Emerg Med. 2012; 19

Dellinger RP, Levy MM, Rhodes A Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013; 41:(2)580-637

Holdgate A, Pollock T Nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for acute renal colic. Cochrane Database Syst Rev. 2004; (1)

Hoppe H, Studer R, Kessler TM, Vock P, Studer UE, Thoeny H Alternate or additional findings to stone disease on unenhanced computerized tomography for acute flank pain can impact management. J Urol. 2006; 175:(5)1725-30

Lindqvist K, Hellstrom M, Holmberg G, Peeker R, Grenabo L Immediate or deferred radiological investigation after acute renal colic; a prospective randomised study. Scand J Urol Nephrol. 2006; 40:(2)119-24

McAnulty K, Wood P, Green E Evaluation of a direct access renal colic pathway for general practitioners. J Med Imaging Radiat Oncol. 2013; 57

Moore CL, Bomann S, Daniels B Derivation and validation of a clinical prediction rule for uncomplicated ureteral stone-the STONE score: retrospective and prospective observational cohort studies. BMJ. 2014; 348

National Institute for Health and Care Excellence. 2015. http// (accessed 30 January 2016)

Patatas K, Panditaratne N, Wah TM, Weston MJ, Irving HC Emergency department imaging protocol for suspected acute renal colic: re-evaluating our service. Br J Radiol. 2012; 85:(1016)1118-22

Penaloza A, Verschuren F, Meyer G Comparison of the unstructured clinician gestalt, the wells score, and the revised Geneva score to estimate pre-test probability for suspected pulmonary embolism. Ann Emerg Med. 2013; 62:(2)117-24

Pierre J, Nadel N Emergency provider’s ability to stratify risk of renal calculi prior to CT scan confirmation. Acad Emerg Med. 2009; 16

Schoenfeld EM, Elia TR, Budhram GR Questioning the benefit of immediate computerized tomography scanning in suspected renal colic: a retrospective chart review of patients age 50 and under presenting with flank pain. Acad Emerg Med. 2014; 21

Schoenfeld EM, Poronsky KE, Elia TR, Budhram GR, Garb JL, Mader TJ Young patients with suspected uncomplicated renal colic are unlikely to have dangerous alternative diagnoses or need emergency intervention. West J Emerg Med. 2015; 16:(2)269-75

Stewart A, Joyce A Modern management of renal colic. Trends in Urology Gynaecology and Sexual Health. 2008; 13:(3)14-17

Türk C, Petrík A, Sarica K EAU Guidelines on Interventional Treatment for Urolithiasis. Eur Urol. 2015; pii

Wang RC, Rodriguez R, Noble V External validation of the STONE score, a clinical prediction rule for ureteral stone: an observational multi-institutional study. Ann Emerg Med. 2015;

Xavier A, Maxwell AP Which patients with renal colic should be referred?. The Practitioner. 2011; 255:(1737)15-17

Zwank MD, Ho BM, Gresback D, Stuck LH, Salzman JG, Woster WR Does computed tomographic scan affect diagnosis and management of patients with suspected renal colic?. Am J Emerg Med. 2014; 32:(4)367-70

Diagnosing and imaging renal calculi: what can be done in the pre-hospital environment?

02 February 2016
Volume 8 · Issue 2


Renal colic is a common pre-hospital presentation that is often conveyed to hospital due to diagnostic uncertainty. The use of the STONE score and a greater understanding of computerised tomography (CT) requirement in the diagnostic process can aid the pre-hospital clinician in making an informed decision about the management of these patients.


A 48-year-old female presenting with symptoms of renal colic who was assessed, managed and treated at home.


A literature search was carried out on Medline, Cinahl, BNI and Embase. In addition, searches of the NHS evidence database ( and the Cochrane Database of Systematic Reviews ( were completed.


The search yielded 536 results, each of which were browsed for relevance, duplicates removed and their references reviewed. 16 articles were relevant to the use of CT to diagnose renal calculi and four addressed the derivation and validation of the STONE score. These were critically reviewed and conclusions drawn about their applicability to the pre-hospital environment.


The STONE score, when combined with clinical judgement and if applied to the right patient group, is an appropriate clinical decision tool to identify uncomplicated renal calculi. CT imaging of this low-risk patient group is not required to confirm diagnosis; however, delayed CT scanning is required to form a management plan.

Renal calculi are common in the UK with an incidence of 2–3%, with 0.5% of the population experiencing an acute episode of renal colic every year (British Association of Urologic Surgeons, 2015). These episodes are responsible for over 12 000 hospital admissions yearly and incidence rates have been rising (British Association of Urologic Surgeons, 2015). Anecdotal evidence suggests that these patients are seen commonly in the pre-hospital environment; however, due to diagnostic uncertainty they are often conveyed to the emergency department.

This article seeks to evaluate the current evidence for diagnosing renal calculi in the pre-hospital environment and address the requirement for, and timing of, computerised tomography (CT) scanning in the renal colic patient. The case study discussed is an example of confident diagnosis resulting in appropriate management and avoidance of unnecessary hospital admission.

The case study describes a 48-year-old female who called 999 with symptoms descriptive of renal colic. The pain had started during the night, coming in waves and had worsened throughout the morning. The patient described her pain as sharp with associated nausea but no vomiting. Her previous medical history consisted of chronic obstructive pulmonary disease, previous mastectomy and a left-sided kidney stone 2 years earlier. Observations revealed a respiratory rate of 21 breaths per minute, heart rate of 98 bpm, blood pressure of 152/90 mmHg, oxygen saturations of 98% and a temperature of 36.8°C. On inspection, the patient's abdomen showed no signs of scars, peritoneal bruising or asymmetry. Auscultation revealed active bowel sounds; percussion, tympany throughout and palpation elicited mild tenderness over the site of pain and over the right renal angle.

Subscribe to get full access to the Journal of Paramedic Practice

Thank you for visiting the Journal of Paramedic Practice and reading our archive of expert clinical content. If you would like to read more from the only journal dedicated to those working in emergency care, you can start your subscription today for just £48.

What's included

  • CPD Focus

  • Develop your career

  • Stay informed