Pain Imaging pp 275-302 | Cite as

Imaging of Renal Colic

  • Paola MartinganoEmail author
  • Marco F. M. Cavallaro
  • Fulvio Stacul
  • Maria Assunta Cova


Renal colic indicates a type of abdominal pain due to urinary tract obstruction, commonly caused by urinary stones. The classic presentation of renal colic is the sudden onset of severe loin pain, but depending on the site of obstruction, the pain will radiate to the flank, groin, and testes or labia majora. Unfortunately, symptoms due to many other abdominal diseases could be indistinguishable from renal colic, and therefore emergency imaging in patients with suspected renal colic is necessary to rule out other clinical conditions, either renal diseases or gynecologic, gastrointestinal, pancreatic, hepatobiliary, vascular, and musculoskeletal conditions. In this setting, imaging is required to allow rapid diagnosis, to guide patient management, and to evaluate active treatment complications.

Abdominal plain films recognize a urinary stone for its opacity, but only 48–63% of urinary stones are visible. Intravenous urography nowadays has been almost everywhere substituted by ultrasound or computed tomography. Ultrasonography is often performed as an initial imaging modality in case of abdominal pain evaluation since it is safe, noninvasive, repeatable, and quite low expensive. It directly identifies stones as hyperechoic structures with posterior shadowing and recognizes secondary signs of obstruction. Computed tomography generally visualizes urinary calculi, even <3 mm, as high attenuating formations inside urinary tract, it identifies hydronephrosis and perinephric edema, and it is highly sensible in recognizing alternative diagnosis. The low availability of MR in emergency setting does not allow its routine use in renal colic workup but is a useful tool in the evaluation of pregnant and pediatric patients after not conclusive ultrasound imaging.


Renal colic Urinary stones Ultrasound Computed tomography Magnetic resonance 

Supplementary material

Video 15.1

Elderly patient presenting in emergency room with acute abdominal pain. Axial reconstruction of unenhanced CT show incomplete duplication with multiple renal stones and dilation. A lumbar ureteral stone is located in the upper system, cranial to ureteral fusion, and multiple stones are impacted in the single pelvic ureter, with the typical “soft tissue rim sign”. Multiple phleboliths are also present. (AVI 23814 kb)

Video 15.2

Male patient with right renal colic. Unenhanced CT, axial images, shows moderate right hydronephrosis with fat stranding and perinephric edema. A right obstructing high attenuating stone with “soft tissue rim sign” is recognizable at pyelo-ureteral junction. (AVI 21510 kb)

Video 15.3

Male patient with right renal colic. Coronal reconstructed images of unenhanced CT show moderate right hydronephrosis with fat stranding and perinephric edema. A right obstructing high attenuating stone with a larger diameter in the longitudinal axis is recognizable at pyelo-ureteral junction. (AVI 2700 kb)


  1. 1.
    Kambadakone AR, et al. New and evolving concepts in the imaging and management of urolithiasis: urologists’ perspective. Radiographics. 2010;30(3):603–23.PubMedGoogle Scholar
  2. 2.
    Cheng PM, et al. What the radiologist needs to know about urolithiasis: part 1--pathogenesis, types, assessment, and variant anatomy. AJR Am J Roentgenol. 2012;198(6):W540–7.PubMedGoogle Scholar
  3. 3.
    Heidenreich A, Desgrandschamps F, Terrier F. Modern approach of diagnosis and management of acute flank pain: review of all imaging modalities. Eur Urol. 2002;41(4):351–62.PubMedGoogle Scholar
  4. 4.
    Taourel P, et al. Computed tomography in the nontraumatic renal causes of acute Flank pain. Semin Ultrasound CT MRI. 2008;29(5):341–52.Google Scholar
  5. 5.
    Jha P, et al. Imaging of flank pain: readdressing state-of-the-art. Emerg Radiol. 2017;24(1):81–6.PubMedGoogle Scholar
  6. 6.
    Stamatelou KK, et al. Time trends in reported prevalence of kidney stones in the United States: 1976–1994. Kidney Int. 2003;63(5):1817–23.PubMedGoogle Scholar
  7. 7.
    Samim M, et al. Incidental findings on CT for suspected renal colic in emergency department patients: prevalence and types in 5,383 consecutive examinations. J Am Coll Radiol. 2015;12(1):63–9.PubMedGoogle Scholar
  8. 8.
    Leveridge M, et al. Renal colic: current protocols for emergency presentations. Eur J Emerg Med. 2016;23(1):2–7.PubMedGoogle Scholar
  9. 9.
    Tirotta D, et al. Abdominal pain: a synthesis of recommendations for its correct management. Ital J Med. 2015;9(2):193–202.Google Scholar
  10. 10.
    Jindal G, Ramchandani P. Acute flank pain secondary to urolithiasis: radiologic evaluation and alternate diagnoses. Radiol Clin North Am. 2007;45(3):395–410. vii.PubMedGoogle Scholar
  11. 11.
    Moore CL, Scoutt L. Sonography first for acute flank pain? J Ultrasound Med. 2012;31(11):1703–11.PubMedGoogle Scholar
  12. 12.
    Wolf JS. Treatment selection and outcomes: Ureteral calculi. Urol Clin North Am. 2007;34(3):421.PubMedGoogle Scholar
  13. 13.
    Preminger GM, et al. 2007 guideline for the management of ureteral calculi. Eur Urol. 2007;52(6):1610–31.PubMedGoogle Scholar
  14. 14.
    Coll DM, Varanelli MJ, Smith RC. Relationship of spontaneous passage of ureteral calculi to stone size and location as revealed by unenhanced helical CT. Am J Roentgenol. 2002;178(1):101–3.Google Scholar
  15. 15.
    Wen CC, Nakada SY. Treatment selection and outcomes: Renal calculi. Urol Clin North Am. 2007;34(3):409.PubMedGoogle Scholar
  16. 16.
    Perks AE, et al. Stone attenuation and skin-to-stone distance on computed tomography predicts for stone fragmentation by shock wave lithotripsy. Urology. 2008;72(4):765–9.PubMedGoogle Scholar
  17. 17.
    Nicolau C, et al. Imaging patients with renal colic-consider ultrasound first. Insights Imaging. 2015;6(4):441–7.PubMedPubMedCentralGoogle Scholar
  18. 18.
    Ather MH, et al. Alternate and incidental diagnoses on noncontrast-enhanced spiral computed tomography for acute flank pain. Urol J. 2009;6(1):14–8.PubMedGoogle Scholar
  19. 19.
    Villa L, et al. Imaging for urinary stones: update in 2015. Eur Urol Focus. 2016;2(2):122–9.PubMedGoogle Scholar
  20. 20.
    Piazzese EM, et al. The renal resistive index as a predictor of acute hydronephrosis in patients with renal colic. J Ultrasound. 2012;15(4):239–46.PubMedPubMedCentralGoogle Scholar
  21. 21.
    Song Y, et al. Can ureteral stones cause pain without causing hydronephrosis? World J Urol. 2016;34(9):1285–8.PubMedGoogle Scholar
  22. 22.
    Tomizawa M, et al. Abdominal ultrasonography for patients with abdominal pain as a first-line diagnostic imaging modality. Exp Ther Med. 2017;13(5):1932–6.PubMedPubMedCentralGoogle Scholar
  23. 23.
    Moore CL, et al. Prevalence and clinical importance of alternative causes of symptoms using a renal colic computed tomography protocol in patients with flank or back pain and absence of pyuria. Acad Emerg Med. 2013;20(5):470–8.PubMedGoogle Scholar
  24. 24.
    Cheng PM, et al. What the radiologist needs to know about urolithiasis: part 2--CT findings, reporting, and treatment. AJR Am J Roentgenol. 2012;198(6):W548–54.PubMedGoogle Scholar
  25. 25.
    Elkoushy MA, Andonian S. Lifetime radiation exposure in patients with recurrent nephrolithiasis. Curr Urol Rep. 2017;18(11):85.PubMedGoogle Scholar
  26. 26.
    Jellison FC, et al. Effect of low dose radiation computerized tomography protocols on distal ureteral calculus detection. J Urol. 2009;182(6):2762–7.PubMedGoogle Scholar
  27. 27.
    Westphalen AC, et al. Radiological imaging of patients with suspected urinary tract stones: national trends, diagnoses, and predictors. Acad Emer Med. 2011;18(7):700–7.Google Scholar
  28. 28.
    Chaytor RJ, et al. Determining the composition of urinary tract calculi using stone-targeted dual-energy CT: evaluation of a low-dose scanning protocol in a clinical environment. Br J Radiol. 2016;89(1067):20160408.PubMedPubMedCentralGoogle Scholar
  29. 29.
    Franken A, et al. In Vivo differentiation of uric acid versus non-uric acid urinary calculi with third-generation dual-source dual-energy CT at reduced radiation dose. Am J Roentgenol. 2018;210(2):358–63.Google Scholar
  30. 30.
    Kalb B, et al. Acute abdominal pain: is there a potential role for MRI in the setting of the emergency department in a patient with renal calculi? J Magn Reson Imaging. 2010;32(5):1012–23.PubMedGoogle Scholar
  31. 31.
    Spalluto LB, et al. MR imaging evaluation of abdominal pain during pregnancy: appendicitis and other nonobstetric causes. Radiographics. 2012;32(2):317–34.PubMedGoogle Scholar
  32. 32.
    Masselli G, et al. Stone disease in pregnancy: imaging-guided therapy. Insights Imaging. 2014;5(6):691–6.PubMedPubMedCentralGoogle Scholar
  33. 33.
    Masselli G, et al. Imaging of stone disease in pregnancy. Abdom Imaging. 2013;38(6):1409–14.PubMedGoogle Scholar
  34. 34.
    Semins MJ, et al. Evaluation of acute renal colic: a comparison of non-contrast CT versus 3-T non-contrast HASTE MR urography. Urolithiasis. 2013;41(1):43–6.PubMedGoogle Scholar
  35. 35.
    Ripolles T, et al. Sonographic diagnosis of symptomatic ureteral calculi: usefulness of the twinkling artifact. Abdom Imaging. 2013;38(4):863–9.PubMedGoogle Scholar
  36. 36.
    Kennish SJ, Wah TM, Irving HC. Unenhanced CT for the evaluation of acute ureteric colic: the essential pictorial guide. Postgrad Med J. 2010;86(1017):428–36.PubMedGoogle Scholar
  37. 37.
    Zarse CA, et al. CT visible internal stone structure, but not Hounsfield unit value, of calcium oxalate monohydrate (COM) calculi predicts lithotripsy fragility in vitro. Urol Res. 2007;35(4):201–6.PubMedPubMedCentralGoogle Scholar
  38. 38.
    Christiansen FE, et al. Internal structure of kidney calculi as a predictor for shockwave lithotripsy success. J Endourol. 2016;30(3):323–6.PubMedGoogle Scholar
  39. 39.
    Hiller N, et al. The relationship between ureteral stone characteristics and secondary signs in renal colic. Clin Imaging. 2012;36(6):768–72.PubMedGoogle Scholar
  40. 40.
    Eisner BH, et al. Computerized tomography magnified bone windows are superior to standard soft tissue windows for accurate measurement of stone size: an in vitro and clinical study. J Urol. 2009;181(4):1710–5.PubMedGoogle Scholar
  41. 41.
    Dalla Palma L, Pozzi-Mucelli R, Stacul F. Present-day imaging of patients with renal colic. Eur Radiol. 2001;11(1):4–17.PubMedGoogle Scholar
  42. 42.
    Heneghan JP, et al. Soft-tissue “rim” sign in the diagnosis of ureteral calculi with use of unenhanced helical CT. Radiology. 1997;202(3):709–11.PubMedGoogle Scholar
  43. 43.
    Traubici J, Neitlich JD, Smith RC. Distinguishing pelvic phleboliths from distal ureteral stones on routine unenhanced helical CT: is there a radiolucent center? Am J Roentgenol. 1999;172(1):13–7.Google Scholar
  44. 44.
    Bell TV, et al. Unenhanced helical CT criteria to differentiate distal ureteral calculi from pelvic phleboliths. Radiology. 1998;207(2):363–7.PubMedGoogle Scholar
  45. 45.
    Kameda T, Taniguchi N. Overview of point-of-care abdominal ultrasound in emergency and critical care. J Intensive Care. 2016;4:53.PubMedPubMedCentralGoogle Scholar
  46. 46.
    Rucker CM, Menias CO, Bhalla S. Mimics of renal colic: alternative diagnoses at unenhanced helical CT. Radiographics. 2004;24:S11–28.PubMedGoogle Scholar
  47. 47.
    Stunell H, et al. Imaging of acute pyelonephritis in the adult. Eur Radiol. 2007;17(7):1820–8.PubMedGoogle Scholar
  48. 48.
    Gun C, et al. What do we miss without contrast in patients with flank pain? Am J Emer Med. 2016;34(4):765.e3–5.Google Scholar
  49. 49.
    Revzin MV, et al. Pelvic inflammatory disease: multimodality imaging approach with clinical-pathologic correlation. Radiographics. 2016;36(5):1579–96.PubMedGoogle Scholar
  50. 50.
    Marquardt G, et al. Spontaneous haematoma of the iliac psoas muscle: a case report and review of the literature. Arch Orthop Trauma Surg. 2002;122(2):109–11.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Paola Martingano
    • 1
    Email author
  • Marco F. M. Cavallaro
    • 2
  • Fulvio Stacul
    • 2
  • Maria Assunta Cova
    • 1
  1. 1.Unità Clinico Operativa di Radiologia, Dipartimento Universitario Clinico di Scienze Mediche Chirurgiche e della SaluteOspedale di Cattinara, Azienda Sanitaria Universitaria Integrata di Trieste, Università degli Studi di TriesteTriesteItaly
  2. 2.Struttura Complessa di Radiologia, Ospedale MaggioreAzienda Sanitaria Universitaria Integrata TriesteTriesteItaly

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